Expressed emotion, family environment, and parental bonding in bulimia nervosa: A 6-year investigation

Abstract

As part of a prospective, long-term treatment study, 30 in-patients with bulimia nervosa (BN) were divided into groups with high and low expressed emotion (EE) family backgrounds according to the Camberwell Family Interview, and followed for a period of six years. The high EE group initially showed significantly more psychopathology than the low EE group. No group x time interactions were found, but the high EE group showed a worse outcome on the "conflict" and "organisation" subscales of the Family Environment Scale. They also showed significantly more eating disorder pathology according to the Eating Disorder Inventory (EDI) and the Structured Interview for anorexia nervosa (AN) and BN before treatment at discharge, after two years and, to some degree, even after six years. Depth of depression (Beck Depression Inventory) was significantly higher in the high EE group at admission (moderate depression), discharge and after the 6-year follow-up (still slight depression). The Parental Bonding Instrument (PBI) showed no differences between the high EE and low EE groups, but the individuals with "affectionless control" according to the PBI had more negative scores on three of the subscales of the Family Environment Scale (FES). In brief, the high EE individuals with BN were initially sicker and did not fully catch up over time in comparison with the symptomatic recovery of the low EE individuals. These data suggest that EE status upon admission to in-patient treatment is a relevant predictor of the severity and course of BN and depressive symptoms.

Bonding and Expressed Emotion: Two Interlinked Concepts?

“…Indeed, investigation using the FMSS lasts only 5 min, while the CFI is a 1-hour interview [25]. With regard to the PBI, Parker et al [32] used a version implementing only 2 factors (as did Hedlund et al [33]), whereas the French validated version used 3 [11,12,13,14]. …”

“…In the two studies that previously explored links between bonding and EE (Parker et al [32] and Hedlund et al [33]), the two bonding dimensions (Care and Overprotection) were linked respectively to the number of critical comments expressed by parents and to EOI (evaluated by the CFI). In the FMSS, unlike the CFI, Critical EE and EOI are qualitative variables.…”

“…The Emotional Overinvolvement dimension was correlated with Overprotection, but ‘more markedly' for the mother than for the father (r = 0.43 vs. 0.20) [p. 440 in [31]]. Hedlund et al [33] tested this same hypothesis in a smaller sample of 30 bulimic patients (6.6% males, mean age 24.3 years) using the CFI and PBI measures. Care and Overprotection were not found to be linked with family levels of EE, while the links with each of the dimensions critical comments and EOI were not studied.…”

Bulimia nervosa in males: a case report

“…There are studies indicating that the frequency of this disease increases among men, too. These studies suggest that the disease is underdiagnosed in men due to embarrassment and an effort at hiding the condition (6)(7)(8). It is thought that the fear of obesity is epidemic and the perception of the ideal body is changing in all societies due to an increase in mass communication presenting an ideal body image.…”

“…It is thought that the fear of obesity is epidemic and the perception of the ideal body is changing in all societies due to an increase in mass communication presenting an ideal body image. Consequently, the frequency of eating disorders increases (6,9,10). Patients with eating disorders often simultaneously display other psychiatric disorders.…”