Expressed emotion in schizophrenia refers to how caregivers or loved ones express their thoughts and feelings about the person living with schizophrenia. It can have an important effect on treatment outcomes.

Expressed emotion may be either high or low. High expressed emotion is a risk factor for worse outcomes due to the generally negative attitudes from caregivers and loved ones.

Low expressed emotion may help improve a person’s chances of ongoing, constructive treatment.

This article explores what expressed emotion in schizophrenia means, provides some examples, and explains the evaluation process. It also presents what studies say about relapse and expressed emotion.

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Expressed emotion in schizophrenia refers to how caregivers and loved ones express their attitudes, emotions, and thoughts toward the person living with schizophrenia. They are the reactions or responses a loved one or caregiver gives to the person living with schizophrenia.

Mental health professionals can often gauge expressed emotion from caregivers from the comments they make about the person during an interview process.

The concept of expressed emotion started in the 1950s when a researcher named George Brown, working at the Medical Research Council Social Psychiatry Unit of London, conducted a study on people released from a clinical hospital setting to their homes.

The impetus for the study involved the large number of people who went home, relapsed, and returned to the hospital for treatment. What he found was that people’s living situation and, more specifically, their support network (caregivers, loved ones, etc) affected the chances of relapse.

In the study, he identified five components of expressed emotion. They included:

  • Critical comments: Critical comments involve observing how caregivers or loved ones interact with the person living with schizophrenia. It can involve tone, volume, tempo of speech, and the comments themselves.
  • Hostility: Hostility is a general rejection of the person. It can include critical comments or expressions of rejection of the person.
  • Emotional overinvolvement: Emotional overinvolvement involves a caregiver expressing overidentification, excessive self-sacrifice, or extreme overprotective behavior toward the person. It can result from feelings of guilt. It can lead to a poor overall outlook and may hamper treatment efforts.
  • Positive remarks/regard: Positive remarks or regard can include both verbal and nonverbal expressions of acceptance and appreciation of the person living with schizophrenia.
  • Warmth: Warmth — similar to positive regard — involves verbal and nonverbal expressions of concern, empathy, or kindness.

The first three are associated with poor overall outcomes and a higher chance of relapse. The last two may increase a person’s chances of having a positive outcome and successful treatment.

High vs. low emotional expression

Experts break emotional expression’s five components down into two categories: high and low emotional expression.

High emotional expression includes negative expressions, such as hostility, critical comments, and emotional overinvolvement. A higher presence or expression of any of these components in caregivers is associated with a high risk of relapse of schizophrenia.

High emotional expression may also increase the risk of intergenerational or transmitted mental health disorders in families. Critical comments likely have the largest effect on the transmission of mental health disorders from a parent or caregiver to a child later on in their lifetime.

Low emotional expression includes positive expressions from a caregiver or loved one, including warmth and positive regard. Higher expression of low emotional expression is associated with a generally better adherence to treatment and lower risk of relapse.

Most people with schizophrenia will experience a mix of both negative and positive emotions when interacting with a loved one with schizophrenia. The overall trend toward high or low emotional expression helps mental health professionals get a better idea of the person’s home environment and possible hurdles or help with treatment success.

Learn more about schizophrenia.

Expressed emotion in schizophrenia can present in different ways. It can include both verbal and nonverbal communication.

High emotional expression

Critical comments involve making negative statements about the person. Examples may include:

  • “Nothing I say to him gets through to him. He keeps ignoring my advice.”
  • “She constantly causes problems for the rest of the family.”
  • “It is so hard to live with them.”

A person’s tone, volume, or tempo (rate of speaking) may also change, indicating a critical viewpoint toward the person.

Some older evidence from 2013 suggests that high levels of critical comments can increase the chances of relapse as well as intensification of positive symptoms in people living with schizophrenia.

Hostility is similar to critical comments. It is the expression of anger, frustration, or similar emotions toward the person living with schizophrenia. Some examples could include:

  • shouting at the person frequently
  • expressing a desire to live away from the person
  • getting easily agitated or angry at the person

Emotional overinvolvement comes from a general feeling of guilt about the person. Examples may include:

  • showing a sense of pity toward the person
  • stopping them from doing normal activities due to feelings of guilt
  • providing the person with personal needs instead of the care needed to help them

Low emotional expression

Low emotional expression involves warmth and positive regard. Examples can include:

  • making a lot of positive comments about the person, such as they get along well with others and enjoy being around them
  • expressing appreciation for small efforts
  • expressing a feeling of closeness to the person

Read about the symptoms of schizophrenia.

Several assessments can help gauge expressed emotion in caregivers. Some examples include:

  • Perceived criticism: This is a single question about how critical a family member is of them.
  • Camberwell family interview: This is considered the gold standard. It involves an interview of family members following inpatient placement that assesses their feelings toward the individual.
  • Level of expressed emotion scale: This is a 60-item, true-false assessment that is self-administered.
  • Family emotional involvement and criticism scale: This assesses emotional overinvolvement and criticism levels.
  • Family attitude scale: This helps measure hostility and criticism.
  • 5-minute speech sample: This is a recorded interview where the family member discusses the person for 5 minutes to get an overall expressed emotion levels, criticism, and emotional overinvolvement.

Read about treatment for schizophrenia.

High expressed emotions — critical comments, emotional overinvolvement, and hostility — are associated with relapse in schizophrenia.

It may also increase the risk of intergenerational or transmitted mental health conditions from parent to child.

Mental health resources

Visit our dedicated hub for more research-backed information and resources on mental health and well-being.

Was this helpful?

Expressed emotion in schizophrenia may either help or hinder treatment.

High expressed emotions include negative thoughts and feelings. It is a risk factor for poor treatment outcomes and relapse.

Low expressed emotions include positive feelings and thoughts about the person. It is generally associated with better outcomes for the person living with schizophrenia.