A special role of negative emotion in children and adolescents with schizophrenia and other psychoses

Four attachment-based categories of emotion regulation in adolescent psychic troubles

Introduction

Emotion regulation is altered in many psychiatric disorders in adolescence, but the understanding of mechanisms that underlie this alteration is still poor.

Methods

The PERCEPT study explores alexithymia, empathy, facial emotion recognition (FER) and defence mechanisms in a sample of adolescents in psychiatric care (n = 61, 74% of girls, mean age = 15.03 y.o.), in relation with participants' attachment styles.

Results

Results revealed correlations between attachment dimensions and all of the emotion regulation variables, suggesting that attachment modalities have functional links with emotional regulation at its different levels: FER accuracy was inversely correlated with avoidant attachment, while affective empathy, difficulty in identifying feelings (alexithymia) and immature as well as neurotic defence mechanisms were positively correlated with anxious attachment. Moreover, attachment categories delineated distinct emotional perception profiles. In particular, preoccupied attachment included adolescents with the highest levels of facial emotion perception (sensitivity and accuracy) and of affective empathy, whereas detached attachment included adolescents with the lowest levels of these variables. Neurotic defence mechanisms and difficulty to identify feelings were correlated with preoccupied attachment; immature defence mechanisms and difficulty to describe feelings to others characterized fearful attachment.

Discussion

These results suggest that attachment categories underlie emotion regulation processes in psychiatric disorders in adolescence. Theoretical and clinical implications are discussed.

Working memory deficits in children with schizophrenia and its mechanism, susceptibility genes, and improvement: A literature review

The negative influence on the cognitive ability of schizophrenia is one of the issues widely discussed in recent years. Working memory deficits are thought to be a core cognitive symptom of schizophrenia and lead to poorer social functions and worse academic performance. Previous studies have confirmed that working memory deficits tend to appear in the prodromal phase of schizophrenia. Therefore, considering that children with schizophrenia have better brain plasticity, it is critical to explore the development of their working memory. Although the research in this field developed gradually in recent years, few researchers have summarized these findings. The current study aims to review the recent studies from both behavior and neuroimaging aspects to summarize the working memory deficits of children with schizophrenia and to discuss the pathogenic factors such as genetic susceptibility. In addition, this study put forward some practicable interventions to improve cognitive symptoms of schizophrenia from psychological and neural perspectives.

Facial emotion perception in schizophrenia: Does sex matter?

AIM: To review the literature on sex differences in facial emotion perception (FEP) across the schizophrenia spectrum.

METHODS: We conducted a systematic review of empirical articles that were included in five separate meta-analyses of FEP across the schizophrenia spectrum, including meta-analyses that predominantly examined adults with chronic schizophrenia, people with early (onset prior to age 18) or recent-onset (experiencing their first or second psychotic episode or illness duration less than 2 years) schizophrenia, and unaffected first-degree relatives of people with schizophrenia. We also examined articles written in English (from November 2011 through June 2015) that were not included in the aforementioned meta-analyses through a literature search in the PubMed database. All relevant articles were accessed in full text. We examined all studies to determine the sample sizes, diagnostic characteristics, demographic information, methodologies, results, and whether each individual study reported on sex differences. The results from the meta-analyses themselves as well as the individual studies are reported in tables and text.

RESULTS: We retrieved 134 articles included in five separate meta-analyses and the PubMed database that examined FEP across the schizophrenia spectrum. Of these articles, 38 examined sex differences in FEP. Thirty of these studies did not find sex differences in FEP in either chronically ill adults with schizophrenia, early-onset or recently diagnosed people with schizophrenia, or first-degree relatives of people with schizophrenia. Of the eight studies that found sex differences in FEP, three found that chronically ill women outperformed men, one study found that girls with early-onset schizophrenia outperformed boys, and two studies found that women (including first-degree relatives, adults with schizophrenia, and the healthy control group) outperformed men on FEP tasks. In total, six of the eight studies that examined sex differences in FEP found that women outperformed men across the schizophrenia spectrum.

CONCLUSION: Evidence to date suggests few sex differences in FEP in schizophrenia; both men and women across the schizophrenia spectrum have deficits in FEP.

Facial, vocal and cross-modal emotion processing in early-onset schizophrenia spectrum disorders

Recognition of emotional expressions plays an essential role in children's healthy development. Anomalies in these skills may result in empathy deficits, social interaction difficulties and premorbid emotional problems in children and adolescents with schizophrenia. Twenty-six subjects with early onset schizophrenia spectrum (EOSS) disorders and twenty-eight matched healthy controls (HC) were instructed to identify five basic emotions and a neutral expression. The assessment entailed presenting visual, auditory and congruent cross-modal stimuli. Using a generalized linear mixed model, we found no significant association for handedness, age or gender. However, significant associations emerged for emotion type, perception modality, and group. EOSS patients performed worse than HC in uni- and cross-modal emotional tasks with a specific negative emotion processing impairment pattern. There was no relationship between emotion identification scores and positive or negative symptoms, self-reported empathy traits or a positive history of developmental disorders. However, we found a significant association between emotional identification scores and nonverbal communication impairments. We conclude that cumulative dysfunctions in both nonverbal communication and emotion processing contribute to the social vulnerability and morbidity found in youths who display EOSS disorder.

Facial emotion identification in early-onset and first-episode psychosis: a systematic review with meta-analysis

OBJECTIVE

Patients with chronic schizophrenia are characterized by deficits in identifying facial expressions of emotion, and these deficits relate to impaired social and occupational function. It is not yet known if these deficits are trait-like and present at the onset of psychosis, preceding a subsequent diagnosis of schizophrenia. Our objective was to systematically review and analyze the extant literature to assess if there is a consistent profile of emotion identification problems in early-onset and first-episode psychosis.

METHODS

We conducted a systematic review and meta-analysis of 12 peer-reviewed studies of facial emotion identification in early-onset and first-episode psychosis, published between 1980 and March 2013. We examined the average mean difference between patients and controls on measures of facial emotion identification.

RESULTS

Findings suggest that patients with early-onset and first-episode psychosis have impairment in identifying facial expressions of biologically salient emotion. Across the 12 studies, the onset of psychosis was distinguished by a generalized effect of significantly poorer accuracy for identifying facial expressions of emotion than healthy controls, and this difference had a substantial effect size (d=-0.88, N=378, 95% CI=-1.42 to -0.32). Within this general effect some emotions were also harder for patients to identify than others, with the magnitude of impairment found to be (i) large for disgust, fear and surprise, and (ii) medium for sadness, and happiness. No between groups mean differences were found for anger or neutral facial expressions.

CONCLUSIONS

Deficits in facial emotion identification are evident at first onset of a psychotic episode. The findings suggest that, over and above a generalized deficit in identifying facial emotion, patients may find some emotions harder to identifying than others. This reflects findings with chronic schizophrenia populations and suggests that emotion identification impairment represents a trait susceptibility marker, rather than a sequeale of illness. They signal the urgent need to treat emotion identification deficits at the onset of illness, which could improve functional outcomes.

Diminished emotion expressivity but not experience in men and women with schizophrenia

Prior studies indicate that men with schizophrenia are less outwardly expressive but report similar emotion experience as healthy people. However, it is unclear whether women with schizophrenia show this same disconnect between expressivity and experience. Men (n = 24) and women (n = 25) with schizophrenia or schizoaffective disorder and women without schizophrenia (n = 25) viewed emotionally evocative film clips and were video recorded to assess facial expressivity. Participants also reported their emotion experience after each clip. Men and women with schizophrenia did not significantly differ from one another in the frequency of facial expressions, but both groups exhibited fewer expressions than women without schizophrenia. People with schizophrenia also reported lower levels of trait expressivity compared with women without schizophrenia. Overall, people with schizophrenia did not differ from controls on self-reported emotion experience with one exception: Women with schizophrenia reported more unpleasant emotion than controls. These results indicate that both women and men with schizophrenia exhibit fewer outward expressions but experience comparable emotion experience as people without schizophrenia.

Self-concept, emotion and memory performance in schizophrenia

The "self-reference effect" describes better memory for material someone has related to one's self previously. Schizophrenia can affect aspects of the inner self such as own thoughts or actions. Schizophrenia symptoms, therefore, might not only have an influence on the self-concept, including the self-attribution of positive or negative personality traits, but also reduce the self-reference effect. 15 schizophrenia patients and 15 matched healthy controls were asked to decide on positive and negative personality traits across three separate conditions: self-evaluation, other evaluation (of an intimate person), and during a lexical control task, respectively. An unannounced recognition task followed. Patients revealed a negative bias in the evaluation of themselves and of the well-known other person. The reference to a person (oneself, close other) increased later recognition performance. However, patients with schizophrenia revealed an overall decreased recognition performance. The amount of patients' passivity symptoms, i.e., an increase in the permeability of their "self-other boundary", correlated negatively with their recognition performance for previously self-referred characteristics and traits referred to the intimate other. This was not the case for lexically processed stimuli or an increase of negative symptoms. Our data underline the necessity of taking into account symptom subgroups when dealing with specific cognitive dysfunctions in schizophrenia.

Emotional experience predicts social adjustment independent of neurocognition and social cognition in schizophrenia

BACKGROUND

Emotional abnormalities are prominent features of schizophrenia. While the capacity for emotions is essential to social adaptation, little is known about the role of emotional experience in the social dysfunction observed in schizophrenia.

OBJECTIVE

This study examined the contribution of emotional experience, neurocognition, and social cognition to functional outcome in schizophrenia.

METHOD

Self-reported emotional experience (anhedonia, affect intensity, and emotion frequency) was assessed in 33 stable schizophrenic/schizoaffective patients and 33 healthy controls. Symptoms, neurocognition, social cognition, and functional outcome were also assessed.

RESULTS

Patients and controls exhibited good internal reliability on all self-report scales, except for negative affect intensity. Patients reported equally intense but less frequent positive emotions, more intense and frequent negative emotions, and more anhedonia. Results of hierarchical regression analyses showed that emotional experience accounted for significant amounts of variance of social adjustment independent of neurocognition and social cognition.

CONCLUSION

These data show that emotional experience can be reliably assessed and is an important determinant of functional outcome in schizophrenia.

Facial emotion perception in schizophrenia: a meta-analytic review

OBJECTIVES

A considerable body of literature has reported on emotion perception deficits and the relevance to clinical symptoms and social functioning in schizophrenia. Studies published between 1970-2007 were examined regarding emotion perception abilities between patient and control groups and potential methodological, demographic, and clinical moderators. DATA SOURCES AND REVIEW: Eighty-six studies were identified through a computerized literature search of the MEDLINE, PsychINFO, and PubMed databases. A quality of reporting of meta-analysis standard was followed in the extraction of relevant studies and data. Data on emotion perception, methodology, demographic and clinical characteristics, and antipsychotic medication status were compiled and analyzed using Comprehensive Meta-analysis Version 2.0 (Borenstein M, Hedges L, Higgins J and Rothstein H. Comprehensive Meta-analysis. 2. Englewood, NJ: Biostat; 2005).

RESULTS

The meta-analysis revealed a large deficit in emotion perception in schizophrenia, irrespective of task type, and several factors that moderated the observed impairment. Illness-related factors included current hospitalization and--in part--clinical symptoms and antipsychotic treatment. Demographic factors included patient age and gender in controls but not race.

CONCLUSION

Emotion perception impairment in schizophrenia represents a robust finding in schizophrenia that appears to be moderated by certain clinical and demographic factors. Future directions for research on emotion perception are discussed.

Impaired facial emotion perception in schizophrenia: a meta-analysis

Research into facial emotion perception in schizophrenia has burgeoned over the past several decades. The evidence is mixed regarding whether patients with schizophrenia have a general facial emotion perception deficit (a deficit in facial emotion perception plus a more basic deficit in facial processing) or specific facial emotion perception deficits (deficits only in facial emotion perception tasks). A meta-analysis is conducted of 28 facial emotion perception studies that include control tasks. These studies use differential deficit designs to examine whether patients with schizophrenia demonstrate a general deficit or specific deficit in facial emotion perception. A significant mean effect size is found for total facial emotion perception (d=-0.85). Patients with schizophrenia demonstrate impaired ability to perform corresponding control tasks, and the mean effect size is -0.70. The current findings suggest that patients with schizophrenia have moderately to severely impaired perception of facial emotion.

Multisensory integration of emotionally valenced olfactory-visual information in patients with schizophrenia and healthy controls

BACKGROUND

Patients with schizophrenia frequently have deficits in social cognition, and difficulties in the discrimination of emotional facial expressions have been discussed as an important contributing factor. We investigated whether this impairment is aggravated by difficulties relating the observed facial expression to contextual information, as is often provided by emotionally valenced crossmodal stimulation.

METHODS

We investigated the effects of odorant primes on the accuracy and speed of emotional face recognition. Healthy controls and patients with schizophrenia were exposed to 2-second odorant stimuli: vanillin (pleasant), ambient air (neutral) and hydrogen sulfide (unpleasant). The odours were followed by an emotional face recognition task, in which participants determined if a face showed happiness, disgust or neutral affect.

RESULTS

Controls showed improved performance in the categorization of disgusted faces after all types of odour stimulation irrespective of the emotional valence. However, in controls, the response time for happy faces was slower after presentation of any odour. Schizophrenia patients showed an attenuated effect of olfactory priming on disgust recognition, which resulted in the increased performance differences between the groups. This effect was particularly strong for the unpleasant odour.

LIMITATIONS

The study design did not allow us to fully differentiate between the effects of perceived odour intensity and valence. A possible contribution of cognitive deficits on the observed effects should be investigated in future studies.

CONCLUSION

Our results provide novel evidence for a special connection between the presentation of odorant cues and the accuracy of recognition of disgusted faces in healthy controls. This recognition advantage is disturbed in patients with schizophrenia and appears to contribute to the observed deficit in emotional face recognition.

Emotional experience in patients with schizophrenia revisited: meta-analysis of laboratory studies

Our understanding of the emotion deficits in schizophrenia is limited. Findings from studies employing trait emotion instruments suggest that patients have attenuated levels of positive emotion (ie, anhedonia) and increased levels of negative emotion. Conversely, patients and controls have not statistically differed in their subjective reactions to positive or negative valenced stimuli in most laboratory studies to date. Further obfuscating this issue is the fact that many of these laboratory studies are underpowered and a handful of emotion induction studies have found evidence of anhedonia. We conducted a meta-analysis of 26 published studies employing laboratory emotion induction procedures in patients with schizophrenia and healthy controls. Patients did not differ from controls when strictly rating their subjective hedonic reactions to the stimuli. However, they reported experiencing relatively strong aversion to both positive and neutral stimuli (Hedges D = .72 and .64, respectively). These findings were not the result of demonstrable sample or methodological differences across studies. Patients' ability to experience hedonic emotion is preserved, although they also show relatively strong, simultaneously occurring aversive emotion when processing laboratory stimuli considered by others to be pleasant or neutral.

Facial emotion perception in schizophrenia: a meta-analytic review

OBJECTIVES

A considerable body of literature has reported on emotion perception deficits and the relevance to clinical symptoms and social functioning in schizophrenia. Studies published between 1970-2007 were examined regarding emotion perception abilities between patient and control groups and potential methodological, demographic, and clinical moderators. DATA SOURCES AND REVIEW: Eighty-six studies were identified through a computerized literature search of the MEDLINE, PsychINFO, and PubMed databases. A quality of reporting of meta-analysis standard was followed in the extraction of relevant studies and data. Data on emotion perception, methodology, demographic and clinical characteristics, and antipsychotic medication status were compiled and analyzed using Comprehensive Meta-analysis Version 2.0 (Borenstein M, Hedges L, Higgins J and Rothstein H. Comprehensive Meta-analysis. 2. Englewood, NJ: Biostat; 2005).

RESULTS

The meta-analysis revealed a large deficit in emotion perception in schizophrenia, irrespective of task type, and several factors that moderated the observed impairment. Illness-related factors included current hospitalization and--in part--clinical symptoms and antipsychotic treatment. Demographic factors included patient age and gender in controls but not race.

CONCLUSION

Emotion perception impairment in schizophrenia represents a robust finding in schizophrenia that appears to be moderated by certain clinical and demographic factors. Future directions for research on emotion perception are discussed.

Generalized deficit in all core components of empathy in schizophrenia

Empathy is a multidimensional construct composed of several components such as emotion recognition, emotional perspective taking and affective responsiveness. Patients with schizophrenia demonstrate deficits in several domains of emotion processing and perspective taking, thus suggesting a dysfunctional emotional competence. We assessed empathic abilities via three paradigms measuring emotion recognition, perspective taking and affective responsiveness as well as self-report empathy questionnaires in 24 (12 females, 12 males) schizophrenia patients meeting the DSM-IV criteria for schizophrenia and 24 matched healthy volunteers. Patients were recruited from the Department of Psychiatry and Psychotherapy, RWTH Aachen University and healthy volunteers were recruited via advertisement. Groups were matched for age, gender and parental education. Data analysis indicates a significant empathic deficit in patients, reflected in worse performance in all three domains. This deficit was only partly reflected in the self-report empathy questionnaires. Comparing the different tasks, emotional perspective taking was the most difficult task for all subjects and symptomatology worsened affective responsiveness. Schizophrenia patients not only struggle to correctly identify emotions, but also have difficulties in spontaneously simulating another person's subjective world (perspective taking) and might not be able to respond adequately in terms of their own emotional experience (affective responsiveness), which are not caused by emotion perception deficits. The results suggest that all domains of empathy are affected in schizophrenia and have to be addressed independently in behavioral therapies, thereby offering a possibility to improve socio-occupational life.

Neuronal correlates of facial emotion discrimination in early onset schizophrenia

Emotion discrimination deficits represent a well-established finding in schizophrenia. Although imaging studies addressed the cerebral dysfunctions underlying emotion perception in adult patients, the question of trait vs state characteristics is still unresolved. The investigation of juvenile patients offers the advantage of studying schizophrenia at an age where influences of illness course and long-term medication are minimized. This may enable a more detailed characterization of emotion discrimination impairments and their cerebral correlates with respect to their appearance and exact nature. A total of 12 juvenile patients with early onset schizophrenia and matched healthy juveniles participated in this study. fMRI data were acquired during an emotion discrimination task consisting of standardized photographs of faces displaying happy, sad, angry, fearful, or neutral facial expression. Similar to findings in adult patients, juvenile patients exhibited reduced performance specificity whereas sensitivity was unaffected. Independent of the valence, their processing of emotional faces was associated with hypoactivations in both fusiform gyri and in the left inferior occipital gyrus. In addition, hyperactivations in patients were found in the right cuneus common to happy, angry, and fearful faces. Further, most distinct changes were present in juvenile patients when processing sad faces. These results point to a dysfunction in cerebral circuits relevant for emotion processing already prominent in adolescent schizophrenia patients. Regions affected by a decrease in activation are related to visual and face processing, similar to deficits reported in adult patients. These changes are accompanied by hyperactivations in areas related to emotion regulation and attribution, possibly reflecting compensatory mechanisms.

Cerebral dysfunctions of emotion-cognition interactions in adolescent-onset schizophrenia

OBJECTIVE

Schizophrenia is among the most severe of psychiatric disorders, leading to impairments of affective and cognitive abilities. These dysfunctions affect each other mutually. Adolescent-onset schizophrenia (AOS) constitutes a particularly severe form of the disorder. In this study, possible dysfunctions of the neural correlates underlying the interaction of negative emotion and working memory in AOS were investigated.

METHOD

During functional magnetic resonance imaging, 12 patients with AOS and 12 non-AOS adolescents performed a verbal n-back task. Intermittently, negative and neutral emotions were induced by olfactory stimulation. Group differences in working memory, emotion, and their interaction were evaluated.

RESULTS

In patients with AOS, lower performance sensitivity was observed, along with dorsolateral prefrontal, anterior cingulate, and inferior parietal hypoactivation during working memory demands. For negative versus neutral emotion induction, patients with AOS mainly showed increased brain activation compared with control subjects in widespread brain regions including the left orbitofrontal cortex and the medial frontal gyrus. Finally, during the interaction of emotion and cognition, altered patterns of activation in patients with AOS were found in the thalamocortical network, including the angular and the middle cingulate gyri extending to the precuneus. These activation differences were further decomposed by parameter estimates.

CONCLUSIONS

Our results provide new insights into the neural correlates underlying the mutual influence of affective and cognitive symptoms in AOS. During the n-back task, areas typically associated with working memory performance were found hypoactivated in patients relative to the control subjects, including the dorsolateral prefrontal and parietal cortex and the anterior cingulate. However, patients with AOS mainly demonstrated increased activation in key areas of emotion processing, such as the left orbitofrontal cortex and medial frontal areas, during negative emotion induction. A dysfunctional thalamocortical network during the interaction mainly included regions involved in the integration of converging information--either on the subcortical (thalamus) or on a higher-order cortical level (comprising the angular gyrus). These findings point to dysfunctional emotion-cognition interactions in AOS, which may explain its poor prognosis.

Neural substrates of olfactory processing in schizophrenia patients and their healthy relatives

Odorants represent powerful stimuli capable of eliciting various emotional responses. In schizophrenia patients and their non-affected relatives, olfactory and emotional functions are impaired, revealing a familial influence on these deficits. We aimed at determining the neural basis of emotional olfactory dysfunctions using odors of different emotional valence for mood induction and functional magnetic resonance imaging (fMRI) by comparing 13 schizophrenia patients, their non-affected brothers and 26 matched healthy controls. Blood-oxygen-level-dependent (BOLD) effects and subjective mood changes were assessed during negative (rotten yeast), positive (vanilla) and neutral (ambient air) olfactory stimulation. Group comparisons of brain activation were performed in regions of interest. Subjective ratings were comparable between groups and indicated successful mood induction. However, during stimulation with the negative odor, hypofunctional activity emerged in regions of the right frontal and temporal cortex in the patients. A familial influence in the neural substrates of negative olfactory dysfunction was indicated by a similar reduced frontal brain activity in relatives. Dysfunctions therefore appeared to be located in regions involved in higher cognitive processes associated with olfaction. No familial influences were indicated for cerebral dysfunctions during positive olfactory stimulation. Results point to a differentiation between trait and state components in cerebral dysfunctions during emotional olfactory processing in schizophrenia.

Stress sensitization in schizophrenia

It is well known that environmental factors, such as early life events, perinatal damage, and urbanicity, which interact with multiple genes, induces persistent sensitization to stress possibly through an imbalance in interactions between dopaminergic and glutamatergic systems. This stress sensitization may be critical in the development or relapse of schizophrenia. The neural correlates of a negative mood might be impaired, resulting in stress sensitization and difficulties in social adjustment (Dr. Habel). Urbanicity is associated with later schizophrenia. Metabolic stress induces stress sensitization via dysregulation of dopaminergic and/or noradrenergic systems in activated HVA and cortical response (Dr. Marcelis). The glutamatergic regulation activates HPA axis in stress response (Dr. Zelena). Ameloblast activity in human molar's enamel slowed by exposure to stress, and the segment of enamel rods is smaller, making a particular dark line. Stress sensitization may be induced at the age of 10.5 to 11.5 years resulting from severe emotional stress at the age of 10.5 to 11.5 years (Dr. Yui). It has been reported that volume reductions in the amygdala, hippocampus, superior temporal gyrus, and anterior parietal cortex common to both patient groups may represent the vulnerability to schizophrenia, while volume loss of the prefrontal cortex, posterior parietal cortex, cingulate, insula, and fusiform cortex preferentially observed in schizophrenia may be critical for overt manifestation of psychosis (Dr. Suzuki).