Affective dysfunctions in adolescents at risk for psychosis: Emotion awareness and social functioning

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Abstract

Studies of individuals at ultra high risk (UHR) for psychosis have revealed deviations in cognitive and neural development before the onset of psychosis. As affective impairments are among the core dysfunctions in psychotic disorders such as schizophrenia, this study assessed emotion processing and the relationship with social competence in adolescents at risk for psychosis. Thirty-four adolescents at UHR for psychosis and twenty-three non-clinical controls completed the Bermond–Vorst Alexithymia Questionnaire, a measure of emotion awareness. Social inadequacy was measured using the Dutch Personality Questionnaire. Schizophrenia spectrum psychopathology was assessed using self-report and clinical instruments. The Wechsler Adult Intelligence Scale (WAIS) was used to evaluate intellectual functioning. UHR adolescents showed difficulties in identifying and verbalizing their own emotions, independent of intelligence scores. Emotion awareness problems were related to social inadequacy and schizotypal traits in the high risk group. These findings suggest that UHR adolescents may have reduced emotion awareness, independent of intellectual functioning. The relationship with social inadequate behavior fits with the idea that emotion awareness is a prerequisite for the regulation of emotions in social contexts. In the search for early vulnerability markers of risk for psychosis, studying emotion processing besides cognitive abilities might increase our understanding of ‘at risk’ developmental pathways.

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).

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