[From external assessment of pain to automated multimodal measurement of pain intensity : Narrative review of state of research and clinical perspectives]

BACKGROUND

In patients with limited communication skills, the use of conventional scales or external assessment is only possible to a limited extent or not at all. Multimodal pain recognition based on artificial intelligence (AI) algorithms could be a solution.

OBJECTIVE

Overview of the methods of automated multimodal pain measurement and their recognition rates that were calculated with AI algorithms.

METHODS

In April 2018, 101 studies on automated pain recognition were found in the Web of Science database to illustrate the current state of research. A selective literature review with special consideration of recognition rates of automated multimodal pain measurement yielded 14 studies, which are the focus of this review.

RESULTS

The variance in recognition rates was 52.9-55.0% (pain threshold) and 66.8-85.7%; in nine studies the recognition rate was ≥80% (pain tolerance), while one study reported recognition rates of 79.3% (pain threshold) and 90.9% (pain tolerance).

CONCLUSION

Pain is generally recorded multimodally, based on external observation scales. With regard to automated pain recognition and on the basis of the 14 selected studies, there is to date no conclusive evidence that multimodal automated pain recognition is superior to unimodal pain recognition. In the clinical context, multimodal pain recognition could be advantageous, because this approach is more flexible. In the case of one modality not being available, e.g., electrodermal activity in hand burns, the algorithm could use other modalities (video) and thus compensate for missing information.

The uulmMAC Database-A Multimodal Affective Corpus for Affective Computing in Human-Computer Interaction

In this paper, we present a multimodal dataset for affective computing research acquired in a human-computer interaction (HCI) setting. An experimental mobile and interactive scenario was designed and implemented based on a gamified generic paradigm for the induction of dialog-based HCI relevant emotional and cognitive load states. It consists of six experimental sequences, inducing Interest, Overload, Normal, Easy, Underload, and Frustration. Each sequence is followed by subjective feedbacks to validate the induction, a respiration baseline to level off the physiological reactions, and a summary of results. Further, prior to the experiment, three questionnaires related to emotion regulation (ERQ), emotional control (TEIQue-SF), and personality traits (TIPI) were collected from each subject to evaluate the stability of the induction paradigm. Based on this HCI scenario, the University of Ulm Multimodal Affective Corpus (uulmMAC), consisting of two homogenous samples of 60 participants and 100 recording sessions was generated. We recorded 16 sensor modalities including 4 × video, 3 × audio, and 7 × biophysiological, depth, and pose streams. Further, additional labels and annotations were also collected. After recording, all data were post-processed and checked for technical and signal quality, resulting in the final uulmMAC dataset of 57 subjects and 95 recording sessions. The evaluation of the reported subjective feedbacks shows significant differences between the sequences, well consistent with the induced states, and the analysis of the questionnaires shows stable results. In summary, our uulmMAC database is a valuable contribution for the field of affective computing and multimodal data analysis: Acquired in a mobile interactive scenario close to real HCI, it consists of a large number of subjects and allows transtemporal investigations. Validated via subjective feedbacks and checked for quality issues, it can be used for affective computing and machine learning applications.

Multi-Modal Signals for Analyzing Pain Responses to Thermal and Electrical Stimuli

The assessment of pain relies mostly on methods that require a person to communicate. However, for people with cognitive and verbal impairments, existing methods are not sufficient as they lack reliability and validity. To approach this problem, recent research focuses on an objective pain assessment facilitated by parameters of responses derived from physiology, and video and audio signals. To develop reliable automated pain recognition systems, efforts have been made in creating multimodal databases in order to analyze pain and detect valid pain patterns. While the results are promising, they only focus on discriminating pain or pain intensities versus no pain. In order to advance this, research should also consider the quality and duration of pain as they provide additional valuable information for more advanced pain management. To complement existing databases and the analysis of pain regarding quality and length, this paper proposes a psychophysiological experiment to elicit, measure, and collect valid pain reactions. Participants are subjected to painful stimuli that differ in intensity (low, medium, and high), duration (5 s / 1 min), and modality (heat / electric pain) while audio, video (e.g., facial expressions, body gestures, facial skin temperature), and physiological signals (e.g., electrocardiogram [ECG], skin conductance level [SCL], facial electromyography [EMG], and EMG of M. trapezius) are being recorded. The study consists of a calibration phase to determine a subject's individual pain range (from low to intolerable pain) and a stimulation phase in which pain stimuli, depending on the calibrated range, are applied. The obtained data may allow refining, improving, and evaluating automated recognition systems in terms of an objective pain assessment. For further development of such systems and to investigate pain reactions in more detail, additional pain modalities such as pressure, chemical, or cold pain should be included in future studies. Recorded data of this study will be released as the "X-ITE Pain Database".

Head movements and postures as pain behavior

Pain assessment can benefit from observation of pain behaviors, such as guarding or facial expression, and observational pain scales are widely used in clinical practice with nonverbal patients. However, little is known about head movements and postures in the context of pain. In this regard, we analyze videos of three publically available datasets. The BioVid dataset was recorded with healthy participants subjected to painful heat stimuli. In the BP4D dataset, healthy participants performed a cold-pressor test and several other tasks (meant to elicit emotion). The UNBC dataset videos show shoulder pain patients during range-of-motion tests to their affected and unaffected limbs. In all videos, participants were sitting in an upright position. We studied head movements and postures that occurred during the painful and control trials by measuring head orientation from video over time, followed by analyzing posture and movement summary statistics and occurrence frequencies of typical postures and movements. We found significant differences between pain and control trials with analyses of variance and binomial tests. In BioVid and BP4D, pain was accompanied by head movements and postures that tend to be oriented downwards or towards the pain site. We also found differences in movement range and speed in all three datasets. The results suggest that head movements and postures should be considered for pain assessment and research. As additional pain indicators, they possibly might improve pain management whenever behavior is assessed, especially in nonverbal individuals such as infants or patients with dementia. However, in advance more research is needed to identify specific head movements and postures in pain patients.

The Impact of Sex Differences on Odor Identification and Facial Affect Recognition in Patients with Schizophrenia Spectrum Disorders

BACKGROUND

Social interactive functions such as facial emotion recognition and smell identification have been shown to differ between women and men. However, little is known about how these differences are mirrored in patients with schizophrenia and how these abilities interact with each other and with other clinical variables in patients vs. healthy controls.

METHODS

Standardized instruments were used to assess facial emotion recognition [Facially Expressed Emotion Labelling (FEEL)] and smell identification [University of Pennsylvania Smell Identification Test (UPSIT)] in 51 patients with schizophrenia spectrum disorders and 79 healthy controls; furthermore, working memory functions and clinical variables were assessed.

RESULTS

In both the univariate and the multivariate results, illness showed a significant influence on UPSIT and FEEL. The inclusion of age and working memory in the MANOVA resulted in a differential effect with sex and working memory as remaining significant factors. Duration of illness was correlated with both emotion recognition and smell identification in men only, whereas immediate general psychopathology and negative symptoms were associated with emotion recognition only in women.

CONCLUSION

Being affected by schizophrenia spectrum disorder impacts one's ability to correctly recognize facial affects and identify odors. Converging evidence suggests a link between the investigated basic and social cognitive abilities in patients with schizophrenia spectrum disorders with a strong contribution of working memory and differential effects of modulators in women vs. men.

Affective Computing and the Impact of Gender and Age

Affective computing aims at the detection of users’ mental states, in particular, emotions and dispositions during human-computer interactions. Detection can be achieved by measuring multimodal signals, namely, speech, facial expressions and/or psychobiology. Over the past years, one major approach was to identify the best features for each signal using different classification methods. Although this is of high priority, other subject-specific variables should not be neglected. In our study, we analyzed the effect of gender, age, personality and gender roles on the extracted psychobiological features (derived from skin conductance level, facial electromyography and heart rate variability) as well as the influence on the classification results. In an experimental human-computer interaction, five different affective states with picture material from the International Affective Picture System and ULM pictures were induced. A total of 127 subjects participated in the study. Among all potentially influencing variables (gender has been reported to be influential), age was the only variable that correlated significantly with psychobiological responses. In summary, the conducted classification processes resulted in 20% classification accuracy differences according to age and gender, especially when comparing the neutral condition with four other affective states. We suggest taking age and gender specifically into account for future studies in affective computing, as these may lead to an improvement of emotion recognition accuracy.

The FAMULATUR PLUS as an innovative approach for teaching physical examination skills

The FAMULATUR PLUS is an innovative approach to teaching physical examination skills. The concept is aimed at medical students during the clinical part of their studies and includes a clinical traineeship (English for "Famulatur") extended to include various courses ("PLUS"). The courses are divided into clinical examination courses and problembased-learning (PBL) seminars. The concept's special feature is the full integration of these courses into a 30-day hospital traineeship. The aim is to facilitate the transfer of knowledge from the courses into daily practice. Each week of the FAMULATUR PLUS is structured in line with the courses and focuses on a particular part of the body (e.g., abdomen). A physical examination course under the supervision of a physician is offered at the beginning of the week. Here, medical students learn the relevant examination techniques by practicing on each other (partner exercises). Subsequently, the techniques taught are applied independently during everyday work on the ward, corrected by the supervisor, if necessary, and thereby reinforced. The final POL seminar takes place towards the end of the week. Possible differential diagnoses are developed based on a clinical case study. The goal is to check these by taking a fictitious medical history and performing a physical examination, as well as to make a preliminary diagnosis. Finally, during the PBL seminar, medical students will be shown how physical examination techniques can be efficiently applied in the diagnosis of common cardinal symptoms (e.g., abdominal pain). The initial implementation of the FAMULATUR PLUS proved the practical feasibility of the concept. In addition, the accompanying evaluation showed that the participants of the pilot project improved with regard to their practical physical examination skills.

Recognition of Intensive Valence and Arousal Affective States via Facial Electromyographic Activity in Young and Senior Adults

Background

Research suggests that interaction between humans and digital environments characterizes a form of companionship in addition to technical convenience. To this effect, humans have attempted to design computer systems able to demonstrably empathize with the human affective experience. Facial electromyography (EMG) is one such technique enabling machines to access to human affective states. Numerous studies have investigated the effects of valence emotions on facial EMG activity captured over the corrugator supercilii (frowning muscle) and zygomaticus major (smiling muscle). The arousal emotion, specifically, has not received much research attention, however. In the present study, we sought to identify intensive valence and arousal affective states via facial EMG activity.

Methods

Ten blocks of affective pictures were separated into five categories: neutral valence/low arousal (0VLA), positive valence/high arousal (PVHA), negative valence/high arousal (NVHA), positive valence/low arousal (PVLA), and negative valence/low arousal (NVLA), and the ability of each to elicit corresponding valence and arousal affective states was investigated at length. One hundred and thirteen participants were subjected to these stimuli and provided facial EMG. A set of 16 features based on the amplitude, frequency, predictability, and variability of signals was defined and classified using a support vector machine (SVM).

Results

We observed highly accurate classification rates based on the combined corrugator and zygomaticus EMG, ranging from 75.69% to 100.00% for the baseline and five affective states (0VLA, PVHA, PVLA, NVHA, and NVLA) in all individuals. There were significant differences in classification rate accuracy between senior and young adults, but there was no significant difference between female and male participants.

Conclusion

Our research provides robust evidences for recognition of intensive valence and arousal affective states in young and senior adults. These findings contribute to the successful future application of facial EMG for identifying user affective states in human machine interaction (HMI) or companion robotic systems (CRS).

Pain Intensity Recognition Rates via Biopotential Feature Patterns with Support Vector Machines

BACKGROUND

The clinically used methods of pain diagnosis do not allow for objective and robust measurement, and physicians must rely on the patient's report on the pain sensation. Verbal scales, visual analog scales (VAS) or numeric rating scales (NRS) count among the most common tools, which are restricted to patients with normal mental abilities. There also exist instruments for pain assessment in people with verbal and / or cognitive impairments and instruments for pain assessment in people who are sedated and automated ventilated. However, all these diagnostic methods either have limited reliability and validity or are very time-consuming. In contrast, biopotentials can be automatically analyzed with machine learning algorithms to provide a surrogate measure of pain intensity.

METHODS

In this context, we created a database of biopotentials to advance an automated pain recognition system, determine its theoretical testing quality, and optimize its performance. Eighty-five participants were subjected to painful heat stimuli (baseline, pain threshold, two intermediate thresholds, and pain tolerance threshold) under controlled conditions and the signals of electromyography, skin conductance level, and electrocardiography were collected. A total of 159 features were extracted from the mathematical groupings of amplitude, frequency, stationarity, entropy, linearity, variability, and similarity.

RESULTS

We achieved classification rates of 90.94% for baseline vs. pain tolerance threshold and 79.29% for baseline vs. pain threshold. The most selected pain features stemmed from the amplitude and similarity group and were derived from facial electromyography.

CONCLUSION

The machine learning measurement of pain in patients could provide valuable information for a clinical team and thus support the treatment assessment.

The complex duration perception of emotional faces: effects of face direction

The perceived duration of emotional face stimuli strongly depends on the expressed emotion. But, emotional faces also differ regarding a number of other features like gaze, face direction, or sex. Usually, these features have been controlled by only using pictures of female models with straight gaze and face direction. Doi and Shinohara (2009) reported that an overestimation of angry faces could only be found when the model's gaze was oriented toward the observer. We aimed at replicating this effect for face direction. Moreover, we explored the effect of face direction on the duration perception sad faces. Controlling for the sex of the face model and the participant, female and male participants rated the duration of neutral, angry, and sad face stimuli of both sexes photographed from different perspectives in a bisection task. In line with current findings, we report a significant overestimation of angry compared to neutral face stimuli that was modulated by face direction. Moreover, the perceived duration of sad face stimuli did not differ from that of neutral faces and was not influenced by face direction. Furthermore, we found that faces of the opposite sex appeared to last longer than those of the same sex. This outcome is discussed with regards to stimulus parameters like the induced arousal, social relevance, and an evolutionary context.

Similarities and differences of emotions in human-machine and human-human interactions: what kind of emotions are relevant for future companion systems?

Cognitive-technical intelligence is envisioned to be constantly available and capable of adapting to the user's emotions. However, the question is: what specific emotions should be reliably recognised by intelligent systems? Hence, in this study, we have attempted to identify similarities and differences of emotions between human-human (HHI) and human-machine interactions (HMI). We focused on what emotions in the experienced scenarios of HMI are retroactively reflected as compared with HHI. The sample consisted of N = 145 participants, who were divided into two groups. Positive and negative scenario descriptions of HMI and HHI were given by the first and second groups, respectively. Subsequently, the participants evaluated their respective scenarios with the help of 94 adjectives relating to emotions. The correlations between the occurrences of emotions in the HMI versus HHI were very high. The results do not support the statement that only a few emotions in HMI are relevant.

The effect of forced choice on facial emotion recognition: a comparison to open verbal classification of emotion labels

OBJECTIVE

This article includes the examination of potential methodological problems of the application of a forced choice response format in facial emotion recognition.

METHODOLOGY

33 subjects were presented with validated facial stimuli. The task was to make a decision about which emotion was shown. In addition, the subjective certainty concerning the decision was recorded.

RESULTS

The detection rates are 68% for fear, 81% for sadness, 85% for anger, 87% for surprise, 88% for disgust, and 94% for happiness, and are thus well above the random probability.

CONCLUSION

This study refutes the concern that the use of forced choice formats may not adequately reflect actual recognition performance. The use of standardized tests to examine emotion recognition ability leads to valid results and can be used in different contexts. For example, the images presented here appear suitable for diagnosing deficits in emotion recognition in the context of psychological disorders and for mapping treatment progress.

Emotional ambivalence and post-traumatic stress disorder (PTSD) in soldiers during military operations

Objective: This pilot study examined the extent to which a specific mechanism of emotion regulation – namely, ambivalence concerning the expressiveness of German soldiers’ emotions – affects the severity of PTSD symptoms after a military operation.

Methodology: A survey was conducted at three points in time among 66 soldiers deployed on military crisis operations. The Harvard Trauma Questionaire (HTQ), the Ambivalence over Emotional Expressiveness Questionnaire (AEQ-G18), and a questionnaire on the particular stress of German soldiers during military operations were used.

Results: The study showed a significant correlation between emotional ambivalence and traumatization. Furthermore, it was shown that the subjective stress of soldiers leading up to deployment is more pronounced when emotional ambivalence is stronger in the context of military operations. This particular stress is greater before and during the military operation than after. Compared to a male control sample, the average AEQ-G18 scores of the soldier sample examined here are considerably lower.

Conclusion: This pilot study clearly indicates that the AEQ-G18 could be a suitable predictor of the psychological burden on soldiers. The correlations between emotional ambivalence on the one hand and the particular and post-traumatic stressors on the other hand are not only statistically significant in the present pilot study, but may also be relevant as risk factors. It is, therefore, necessary to conduct more extensive studies on soldiers participating in military operations to verify the results of this pilot study.

[Mortui vivos docent?--experienced burdens of medical students in the gross anatomy course]

The dissection course (here abbreviated: PK) is still an obligatory part of medical schools in Germany. In this study we investigated the experiences and burdens of medical students in gross anatomy, especially "distancing from the human body".This study was carried out three times with the self-composed questionnaire BF-PK: before, while and after PK. In total 371 students participated in the PK. 297 students participated at measurement 1. In advance 25-30% of the medical students reported anxiety and emotional inhibition, during the course only 7-10%. The coping strategy "distancing from the human body" was prominent. Anxiety, emotional inhibition and disgust remained for 5-10% of the participants.The gross anatomy course causes emotional stress for a considerable amount of medical students. For those students that were not able to overcome the mental stress themselves service offers should be implemented.

Alexithymic and somatisation scores in patients with temporomandibular pain disorder correlate with deficits in facial emotion recognition

Current studies suggest dysfunctional emotional processing as a key factor in the aetiology of temporomandibular disorder (TMD). Investigating facial emotion recognition (FER) may offer an elegant and reliable way to study emotional processing in patients with TMD. Twenty patients with TMD and the same number of age-, sex- and education-matched controls were measured with the Facially Expressed Emotion Labelling (FEEL) test, the 26-item Toronto Alexithymia Scale (TAS-26), the Screening for Somatoform Symptoms (SOMS-2a), the German Pain Questionnaire and the 21-item Hamilton Depression Rating Scale (HAMD). The patients had significantly lower Total FEEL Scores (P = 0·021) as compared to the controls, indicating a lower accuracy of FER. Furthermore, we were able to demonstrate significant group differences with respect to the following issues: patients were more alexithymic (P = 0·006), stated more somatoform symptoms (P < 0·004) and had higher depressive scores in the HAMD (P < 0·003). The factors alexithymia and somatisation could explain 31% (adjusted 27%) of the variance of the FEEL Scores in the sample. The estimation of the standardised regression coefficients suggests an equivalent influence of TAS-26 and SOMS-2a on the FEEL Scores, whereas 'group' (patients versus healthy controls) and depressive symptoms did not contribute significantly to the model. Our findings highlight FER deficits in patients with TMD, which are partially explained by concomitant alexithymia and somatisation. As suggested previously, impaired FER in patients with TMD may further point to probable aetiological proximities between TMD and somatoform disorders.

The influence of neuroticism and psychological symptoms on the assessment of images in three-dimensional emotion space

Objective: The present study investigated the influence of neuroticism (NEO Five-Factor Inventory (NEO-FFI)) and psychological symptoms (Brief Symptom Inventory (BSI)) on pleasure, arousal, and dominance (PAD) ratings of the International Affective Picture System (IAPS).

Methods: The subjects (N=131) were presented with images from the IAPS (30 images) and new images (30 images). The influence of neuroticism and BSI (median split: high vs. low) on the assessment of pleasure, arousal and dominance of the images was examined. Correlations of pleasure, arousal and dominance were presented in a 3-D video animation.

Results: Subjects with high scores (compared to subjects with low scores by median split) of neuroticism and psychological symptoms of the BSI rated the presented emotional images more negative in the valence dimension (pleasure), higher in arousal and less dominant.

Conclusion: Neuroticism and psychological symptoms influence the subjective emotional evaluation of emotional images. Therefore the location in the three-dimensional emotion space depends on individual differences. Such differences must be kept in mind, if correlations between emotion ratings and other variables like psychobiological measures are analyzed.

Neural correlates of the perception of dynamic versus static facial expressions of emotion

Aim: This study investigated brain areas involved in the perception of dynamic facial expressions of emotion.

Methods: A group of 30 healthy subjects was measured with fMRI when passively viewing prototypical facial expressions of fear, disgust, sadness and happiness. Using morphing techniques, all faces were displayed as still images and also dynamically as a film clip with the expressions evolving from neutral to emotional.

Results: Irrespective of a specific emotion, dynamic stimuli selectively activated bilateral superior temporal sulcus, visual area V5, fusiform gyrus, thalamus and other frontal and parietal areas. Interaction effects of emotion and mode of presentation (static/dynamic) were only found for the expression of happiness, where static faces evoked greater activity in the medial prefrontal cortex.

Conclusions: Our results confirm previous findings on neural correlates of the perception of dynamic facial expressions and are in line with studies showing the importance of the superior temporal sulcus and V5 in the perception of biological motion. Differential activation in the fusiform gyrus for dynamic stimuli stands in contrast to classical models of face perception but is coherent with new findings arguing for a more general role of the fusiform gyrus in the processing of socially relevant stimuli.

Expression intensity, gender and facial emotion recognition: Women recognize only subtle facial emotions better than men

Two experiments were conducted in order to investigate the effect of expression intensity on gender differences in the recognition of facial emotions. The first experiment compared recognition accuracy between female and male participants when emotional faces were shown with full-blown (100% emotional content) or subtle expressiveness (50%). In a second experiment more finely grained analyses were applied in order to measure recognition accuracy as a function of expression intensity (40%-100%). The results show that although women were more accurate than men in recognizing subtle facial displays of emotion, there was no difference between male and female participants when recognizing highly expressive stimuli.

Pain and emotional processing in psychological trauma

Extreme psychological and physical traumas cause dramatic symptom patterns which are insufficiently described by the psychiatric diagnostic criteria of post traumatic stress disorders (PTSD). Additionally, due to the neurobiological proximity and similarity of processing mechanisms of physical and psychological pain stimulation and extremely negative emotions, the patients often suffer from persistent pains even after the somatic healing process is completed. Epidemiological studies confirm the joint occurrence of pain and PTSD. The close relationship and the etiological and behavioral similarities of both disorders have led to the development of joined vulnerability and mutual maintenance models. The particular suffering of patients with PTSD due to chronic pain necessitates pain-therapeutic interventions. On the other hand, in chronic pain patients, the etiological role of severe traumas should be considered.

Habitual emotion regulation strategies and depressive symptoms in healthy subjects predict fMRI brain activation patterns related to major depression

The response-focused emotion regulation style 'Expressive suppression' has been associated with symptoms of lower psychological well-being and increased function magnetic resonance imaging (fMRI) activation of the sublenticular extended amygdala (SLEA) in patients with major depression. Extending prior studies on active emotion regulation, we were interested in effects of habitual emotion regulation on neurobiology. Thirty subjects with either relatively high or low suppression scores as assessed with the Emotion Regulation Questionnaire without symptoms of clinical depression participated in the study. They were instructed to expect and then perceive emotionally unpleasant, pleasant or neutral stimuli selected from the International Affective Picture System that were announced by a congruent cue during fMRI. In the subjects with high suppression scores, decreased activation of the orbital medial prefrontal cortex (oMFC) when expecting negative pictures and increased activation of the SLEA upon presentation of neutral stimuli were found. Subclinical depression ratings independently of suppression scores in the healthy subjects were positively correlated with brain activation in the SLEA when expecting negative pictures. SLEA hyperactivity may represent an emotional responsivity that involves less successful habitual emotion regulation and a tendency to depressed mood in healthy subjects, as shown in patients with major depression. Decreased anticipatory oMFC activation may parallel a lack of antecedent emotion regulation in subjects with high suppression scores, representing another neurobiological predictor of lower mental well-being.

Subjektive Krankheitskonzepte bei depressiven Störungen

Zusammenfassung. Depressive Störungen sind ein weit verbreitetes und oft chronisches Gesundheitsproblem mit erheblichem Leiden des Individuums und hohen Gesundheitskosten. Die subjektiven Wahrnehmungen einer solchen Erkrankung korrelieren mit deren Bewältigung. Dies kann insbesondere für depressive Störungen angenommen werden, da bei Depressionen die dysfunktionalen kognitiven Bewertungsprozesse sowohl ätiologisch relevant sind als auch die Krankheitsbewältigung ungünstig beeinflussen. Diese Studie hat zum Ziel, Zusammenhänge zwischen Dimensionen der Krankheitskonzepte von Patientinnen und Patienten, der depressiven Symptomatik und positivem Affekt zu untersuchen. Dazu wurden 60 Patientinnen und Patienten einer stationären psychosomatischen Rehabilitationsmaßnahme sowohl im Quer- als auch im Längsschnitt bis zur dreimonatigen Katamnese nach Entlassung befragt. Die Studienteilnehmer wurden weiterhin randomisiert einer Expressiven Schreib- oder einer Kontrollbedingung zugeteilt, um die Effekte dieser Minimalintervention als adjunkte Maßnahme zu untersuchen. Die Ergebnisse zeigen, dass die Wahrnehmung des zeitlichen Verlaufs und des Schwergrads der Depression sowie die emotionalen Repräsentationen der eigenen Erkrankung mit vermehrten depressiven Symptomen assoziiert sind. Im Längsschnitt zeigt sich, dass die Ausprägung kontrollbezogener subjektiver Krankheitskonzepte mit unterschiedlichen Verläufen der depressiven Symptomatik und des Wohlbefindens über einen Zeitraum von 3 Monaten nach Beendigung des stationären Aufenthalts im Zusammenhang stehen. Die subjektiv erlebte Kohärenz des Krankheitskonzepts war nur mit dem Wohlbefinden, aber nicht mit Depression verbunden. Expressives Schreiben konnte in dieser kleinen Gruppe zusätzlich zum stationären Aufenthalt zwar keine signifikanten Verbesserungen erzielen, jedoch zeigt sich, dass Personen mit einer stark ausgeprägten Neigung zu emotionalen Repräsentationen tendenziell mehr vom Schreiben profitieren und dass sich dieser Effekt über die Zeit zu verstärken scheint.

The gross anatomy course: an analysis of its importance

The gross anatomy dissection course is a cost-intensive piece of undergraduate medical education that students and professionals alike describe as very important within the overall medical curriculum. We sought to understand more explicitly students' valuation of gross anatomy as an "important" course and so developed a quantitative longitudinal questionnaire. Medical students (n = 124) enrolled in the winter term 2006/2007 gross anatomy course at the Ulm University Faculty of Medicine were surveyed anonymously prior to, in the middle of, and at the end of the dissection course. Subgroups of students expressing rising or falling opinions of course value were identified and correlated with student opinions about the course's ability to convey professional competencies. Five-point Likert scales were used for each survey item, which included such standardized instruments as the NeoFFI, BSI, and FBM. The study confirmed that medical students believe dissection to be valuable. Students indicated that participation in the course facilitated acquisition of anatomy knowledge as well as skills related to teamwork, coping with stress, and, to a lesser extent, time management. Students also noted that they developed less empathy than expected beforehand. Significant subgroup differences were observed relative to the competencies of teamwork, stress coping strategies, and empathy, as well as in students' stress levels associated with having to take a dissection course. Our study builds on previous work that has shown dissection courses help students develop professional competencies. The increase in professionalism might be a reason for the generally high value students place on the gross anatomy dissection course.

[Regulation of emotions and alexithymia: a correlative study]

This study assessed the correlations between Alexithymia and the recognition and regulation of emotions in a sample of healthy subjects. The first focus was on the relation between self-rated alexithymia (TAS-20) and objectively measured emotion recognition ability from faces and scenic descriptions of social interactions. Furthermore expressive suppression as a means of emotion regulation was related to alexithymia. Using the new factorial structure for the German version of the TAS-20, we were able to show differential effects: Objectively assessed emotion recognition correlated negatively with external thinking and positively with the importance of emotional introspection, but not with the core of alexithymia, particularly difficulties identifying and describing emotions. Expressive suppression on the other hand correlated mainly with this central feature of alexithymia. This overlap of constructs suggests to including complementary test in the assessment of alexithymia.

Facial emotion recognition and alexithymia in adults with somatoform disorders

OBJECTIVE

The primary aim of this study was to investigate facial emotion recognition in patients with somatoform disorders (SFD). Also of interest was the extent to which concurrent alexithymia contributed to any changes in emotion recognition accuracy.

METHODS

Twenty patients with SFD and twenty healthy, age, sex and education matched, controls were assessed with the Facially Expressed Emotion Labelling Test of facial emotion recognition and the 26-item Toronto Alexithymia Scale (TAS-26).

RESULTS

Patients with SFD exhibited elevated alexithymia symptoms relative to healthy controls. Patients with SFD also recognized significantly fewer emotional expressions than did the healthy controls. However, the group difference in emotion recognition accuracy became nonsignificant once the influence of alexithymia was controlled for statistically.

CONCLUSIONS

This suggests that the deficit in facial emotion recognition observed in the patients with SFD was most likely a consequence of concurrent alexithymia. Impaired facial emotion recognition observed in the patients with SFD could plausibly have a negative influence on these individuals' social functioning.

Facial emotion recognition and alexithymia in adults with somatoform disorders

The primary aim of this study was to investigate facial emotion recognition (FER) in patients with somatoform disorders (SFD). Also of interest was the extent to which concurrent alexithymia contributed to any changes in emotion recognition accuracy. Twenty patients with SFD and 20 healthy, age, sex and education matched, controls were assessed with the Facially Expressed Emotion Labelling Test of FER and the 26-item Toronto Alexithymia Scale. Patients with SFD exhibited elevated alexithymia symptoms relative to healthy controls. Patients with SFD also recognized significantly fewer emotional expressions than did the healthy controls. However, the group difference in emotion recognition accuracy became nonsignificant once the influence of alexithymia was controlled for statistics. This suggests that the deficit in FER observed in the patients with SFD was most likely a consequence of concurrent alexithymia. It should be noted that neither depression nor anxiety was significantly related to emotion recognition accuracy, suggesting that these variables did not contribute the emotion recognition deficit. Impaired FER observed in the patients with SFD could plausibly have a negative influence on these individuals' social functioning.

Symmetries in a standardized set of emotional facial expressions (JACFEE)

OBJECTIVE

To investigate possible asymmetry in a widely used set of standardized emotional facial expressions (JACFEE, Japanese and Caucasian Facial Expressions of Emotion).

METHOD

Chimeric pictures with either two left (LL) or two right (RR) halves of the emotional face were produced from the original set and presented to healthy subjects who rated their intensity.

RESULTS

With the exception of "happiness", for all other emotions (sadness, disgust, anger, fear and surprise) LL and RR composites were given comparable intensities, speaking for high symmetry in the faces.

CONCLUSIONS

The JACFEE facial emotion pictures are mostly symmetrical, possibly due to their standardisation procedure when producing the pictures.

Ambivalence over Emotional Expressiveness: psychometric evaluation of the AEQ-G18 in a representative German survey

OBJECTIVE

The present study evaluates a questionnaire on ambivalence over emotional expressiveness, the AEQ-G18 [1], [2], with regard to its statistical parameters, the influence of socio-demographic variables, and its interrelationship with depression and quality of life.

METHODS

A representative German sample (1009 participants from East Germany and 1034 participants from West Germany) completed the AEQ-G18 [1], [2], the depression screener DEP-2 [3], the Profile of Mood States POMS [4], the revised Beck Depression Inventory BDI [5], the short form of the Patient Health Questionnaire PHQ-9 [6] and the SF-36 health survey questionnaire [7].

RESULTS

Our study was only partially able to confirm the two factors effect ambivalence and competence ambivalence postulated by Traue et al. [1], [2]. Women scored somewhat higher on the scale effect ambivalence. Participants with a higher educational background exhibited less emotional ambivalence. Emotional ambivalence correlated positively with depression and reduced psychological state of health (depression, fatigue, and anger), whereas it correlated negatively with health-related quality of life and positive attitude (vigor). In addition to the scales of the AEQ-G18, we developed a short form, the AEQ-G10, and provide normative data for the AEQ-G18 and the AEQ-G10.

CONCLUSION

This study presents normative data for two variations of a clinically relevant, valid, and time-efficient diagnostic instrument used for the evaluation of ambivalence over emotional expressiveness, the AEQ-G18 and its short form, the AEQ-G10.

Emotion recognition patterns in patients with panic disorder

Recognition of facially expressed emotions is essential in social interaction. For patients with social phobia, general anxiety disorders, and comorbid anxiety, deficits in their emotion recognition and specific biases have already been reported. This is the first study to investigate facial emotion recognition patterns in patients with panic disorder [PD]. We assumed a general performance deficit in patients with PD. Exploratory analyses should have revealed recognition patterns and specific types of errors. Additionally, we checked the influence of depression and anxiety symptoms, per se, on recognition. A carefully selected group of 37 patients with PD without agoraphobia [DSM-IV 300.01] and no psychiatric comorbidity was compared to 43 controls matched for age and sex. We assessed emotion recognition with the FEEL Test [Facially Expressed Emotion Labeling], using faces displaying fear, anger, sadness, happiness, disgust, and anger. Recognition of emotions in patients with PD was significantly worse than that of controls, specifically, sadness and anger. They also showed a tendency to interpret nonanger emotions as anger. Interestingly, in patients with PD, depressive symptoms were more strongly related to emotion recognition than were anxiety symptoms, and recognition differences between patients and controls disappeared when we controlled for depression. This effect is discussed in the context of previous studies reporting emotion recognition deficits of depressed patients.

Emotionale Ambivalenz, Körperbeschwerden, Depressivität und soziale Interaktion

Zusammenfassung. Es wurde eine deutsche Version (AEQ-G18) des Ambivalence over Emotional Expressiveness Questionnaire (AEQ) von King und Emmons (1990) mit 18 Items erarbeitet. In drei voneinander unabhängigen Studien wurden korrelative Zusammenhänge zwischen emotionaler Ambivalenz, Krankheitsverhalten, Depressivität und sozialer Unterstützung untersucht. In der ersten Studie ergab die Faktorenanalyse der übersetzten AEQ-Items eine Faktorenstruktur mit zwei Faktoren: Kompetenzambivalenz und Effektambivalenz. Kompetenzambivalenz bezieht sich auf Zweifel und Unsicherheiten hinsichtlich der Fähigkeit positive Emotionen zu zeigen, und Effektambivalenz erfasst Befürchtungen über die Auswirkungen von negativ emotionaler Expressivität. In allen Studien (mit Stichproben aus der Allgemeinbevölkerung, von Studenten und von Patienten der Allgemeinmedizin) korrelierten Körpersymptome, Depressivität und soziale Unterstützung differenziert mit beiden Ambivalenzfaktoren des AEQ-G18. Diese Zusammenhänge schwächten sich jedoch nach Herauspartialisierung von Neurotizismus ab.

Alexithymia and facial emotion recognition in patients with eating disorders

OBJECTIVE

Patients with anorexia or bulimia nervosa are reported to show high levels of alexithymia and to have difficulties recognizing facially displayed emotions. The current study tested whether it could be that facial emotion recognition is a basic skill that is independent from alexithymia.

METHOD

We assessed emotion recognition skills and alexithymia in a group of 79 female inpatients with eating disorders and compared them with a group of 78 healthy female controls. Instruments used were the Toronto Alexithymia Scale, the Facially Expressed Emotion Labeling (FEEL) test, and the revised Symptom Check List (SCL-90-R).

RESULTS

There were no significant differences between patients and controls in their emotion recognition scores, but patients with eating disorders displayed significantly more alexithymia and psychopathology. Emotion recognition in patients was not related to alexithymia, psychopathology, or clinical symptoms.

CONCLUSION

We suggest that the reported alexithymia of patients with eating disorders is complex and independent from basic facial emotion recognition.

Psychiatric treatment for extremely traumatized civil war refugees from former Yugoslavia. Possibilities and limitations of integrating psychotherapy and medication

Patients with a history of extremely traumatic experiences show a complex pattern of psychological and physical disorders which represents a special challenge for psychiatric care. This problem is described using the example of the psychiatric/psychotherapeutic treatment of 13 civil war refugees with a history of traumatic experiences from former Yugoslavia in psychiatric treatment at the Psychiatric Clinic of the University of Ulm. One substantial problem encountered by these patients is that, in addition to the original traumatization in their country of origin, the unstable psychosocial conditions of their legal exile condition can lead to re-traumatization which must be responded to with psychiatric treatment.

Emotion recognition in stroke patients with left and right hemispheric lesion: Results with a new instrument—the FEEL Test

The aim of this study was to investigate the effect of a stroke event on people's ability to recognize basic emotions. In particular, the hypothesis that right brain-damaged (RBD) patients would show less of emotion recognition ability compared with left brain-damaged (LBD) patients and healthy controls, was tested. To investigate this the FEEL Test (Facially Expressed Emotion Labeling) was used, a computer based psychometric test that assesses one's ability to recognize facially displayed basic emotions via a forced-choice paradigm. We examined 24 patients after a stroke event (13 RBD, 11 LBD) and compared them with a matched group of healthy controls (HC, n=29). Results showed that the stroke patients performed significantly worse in the FEEL Test than did HC (p<.001). This deficit was especially evident for negative emotions (fear, anger, sadness, and disgust). In contrast to other studies we did not find any significant differences between RBD and LBD patients in their ability to recognize emotions. These results indicate that a stroke event has a negative effect on the recognition of facially displayed emotions but suggest that this effect is apparently not dependent on the side of the brain damage.

[Awareness of memory deficits in patients with probable Alzheimer's disease]

Thirty-eight patients with Alzheimer's disease were asked to give a qualitative (estimation of memory changes) and quantitative assessment of their own performance on memory tasks and also of their relatives' performance. Qualitative assessment showed to be independent from measured memory-deficits, while the precision of quantitative prediction of performance deteriorated with increased cognitive impairment. Cognitive impairment of the demented patients did not influence the prediction of the performance of their relatives. Both, qualitative and quantitative assessment of memory performance were influenced by premorbid coping-strategies. Patients, who were attributed to use strategies of cognitive avoidance, more often claimed to have no changes in memory function or over-estimated their memory performance. The results of this investigation reveal that methodological issues influence studies on the association of meta-cognitive abilities with the severity of dementia to a great extent. They also suggest that awareness of deficits should be based on a complex, multi-dimensional concept.