Expressed emotion refers to how caregivers and loved ones express themselves toward the person they care for. If you have schizophrenia, your peers’ expressed emotion can affect your mental health outcomes.

Receiving a schizophrenia diagnosis can leave you stunned and feeling overwhelmed. You’re being told things that feel real to you — like hallucinations and delusions — are actually symptoms of a mental health disorder.

What’s more, you learn that schizophrenia is a lifelong, progressive condition. It will require multidimensional treatment, which often includes building understanding and support in those closest to you.

How caregivers and loved ones interact with you matters. Their high or low expressed emotion (EE) can help you feel supported or can perpetuate negativity, increasing your chances of schizophrenia relapse.

Expressed emotion refers to the way caregivers and loved ones express their attitudes toward you when you live with a mental health disorder.

Dr. Casey Mangnall, a licensed psychologist from Jordan, Utah, indicates there are five components of EE:

  • Critical comments: These are negative statements about the person living with schizophrenia.
  • Hostility: This is anger, aggression, or irritation toward that person.
  • Emotional over-involvement: This involves practicing excessive self-sacrificing behaviors.
  • Warmth: This is showing empathy, kindness, and compassion.
  • Positive regard: This means making supportive statements and showing appreciation for the person living with schizophrenia.

The rate at which you experience expression in these areas determines whether those around you have high or low EE.

What is high vs. low emotional expression?

EE can be high or low, depending on the way feelings are communicated.

High EE indicates feelings are demonstrated in negative ways, while low EE suggests a more balanced, compassionate approach.

“Families with high expressed emotion tend to exhibit high levels of hostility, over-involvement, and criticism toward the patient,” says Mangnall. “Therefore, these interactions tend to be oppositional, intense, rigid, and negative. Families with low expressed emotion tend to exhibit high levels of warmth and positive regard.”

Low EE doesn’t mean you won’t experience negative emotions as a caregiver. Schizophrenia can be challenging for everyone, not just the person who receives the diagnosis.

Low EE does mean, however, that any negative emotions aren’t communicated in unhelpful ways. Rather than being confrontational about concerns, for example, caregivers with low EE communicate through an understanding, proactive approach.

Here are some examples of expressed emotion toward someone with schizophrenia:

High EE

  • physical aggression
  • insulting language
  • lack of understanding
  • blaming/shaming/guilting
  • resentment
  • frustration/annoyance

Low EE

  • acceptance
  • understanding
  • unconditional love
  • respect for boundaries and privacy
  • willingness to help/being available
  • encouraging autonomy

Mangnall gives the situational example of poor hygiene, a possible effect of schizophrenia symptoms.

“Families with high levels of expressed emotion are more likely to attribute this behavior to a character flaw,” she says. “For example, they may refer to the patient as ‘lazy’ and view them as incapable.”

Family members with low expressed emotion, on the other hand, are more likely to recognize when behaviors are symptoms of schizophrenia, she adds. This translates to an understanding that hygiene tasks can be challenging for someone living with schizophrenia and that more support is needed.

When good intentions equal high emotional expression

Though it can feel like it, not all high EE comes from a negative attitude toward schizophrenia.

Dr. Zishan Khan, a board certified psychiatrist from Frisco, Texas, gives another situational example that starts with good intentions.

“Let’s say a person is experiencing negative symptoms of schizophrenia, and as a result, they are unmotivated and struggle to get up in the morning, choosing instead to remain in bed in the comfort of their room,” says Khan.

“Their mother, who has good intentions and wants what is best for their kid, encourages them to get up and be productive but eventually begins to get frustrated when it seems their child is not listening to them and raises her voice.”

This situation resulted in high EE, not necessarily because of a negative attitude toward schizophrenia but more from a lack of understanding about what it means to live with the condition.

Expressed emotion can be assessed by a mental health professional through family-focused evaluations.

“There are a number of measures used to assess expressed emotion in a family system,” says Mangnall. “Some measures assess the patient’s view of the family dynamics, while other measures rate the quality of the family’s interactions.”

Possible evaluation tools include:

  • Camberwell Family Interview
  • Level of Expressed Emotion Scale
  • Five-Minute Speech Sample
  • Family Emotional Involvement and Criticism Scale
  • Family Attitude Scale

When you perceive the attitudes of your loved ones are negative, unsupportive, and unaccepting, it can make you more likely to relapse when living with schizophrenia.

A 2019 review found high EE was associated with a 95% increased likelihood of relapse in conditions of psychosis, like schizophrenia. This finding was true across cultures and countries, even though EE experiences varied globally.

“It’s important to understand that expressions of emotions that may not affect the average person can still adversely impact a person with schizophrenia,” explains Khan.

“The presence of highly expressed emotion within the family context may be a form of trauma for a schizophrenic individual. As a result, it can exacerbate or possibly trigger psychosis in someone susceptible.”

Expressed emotion refers to how you convey your feelings and thoughts toward a loved one living with schizophrenia.

High EE, which is associated with an increased risk of relapse, may involve sarcasm, frustration, hostility, and over-protectiveness that interferes with autonomy.

Low EE involves an approach of warmth, empathy, and compassion toward what your loved one is going through. When negative thoughts and emotions pop up, they’re handled in positive ways.

Expressed emotion in schizophrenia matters. It can make a difference in your loved one’s long-term mental health and well-being.