Affective dysfunctions in adolescents at risk for psychosis: Emotion awareness and social functioning
Introduction
The onset of psychotic disorders such as schizophrenia is often preceded by subtle deviations from typical developmental trajectories in childhood and adolescence. In order to uncover early risk or protective factors in development, ‘high risk’ approaches have been developed. Such high risk approaches are founded on the premise that certain groups of young individuals are considered more vulnerable for developing psychosis later in life than others, as for instance indicated by genetic relatedness to a family member with schizophrenia or the presence of prodromal symptoms.
Two-hit models of psychosis (Cannon et al., 2003, Weinberger, 1987), on which the concept of high risk studies has been based, postulate that 1) multiple genes are involved in several key events during neurodevelopment and/or brain maturation early in life that lead to a ‘predisposition’ and (2) that the manifestation of psychosis later in life results from interaction with environmental factors such as viral infections, birth complications, stressors and/or aspects of normal maturational processes. By studying behavior, cognitive abilities and brain functioning in high risk populations, one may gain insight in vulnerability markers, although such factors may not be necessary or sufficient for transition to full-threshold psychotic illness.
Although many high risk studies have focused on impairments in neurocognitive development, such as attention, memory and executive functioning (for a review see Brewer et al., 2006), very few studies have investigated problems in emotion processing as possible vulnerability markers for psychosis and related social dysfunction. An increasing interest in the role of emotion processing in daily life functioning and mental health has led to a range of studies showing that the ability to perceive, use, understand and manage one's own emotions has a significant contribution to social adaptive behavior, which seems independent of general intelligence (Brackett et al., 2004, Ciarrochi et al., 2000, Eisenberg et al., 2000, Halberstadt et al., 2001, Lopes et al., 2004, Lopes et al., 2005, Song et al., 2010). Considering that social behavior is one of the major domains of dysfunction observed well before onset of psychosis later in life (Brunner et al., 1993, Tarbox and Pogue-Geile, 2008), and uniquely contributes to the prediction of psychosis (Cannon et al., 2008), studying emotion processing may add to our understanding of vulnerability to psychosis and schizophrenia.
This idea is supported by several studies pointing to emotion processing deficits in high risk populations (Addington et al., 2008, Bolte and Poustka, 2003, Eack et al., 2009, Hambrecht et al., 2002), although some studies found partial or no impairments (Pinkham et al., 2007, Toomey et al., 1999). However, all previous studies have been largely confined to measurements of perception and identification of affective facial expressions of others. Although picking up emotional signals of others is important for successful social interactions (Hooker and Park, 2002, Pinkham and Penn, 2006), interpreting and regulating (using, understanding and managing) one's own emotions seem equally important for social adaptive behavior (Lopes et al., 2004, Lopes et al., 2005). To be able to regulate emotions one needs to be aware of specific emotions, for which the term ‘emotion awareness’ has been coined (Salovey and Grewal, 2005, Taylor et al., 1997). Reading your own emotions as well as those of others requires awareness of these emotions, involving attention to emotions and the skill to discern between different emotions by discriminating between different physiological experiences and using discrete verbal labels to disentangle distinct emotions. Being aware of specific emotions in yourself and people around you is essential for adapting to your environment. For example, in a conflict with your boss it is crucial to know whether you are feeling stressed, angry, disappointed, insecure or fearful, in order to understand and deal with the situation and keep your job.
Reduced emotion awareness as expressed in a reduced ability to identify, experience, verbally describe and reflect on one's own emotions, has also been conceptualized as ‘alexithymia’ (literally translated ‘lacking words for feelings’) (Booth-Butterfield and Booth-Butterfield, 1990, Sifneos, 1973). Measures of alexithymia have been shown to be strongly correlated to emotion processing capacities (Parker et al., 2001, Schutte et al., 1998). Hence, when studying deficits in emotion processing as a means of understanding social dysfunction in adolescents at high risk for psychosis, we may gain insight by focusing on alexithymia.
The lack of studies on emotion processing in high risk populations is somewhat surprising, considering the line of evidence pointing to affective impairments as belonging to the core dysfunctions of schizophrenia (for a review see Aleman and Kahn, 2005). Reduced emotion awareness, more specifically difficulties in identifying and verbalizing emotions as measured with alexithymia questionnaires, has been found in patients with schizophrenia (Baslet et al., 2009, Cedro et al., 2001, Maggini et al., 2002, Serper and Berenbaum, 2008, Stanghellini and Ricca, 1995, van 't Wout et al., 2007). The idea that such deficits in emotion awareness may constitute a vulnerability marker for schizophrenia is supported by studies showing that individuals with high levels of schizotypal traits also have difficulties in this domain (Bach et al., 1994, Berenbaum et al., 2006, Kerns, 2005, van 't Wout et al., 2004).
The aim of this study was to test the hypothesis that adolescents at high risk for psychosis show reduced emotion awareness. Also, we hypothesized that reduced emotion awareness would be related to social dysfunctioning. We tested our hypotheses in a population of adolescents from the University Medical Center who met the criteria for ‘ultra high risk’ (UHR) for psychosis. The reason for studying this group is that previous studies have shown high rates of transition to psychosis in adolescents meeting such criteria (for a review see Olsen and Rosenbaum, 2006). UHR adolescents are considered to be at imminent risk for full-threshold psychosis as they are characterized by prodromal signs, based on which this group can be dissociated from other high risk groups (such as familial risk groups) (Woods et al., 2009). However, rather than finding predictors of progression to full-threshold psychosis later in development, our focus was on vulnerability markers of psychosis. By studying this clinical population in the 12–18 age range, we may gain insight into early affective dysfunctions in those at risk for psychosis.
Section snippets
Subjects
We included 34 adolescents at ultra high risk of psychosis and 23 non-clinical controls in the age range of 12–18 years. The groups were matched on social economic status (SES) indicated by average parental education (F(1,55) = 1.1, P = 0.29), on age, on gender and on Intelligence Quotient (IQ) (see Table 1). For both groups mental retardation and neurological disorders were exclusion criteria.
The UHR group was derived from a referred sample at the department of Child Psychiatry at the University
Schizophrenia symptoms and schizotypal traits
Total SPQ score was 37.0 (S.D. 17.7) in the UHR group and 10.9 (S.D. 8.1) in the control group. All three dimensions of the SPQ (positive, negative, and disorganized) were entered in MANOVA, revealing a multivariate effect of group, F(3,53) = 17.9, P < 0.001. Univariate results showed that in the UHR group scores were significantly elevated in all domains of the SPQ (see Table 2). Total PANSS score was 48.7 (S.D. 7.6) in the UHR group and 32.2 (S.D. 2.6) in the control group. The three PANSS
Discussion
This study examined emotion awareness, conceptualized as the processing of own emotions, and social inadequacy, i.e. feelings of incompetence in social interactions, in adolescents at high risk (UHR) for psychosis. Our findings suggest that UHR adolescents have difficulties in identifying and verbalizing their own emotions, deficits that appear independent of intellectual functioning. Problems in identifying one's own emotions were related to social inadequacy, and not to general inadequacy, in
Acknowledgements
This work was supported by a VernieuwingsImpuls grant (grant number 016.026.027 to AA) and a VENI grant (grant number 016.095.060 to SVR) from the Netherlands Organization for Scientific Research (NWO).
References (74)
- et al.
Emotional intelligence and social functioning in persons with schizotypy
Schizophrenia Research
(2008) - et al.
Strange feelings: do amygdala abnormalities dysregulate the emotional brain in schizophrenia?
Progress in Neurobiology
(2005) - et al.
Alexithymia: relationship to personality disorders
Comprehensive Psychiatry
(1994) - et al.
The 20-item Toronto-Alexithymia-Scale. 2. Convergent, discriminant, and concurrent validity
Journal of Psychosomatic Research
(1994) - et al.
Emotional intelligence and its relation to everyday behaviour
Personality and Individual Differences
(2004) - et al.
A critical evaluation of the emotional intelligence construct
Personality and Individual Differences
(2000) - et al.
Regulation of emotions during experimental stress in alexithymia
Journal of Psychosomatic Research
(2007) - et al.
Emotion processing and its relationship to social functioning in schizophrenia patients
Psychiatry Research
(2002) - et al.
Is alexithymia the emotional equivalent of blindsight?
Biological Psychiatry
(1997) - et al.
Emotional intelligence, personality, and the perceived quality of social relationships
Personality and Individual Differences
(2003)
The moderating impact of emotional intelligence on free cortisol responses to stress
Psychoneuroendocrinology
Assessing the reliability and validity of the Bermond–Vorst Alexithymia Questionnaire among U.S. Anglo and U.S. Hispanic samples
Journal of Psychosomatic Research
The relationship between emotional intelligence and alexithymia
Personality and Individual Differences
Neurocognitive and social cognitive predictors of interpersonal skill in schizophrenia
Psychiatry Research
Development and validation of a measure of emotional intelligence
Personality and Individual Differences
The relation between emotional awareness and hallucinations and delusions in acute psychiatric inpatients
Schizophrenia Research
The differential effects of general mental ability and emotional intelligence on academic performance and social interactions
Intelligence
Pathways to psychosis: a comparison of the pervasive developmental disorder subtype multiple complex developmental disorder and the “at risk mental state”
Schizophrenia Research
Adolescent dissociation and alexithymia are distinctive but overlapping phenomena
Psychiatry Research
Poor perception of nonverbal social–emotional cues in relatives of schizophrenic patients
Schizophrenia Research
Emotion regulation strategies in patients with schizophrenia
Psychiatry Research
Emotional processing in a non-clinical psychosis-prone sample
Schizophrenia Research
No words for feelings: alexithymia in schizophrenia patients and first-degree relatives
Comprehensive Psychiatry
Does the Schizotypal Personality Questionnaire reflect the biological–genetic vulnerability to schizophrenia?
Schizophrenia Research
Validity and reliability of the Bermond–Vorst Alexithymia Questionnaire
Personality and Individual Differences
Facial affect recognition in individuals at clinical high risk for psychosis
The British Journal of Psychiatry
Knowing what you're feeling and knowing what to do about it: mapping the relation between emotion differentiation and emotion regulation
Cognition and Emotion
Deficits in emotional awareness in schizophrenia and their relationship with other measures of functioning
The Journal of Nervous and Mental Disease
Emotional correlates of the different dimensions of schizotypal personality disorder
Journal of Abnormal Psychology
The recognition of facial affect in autistic and schizophrenic subjects and their first-degree relatives
Psychological Medicine
Conceptualizing affect as information in communication production
Human Communication Research
Relating emotional abilities to social functioning: a comparison of self-report and performance measures of emotional intelligence
Journal of Personality and Social Psychology
Generalized and specific cognitive performance in clinical high-risk cohorts: a review highlighting potential vulnerability markers for psychosis
Schizophrenia Bulletin
Abnormal-behavior associated with a point mutation in the structural gene for monoamine oxidase-A
Science
Early and late neurodevelopmental influences in the prodrome to schizophrenia: contributions of genes, environment, and their interactions
Schizophrenia Bulletin
Prediction of psychosis in youth at high clinical risk: a multisite longitudinal study in North America
Archives of General Psychiatry
Alexithymia in schizophrenia: an exploratory study
Psychological Reports
Cited by (54)
Bullying in individuals at ultra-high risk for psychosis
2023, Annales Medico-PsychologiquesEmbodiment of emotion in schizophrenia in the context of culture
2022, Psychiatry Research CommunicationsAwareness and rumination moderate the affective pathway to paranoia in daily life
2020, Schizophrenia ResearchCitation Excerpt :More specifically, our findings indicate that emotion awareness constitutes a resilience factor that prevents the emergence of paranoia due to negative emotional states. This further corroborates the view that the ability to be aware of emotions is a crucial prerequisite of ER (Van Rijn et al., 2011) and the bedrock for the successful application of further skills to modify emotions (Berking and Whitley, 2014). Interestingly, the fact that awareness of emotions appears to play a significant role in the translation of negative affect to paranoia corresponds with previous research, which widely suggested that people with psychosis have difficulties in emotion awareness.
Affective and physiological reactivity to emotional comments in individuals at elevated risk for psychosis
2019, Schizophrenia ResearchCitation Excerpt :Thus, elevated-risk individuals' ability to process negative emotion and/or regulate their stress response following criticism may be impaired. There is a paucity of literature examining emotion regulation in at-risk individuals; however, some work suggests that emotion regulation is a deficit in this population (Amminger et al., 2011; Gee et al., 2012; van Rijn et al., 2011). Overall, these self-report and physiological responses have important implications for elevated-risk individuals, as they suggest that these individuals respond similarly to criticism relative to controls but have difficulties regulating their physiological stress response following stressful social interactions.
Childhood trauma and psychotic experiences in a general population sample: A prospective study on the mediating role of emotion regulation
2017, European PsychiatryCitation Excerpt :Thus, the fewer ER skills an individual endorsed at a given time-point, the higher the likelihood that this individual would be distressed by psychotic experiences at the next time-point. This finding adds to the preliminary evidence indicating a covariation of at risk-mental states and ER [38–40], a causal influence of ER on psychotic symptoms and distress [36,41], and suggests that the ability to effectively regulate emotions is crucial to arrive at low levels of symptom distress. Given the overwhelming evidence for affective pathways to psychosis [61,62], we were surprised by the absence of a significant path from ER to symptom frequency.
An ecological momentary assessment evaluation of emotion regulation abnormalities in schizophrenia
2018, Psychological Medicine