Expressed Emotion and Caregiver Burden in Bipolar Affective Disorder

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Journal of MedVerse Research & Practice

ISSN: 3107-4278

Expressed Emotion and Caregiver Burden in Bipolar Affective Disorder

Dr. Vasanth E, Dr. James Robert

Assistant Professor, Professor

Department of Psychiatry

Psychiatry Centre of a tertiary care hospital, Western Maharashtra.

Email ID: dr.vasanth@gmail.com

Submission Date: 24.12.2025

Accepted Date: 20.01.2026

Published Date: 31.01.2026

DOI: 10.65188/nurexus.1062

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted

use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Background: Caregivers of individuals with Bipolar Affective Disorder play a crucial role in long-term illness

management. The chronic and relapsing course of the disorder places caregivers at risk of significant burden, which

may influence emotional responses toward patients and affect clinical outcomes.

Objectives: To assess the level of caregiver burden and expressed emotion among caregivers of patients with Bipolar

Affective Disorder and to examine the association between caregiver burden and expressed emotion.

Materials and Methods: This cross-sectional observational study was conducted over 24 months at the Psychiatry

Centre of a tertiary care hospital in Western Maharashtra. A total of 55 patients diagnosed with Bipolar Affective

Disorder for a minimum duration of two years and their primary caregivers were included. Sociodemographic and

clinical data were collected using a semi-structured proforma. Caregiver burden was assessed using the Caregiver

Burden Scale, and expressed emotion was evaluated using the Family Emotional Involvement and Criticism Scale.

Statistical analysis was performed using SPSS version 26.0, employing descriptive statistics, correlation analysis,

and multivariate regression, with a p value of less than 0.05 considered statistically significant.

Results: Most caregivers experienced moderate to severe levels of caregiver burden. Expressed emotion scores were

elevated, with emotional over-involvement being more prominent than perceived criticism. A statistically significant

association was observed between higher caregiver burden and elevated expressed emotion. Caregiver burden

showed a moderate positive correlation with both perceived criticism and emotional over-involvement. Longer

duration of caregiving, female gender, family history of psychiatric illness, and higher emotional over-involvement

emerged as significant predictors of caregiver burden.

Conclusion: Caregivers of patients with Bipolar Affective Disorder experience substantial burden, which is

significantly associated with adverse emotional responses. Early identification of high caregiver burden and

expressed emotion may facilitate targeted family-focused interventions, improving caregiver well-being and

potentially enhancing patient outcomes.

Keywords: Bipolar Affective Disorder; Caregiver burden; Expressed emotion; Family Emotional Involvement and

Criticism Scale; Caregiver Burden Scale; Mental health caregiving

Introduction

Caregivers form the backbone of long-term care for individuals with severe mental illnesses, particularly

in settings where family-based care predominates. Under the Mental Healthcare Act, 2017, a caregiver is

defined as a person who lives with and provides care to an individual with mental illness, either voluntarily

or otherwise, and may be a family member or another responsible individual [1]. In clinical practice,

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caregivers are actively involved in medication supervision, monitoring of symptoms, management of crises,

and provision of continuous emotional and social support. Severe mental disorders are often chronic,

episodic, and disabling, resulting in sustained caregiving demands over extended periods. The burden

experienced by caregivers of individuals with psychiatric illnesses has been reported to be greater than that

associated with many chronic physical conditions [2]. Factors such as early age of onset, frequent relapses,

prolonged duration of illness, functional impairment, and behavioral disturbances substantially increase

caregiving responsibilities and psychological stress.

Caregiver burden refers to the cumulative physical, emotional, social, and financial strain experienced while

providing care to a person with chronic illness [3]. It includes both objective components, such as disruption

of daily routines, financial difficulties, and reduced occupational functioning, and subjective components,

which encompass emotional distress, feelings of exhaustion, frustration, guilt, and helplessness [4]. When

sustained over time, caregiver burden can negatively affect physical health, mental well-being, coping

ability, and quality of life, ultimately influencing caregiving effectiveness.

In low- and middle-income countries, including India, family members constitute the primary support

system for individuals with mental illness [5]. Despite their central role, caregivers often receive minimal

formal support from mental health services. Conditions such as bipolar affective disorder place particularly

high demands on caregivers due to their recurrent course, fluctuating symptom severity, and need for long-

term pharmacological and psychosocial management. Family dynamics and caregiver responses have been

shown to significantly influence treatment adherence, relapse risk, and overall clinical outcomes [6].

Expressed emotion (EE) is a widely studied construct that captures the emotional attitudes and interaction

patterns of caregivers toward individuals with mental illness. High expressed emotion, typically

characterized by critical comments, hostility, and excessive emotional involvement, has been consistently

associated with increased relapse rates and poorer outcomes across psychiatric disorders [7]. George Brown

originally conceptualized expressed emotion as comprising five dimensions: criticism, hostility, emotional

over-involvement, warmth, and positive regard, reflecting the emotional climate within the family

environment [8]. Evidence suggests a close relationship between caregiver burden and expressed emotion.

Elevated burden may reduce emotional resilience and adaptive coping, leading to critical, overprotective,

or hostile caregiving behaviors [9]. Sociodemographic factors such as female gender, lower educational

status, longer duration of caregiving, advancing age, and socioeconomic disadvantage have been associated

with higher levels of caregiver burden and adverse emotional responses.

Bipolar affective disorder is a severe and lifelong psychiatric condition characterized by recurrent episodes

of mania, hypomania, and depression, resulting in significant psychosocial impairment [10]. The illness

typically follows a relapsing course, with most individuals experiencing multiple episodes across their

lifetime [11]. The unpredictability of mood episodes, behavioral disturbances during manic phases, and

functional decline during depressive episodes impose considerable emotional and practical challenges on

caregivers.

Caregivers of individuals with bipolar affective disorder often experience substantial psychological distress,

disruption of family routines, social isolation, and financial strain [12]. The cyclical nature of remission

and relapse, combined with long-term treatment requirements, may contribute to heightened caregiver

burden and increased levels of expressed emotion. Understanding the interaction between caregiver burden

and expressed emotion in this population is therefore essential for designing targeted family-based

interventions that can improve caregiver well-being and enhance patient outcomes.

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Materials and Methods

This cross-sectional observational study was conducted over a period of 24 months at the Psychiatry Centre

of a tertiary care hospital located in Western Maharashtra. During the study period, all patients diagnosed

with Bipolar Affective Disorder (BPAD) attending psychiatry outpatient services, including service OPD

and civil OPD, or admitted to the psychiatry wards were screened for eligibility. Patients fulfilling the

inclusion criteria were enrolled along with their primary caregivers, and a minimum of 55 patients with

BPAD of at least two years’ duration and their respective caregivers constituted the study sample. Inclusion

criteria for patients included a confirmed diagnosis of Bipolar Affective Disorder as per ICD-10 criteria

(F31), age between 18 and 60 years, and willingness to participate. Primary caregivers were defined as

relatives residing with the patient, aged 18 years or above, providing unpaid care for a minimum of six

months, and actively involved in daily caregiving. Patients with comorbid psychiatric disorders, chronic

medical or surgical illnesses, or BPAD secondary to alcohol or substance use were excluded, as were

caregivers with a known psychiatric illness, those receiving remuneration, or those not biologically or

legally related to the patient.

Sociodemographic and clinical data were collected using a semi-structured proforma after enrollment, and

psychiatric diagnoses were confirmed by a qualified psychiatrist. Patient-related variables included age,

gender, residence, marital status, education, occupation, socioeconomic status assessed using the

Kuppuswamy scale, substance use history, age at onset and diagnosis of BPAD, family history of

psychiatric illness, type of family, number of family members, and current treatment details. Caregiver-

related variables included age, gender, relationship to the patient, occupation, duration of caregiving, daily

hours spent in caregiving, and presence of medical or psychiatric illness. Expressed emotion was assessed

using the Family Emotional Involvement and Criticism Scale, a 14-item self-report instrument measuring

perceived criticism and emotional over-involvement on a five-point Likert scale, with higher scores

indicating greater expressed emotion. Caregiver burden was evaluated using the Caregiver Burden Scale, a

21-item standardized instrument assessing physical, emotional, social, and financial dimensions of

caregiving burden, with higher scores reflecting greater perceived burden.

The study protocol was reviewed and approved by the Institutional Ethics Committee prior to

commencement of the study. Written informed consent was obtained from all participants before

enrollment, and confidentiality of participant information was strictly maintained throughout the study.

Data were entered into Microsoft Excel and analyzed using the Statistical Package for the Social Sciences

software version 26.0. Continuous variables were summarized as mean and standard deviation or median

with interquartile range based on data distribution, while categorical variables were expressed as

frequencies and percentages. Normality was assessed using the Shapiro–Wilk test. Group comparisons were

performed using appropriate parametric or non-parametric tests, and associations between categorical

variables were analyzed using Chi-square or Fisher’s exact test. Correlation between caregiver burden and

expressed emotion scores was assessed using Pearson’s or Spearman’s correlation coefficients, and

multiple linear regression analysis was performed to identify independent predictors after adjusting for

potential confounders. A two-tailed p value of less than 0.05 was considered statistically significant.

Results

Table 1. Sociodemographic profile of patients with Bipolar Affective Disorder (n = 55)

Variable

Number (%)

Age (years)

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18–30

14 (25.5)

31–45

26 (47.3)

46–60

15 (27.2)

Gender

Male

33 (60.0)

Female

22 (40.0)

Residence

Rural

31 (56.4)

Urban

24 (43.6)

Marital status

Married

38 (69.1)

Unmarried

17 (30.9)

Most patients were in the 31–45-year age group (47.3%), followed by 46–60 years (27.2%). Males

constituted a higher proportion (60%) than females. A majority of patients were from rural areas (56.4%)

and were married (69.1%), indicating that BPAD predominantly affected middle-aged, married individuals

from rural backgrounds.

Table 2. Sociodemographic profile of caregivers (n = 55)

Variable

Number (%)

Age (years)

<40

21 (38.2)

≥40

34 (61.8)

Gender

Male

29 (52.7)

Female

26 (47.3)

Relationship to patient

Spouse

24 (43.6)

Parent

18 (32.7)

Sibling

13 (23.7)

Duration of caregiving

<5 years

19 (34.5)

≥5 years

36 (65.5)

Most caregivers were aged 40 years or above (61.8%), with an almost equal distribution of males (52.7%)

and females (47.3%). Spouses were the primary caregivers (43.6%), followed by parents (32.7%). A large

proportion had been providing care for five years or more (65.5%), reflecting long-term caregiving

responsibilities.

Table 3. Clinical profile of patients with BPAD (n = 55)

Variable

Number (%)

Duration of illness

2–5 years

22 (40.0)

>5 years

33 (60.0)

Predominant episode type

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Manic

19 (34.5)

Depressive

21 (38.2)

Mixed

15 (27.3)

Family history of psychiatric illness

Present

17 (30.9)

Absent

38 (69.1)

Sixty percent of patients had an illness duration exceeding five years, indicating chronicity. Depressive

episodes (38.2%) were slightly more common than manic episodes (34.5%), while mixed episodes were

also frequent (27.3%). Nearly one-third of patients (30.9%) had a positive family history of psychiatric

illness.

Figure 1. Levels of caregiver burden based on Caregiver Burden Scale (CBS)

Most caregivers experienced moderate (41.8%) or severe (30.9%) levels of burden. Only 20% reported

mild burden, and a small proportion (7.3%) experienced extreme burden. This highlights the significant

caregiving strain associated with BPAD.

Table 4. Levels of expressed emotion among caregivers (FEICS subscales)

Expressed emotion component

Mean ± SD

Perceived criticism

16.8 ± 4.2

Emotional over-involvement

18.9 ± 4.6

The mean score for emotional over-involvement (18.9 ± 4.6) was higher than perceived criticism (16.8 ±

4.2). This suggests that caregivers tended to be more emotionally over-involved rather than critical toward

patients.

Table 5. Association between caregiver burden and expressed emotion levels

Caregiver burden level

High EE n (%)

Low EE n (%)

p value

Mild to moderate

12 (35.3)

22 (64.7)

Severe to extreme

17 (81.0)

4 (19.0)

0.001*

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High expressed emotion was present in 81% of caregivers with severe to extreme burden, compared to

35.3% among those with mild to moderate burden. This statistically significant association (p = 0.001)

indicates that higher caregiver burden is linked to increased expressed emotion.

Table 6. Correlation between caregiver burden and expressed emotion scores

Variables

Correlation coefficient (r)

p value

CBS vs Perceived criticism

0.46

<0.001

CBS vs Emotional over-involvement

0.52

<0.001

Caregiver burden showed a moderate positive correlation with perceived criticism (r = 0.46) and emotional

over-involvement (r = 0.52). These significant correlations indicate that higher burden levels are associated

with increased expressed emotion.

Table 7. Predictors of high caregiver burden (multiple linear regression)

Predictor

β coefficient

p value

Duration of caregiving ≥5 years

0.38

0.002

Female caregiver

0.29

0.01

Family history of psychiatric illness

0.26

0.02

Emotional over-involvement score

0.41

<0.001

Longer duration of caregiving (≥5 years) and higher emotional over-involvement scores were the strongest

predictors of caregiver burden. Female caregivers and a family history of psychiatric illness were also

significantly associated with increased caregiver burden.

Discussion

The present study assessed caregiver burden and expressed emotion among caregivers of patients with

Bipolar Affective Disorder and demonstrated a significant association between caregiving burden and

adverse emotional responses. The findings underscore the substantial psychosocial impact of bipolar

affective disorder on caregivers and highlight the importance of addressing family-related factors in

comprehensive psychiatric care.

A majority of caregivers in the present study experienced moderate to severe levels of burden. This

observation is consistent with previous research indicating that bipolar affective disorder imposes

considerable emotional, social, and functional strain on caregivers due to its chronic, recurrent, and

unpredictable course [13,14]. Frequent relapses, prolonged treatment requirements, and persistent

functional impairment of patients contribute cumulatively to caregiver stress and reduced quality of life.

Expressed emotion levels were notably elevated among caregivers, with emotional over-involvement being

more prominent than perceived criticism. Similar patterns have been reported in earlier studies, suggesting

that caregivers of individuals with bipolar disorder often respond with excessive concern,

overprotectiveness, and self-sacrificing behaviors rather than overt hostility [15–17]. Emotional over-

involvement may reflect caregivers’ attempts to prevent relapse and manage behavioral disturbances,

particularly during manic or depressive episodes.

A key finding of this study was the statistically significant association between higher caregiver burden and

elevated expressed emotion. Caregivers experiencing severe to extreme burden were more likely to exhibit

high levels of expressed emotion. This finding aligns with previous evidence demonstrating that sustained

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caregiving stress adversely affects emotional regulation and coping mechanisms, resulting in critical or

over-involved caregiving attitudes [18–20]. Such emotional responses may further contribute to

interpersonal stress within the family environment.

Correlation analysis revealed a moderate positive relationship between caregiver burden and both perceived

criticism and emotional over-involvement. These findings are in agreement with earlier studies that reported

increased emotional reactivity among caregivers experiencing higher levels of stress [21,22]. Emotional

over-involvement may arise from heightened anxiety about illness outcomes, whereas perceived criticism

may reflect frustration related to functional limitations and treatment non-adherence.

Longer duration of caregiving emerged as an independent predictor of higher caregiver burden. This

observation supports earlier findings indicating that prolonged caregiving is associated with cumulative

psychological strain, caregiver burnout, and reduced adaptive capacity [23]. As caregiving responsibilities

extend over several years, coping resources may diminish, increasing vulnerability to emotional distress.

Female caregivers were found to experience significantly higher levels of burden compared to male

caregivers. Similar gender differences have been consistently reported in the literature, with female

caregivers exhibiting greater emotional involvement and role-related stress [24–26]. Sociocultural

expectations, greater involvement in day-to-day caregiving activities, and limited access to social support

may contribute to this disparity.

The presence of a family history of psychiatric illness was also associated with increased caregiver burden.

Caregivers with familial psychiatric vulnerability may experience heightened concerns regarding illness

prognosis, relapse risk, and long-term caregiving demands. Comparable findings have been reported by

previous studies emphasizing the influence of genetic and familial context on caregiver stress and emotional

responses [27,28].

The strong association observed between emotional over-involvement and caregiver burden highlights the

clinical relevance of assessing family emotional climate in bipolar affective disorder. High expressed

emotion has been consistently linked to increased relapse rates and poorer clinical outcomes [29].

Psychosocial interventions focusing on caregiver education, stress management, and emotional regulation

have demonstrated effectiveness in reducing expressed emotion and improving both caregiver well-being

and patient outcomes [30].

Limitations: The cross-sectional design limits causal inference between caregiver burden and expressed

emotion. The study was conducted at a single tertiary care center with a relatively modest sample size,

which may limit generalizability. Self-report measures may be subject to response bias. Longitudinal, multi-

center studies incorporating patient symptom severity and functional outcomes are recommended for future

research.

Conclusion

The present study demonstrates that caregivers of patients with Bipolar Affective Disorder experience

substantial levels of burden, with a significant proportion exhibiting high expressed emotion. A strong

association was observed between caregiver burden and expressed emotion, particularly emotional over-

involvement. Longer duration of caregiving, female gender, family history of psychiatric illness, and higher

expressed emotion emerged as important contributors to caregiver burden. These findings highlight the

need for routine assessment of caregiver well-being and incorporation of family-focused psychosocial

interventions in the comprehensive management of bipolar affective disorder.

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Conflict of interest: No Conflict of interest

Source of Fund: Nil

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