Facial affect recognition in individuals at clinical high risk for psychosis

Facial affect discrimination and identification were assessedin 86 clinical high-risk individuals and compared with 50 individualswith first-episode psychosis, 53 with multi-episode schizophreniaand 55 non-psychiatric controls. On the identification taskthe non-psychiatric controls performed significantly betterthan all other groups, and on discrimination significantlybetter than both patient groups. Deficits in facial affectrecognition appear to be present before the onset of psychosis and may be a vulnerability marker.

INTRODUCTION

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INTRODUCTION

Social cognition is of interest in schizophrenia research, partlyowing to its association with poor social functioning. Facialaffect recognition is one component of social cognition andit has been well established that individuals with schizophreniagenerally show deficits in both identification and discriminationof facial affect at all stages of the illness. These are stabledeficits that appear to be unrelated to symptoms.^1,2 Sincesocial deficits often precede the onset of full-blown psychosis,³the purpose of this paper was to determine whether facial affectdeficits are present in people at clinical high risk for psychosis(i.e. putatively prodromal).

Method

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Method

The sample consisted of 86 individuals at clinical high riskfor psychosis, 50 individuals with a first episode of psychosis,53 with a chronic course of schizophrenia and 55 non-psychiatriccontrols. All clinical high-risk individuals are participantsin the PREDICT study at the University of Toronto (n=34), theUniversity of North Carolina (n=32) or Yale University (n=20),a three-site study determining predictors of conversion topsychosis. All clinical high-risk individuals met the Criteria of Prodromal States using the Structured Interview for Prodromal Symptoms.⁴ All participants met attenuated positive symptomstate criteria, which included the emergence or worsening ofa non-psychotic disturbance of thought content, thought processor perceptual abnormality over the past year.

The first-episode, multi-episode and control participants werespecifically recruited for studies examining facial affectrecognition in psychosis at the University of Calgary and havebeen well described elsewhere.¹ Using the Structured Interviewfor DSM–IV (SCID), all of the first-episode and multi-episodeindividuals met DSM–IV criteria for a schizophrenia-spectrumdisorder except nine first-episode participants who met criteriafor other psychotic disorders. Based on SCID criteria therewere no current or past psychiatric disorders in the controlparticipants. Demographic data are presented in Table 1. Theonly site differences were in the number of students from North Carolina.

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Table 1 Demographic data and differences between groups on facial affect recognition tasks

The facial affect recognition tests were the Facial EmotionIdentification Test (FEIT) and the Facial Emotion DiscriminationTest (FEDT).⁵ Both use black and white photographs of facialemotions that are presented on DVD. The FEIT consists of 19faces each depicting one of six different emotions (happiness,sadness, anger, surprise, disgust, shame), shown one at a timefor 15 s, with 10 s of blank screen between each stimulus presentation.After each stimulus, the participant makes a forced choiceby selecting which of the six emotions is depicted. The scoreis the sum of the number of correct emotion identifications(0–19). The FEDT consists of 30 pairs of photographs, each pair showing two different people displaying one or twoof the six emotions depicted in the FEIT. The pairs are presentedsimultaneously for 15 s, with 15 s of blank screen betweeneach presentation. The task is to judge whether the two peoplein each pair have the same or different emotions. The scoreis the number of correct discriminations (0–30). All individuals except those in the control group were assessed with the Positiveand Negative Syndrome Scale for Schizophrenia (PANSS).⁶

Formal consent was obtained from all participants. Testing tookplace during two sessions, usually on the same day but alwayswithin a 7-day period. For PREDICT, all three sites participatedin a rater training programme developed at Yale that teachesclinical researchers to identify the prodromal syndrome withgood reliability.⁴ The kappa statistic was used to comparetrainee agreement with the gold standard diagnosis of the presenceor absence of a prodromal syndrome. Kappa was greater than0.80 at all sites and the overall kappa was 0.90. J.A. chaired weekly conference calls to review criteria for every clinicalhigh-risk individual admitted to the study. Facial affect recognitionassessments were conducted by trained research assistants underthe supervision of D.P. Detailed descriptions of quality trainingand good to excellent reliability for the data from all otherparticipants has been described elsewhere.¹

Results

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Results

All results are presented in Table 1. One-way ANOVAs were usedto compare groups with Tukey post hoc tests to determine specificgroup differences. The groups differed significantly in age,with the multi-episode group being significantly older andthe clinical high-risk group significantly younger. The first-episode, multi-episode and clinical high-risk groups did not differon the General Psychopathology Scale of the PANSS. The multi-episodegroup rated significantly higher on positive symptoms thanthe first-episode group, with the clinical high-risk groupin between without significantly differing from either. Theclinical high-risk group had significantly lower ratings on negative symptoms than the first-episode and multi-episodegroups.

A one-way between-groups MANOVA was performed to determine group differences on facial affect recognition, controlling for age.There was a statistically significant difference between groupson the combined dependent variables (F[4, 240]=6.27; P=0.0001;Wilks’ ${lambda}$ =0.86; partial ${eta}$ ²=0.07). Both the identificationtask (F[2, 242]=10.15; P=0.0001; partial ${eta}$ ²=0.11) and the discriminationtask (F[2, 242]=5.52; P=0.001; partial ${eta}$ ²=0.07) were statisticallysignificant. The one-way ANOVA (Table 1) demonstrates thaton the identification task, the control group performed significantlybetter than the clinical high-risk and patient groups. On thediscrimination task, patient groups performed significantlymore poorly than the control group, and the performance ofthe clinical high-risk group fell between that of the patient and control groups without significantly differing from either.

Discussion

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Discussion

This is one of the first studies to examine facial affect recognitionin a group of individuals at high risk of developing psychosis.A previous study did not detect any differences between controlindividuals and a very small (n=19) clinical high-risk sample.³The young people in our at-risk sample were seeking help andhad significant disability. Their ability to identify emotionsdid not differ from the patient groups and was significantlyworse than the control group. Their ability to differentiate emotions did not differ significantly from either group, mostlikely because the discrimination task is less difficult thanthe identification task.¹ It has been suggested⁷ that such deficits may be vulnerability factors in that subtle deficitsin affect perception were detected in unaffected biologicalsiblings of patients with schizophrenia. Our study suggeststhat these deficits are present, before the full expressionof a psychotic illness, in high-risk individuals of whom only about 25% will go on to develop a full-blown psychotic illness.⁸

Our study has limitations. It is cross-sectional and does notaddress predictors of conversion. The control individuals areat a different site but do demonstrate results consistent withthe rest of the literature. There was no control task to determinewhether the impairment was specific to emotions or is generalised,although results of using a differential design in the literatureare mixed.¹ The strengths of our study are the reasonablylarge numbers in each group, the well-defined clinical high-riskgroup and the use of three control groups.

There may be implications for affect recognition deficits inthe conversion to psychosis that can be examined only in longitudinalstudies. In addition, if we want to better understand the socialdecline observed prior to the onset of psychosis, future studiesshould examine the relationship between social functioning,affect recognition and cognition.¹

ACKNOWLEDGMENTS

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ACKNOWLEDGMENTS

This study was supported by NIMH grants: U01MH066134 to J.A.,U01MH066069 to D.P. and U01MH066160 to S.W. J.A. also receiveda grant from the Canadian Institutes of Health Research.

REFERENCES

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