The effect of antipsychotic medication on facial affect recognition in schizophrenia: a review

Emotional Context Effects on the Rating of Ambiguous Facial Expressions in Depression and Schizophrenia Spectrum Disorders

ObjectiveTo investigate the influence of visual contextual information on emotion recognition of ambiguous facial expressions in depression and schizophrenia spectrum disorders. Method: Ambiguous facial expressions and emotional contexts representing anger, disgust, fear, joy, sadness and surprise were validated in a pre-test with healthy independent raters. Afterwards, 20 healthy participants (8 women, 12 men; mean age 24.35 ± 2.85 years), 20 participants with schizophrenia spectrum disorders (9 women, 11 men; mean age 40.25 ± 11.68 years) and 19 participants with depression (11 women, 8 men; mean age 43.74 ± 12.65 years) rated the emotional content of nine different faces in seven different emotion-suggesting contexts. The proportions of context-congruent answers and differences between emotion ratings in each context were analysed using non-parametric Kruskal-Wallis and explorative, paired Wilcoxon tests. Correlational analyses explored the influence of clinical symptoms assessed by clinician-administered scales. Results: The overall proportion of context-congruent answers did not differ between participants with depression and schizophrenia spectrum disorders compared to healthy participants. Participants with schizophrenia spectrum disorders were more susceptible to anger-suggesting contexts and participants with depression were more susceptible to fear-suggesting contexts. Differences in emotion recognition were associated with the severity of depressive, but not psychotic, symptoms. Conclusion: Despite increased susceptibility to anger-suggesting cues in schizophrenia and to fear-suggesting cues in depression, visual contextual influence remains largely consistent with healthy participants. Preserved emotional responsiveness suggests an efficacy of emotion training but emphasizes the need for additional research focusing on other factors contributing to social interaction deficits.

Can the Ability to Recognize Facial Emotions in Individuals With Neurodegenerative Disease be Improved? A Systematic Review and Meta-analysis

BACKGROUND

Facial emotion recognition (FER) is commonly impaired in individuals with neurodegenerative disease (NDD). This impairment has been linked to an increase in behavioral disorders and caregiver burden.

OBJECTIVE

To identify interventions targeting the improvement of FER ability in individuals with NDD and investigate the magnitude of the efficacy of the interventions. We also wanted to explore the duration of the effects of the intervention and their possible impacts on behavioral and psychological symptoms of dementia and caregiver burden.

METHOD

We included 15 studies with 604 individuals who had been diagnosed with NDD. The identified interventions were categorized into three types of approach (cognitive, neurostimulation, and pharmacological) as well as a combined approach (neurostimulation with pharmacological).

RESULTS

The three types of approaches pooled together had a significant large effect size for FER ability improvement (standard mean difference: 1.21, 95% CI = 0.11, 2.31, z = 2.15, P = 0.03). The improvement lasted post intervention, in tandem with a decrease in behavioral disorders and caregiver burden.

CONCLUSION

A combination of different approaches for FER ability improvement may be beneficial for individuals with NDD and their caregivers.

Specific facial emotion recognition deficits across the course of psychosis: A comparison of individuals with low-risk, high-risk, first-episode psychosis and multi-episode schizophrenia-spectrum disorders

Our study aimed to explore the recognition of specific emotions across the course of psychosis. A visual task representing the six basic emotions was used to assess facial emotion recognition (FER) in 204 healthy controls classified into 152 low-risk (LR) and 52 high-risk for psychosis (HR), following a psychometric risk approach; and 100 patients: 44 with first-episode psychosis (FEP) and 56 with multi-episode schizophrenia-spectrum disorders (MES). First, we performed a MANCOVA to compare the four conditions. Next, we conducted a logistic regression to explore whether specific FER deficits predicted the presence of psychosis. Finally, we investigated the relationships of FER with psychosis-like experiences (PLEs) and psychotic symptoms. Global FER, anger and fear recognition were impaired in HR, FEP and MES. No differences between HR and FEP appeared. Moreover, fear and anger correctly classified 83% of individuals into LR or psychosis. FER was associated with PLEs and psychotic symptoms. Concluding, FER is early impaired in HR individuals and increases along the psychosis continuum. However, fear recognition is similarly impaired throughout the illness, suggesting a possible vulnerability marker. Furthermore, deficits in anger and fear recognition predicted the presence of psychosis. Therefore, we suggest that FER may be essential in detecting psychosis risk.

Facial expression-based indicators of schizophrenia: Evidence from recent research

Impaired ability to recognize emotion in other's face (decoding) or to express emotion through the face (encoding) are considered critical in schizophrenia. The topic of research draws considerable attention since clinicians rely heavily on the patient's facial expressions for diagnosis and on the patient's ability to understand the clinician's communicative intent. While most researchers argue in favor of a generalized emotion deficit, others indicate an emotion-specific deficit in schizophrenia. An early review (Mandal et al., 1998) indicated a possible breakdown in perception-expression-experience link of emotion; later reviews (Kohler et al., 2010; Chan et al., 2010) pointed to a generalized emotion processing deficit due to perceptual deficits in schizophrenia. The present review (2010-2022) revisits this controversy with 47 published studies (37 decoding, 10 encoding) conducted on 2364 patients in 20 countries. Schizophrenia is characterized by reduced emotion processing ability, especially with negative symptoms and at an acute state of illness. It is however still unclear whether this dysfunction is independent of a generalized face perception deficit or of subjective experience of emotion in schizophrenia.

Sex Differences in Social Cognition and Association of Social Cognition and Neurocognition in Early Course Schizophrenia

Background

Both impairment and sex differences in social cognition and neurocognition have been documented in schizophrenia. However, whether sex differences exist in the association between social cognition and neurocognition are not known. We aimed to investigate the contribution of areas of neurocognition to theory of mind (ToM) and hostility bias, representing social cognition, according to sex in early course schizophrenia.

Methods

In this cross-sectional study, we assessed neurocognition using the Japanese version of the Brief Assessment of Cognition in Schizophrenia (BACS) and assessed the ToM and hostility bias subdomains of social cognition using the Social Cognition Screening Questionnaire (SCSQ) in 131 participants (65 female, 66 male) diagnosed with schizophrenia within 5 years of onset. Sex differences were analyzed using t-tests. The associations of neurocognitive subdomains with ToM and hostility bias according to sex were analyzed using multiple regression analysis. Results were adjusted by age, estimated premorbid intelligence quotient, and symptomatology.

Results

No sex differences were found in ToM (p = 0.071) or hostility bias (p = 0.057). Higher verbal fluency was significantly associated with higher ToM in females (p < 0.01), whereas higher executive function was significantly associated with higher ToM in males (p < 0.05). Higher verbal fluency was significantly associated with lower hostility bias in females (p < 0.05), whereas neurocognition and hostility bias were not significantly associated in males.

Conclusion

The results suggest that neurocognition associated with social cognition differ according to sex. These differences should be considered for more effective treatment of social cognition.

Bottom-up processing of fearful and angry facial expressions is intact in schizophrenia

INTRODUCTION

Judgments of emotion from faces are reportedly impaired in schizophrenia. However, it is unclear whether this is due to a top-down cognitive deficit in evaluating sensory information or a fundamental bottom-up perturbation in the early stages of face encoding. This study examined whether deficits in emotion processing reflect imprecision in the initial preconscious registration of emotional face expressions within the visual system.

METHODS

Using continuous flash suppression (CFS), we presented participants (18 patients with schizophrenia, 8M/10F; 20 healthy controls, 13M/7F) with fearful and angry faces. Previous CFS research on healthy participants reveals that fearful facial expressions gain privileged access to awareness over angry faces-demonstrating the visual system's ability to discriminate these emotions at a preconscious level. We used this same approach to probe the integrity of early emotion encoding whilst minimising the potential contribution of any top-down cognitive biases on perceptual judgments.

RESULTS

In both groups, fearful faces were perceived faster than angry faces, with no differences observed between patients and controls.

CONCLUSIONS

Emotion processing difficulties in schizophrenia are unlikely to reflect an early sensory deficit, but rather a deficit in social cognition that has a top-down impact on the conscious evaluation of facial expressions.

Impaired facial emotion perception of briefly presented double masked stimuli in violent offenders with schizophrenia spectrum disorders

Social interactions require decoding of subtle rapidly changing emotional cues in others to facilitate socially appropriate behaviour. It is possible that impairments in the ability to detect and decode these signals may increase the risk for aggression. Therefore, we examined violent offenders with schizophrenia spectrum disorders (SSD) and compared these with healthy controls on a computerized paradigm of briefly presented double masked faces exhibiting 7 basic emotions. Our hypotheses were that impaired semantic understanding of emotion words and low cognitive ability would yield lowest emotion recognition. SSD exhibited lower accuracy of emotion perception than controls (46.1% compared with 64.5%, p = 0.026), even when considering the unbiased hit rate (22.4% compared with 43%, Z = 2.62, p < 0.01). Raw data showed uncommon but significant misclassifications of fear as sad, disgust as sad, sad as happy and angry as surprise. Once guessing and presentation frequencies were considered, only overall accuracy differed between SSD and healthy controls. There were significant correlations between cognitive ability, antipsychotic dose, speed and emotion accuracy in the SSD group. In conclusion, that there were no specific emotion biases in the SSD group compared to healthy controls, but particular individuals may have greater impairments in facial emotion perception, being influenced by intellectual ability, psychomotor speed and medication dosages, rather than specifically emotion word understanding. This implies that both state and trait factors influence emotion perception in the aggressive SSD group and may reveal one source of potential misunderstanding of social situations which may lead to boundary violations and aggression.

Emotion recognition and theory of mind in schizophrenia: A meta-analysis of neuroimaging studies

OBJECTIVES

Patients with schizophrenia have difficulties processing the emotional and cognitive states of others. Neuroimaging studies show inconsistent findings.

METHODS

We used a Seed-based d Mapping meta-analytic method to explore brain activation during facial emotion recognition and theory of mind tasks in schizophrenia patients.

RESULTS

The patients showed lesser recruitment of the facial emotion processing network; behavioural performance was associated with the activation of the precentral gyrus. We found abnormal activation of the mentalising network in schizophrenia patients during reasoning about other people's mental states; patients with worse performances showed lesser activation in the right insula and superior temporal gyrus. Multimodal meta-analysis showed overlaps of brain-related abnormalities for both modalities in schizophrenia, with reduced recruitment of the right insula, anterior cingulate and medial prefrontal cortex and increased activation in the bilateral parietal cortex. Meta-regression results indicate that illness duration, medication and symptomatology might influence social-cognitive network disruptions in schizophrenia.

CONCLUSIONS

These findings suggest the complex impairment of social cognition, as demonstrated by neural-related circuit disruptions during facial emotion processing and theory of mind tasks in schizophrenia.

Visualizing mental representations in schizophrenia patients: A reverse correlation approach

Schizophrenia patients have difficulties recognizing emotional states from faces, in particular those with negative valence, with severe consequences for daily life. What do these patients see in their minds eye, when they think of a face expressing a particular emotion or trait? The content of such mental representations can shed light into the nature of their deficits, but are usually inaccessible. For the first time, we explored the applicability of reverse correlation, which has been successfully used to visualize mental representations in healthy populations, to visualize mental representations in schizophrenia patients.

We investigated mental representations of trustworthy faces, a primary dimension of social face evaluation that is highly correlated with valence. Patients (n = 23) and healthy controls (n = 34) classified images of noise-distorted faces as ‘trustworthy’, ‘untrustworthy’ or ‘neutral’. We visualized their mental representations of these concepts by averaging the noise patterns based on their classifications. These visualizations were then rated on trustworthiness by an independent sample of participants.

Patients were able to perform the reverse correlation task, with response times and biases similar to those of healthy controls, and the obtained images vividly reflected the respective constructs of interest. However, there were no significant differences between the ratings of the visualizations of patients and controls.

Conclusion: These novel findings provide a proof of principle that the reverse correlation technique can be applied to investigate mental representations in schizophrenia patients.

Can childhood trauma influence facial emotion recognition independently from a diagnosis of severe mental disorder?

INTRODUCTION

Facial emotion recognition (FER) is a fundamental component in social interaction. We know that FER is disturbed in patients with severe mental disorder (SMD), as well as those with a history of childhood trauma.

MATERIAL AND METHODS

We intend to analyze the possible relationship between the existence of trauma in childhood irrespective of a SMD, measured by the CTQ scale and facial expression recognition, in a sample of three types of subjects (n=321): healthy controls (n=179), patients with BPD (n=69) and patients with a first psychotic episode (n=73). Likewise, clinical and socio-demographic data were collected. The relationship was analyzed by a technique of multivariate regression adjusting for sex, age, IQ, current consumption of drugs and group to which the subject belonged.

RESULTS

Sexual and/or physical trauma in childhood related independently to the existence of SMD with a worse total FER ratio, as well as to a worse rate of recognition in expressions of happiness. Furthermore, the subjects with a history of childhood trauma attributed expressions of anger and fear more frequently to neutral and happy faces, irrespective of other variables.

CONCLUSIONS

The existence of trauma in childhood seems to influence the ability of subjects to recognize facial expressions, irrespective of SMD. Trauma is a preventable factor with specific treatment; therefore, attention should be paid to the existence of this background in clinical populations.

The relationship between theory of mind deficits and neurocognition in first episode-psychosis

Research suggests that theory of mind (ToM) deficits are related to chronic psychosis and to first-episode psychosis (FEP) independently of other neurocognition domains. The aim of this study was to measure the differences in ToM area in a Spanish population of FEP sample (N = 32) and in a healthy control group (N = 32). A further aim was to describe the relationship between different domains of neurocognition, psychotic symptoms and social functioning with ToM in this sample. ToM was assessed with the MASC task. Estimated IQ with a short version of the WAIS III, Rey-Osterrieth Complex figure, Trail Making Test, Stroop test and Wisconsin Carting Sorting test were used to assess neurocognition. Psychotic symptoms were assessed with Community Assessment of Psychic Experiences (CAPE) in both groups and with PANSS scale in FEP group. GAF and Cannon-Spoor scales were used to measure social functioning before and after onset of psychosis. FEP showed important deficits in ToM domain compared to controls. A worse executive functioning was associated with worse scores in ToM task. However, no relation was found between positive or negative psychotic symptoms and ToM or social functioning and ToM. In our sample neurocognition tests were strongly related to ToM domain independently of other variables.

Randomized Clinical Trial with e-MotionalTraining® 1.0 for Social Cognition Rehabilitation in Schizophrenia

BACKGROUND

Schizophrenia patients present deficits in social cognition (SC), emotion and social perception, theory of mind (ToM), and attributional style. This study tested the efficacy, in real clinical conditions, of a online self-training program in SC, e-Motional Training^®, in comparison with treatment as usual.

METHOD

A randomized single-blinded multicenter clinical trial was conducted with 60 schizophrenia stable outpatients. All patients (control and intervention) were treated with drug therapy, case management, and individual and group psychotherapy (not focused on SC). Intervention group was treated with e-Motional Training^®, an online program devised for SC rehabilitation.

STATISTICAL ANALYSIS

A descriptive analysis and parametric/non-parametric tests were used to compare both groups at baseline. Analysis of covariance was used to compared post-pre changes in SC between the two interventions. If the group effect was significant, follow-up univariate test (t-test for dependent samples) was carried out in each group to verify whether the effect was due to improvement in the intervention group or deterioration in the control group. We considered statistically significant differences with P < 0.05.

RESULTS

Significant improvements were obtained in the intervention group in emotion recognition and most ToM variables in comparison with the control group.

DISCUSSION

e-Motional Training^® seems to be a promising online training tool for SC deficits in schizophrenia, covering the lack of similar intervention instruments in our community.

The relationship between childhood trauma, emotion recognition, and irritability in schizophrenia patients

This study investigated the relationship between childhood trauma, irritability, and emotion recognition, in schizophrenia patients during a psychotic break. Thirty-six schizophrenia inpatients and 36 healthy controls were assessed with the Irritability Questionnaire (IRQ) and two facial emotion recognition tasks, the Emotion Discrimination Test (EDT) and Emotion Identification Test (EIT). Patients were further assessed with the Structured Clinical Interview for DSM III-R Axis II Disorders (SCID-II), the Positive and Negative Symptom Scale (PANSS), and the Childhood Trauma Questionnaire-28 (CTQ-28). EDT and EIT performance was significantly impaired in patients compared to healthy controls. Furthermore, patients tended to misidentify sad, surprised, or angry faces as showing fear, and this misidentification correlated with the patients' irritability. Childhood adversity increased irritability both directly and indirectly through emotion misidentification.

Integration of verbal and nonverbal emotional signals in patients with schizophrenia: Decreased nonverbal dominance

In day-to-day social interaction, emotions are usually expressed by verbal (e.g. spoken words) and nonverbal signals (e.g. facial expressions, prosody). In case of conflicting signals nonverbal signals are perceived as being the more reliable source of information. Deficits in interpreting nonverbal signals - as described for patients with schizophrenic disorders - might interfere with the ability to integrate verbal and nonverbal social cues into a meaningful whole. The aim of this study was to examine how schizophrenic disorders influence the integration of verbal and nonverbal signals. For this purpose short video sequences were presented to 21 patients with schizophrenia and 21 healthy controls. Each sequence showed an actor speaking a short sentence with independently varying emotional connotations at the verbal and the nonverbal level. The participants rated the valence of the speaker's emotional state on a four-point scale (from very negative to very positive). The relative impact of nonverbal cues as compared to verbal cues on these ratings was evaluated. Both groups base their decisions primarily on nonverbal information. However, this effect is significantly less prominent in the patient group. Patients tend to base their decisions less on nonverbal signals and more on verbal information than healthy controls.

Differences in Facial Emotion Recognition between First Episode Psychosis, Borderline Personality Disorder and Healthy Controls

Background

Facial emotion recognition (FER) is essential to guide social functioning and behaviour for interpersonal communication. FER may be altered in severe mental illness such as in psychosis and in borderline personality disorder patients. However, it is unclear if these FER alterations are specifically related to psychosis. Awareness of FER alterations may be useful in clinical settings to improve treatment strategies. The aim of our study was to examine FER in patients with severe mental disorder and their relation with psychotic symptomatology.

Materials and Methods

Socio-demographic and clinical variables were collected. Alterations on emotion recognition were assessed in 3 groups: patients with first episode psychosis (FEP) (n = 64), borderline personality patients (BPD) (n = 37) and healthy controls (n = 137), using the Degraded Facial Affect Recognition Task. The Positive and Negative Syndrome Scale, Structured Interview for Schizotypy Revised and Community Assessment of Psychic Experiences scales were used to assess positive psychotic symptoms. WAIS III subtests were used to assess IQ.

Results

Kruskal-Wallis analysis showed a significant difference between groups on the FER of neutral faces score between FEP, BPD patients and controls and between FEP patients and controls in angry face recognition. No significant differences were found between groups in the fear or happy conditions. There was a significant difference between groups in the attribution of negative emotion to happy faces. BPD and FEP groups had a much higher tendency to recognize happy faces as negatives. There was no association with the different symptom domains in either group.

Conclusions

FEP and BPD patients have problems in recognizing neutral faces more frequently than controls. Moreover, patients tend to over-report negative emotions in recognition of happy faces. Although no relation between psychotic symptoms and FER alterations was found, these deficits could contribute to a patient’s misinterpretations in daily life.

Effects of cue modality and emotional category on recognition of nonverbal emotional signals in schizophrenia

BACKGROUND

Impaired interpretation of nonverbal emotional cues in patients with schizophrenia has been reported in several studies and a clinical relevance of these deficits for social functioning has been assumed. However, it is unclear to what extent the impairments depend on specific emotions or specific channels of nonverbal communication.

METHODS

Here, the effect of cue modality and emotional categories on accuracy of emotion recognition was evaluated in 21 patients with schizophrenia and compared to a healthy control group (n = 21). To this end, dynamic stimuli comprising speakers of both genders in three different sensory modalities (auditory, visual and audiovisual) and five emotional categories (happy, alluring, neutral, angry and disgusted) were used.

RESULTS

Patients with schizophrenia were found to be impaired in emotion recognition in comparison to the control group across all stimuli. Considering specific emotions more severe deficits were revealed in the recognition of alluring stimuli and less severe deficits in the recognition of disgusted stimuli as compared to all other emotions. Regarding cue modality the extent of the impairment in emotional recognition did not significantly differ between auditory and visual cues across all emotional categories. However, patients with schizophrenia showed significantly more severe disturbances for vocal as compared to facial cues when sexual interest is expressed (alluring stimuli), whereas more severe disturbances for facial as compared to vocal cues were observed when happiness or anger is expressed.

CONCLUSION

Our results confirmed that perceptual impairments can be observed for vocal as well as facial cues conveying various social and emotional connotations. The observed differences in severity of impairments with most severe deficits for alluring expressions might be related to specific difficulties in recognizing the complex social emotional information of interpersonal intentions as compared to "basic" emotional states. Therefore, future studies evaluating perception of nonverbal cues should consider a broader range of social and emotional signals beyond basic emotions including attitudes and interpersonal intentions. Identifying specific domains of social perception particularly prone for misunderstandings in patients with schizophrenia might allow for a refinement of interventions aiming at improving social functioning.

Factors contributing to social cognition impairment in borderline personality disorder and schizophrenia

Social cognition (SC) deficits have been described both in patients with schizophrenia and borderline personality disorder (BPD). However, while the former tend towards simplistic mental state attributions (undermentalizing), the latter are more likely to make overly complex mental state inferences (overmentalizing). Performance on complex SC tasks has been shown to correlate with neurocognitive ability, emotion perception, a history of trauma, and overconfidence in errors. However, it is unclear how these factors relate to different aspects of SC deficits. Aim of the present study was to examine the pathways of SC impairment by investigating performance profiles and their predictors comparatively in BPD and schizophrenia. Participants were 44 patients with BPD, 36 patients with schizophrenia, and 38 healthy controls. Undermentalizing and overmentalizing were assessed with an ecologically valid SC task. Patients with BPD exhibited increased overmentalizing, whereas patients with schizophrenia showed a more extensive deficit pattern, their main error type being undermentalizing. Overconfidence in errors was the most important predictor for overmentalizing, while undermentalizing depended mainly on verbal memory and emotion perception. Thus, BPD und schizophrenia exhibited different SC impairment patterns, and different types of SC errors were predicted by different factors. These findings have implications for the optimization of treatment approaches.

Training of Affect Recognition impacts electrophysiological correlates of facial affect recognition in schizophrenia: Analyses of fixation-locked potentials

OBJECTIVES

Training of Affect Recognition (TAR) is a useful approach to restoring cognitive function in schizophrenic patients. Along with improving visual exploration of faces and altering central information processing in relevant brain areas, TAR attenuates impairments in facial affect recognition. In the present study, we investigate the effects of TAR on early electrophysiological correlates of facial affect recognition in schizophrenia.

METHODS

The study population comprised 12 schizophrenic patients and 14 healthy controls. In each individual, we carried out EEG, concomitant measurements of scanning eye movements and fixation-based low resolution electromagnetic tomography (sLORETA) analyses of brain electric activity. All analyses were performed at baseline and after participation in TAR.

RESULTS

In patients, brain activation patterns significantly changed after completing the TAR. Functional improvements were particularly pronounced in the superior parietal and inferior parietal lobes, where trained patients showed a larger increase in activation than untrained healthy controls.

CONCLUSIONS

The TAR activates compensatory brain processes involved in the perception, attention and evaluation of emotional stimuli. This may underlie the established behavioral effects of the TAR in schizophrenic patients, which include improvements in facial affect recognition and alterations of visual exploration strategies.

Impaired facial emotion recognition in individuals at ultra-high risk for psychosis and with first-episode schizophrenia, and their associations with neurocognitive deficits and self-reported schizotypy

OBJECTIVE

This study aims to quantify facial emotion recognition abnormalities and their relation to neurocognitive dysfunction and schizotypy in individuals at ultra-high risk (UHR) for psychosis and patients with first-episode schizophrenia (FES).

METHODS

Forty individuals at UHR for psychosis, 24 patients with FES and 46 normal controls performed a facial emotion recognition task that presented facial photographs encompassing all basic emotions. The perceptual aberration scale and revised social anhedonia scale were employed for self-reported assessment of schizotypy. An intellectual functioning (IQ) test and a broad battery of neurocognitive tests were conducted. Emotional task performance indexed by accuracy rate of specific emotion was compared among three groups. The correlation of accuracy rate with neurocognitive tests and schizotypy scales were analyzed within each clinical group.

RESULTS

A recognition deficit of facial emotions was present in both clinical groups, even after adjusting for IQ and gender as covariates. This emotional deficit showed few significant relationships with broad range of individual neurocognitive measures. Meanwhile, this deficit demonstrated significant relationships with schizotypy, especially perceptual aberration in each clinical group.

CONCLUSIONS

Facial emotion recognition deficit may not only be present in FES patients, but may already have evolved prior to the onset of overt psychotic symptoms. This emotion recognition deficit may be linked to a perceptual aberration and largely independent of broad range of neurocognitive dysfunction.

Facial affect processing deficits in schizophrenia: a meta-analysis of antipsychotic treatment effects

Social cognition, including emotion processing, is a recognised deficit observed in patients with schizophrenia. It is one cognitive domain which has been emphasised as requiring further investigation, with the efficacy of antipsychotic treatment on this deficit remaining unclear. Nine studies met our criteria for entry into a meta-analysis of the effects of medication on facial affect processing, including data from 1162 patients and six antipsychotics. Overall we found a small, positive effect (Hedge's g = 0.13, 95% CI 0.05 to 0.21, p = 0.002). In a subgroup analysis this was statistically significant for atypical, but not typical, antipsychotics. It should be noted that the pooled sample size of the typical subgroup was significantly lower than the atypical. Meta-regression analyses revealed that age, gender and changes in symptom severity were not moderating factors. For the small, positive effect on facial affect processing, the clinical significance is questionable in terms of treating deficits in emotion identification in schizophrenia. We show that antipsychotic medications are poor at improving facial affect processing compared to reducing symptoms. This highlights the need for further investigation into the neuropharmacological mechanisms associated with accurate emotion processing, to inform treatment options for these deficits in schizophrenia.

Theory of Mind in Bipolar Disorder, with Comparison to the Impairments Observed in Schizophrenia

Our ability to make sense of information on the potential intentions and dispositions of others is of paramount importance for understanding their communicative intent, and for judging what an appropriate reaction might be. Thus, anything that impinges on this ability has the potential to cause significant social impairment, and compromise an individual's level of functioning. Both bipolar disorder and schizophrenia are known to feature theory of mind impairment. We conducted a theoretical review to determine the extent and types of theory of mind impairment in bipolar disorder, and evaluate their relationship to medication and symptoms. We also considered possible mediatory mechanisms, and set out to discover what else could be learnt about the impairment in bipolar disorder by comparison to the profile of impairment in schizophrenia. The literature established that in bipolar disorder (i) some form of theory of mind impairment has been observed in all mood states, including euthymia, (ii) the form of theory of mind assessed and task used to make the assessment influence the impairment observed, and (iii) there might be some relationship to cognitive impairment, although a relationship to standard clinical variables was harder to establish. What also became clear in the literature on bipolar disorder itself was the possible relationship of theory of mind impairment to history of psychotic symptoms. Direct comparative studies, including patients with schizophrenia, were thus examined, and provided several important directions for future research on the bases of impairment in bipolar disorder. Particularly prominent was the issue of whether theory of mind impairment could be considered a candidate endophenotype for the psychoses, although current evidence suggests that this may be premature. The differences in impairment across schizophrenia and bipolar disorder may, however, have genuine differential effects on social functioning and the likely success of remediation.

Emotional perception and theory of mind in first episode psychosis: the role of obsessive-compulsive symptomatology

The aim of the present study was to investigate the effects of comorbid obsessive-compulsive symptoms on emotional perception and theory of mind (ToM) in patients with first-episode psychosis. Participants were 65 patients with non-affective first episode psychosis (FEP) and 47 healthy controls. The patient group was divided into two subgroups, those with (FEP+; n=38) and those without obsessive-compulsive symptomatology (FEP-; n=27). Emotion perception and ToM were assessed with the Perception of Social Inference Test. Severity of psychotic and obsessive-compulsive symptoms was assessed with the Positive and Negative Syndrome Scale (PANSS) and the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), respectively. Deficits in emotion recognition and theory of mind were confirmed in patients with non-affective first-episode psychosis compared to healthy controls. In patients, comorbidity with obsessive-compulsive symptoms was associated with worse performance on certain aspects of social cognition (ToM 2nd order) compared to FEP- patients. Our findings of impaired emotion perception and ToM in patients with first-episode psychosis support the hypothesis that deficits are already present at illness onset. Presence of OCS appears to have further deleterious effects on social cognition, suggesting that these patients may belong to a schizo-obsessive subtype of schizophrenia characterized by more extensive neurobiological impairment.

Facial emotion recognition in paranoid schizophrenia and autism spectrum disorder

Schizophrenia (SZ) and autism spectrum disorder (ASD) share deficits in emotion processing. In order to identify convergent and divergent mechanisms, we investigated facial emotion recognition in SZ, high-functioning ASD (HFASD), and typically developed controls (TD). Different degrees of task difficulty and emotion complexity (face, eyes; basic emotions, complex emotions) were used. Two Benton tests were implemented in order to elicit potentially confounding visuo-perceptual functioning and facial processing. Nineteen participants with paranoid SZ, 22 with HFASD and 20 TD were included, aged between 14 and 33 years. Individuals with SZ were comparable to TD in all obtained emotion recognition measures, but showed reduced basic visuo-perceptual abilities. The HFASD group was impaired in the recognition of basic and complex emotions compared to both, SZ and TD. When facial identity recognition was adjusted for, group differences remained for the recognition of complex emotions only. Our results suggest that there is a SZ subgroup with predominantly paranoid symptoms that does not show problems in face processing and emotion recognition, but visuo-perceptual impairments. They also confirm the notion of a general facial and emotion recognition deficit in HFASD. No shared emotion recognition deficit was found for paranoid SZ and HFASD, emphasizing the differential cognitive underpinnings of both disorders.

Facial affect recognition performance and event-related potentials in violent and non-violent schizophrenia patients

We investigated whether male inpatients with schizophrenia and a history of hands-on violent offences (forensic schizophrenic, FOS) are more impaired in emotion recognition than matched schizophrenia patients without any history of violence (general psychiatric schizophrenic, GPS). This should become apparent in performance in psychometry and in scalp event-related brain potentials (ERPs) evoked by pictures of facial affect. FOS and GPS (each n = 19) were matched concerning age, intelligence, comorbid addiction, medication and illness duration. FOS revealed significantly poorer affect recognition (AR) performance, especially of neutral and fear stimuli. Analysis of ERPs revealed a significant interaction of hemisphere, electrode position and group of the N250 component. Post hoc analysis of group effect showed significantly larger amplitudes in FOS at FC3. These results support the hypothesis that in FOS emotional faces are more salient and evoke higher arousal. Larger impairment in AR performance combined with higher salience and arousal may contribute to the occurrence of violent acts in schizophrenia patients.

Emotional facial expression processing in depression: data from behavioral and event-related potential studies

Behavioral literature investigating emotional processes in depressive populations (i.e., unipolar and bipolar depression) states that, compared to healthy controls, depressive subjects exhibit disrupted emotional processing, indexed by lower performance and/or delayed response latencies. The development of brain imaging techniques, such as functional magnetic resonance imaging (fMRI), provided the possibility to visualize the brain regions engaged in emotional processes and how they fail to interact in psychiatric diseases. However, fMRI suffers from poor temporal resolution and cognitive function involves various steps and cognitive stages (serially or in parallel) to give rise to a normal performance. Thus, the origin of a behavioral deficit may result from the alteration of a cognitive stage differently situated along the information-processing stream, outlining the importance of access to this dynamic "temporal" information. In this paper, we will illustrate, through depression, the role that should be attributed to cognitive event-related potentials (ERPs). Indeed, owing to their optimal temporal resolution, ERPs can monitor the neural processes engaged in disrupted cognitive function and provide crucial information for its treatment, training of the impaired cognitive functions and guidelines for clinicians in the choice and monitoring of appropriate medication for the patient.

Familiarity and face emotion recognition in patients with schizophrenia

OBJECTIVE

To assess the emotion recognition in familiar and unknown faces in a sample of schizophrenic patients and healthy controls.

METHODS

Face emotion recognition of 18 outpatients diagnosed with schizophrenia (DSM-IVTR) and 18 healthy volunteers was assessed with two Emotion Recognition Tasks using familiar faces and unknown faces. Each subject was accompanied by 4 familiar people (parents, siblings or friends), which were photographed by expressing the 6 Ekman's basic emotions. Face emotion recognition in familiar faces was assessed with this ad hoc instrument. In each case, the patient scored (from 1 to 10) the subjective familiarity and affective valence corresponding to each person.

RESULTS

Patients with schizophrenia not only showed a deficit in the recognition of emotions on unknown faces (p=.01), but they also showed an even more pronounced deficit on familiar faces (p=.001). Controls had a similar success rate in the unknown faces task (mean: 18 +/- 2.2) and the familiar face task (mean: 17.4 +/- 3). However, patients had a significantly lower score in the familiar faces task (mean: 13.2 +/- 3.8) than in the unknown faces task (mean: 16 +/- 2.4; p<.05). In both tests, the highest number of errors was with emotions of anger and fear. Subjectively, the patient group showed a lower level of familiarity and emotional valence to their respective relatives (p<.01).

CONCLUSIONS

The sense of familiarity may be a factor involved in the face emotion recognition and it may be disturbed in schizophrenia.

Symptom correlates of facial emotion recognition impairment in schizophrenia

BACKGROUND

The ability to facial emotion recognition (FER), a key component of socioemotional competence, is often impaired in schizophrenic disorders. The purpose of the present study was to examine the relationship between emotion recognition performance and symptoms in a group of patients with schizophrenia spectrum disorders.

SAMPLING AND METHODS

Seventy-nine patients meeting DSM-IV-TR criteria for schizophrenia, schizophreniform disorder and schizoaffective disorder were assessed by the Positive and Negative Syndrome Scale and a FER task. In schizophrenia patients and healthy control subjects, FER performance was compared. In order to avoid a possible confounding role of cognitive impairment, we carried out partial correlations corrected for an index of global cognition.

RESULTS

Patients performed worse than a healthy control group on all negative emotions. Partial correlations showed that cognitive/disorganized symptoms correlated with a worse performance in the FER task, whereas no correlations were found with positive, negative, excitement and depressive symptoms.

CONCLUSIONS

Our findings support that in schizophrenia FER impairment is specific for negative emotions and that there is a relationship between this deficit and cognitive/disorganized symptoms, regardless of the general cognitive level.

Training of affect recognition in schizophrenia patients with violent offences: behavioral treatment effects and electrophysiological correlates

Violent offenders with schizophrenia have a particularly poor performance level in facial affect recognition. Nineteen male schizophrenia patients, who had been committed to psychiatric hospital detention because of violent offences and lack of criminal responsibility, were recruited to receive the Training of Affect Recognition (TAR). Performance in the Pictures of Facial Affect (PFA)-test and event-related potentials (ERPs) were registered in a pre-post-treatment design. TAR was feasible with a very high treatment effect (Cohen's d = 1.88), which persisted for 2 months post-treatment. ERPs remained unchanged post- vs. pre-treatment, while low resolution brain electromagnetic tomography (LORETA) revealed activation decreases in left-hemispheric parietal-temporal-occipital regions at 172 msec and activation increases in right dorsolateral prefrontal cortex and anterior cingulate at 250 msec. Possibly, violent offenders with schizophrenia are particularly amenable to TAR because of a high level of dysfunction at baseline. Post- vs. pre-treatment changes of neural activity (LORETA) may mirror a gain of efficiency in structural face decoding and a shift towards a more reflective mode of emotional face decoding, relying on increased frontal brain activity. Functional magnetic resonance imaging (BOLD-fMRI) -data from another study further supports this notion. TAR treatment might enable subjects with schizophrenia and a disposition to violence to reach a higher degree of deliberation of their reactive behavior to facial affect stimuli.

Can antipsychotics improve social cognition in patients with schizophrenia?

Social cognition is described as the higher mental processes that are engaged while people store, process, and use social information to make sense of themselves and others. Aspects of social cognition include emotion perception, social cue interpretation, attribution style, and theory of mind, all of which appear disordered in schizophrenia. Such social cognitive deficits are believed to be important predictors of functional outcome in schizophrenia, therefore they may represent a crucial treatment target. Few studies have evaluated the influence of antipsychotic treatment on these deficits. The purpose of this review is to examine the relationship between antipsychotic treatment and social cognition, whether antipsychotics improve social cognitive function, and if so to explore differential medication effects. Comprehensive searches of PsycINFO and MEDLINE/PUBMED were conducted to identify relevant published manuscripts. Fifteen relevant papers published in English were found, describing original studies. On the basis of this review, we have drawn the following conclusions: first, the results do not engender optimism for the possibility that antipsychotic drugs can specifically facilitate social recovery. Second, the actions of antipsychotics on social cognition are inconclusive, due to lack of standardization across research groups, leading to inconsistencies between study designs, methods used, and medication dosages. Third, large-scale longitudinal investigations are needed to explore the unclear relationships between social cognition, symptoms, and functional outcome. Other non-pharmacological treatments focusing on training patients in the social cognitive areas may hold more promise.

Efficacy of social cognition remediation programs targeting facial affect recognition deficits in schizophrenia: a review and consideration of high-risk samples and sex differences

Schizophrenia patients suffer from significant social functioning deficits. Social cognition, particularly facial affect recognition (FAR), is an important predictor of functional outcome. Recently, investigators developed numerous social cognition remediation programs targeting FAR deficits with the goal of improving social functioning and quality of life in schizophrenia patients. This article builds on Horan et al.'s (2008) comprehensive review and Kurtz and Richardson's (2012) meta-analysis of a broad range of social cognition remediations, by systematically reviewing efficacy of empirically based remediations in schizophrenia specifically targeting FAR (across 23 studies), and their potential functional benefits. We describe each FAR-based social cognition remediation program, which may aid clinical scientists and clinicians in selecting programs for further study and practice. We critically evaluate limitations of FAR remediation programs and applications. Our review concludes FAR remediation programs are strongly efficacious in improving FAR performance and functional status in schizophrenia. Importantly, we provide rationale for and recommend that future research consider (as yet underexplored) sexual dimorphisms in FAR remediation effects, and examine FAR remediation in clinical high-risk for psychosis populations. The goal is to mitigate deficits, perhaps hinder illness onset, and individually tailor treatments across the psychosis continuum in a way that maximally aids those in greatest need.

Emotion recognition impairment is present early and is stable throughout the course of schizophrenia

Individuals with schizophrenia experience problems in the perception of emotion throughout the course of the disorder. Few studies have addressed the progression of the deficit over time. The present investigation explores face emotion recognition (FER) performance throughout the course of schizophrenia. The aim of the study was to test the hypotheses that: 1) FER impairment was present in ultra high-risk (putatively prodromal) individuals, and that 2) impairment was stable across the course of the illness. Forty-three individuals with a putative prodromal syndrome, 50 patients with first episode of schizophrenia, 44 patients with multi-episode schizophrenia and 86 unaffected healthy control subjects were assessed to examine emotion recognition ability. ANCOVA analysis adjusted for possible confounder factors and subsequent planned contrasts with healthy controls was undertaken. The results revealed deficits in recognition of sadness and disgust in prodromal individuals, and of all negative emotions in both first-episode and multi-episode patients. Furthermore, there were no significant differences between clinical groups. Within the framework of the neurodevelopmental model of schizophrenia, our results suggest the presence of emotional recognition impairment before the onset of full-blown psychosis. Moreover, the deficit remains stable over the course of illness, fitting the pattern of a vulnerability indicator in contrast to an indicator of chronicity or severity.

Attentional and emotional functioning in schizophrenia patients treated with conventional and atypical antipsychotic drugs

BACKGROUND

Effectiveness of antipsychotics in treating emotional and cognitive deficits in schizophrenia still remains controversial. The aim of our study was to assess emotional and cognitive functioning in schizophrenic inpatients currently treated with typical antipsychotics (perphenazine, perazine, fluphenazine, and haloperidol) and in another group of schizophrenic inpatients currently on atypical antipsychotics (olanzapine, risperidone, amisulpride, and quetiapine).

MATERIAL/METHODS

One hundred patients with DSM-IV schizophrenia or schizoaffective disorders (39 treated using typical antipsychotics and 61 treated with atypical antipsychotics) under naturalistic treatment conditions, and 50 healthy controls were given the following: Test of Everyday Attention, Facial Emotion Recognition Test, Facial Memory Recognition Test, and "Reading the mind in the eyes" Test.

RESULTS

Patients with a diagnosis of schizophrenia revealed the following deficits: facial emotion perception, empathy /theory of mind, visual selective attention/speed, attentional switching, and auditory-verbal working memory. Our results show a significant difference between schizophrenic and healthy controls in all tasks, with schizophrenic patients performing worse than controls. Interestingly, our patients on atypical neuroleptics performed similarly compared to schizophrenic patients treated with conventional neuroleptics on all tasks provided. There were some significant relationships between emotional and cognitive deficits and clinical variables.

CONCLUSIONS

Our findings remain consistent with other recent studies in which atypical antipsychotics did not show a clear advantage over typical antipsychotics on both emotional and cognitive functioning.

Misreading the facial signs: specific impairments and error patterns in recognition of facial emotions with negative valence in borderline personality disorder

Patients with borderline personality disorder (BPD) exhibit impairment in labeling of facial emotional expressions. However, it is not clear whether these deficits affect the whole domain of basic emotions, are valence-specific, or specific to individual emotions. Whether BPD patients' errors in a facial emotion recognition task create a specific pattern also remains to be elucidated. Our study tested two hypotheses: first, we hypothesized, that the emotion perception impairment in borderline personality disorder is specific to the negative emotion domain. Second, we hypothesized, that BPD patients would show error patterns in a facial emotion recognition task more commonly and more systematically than healthy comparison subjects. Participants comprised 33 inpatients with BPD and 32 matched healthy control subjects who performed a computerized version of the Ekman 60 Faces test. The indices of emotion recognition and the direction of errors were processed in separate analyses. Clinical symptoms and personality functioning were assessed using the Symptom Checklist-90-Revised and the Young Schema Questionnaire Long Form. Results showed that patients with BPD were less accurate than control participants in emotion recognition, in particular, in the discrimination of negative emotions, while they were not impaired in the recognition of happy facial expressions. In addition, patients over-attributed disgust and surprise and under-attributed fear to the facial expressions relative to controls. These findings suggest the importance of carefully considering error patterns, besides measuring recognition accuracy, especially among emotions with negative affective valence, when assessing facial affect recognition in BPD.

Social-cognitive remediation in schizophrenia: generalization of effects of the Training of Affect Recognition (TAR)

In the last decade, several social cognitive remediation programs have been developed for use in schizophrenia. Though existing evidence indicates that such programs can improve social cognition, which is essential for successful social functioning, it remains unclear whether the improvements generalize to social cognitive domains not primarily addressed by the intervention and whether the improved test performance transfers into everyday social functioning. The present study investigated whether, beyond its known effects on facial affect recognition, the Training of Affect Recognition (TAR) has effects on prosodic affect recognition, theory of mind (ToM) performance, social competence in a role-play task, and more general social and occupational functioning. Thirty-eight inpatients with a diagnosis of schizophrenia or schizoaffective disorder were randomly assigned to 6 weeks of treatment with the TAR--primarily targeted at facial affect recognition-or Cognitive Remediation Training (CRT)--primarily targeted at neurocognition. Intention-to-treat analyses found significantly larger pre-post improvements with TAR than with CRT in prosodic affect recognition, ToM, and social competence and a trend effect in global social functioning. However, the effects on ToM and social competence were no longer significant in the smaller group of patients who completed treatment according to protocol. Results suggest that TAR effects generalize to other social cognitive domains not primarily addressed. TAR may also enhance social skills and social functioning, although this has to be confirmed. Results are discussed with regard to the need to improve functional outcome in schizophrenia against the background of current evidence from other social cognitive remediation approaches.