Preventing the Entrenchment of High Expressed Emotion in First Episode Psychosis: Early Developmental Attachment Pathways

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Abstract
Objective: As part of a strategy to consider the options for preventing the developmental entrenchment of expressed emotion (EE), we examine the early ontogeny of EE in a first-episode sample of individuals with psychosis and its links with the process of adaptation to change. Methods: The key relatives of 50 first-episode psychosis patients from two locations were interviewed soon after patient referral and again 9 months later using measures of expressed emotion and loss. Results: The developmental pathways of components of expressed emotion, particularly criticism and emotional over-involvement, were independent despite having a similar effect on outcome for patients. Initially, high levels of emotional over-involvement were reduced by follow up, with 37%% resolving into high criticism. Overall expressed emotion status changed in 28.2%% of key relatives (all parental), predominantly from high to low. High emotional over-involvement and low criticism are associated with significantly high levels of perceived loss in relatives. The metamorphosis of emotional over-involvement to criticism was linked to a reduction in perceived loss. Conclusions: Expressed emotion is not a stable index in relatives of first-episode psychosis samples. Appraisals of loss by relatives may be driving high emotional over-involvement with implications for family intervention programs. Attachment theory may help to explain some of the processes underlying resistance to change in some of the high-EE behaviours measured by expressed emotion.