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Review: emotion identification deficits are associated with functional impairments in people with schizophrenia
  1. Fabien Tremeau1,2,
  2. Daniel Antonius2
  1. 1Nathan Kline Institute, New York, USA
  2. 2Department of Psychiatry, New York University, New York, USA

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Question

Question: What is the strength of the relationship between emotional perception and function in people with schizophrenia and what factors moderate this relationship?

Outcomes: Strength of the association between emotion perception and functional outcomes in people with schizophrenia spectrum disorders. Emotion perception was assessed with: emotion identification tasks (assigning a qualitative label eg, happy or sad, to emotional facial or vocal expressions) and emotion differentiation tasks (assessing the ability to identify differences between intensities of emotional expressions). Function was assessed in four domains: ‘social behaviour in the milieu’ (staff rated assessments of behaviour across a range of treatment settings); social skills (evaluated by role plays and a rating of specific interactional skills such as eye contact); social problem solving (ability to generate solutions to everyday social problems); and community functioning (encompassing behaviours and activities related to independent living skills such as social or work functioning).

Methods

Design: Systematic review and meta-analysis.

Data sources: PubMed and PsychInfo were searched for English language studies published up to September 2010.

Study selection and analysis: Studies that reported correlations between measures of emotional perception and function in schizophrenia spectrum disorders were included if they provided data that allowed calculation of effect sizes. The included studies were cross-sectional. Publication bias was assessed using a funnel plot, Eggers test and an adjusted rank-correlation test. Heterogeneity was assessed using the Cochran Q-statistic. A fixed effects model was used unless there was significant heterogeneity, in which case a random effects model was used. In cases where there was significant heterogeneity, meta-regression was used to assess potential demographic and clinical moderators. Demographic variables included sex, age, race, education and marital status. Clinical variables included age of onset, duration of illness, setting, symptoms, antipsychotic medication and patient diagnosis.

Main results

A total of 25 studies met inclusion criteria, comprising 1306 people with schizophrenia spectrum disorders (mean age 36.7 years, 64% men, 63% Caucasian). There was no evidence of publication bias. Overall, a significant relationship was found between emotional perception and function in individuals with schizophrenia or schizoaffective disorder (effect size 0.31, 95% CI 0.13 to 0.49, p=0.001). Substantial heterogeneity was identified in the meta-analysis (p<0.001, I2=54.55). Emotion identification was positively associated with function (24 studies; effect size 0.36, 95% CI 0.14 to 0.57; I2=60.63, p for heterogeneity <0.001). Emotion differentiation was not associated with function (effect size +0.16, 95% CI −0.10 to +0.42). The strength of the association between emotion identification and function was significantly affected by sex (%male), race (Caucasian) and clinical symptoms (negative and positive), but not by other clinical and demographic variables.

Conclusions

Emotion identification deficits are associated with functional impairments in people with schizophrenia spectrum disorders. This relationship is moderated by gender, race and clinical symptoms.

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Commentary

Over the last decade, research has focused on the poor levels of functioning of individuals with schizophrenia. These deficits are debilitating, and may affect multiple social domains, including the ability to adequately care for their own basic needs, live independently, have meaningful relationships and be competitive on the job-market. In fact, many people with schizophrenia are single and unemployed, with few social contacts. Explaining these poor outcomes has not been an easy task. Negative symptoms and deficits in social cognition have most frequently been linked to functional outcomes in schizophrenia. Adding to the literature, Irani and colleagues reviewed the evidence that one domain of social cognition, emotion perception, correlates with functional outcomes. The authors conducted a comprehensive meta-analysis (25 studies; 1306 patients) and identified moderators. Specifically, they found that emotion identification significantly correlated with various domains of functional outcomes, and effect sizes were moderate. Among the moderators, male gender, non-Caucasian races and low levels of psychopathology were associated with stronger correlations between emotion perception and social outcomes. The authors concluded that remediation of emotion perception could be an important treatment of functioning deficits, particularly for men. Overall, this paper adds to the growing evidence that deficits in social cognition contribute to poor functioning outcomes in schizophrenia, and supports the ongoing remediation research programmes that target emotion identification deficits. However, as noted by the authors, this kind of meta-analysis cannot demonstrate the causal role of emotion identification deficits in poor outcomes, and only implies a beneficial role of improved emotion recognition on social outcomes. Future research needs to clarify the specific role of explicit emotion perception in daily life functioning, and demonstrate that improving emotion recognition leads to an improvement in any social cognition and functional outcomes domains. As remediation programmes will likely become much more widespread in the future,1 these treatment programmes should be tailored to target patients’ specific deficits in social cognition.

Reference

Footnotes

Footnotes

  • Competing interests None.