Beyond criticism, hostility, and emotional overinvolvement: Development and psychometric validation of the Comprehensive Expressed Emotion Scale (CEES) in schizophrenia

Abstract

<p>Background: Expressed Emotion (EE) is a well-established predictor of schizophrenia relapse, but concerns remain regarding the content validity of its traditional components—criticism, hostility, and emotional overinvolvement (EOI). Recent research suggests a covert EE dimension (disassociation, apathy) unmeasured by current scales. This study developed and validated a self-report EE scale, the Comprehensive Expressed Emotion Scale (CEES), to reconceptualize EE. Methods: 319 adults with schizophrenia in Mainland China completed CEES, relevant Family Environment Scale—Chinese Version (FES-CV) subscales, and SF-12. Ten patient–family dyads also underwent the Camberwell Family Interview (CFI). Exploratory and confirmatory factor analyses determined factor structure; reliability and validity were evaluated using established indices and correlations. Results: EFA supported a three-factor model—overt (criticism, hostility), covert (disassociation, apathy), and EOI—explaining 64 % of variance. CFA confirmed strong loadings for overt and covert items (0.70–0.91 and 0.72–0.90; all p < 0.001), but weaker, mostly non-significant loadings for EOI items. The three-factor model showed good fit (χ²(402) = 657.17, CFI = 0.971, TLI = 0.968, RMSEA = 0.061, SRMR = 0.079). The total scale and overt and covert subscales showed high internal consistency and strong construct and concurrent validity; EOI subscale reliability was moderate. Conclusions: CEES operationalizes covert EE in Chinese families, broadening EE assessment to include implicit conflict. It demonstrates strong psychometric properties and potential for targeted interventions, though EOI subscale reliability and generalizability remain limitations. <br></p>