Research report Dyadic view of expressed emotion, stress, and eating disorder psychopathology Cristina Medina-Pradas a, *, J. Blas Navarro b , Steven. R. Lo ´ pez c , Antoni Grau d , Jordi E. Obiols a a Department of Clinical and Health Psychology, Autonomous University of Barcelona, Barcelona, Spain b Department of Psychobiology and Methodology of the Health Sciences, Autonomous University of Barcelona, Barcelona, Spain c Department of Psychology, University of Southern California, Los Angeles, CA, USA d Eating Disorders Institute, Barcelona, Spain The family emotional climate, as assessed by the construct Expressed Emotion (EE) (Hodes & Le Grange, 1993; Hooley, 2007), is associated with the course of serious mental illness including eating disorders (ED). EE refers to the emotional nature of the relationship between the patient and a significant other and is comprised of five indices: criticism, hostility, emotional over- involvement (EOI), warmth, and positive remarks (Leff & Vaughn, 1985). Patients with different chronic illnesses living in a high-EE environment (high in criticism, hostility and/or EOI) have significantly more risk of relapse than do patients in a low-EE environment (low in criticism, hostility and EOI; Wearden, Tarrier, & Barrowclough, 2000). The amount of time the patient and caregiver spent together also predict the relapse rate (Bebbington & Kuipers, 1994). A meta-analysis of EE and relapse studies reported a medium (large) effect size (w = .51) among a handful of studies of ED (Butzlaff & Hooley, 1998). Moreover, family-based treatments that reduce EE have also improved ED symptomatology (Le Grange & Eisler, 2009; Sepu ´ lveda, Lopez, Todd, Whitaker, & Treasure, 2008). Most studies of EE apply the Camberwell Family Interview (CFI; Vaughn & Leff, 1976) or a similar instrument, which directly measure the caregiver’s degree of EE (e.g., criticism) directed at the ill relative. For example, van Furth et al. (1996) found that caregiver’s critical and overinvolved attitudes were associated with a worsening of the patient’s symptoms. In addition, van Furth et al. found that a lower degree of positive affect (less presence of positive remarks) was associated with a longer duration of treatment. Although most studies of EE use the objective measure of caregiver’s actual criticism and EOI, there is a small but growing literature examining patient’s perception of caregiver’s EE, particularly the patient’s perception of their caregiver’s level of criticism. For example, perceived maternal criticism was associat- ed with patients’ lower desire to involve their relatives in therapy (Perkins et al., 2005). We believe that including both measures of caregivers’ actual level of their criticism and EOI and patients’ perceptions of their caregivers’ emotional stance can enrich our understanding of the role of family processes and the course and treatment of ED. Doing so provides a balanced assessment of the dyad, not just the caregiver’s or patient’s perspective. Appetite 57 (2011) 743–748 A R T I C L E I N F O Article history: Received 25 February 2011 Received in revised form 23 August 2011 Accepted 25 August 2011 Keywords: Expressed emotion Perceived stress Perceptions Anorexia nervosa Bulimia nervosa Criticism Emotional overinvolvement Warmth A B S T R A C T Prevailing models of the association between expressed emotion (EE) and relapse conceptualize EE as a form of stress for patients. In eating disorders (ED), there is no research addressed to evaluate the degree to which patients feel stress due to their relatives’ EE. It has been neither investigated how the EE and the subsequent stress relate to disordered behaviours and attitudes neither. Using a sample of 77 inpatients with ED, this study aimed to: (1) evaluate patients’ reported level of stress as it relates to their caregivers’ EE, particularly as associated with carer’s criticism, emotional overinvolvement and warmth; (2) examine the associations of stress with the patients’ perceptions (self-reported) and the caregivers’ perspective (assessed by the Camberwell Family Interview) of the EE; and (3) study how the two views of EE (patients’ and caregivers’) and the stress due to EE relate to the ED symptoms. The findings indicate that patients judged their carers’ critical stance as the most stressful, followed by emotional overinvolvement. Secondly, patients’ perceptions of EE, whereas none of the interview indices focused on the caregivers’ perspective, were associated to the stress and to the ED symptomatology. Additionally, the patients’ stress due to criticism was positively related to the ED symptoms, while the stress associated with emotional overinvolvement and warmth was not. Clinical and research implications are discussed. Findings suggest attention to the ED patients’ view of their family environment and support the utility of assessing their appraisals of EE. ß 2011 Elsevier Ltd. All rights reserved. * Corresponding author at: Department of Clinical and Health Psychology, Universidad Auto ´ noma de Barcelona, Campus de Bellaterra, Edificio B, Cerdanyola del Valle `s, 08193 Barcelona, Spain. Tel.: +34 935868528; fax: +34 935812125. E-mail address: cristina.medina.pradas@gmail.com (C. Medina-Pradas). Contents lists available at SciVerse ScienceDirect Appetite jo u rn al h om epag e: ww w.els evier.c o m/lo cat e/app et 0195-6663/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.appet.2011.08.016