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Expressed Emotion in Eating Disorders Assessed via

Self-Report: An Examination of Factors Associated with
Expressed Emotion in Carers of People with Anorexia
Nervosa in Comparison to Control Families
whereas 47% (71/151) of carers showed
Olivia Kyriacou, MA* ABSTRACT
high criticism (CC) compared with 15%
Objective: High expressed emotion (EE)
Janet Treasure, PhD, FRCP, (14/93) of controls. The most significant
has been linked to outcome in anorexia
FRCPsych nervosa (AN). Traditional interview meas-
variable related to CC was ‘‘negative/diffi-
Ulrike Schmidt, MRCPsych, MD, cult behaviors,’’ and anxiety, for EOI.
ures of EE require considerable resources.
PhD The aim was to compare EE, measured with Conclusion: The FQ was sensitive both
a self report tool, in parents of people with to CC and EOI. Interventions aimed at
AN (carers; N 5 151) with that of parents of reducing EE may need to focus on
healthy people (controls; N 5 93), and to decreasing carers’ anxiety and teaching
explore factors associated with EE. skills to moderate difficult behaviors.
C 2007 by Wiley Periodicals, Inc.
Method: A cross-sectional design was
used to assess EE (Family Questionnaire)
Keywords: expressed emotion; eating
and psychological distress (Hospital Anxi-
disorders; carers; families
ety and Depression Scale).

Results: Over 60% (96/151) of carers

showed high emotional over-involvement
(EOI) compared with 3% (3/93) of controls, (Int J Eat Disord 2008; 41:37–46)

there are the stresses of caring for someone who

may deny the seriousness of their illness and be
Caregiving in the area of mental illness has been ambivalent or resistant to treatment.3,4 In addition,
well documented across a diverse range of disor- the entire family unit is known to be disrupted as
ders such as schizophrenia and Alzheimer’s disease parents may experience shame and self-blame for
and has been associated with both physical and the development of the illness while family mem-
psychological distress of carers.1 Eating disorders bers may struggle to understand, feel stigmatised
(ED) and particularly anorexia nervosa (AN) are and isolated as a result of social misperceptions of
thought to present unique demands on carers, ED, as well as experience anxiety, loss, anger, grief,
stemming from the severity and extended course of and helplessness at the relentless, controlling and
the illness. These include the strain of a develop- all-encompassing grip of the illness.5–11 Further-
mental ‘‘inappropriateness’’ involved in caring for more, carers face difficulties accessing services and
increasingly dependent adult children.2 Moreover, often feel excluded, misunderstood, or blamed by
professionals, and report unmet needs for informa-
tion on treatment, prognosis, and coping strategies,
Accepted 15 July 2007
Part of this work has been presented as a poster in the
as well as lack of social and professional sup-
International Conference of Eating Disorders of the Academy for port.6,7,12,13 In light of the severity of the illness and
Eating Disorders, in June 2006 in Barcelona, Spain. the tremendous impact on carers and families, it is
Supported by 284286 from Nina Jackson fellowship by Research
becoming increasingly recognized that professio-
Into Eating Disorders in association with the Psychiatry Research
Trust, UK. nals need to address carer needs and provide fami-
*Correspondence to: Ms. Olivia Kyriacou, Section of Eating lies with the resources necessary to enable caregiv-
Disorders, PO 59, Institute of Psychiatry, King’s College London, ing as well as help to create a familial environment,
De Crespigny Park, London SE5 8AF, UK.
which is conducive to adaptive changes in family
Section of Eating Disorders, Institute of Psychiatry, King’s functioning.13,14
College London, London, United Kingdom The concept of caregivers’ expressed emotion
Published online 5 October 2007 in Wiley InterScience
( DOI: 10.1002/eat.20469
(EE) has been of interest in psychiatry because
C 2007 Wiley Periodicals, Inc. overprotection, criticism (CC), and hostility influ-

International Journal of Eating Disorders 41:1 37–46 2008—DOI 10.1002/eat 37


ence the course of and predict relapse of many dis- EOI, but differences may not be statistically signifi-
orders, including ED.15 In the Maudsley model of cant.28–30 Based on this information, we would
maintenance of AN carers’ high EE is a key compo- therefore expect mothers in AN families to report
nent of the interpersonal domain that is thought to higher EOI and distress than fathers. Part of the
impact on outcome.16 aims of the current study was to further explore
The mechanisms underpinning the development these hypothesized gender differences.
of high EE are not fully understood. Parents can EE is traditionally assessed from an audiotaped
become critical and/or over protective because of semistructured interview, the Camberwell Family
how they understand aspects of the illness or how Interview (CFI).31 However, this method requires a
they perceive the individual with the illness.17 high level of resources. The interview takes 1–2 h to
For example, in schizophrenia, critical relatives conduct and must be administered by a trained
assumed that the patients had more volitional con- interviewer, while coding by an experienced rater
trol and choice over their behaviors whereas over- may require an additional 3 h. The average training
involved relatives assumed that the patient was a period for rater trainings is 2 weeks, hence curtail-
passive, impotent victim of the illness.18 In this ing the applicability of the method to routine clini-
case the parents took over control and responsibil- cal and research purposes. The Five Minute Speech
ity from the patient. In a qualitative exploration of Sample is a shorter alternative but it also requires
the experience of caregiving in AN, carer misper- the training of interviewers and raters.32 The FMSS
ceptions were associated with CC and hostility has been found to have correspondence rates of
towards the person with AN, whereas fear of the 80–90% with CFI ratings of CC and hostility, how-
consequences of the illness was found to contrib- ever, it has been found to underestimate high
ute to over-protectiveness and even collusion with EOI.33,34 In an ED sample the results from the
symptomatic behaviors, especially in mothers.19 FMSS differed from those obtained with the CFI.35
The level of EE may be related to the duration of These authors argued that the FMSS is not an
the disorder. In adolescents with AN with an aver- adequate alternative for evaluating EE in families of
age illness duration of less than a year only 6% of individuals with ED.
parents were rated as high EE using standard cut Self-report measures of EE may be preferable to
off scores.20 The level of EE increased in the group interview methods, which may preclude or inhibit
with a poor outcome and decreased in those with a the free expression of CC or concern by relatives of
good outcome. patients. Two questionnaire measures of EE, the
High levels of EE may result from mood disorders Level of Expressed Emotion Scale (LEE)36 and the
in the parents. Many studies across different disor- Influential Relationships Questionnaire (IRQ),37
ders have found that carers with high EE have poor administered to patients with schizophrenia and
mental health, greater caregiving strain, in addition their carers have shown agreement and consistency
to endorsing unhelpful attributions about the ill- with the Camberwell Family Interviews (CFI).38
ness.21–25 Parents of people with AN with high EE Relatives’ Warmth and Critical Comments scores
blamed themselves for the illness.26 This guilt may on the CFI correlated with the LEE Total and Atti-
be a symptom or a cause of depression and anxiety. tude Toward Illness scores (r 5 2.41, p \ .05, for
Qualitative evidence19 suggests that mothers caring CFI Warmth and LEE Attitude Toward Illness;
for daughters with ED experience high distress and r 5 .41, p \ .05, for CFI CC and LEE Attitude To-
particularly anxiety, which typically manifest as ward Illness; r 5 .38, p \ .05, for CFI CC and LEE
self-blame and helplessness in response to the ill- Total score). The only significant correlation
ness, and are accompanied by high emotional between both Patient and Relative versions of the
over-involvement (EOI).19 Overall CC in ED fami- IRQ scores and the CFI was for IRQ CC scale of the
lies has been found to be lower than in families Patient Version and CFI EOI (r 5 .48, p \ .05), with
with schizophrenia27 and EE levels in ED families a near-significant correlation between the IRQ
have been described as low.28 It is possible that in Overprotection scores and CFI EOI ratings (r 5 .39;
ED, and especially in AN families, EOI rather than r 5 .41 required for significance).38 An adapted ver-
CC is a marked and more characteristic response as sion of the LEE has been used in people with ED. In
parents, and especially mothers, are likely to feel a sample of adolescents with bulimia nervosa,
highly anxious because of the severity of the illness, patient ratings of EE predicted a negative experi-
whereas in families of people with bulimia nervosa, ence of caregiving by the parents.39 The Family
frustration and CC may be more common.27 There Questionnaire (FQ)40 was also created as a more ef-
is some empirical evidence to suggest higher ficient and research-applicable alternative measure
maternal EOI in AN, as compared with paternal of EE in schizophrenia. It measures CC and EOI.

38 International Journal of Eating Disorders 41:1 37–46 2008—DOI 10.1002/eat


The scale shows sensitivity and successfully pre- Participants

dicts both high and low EE and is more cost-effec- Carers. Parents on the Carers Volunteer Database main-
tive than the FMSS. The FQ has also shown better tained by the eating disorder unit (EDU) of the IOP and
agreement with the CFI on EOI than other short EE Maudsley Hospital were offered the opportunity to par-
questionnaires.40 The authors report a correspon- ticipate in this project. The study was also advertised on
dence of 74% (combined CC and EOI subscales of the website of the EDU and in the EDU newsletter. At the
the FQ) with CFI EE ratings in both their original time of recruitment for this project, the Carers Volunteer
sample and their validation sample (Pearson’s cor- Database consisted of 197 carers.a Parents who con-
relations of FQ CC to CFI CC: r 5 .44, p \ .001; firmed interest and willingness to participate were then
Pearson’s correlations of FQ EOI to CFI EOI: r 5 .42, sent the full set of questionnaires, along with an informa-
p \ .001).40 The measure has been successfully tion and consent sheet and a prepaid return envelope.
used in predicting stress of carers of people hospi- Participants were not offered any incentives for partici-
talized for schizophrenia or depression.41,42 This pation.
instrument has not yet been used to measure EE in
The inclusion criteria for parents were that they were
the families of people with ED.
currently caring for a child with AN (siblings and partners
The aim of this study was to compare EE meas- were excluded). One hundred and twenty-nine carers (a
ured with a self report tool (FQ) in parents of peo- response rate of 65%) from the database and 36 parents
ple with AN with that of parents of healthy young from current EDU patients offered to participate giving a
people. Our hypothesis was that parents of people total of 165 carers. Fourteen carers were excluded
with AN would show high levels of EOI and a mod- because their responses were incomplete and/or the
erate increase in CC. An additional aim was to patient was currently well. The final sample consisted of
examine factors associated with EE and specifically, 151 carers (91 mothers and 60 fathers).
whether the level of EE was related to the experi-
ence of burden from caregiving and/or anxiety and Controls. Control parents (ascertained from contacts of
depression in the parents. Our hypothesis was that the ED carers and via e-mail advertisements to King’s
carer-related and illness-related characteristics College London staff and students) were recruited. The
would be associated with parental depression and inclusion criteria were parents of female offspring cur-
anxiety, which in turn would be related to over- rently or until recently living at home, with no history of
involvement or CC. An additional hypothesis was an ED in the parents or daughters. The final sample con-
that mothers would show higher emotional over sisted of 93 parents (53 mothers and 40 fathers).
involvement than fathers in the AN carers group.

Assessment Measures
Family Questionnaire. Created as a more efficient self-
report alternative to the CFI, the FQ40 has shown good in-
Method ternal consistency of subscales (ranging from 0.78 to 0.80
for EOI and from 0.91 to 0.92 for CC. The measure con-
sists of 20 items, 10 for each subscale, asking carers to
This was a cross-sectional study using self-report rate the applicability of each item in describing their feel-
questionnaires to examine EE in parents of people with ings and thoughts of the patient, such as ‘‘I can’t sleep
AN and a comparison group. As the study was cross-sec- because of him/her’’ (EOI), and, ‘‘He/she does not appre-
tional it precluded the examination of the exact mecha-
nisms and mediators leading to the development of a
Carers in this database come from a variety of sources, such as
parental distress and of EE; such a ‘‘mechanism hypothe- Beat [beat is a national charity (Registered Charity No. 801343)
based in the UK providing information, help, and support for
sis’’ would require a longitudinal design. Regression anal-
people affected by eating disorders and, in particular, anorexia
yses as used in the study are meant to assess level of sig- and bulimia nervosa and their carers, families, etc]. All of the 197
nificance of association between the variables under ex- carers were eligible to participate, however, 68 did not respond to
ploration, and are not meant to imply causality or the study invitation. In addition, 36 carers came from current EDU
inpatients. This sample was self-selected and we are unable to
chronological direction and antecedence. The parents
accurately comment on how many of the parents of inpatients
gave information about the eating disorder symptoms were initially approached over the period of recruitment, how
and history, in addition to demographic information for many refused to participate or what their exact reasons were for
parents and patients. Ethical approval and registration of nonparticipation. This raises the issue of representativeness as the
self-selected sample of carers may be skewed in terms of over-
the study protocol was obtained from the Institute of
representation of actively involved and ‘‘empowered’’ carers.
Psychiatry Research Ethics Committee and Research and Possible limitations as a result of the sample are addressed in the
Development Department (Ref. No. 317/03). ‘‘Discussion’’ section of this article.

International Journal of Eating Disorders 41:1 37–46 2008—DOI 10.1002/eat 39


ciate what I do for him/her’’ (CC). Responses range from observations of their child over the past month, answer-
‘‘never/very rarely,’’ with a score of 1, to ‘‘very often,’’ ing yes, no, or unsure as to whether the behavior
with a score of 4, and higher total score indicates higher occurred. The scale is scored as follows: ‘‘yes’’ (2 points),
EE. The authors give a cut-off point of 23 for CC as an ‘‘?’’ (1 point), and ‘‘no’’ (0 points), with a higher score
indication of high CC, and 27 for EOI. indicating higher frequency of symptomatic or patholog-
ical behavior. Parents are instructed to rate an item, such
Hospital Anxiety and Depression Scale. The Hospital as ‘‘Patient shows obvious signs of tension at mealtimes,’’
Anxiety and Depression Scale (HADS)43 is a reliable, self- as ‘‘unsure’’ if they did not have the opportunity to
report measure of anxiety and depression. The subscales observe the behavior directly, if they were told it
have shown high internal consistency, with Cronbach’s a occurred, or if they can only suppose it did. The scale has
of 0.80–0.93 for anxiety and 0.81–0.90 for depression. A a cut-off score of 1947 to indicate the presence of ano-
score of 11 or higher for each subscale is indicative of the rexic symptoms. The scale has demonstrated three sepa-
corresponding mood disorder, and a score of 8–10 is rate factors: (1) eating behavior, concern with weight and
suggestive.44 food, denial of problems; (2) bulimic-like behavior; and
(3) hyperactivity, with sufficient internal consistency
Experience of Caregiving Inventory. The Experience of (Cronbach’s a values of 0.80, 0.69, and 0.69, respectively).
Caregiving Inventory (ECI)45 is a 66-item self-report The scale was used to yield a combined score indicative
questionnaire, which assesses carers’ perceptions of their of AN symptomatology as reported by carers.
experience of caregiving. Items ask carers to rate the fre-
quency of experiences they have had over the past
month, such as, ‘‘How often in the past month have you Parametric tests were first carried out to check for the
thought about whether she/he will ever get well?’’ on a 5- homogeneity of the variance and normal distribution of
point Likert scale ranging from 0, ‘‘Never’’ to 4, ‘‘Nearly the data. Data were entered and checked for normality in
always,’’ with higher scores indicating greater frequency SPSS 13.48 The analyses were performed in STATA 9.49 A
or severity. The measure is comprised of 10 subscales, 8 series of simple (univariate) and multiple (multivariate)
of them being negative and 2 delving into positive regressions were conducted, to test gender and group dif-
aspects of caregiving, with the aim of assessing an over- ferences, as well as the degree of association between
all, all-encompassing experience of caregiving. The scale variables. Comparisons between mothers and fathers in
can be used as a combined score of positive and negative the carer group included only parents from the same
caregiving, or assessed per individual subscale. The ECI families.
has shown high internal reliability (Cronbach’s a values There was clustering within families as 120 of the 151
ranging from 0.74 to 0.91) as well as strong construct carers were from the same families and caring for the
validity.45,46 It has been shown to predict a large portion same individual with AN (i.e., 60 pairs of parents (60
of the variability of carers’ psychological distress and its mothers, and 60 fathers), were from the same families
use with carers of people with AN has been found to be and caring for the same individual within each family).
valid and effective.2 For the purpose of this study only This violates the first assumption required for analysis of
two of the negative scales of the ECI were used to isolate variance, that is, independence of observations. Robust
specific negative aspects of caregiving in ED, while simul- cluster regression controls for minor deviations from nor-
taneously allowing the inclusion of items that would be mal distributions and heterogeneity in the data, as well
suitable for both carers and parents of healthy controls. as allows for analyses to be conducted using a sample
Difficult Behaviors (e.g., him/her being unpredictable) that may contain ‘‘intraclass’’ correlations within obser-
and Negative Symptoms (e.g., him/her being withdrawn) vations. Huber-white sandwich estimators of variance50,51
were used as a combined score (i.e., Negative/difficult using the robust cluster option in STATA were thus used.
behaviors). The robust cluster option in STATA does not provide
standardized beta coefficients, therefore the regression
Anorectic Behavior Observation Scale. The Anorectic coefficients presented in this study are unstandardized.
Behavior Observation Scale47 was developed as a self- Furthermore, when measuring the effect of an independ-
report questionnaire specifically aimed at parents’ obser- ent variable on an outcome, it is suggested that unstan-
vations of their son/daughter’s behaviors that may be dardized regression coefficients are superior and prefera-
symptomatic for AN or BN. The measure has been found ble to correlation coefficients.52
to obtain reliable information from parents and to have A series of univariate regressions were first carried out
specificity and sensitivity in capturing parents’ observa- to identify the association between demographic and
tions of both behaviors and attitudes in their children patient/illness/carer-related characteristics and anxiety
that may be symptomatic of ED. The complete scale con- and depression, as well as EE (CC and EOI). Variables
sists of 30 items, asking parents to respond based on their reaching significance of p \ .01 were then explored for

40 International Journal of Eating Disorders 41:1 37–46 2008—DOI 10.1002/eat


degree of association via multivariate regressions using for Depression compared with 1% (n 5 1, m 5 1)
forward selection procedures; variables were added to in the control group.
the model of ascending p-value. R2 partitioning of
variance was then conducted to ascertain the unique Expressed Emotion
variance that could be attributed to each of the variables Higher levels of over involvement and CC were
by fitting a series of models. present in the carers group. Over 60% (n 5 96, m 5
70) of carers had high levels of EOI (using the cut-
off score of 27), compared with 3% (n 5 3, m 5 2)
of the comparison group. Forty-seven percent of
carers (n 5 71, m 5 48) had high levels of CC (using
the cut-off score of 23), as opposed to 15% of con-
Results trols (n 5 14, m 5 8).
Psychometric Properties of Instruments
Regression Analyses of Variables Associated
Internal consistency of ECI and the FQ for carers
with CC
and controls was assessed using Cronbach’s a.b
Results show high consistency. On the combined The variables showing an association at p \ .01
Difficult Behaviors and Negative Symptoms sub- significance with CC in univariate regressions (i.e.,
scales of the ECI, Cronbach’s a was 0.92 for carers anxiety, depression, AN symptomatology, rejection
and 0.89 for the comparison parents. On the FQ, of carer help, ambivalence in accepting illness, neg-
Cronbach’s a values for the CC subscale were 0.90 ative/difficult behaviors) were simultaneously
for carers and 0.88 for comparison parents, and for entered into a forward selection regression model.
the EOI subscale, Cronbach’s a was 0.76 for carers The model accounted for 52% of the variance of
and 0.67 for comparison parents. CC, with two variables showing higher significance
over all remaining variables being adjusted for.
Demographic and Clinical Information According to the order of significance provided by
Demographic and clinical information is pre- the model, R2 partitioning was then used to assess
sented in Table 1. Mean age of carers was 54.3 years the unique portion of the variance attributable
(SD 5 7.2) and 48.9 for control parents (SD 5 5.4). to the variables associated with CC through a series
Women with AN had an average age of 23.3 (SD 5 of models. The most significant variable was nega-
6.6) and comparison daughters had an average age tive/difficult behaviors, which accounted for 50% of
of 17.3 (SD 5 4.6). Average duration of illness was the variance at the first step of R2 partitioning (p \
7.8 years (SD 5 5.5). The comparison group were .001). At the second and final step rejection of
somewhat younger and had younger children as it carers’ help accounted for a further 2% of the
was unusual to have children over the age of 20 still variance. The results are shown in Table 3.
living at home. Gender comparisons within the
Regression Analyses of Variables Associated
carers group are shown in Table 2.
with EOI
Anxiety and Depression The variables showing an association at p \ .01
The level of depression and anxiety in carers and significance with EOI via univariate regressions
especially in mothers (m) was much higher than in (i.e., anxiety, depression, AN symptomatology,
the comparison population. Over 70% of carers (n rejection of carer help, ambivalence in accepting
5 107, m 5 77) scored at or above threshold (score illness, negative/difficult behaviors) were simulta-
8) on the Anxiety subscale, and 38% (n 5 54, m 5 neously entered into a forward selection regression
42) scored at or above threshold on the Depression model. The model accounted for 63% of the var-
subscale, compared with 40% (n 5 37, m 5 24) at iance of EOI, with three variables showing higher
or above threshold on Anxiety and 7% (n 5 7, m 5 significance over all remaining variables being
5) at or above threshold on the Depression subscale adjusted for. According to the order of significance
in the control group. Over 50% of carers (n 5 78, m provided by the model, R2 partitioning was then
5 60) scored at or above the clinical threshold used to assess the unique portion of the variance
(score 11) for Anxiety, compared with 15% (n 5 attributable to the variables associated with EOI
14, m 5 8) of the comparison group, and 13% (n 5 through a series of models. The most significant
20, m 5 15) scored at or above the clinical threshold variable was anxiety, which accounted for 57% of
the variance at the first step of R2 partitioning (p \
For original Cronbach’s a values of these measures please see .001). At the second step depression accounted for a
‘‘Assessment Measures’’ in the ‘‘Method’’ section of this article. further 4% of variance and at the third and final

International Journal of Eating Disorders 41:1 37–46 2008—DOI 10.1002/eat 41

TABLE 1. Clinical and demographic information

No. of No. of Total No./Mean Total No./Mean
Carers Controls Frequencies (s.d.) Carers % (s.d.) Controls %

Demographic characteristics (possible score range)

Parental sexa,b,c 151 93 Female 91 53
Male 60 40

Amount of contact with daughter per week 144 92 \21 h 89 62 54 59

[21 h 55 38 38 41
Parental age in years 145 93 54.3 (7.2) 48.9 (5.4)
Daughter age in years 142 93 23.3 (6.6) 17.3 (4.6)
Parental marital status 151 93 Single 1 1
Married/living together
Divorced/separated/widowed 133 88
17 4
Parental education level 143 93 Up to A level 87 42
University/equivalent 56 51
Parental employment statusb 145 93 Full-time 58 52
Not full time 87 41
Residing with daughter 151 93 Yes 93 74
No 58 19
Patient/illness-related characteristics
Anorexic behaviours observation scale (ABOS) (0–60)a,b,c,d 149 — 27.5 (10.6) N/A
Duration of illness in years 140 — 7.8 (5.5) N/A
Acceptance/rejection of eating disorder by suffererc,d 149 — Denies/ambivalent 33 22 N/A
Acceptance of ED 116 78
Rejection of carers’ help by sufferer 151 — Yes 102 67 N/A
No 49 32
Additional diagnosis/comorbidity of daughter 150 93 Yes 87 93
No 63 0
Sufferer’s average number of hospital admissions 110 — 2.9 (2.7) N/A
Sufferer currently in treatment 149 — Yes 112 N/A
No 37
Age of diagnosis 137 — 16.7 (4.4) N/A
Age of onset 140 — 15.2 (4.7) N/A
Parent-related characteristics
Hospital anxiety & depression scale (HADS)
Total of combined anxiety and ression scales (0–42)c,d* 150 93 16.6 (7.9) 39.5 9.9 (5.6) 23.6
Anxiety scale (0–21)c,d* 150 93 10.4 (4.9) 49.5 6.8 (3.8) 32.4
Depression Scale (0–21)c,d* 150 93 6.2 (3.7) 29.5 3.1 (2.6) 14.8
Experience of caregiving inventory (ECI)
Total of combined difficult behaviours and 150 93 24.9 (12.3) 44 11.1 (7.4) 20
negative symptoms scales (0–56)a,b,c,d*
Family questionnaire (FQ) Criticism (10–40)* 149 93 22.5 (6.1) 56 17.3 (4.5) 43
Emotional over-involvement (10–40)* 149 93 27.9 (4.5) 70 19.7 (5.6) 49
Notes: Percentage out of total score enables quick comparisons between subscales. This transforms the ratio of mean value to maximum total value into a percentage value for each individual subscale, show-
ing level of subscale endorsement.
Regressions results for Carers Group:
Univariate association with anxiety significant at p \ .01.
Univariate association with depression significant at p \ .01.
Univariate association with emotional over-involvement significant at p \ .01.
Univariate association with criticism significant at p \ .01.
Group comparisons:

International Journal of Eating Disorders 41:1 37–46 2008—DOI 10.1002/eat

* Significant group difference between carers and controls at p \ .001.

TABLE 2. Gender comparisons via regressions (carers group)

Measure (Possible Score Range) Mother, N Mother, Mean (s.d.) % Father, N Father, Mean (s.d.) %

Rejection of carers’ help 60 Yes: 43 71.6 60 Yes: 37 62

No: 17 28.4 No: 23 38
Amount of weekly contact 53 60
\21 h 28 53 45 75
[21 h 25 47 15 25
Hospital anxiety and depression scale (HADS)
Total of combined anxiety and 60 18.7 (7) 44.5 59 13.2 (8.1) 31
depression scales (0–42)*
Anxiety subscale (0–21)* 60 11.7 (4.3) 55.7 59 8.3 (5.1) 39.5
Depression subscale (0–21)* 60 7 (3.5) 33.3 59 5 (3.6) 23.8
Experience of caregiving inventory (ECI)
Total of combined difficult behaviours and 60 26.3 (12) 47 59 22.8 (12.5) 41
negative symptoms scales (0–56)
Family questionnaire
Criticism (10–40) 60 23 (6.4) 57.5 58 21.6 (5.7) 54
Emotional over-involvement (10–40)* 60 29 (3.9) 72.5 58 26.2 (4.8) 65.5
Anorexic behaviours observation scale (ABOS)
Total score (0–60) 59 27.9 (10.8) 46.5 60 27 (10.5) 45
Note: Percentage out of total score enables quick comparisons between subscales. This transforms the ratio of mean value to maximum total value into
a percentage value for each individual subscale, showing level of subscale endorsement.
* Significant gender difference at p \ .001.

TABLE 3. Multivariate regression of variables associated with criticism

Forward Selection Model Reg. Coef. Rob. Stand. Error t-Test Statistic (DF) p-Value R2

Model 1
Negative/difficult behaviours .35 .02 15.16 (1, 114) \.001 .495
Model 2
Negative/difficult behaviours .30 .03 9.14 \.001 .519
Rejection of carer’s help 2.44 .97 2.52 (2, 114) .013
At final step F(2, 114) 5 116.02, p \ .001. Degrees of Freedom given for clusters, not individual cases. Reference groups as follows: patient accepts carer’s
help. All remaining variables are continuous.

TABLE 4. Multivariate regression of variables associated with emotional over-involvement

Forward Selection Model Reg. Coef. Rob. Stand. Error t-Test Statistic (DF) p-Value R2

Model 1
Anxiety .69 .05 13.39 (1, 114) \.001 .572
Model 2
Anxiety .52 .06 8.62 \.001 .611
Depression .33 .08 4.11 (2, 115) \.001
Model 3
Anxiety .45 .06 7.31 \.001 .628
Depression .31 .08 3.93 \.001
Negative/difficult behaviours .07 .02 3.10 (3, 114) .002
At final step F(3, 114) 5 73.87, p \ .001. Degrees of freedom given for clusters, not individual cases.

step negative/difficult behaviors accounted for an results confirmed our first hypothesis in that over
additional 2% of the variance. The results are 60% of carers had high levels of EOI compared with
shown in Table 4. 3% parents from the comparison group. Forty-
seven percent of carers had high levels of CC as
opposed to 15% of the comparison group. Mothers
in particular had high levels of EOI. Mothers also
had significantly higher levels of anxiety and
depression and EOI as compared with fathers in
The aim of this study was to compare EE measured the carers group. Carers of people with AN also
with a self report tool in parents of people with AN showed significantly higher levels of anxiety and
with that of parents of healthy young people. The depression than parents of healthy controls. An

International Journal of Eating Disorders 41:1 37–46 2008—DOI 10.1002/eat 43


additional aim was to examine whether aspects of (Anxiety: M 5 7.4, SD 5 4.4, 23.5% of carers;
EE were related to caregiving burden and/or paren- Depression: M 5 5.1, SD 5 4, 10.5% of carers)54 our
tal anxiety and depression. Negative/difficult carers show higher psychological morbidity. This
behaviors and rejection of carers’ help were the difference is consistent with evidence reported by
most significant variables associated with CC, Treasure et al.,2 who compared caregivers’ mental
accounting for over 50% of the variance. Parental wellbeing in psychosis and AN and found that AN
anxiety, depression and the negative/difficult carers had significantly higher GHQ scores (in psy-
behaviors of the individual with an eating disorder chosis, mean GHQ score was 16.4 (SD 5 8), which
accounted for over 60% of the variance of EOI. is suggestive of clinical psychological distress,
These findings suggest that this self report tool is whereas in AN the mean GHQ score was 27.7 (SD
clearly sensitive both to CC and EOI in families of 5 6.2), meeting clinical the clinical caseness crite-
people with ED. Indeed it is possible that it is a rion. Our findings therefore offer additional evi-
more sensitive measure of CC than the CFI for use dence of the considerable psychological morbidity
in ED Previous work using the CFI did not find dif- experienced by carers in ED.
ferences in CC between families with an eating dis- Notably, no significant gender differences were
order and a control group.53 Also, earlier studies found in the control group on any of the measures.
that have reported low CC have tended to use the This suggests that the salient gender differences
conventional cut-off thresholds used in schizo- found in our group of carers are likely to be inher-
phrenia (e.g., Refs. 20, 53), whereas use of a lower ent in the caregiving role and that the impact on
threshold, as sometimes used in depression carers’ distress is different for fathers and mothers
research, is found to warrant the classification of caring for a daughter with AN.
high EE in a greater number of carers. Furthermore,
the difference between carers and controls in high
EOI classification is far more striking compared Limitations
with CC, which is consistent with previous infer- The current sample of carers was self-selected as
ences according to which overall, CC is lower in participants from an existing database were sought,
eating disorder families as compared with schizo- which raises the question of representativeness of
phrenia and other disorders.27,30 the respondents. Although some of the carers on this
Furthermore, we found that the level of EOI was database are parents of the unit’s inpatients (36
related to parental anxiety and depression and parents in the current sample), they may also come
aspects of the illness. This is in agreement with the from a variety of sources, such as Beat, and may dif-
findings of Blair et al., who found that the levels of fer in terms of experience of caregiving and familiar-
EE were higher than that seen in the comparison ity with services and resources to carers, which may
population but were similar to those of parents car- impact on physical and psychological wellbeing. It
ing for an offspring with cystic fibrosis.53 Higher could be argued, furthermore, that these carers are
EOI, as Blair et al. suggest, may be a more charac- more empowered and actively involved in seeking
treatment and support for themselves and their
teristic familial reaction than CC in response to a
loved ones, which could lead to a skewed sample.
serious illness in a child. In terms of gender differ-
We have explored main demographic and clinical
ences furthermore, mothers in the carers group
characteristics of nonrespondents in comparison to
showed higher EOI, which is somewhat consistent those of responders from the database. Although our
with previous findings, as Szmukler et al.,29 found comparison has yielded no significant differences we
that fathers generally had lower scores on EE than do acknowledge a limitation as regards the represen-
mothers, however, mothers did not differ in CC as tativeness of the database sample.
reported elsewhere.28 It is possible that CC is more As the current study was cross-sectional in design,
characteristic of families with BN as identified by results suggest the degree of association between EE
Winn et al.,39 whereas EOI may be a more salient and the variables under study, however, no causal
factor in carers of AN. links can be identified. A longitudinal study of carer
In terms of comparability of psychological dis- distress and EE from the early stages over the course
tress of the current carer sample to carers in other of an eating disorder and exploring the mechanisms
areas of mental health, it appears that these AN contributing to both carer distress and EE would be
carers experience significant psychological morbid- needed to elucidate the exact process leading to the
ity, and particularly anxiety, similar to or even development of these constructs. No inferences can
greater than in other areas. In comparison to HADS be made as to the direction of the relationship
scores of carers in Alzheimer’s disease, for example, between EE and carers’ distress. It has been sug-

44 International Journal of Eating Disorders 41:1 37–46 2008—DOI 10.1002/eat


gested that EE is not a static construct but one that 2. Treasure J, Murphy T, Szmukler G, Todd G, Gavan K, Joyce J.
changes over time and generally decreases over the The experience of caregiving for severe mental illness: A com-
parison between anorexia nervosa and psychosis. Soc Psychia-
treatment period.28 try Psychiatr Epidemiol 2001;36:343–347.
The control group used in the current study is 3. Zucker NL, Marcus M, Bulik C. A group parent-training pro-
similar in amount of weekly contact between par- gram: A novel approach for eating disorder management. Eat
ent and offspring, however, both parents and off- Weight Disord 2006;11:78–82.
4. Strober M. Managing the chronic, treatment-resistant patient
spring in the comparison group were younger. We with anorexia nervosa. Int J Eat Disord 2004;36:245–255.
did not have the resources to simultaneously mea- 5. Perkins S, Winn S, Murray J, Murphy R, Schmidt U. A qualitative
sure EE in this group using the original methodol- study of the experience of caring for a person with bulimia
ogy the CFI, neither were we able to examine the nervosa, Part 1: The emotional impact of caring. Int J Eat Dis-
validity of the constructs as measured by this ord 2004;36:256–268.
6. Haigh R, Treasure J. Investigating the needs of carers in the
instrument in terms of whether they have an area of eating disorders: Development of the carers’ needs
impact of the outcome of AN. This work needs to assessment measure (CaNAM). Eur Eat Disord Rev 2003;11:125–
be done next. Also, replication using more sophisti- 141.
cated methods of analysis, such as structural equa- 7. Treasure J, Gavan K, Todd G, Schmidt U. Changing the environ-
tion modeling, in larger samples is also to be rec- ment in eating disorders: Working with carers/families to
improve motivation and facilitate change. Eur Eat Disord Rev
ommended. Finally, additional comparisons of EE 2003;11:25–37.
in carers of people with BN as well as carers with a 8. Murphy F, Troop NA, Treasure JL. Differential environmental
different type of chronic illness, e.g., diabetes, factors in anorexia nervosa: A sibling pair study. Br J Clin Psy-
cystic fibrosis or some other mental health prob- chol 2000;39 (Part 2):193–203.
lem, are needed. 9. Cottee-Lane D, Pistrang N, Bryant-Waugh R. Childhood onset
anorexia nervosa: The experience of parents. Eur Eat Disord
Rev 2004;12:169–177.
Clinical Implications 10. Highet N, Thompson M, King RM. The Experience of living with
The FQ appears to be a useful and cost-effective a person with an eating disorder: The impact on the carers. Eat
method to assess family functioning in AN. The Disord 2005;13:327–344.
11. De La Rie SM, van Furth EF, De Koning A, Noordenbos G,
precise nature and direction of the relationship
Donker MCH. The quality of life of family caregivers of eating
between EE dimensions and eating disorder course, disorder patients. Eat Disord 2005;13:345–351.
outcome and impact on carer wellbeing requires 12. Winn S, Perkins S, Murray J, Murphy R, Schmidt U. A qualitative
further research to be deciphered. Specifically, study of the experience of caring for a person with bulimia
future research is needed to explore whether CC nervosa, Part 2: Carers’ needs and experience of services and
other support. Int J Eat Disord 2004;36:269–279.
and EOI can act as outcome and relapse markers in
13. McMaster R, Beale B, Hillege S, Nagy S. The parent experience
AN and BN. The finding that parental depression of eating disorders: Interactions with health professionals. Int J
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We would like to thank all the parents and professionals with eating disorders. Br J Clin Psychol (in press).
for their valuable help with this research. Special thanks 18. van Os J, Marcelis M, Germeys I, Graven S, Delespaul P. High
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