Modification of affect perception deficits in schizophrenia
Introduction
It is well documented that persons with schizophrenia have deficits in their ability to perceive the affect of others. In particular, persons with schizophrenia have deficits in facial affect perception relative to both non-clinical controls and clinical subjects without psychotic features; for reviews, see Edwards et al. (1999), Hellewell and Whittaker (1998), Mandal et al. (1998), and Morrison et al. (1988). These deficits may reflect generalized poor performance, although there is also evidence of specific impairments in emotion perception [discussed in Mandal et al. (1998) and Penn et al. (1997)]. Finally, these deficits appear to have functional significance as they show an association with social functioning (Ihnen et al., 1998, Mueser et al., 1996, Penn et al., 1996).
Given the presence of facial affect perception deficits in schizophrenia, and its association with social behavior, an important question is whether these deficits can be ameliorated. This question can be addressed in a number of ways. For example, there is mixed evidence regarding the stability of facial affect perception deficits in schizophrenia; longitudinal studies indicate a trait-like deficit (Gaebel and Wolwer, 1992), whereas cross-sectional studies, comparing acutely ill with remitted patients, suggest that the deficit may be episodic (Cutting, 1981, Gessler et al., 1989). Another way of addressing this question is by examining whether facial affect perception can be modified by psychopharmacologic or psychosocial interventions. In particular, a recent study showed that Risperidone, relative to Haloperidol, had a greater effect on the performance of treatment-resistant subjects with schizophrenia on a battery of emotional perception tasks, including facial affect perception (Kee et al., 1998). Interestingly, unlike the study of cognitive deficits, there has been little empirical work on developing specific psychological strategies for remediating affect perception deficits schizophrenia. The work that has been done has typically embedded affect perception training within a broader treatment package including both cognitive and behavioral interventions (Brenner et al., 1992, Spaulding et al., 1998). Therefore, it is difficult to evaluate which interventions, if any, accounted for changes in affect perception. Thus, the development of specific psychological interventions focused on facial affect perception is needed.
In this paper, two interventions for modifying deficits in affect perception were investigated. First, there is some evidence that schizophrenia patients' performance on cognitive tasks can be improved with contingent monetary reinforcement, especially when combined with other remediation approaches [reviewed by Green (1993) and Kern et al. (1995); see Hellman et al. (1998) for an exception]. Therefore, a similar intervention was utilized in the current study. Specifically, subjects were rewarded $0.10 for each correct response on an affect identification task. This intervention not only provides a methodological link between this study and that in the cognitive remediation literature, but it also allows for the evaluation of motivation on affect identification performance (Bellack et al., 1999).
The second intervention was based on the ‘Facial Feedback Hypothesis’. According to this theory, facial actions influence experienced emotions. For example, research conducted with non-clinical samples indicates that manipulating one's face into a specific emotional expression (e.g. happiness) is associated with increased experience of that particular emotion (i.e. increased happiness) [reviewed by McIntosh (1996)]. McIntosh (1996, p. 140) has even argued that facial feedback may impact social perception: “…it could provide the subjective experience of others' emotions that allows normal individuals to develop understandings of others”. Recently, Kring et al. (1999) reviewed evidence suggesting a link between mimicry of facial expressions and facial affect perception in non-clinical subjects (e.g. Wallbott, 1991). Kring et al. (1999, p. 187) concluded that “…pictures of facial expressions elicit similar facial reactions in observers, and these reactions may aid in the recognition and perception of emotion depicted in the faces”. Thus, promoting facial feedback, via mimicry, may impact facial affect perception in schizophrenia.
There is indirect evidence that a facial feedback intervention is appropriate for persons with schizophrenia. For example, persons with schizophrenia tend to be less facially expressive than non-clinical control subjects [reviewed by Mandal et al. (1998)]. This lack of expressiveness is present in medication-free subjects (Kring and Neale, 1996) and does not appear to be an artifact of medication side-effects (e.g. Berenbaum and Oltmanns, 1992). This reduced expressiveness may provide persons with schizophrenia with fewer proprioceptive cues when attempting to understand the emotions of themselves or others. Although there is evidence for a disassociation between emotional expression and experience in schizophrenia (Berenbaum and Oltmanns, 1992, Kring and Neale, 1996, Kring et al., 1993), studies in this area have been criticized for investigating only a few types of emotional expression and experience, and for manipulating expressive behaviors indirectly (i.e. via emotionally charged films) rather than directly controlling specific facial expression production [discussed in Flack et al. (1999)]. And, in a recent study, Flack et al. (1999) reported a correspondence between a range of emotions (i.e. happy, sadness, fear, and surprise) and the facial expressions of outpatients with schizophrenia when the expressions were manipulated into a specific emotional state. Furthermore, Shaw et al. (1999) showed that inappropriate affect (as measured by the Scale for the Assessment of Negative Symptoms) was associated with facial affect recognition among inpatients with schizophrenia (although facial affect recognition was not associated with verbal affective expressiveness). Thus, these findings lend support for utilizing a facial feedback intervention for persons with schizophrenia.
It was hypothesized that the two interventions (i.e. monetary reinforcement and facial feedback) would significantly improve performance on a facial affect identification task relative to a no-intervention control condition, with this effect being strongest when the two interventions are combined. These effects were assessed both immediately following the intervention and at 1 week follow-up. Finally, generalization of the effects to an affect discrimination task was investigated.
Section snippets
Participants
A total of inpatients (23 men, 17 women) at Southeast Louisiana State Hospital participated in the study.1 All subjects met criteria for schizophrenia (n=29) or schizoaffective disorder (n=11) based on the Structured Clinical Interview for DSM-IV, Patient version (SCID-P, Spitzer et al., 1995) and a
Data analytic plan
The following steps were taken in the data analyses. First, the four groups were compared on the demographic and clinical variables. Second, analyses of covariance (ANCOVAs) were conducted on FEIT and FEDT performance through the post-test phase with baseline performance as a covariate. A separate series of ANCOVAs was conducted on FEIT and FEDT performance at follow-up because five subjects were unable to complete the follow-up assessment (discussed below). Therefore, the follow-up analyses
Discussion
The present study examined whether performance on a facial affect identification task, the FEIT, could be improved in inpatients with schizophrenia. Furthermore, we investigated whether training effects maintained over time (i.e. a 1 week follow-up) and generalized to a test of facial affect discrimination (i.e. the FEDT). The findings showed that groups receiving monetary reinforcement, facial feedback instructions, or a combination of both, significantly improved their performance on a facial
Acknowledgements
The authors gratefully acknowledge the staff and patients at Southeast Louisiana State Hospital, as well as the following individuals during various phases of the project: Ms Gumpert and Dr Hebert, Dr Arretege, Dr Schwartz, Dr Morris, and Dr Comaty.
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2017, Clinical Psychology ReviewCitation Excerpt :These studies used 15 different AR outcome measures, most (N = 13) consisted of facial affect recognition but two studies used speech measures where participants were required to identify emotion from a recorded speech. Positive effects were found for the majority of studies (n = 15) (Combs et al., 2007, Combs et al., 2008, Eack et al., 2015, Gohar, Hamdi, El Ray, Horan, & Green, 2013, Horan et al., 2009, Horan et al., 2011, Mazza et al., 2010, Penn & Combs, 2000, Popova et al., 2014, Roberts et al., 2014, Sachs et al., 2012, Tas et al., 2012, Taylor et al., 2015, Veltro et al., 2011, Wang et al., 2013). Other studies assessed the effect of the intervention using non-parametric analyses, did not control for baseline scores or did not report the interaction effect.