Expressed emotion as a predictor of the first psychotic episode — Results of the European prediction of psychosis study

Theresa Haidl, Marlene Rosen, Frauke Schultze-Lutter, Dorien Nieman, Susanne Eggers, Markus Heinimaa, Georg Juckel, Andreas Heinz, Anthony Morrison, Don Linszen, Raimo Salokangas, Joachim Klosterkötter, Max Birchwood, Paul Patterson, Stephan Ruhrmann, the European Prediction of Psychosis Study Group

To investigate the impact of expressed emotion (EE) on the risk of developing the first psychotic episode (FEP). The European Prediction of Psychosis Study (EPOS) investigated 245 patients who were at clinical high risk (CHR) of psychosis. The predictive value of EE alone and as a part of the multivariate EPOS model was evaluated. "Perceived irritability", a domain of the Level of Expressed Emotion Scale (LEE), was found to be predictive for the First Psychotic Episode (FEP), even as an individual variable. Furthermore, it was selected in the multivariate EPOS prediction model, thereby replacing two of the original predictor variables. This led to an improved revised version that enabled the identification of three significantly different risk classes with a hazard rate of up to 0.911. CHR subjects who perceive the most important person in their individual social environment to be limited in their stress coping skills had a higher risk of conversion to the first psychotic episode. The importance of this risk factor was further demonstrated by an improvement of risk estimation in the original EPOS predictor model. Perceiving a reference person as stress-prone and thus potentially unreliable might amplify self-experienced uncertainty and anxiety, which are often associated with the prodromal phase. Such an enforcement of stress-related processes could promote a conversion to psychosis.