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Cross-ethnic differences in perception of emotion in schizophrenia
Schizophrenia Research 77 (2005) 289 – 298 www.elsevier.com/locate/schres
Cross-ethnic differences in perception of emotion in schizophrenia John S. Brekkea,T, Eri Nakagamia, Kimmy S. Keeb, Michael F. Greenb a School of Social Work, University of Southern California, Los Angeles, CA 90089-0411, United States Department of Psychiatry and Biobehavioral Science, University of California at Los Angeles, VA Greater Los Angeles Healthcare System, United States
b
Received 27 December 2004; received in revised form 26 March 2005; accepted 4 April 2005 Available online 31 May 2005
Abstract Background: The purpose of this study was to examine cross-ethnic differences in Perception of Emotion (POE) in schizophrenia. POE is an emerging construct in schizophrenia and involves the recognition and accurate identification of emotion in the facial and vocal expression of others. It has been implicated as relevant to instrumental functioning in schizophrenia, as well as a potential core deficit or marker for the disorder. Studies have shown the role of culture in shaping the expression and perception of emotion in non-clinical samples. It was hypothesized that ethnic minorities would have lower POE scores than Caucasians, and that the differences on POE would remain significant after controlling for neurocognition. Method: Individuals, 131, diagnosed with schizophrenia or schizoaffective disorder participated in the study. There were 59 Euro-American Caucasian, 56 were African-American, and 16 were Latino. Neurocognition was measured as a standardized sum of five neuropsychological measures. Perception of Emotion was measured with facial and voice recognition tasks. Results: Both Latinos and African-Americans scored lower on POE than Caucasians. The cross-ethnic differences on POE remained significant after controlling for neurocognition and overall symptom level. Post hoc analyses showed some support for the predictive validity of the POE measure across cultural contexts. Conclusions: These results suggest that POE in schizophrenia is influenced by ethnicity, and that the ethno-cultural mechanisms influencing POE transcend the shared variation of POE and neurocognition. These results have implications for theories of cross-cultural emotion recognition, measurement bias in POE research, and for the place of culture in the study of POE in schizophrenia. D 2005 Elsevier B.V. All rights reserved. Keywords: Culture; Ethnicity; Perception of emotion; Neurocognition; Schizophrenia
1. Introduction
T Corresponding author. Tel.: +1 213 7400297; fax: +1 213 7408905. E-mail address: [email protected] (J.S. Brekke). 0920-9964/$ - see front matter D 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.schres.2005.04.004
Perception of emotion (POE) is an emerging construct in schizophrenia. POE is one aspect of a larger construct of social cognition that has been defined as the mental operations underlying social
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interactions including perception of emotion, attributional style, and the perception of intent in others (Pinkham et al., 2003). POE involves the recognition and accurate identification of emotion in the facial and vocal expression of others. It has been implicated as relevant to social and instrumental functioning in schizophrenia, as well as a potential core deficit or marker for the disorder (Kee et al., 2003; Pinkham et al., 2003). Concerning the factors that might influence POE, culture has been related to the communication and understanding of emotion in non-clinical samples (Mandal and Ambady, 2004; Elfenbein and Ambady, 2003; Shioiri et al., 1999; Ekman et al., 1987), and has been associated with a variety of phenomena in schizophrenia, ranging from course of illness to symptom patterns and treatment responsiveness (Kulhara and Chakrabarti, 2001; Jablensky, 1989; Kagitcibasi and Barry, 1989; Hopper and Wanderling, 2000; Sartorius et al., 1986; Brekke and Barrio, 1997). The purpose of this study was to examine the cross-ethnic differences in POE in schizophrenia. The findings will have implications for the measurement and understanding of POE in schizophrenia, as well as for models of psychosocial functioning and clinical intervention for schizophrenia.
individuals are accurately perceived (Matsumoto, 1992a), the influence of language on the emotion lexicons (Matsumoto, 1992b; Russell, 1991), the cultural display or labeling of emotions (Matsumoto and Assar, 1992; Izard, 1971), as well as how dimensions of the broader social structures influence emotions (Matsumoto, 1989). Two theories that have particular relevance to POE are Other Race Bias (ORB; Meissner and Brigham, 2001), and Dialect Theory (Elfenbein and Ambady, 2003). Other Race Bias suggests that own-race faces are better remembered and discriminated than otherrace faces; it is therefore, most relevant to visual POE phenomena. Dialect Theory is a more general case as it is relevant to visual, nonverbal, and verbal POE modalities. Dialect Theory suggests that there are universal affect recognition perceptual capacities, and hence, similarities in cross-cultural affect recognition. But, this theory also suggests that cross-cultural differences in affect perception and recognition exist and are guided by culturally specific affect display and affect decoding rules. Taken together, both theories would predict differences in POE tasks based on race or culture. 1.2. Perception of emotion and schizophrenia
1.1. Cultural factors and emotion A range of cultural factors have emerged in the study of human emotion. Investigators have documented the universality of some expressed emotions (Brandt and Boucher, 1985) and perceptions or judgments of particular emotions (Ekman et al., 1972; Ekman and Friesen, 1971). However, in recent studies cultures have been found to differ in expressed emotion (Marsh et al., 2003) and in how emotion is recognized (Ekman et al., 1987). These cultural differences have been related to the level of affect recognition (Matsumoto et al., 1999; Izard, 1971), to ratings of emotional intensity (Matsumoto and Ekman, 1989), as well as to situations perceived as likely to give rise to certain emotions (Mesquita and Frijida, 1992). These cultural variations may be due to the way an event is appraised (Markham and Wang, 1996), the particular sanctions that cultures may exert against recognizing or acknowledging some emotions (Markham and Wang, 1996), the familiarity of particular events and the degree to which different
Several studies have indicated that people with schizophrenia are less accurate than non-clinical controls in POE, including the recognition of facial and vocal emotions in a range of settings (Whittaker et al., 2001; Kerr and Neale, 1993; Bryson et al., 1998; Bellack et al., 1996; Mandal et al., 1998). The lower performance by schizophrenic individuals on affect perception tests has been associated with psychotic symptoms (Addington and Addington, 1998; Kohler et al., 2000), bizarre behavior (Poole et al., 2000; Schneider et al., 1998), as well as some negative symptoms (Mueser et al., 1996). The impairments do not appear to be related to the use of traditional antipsychotics (Gaebel and Wolwer, 1992), atypical antipsychotics (Kee et al., 1998), or the side effects of these antipsychotics as they have been identified in unmedicated patients (Kerr and Neale, 1993). While the impairments are seen during periods of acute psychotic symptom exacerbations (Gessler et al., 1989), they also manifest during periods of clinical remission (Gessler et al., 1989) and may be more
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pronounced in individuals diagnosed with schizophrenia than non-psychotic disorders (Archer and Andrew, 1992). The deficits have been shown to be moderately stable over time (Gaebel and Wolwer, 1992) and not attributable to chronicity as they have been found in first-episode patients (Edwards et al., 2001). The underlying cause of poor performance on POE tests by individuals with schizophrenia has been attributed to a generalized performance deficit (Johnston et al., 2001; Salem et al., 1996) or to an emotionspecific deficit (Silver et al., 2002; Penn et al., 2000; Borod et al., 1993). A third notion suggests that measures of social cognition when compared to nonsocial cognition may have a stronger association with the differences in clinical symptoms that affect social functioning (Penn et al., 1997). POE deficits have also been linked to basic neurocognitive ability such as executive functioning (Whittaker et al., 2001), early perceptual processing (Kee et al., 1998), memory, abstraction and spatial tasks (Schneider et al., 1998), along with short-term memory, attention, concentration, and flexibility (Bryson et al., 1998). The impact of POE deficits on the social and interpersonal functioning of people with schizophrenia is potentially significant (Pinkham et al., 2003). Performance on facial emotion perception tasks were correlated with the ability to make appropriate social contacts, attend to personal appearance and hygiene (Mueser et al., 1996), as well as with interpersonal relationships (Poole et al., 2000). POE impairments predicted poor adaptive hospital ward behavior (Penn et al., 1997), and Kee et al. (2003) found that emotional processing was a significant determinant of vocational functioning and self-care outcome over 1 year for outpatients with schizophrenia.
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national groups, the results also showed that the Indian groups, both patients and controls, showed significantly lower performance on facial discrimination than their American and German counterparts. While this study provided evidence for cross-national differences in facial emotion discrimination for schizophrenia patients as well as normal controls, the investigation was limited in that the Indian patient sample had greater chronicity of illness and was entirely male, and relevant psychopathological data for the German and Indian groups were not available. Concerning cross-ethnic differences on basic neurocognitive tests, there is some evidence that culture and education affect performance on non-verbal neuropsychological tests in non-clinical populations (Rosselli and Ardila, 2003), although a recent study found that tests similar to the ones used in this study had been successfully translated and used crossnationally for individuals with schizophrenia (Harvey et al., 2003). The present study aimed to address the limitations in existing research on cross-ethnic differences in POE for individuals diagnosed with schizophrenia. The ethnic groups in this study (Caucasian, AfricanAmerican, Latino) came from a single nationally bound sample, and they were similar on a wide range of demographic and psychosocial variables. Based on the literature cited above, we hypothesized: a) that African-Americans and Latinos would have lower performance compared to the Caucasian group on POE; b) that there would be no differences on neurocognitive tests across the three ethnic groups; and c) that while POE and basic neurocognition scores would be related, the cross-ethnic differences in POE would not be entirely explained by performance on neurocognitive measures.
1.3. Culture, POE, and schizophrenia In spite of the evidence regarding cross-cultural differences in POE in non-clinical groups, affect perception in schizophrenia has rarely been examined across cultures. In the one study we are aware of, Habel et al. (2000) assessed the performance of American, German, and Indian patients together with normal controls on standardized emotion discrimination tasks and mood induction. While the results indicated that normal controls performed significantly better than schizophrenia patients in each of the three
2. Method Participants in this study were recruited as they were admitted to community-based psychosocial rehabilitation programs in urban Los Angeles. They were assessed at baseline before treatments began as part of a longitudinal study. Psychosocial and functional status data were generally gathered within 2 weeks of the neuropsychological and social cognition testing. The psychosocial interviews were completed
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by trained research interviewers who were blind to the neuropsychological results. Neuropsychological and social cognition testers were blind to the scores on the psychosocial measures.
2.2. Measures
2.1. Subjects
The social cognition and neurocognitive data came from laboratory-based assessments in a facility designed for this study. All psychosocial variables came from data gathered in face-to-face interviews.
The sample consisted of 131 individuals diagnosed with schizophrenia or schizoaffective disorder who completed baseline test batteries including neurocognition, social cognition, and psychosocial functioning. Diagnoses were determined using clinical records, a DSM-IV checklist, and collateral reports from the admitting clinician and on-site psychiatrist. Subjects were excluded if they met criteria for alcohol or drug dependence in the previous 6 months or if they had an identified neurological disorder. All subjects signed an informed consent under protocols approved by the Institutional Review Board at the University of Southern California. Sample descriptive data are summarized in Table 1. The Latino subjects were well acculturated based on language preference, place of birth, and where they were educated. The large majority of subjects were on anti-psychotic medication for the previous 6 months.
2.2.1. Social cognition measures Affect perception was measured by the following three scales from which the simple sum of correct responses was derived: (1) the Facial Emotion Identification Test (FEIT; Kerr and Neale, 1993), (2) the Voice Emotion Identification Test (VEIT; Kerr and Neale, 1993), and (3) the Videotape Affect Perception Test (VAP; Bellack et al., 1996). These tests and the procedures for administering them are fully described in Kee et al. (1998). All three require the subject to select one of six basic emotions (i.e., happy, angry, afraid, sad, surprised, and ashamed) that best describes the emotion presented in photographs, on audiotape, or in videotaped scenes of interpersonal situations. The stimulus faces on the FEIT are all Euro-American Caucasian, as are the voices on the VEIT. On the VAP, 87% of the individuals are Caucasian, and 13% are AfricanAmerican.
Table 1 Comparison of three ethnic groups White (1) N = 59 Gender Male Female Age X (SD) Days in hospital in previous 6 months Length of illness in years Education years BPRS total BPRS negative RFS Prognosis Days on meds in 6 mo. Neuro-cognition POE Total POE visual POE voice POE scenes a
Africa-American (2) N = 56
Latino (3) N = 16
Test statistic 2
F
8.8 35 24 38.4 13.7 14.8 11.9 39.4 4.3 9.0 23.1 140 1.1 41.2 11.9 10.2 19.3
(8.9) (31.2) (10.6) (1.7) (9.0) (2.1) (3.6) (4.5) (66) (3.0) (8.7) (3.2) (3.0) (3.8)
47 9 40.2 26.4 15.5 12.0 38.9 4.2 7.7 22.1 148 0.25 36.5 9.8 8.8 17.8
(8.9) (55.3) (10.1) (1.8) (11.15) (1.9) (3.6) (5.8) (63) (3.5) (9.9) (3.3) (3.4) (5.5)
10 6 32.8 8.1 7.4 11.2 39.6 4.6 7.6 22.7 166 3.3 34.5 10.4 7.8 17.3
(8.3) (17.9) (6.4) (2.0) (11.7) (2.3) (3.5) (4.1) (45) (3.3) (9.5) (3.6) (3.7) (2.1)
One-tailed tests of statistical significance, all significant in the hypothesized direction.
df
p 2
4.3 1.8 4.2 1.3 0.04 0.27 2.3 0.72 1.2 7.9 5.3 6.3 4.7 1.9
2128 2128 2122 2123 2128 2128 2128 2118 2127 2105 2128 2129 2129 2127
Contrasts
0.01
0.02 0.17 0.02 0.28 0.96 0.77 0.11 0.49 0.32 0.001 0.006a 0.001a 0.005a 0.07a
3 b 1, 2 3 b 1, 2
1, 2 N 3 1 N 2, 3 1N2 1 N 2, 3
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2.2.2. Neurocognitive measures The neurocognitive variable in this study was a composite created from measures of verbal fluency, immediate memory, secondary memory, sustained attention, and mental flexibility. These specific neurocognitive variables were chosen because they have been related to functional outcomes in schizophrenia, and their composite has been used in previous research (Green et al., 2000). A principal components factor analysis of the five scores found that there was a single factor with eigen value above 1.0 that accounted for over 50% of the total score variance. The average Pearson correlation among the five measures was .38, with a range of .25–.53 (all statistically significant at p b .006). The composite was derived from the following five tests by summing the standardized scores. (1) Controlled Oral Word Association Test (COWAT; Lezak, 1995) requires the subject to name as many words as possible that begin with the letters F, A, and S. The score is the sum of all acceptable words produced in three 1-min trials. This word fluency test appears to be a sensitive indicator of frontal functioning. (2) Digit Span Distractibility Test (DSDT; Oltmanns and Neale, 1975) is an audiotape measure of short-term verbal recall with and without distraction. The mean of correct responses in the two conditions is an indicator of immediate or working memory. (3) California Verbal Learning Test (CVLT; Delis et al., 1987) uses oral presentation of 16 items and allows examination of several aspects of verbal memory. This study used an overall recall score as a measure of secondary memory. (4) Degraded-Stimulus Continuous Performance Test (DS-CPT; Nuechterlein et al., 1992) is a computer-based measure of focused, sustained attention with a fast-paced visual vigilance task. Subjects are asked to detect stimuli that are increasingly degraded. The sensitivity score measures an ability to discriminate signal from noise. (5) Wisconsin Card Sorting Test (WCST; Heaton, 1981) is sensitive to activity in the prefrontal cortex and measures executive functioning, including the ability to attain and shift a cognitive
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set. Several indices come from the WCST; we used the score for perseverative errors. 2.2.3. Psychosocial measures Several psychosocial variables were used to describe the sample and to provide covariates for ruling out alternative explanations for patterns found in the data. Functional variables were obtained from the Community Adjustment Form (CAF; Test et al., 1991). The CAF uses trained interviewers to gather behavioral event data from 17 domains of community functioning such as living situation, work and social functioning, family involvement, social competence, and medication usage. A functional outcome measure administered during the CAF interview is the Role Functioning Scale (RFS; Goodman et al., 1993; McPheeters, 1984), which was selected as a scale of choice for this population (Green and Gracely, 1987). We used the global score which is the sum of the three RFS items. The CAF provided data regarding medication usage, and the Expanded Brief Psychiatric Rating Scale measured symptoms (Lukoff et al., 1986). The Demographic Interview Form (Test et al., 1991) supplied demographic information, including ethnicity and acculturation, and prognosis came from the Strauss and Carpenter Prognostic Scale (Strauss and Carpenter, 1974). The protocols used for establishing the field reliability of these instruments are available (Brekke, 1992; Brekke et al., 1993).
3. Results Before testing our main hypotheses, the three ethnic groups were compared on a range of demographic, clinical, and functional variables (see Table 1). As can be seen from Table 1, there were no statistically significant differences across ethnic groups on education, hospitalized days in the previous 6 months, global symptom level, days on antipsychotic medication in the previous 6 months, prognosis, negative symptoms, or global psychosocial functioning. There were significant cross-ethnic differences on age at study admission (Latinos were younger than AfricanAmericans), length of illness (Latinos were ill fewer months than African-Americans or Caucasians), and gender (African-American females are relatively under-represented). Since there were no statistically significant relationships between POE and either length of illness, gender, or age,
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(r = .01, r = .15, r = .09; p N .05 in all cases) these variables were not used as covariates in subsequent hypothesis testing about ethnicity and POE. The main study hypotheses were tested using analysis of variance and analysis of covariance (ANOVA and ANCOVA) (see Table 1). As can be seen from Table 1, there were significant cross-ethnic differences in the total POE score. As was hypothesized, the post hoc analyses revealed that Caucasians scored significantly higher than both Latinos and African-Americans, and there was no statistically significant difference between Latinos and African-Americans. The POE component scales (facial, vocal, and interpersonal scenes) all showed differences in the hypothesized direction, with statistically significant differences for facial and vocal measures, and a trend for the scenes measure. The contrasts revealed that Caucasians were significantly higher than both Latinos and AfricanAmericans on the vocal task, and that Caucasians were significantly higher than African-Americans on the facial task. From Table 1 it can be seen that there were also statistically significant cross-ethnic differences on basic neurocognition. This finding is contrary to our second hypothesis, but the post hoc contrasts reveal that both Caucasians and African-Americans scored higher than Latinos, with no difference between Caucasians and African-Americans. This difference remained significant after controlling for education. As will be discussed below, these differences could reflect factors other than culture. Hypothesis three proposed that whereas POE and basic neurocognition scores would be related, the cross-ethnic differences in POE would not be explained by the level of performance on neurocognitive measures. While neurocognition and POE were significantly correlated (Pearson r = .43, p b .000), the cross-ethnic findings on the total POE score remained statistically significant after controlling for neurocognition as well global symptom level ( F = 3.6, df 2, 125; p = .03). Since there have been arguments that POE could be a culturally embedded construct (Mandal and Ambady, 2004; Elfenbein and Ambady, 2003; Shioiri et al., 1999), the presence of bias in the measure of POE is salient. Therefore, Table 2 presents the correlations between POE and both neurocognition and functional outcome for each ethnic group. As stated earlier, previous research has found strong correlations between POE and both neurocognition and functional outcomes. While this was not a definitive test of the cultural bias hypothesis, it did provide data on the degree to which the instrument functioned similarly across ethnic groups in ways that would be predicted. Concerning the relationship between POE and functional outcome, the Pearson correlation value is quite similar across the ethnic
Table 2 Pearson correlations between POE and both functional and neurocognitive measures in three ethnic groups White
African-American Latino
POE/role functioning 0.29 (0.02)T 0.28 (0.04) POE/neurocognition 0.44 (0.001) 0.38 (0.01)
0.34 (0.20) 0.38 (0.28)
T p-value in parenthesis.
groups, and is highest in the Latino group, although it is not statistically significant due to the small Latino sample. Concerning neurocognition, the magnitude of the correlation with POE is also very similar across ethnic groups. These results suggest that while the mean level of POE differs significantly between Euro-American Caucasians and both Latinos and African-Americans, the POE measure has similar predictive validity across the three ethnic groups.
4. Discussion This is the first study to examine cross-ethnic differences in perception of emotion (POE) using a single nationally bound outpatient sample of individuals diagnosed with schizophrenia. We found support for cross-ethnic POE differences in schizophrenia, with both Latinos and African-Americans scoring lower than Euro-American Caucasians. This argues for the consideration of ethno-cultural factors when attempting to fully understand POE among individuals with schizophrenia. There has also been speculation about the cause of the POE deficit in schizophrenia. A generalized performance deficit and symptom sensitivity hypotheses have been advanced (Johnston et al., 2001; Silver and Shlomo, 2001; Penn et al., 1997; Salem et al., 1996). We found that the cross-ethnic differences on POE remained significant after controlling for basic neurocognition and overall symptom level. This suggests that the cross-ethnic differences cannot be explained by symptom influences, and that the ethno-cultural mechanisms influencing POE transcend the shared variation of POE and neurocognition. The cross-ethnic differences on POE among people with schizophrenia have also been found among nonclinical samples of adults. Therefore, the posited ethno-cultural mechanisms among non-clinical samples might be applicable to schizophrenia as well. This suggests that factors such as the way an event is
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appraised (Markham and Wang, 1996), the sanctions that cultures exert against recognizing or acknowledging some emotions (Markham and Wang, 1996), the familiarity of particular events and the degree to which different individuals are accurately perceived (Matsumoto, 1992a), the influence of language on the emotion lexicons (Matsumoto and Assar, 1992; Russell, 1991), the cultural display or labeling of emotions (Izard, 1971), as well as factors such as power distance and individualism versus collectivism (Matsumoto, 1990; Triandis et al., 1988; Hofstede, 1980) could all be mechanisms to be investigated in schizophrenia. Two theories that have particular relevance to the current study are Other Race Bias (ORB; Meissner and Brigham, 2001), and Dialect Theory (Elfenbein and Ambady, 2003). In the present study, it might be predicted that ORB would be most salient on the facial emotion recognition task (since all of the stimuli faces are Caucasian) and not as salient on the vocal task (assuming that race would not be as recognizable in the voice-only stimuli). In terms of Dialect Theory, we might expect differences on all modalities. Our results indicated that all of the subscale results (facial, vocal, and scenes) were in the predicted direction, but were the strongest in the voice condition. Therefore, our results suggest that ORB is a possible explanatory mechanism, but that Dialect Theory has particular relevance due to the findings across all three perceptual modalities. While this study was not designed to test differential predictions across perceptual modalities, these findings can guide the development of hypotheses for future research. These theories also facilitate the explanation of the findings on emotion processing from the Habel et al. (2000). In a cross-national study, Habel et al. (2000) concluded that the use of existing emotional processing measures across cultures was supported because they found that the poorer performance on these measures among individuals with schizophrenia when compared to normal controls was consistent across three national groups. However, there were also significant differences between national groups for both patients and controls, with the Indian samples scoring significantly lower than the American and German samples on facial recognition tasks. ORB and Dialect Theory provide possible explan-
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ations for these cross-national findings. While our cross-ethnic findings on the level of POE are similar to Habel et al., we had much greater similarity across ethnic groups on symptom level and other relevant demographic and psychosocial characteristics, and our data on basic neurocognition also strengthened the assessment of effects due to ethnocultural factors. Both ORB and Dialect Theory provide a challenge to measurement strategies in the area of POE. Since in this study both ethnic minority groups did poorer on POE than the majority group, this could suggest that our measure of POE is culturally laden. Specifically, it is possible that our cross-ethnic findings are due to a culturally invalid measure of POE, and that the ethnic minority schizophrenic individuals could be accurate in POE within their own cultural contexts. In this regard, Matsumoto has developed a measure of POE specifically for the Japanese (Matsumoto et al., 2000; Biehl et al., 1997), and they delineate methodological requirements for studies attempting to detect both cross-cultural similarities and differences in emotion perception. To partially address the issue of cross-cultural measurement bias in the current measure of POE, we examined the correlations between POE and both functional outcome and neurocognition in the three ethnic groups. We found that even though the level of POE was significantly lower in both ethnic minority groups, the measure functioned similarly in its relationship with other related factors across the ethnic groups. Taken together, the current study as well as Habel et al. (2000), suggest that while there is evidence for the discriminant and predictive validity of some POE measures in cross-ethnic contexts, the actual level of POE was influenced by cross-national and ethnic factors. However, since the actual level of POE is important in many studies involving individuals with schizophrenia, the issue of measurement bias in POE requires attention in future research. Strategies for assessing measurement bias due to cultural factors are available (Sue and Chu, 2003; Okazaki and Sue, 1995), and Bae and Brekke (2002) provide an example concerning the measurement of self-esteem in schizophrenia. Currently, we would suggest a cautious approach to using existing POE measures when there is ethnic or racial heterogeneity in samples. Unless the POE measures
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have been specifically designed to account for ethnicity or race in their use, the results to date would suggest that there could be notable bias in the level of POE across ethno-cultural groups, but that little bias might exist when testing hypotheses based on covariance structures. There is also growing evidence that POE is related to functional outcomes in schizophrenia (Kee et al., 2003; Pinkham et al., 2003); therefore, it is important that ethnic differences in POE be understood as either related to ethno-cultural factors or cross-cultural measurement biases so that the relationships to functional outcomes can be assessed cross-culturally. As interventions are designed for deficits in POE for individuals with schizophrenia, it is essential that the cultural influences on POE be accurately understood so that interventions can be applied or adapted accurately to ethnic minority groups. We also found that there were cross-ethnic differences on basic neurocognition. Specifically, there was no difference between Caucasians and African-Americans, and both groups scored higher than Latinos. Given the small sample of Latinos, this finding should be replicated on a larger sample before cultural factors are implicated for these neurocognitive measures. Future research should also be informed by the work of Biehl et al. (1997) when designing cross-cultural studies of POE, and of Meissner and Brigham (2001) and Elfenbein and Ambady (2003) when trying to disentangle the effects of race and culture across perceptual modalities in POE. At a minimum, these studies need to be balanced across ethnicity in the sample and in the POE stimuli that are used (Elfenbein and Ambady, 2003). There are several limitations to this study. First, it is possible that minority status within the United States could account for our findings. Cross-national studies could shed light on this issue. Second, these findings are generalizable to outpatients with schizophrenia who are seeking rehabilitation. Third, POE is only one indicator of a larger construct of social cognition. Cross-ethnic influences on other aspects of social cognition such as theory of mind and attributional style are needed. Fourth, the Latino sample in this study was very small. Future studies should include a range of well-represented ethnic groups. Fifth, while our measure of POE detected ethnic
differences, it was not developed to study them. As noted above, there are methodological approaches to understanding the mechanisms of ethnicity, nationality, majority/minority status, bilingualism, and the effects of cultural learning in this area (Elfenbein and Ambady, 2003). Finally, given the complexity and contextually embedded nature of ethno-cultural factors, the use of qualitative and mixed method approaches for generating hypotheses and new theoretical approaches is important to future research in this area.
Acknowledgements This research was supported by grants MH53282 and MH01628 from the National Institute of Mental Health awarded to the first author, and by the Department of Veterans Affairs VISN 22 Mental Illness Research Education and Clinical Center.
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Rosselli, M., Ardila, A., 2003. The impact of culture and education on non-verbal neuropsychological measurements: a critical review. Brain and Cognition 52 (3), 326 – 333. Russell, J.A., 1991. Culture and the categorization of emotions. Psychological Bulletin 110, 426 – 450. Salem, J.E., Kring, A.M., Kerr, S.L., 1996. More evidence for generalized poor performance in facial emotion perception in schizophrenia. Journal of Abnormal Psychology 105, 480 – 483. Sartorius, N., Jablensky, A., Korten, A., Ernberg, G., Anker, M., Cooper, J.E., 1986. Early manifestations and 1st-contact incidence of schizophrenia in different cultures. Psychological Medicine 16 (4), 909 – 928. Schneider, F., Weiss, U., Kessler, C., Salloum, J.B., Posse, S., Grodd, W., Muller-Gartner, H.W., 1998. Differential amygdala activation in schizophrenia during sadness. Schizophrenia Research 34 (3), 133 – 142. Shioiri, T., Someya, T., Helmeste, D., Tang, S.W., 1999. Cultural difference in recognition of facial emotional expression: contrast between Japanese and American raters. Psychiatry and Clinical Neurosciences 53 (6), 629 – 633. Silver, H., Shlomo, M., 2001. Perception of facial emotions in chronic schizophrenia does not correlate with negative symptoms but correlates with cognitive and motor dysfunction. Schizophrenia Research 52 (3), 265 – 273. Silver, H., Shlomo, N., Turner, T., Gur, R.C., 2002. Perception of happy and sad facial expressions in chronic schizophrenia: evidence for two evaluative systems. Schizophrenia Research 55 (1–2), 171 – 177. Strauss, J.S., Carpenter, W.T., 1974. The prediction of outcome in schizophrenia: I. Characteristics of outcome. Archives of General Psychiatry 27, 739 – 746. Sue, S., Chu, J.Y., 2003. The mental health of ethnic minority groups: challenges posed by the supplement to the Surgeon General’s report on mental health. Culture, Medicine and Psychiatry 27 (4), 447 – 465 (Special The Politics of Science: Culture, race, ethnicity, and the Supplement to the Surgeon General’s Report on Mental Health). Test, M.A., Knoedler, W.H., Allness, D.J., Burke, S.S., Brown, R.L., Wallisch, L.S., 1991. Long-Term Community Care Through an Assertive Continuous Treatment Team. Triandis, H.D., Botempo, R., Villareal, M.J., Asai, M., Lucca, N., 1988. Individualism and collectivism: cross-cultural perspectives on self-in-group relationships. Journal of Personality and Social Psychology 54, 323 – 338. Whittaker, J.F., Deakin, J.F.W., Tomenson, B., 2001. Face processing in schizophrenia: defining the deficit. Psychological Medicine 31 (3), 499 – 507.
Cross-ethnic differences in perception of emotion in schizophrenia John S. Brekkea,T, Eri Nakagamia, Kimmy S. Keeb, Michael F. Greenb a School of Social Work, University of Southern California, Los Angeles, CA 90089-0411, United States Department of Psychiatry and Biobehavioral Science, University of California at Los Angeles, VA Greater Los Angeles Healthcare System, United States
b
Received 27 December 2004; received in revised form 26 March 2005; accepted 4 April 2005 Available online 31 May 2005
Abstract Background: The purpose of this study was to examine cross-ethnic differences in Perception of Emotion (POE) in schizophrenia. POE is an emerging construct in schizophrenia and involves the recognition and accurate identification of emotion in the facial and vocal expression of others. It has been implicated as relevant to instrumental functioning in schizophrenia, as well as a potential core deficit or marker for the disorder. Studies have shown the role of culture in shaping the expression and perception of emotion in non-clinical samples. It was hypothesized that ethnic minorities would have lower POE scores than Caucasians, and that the differences on POE would remain significant after controlling for neurocognition. Method: Individuals, 131, diagnosed with schizophrenia or schizoaffective disorder participated in the study. There were 59 Euro-American Caucasian, 56 were African-American, and 16 were Latino. Neurocognition was measured as a standardized sum of five neuropsychological measures. Perception of Emotion was measured with facial and voice recognition tasks. Results: Both Latinos and African-Americans scored lower on POE than Caucasians. The cross-ethnic differences on POE remained significant after controlling for neurocognition and overall symptom level. Post hoc analyses showed some support for the predictive validity of the POE measure across cultural contexts. Conclusions: These results suggest that POE in schizophrenia is influenced by ethnicity, and that the ethno-cultural mechanisms influencing POE transcend the shared variation of POE and neurocognition. These results have implications for theories of cross-cultural emotion recognition, measurement bias in POE research, and for the place of culture in the study of POE in schizophrenia. D 2005 Elsevier B.V. All rights reserved. Keywords: Culture; Ethnicity; Perception of emotion; Neurocognition; Schizophrenia
1. Introduction
T Corresponding author. Tel.: +1 213 7400297; fax: +1 213 7408905. E-mail address: [email protected] (J.S. Brekke). 0920-9964/$ - see front matter D 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.schres.2005.04.004
Perception of emotion (POE) is an emerging construct in schizophrenia. POE is one aspect of a larger construct of social cognition that has been defined as the mental operations underlying social
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interactions including perception of emotion, attributional style, and the perception of intent in others (Pinkham et al., 2003). POE involves the recognition and accurate identification of emotion in the facial and vocal expression of others. It has been implicated as relevant to social and instrumental functioning in schizophrenia, as well as a potential core deficit or marker for the disorder (Kee et al., 2003; Pinkham et al., 2003). Concerning the factors that might influence POE, culture has been related to the communication and understanding of emotion in non-clinical samples (Mandal and Ambady, 2004; Elfenbein and Ambady, 2003; Shioiri et al., 1999; Ekman et al., 1987), and has been associated with a variety of phenomena in schizophrenia, ranging from course of illness to symptom patterns and treatment responsiveness (Kulhara and Chakrabarti, 2001; Jablensky, 1989; Kagitcibasi and Barry, 1989; Hopper and Wanderling, 2000; Sartorius et al., 1986; Brekke and Barrio, 1997). The purpose of this study was to examine the cross-ethnic differences in POE in schizophrenia. The findings will have implications for the measurement and understanding of POE in schizophrenia, as well as for models of psychosocial functioning and clinical intervention for schizophrenia.
individuals are accurately perceived (Matsumoto, 1992a), the influence of language on the emotion lexicons (Matsumoto, 1992b; Russell, 1991), the cultural display or labeling of emotions (Matsumoto and Assar, 1992; Izard, 1971), as well as how dimensions of the broader social structures influence emotions (Matsumoto, 1989). Two theories that have particular relevance to POE are Other Race Bias (ORB; Meissner and Brigham, 2001), and Dialect Theory (Elfenbein and Ambady, 2003). Other Race Bias suggests that own-race faces are better remembered and discriminated than otherrace faces; it is therefore, most relevant to visual POE phenomena. Dialect Theory is a more general case as it is relevant to visual, nonverbal, and verbal POE modalities. Dialect Theory suggests that there are universal affect recognition perceptual capacities, and hence, similarities in cross-cultural affect recognition. But, this theory also suggests that cross-cultural differences in affect perception and recognition exist and are guided by culturally specific affect display and affect decoding rules. Taken together, both theories would predict differences in POE tasks based on race or culture. 1.2. Perception of emotion and schizophrenia
1.1. Cultural factors and emotion A range of cultural factors have emerged in the study of human emotion. Investigators have documented the universality of some expressed emotions (Brandt and Boucher, 1985) and perceptions or judgments of particular emotions (Ekman et al., 1972; Ekman and Friesen, 1971). However, in recent studies cultures have been found to differ in expressed emotion (Marsh et al., 2003) and in how emotion is recognized (Ekman et al., 1987). These cultural differences have been related to the level of affect recognition (Matsumoto et al., 1999; Izard, 1971), to ratings of emotional intensity (Matsumoto and Ekman, 1989), as well as to situations perceived as likely to give rise to certain emotions (Mesquita and Frijida, 1992). These cultural variations may be due to the way an event is appraised (Markham and Wang, 1996), the particular sanctions that cultures may exert against recognizing or acknowledging some emotions (Markham and Wang, 1996), the familiarity of particular events and the degree to which different
Several studies have indicated that people with schizophrenia are less accurate than non-clinical controls in POE, including the recognition of facial and vocal emotions in a range of settings (Whittaker et al., 2001; Kerr and Neale, 1993; Bryson et al., 1998; Bellack et al., 1996; Mandal et al., 1998). The lower performance by schizophrenic individuals on affect perception tests has been associated with psychotic symptoms (Addington and Addington, 1998; Kohler et al., 2000), bizarre behavior (Poole et al., 2000; Schneider et al., 1998), as well as some negative symptoms (Mueser et al., 1996). The impairments do not appear to be related to the use of traditional antipsychotics (Gaebel and Wolwer, 1992), atypical antipsychotics (Kee et al., 1998), or the side effects of these antipsychotics as they have been identified in unmedicated patients (Kerr and Neale, 1993). While the impairments are seen during periods of acute psychotic symptom exacerbations (Gessler et al., 1989), they also manifest during periods of clinical remission (Gessler et al., 1989) and may be more
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pronounced in individuals diagnosed with schizophrenia than non-psychotic disorders (Archer and Andrew, 1992). The deficits have been shown to be moderately stable over time (Gaebel and Wolwer, 1992) and not attributable to chronicity as they have been found in first-episode patients (Edwards et al., 2001). The underlying cause of poor performance on POE tests by individuals with schizophrenia has been attributed to a generalized performance deficit (Johnston et al., 2001; Salem et al., 1996) or to an emotionspecific deficit (Silver et al., 2002; Penn et al., 2000; Borod et al., 1993). A third notion suggests that measures of social cognition when compared to nonsocial cognition may have a stronger association with the differences in clinical symptoms that affect social functioning (Penn et al., 1997). POE deficits have also been linked to basic neurocognitive ability such as executive functioning (Whittaker et al., 2001), early perceptual processing (Kee et al., 1998), memory, abstraction and spatial tasks (Schneider et al., 1998), along with short-term memory, attention, concentration, and flexibility (Bryson et al., 1998). The impact of POE deficits on the social and interpersonal functioning of people with schizophrenia is potentially significant (Pinkham et al., 2003). Performance on facial emotion perception tasks were correlated with the ability to make appropriate social contacts, attend to personal appearance and hygiene (Mueser et al., 1996), as well as with interpersonal relationships (Poole et al., 2000). POE impairments predicted poor adaptive hospital ward behavior (Penn et al., 1997), and Kee et al. (2003) found that emotional processing was a significant determinant of vocational functioning and self-care outcome over 1 year for outpatients with schizophrenia.
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national groups, the results also showed that the Indian groups, both patients and controls, showed significantly lower performance on facial discrimination than their American and German counterparts. While this study provided evidence for cross-national differences in facial emotion discrimination for schizophrenia patients as well as normal controls, the investigation was limited in that the Indian patient sample had greater chronicity of illness and was entirely male, and relevant psychopathological data for the German and Indian groups were not available. Concerning cross-ethnic differences on basic neurocognitive tests, there is some evidence that culture and education affect performance on non-verbal neuropsychological tests in non-clinical populations (Rosselli and Ardila, 2003), although a recent study found that tests similar to the ones used in this study had been successfully translated and used crossnationally for individuals with schizophrenia (Harvey et al., 2003). The present study aimed to address the limitations in existing research on cross-ethnic differences in POE for individuals diagnosed with schizophrenia. The ethnic groups in this study (Caucasian, AfricanAmerican, Latino) came from a single nationally bound sample, and they were similar on a wide range of demographic and psychosocial variables. Based on the literature cited above, we hypothesized: a) that African-Americans and Latinos would have lower performance compared to the Caucasian group on POE; b) that there would be no differences on neurocognitive tests across the three ethnic groups; and c) that while POE and basic neurocognition scores would be related, the cross-ethnic differences in POE would not be entirely explained by performance on neurocognitive measures.
1.3. Culture, POE, and schizophrenia In spite of the evidence regarding cross-cultural differences in POE in non-clinical groups, affect perception in schizophrenia has rarely been examined across cultures. In the one study we are aware of, Habel et al. (2000) assessed the performance of American, German, and Indian patients together with normal controls on standardized emotion discrimination tasks and mood induction. While the results indicated that normal controls performed significantly better than schizophrenia patients in each of the three
2. Method Participants in this study were recruited as they were admitted to community-based psychosocial rehabilitation programs in urban Los Angeles. They were assessed at baseline before treatments began as part of a longitudinal study. Psychosocial and functional status data were generally gathered within 2 weeks of the neuropsychological and social cognition testing. The psychosocial interviews were completed
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by trained research interviewers who were blind to the neuropsychological results. Neuropsychological and social cognition testers were blind to the scores on the psychosocial measures.
2.2. Measures
2.1. Subjects
The social cognition and neurocognitive data came from laboratory-based assessments in a facility designed for this study. All psychosocial variables came from data gathered in face-to-face interviews.
The sample consisted of 131 individuals diagnosed with schizophrenia or schizoaffective disorder who completed baseline test batteries including neurocognition, social cognition, and psychosocial functioning. Diagnoses were determined using clinical records, a DSM-IV checklist, and collateral reports from the admitting clinician and on-site psychiatrist. Subjects were excluded if they met criteria for alcohol or drug dependence in the previous 6 months or if they had an identified neurological disorder. All subjects signed an informed consent under protocols approved by the Institutional Review Board at the University of Southern California. Sample descriptive data are summarized in Table 1. The Latino subjects were well acculturated based on language preference, place of birth, and where they were educated. The large majority of subjects were on anti-psychotic medication for the previous 6 months.
2.2.1. Social cognition measures Affect perception was measured by the following three scales from which the simple sum of correct responses was derived: (1) the Facial Emotion Identification Test (FEIT; Kerr and Neale, 1993), (2) the Voice Emotion Identification Test (VEIT; Kerr and Neale, 1993), and (3) the Videotape Affect Perception Test (VAP; Bellack et al., 1996). These tests and the procedures for administering them are fully described in Kee et al. (1998). All three require the subject to select one of six basic emotions (i.e., happy, angry, afraid, sad, surprised, and ashamed) that best describes the emotion presented in photographs, on audiotape, or in videotaped scenes of interpersonal situations. The stimulus faces on the FEIT are all Euro-American Caucasian, as are the voices on the VEIT. On the VAP, 87% of the individuals are Caucasian, and 13% are AfricanAmerican.
Table 1 Comparison of three ethnic groups White (1) N = 59 Gender Male Female Age X (SD) Days in hospital in previous 6 months Length of illness in years Education years BPRS total BPRS negative RFS Prognosis Days on meds in 6 mo. Neuro-cognition POE Total POE visual POE voice POE scenes a
Africa-American (2) N = 56
Latino (3) N = 16
Test statistic 2
F
8.8 35 24 38.4 13.7 14.8 11.9 39.4 4.3 9.0 23.1 140 1.1 41.2 11.9 10.2 19.3
(8.9) (31.2) (10.6) (1.7) (9.0) (2.1) (3.6) (4.5) (66) (3.0) (8.7) (3.2) (3.0) (3.8)
47 9 40.2 26.4 15.5 12.0 38.9 4.2 7.7 22.1 148 0.25 36.5 9.8 8.8 17.8
(8.9) (55.3) (10.1) (1.8) (11.15) (1.9) (3.6) (5.8) (63) (3.5) (9.9) (3.3) (3.4) (5.5)
10 6 32.8 8.1 7.4 11.2 39.6 4.6 7.6 22.7 166 3.3 34.5 10.4 7.8 17.3
(8.3) (17.9) (6.4) (2.0) (11.7) (2.3) (3.5) (4.1) (45) (3.3) (9.5) (3.6) (3.7) (2.1)
One-tailed tests of statistical significance, all significant in the hypothesized direction.
df
p 2
4.3 1.8 4.2 1.3 0.04 0.27 2.3 0.72 1.2 7.9 5.3 6.3 4.7 1.9
2128 2128 2122 2123 2128 2128 2128 2118 2127 2105 2128 2129 2129 2127
Contrasts
0.01
0.02 0.17 0.02 0.28 0.96 0.77 0.11 0.49 0.32 0.001 0.006a 0.001a 0.005a 0.07a
3 b 1, 2 3 b 1, 2
1, 2 N 3 1 N 2, 3 1N2 1 N 2, 3
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2.2.2. Neurocognitive measures The neurocognitive variable in this study was a composite created from measures of verbal fluency, immediate memory, secondary memory, sustained attention, and mental flexibility. These specific neurocognitive variables were chosen because they have been related to functional outcomes in schizophrenia, and their composite has been used in previous research (Green et al., 2000). A principal components factor analysis of the five scores found that there was a single factor with eigen value above 1.0 that accounted for over 50% of the total score variance. The average Pearson correlation among the five measures was .38, with a range of .25–.53 (all statistically significant at p b .006). The composite was derived from the following five tests by summing the standardized scores. (1) Controlled Oral Word Association Test (COWAT; Lezak, 1995) requires the subject to name as many words as possible that begin with the letters F, A, and S. The score is the sum of all acceptable words produced in three 1-min trials. This word fluency test appears to be a sensitive indicator of frontal functioning. (2) Digit Span Distractibility Test (DSDT; Oltmanns and Neale, 1975) is an audiotape measure of short-term verbal recall with and without distraction. The mean of correct responses in the two conditions is an indicator of immediate or working memory. (3) California Verbal Learning Test (CVLT; Delis et al., 1987) uses oral presentation of 16 items and allows examination of several aspects of verbal memory. This study used an overall recall score as a measure of secondary memory. (4) Degraded-Stimulus Continuous Performance Test (DS-CPT; Nuechterlein et al., 1992) is a computer-based measure of focused, sustained attention with a fast-paced visual vigilance task. Subjects are asked to detect stimuli that are increasingly degraded. The sensitivity score measures an ability to discriminate signal from noise. (5) Wisconsin Card Sorting Test (WCST; Heaton, 1981) is sensitive to activity in the prefrontal cortex and measures executive functioning, including the ability to attain and shift a cognitive
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set. Several indices come from the WCST; we used the score for perseverative errors. 2.2.3. Psychosocial measures Several psychosocial variables were used to describe the sample and to provide covariates for ruling out alternative explanations for patterns found in the data. Functional variables were obtained from the Community Adjustment Form (CAF; Test et al., 1991). The CAF uses trained interviewers to gather behavioral event data from 17 domains of community functioning such as living situation, work and social functioning, family involvement, social competence, and medication usage. A functional outcome measure administered during the CAF interview is the Role Functioning Scale (RFS; Goodman et al., 1993; McPheeters, 1984), which was selected as a scale of choice for this population (Green and Gracely, 1987). We used the global score which is the sum of the three RFS items. The CAF provided data regarding medication usage, and the Expanded Brief Psychiatric Rating Scale measured symptoms (Lukoff et al., 1986). The Demographic Interview Form (Test et al., 1991) supplied demographic information, including ethnicity and acculturation, and prognosis came from the Strauss and Carpenter Prognostic Scale (Strauss and Carpenter, 1974). The protocols used for establishing the field reliability of these instruments are available (Brekke, 1992; Brekke et al., 1993).
3. Results Before testing our main hypotheses, the three ethnic groups were compared on a range of demographic, clinical, and functional variables (see Table 1). As can be seen from Table 1, there were no statistically significant differences across ethnic groups on education, hospitalized days in the previous 6 months, global symptom level, days on antipsychotic medication in the previous 6 months, prognosis, negative symptoms, or global psychosocial functioning. There were significant cross-ethnic differences on age at study admission (Latinos were younger than AfricanAmericans), length of illness (Latinos were ill fewer months than African-Americans or Caucasians), and gender (African-American females are relatively under-represented). Since there were no statistically significant relationships between POE and either length of illness, gender, or age,
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(r = .01, r = .15, r = .09; p N .05 in all cases) these variables were not used as covariates in subsequent hypothesis testing about ethnicity and POE. The main study hypotheses were tested using analysis of variance and analysis of covariance (ANOVA and ANCOVA) (see Table 1). As can be seen from Table 1, there were significant cross-ethnic differences in the total POE score. As was hypothesized, the post hoc analyses revealed that Caucasians scored significantly higher than both Latinos and African-Americans, and there was no statistically significant difference between Latinos and African-Americans. The POE component scales (facial, vocal, and interpersonal scenes) all showed differences in the hypothesized direction, with statistically significant differences for facial and vocal measures, and a trend for the scenes measure. The contrasts revealed that Caucasians were significantly higher than both Latinos and AfricanAmericans on the vocal task, and that Caucasians were significantly higher than African-Americans on the facial task. From Table 1 it can be seen that there were also statistically significant cross-ethnic differences on basic neurocognition. This finding is contrary to our second hypothesis, but the post hoc contrasts reveal that both Caucasians and African-Americans scored higher than Latinos, with no difference between Caucasians and African-Americans. This difference remained significant after controlling for education. As will be discussed below, these differences could reflect factors other than culture. Hypothesis three proposed that whereas POE and basic neurocognition scores would be related, the cross-ethnic differences in POE would not be explained by the level of performance on neurocognitive measures. While neurocognition and POE were significantly correlated (Pearson r = .43, p b .000), the cross-ethnic findings on the total POE score remained statistically significant after controlling for neurocognition as well global symptom level ( F = 3.6, df 2, 125; p = .03). Since there have been arguments that POE could be a culturally embedded construct (Mandal and Ambady, 2004; Elfenbein and Ambady, 2003; Shioiri et al., 1999), the presence of bias in the measure of POE is salient. Therefore, Table 2 presents the correlations between POE and both neurocognition and functional outcome for each ethnic group. As stated earlier, previous research has found strong correlations between POE and both neurocognition and functional outcomes. While this was not a definitive test of the cultural bias hypothesis, it did provide data on the degree to which the instrument functioned similarly across ethnic groups in ways that would be predicted. Concerning the relationship between POE and functional outcome, the Pearson correlation value is quite similar across the ethnic
Table 2 Pearson correlations between POE and both functional and neurocognitive measures in three ethnic groups White
African-American Latino
POE/role functioning 0.29 (0.02)T 0.28 (0.04) POE/neurocognition 0.44 (0.001) 0.38 (0.01)
0.34 (0.20) 0.38 (0.28)
T p-value in parenthesis.
groups, and is highest in the Latino group, although it is not statistically significant due to the small Latino sample. Concerning neurocognition, the magnitude of the correlation with POE is also very similar across ethnic groups. These results suggest that while the mean level of POE differs significantly between Euro-American Caucasians and both Latinos and African-Americans, the POE measure has similar predictive validity across the three ethnic groups.
4. Discussion This is the first study to examine cross-ethnic differences in perception of emotion (POE) using a single nationally bound outpatient sample of individuals diagnosed with schizophrenia. We found support for cross-ethnic POE differences in schizophrenia, with both Latinos and African-Americans scoring lower than Euro-American Caucasians. This argues for the consideration of ethno-cultural factors when attempting to fully understand POE among individuals with schizophrenia. There has also been speculation about the cause of the POE deficit in schizophrenia. A generalized performance deficit and symptom sensitivity hypotheses have been advanced (Johnston et al., 2001; Silver and Shlomo, 2001; Penn et al., 1997; Salem et al., 1996). We found that the cross-ethnic differences on POE remained significant after controlling for basic neurocognition and overall symptom level. This suggests that the cross-ethnic differences cannot be explained by symptom influences, and that the ethno-cultural mechanisms influencing POE transcend the shared variation of POE and neurocognition. The cross-ethnic differences on POE among people with schizophrenia have also been found among nonclinical samples of adults. Therefore, the posited ethno-cultural mechanisms among non-clinical samples might be applicable to schizophrenia as well. This suggests that factors such as the way an event is
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appraised (Markham and Wang, 1996), the sanctions that cultures exert against recognizing or acknowledging some emotions (Markham and Wang, 1996), the familiarity of particular events and the degree to which different individuals are accurately perceived (Matsumoto, 1992a), the influence of language on the emotion lexicons (Matsumoto and Assar, 1992; Russell, 1991), the cultural display or labeling of emotions (Izard, 1971), as well as factors such as power distance and individualism versus collectivism (Matsumoto, 1990; Triandis et al., 1988; Hofstede, 1980) could all be mechanisms to be investigated in schizophrenia. Two theories that have particular relevance to the current study are Other Race Bias (ORB; Meissner and Brigham, 2001), and Dialect Theory (Elfenbein and Ambady, 2003). In the present study, it might be predicted that ORB would be most salient on the facial emotion recognition task (since all of the stimuli faces are Caucasian) and not as salient on the vocal task (assuming that race would not be as recognizable in the voice-only stimuli). In terms of Dialect Theory, we might expect differences on all modalities. Our results indicated that all of the subscale results (facial, vocal, and scenes) were in the predicted direction, but were the strongest in the voice condition. Therefore, our results suggest that ORB is a possible explanatory mechanism, but that Dialect Theory has particular relevance due to the findings across all three perceptual modalities. While this study was not designed to test differential predictions across perceptual modalities, these findings can guide the development of hypotheses for future research. These theories also facilitate the explanation of the findings on emotion processing from the Habel et al. (2000). In a cross-national study, Habel et al. (2000) concluded that the use of existing emotional processing measures across cultures was supported because they found that the poorer performance on these measures among individuals with schizophrenia when compared to normal controls was consistent across three national groups. However, there were also significant differences between national groups for both patients and controls, with the Indian samples scoring significantly lower than the American and German samples on facial recognition tasks. ORB and Dialect Theory provide possible explan-
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ations for these cross-national findings. While our cross-ethnic findings on the level of POE are similar to Habel et al., we had much greater similarity across ethnic groups on symptom level and other relevant demographic and psychosocial characteristics, and our data on basic neurocognition also strengthened the assessment of effects due to ethnocultural factors. Both ORB and Dialect Theory provide a challenge to measurement strategies in the area of POE. Since in this study both ethnic minority groups did poorer on POE than the majority group, this could suggest that our measure of POE is culturally laden. Specifically, it is possible that our cross-ethnic findings are due to a culturally invalid measure of POE, and that the ethnic minority schizophrenic individuals could be accurate in POE within their own cultural contexts. In this regard, Matsumoto has developed a measure of POE specifically for the Japanese (Matsumoto et al., 2000; Biehl et al., 1997), and they delineate methodological requirements for studies attempting to detect both cross-cultural similarities and differences in emotion perception. To partially address the issue of cross-cultural measurement bias in the current measure of POE, we examined the correlations between POE and both functional outcome and neurocognition in the three ethnic groups. We found that even though the level of POE was significantly lower in both ethnic minority groups, the measure functioned similarly in its relationship with other related factors across the ethnic groups. Taken together, the current study as well as Habel et al. (2000), suggest that while there is evidence for the discriminant and predictive validity of some POE measures in cross-ethnic contexts, the actual level of POE was influenced by cross-national and ethnic factors. However, since the actual level of POE is important in many studies involving individuals with schizophrenia, the issue of measurement bias in POE requires attention in future research. Strategies for assessing measurement bias due to cultural factors are available (Sue and Chu, 2003; Okazaki and Sue, 1995), and Bae and Brekke (2002) provide an example concerning the measurement of self-esteem in schizophrenia. Currently, we would suggest a cautious approach to using existing POE measures when there is ethnic or racial heterogeneity in samples. Unless the POE measures
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have been specifically designed to account for ethnicity or race in their use, the results to date would suggest that there could be notable bias in the level of POE across ethno-cultural groups, but that little bias might exist when testing hypotheses based on covariance structures. There is also growing evidence that POE is related to functional outcomes in schizophrenia (Kee et al., 2003; Pinkham et al., 2003); therefore, it is important that ethnic differences in POE be understood as either related to ethno-cultural factors or cross-cultural measurement biases so that the relationships to functional outcomes can be assessed cross-culturally. As interventions are designed for deficits in POE for individuals with schizophrenia, it is essential that the cultural influences on POE be accurately understood so that interventions can be applied or adapted accurately to ethnic minority groups. We also found that there were cross-ethnic differences on basic neurocognition. Specifically, there was no difference between Caucasians and African-Americans, and both groups scored higher than Latinos. Given the small sample of Latinos, this finding should be replicated on a larger sample before cultural factors are implicated for these neurocognitive measures. Future research should also be informed by the work of Biehl et al. (1997) when designing cross-cultural studies of POE, and of Meissner and Brigham (2001) and Elfenbein and Ambady (2003) when trying to disentangle the effects of race and culture across perceptual modalities in POE. At a minimum, these studies need to be balanced across ethnicity in the sample and in the POE stimuli that are used (Elfenbein and Ambady, 2003). There are several limitations to this study. First, it is possible that minority status within the United States could account for our findings. Cross-national studies could shed light on this issue. Second, these findings are generalizable to outpatients with schizophrenia who are seeking rehabilitation. Third, POE is only one indicator of a larger construct of social cognition. Cross-ethnic influences on other aspects of social cognition such as theory of mind and attributional style are needed. Fourth, the Latino sample in this study was very small. Future studies should include a range of well-represented ethnic groups. Fifth, while our measure of POE detected ethnic
differences, it was not developed to study them. As noted above, there are methodological approaches to understanding the mechanisms of ethnicity, nationality, majority/minority status, bilingualism, and the effects of cultural learning in this area (Elfenbein and Ambady, 2003). Finally, given the complexity and contextually embedded nature of ethno-cultural factors, the use of qualitative and mixed method approaches for generating hypotheses and new theoretical approaches is important to future research in this area.
Acknowledgements This research was supported by grants MH53282 and MH01628 from the National Institute of Mental Health awarded to the first author, and by the Department of Veterans Affairs VISN 22 Mental Illness Research Education and Clinical Center.
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