Abstract
Expressed emotion (EE) and self-esteem (SE) have been implicated in the onset and development of paranoia and positive symptoms of psychosis. However, the impact of EE on patients' SE and ultimately on symptoms in the early stages of psychosis is still not fully understood. The main objectives of this study were to examine whether: (1) patients' SE mediated the effect of relatives' EE on patients' positive symptoms and paranoia; (2) patients' perceived EE mediated the effect of relatives' EE on patients' SE; (3) patients' SE mediated between patients' perceived EE and patients' symptomatology; and (4) patients' perceived EE and patients' SE serially mediated the effect of relatives' EE on patients' positive symptoms and paranoia. Incipient psychosis patients (at-risk mental states and first-episode of psychosis) and their respective relatives completed measures of EE, SE, and symptoms. Findings indicated that: (1) patients' perceived EE mediated the link between relatives' EE and patients' negative, but not positive, SE; (2) patients' negative SE mediated the effect of patients' perceived EE on positive symptoms and paranoia; (3) the association of relatives' EE with positive symptoms and paranoia was serially mediated by an increased level of patients' perceived EE leading to increases in negative SE; (4) high levels of patients' distress moderated the effect of relatives' EE on symptoms through patients' perceived EE and negative SE. Findings emphasize that patients' SE is relevant for understanding how microsocial environmental factors impact formation and expression of positive symptoms and paranoia in early psychosis. They suggest that broader interventions for patients and their relatives aiming at improving family dynamics might also improve patients' negative SE and symptoms.