Facial emotion perception in schizophrenia: Does sex matter?

Facial Emotion Recognition Ability in Individuals with Remitted Schizophrenia in Comparison to Healthy Population: A Cross-Sectional Study

Background

Facial emotion recognition is one of the significant domains of social cognition that underlie social interactions. These deficits can influence the functional outcome in individuals with schizophrenia by impairing judgment toward others and reducing their capability to function. We aimed to assess the facial emotion recognition deficits in individuals with schizophrenia in comparison to healthy individuals and find their association with clinical and demographic profiles.

Methods

This cross-sectional study compared individuals with schizophrenia in a stable remitted phase of illness to an age, gender, and education-matched healthy population, including 30 participants in each group. The assessment was done using Addenbrooke's Cognitive Examination (ACE-III), AIIMS Facial Toolbox for Emotion Recognition (AFTER), and the Positive and Negative Syndrome Scale (PANSS). Intergroup comparison was done using the Independent sample t-test, and the association of facial emotional deficit with any clinical or demographic factor was analyzed using Pearson's correlation.

Results

The schizophrenia group performed significantly worse than healthy controls on identifying positive and negative emotions except for happiness. The time to recognize emotion was also found to be significantly more in the schizophrenia group than in controls. Also, significant cognitive deficits were found in the schizophrenia group in comparison to the healthy population. Negative emotions were found to be more correlated to psychopathology.

Conclusion

Individuals with schizophrenia appear to have a stable deficit in facial emotion recognition (more in negative emotions). Cognitive deficits are seen more in individuals with schizophrenia as compared to healthy populations, even in their stable phase of illness.

Impact of Biological Sex on Emotional Perception Among Adults With Schizophrenia Spectrum Disorders: Protocol for a Systematic Review

BACKGROUND

It is well established that individuals with schizophrenia experience deficits in emotional perception that can impact long-term social and occupational functioning. Understanding the factors that impact these impairments is important for targeting interventions to improve recovery. In the general population, compared with males, females tend to show greater perception of emotions. Whether this sex difference persists in schizophrenia is less clear. In contrast to males, females diagnosed with schizophrenia tend to have a higher age of disease onset and better premorbid functioning but do not necessarily have better outcomes. Effective treatments for social cognitive impairments are highly relevant to long-term functional rehabilitation. A greater understanding of the cognitive deficits in emotional perception within females and males living with schizophrenia may assist interventions to be better tailored to individuals.

OBJECTIVE

This systematic review aims to collate, synthesize, and critically appraise evidence considering the influence of biological sex (female and male) on the emotional perception of individuals with schizophrenia.

METHODS

This is a systematic review protocol based on the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) guidelines. The electronic databases MEDLINE, Embase, CENTRAL, CINAHL, and PsycINFO will be systematically searched. To be included in this review, studies must compare the emotional perceptions of male and female participants older than 18 years who have a primary diagnosis of a schizophrenia spectrum disorder. Qualitative studies, case reports, case series, unpublished manuscripts, and studies not reported in English will be excluded. Key search strategies will include combinations of the following terms: "men," "male," "man," "female," "women," "woman," "sex," "gender," "emotional perception," "emotional processing," "schizophrenia," "schizophren," "psychotic disorders," "psychosis," "psychoses," "psychotic," "schizoaffective," "schizotypal personality disorder," and "schizotyp." Identified studies will be uploaded to the web-based Covidence systematic review management software. The risk of bias for individual studies will be assessed using the relevant Joanna Briggs Institute checklist tools. The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system will also be used to evaluate the strength of the evidence base. Findings will be synthesized to provide a systematic summary of the existing literature. If sufficiently comparable data to permit meta-analysis emerges, a random-effects meta-analysis will be performed.

RESULTS

This systematic review was registered with the PROSPERO (International Prospective Register of Systematic Reviews) in October 2023. The search and screening of study titles and abstracts are currently underway. Data are expected to be extracted and analyzed in July 2024.

CONCLUSIONS

Results will contribute to an improved understanding of the social cognitive profiles of males and females with schizophrenia. This knowledge is expected to inform the adaptation of interventions to improve functional outcomes.

TRIAL REGISTRATION

PROSPERO CRD42023463561; https://tinyurl.com/34sr3rnf.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56977.

The relationship between sex and functional outcome in first-episode schizophrenia: the role of premorbid adjustment and insight

BACKGROUND

Studies that examined sex differences in first-episode patients consistently show that males compared to females have poor premorbid adjustment, earlier age of onset, worse clinical characteristics, and poorer outcomes. However, little is known about potential mediators that could explain these sex differences.

METHODS

Our sample consisted of 137 individuals with first episode schizophrenia (males, n = 105; 77%) with a mean age of 22.1(s.d. = 4.1) years and mean education of 12.5(s.d. = 1.7) years. At entry, patients were within 2 years of their first psychotic episode onset. Baseline assessments were conducted for premorbid adjustment, symptoms, cognitive functioning, insight, and at 6-months for role and social functioning.

RESULTS

Males as compared to females had poorer premorbid adjustment across several key developmental periods (p < 0.01), an earlier age of onset [M = 20.3(3.3) v. 22.8(5.6), p = 0.002], more negative symptoms (p = 0.044), poorer insight (p = 0.031), and poorer baseline and 6-month role (p = 0.002) and social functioning (p = 0.034). Several of these variables in which males showed impairment were significant predictors of 6-month role and social functioning. Premorbid adjustment and insight mediated the relationship between sex and role and social functioning at 6-months, but not negative symptoms.

DISCUSSION

Males compared to females were at lower levels across several key premorbid and clinical domains which are strongly associated with functional outcome supporting the hypothesis that males might have a more disabling form of schizophrenia. The relationship between sex with role and social functioning was mediated through premorbid adjustment and insight suggesting pathways for understanding why females might have a less disabling form of schizophrenia.

Impaired emotion perception in schizophrenia shows sex differences with channel- and category-specific effects: A pilot study

Individuals with schizophrenia reportedly demonstrate deficits in emotion perception. Relevant studies on the effects of decoder's sex, communication channels and emotion categories have produced mixed findings and seldom explored the interactions among these three key factors. The present pilot study examined how male and female individuals with schizophrenia and healthy controls perceived emotional (e.g., angry, happy, and sad) and neutral expressions from verbal semantic and nonverbal prosodic and facial channels. Twenty-eight (11 females) individuals with schizophrenia and 30 healthy controls (13 females) were asked to recognize emotional facial expressions, emotional prosody, and emotional semantics. Both accuracy and response time showed subpar performance for all communication channels and emotional categories in the schizophrenia group. More severe emotion perception deficits were found with the nonverbal (not the verbal) materials. There was also a reduced level of impairment with anger perception, especially in the female individuals with schizophrenia while biased perception towards emotional semantics was more pronounced in male individuals with schizophrenia. These findings, although preliminary, indicate the channel- and category-specific nature of emotion perception with potential sex differences among people with schizophrenia, which has important theoretical and practical implications.

Severe childhood trauma and emotion recognition in males and females with first-episode psychosis

AIM

Childhood trauma increases social functioning deficits in first-episode psychosis (FEP) and is negatively associated with higher-order social cognitive processes such as emotion recognition (ER). We investigated the relationship between childhood trauma severity and ER capacity, and explored sex as a potential factor given sex differences in childhood trauma exposure.

METHODS

Eighty-three FEP participants (52 males, 31 females) and 69 nonclinical controls (49 males, 20 females) completed the CogState Research Battery. FEP participants completed the Childhood Trauma Questionnaire. A sex × group (FEP, controls) ANOVA examined ER differences and was followed by two-way ANCOVAs investigating sex and childhood trauma severity (none, low, moderate, and severe) on ER and global cognition in FEP.

RESULTS

FEP participants had significantly lower ER scores than controls (p = .035). No significant sex × group interaction emerged for ER F(3, 147) = .496, p = .438 [95% CI = -1.20-0.57], partial η²  = .003. When controlling for age at psychosis onset, a significant interaction emerged in FEP between sex and childhood trauma severity F(3, 71) = 3.173, p = .029, partial η²  = .118. Males (n = 9) with severe trauma showed ER deficits compared to females (n = 8) (p = .011 [95% CI = -2.90 to -0.39]). No significant interaction was observed for global cognition F(3, 69) = 2.410, p = .074, partial η²  = .095.

CONCLUSIONS

These preliminary findings provide support for longitudinal investigations examining whether trauma severity differentially impacts ER in males and females with FEP.

Deconstructing Mechanisms of Abnormal Categorical Perception of Emotional Facial Expressions in Schizophrenia Patients

OBJECTIVE

The current study aims to find out the potential reasons why most schizophrenia patients have a relatively low sensitivity to the classification of emotional facial expressions.

METHODS

By using an emotional categorical perception task, eighty-three schizophrenia patients and seventy-one healthy adults are provided with morphed emotional continuums with two emotional facial expressions (a positive emotional valence: happy; a negative emotional valence: sad).

RESULTS

Through comparing the difference between schizophrenia patients and healthy adults in the processes of estimating facial expressions with ambiguous emotions, we find that the pattern of emotional categorical perception for schizophrenia patients is significantly different from that of healthy controls when they process signals on the local facial areas. Compared to healthy people, schizophrenia patients have a significantly separate classification pattern in processing emotional signals between the eyes and mouth regions. It indicates that compared to healthy adults, schizophrenia patients have larger conflicts in integrating emotional signals from different facial areas. To overcome conflicts, more cognitive resources are required. Unfortunately, the lack of cognitive resources leads to the failure of integration, which further increases the difficulty of estimating facial expressions with ambiguous emotions, and finally leads to the relatively low sensitivity of emotional facial expressions classification.

CONCLUSION

To sum up, the deficit of abnormal perceptions of emotional facial expressions in schizophrenia patients results from an integrated deficit of signals on facial areas.

Facial affect recognition in first-episode psychosis is impaired but not associated with psychotic symptoms

Introduction

Aims

Method

Results

Discussion

•

Impaired affect recognition (FAR) present already in first episode psychosis (FEP).

•

Preserved FAR of happiness found in individuals with FEP.

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Individuals with FEP mainly have impaired FAR of negative affects.

•

Both FEP and controls mainly mistook negative affects for other negative affects.

•

Psychotic symptoms are not associated with FAR in individuals with FEP.

Group and sex differences in social cognition in bipolar disorder, schizophrenia/schizoaffective disorder and healthy people

BACKGROUND

Impairment of social cognition is documented in bipolar disorder (BD) and schizophrenia/schizoaffective disorder (SCH). In healthy individuals, women perform better than men in some of its sub-domains. However, in BD and SCH the results are mixed. Our aim was to compare emotion recognition, affective Theory of Mind (ToM) and first- and second-order cognitive ToM in BD, SCH and healthy subjects, and to investigate sex-related differences.

METHODS

120 patients (BD = 60, SCH = 60) and 40 healthy subjects were recruited. Emotion recognition was assessed by the Pictures of Facial Affect (POFA) test, affective ToM by the Reading the Mind in the Eyes Test (RMET) and cognitive ToM by several false-belief stories. Group and sex differences were analyzed using parametric (POFA, RMET) and non-parametric (false-belief stories) tests. The impact of age, intelligence quotient (IQ) and clinical variables on patient performance was examined using a series of linear/logistic regressions.

RESULTS

Both groups of patients performed worse than healthy subjects on POFA, RMET and second-order false-belief (p < 0.001), but no differences were found between them. Instead, their deficits were related to older age and/or lower IQ (p < 0.01). Subthreshold depression was associated with a 6-fold increased risk of first-order false-belief failure (p < 0.001). Sex differences were only found in healthy subjects, with women outperforming men on POFA and RMET (p ≤ 0.012), but not on first/second-order false-belief.

LIMITATIONS

The cross-sectional design does not allow for causal inferences.

CONCLUSION

BD and SCH patients had deficits in emotion recognition, affective ToM, and second-order cognitive ToM, but their performance was comparable to each other, highlighting that the differences between them may be subtler than previously thought. First-order cognitive ToM remained intact, but subthreshold depression altered their normal functioning. Our results suggest that the advantage of healthy women in the emotional and affective aspects of social cognition would not be maintained in BD and SCH.

Development of the CAT–FER: A Computerized Adaptive Test of Facial Emotion Recognition for Adults With Schizophrenia

Importance: The most frequently used measures of facial emotion recognition (FER) are insufficiently comprehensive, reliable, valid, and efficient; moreover, the impact of gender on scoring has not been controlled.

Objective: To develop a computerized adaptive test of FER for adults with schizophrenia.

Design: First, we selected photographs from a published database. Second, items that fitted well to a Rasch model were used to form the item bank. Third and last, we determined the best administration mode for prospective users to achieve both high reliability and efficiency.

Setting: Psychiatric hospitals and the community.

Participants: Adults living with schizophrenia (n = 351) and adults without diagnosed mental illness (n = 101).

Results: After removal of misfit items (infit or outfit ≥1.4), the remaining 165 items were selected to form an item bank. Among them, 39 showed severe gender bias, so the item difficulties were adjusted accordingly. On the basis of the item bank, two administration modes were recommended for prospective users. The reliable mode required approximately 128 items (nearly 20 min) to achieve reliability (.72–.81), similar to that of the entire item bank. The efficient mode required approximately 73 items (approximate 11 min) to provide acceptable reliability (.69–.73) for the seven domain scores.

Conclusions and Relevance: Our newly developed measure provides comprehensive, valid, and unbiased (to examinees’ gender) assessments of FER in adults living with schizophrenia. In addition, the administration modes can be flexibly changed to optimize the reliability or efficiency for prospective users.

What This Article Adds: This newly developed FER measure can help occupational therapists identify deficits in recognizing specific basic emotions and plan corresponding interventions to manage the impact on their clients’ social functions.

A Short Empathy Paradigm to Assess Empathic Deficits in Schizophrenia

Empathy is important for successful social interaction and maintaining relationships. Several studies detected impairments in empathic abilities in schizophrenia, with some even indicating a broader deficit in several components, including emotion recognition, perspective taking, and affective responsiveness. The aim of our study was to validate a short version of the previous empathy paradigm as a reliable and easily applicable method to assess empathic deficits in patients with schizophrenia potentially within clinical routine. To do so, we applied the short version to 30 patients (14 females) diagnosed with schizophrenia meeting the DSM-5 criteria and 30 well-matched healthy controls (14 females). The data analysis indicates a significant empathic deficit in patients due to worse performance in all three domains. We managed to replicate most of the findings of our previous study. In contrary to the previous study, significant correlations between performance in the empathy tasks and psychopathology occurred: the severity of negative symptoms was negatively associated with performance in the emotion recognition task and the affective responsiveness task. Gender did not significantly affect performance in the empathy tasks. Regarding the results, our short empathy paradigm appears to be a valid method in assessing empathic impairments in schizophrenia that may be useful in clinical routine.

Sex differences in facial emotion recognition in health and psychotic disorders

BACKGROUND

Previous studies examining sex-differences in facial emotion recognition (FER) in psychosis yielded inconsistent results. Although females are considered to be superior in FER in health, it remains unclear whether the specific sex-difference is present in psychosis. We aimed to examine whether women and men differ in FER ability in health and in psychosis, and to explore potential sex differences in the illness' effects on FER.

METHODS

Remitted psychotic patients and controls were assessed using the CANTAB Emotion Recognition Task (ERT) examining accuracies/response latencies in identifying basic emotional expressions. General linear model was performed to assess the effects of group, sex and their interactions on ERT performance.

RESULTS

Healthy females showed FER advantage in comparison to healthy males, while the aforementioned sex-difference was not observed in remitted psychotic patients. Our results also demonstrated the existence of overall FER deficit in psychosis in comparison to healthy controls, as well as the differential illness' effects on the recognition accuracy of facial expression of anger in males and females-suggesting that females with psychotic disorders undergo more profound deterioration of FER ability than their male counterparts.

CONCLUSION

The assessment of sex-differences in FER and other important features of psychosis is important for better understanding of its neurobiological basis and for the development of targeted treatments for improved functioning.

Sexual Behavior in Patients with Psychosis Admitted to a Hospital Unit

The sexual dimension is part of a person's functionality. Patients with mental disorders have the same sexual needs as any other person, although they may not always be recognized. This is a retrospective observational study to describe the information on sexuality of patients with mental disorders, admitted to an acute short-stay inpatient unit between 2011 and 2015. We analyzed 293 clinical histories of patients, comprising diagnoses in the ICD-10 (International Classification of Diseases) between F20 and F29, inclusively. The information collected corresponded to the beginning of hospitalization, its duration and discharge. The results showed that 24% of the patients had sexual delusions. These delusions were more frequent in women, who in turn had more emotional symptoms, persecutory deception being the most common. There were few reports found on sexual dysfunction. In conclusion, the lack of data in the reports shows little recognition of sexuality in hospitalized patients with mental disorder, highlighting the need to promote the training of health personnel.

The Effect of Age, Race, and Sex on Social Cognitive Performance in Individuals With Schizophrenia

Age, race, and sex are linked to social cognitive performance among healthy individuals, but whether similar effects are evident in schizophrenia is unknown. Data from 170 individuals with schizophrenia or schizoaffective disorder and 98 healthy controls were used to examine relations between these demographic factors and performance across multiple domains and measures of social cognition. Sex was not related to performance on any domain, but older age was related to poorer emotion recognition from dynamic stimuli in both patients and controls. In patients, older age was also associated with better abilities to decipher hints. Both Caucasian patients and controls performed better than African American individuals on emotion recognition and mental state attribution tasks that use only Caucasian individuals as visual stimuli. Findings suggest rather limited influences of demographic factors but do demonstrate normative age and race effects among patients. Findings also highlight important methodological considerations for measurement of social cognition.