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A preliminary comparison of flat affect schizophrenics and brain-damaged patients on meausres of affective processing
J. COMMUN. DISORD. 22 (1989), 93-104
A PRELIMINARY COMPARISON OF FLAT AFFECT SCHIZOPHRENICS AND BRAINDAMAGED PATIENTS ON MEAUSRES OF AFFECTIVE PROCESSING JOAN C. BOROD Departments of Psychology, The City University of New Medical Center
Queens College, and Neurology, Mount Sinai Medical Center, York, and Department of Psychiatry, New York University
MURRAY ALPERT, ALIZAH BROZGOLD, and CANDACE MARTIN Department
of Psychiatry,
New York Universiry Medical
Center
JOAN WELKOWITZ Department
of Psychology,
LEONARD Department
of Psychiatry,
ABRAHAM Department
York University
DILLER
of Rehabilitation
ERIC PESELOW Department
New
Medicine,
New
York University
Medical
Center
and BURTON ANGRIST New York University
Medical
Center
LIEBERMAN
of Neurology,
New
York University
Medical
Center
Flat affect is a major component of schizophrenia and is often also seen in neurological disorders. A preliminary set of comparisons were conducted to delineate neuropsychological mechanisms underlying flat affect in schizophrenia, and new measures are described for the assessment of affective deficits in clinical populations. Subjects were schizophrenic with flat affect (SZs), right brain-damaged (RBD), Parkinson’s Disease (PDs), and normal control (NC) right-handed adults. Subjects were administered affective measures of expression and perception in both facial and vocal channels. For both perceptual and expressive tasks the SZs performed signiticantly less accurately than the NCs and the PDs but did not differ from the RBDs. This was the case for both face and voice. This finding lends support to the speculation that right hemisphere mechanisms, especially cortical ones, may be compromised among schizophrenics with flat affect.
Address correspondence to Dr. Joan C. Borod, Psychology Department, NSB E318, Flushing, NY 11367. 0 1989 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
Queens College,
93 0021~9924/89/$3.50
94
J. C. BOROD
et al.
INTRODUCTION Flattening of affect, a constriction or blunting in the range of expression of feelings, is the most common clinically observed disturbance of affect. By affect, we refer to feeling states that are brief in duration and associated with objectifiable behaviors, such as facial expression. In schizophrenia, flat affect is a powerful predictor of the course and outcome of the illness (Knight, Roff, Barnett, and Moss, 1979; Pougue-Geile and Harrow, 1985; Strauss and Carpenter, 1972) and has a special role in diagnostic formulations. Disturbances of affect have also been noted in patients with neurological disorders, e.g., right hemisphere strokes (Borod, Koff, and Caron, 1983; Gardner, 1975) and Parkinson’s Disease (Buck and Duffy, 1980). The purpose of this study was to compare the performance of schizophrenics with flat affect to that of patients with Parkinson’s Disease and right-hemisphere brain damage. Evidence of similar performance between these groups should have implications for brain/behavior mechanisms underlying schizophrenia. Although the predominant current opinion supports left hemisphere dysfunction in schizophrenia (Flor-Henry, 1979; Gur, 1978; Seidman, 1983; Tucker, 1981; Wexler, 1981), there are a number of studies where the performance of schizophrenic patients does not differ from that of normal controls (Fennel, Moskowitz, and Backus, 1982; Templer and Connolly, 1976; Wexler and Heninger, 1979) or where findings suggest right rather than left hemisphere dysfunction (Nelson, Maxwell, and Townes, 1986). The studies in the literature have been concerned primarily with cognitive and perceptual tasks, a factor that may have obscured brain-behavior relationships, since schizophrenia also involves significant affective and expressive deficits. Furthermore, the inclusion of different subgroups of schizophrenics might have confounded the results of such studies. One clinical distinction, viz., lexically deficient versus spatially deficient (Alpert and Martz, 1977), suggests that some schizophrenics (the spatially deficient) may have deficits that are similar to those seen among patients with right hemisphere pathology. According to Alpert and Martz, the “lexical” and “spatial” schizophrenic subgroups may correspond to the “productive” (Type I) and “deficit” (Type II) distinction, postulated by Crow (1980). In the current study, schizophrenics with flat affect were compared on affective measures to right-hemisphere brain-damaged patients, to Parkinson’s Disease patients, and to normal control subjects. Patients with Parkinson’s Disease were included for study in light of clinical descriptions of diminished expressiveness (Todes and Lees, 1985) and the hallmark symptom of masked facies in this population. The measures utilized in the current study examine the expression and perception of affect in both facial and vocal channels and are part of a larger affect battery,
FLAT AFFECT SCHIZOPHRENIA Table 1.
95
Age and Education, in Years, for Each Subject Group Age
Subject
sz RB PD NC
group
Education
N
Mean
SD
Mean
SD
6 5 6 4
38.5 69.2 63.8 34.8
13.3 7.6 10.4 6.2
11.0 13.2 15.6 15.8
1.7 2.7 3.2 1.7
recently developed by Borod, Alpert, and co-workers. It was our hypothesis that schizophrenics with flat affect would perform more similarly to right brain-damaged patients than to normal controls or Parkinsonian patients.
METHODS Subjects The subjects included six schizophrenics (SZs), live right brain-damaged patients (RBDs), six Parkinson’s Disease patients (PDs), and four normal adult controls (NCs). All subjects were adult males (except for one RBD female and two PD females). All were right-handed; handedness was determined by self-report and confirmed by a preference inventory (Coren, Porac, and Duncan, 1979). Subjects were screened to ensure at least average intellectual functioning [Vocabulary subtest from the WAIS-R (Wechsler, 1981)] and no evidence of dementia [Dementia Rating Scale (Mattis, 1973)] or history of serious alcohoVdrug abuse. Table 1 presents mean age and education values for each subject group. There were significant group difference for age (F = 14.66; & = 3, 17; p < .OOl>and for education (F = 4.59; df = 3, 16; p < .05). SZs with flat affect in the clinical setting were referred to us by a psychiatrist (EP) experienced in clinical diagnosis. The SZs all were diagnosed as “chronic schizophrenics,” using the Schedule for Affective Disorders and Schizophrenia (SADS) (Endicott and Spitzer, 1978) and Research Diagnostic Criteria (Spitzer, Endicott, and Robins, 1978). SZs were included if their illness was at least two years in duration (x duration = 47.5 months) and if they had no history of neurological disorder. RBDs were tested at least one month postonset (x duration = 2.5 months) and had unilateral lesions resulting from single episode cerebrovascular accidents (contirmed by CT scan). Lesion etiology and locus were as follows for the five RBDS: fronto-temporal hemorrhage, fronto-parietal hemorrhage, basal ganglia infarct with “frontal mass effect,” and two middle cerebral artery thrombotic occlusions. RBDs had no history of secondary
J. C. BOROD et al. neurological disease or premorbid psychiatric disorder (as confirmed by the Lifetime SADS, Endicott and Spitzer, 1978). Patients with idiopathic Parkinson’s Disease (x MPO = 52.1, SD = 32.9) using diagnostic criteria developed by Lieberman et al. (1979), were studied. PDs were free from secondary neurological disorder and premorbid psychiatric history (Lifetime SADS).
Procedures Each subject (S) was individually examined on perceptual and expressive measures of facial and vocal affect. For perception, subjects were required to identify photographs of facial emotion and recordings of emotionally intoned sentences. For expression, subjects were required to produce a range of facial and vocal emotional expressions to oral command. Informed consent was obtained after the procedures had been explained. Facial Perception. For the facial channel, Ss were requested to carry out an identification task involving positive and negative emotions. Stimuli were selected from a pool of slides (Ekman and Friesen, 1976) depicting 12 different posers (6 males, 6 females), each displaying the six basic emotions (according to Ekman, 1983) (happiness, surprise, sadness, fear, anger, disgust) and a neutral expression. Ss were presented with a slide of an emotional expression (on a Caramate) and required to identify the emotion that was being portrayed. A slide was presented for approximately three seconds. Ss were required to point to the correct response on a 5 x &in. card on which the names of the seven expressions (the six basic emotions plus neutral) were printed in a vertical array. There was no time limit. To control for any response or perceptual bias, there were four response cards with different orders that were randomized within and across subjects. There were 32 trials on this task (a male and Bfemale posers, balanced across the seven emotions); each of the seven emotions was presented four or five times. Vocal Perception. For the vocal channel, Ss were requested to carry out an identification task involving positive and negative emotions. This task was developed by Tucker, Watson, and Heilman (1977); some minor modifications in the response format were made. Stimuli consisted of four sentences of neutral content, e.g., “Fish can jump out of the water,” spoken by a male poser in one of three emotional tones (happiness, sadness, anger) and in an indifferent tone. Ss were presented with tape recordings of emotionally intoned sentences and required to identify the emotion being portrayed. Ss were required to point to the correct response on a 5 x 8-in card on which the names of the four possible responses (three emotions plus indifference)
FLAT AFFECT
SCHIZOPHRENIA
97
were printed in a vertical array. There were four separate cards with different orders that were randomized within and across subjects. There were 16 trials on this task; each of four emotions was presented four times (using each of the four neutral sentences). Facial Expression. For the facial channel, Ss were videotaped while deliberately producing a range of emotional expressions, including both positive ones (happiness, surprise, interest/excitement) and negative ones (sadness, anger, fear, disgust). In this task, Ss were requested to pose each emotion to oral command, e.g., “Look happy.” To maximize deliberate control over the expression and to facilitate rating procedures, Ss were requested to make each expression immediately following a command of “Ready, go!” This task utilized procedures developed by Borod et al. for normal (Borod and Caron, 1980; Borod, Koff, and White, 1983) and clinical (Borod, Koff, Larch, Nicholas, and Welkowitz, 1988; Jaeger, Borod, and Peselow, 1986) populations. Ss were required to pose each of the seven expressions (3 positive, 4 negative) two times, resulting in 14 trials. Expression order was randomized within and across subjects. Vocal Expression. For the vocal channel, Ss were audiotaped while intoning sentences with the same seven emotions listed in the facial expression section. Ss were instructed to use one of two neutral sentences chosen for grammatical and rhythmic similarity: (a) “She ran to catch the bus,” or (b) “They found it in the room.” Ss were instructed to intone each of the seven emotions two times (using sentences a and b), resulting in 14 trials. Again, expressions were randomized within and across Ss. scoring
Perception. For the facial and vocal perception tasks, each was scored for accuracy (0 for inaccurate, 1 for accurate), and all items combined into a total score. The total raw score was converted to percent correct. Expression. Three right-handed normal adults, naive regarding the hypotheses of the study and the subject group characteristics, made accuracy and intensity ratings of the facial and vocal data from the video- and audiotapes. Intensity of each expression was rated on a seven-point Likert scale from minimal (a score of 1) to maximal (a score of 7). Examples of responses at several levels of intensity, from earlier studies (e.g., Borod, Koff, and White, 1983) were used for training purposes. For category accuracy, raters indicated the emotion produced from a multiple-choice format, using all seven emotions. Prior to ratings, raters were familiarized with photographed exemplars of prototypical emotional expressions (Ekman and Friesen, 1976; Izard, 1971) and with previously rated video-
J. C. BOROD et al.
98
PERCEPTION
0.80
0.60
Subject
Group
Mean accuracy scores for the affect perception tasks, by subject group. x Channel interaction (F = 1.10; df = 3, 13; p > .300), scores for face and voice tasks were combined.
Figure 1.
Since there was no significant Group
tapes. Responses for category accuracy were scored as correct (1) or incorrect (0). Inter-rater reliability was assessed on a presample of facial expressions (N = 15) and vocal expressions (N = 54). For category accuracy, two or three out of the three raters were in complete agreement for 80% of the facial expressions and for 83% of the vocal expressions. For intensity, the three raters made ratings that were identical or one point different for 80% of the facial and 74% of the vocal expressions. For the analyses to follow, ratings were averaged across the three raters. For each expression task, the mean ratings for each trial were averaged.
RESULTS Two-way repeated measures analyses of variance (ANOVA) (Group [4] x Channel [2]) were conducted, separately, for perception accuracy, expression accuracy, and expression intensity. In all cases, post-hoc analyses were conducted using the protected t-test (one-tail) (Welkowitz,
99
FLAT AFFECT SCHIZOPHRENIA
EXPRESSION 1 .oo 2 00 m 0.60 u” 2 0.50 z cc 0.40 k 2
0.30
Subject
Group
Mean accuracy scores for the affect expression tasks, by subject group. Since there was no significant Group x Channel interaction (F = 0.28; & = 3, 12; p > .500), scores for face and voice tasks were combined.
Figure 2.
Ewen, and Cohen, 1976). Since the subject groups differed significantly as a function of age and education, these variables were correlated with each of the perceptual and expressive measures. Since so few significant correlations occurred (not more than would be expected by chance), age and education were not controlled in the analyses to follow. Perception Accuracy. When the two-way ANOVA (Group x Channel) was carried out on the perception accuracy scores, there was a significant main effect of Group (F = 3.48; df = 3, 13; p < .05). Overall, SZs (x = S9) and RBDs (x = .63) were impaired relative to PDs (x = .78) and NCs (x = .85>. See Figure 1. Using post-hoc analyses, SZs (p <: .OS) and RBDs (p < .10) performed substantially lower than NCs. SZs were significantly (p < .OS)different from PDs but did not differ from the RBDs. There was also a significant main effect for Channel (F = 6.24; & = 1, 13; p < .05), such that emotional_voices (X = .77) were more accurately perceived than emotional faces (X = .66). Expression
Accuracy.
When the two-way ANOVA (Group x Channel)
J. C. BOROD et al.
100
EXPRESS ION
Voice
Face
Figure 3. Mean intensity scores for the voice and face affect expression tasks, by subject group.
was carried out on the expression accuracy ratings, there was a significant main effect of Group (F = 3.87; df = 3, 12; p < .05). See Figure 2. Again, SZs (x = .30) and RBDs (x = .36) were impaired relative to PDs (x = .49) and NCs (x = 54). Using post-hoc analyses, SZs (p < .05) and RBDs (p < .lO) performed substantially lower than NCs. SZs differed (p < .lO) from PDs but not from RBDs. Expression Intensity. A two-way ANOVA (Group x Channel) was carried out on the expression intensity ratings. There was a significant main effect of Group (F = 3.59; & = 3, 12; p < .05), such that SZs (x = 3.32) were rated as showing less intense expressions than PDs (x = 4.12), RBDs (x = 4.27), and NCs (x = 4.84). Using post-hoc analyses, SZs were significantly (p < .05) less intense than NCs; none of the other comparisons were significant. Finally, there was a significant Group x Channel interaction (F = 6.73; & = 3, 12; p < .Ol). See Figure 3. Post-hoc tests were conducted separately for channel and group. When examining group differences for the
FLAT AFFECT SCHIZOPHRENIA
101
facial channel, SZs and PDs were significantly (p < .05) less intense than NCs and RBDs. For the vocal channel, SZs were significantly less intense than RBDs (p < .05), PDs (p < .005), and NCs (p < .OOl); RBDs were significantly less intense than PDs (p < .05) and NCs (p < .005). When examining channel differences for each subject group, all differences were significant except for the NCs. Facial expressions were more intense than vocal expressions for SZs and RBDs, while vocal expressions were more intense than facial expressions for PDs. DISCUSSION From this preliminary sample of psychiatric and neurological patients, both schizophrenics and right brain-damaged patients showed deficits in the accuracy of affective processing when compared with normal controls. In addition, the SZs and the RBDs performed at equivalent levels. This was the case for both perceptual and expressive measures, and for both vocal and facial channels. While affective deficits have been previously demonstrated in separate studies of schizophrenic (Andreasen, 1979) and brain-damaged (Gainotti, 1972) populations, to our knowledge, this is the first comparison of actual levels of affective performance between these groups using the same assessment measures and the same raters. The findings for perception are consistent with our hypothesis that schizophrenics with flat affect would show aberrant patterns of performance on perceptual tasks typically associated with right hemisphere processing. Further, this finding is compatible with a recent report (Mayer, Alpert, Stastney, Perlick, and Empfield, 1985) that schizophrenic patients who were rated as showing flat affect and other “negative symptoms” performed more poorly on neuropsychological tasks associated with the right hemisphere (e.g., a test of neutral face recognition) than SZ patients with minimal negative symptoms. Findings associating flat affect and anomolous performance on a task using whole body, as well as facial, stimuli and requiring the use of emotional constructs also were reported by McPherson et al. (1970). The results for expression accuracy were similar to those for perception, i.e., SZs and RBDs performed at approximately the same level and both groups were impaired relative to normal controls. The findings for intensity were less clearcut, and were related to communication channel. Overall, SZs consistently produced less intense expressions than the other subject groups. For voice, again SZs and RBDs were significantly less intense than normals; for face, however, SZs and PDs showed the least intense facial expressions. This particular finding for PDs is not surprising because of the masked facies and is consistent with a recent study by Scott, Caird, and Williams (1984). While these findings are suggestive, larger numbers of subjects are nec-
102
J. C. BOROD et al.
essary to substantiate the findings for perception and expression accuracy and to clarify the findings for expression intensity. In addition, the inclusion of a subgroup of schizophrenics with relatively more “positive” and less “negative” symptoms should permit a more sensitive statement about flat affect in this population. In view of the finding that SZs were more impaired than PDs but not different from RBDs, one could speculate that neuropsychological mechanisms underlying flat affect schizophrenia are more reflective of cortical than of subcortical dysfunction. Clearly the inclusion of a larger group of RBDs with lesions restricted to cortical regions would be critical to this argument. This research was supported by USPHS grant No. MH 37592. Portions of this paper were presented at the meeting of the International Neuropsychology Society, Denver, Colorado, 1986.
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MacPherson, F. M., Barden, V., Hay, A. J., Johnstone, W., and Kushner, A. W. (1970). Flattening of affect and personal constructs. Br. J. Psychiatry 116:39-43. Mattis, S. (1973). Dementia Rating Scale. New York. Mayer, M., Alpert, M., Stastney, P., Perlick, D., and Empfield, M. (1985). Multiple contributions to the clinical presentation of flat affect in a schizophrenic population. Schiz. Bull. 11:420-426. Nelson, D. V., Maxwell, J. K., and Townes, B. D. (1986). Cerebral laterality and interhemispheric relations in schizophrenia and affective disorders. Paper presented at the INS meeting, Denver, Colorado. Pougue-Geile, M. F., and Harrow, M. (1985). Negative symptoms in schizophrenia: Their longitudinal course and prognostic importance. Schiz. Bull. 11:427-439. Schweitzer, L. (1982). Evidence for right hemisphere dysfunction in schizophrenic patients with left hemisphere overactivation. Biol. Psychiatry 17:655673.
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Todes, C. J., and Lees, A. J. (1985). The premorbid personality of patients with Parkinson’s Disease. J. Neurol. Neurosurg. Psychiatry 48:97-100. Tucker,
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A PRELIMINARY COMPARISON OF FLAT AFFECT SCHIZOPHRENICS AND BRAINDAMAGED PATIENTS ON MEAUSRES OF AFFECTIVE PROCESSING JOAN C. BOROD Departments of Psychology, The City University of New Medical Center
Queens College, and Neurology, Mount Sinai Medical Center, York, and Department of Psychiatry, New York University
MURRAY ALPERT, ALIZAH BROZGOLD, and CANDACE MARTIN Department
of Psychiatry,
New York Universiry Medical
Center
JOAN WELKOWITZ Department
of Psychology,
LEONARD Department
of Psychiatry,
ABRAHAM Department
York University
DILLER
of Rehabilitation
ERIC PESELOW Department
New
Medicine,
New
York University
Medical
Center
and BURTON ANGRIST New York University
Medical
Center
LIEBERMAN
of Neurology,
New
York University
Medical
Center
Flat affect is a major component of schizophrenia and is often also seen in neurological disorders. A preliminary set of comparisons were conducted to delineate neuropsychological mechanisms underlying flat affect in schizophrenia, and new measures are described for the assessment of affective deficits in clinical populations. Subjects were schizophrenic with flat affect (SZs), right brain-damaged (RBD), Parkinson’s Disease (PDs), and normal control (NC) right-handed adults. Subjects were administered affective measures of expression and perception in both facial and vocal channels. For both perceptual and expressive tasks the SZs performed signiticantly less accurately than the NCs and the PDs but did not differ from the RBDs. This was the case for both face and voice. This finding lends support to the speculation that right hemisphere mechanisms, especially cortical ones, may be compromised among schizophrenics with flat affect.
Address correspondence to Dr. Joan C. Borod, Psychology Department, NSB E318, Flushing, NY 11367. 0 1989 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
Queens College,
93 0021~9924/89/$3.50
94
J. C. BOROD
et al.
INTRODUCTION Flattening of affect, a constriction or blunting in the range of expression of feelings, is the most common clinically observed disturbance of affect. By affect, we refer to feeling states that are brief in duration and associated with objectifiable behaviors, such as facial expression. In schizophrenia, flat affect is a powerful predictor of the course and outcome of the illness (Knight, Roff, Barnett, and Moss, 1979; Pougue-Geile and Harrow, 1985; Strauss and Carpenter, 1972) and has a special role in diagnostic formulations. Disturbances of affect have also been noted in patients with neurological disorders, e.g., right hemisphere strokes (Borod, Koff, and Caron, 1983; Gardner, 1975) and Parkinson’s Disease (Buck and Duffy, 1980). The purpose of this study was to compare the performance of schizophrenics with flat affect to that of patients with Parkinson’s Disease and right-hemisphere brain damage. Evidence of similar performance between these groups should have implications for brain/behavior mechanisms underlying schizophrenia. Although the predominant current opinion supports left hemisphere dysfunction in schizophrenia (Flor-Henry, 1979; Gur, 1978; Seidman, 1983; Tucker, 1981; Wexler, 1981), there are a number of studies where the performance of schizophrenic patients does not differ from that of normal controls (Fennel, Moskowitz, and Backus, 1982; Templer and Connolly, 1976; Wexler and Heninger, 1979) or where findings suggest right rather than left hemisphere dysfunction (Nelson, Maxwell, and Townes, 1986). The studies in the literature have been concerned primarily with cognitive and perceptual tasks, a factor that may have obscured brain-behavior relationships, since schizophrenia also involves significant affective and expressive deficits. Furthermore, the inclusion of different subgroups of schizophrenics might have confounded the results of such studies. One clinical distinction, viz., lexically deficient versus spatially deficient (Alpert and Martz, 1977), suggests that some schizophrenics (the spatially deficient) may have deficits that are similar to those seen among patients with right hemisphere pathology. According to Alpert and Martz, the “lexical” and “spatial” schizophrenic subgroups may correspond to the “productive” (Type I) and “deficit” (Type II) distinction, postulated by Crow (1980). In the current study, schizophrenics with flat affect were compared on affective measures to right-hemisphere brain-damaged patients, to Parkinson’s Disease patients, and to normal control subjects. Patients with Parkinson’s Disease were included for study in light of clinical descriptions of diminished expressiveness (Todes and Lees, 1985) and the hallmark symptom of masked facies in this population. The measures utilized in the current study examine the expression and perception of affect in both facial and vocal channels and are part of a larger affect battery,
FLAT AFFECT SCHIZOPHRENIA Table 1.
95
Age and Education, in Years, for Each Subject Group Age
Subject
sz RB PD NC
group
Education
N
Mean
SD
Mean
SD
6 5 6 4
38.5 69.2 63.8 34.8
13.3 7.6 10.4 6.2
11.0 13.2 15.6 15.8
1.7 2.7 3.2 1.7
recently developed by Borod, Alpert, and co-workers. It was our hypothesis that schizophrenics with flat affect would perform more similarly to right brain-damaged patients than to normal controls or Parkinsonian patients.
METHODS Subjects The subjects included six schizophrenics (SZs), live right brain-damaged patients (RBDs), six Parkinson’s Disease patients (PDs), and four normal adult controls (NCs). All subjects were adult males (except for one RBD female and two PD females). All were right-handed; handedness was determined by self-report and confirmed by a preference inventory (Coren, Porac, and Duncan, 1979). Subjects were screened to ensure at least average intellectual functioning [Vocabulary subtest from the WAIS-R (Wechsler, 1981)] and no evidence of dementia [Dementia Rating Scale (Mattis, 1973)] or history of serious alcohoVdrug abuse. Table 1 presents mean age and education values for each subject group. There were significant group difference for age (F = 14.66; & = 3, 17; p < .OOl>and for education (F = 4.59; df = 3, 16; p < .05). SZs with flat affect in the clinical setting were referred to us by a psychiatrist (EP) experienced in clinical diagnosis. The SZs all were diagnosed as “chronic schizophrenics,” using the Schedule for Affective Disorders and Schizophrenia (SADS) (Endicott and Spitzer, 1978) and Research Diagnostic Criteria (Spitzer, Endicott, and Robins, 1978). SZs were included if their illness was at least two years in duration (x duration = 47.5 months) and if they had no history of neurological disorder. RBDs were tested at least one month postonset (x duration = 2.5 months) and had unilateral lesions resulting from single episode cerebrovascular accidents (contirmed by CT scan). Lesion etiology and locus were as follows for the five RBDS: fronto-temporal hemorrhage, fronto-parietal hemorrhage, basal ganglia infarct with “frontal mass effect,” and two middle cerebral artery thrombotic occlusions. RBDs had no history of secondary
J. C. BOROD et al. neurological disease or premorbid psychiatric disorder (as confirmed by the Lifetime SADS, Endicott and Spitzer, 1978). Patients with idiopathic Parkinson’s Disease (x MPO = 52.1, SD = 32.9) using diagnostic criteria developed by Lieberman et al. (1979), were studied. PDs were free from secondary neurological disorder and premorbid psychiatric history (Lifetime SADS).
Procedures Each subject (S) was individually examined on perceptual and expressive measures of facial and vocal affect. For perception, subjects were required to identify photographs of facial emotion and recordings of emotionally intoned sentences. For expression, subjects were required to produce a range of facial and vocal emotional expressions to oral command. Informed consent was obtained after the procedures had been explained. Facial Perception. For the facial channel, Ss were requested to carry out an identification task involving positive and negative emotions. Stimuli were selected from a pool of slides (Ekman and Friesen, 1976) depicting 12 different posers (6 males, 6 females), each displaying the six basic emotions (according to Ekman, 1983) (happiness, surprise, sadness, fear, anger, disgust) and a neutral expression. Ss were presented with a slide of an emotional expression (on a Caramate) and required to identify the emotion that was being portrayed. A slide was presented for approximately three seconds. Ss were required to point to the correct response on a 5 x &in. card on which the names of the seven expressions (the six basic emotions plus neutral) were printed in a vertical array. There was no time limit. To control for any response or perceptual bias, there were four response cards with different orders that were randomized within and across subjects. There were 32 trials on this task (a male and Bfemale posers, balanced across the seven emotions); each of the seven emotions was presented four or five times. Vocal Perception. For the vocal channel, Ss were requested to carry out an identification task involving positive and negative emotions. This task was developed by Tucker, Watson, and Heilman (1977); some minor modifications in the response format were made. Stimuli consisted of four sentences of neutral content, e.g., “Fish can jump out of the water,” spoken by a male poser in one of three emotional tones (happiness, sadness, anger) and in an indifferent tone. Ss were presented with tape recordings of emotionally intoned sentences and required to identify the emotion being portrayed. Ss were required to point to the correct response on a 5 x 8-in card on which the names of the four possible responses (three emotions plus indifference)
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were printed in a vertical array. There were four separate cards with different orders that were randomized within and across subjects. There were 16 trials on this task; each of four emotions was presented four times (using each of the four neutral sentences). Facial Expression. For the facial channel, Ss were videotaped while deliberately producing a range of emotional expressions, including both positive ones (happiness, surprise, interest/excitement) and negative ones (sadness, anger, fear, disgust). In this task, Ss were requested to pose each emotion to oral command, e.g., “Look happy.” To maximize deliberate control over the expression and to facilitate rating procedures, Ss were requested to make each expression immediately following a command of “Ready, go!” This task utilized procedures developed by Borod et al. for normal (Borod and Caron, 1980; Borod, Koff, and White, 1983) and clinical (Borod, Koff, Larch, Nicholas, and Welkowitz, 1988; Jaeger, Borod, and Peselow, 1986) populations. Ss were required to pose each of the seven expressions (3 positive, 4 negative) two times, resulting in 14 trials. Expression order was randomized within and across subjects. Vocal Expression. For the vocal channel, Ss were audiotaped while intoning sentences with the same seven emotions listed in the facial expression section. Ss were instructed to use one of two neutral sentences chosen for grammatical and rhythmic similarity: (a) “She ran to catch the bus,” or (b) “They found it in the room.” Ss were instructed to intone each of the seven emotions two times (using sentences a and b), resulting in 14 trials. Again, expressions were randomized within and across Ss. scoring
Perception. For the facial and vocal perception tasks, each was scored for accuracy (0 for inaccurate, 1 for accurate), and all items combined into a total score. The total raw score was converted to percent correct. Expression. Three right-handed normal adults, naive regarding the hypotheses of the study and the subject group characteristics, made accuracy and intensity ratings of the facial and vocal data from the video- and audiotapes. Intensity of each expression was rated on a seven-point Likert scale from minimal (a score of 1) to maximal (a score of 7). Examples of responses at several levels of intensity, from earlier studies (e.g., Borod, Koff, and White, 1983) were used for training purposes. For category accuracy, raters indicated the emotion produced from a multiple-choice format, using all seven emotions. Prior to ratings, raters were familiarized with photographed exemplars of prototypical emotional expressions (Ekman and Friesen, 1976; Izard, 1971) and with previously rated video-
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PERCEPTION
0.80
0.60
Subject
Group
Mean accuracy scores for the affect perception tasks, by subject group. x Channel interaction (F = 1.10; df = 3, 13; p > .300), scores for face and voice tasks were combined.
Figure 1.
Since there was no significant Group
tapes. Responses for category accuracy were scored as correct (1) or incorrect (0). Inter-rater reliability was assessed on a presample of facial expressions (N = 15) and vocal expressions (N = 54). For category accuracy, two or three out of the three raters were in complete agreement for 80% of the facial expressions and for 83% of the vocal expressions. For intensity, the three raters made ratings that were identical or one point different for 80% of the facial and 74% of the vocal expressions. For the analyses to follow, ratings were averaged across the three raters. For each expression task, the mean ratings for each trial were averaged.
RESULTS Two-way repeated measures analyses of variance (ANOVA) (Group [4] x Channel [2]) were conducted, separately, for perception accuracy, expression accuracy, and expression intensity. In all cases, post-hoc analyses were conducted using the protected t-test (one-tail) (Welkowitz,
99
FLAT AFFECT SCHIZOPHRENIA
EXPRESSION 1 .oo 2 00 m 0.60 u” 2 0.50 z cc 0.40 k 2
0.30
Subject
Group
Mean accuracy scores for the affect expression tasks, by subject group. Since there was no significant Group x Channel interaction (F = 0.28; & = 3, 12; p > .500), scores for face and voice tasks were combined.
Figure 2.
Ewen, and Cohen, 1976). Since the subject groups differed significantly as a function of age and education, these variables were correlated with each of the perceptual and expressive measures. Since so few significant correlations occurred (not more than would be expected by chance), age and education were not controlled in the analyses to follow. Perception Accuracy. When the two-way ANOVA (Group x Channel) was carried out on the perception accuracy scores, there was a significant main effect of Group (F = 3.48; df = 3, 13; p < .05). Overall, SZs (x = S9) and RBDs (x = .63) were impaired relative to PDs (x = .78) and NCs (x = .85>. See Figure 1. Using post-hoc analyses, SZs (p <: .OS) and RBDs (p < .10) performed substantially lower than NCs. SZs were significantly (p < .OS)different from PDs but did not differ from the RBDs. There was also a significant main effect for Channel (F = 6.24; & = 1, 13; p < .05), such that emotional_voices (X = .77) were more accurately perceived than emotional faces (X = .66). Expression
Accuracy.
When the two-way ANOVA (Group x Channel)
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EXPRESS ION
Voice
Face
Figure 3. Mean intensity scores for the voice and face affect expression tasks, by subject group.
was carried out on the expression accuracy ratings, there was a significant main effect of Group (F = 3.87; df = 3, 12; p < .05). See Figure 2. Again, SZs (x = .30) and RBDs (x = .36) were impaired relative to PDs (x = .49) and NCs (x = 54). Using post-hoc analyses, SZs (p < .05) and RBDs (p < .lO) performed substantially lower than NCs. SZs differed (p < .lO) from PDs but not from RBDs. Expression Intensity. A two-way ANOVA (Group x Channel) was carried out on the expression intensity ratings. There was a significant main effect of Group (F = 3.59; & = 3, 12; p < .05), such that SZs (x = 3.32) were rated as showing less intense expressions than PDs (x = 4.12), RBDs (x = 4.27), and NCs (x = 4.84). Using post-hoc analyses, SZs were significantly (p < .05) less intense than NCs; none of the other comparisons were significant. Finally, there was a significant Group x Channel interaction (F = 6.73; & = 3, 12; p < .Ol). See Figure 3. Post-hoc tests were conducted separately for channel and group. When examining group differences for the
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facial channel, SZs and PDs were significantly (p < .05) less intense than NCs and RBDs. For the vocal channel, SZs were significantly less intense than RBDs (p < .05), PDs (p < .005), and NCs (p < .OOl); RBDs were significantly less intense than PDs (p < .05) and NCs (p < .005). When examining channel differences for each subject group, all differences were significant except for the NCs. Facial expressions were more intense than vocal expressions for SZs and RBDs, while vocal expressions were more intense than facial expressions for PDs. DISCUSSION From this preliminary sample of psychiatric and neurological patients, both schizophrenics and right brain-damaged patients showed deficits in the accuracy of affective processing when compared with normal controls. In addition, the SZs and the RBDs performed at equivalent levels. This was the case for both perceptual and expressive measures, and for both vocal and facial channels. While affective deficits have been previously demonstrated in separate studies of schizophrenic (Andreasen, 1979) and brain-damaged (Gainotti, 1972) populations, to our knowledge, this is the first comparison of actual levels of affective performance between these groups using the same assessment measures and the same raters. The findings for perception are consistent with our hypothesis that schizophrenics with flat affect would show aberrant patterns of performance on perceptual tasks typically associated with right hemisphere processing. Further, this finding is compatible with a recent report (Mayer, Alpert, Stastney, Perlick, and Empfield, 1985) that schizophrenic patients who were rated as showing flat affect and other “negative symptoms” performed more poorly on neuropsychological tasks associated with the right hemisphere (e.g., a test of neutral face recognition) than SZ patients with minimal negative symptoms. Findings associating flat affect and anomolous performance on a task using whole body, as well as facial, stimuli and requiring the use of emotional constructs also were reported by McPherson et al. (1970). The results for expression accuracy were similar to those for perception, i.e., SZs and RBDs performed at approximately the same level and both groups were impaired relative to normal controls. The findings for intensity were less clearcut, and were related to communication channel. Overall, SZs consistently produced less intense expressions than the other subject groups. For voice, again SZs and RBDs were significantly less intense than normals; for face, however, SZs and PDs showed the least intense facial expressions. This particular finding for PDs is not surprising because of the masked facies and is consistent with a recent study by Scott, Caird, and Williams (1984). While these findings are suggestive, larger numbers of subjects are nec-
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essary to substantiate the findings for perception and expression accuracy and to clarify the findings for expression intensity. In addition, the inclusion of a subgroup of schizophrenics with relatively more “positive” and less “negative” symptoms should permit a more sensitive statement about flat affect in this population. In view of the finding that SZs were more impaired than PDs but not different from RBDs, one could speculate that neuropsychological mechanisms underlying flat affect schizophrenia are more reflective of cortical than of subcortical dysfunction. Clearly the inclusion of a larger group of RBDs with lesions restricted to cortical regions would be critical to this argument. This research was supported by USPHS grant No. MH 37592. Portions of this paper were presented at the meeting of the International Neuropsychology Society, Denver, Colorado, 1986.
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