Emotion awareness and regulation in individuals with schizophrenia: Implications for social functioning

Abstract

Successful social functioning requires adaptive forms of emotion awareness and regulation. However, despite well-documented deficits in social functioning in individuals with schizophrenia, little is known about emotion awareness and regulation in this population. Therefore, we compared emotion awareness and regulation in individuals with schizophrenia and healthy controls, and then, within the schizophrenia group, we examined their impact on social functioning. Forty-four individuals with schizophrenia and 20 healthy controls completed measures of emotion awareness, emotion regulation, and social functioning, in addition to control measures, including neurocognitive functioning. Compared to controls, individuals with schizophrenia displayed significant deficits describing and identifying their emotions and used significantly less reappraisal and more suppression to regulate their emotions. Among the schizophrenia group, better social functioning was associated with the ability to identify, and in particular to describe emotions, better emotion management, as well as greater use of reappraisal and less use of suppression. A hierarchical multiple regression analysis indicated that, after controlling for age and neurocognition, difficulties describing feelings accounted for 35% of the social functioning variance. The present study highlights the importance of emotion awareness and regulation in schizophrenia, pointing to their substantial influence on social functioning above and beyond the impact of neurocognitive functioning.

Introduction

Schizophrenia is commonly associated with decreased levels of daily functioning and increased levels of disability (Brekke et al., 2009a). Although the population incidence of schizophrenia is about 1%, it is the ninth leading cause of disability worldwide (Lopez et al., 2006), thus representing a serious public health concern (Green, 2007). Previous attempts to identify the determinants of daily dysfunction and disability in schizophrenia have focused primarily on neurocognitive deficits (Green, 2007, Nuechterlein et al., 2011). Overall, these studies have shown that neurocognition typically explains 20–40% of the functional outcome variance, leaving a substantial proportion of the variance unaccounted (Couture et al., 2006).

In recent years, social cognition has emerged as an important area of research in schizophrenia (Green and Leitman, 2008), in part due to a growing recognition of its critical impact on functional outcomes (Couture et al., 2006). A recent meta-analysis of 52 studies found that social cognition was more strongly associated with community functioning than neurocognition (Fett et al., 2011). Consistent with this emerging appreciation, the National Institute of Mental Health designated social cognition as a priority research area in schizophrenia, specifying five primary domains of research including theory of mind, social perception, social knowledge, attribution bias, and emotion processing (Green et al., 2005, Green and Leitman, 2008). While a number of domains, such as theory of mind, and perceiving other people's emotions have attracted much interest, other components received less attention. In particular, the way in which individuals with schizophrenia process and regulate their own emotions and their impact on social functioning has received relatively little consideration. This scant attention stands in sharp contrast to an extensive basic affective science literature that indicates that successful social functioning is contingent on effective emotion awareness and regulation. This discrepancy between the clinical and basic affective science literatures has been identified as the single most problematic obstacle to progress in social cognition research in schizophrenia (Green and Leitman, 2008). To address this discrepancy, in the next sections we review the basic affective science literature on emotion processing, in particular studies of emotion awareness and regulation, along with the schizophrenia clinical research literature.

Emotion is generally viewed as a relatively brief form of affect (Ekman, 1992) that arises when external or internal stimuli signal to the individual that something important may be at stake. Emotions are important for social functioning as they provide information about the significance of current social situations, as well as guide potential actions to be taken to address such situations (Barrett et al., 2001). In particular, negative emotional experiences have great informational value in signaling the need to change or adjust one's current state or activity, with failure to respond resulting in potential harm. Because different emotions may call for the use of distinct response strategies, lack of awareness or reduced clarity of experienced feelings may make it difficult for individuals to select appropriate response strategies for dealing effectively with the social situation at hand (Barrett et al., 2001), potentially resulting in social dysfunction. Thus, successful adaptation to ever-changing social environments is contingent upon knowledge of one's own emotions, which has been termed “emotion awareness” (Taylor et al., 1997). Such awareness encompasses the capacity to be attentive to one's own emotions, the ability to distinguish between distinct emotions, and the use of discrete verbal labels to describe them, all of which are important for adaptive social functioning.

To describe individuals with low levels of emotion awareness, Sifneos (1996) introduced the term alexithymia. The term now refers to a multi-dimensional subclinical phenomenon that encompasses difficulties identifying and describing feelings, difficulties in distinguishing feelings from the sensations of emotional arousal, impaired symbolization, and a tendency to focus on external events (Taylor et al., 1991). Approximately 10% of the general population is characterized by poor awareness of emotional states (Linden et al., 1994, Salminen et al., 1999). Limited emotion awareness, in particular difficulties in identifying and describing feelings, has been linked to poor social functioning and quality of life (Salminen et al., 1999, Kokkonen et al., 2001). Specifically, difficulties identifying and describing feelings were associated with reduced positive affect, increased negative affect, depression, anxiety, and poor quality of life (Henry et al., 2006). Similarly, individuals with difficulties identifying and describing feelings had significantly lower levels of social contacts, fewer acquaintances, and were more often unmarried (Kauhanen et al., 1993).

Although emotions often seem to play out entirely beyond one's control, individuals in fact can exert considerable influence over the course of their emotions. Emotion regulation has been defined as the processes that are engaged in order to influence which emotions people have, when they have them, and how these emotions are experienced or expressed (Gross, 2007). A number of emotion regulation strategies have been identified—Gross (1998) has described a process model of emotion regulation that distinguishes between antecedent- and response-focused strategies, with the former preceding the full emotional response, and the latter being initiated once the response is already under way.

Previous reports indicate that effective emotion regulation has been linked with enhanced psychosocial functioning (Gross and Muñoz, 1995). In particular, the use of antecedent-focused strategies, such as reappraisal, has been associated with lower negative emotional experience, enhanced social functioning and quality of life, greater expression of positive emotion, increased well-being, as well as better academic performance (John and Gross, 2004, Brackett and Salovey, 2006). In contrast, response-focused strategies such as suppression have been linked to greater expression of negative emotion, poorer social functioning, lower social support, satisfaction and sense of closeness to others, as well as decreased well-being (Gross, 1998, Gross and John, 2003, van't Wout et al., 2010). Consistent with these findings, clinical populations have been found to use significantly less reappraisal and more suppression (Campbell-Sills et al., 2006, Joormann and Gotlib, 2010). The positive influence of reappraisal on social functioning may be attributed to antecedent-focused strategies manipulating information prior to the elicitation of full emotional reaction, thus reducing negative emotions. In contrast, suppression typically influences an already initiated emotional reaction (Gross, 1998).

Difficulties in emotion processing are considered a core component of schizophrenia and have been linked to functional disability (Kee et al., 2003, Baslet et al., 2009, Kring and Caponigro, 2010). The bulk of emotion processing studies in schizophrenia to date have focused on perception and identification of affective facial expressions of others (Laroi et al., 2010). In contrast, few studies concentrated on emotion awareness. van't Wout et al. (2007) found that individuals with schizophrenia reported significantly more difficulties identifying and describing feelings compared to their not-ill siblings, as well as healthy controls. Similarly, Yu et al. (2011) reported significant differences between individuals with paranoid schizophrenia and healthy controls. These findings are consistent with previous reports of substantial emotion awareness deficits in individuals with schizophrenia (Stanghellini and Ricca, 1995, Cedro et al., 2001), although they are not universal (Henry et al., 2010). Such difficulties appear to predate the onset of psychosis, as they have been identified in individuals at clinical high risk for psychosis (Kimhy and Corcoran, 2008, van Rijn et al., 2011). Conflicting with these findings is a substantial literature indicating that individuals with schizophrenia display no in-the-moment emotion awareness deficits. Kring and Moran (2008) reviewed 44 studies in which a plurality reported no in-the-moment emotion experience differences from healthy controls. However, the conclusions of this review are limited on two points: (1) in virtually all of the studies, the participants were required to respond to the stimuli using semi-structured questions in which a limited predetermined range of emotional responses were listed (i.e., happy, sad, anxious). Such semi-structured questions represent an easier task than open-ended questions which require the participant to come up independently with an appropriate label to describe their current emotional state; and (2) such tasks may also have poor ecological validity as individuals typically do not have access to such predetermined list of responses during the course of daily social interactions.

Studies of emotion regulation in schizophrenia have utilized measures assessing both global and strategy-specific emotion regulation indices. For global measures, the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) has been one of the most commonly used instruments. Previous studies using the MSCEIT have reported significant deficits in emotion regulation in individuals with schizophrenia compared to healthy controls (Nuechterlein and Green, 2006), although association with changes in social functioning following cognitive enhancement therapy were modest (Eack et al., 2010). For specific emotion regulation strategies, van der Meer et al. (2009) found that individuals with schizophrenia were significantly more likely than healthy controls to suppress their emotions, even after accounting for level of depression. Other studies provide additional indirect support—for example, Jansen et al. (2000) found individuals with schizophrenia scored significantly higher on use of escape, avoidance, and passive coping strategies compared to healthy controls. However, these findings are not universal – a number of studies reported no differences in use of reappraisal and suppression between individuals with schizophrenia and healthy participants (Henry et al., 2008, Badcock et al., 2011, Perry et al., 2011). Regarding relationship with social functioning, Henry et al. (2008) reported modest correlations with use of reappraisal, but not suppression among individuals with schizophrenia. In contrast, Perry et al. (2011) found greater use of suppression was associated with poorer social functioning, while reappraisal was not significantly related to social functioning.

While a growing clinical literature suggests significant deficits in emotion awareness and regulation in individuals with schizophrenia, a number of important gaps in the literature remain unaddressed. First, there remain inconsistencies in the clinical literature regarding the extent to which individuals with schizophrenia display deficits in emotion awareness and in particular emotion regulation compared to healthy participants. Second, the putative associations of emotion awareness, emotion regulation, and social functioning in individuals with schizophrenia have not been investigated, and it is not known whether difficulties with emotion awareness and regulation would predict social functioning in individuals with schizophrenia above and beyond previously identified neurocognitive difficulties.

Given the evidence of substantial social dysfunction in individuals with schizophrenia, the centrality of emotion awareness and emotion regulation to social functioning, and the dearth of studies exploring their relationship, our aims are: (1) to extend findings from previous studies indicating group differences between individuals with schizophrenia and healthy controls in emotion awareness, emotion regulation, and social functioning; (2) to examine the links between emotion awareness, emotion regulation, and social functioning in individuals with schizophrenia; and (3) to assess whether emotion awareness and emotion regulation would predict social functioning in individuals with schizophrenia, controlling for covariates and previously identified predictors.