- Email: [email protected]
Emotion dysregulation and schizotypy
Available online at www.sciencedirect.com
Psychiatry Research 166 (2009) 116 – 124 www.elsevier.com/locate/psychres
Emotion dysregulation and schizotypy Julie D. Henry a,⁎, Melissa J. Green b , Corinne Restuccia a , Amber de Lucia a , Peter G. Rendell c , Skye McDonald a , Jessica R. Grisham a a
b
School of Psychology, University of New South Wales, Sydney, NSW 2052 Australia School of Psychiatry, University of New South Wales and Black Dog Institute, Prince of Wales Hospital, Sydney, NSW 2031 Australia c School of Psychology, Australian Catholic University National, Victoria 3065 Australia Received 19 October 2007; received in revised form 10 January 2008; accepted 16 January 2008
Abstract In schizophrenia, blunted affect has been argued to reflect difficulties with the amplification of emotion expressive behavior. The aim of the present study was to assess whether ostensibly healthy individuals vulnerable to schizophrenia present with similar difficulties. In the first component of the study, 843 non-clinical participants completed the Schizotypal Personality Questionnaire, of which 27 scoring in the upper 15% (high schizotypy group) and 27 scoring in the lower 15% (low schizotypy group) were asked to watch amusing film clips, whilst engaging in different emotion regulatory strategies, and specifically, amplify the expression of an experienced emotion (‘amplification’) or suppress the expression of an experienced emotion (‘suppression’). The results indicate that highly schizotypal participants present with specific difficulties with the amplification (but not suppression) of emotion expressive behavior. These difficulties are significantly correlated with total negative schizotypy, particularly blunted affect. In the second component of the study, an individual differences approach was used to assess the interrelationship between self-reported use of suppression and schizotypy in an independent sample of 204 community volunteers. The results suggest that, although blunted affect is associated with increased use of suppression, it cannot be regarded as the primary mechanism underpinning this disturbance. Implications for understanding blunted affect in schizophrenia and related disorders are discussed. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Schizotypy; Psychosis-proneness; Schizophrenia; Emotion regulation; Emotional blunting
1. Introduction Blunted affect in schizophrenia is characterized by markedly reduced emotion expressivity, alongside apparently normal emotion experience (Berenbaum and Oltmanns, 1992; Kirkpatrick and Fischer, 2006). Thus, although anhedonia is a core clinical feature of the ⁎ Corresponding author. Tel.: +61 2 9385 3936; fax: +61 2 9385 3641. E-mail address: [email protected] (J.D. Henry).
disorder, recent evidence supports a distinction between anticipatory and consummatory (or in-the-moment) pleasure, and suggests that only the former may be deficient (Gard et al., 2007; Horan et al., 2006). Consequently, most participants with schizophrenia exhibit limited outward expression across multiple channels, i.e. face, voice and gestures, and across both negative and positive emotions, despite reported consummatory emotional experience being normal in terms of valence and arousal (Berenbaum and Oltmanns, 1992; Kring and Neale, 1996; Kring and Werner, 2004). Since any discrepancy
0165-1781/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2008.01.007
J.D. Henry et al. / Psychiatry Research 166 (2009) 116–124
between the emotion experienced and the emotion expressed has the potential to cause communicative misunderstandings during social interactions (Aghevli et al., 2003; Troisi et al., 2007), identification of the mechanisms underpinning blunted affect in schizophrenia is of considerable importance. Recent evidence suggests that this clinical feature may at least partially reflect emotion dysregulation (Henry et al., 2007, 2008; Kring and Werner, 2004). A prominent theoretical account of emotion regulation identifies two broad types of regulatory strategy that can be distinguished according to their temporal initiation in relation to the emotional response (Gross, 2001). Antecedentfocused strategies are applied early in the emotion generation process and thus influence not only what is expressed behaviorally but also what is experienced subjectively. In contrast response-focused emotion regulatory strategies occur after the emotion response has been triggered, and require management of the ongoing emotional experience, expression and physiological response. A typical example of the former strategy is reappraisal of the emotion-eliciting situation (i.e. cognitive transformation of the stimulus), while examples of the latter include suppression (the conscious inhibition of ongoing emotion expressive behavior) and amplification, (the behavioral augmentation of an already initiated emotion, see; Denmaree et al., 2004; Gross, 2001; Kring and Werner, 2004). In their model of emotion dysregulation, Kring and Werner (2004) note that dysregulation may not only involve a deficiency in regulatory processes, but also maladaptive use of otherwise intact processes. In the case of schizophrenia, it has therefore been suggested that blunted affect may reflect a deficiency in the regulatory process of amplification. As Kring and Werner (2004) note, suppression of expressive behavior is usually associated with increased autonomic nervous system activity. However, a selective increase in physiological responding to emotional stimuli for individuals with schizophrenia has not been identified. Although patients with schizophrenia have demonstrated greater skin conductance reactivity to emotional films, increased physiological activity is also observed in response to neutral films (Kring and Neale, 1996). Henry et al. (2008) also found that individuals with schizophrenia did not differ from non-clinical volunteers with regard to their reported habitual use of suppression in day to day life. Further, using an experimental methodology in which the regulatory demands of the emotional task were directly manipulated, Henry et al. (2007) found that individuals with schizophrenia demonstrated significant deficits in the behavioral augmentation of an already initiated emotion, or
117
amplification of emotion expressive behavior, and deficits in this capacity were significantly correlated with clinical levels of blunted affect. This suggests that individuals with schizophrenia may not have the capacity to express a level of emotion that is commensurate with their subjective experience, as they experience problems producing outwardly observable displays of experienced emotion (see; Kring and Werner, 2004). The aim of the present study was to test whether individuals who score highly on schizotypy also demonstrate specific disturbances in the behavioral amplification of emotion expression, and whether they differ from their low schizotypy counterparts with respect to their habitual reported use of suppression. ‘Schizotypy’ refers to a range of enduring, biologically determined, personality and cognitive traits that indicate a predisposition to schizophrenia (Claridge, 1990; see also, Lenzenweger, 2006). Research of schizotypy in ostensibly healthy participants and relatives of schizophrenia patients has revealed similar neurological soft signs and impairments on measures of emotional, social and cognitive functioning that are generally intermediate between individuals with schizophrenia and healthy controls (Berenbaum et al., 2006; Raine, 2006). Stirling et al. (2007), for example, found that individuals who scored highly on schizotypy exhibited ‘heightened’ metacognitive processing that was comparable to the patterns reported in individuals who meet diagnostic criteria for schizophrenia. In the current article, a replication of the schizophrenia study of Henry et al. (2007) is reported, but with non-clinical volunteers scoring either high or low on schizotypy as the participants. Thus, an experimental methodology was used in which the regulatory demands of the emotional task were directly manipulated. Whilst the modulation of both positive and negative emotion expression behavior is clearly of enormous adaptive significance (Gross, 2001), given that anhedonia is a core feature of schizophrenia, the present study focused on capacity to up- and down-regulate positive emotion expressive behavior, and specifically, amusement. It was predicted that, as was shown for individuals with schizophrenia, individuals who score highly on the dimension of schizotypy will present with significant deficits in the amplification (but not the suppression) of emotion expressive behavior. Thus, it will be tested whether the ability to use these different regulation strategies is affected by the presence of schizotypal traits. However, in addition, and as per the study of Henry et al. (2008), in the second component of the study, an individual differences approach will be used to assess whether habitual use of suppression differs
118
J.D. Henry et al. / Psychiatry Research 166 (2009) 116–124
systematically in relation to schizotypal characteristics, and in particular, blunted affect. 2. Method 2.1. Participants For the first part of the study (the experimental component), 843 first year psychology students completed the brief version of the Schizotypal Personality Questionnaire (SPQ), which was presented as part of a larger counterbalanced screening package. Fifty-four participants who scored in either the top or the bottom 15% of the distribution of scores were invited to participate in an individual testing session in which the regulatory demands of an emotional task were directly manipulated. The high schizotypy group consisted of 10 male and 17 female participants, with a mean age of 19.4 years (S.D. = 1.08 years). The low schizotypy group consisted of 9 male and 18 female participants, with a mean age of 19.6 years (S.D. = 3.54). The greater number of females to males is consistent with the greater number of female students in the initial screening sample. For the second part of the study (the individual differences component), 204 adults (who were not involved in the initial screening group) were included. These participants were asked to complete various self-report measures focused on schizotypal personality (the full version of the SPQ), as well as measures of emotion regulation, negative affect and social functioning. These participants were either undergraduate students, or community volunteers recruited by the undergraduate students in return for Psychology Course Credit. The mean age of participants was 45.4 years (S.D. = 20.92) and 57.8% were female. On average, participants had completed 15.1 years of education (S.D. = 3.63). Exclusion criteria for all participants were an identifiable neurological disorder, severe alcohol/drug abuse as indexed by self-reported regular use of illicit substances, or regularly drinking to intoxication. Additionally, only participants who were literate and fluent in English were eligible for inclusion. The study was approved by Human Research Ethics at the University of New South Wales. 2.2. Measures and procedure – part one (experimental component) The SPQ-B (Raine and Benishay, 1995) is a 22-item self-report measure of schizotypy that is modeled on the 74-item full version of the SPQ (Raine, 1991), and
measures the same three factors: positive, negative and disorganized schizotypy. The SPQ-B is estimated to have a substantial 2-month test–retest reliability of 0.90, and good criterion validity (mean r = 0.62; Raine and Benishay, 1995). As noted, scores on the SPQ-B were used in the initial screening component of the study to identify high- and low-schizotypes. For part one of the present study, the film clip stimuli and methodology used were identical to that reported in Henry et al. (2007). The amusement film clips used were selected from pilot work involving 14 film clips that had been shown to elicit high, comparable levels of amusement (and the related emotions of happiness and pleasantness), but only minimal elicitation of other unrelated emotions. Each of these film clips was an average of two minutes duration. Four neutral film clips were also chosen from a set of standardized film stimuli previously identified as eliciting little emotion or low levels of contentment (Rottenberg et al., in press). The neutral clips depicted pleasant scenes from a wildlife documentary on Alaska and were used to habituate participants to the setting and to elicit emotions comparable to those experienced at baseline (Gross and Levenson, 1995). See Henry et al. (2007) for further information related to the stimuli. Prior to commencing, participants were informed that they would be video recorded throughout the study. After providing informed consent, the order of testing was as follows: 1. Neutral film clip 1. To establish baseline emotional responding, participants were randomly assigned to watch one of the four neutral film clips (all neutral film clips were counterbalanced). Prior to each neutral clip, participants were instructed; “Please watch the following film clip carefully” and after watching each film clip the Emotion Rating Form described below was completed. 2. Amusement 1: Control condition. Participants were randomly assigned to watch one of the amusing film clips, presented in a counterbalanced order. In the control condition, participants were instructed: “We will now be showing you a short film clip. It is important to us that you watch the film clip carefully” and were asked to respond naturally and spontaneously. 3. Neutral film clip 2 4. Emotion regulation instructions. Prior to the remaining amusement film clips, two sets of instructions were provided which corresponded to the suppression and amplification conditions (see below). In addition to the film clips, the order of the
J.D. Henry et al. / Psychiatry Research 166 (2009) 116–124
5.
6. 7. 8.
experimental conditions was also counterbalanced across participants. Amusement 2: Suppression OR Amplification (counterbalanced). Suppression instructions were as follows; “This time, if you have any feelings as you watch the film clip, please try your best not to let those feelings show. In other words, as you watch the film clip, try to behave in such a way that a person watching you would not know you were feeling anything. To summarize, as you watch the film clip, try to hide your feelings as much as you can”. Amplification instructions were as follows: “This time, if you have any feelings as you watch the film clip, please try your best to let your feelings show. In other words, as you watch the film clip, try to behave in such a way that a person watching you would clearly know what you're feeling. To summarize, as you watch the film clip, show your feelings as much as you can”. Neutral film clip 3. Amusement 3: Suppression OR Amplification (counterbalanced). Demographic questionnaire, Wechsler's Abbreviated Scale of Intelligence (WASI; Wechsler, 1999) to provide a brief index of current intelligence.
Emotion Response Forms were the same as those used in previous research (Henry et al., 2007). Thus, after each film clip, participants rated on a scale from 0 (not at all/none) to 8 (extremely/a great deal) the extent to which they experienced ten emotions (disgust, anger, happiness, sadness, amusement, confusion, interest, fear, surprise and anxiety). Positive affect was used as the dependent measure of emotional experience, and represented a composite score based on the highly intercorrelated items of happiness, amusement, interest and pleasantness. Cronbach's alpha for the total score based on these four items was extremely high, estimated to be 0.82, 0.85 and 0.92 for the control, suppression and amplification conditions, respectively. Two community volunteers who had received no formal training in any psychology or psychiatry related discipline were paid to act as independent raters of behavioral expression of emotion, and were kept blind to the aims of the study, group status, and which regulation condition the participants were in. These raters were trained to code expressions of amusement from both facial and behavioral expressions using a rating form based on the Emotional Behavior Coding System (Gross and Levenson, 1993). This procedure provided an overall rating of behavioral expression of amusement, as well as other aspects of emotional responding, such as level of positive and negative emotions
119
expressed. As per the study of Henry et al. (2007), behavioral ratings of amusement were the dependent measure of interest. Pearson product-moment correlations between behavioral levels of amusement from the two raters were 0.74 for the control condition, 0.80 for the suppression condition, and 0.70 for the amplification condition. Mean scores collapsed across the two coders were therefore used for analyses. 2.3. Measures and procedure – part two (individual differences component) For part two of the study, participants (N = 204) were asked to complete the following measures, which were administered in a counterbalanced order: The SPQ (Raine, 1991) is a 74-item self-report questionnaire with a dichotomous yes/no response format. The SPQ consists of three schizotypy factors (positive, negative and disorganized) and nine sub-factors corresponding with the nine features of Schizotypal Personality Disorder [SPD] based on criteria defined by the DSM-III-R for SPD. The scoring guidelines of Raine et al. (1994) were used to allocate items to each of the three schizotypy dimensions and to derive subscale scores. As a measure of schizotypy, there is evidence that the SPQ has substantial reliability and validity (Raine, 1991; Raine et al., 1994), and in the present study Cronbach's alpha based on the nine subscales was estimated to be 0.76. The Depression Anxiety Stress Scales-21 [DASS-21] (Lovibond and Lovibond, 1995) consists of three sevenitem self-report scales which measure depression, anxiety and stress. A four point severity scale measures the extent to which each state has been experienced over the past week, with higher scores indicative of greater negative affect. There is considerable evidence for the measure's reliability and validity (Henry and Crawford, 2005). In the present study, scores for the Depression and Anxiety subscales were derived; Cronbach's alpha was estimated to be 0.69 and 0.80, respectively. The Suppression scale of the Emotion Regulation Questionnaire [ERQ] (Gross and John, 2003) consists of four questions which focus upon suppression (e.g. “I keep my emotions to myself”). For each item, use of each emotion regulation strategy is rated from 1 (strongly disagree, indicating that the strategy is not frequently used) to 7 (strongly agree, indicating that the strategy is frequently used). The ERQ has acceptable reliability and has been shown to have considerable validity as an index of the constructs it was developed to assess (Gross and John, 2003). In the present study, α was estimated to be 0.74 for the Suppression scale.
120
J.D. Henry et al. / Psychiatry Research 166 (2009) 116–124
The Social Functioning Scale [SFS] (Birchwood et al., 1990) is a 79-item questionnaire that assesses seven domains of social behavior; Social Engagement/ Withdrawal, Interpersonal Communication, IndependencePerformance, Independence-Competence, Recreation, Prosocial Behavior and Employment/Occupation. Scores on all domains with the exception of Employment/Occupation were pooled. This subscale was omitted because of poor correlations with the other subscales, presumably due to the presence of ceiling effects in responding on this subscale. The SFS has been found to demonstrate adequate reliability, sensitivity and construct validity in patients with schizophrenia and non-psychiatric controls (Birchwood et al., 1990). In the present study, Cronbach's alpha based on the six subscales was estimated to be 0.64. 2.4. Analysis In Study 1, the two groups were compared on each of the background measures of interest (WASI and SPQ-B) using independent samples t-tests. Self- and behavioral ratings of affect were assessed using a series of 2 × 3 mixed ANOVA design, with the between subjects variable of schizotypy status (high, low) and the within subjects variable of emotion regulation condition (control, suppression, amplification). Where significant main effects or interactions were identified, these were followed up with appropriate pair wise comparisons to identify the locus of the effect. Correlational analyses were conducted to assess inter-relationships between psychopathology (as indexed by the SPQ-B) and behaviorally rated amusement. In Study 2, correlational analyses were also used to quantify the relationship between expressive suppression, schizotypy, negative affect and social functioning.
There was a main effect of emotion regulation condition, F(2,104) = 6.44, P = 0.002, with Post hoc Tukey tests on this main effect revealing that participants reported greater amusement in both the control and amplification conditions relative to the suppression condition (Ps b 0.05). The main effect of schizotypy status only just failed to attain significance, F(1,52) = 3.67, P = 0.061, indicating that there was a trend for rated positive affect to be generally higher in the low relative to the high schizotypy group. However, importantly, schizotypy status and emotion regulation condition did not interact, F(2,104) = 1.43, P = 0.245. 3.1.1. Regulation of amusement Since the primary focus of the present study was to assess the capacity to regulate the emotional experience of amusement in schizotypy, an essential prerequisite for inclusion in these analyses was that each participant finds the target film clips amusing. Given the noted lack of interaction between-group status and self-reported affect in the three emotion regulation conditions, selfrated positive affect across the three conditions was collapsed in order to quantify average level of emotional responding. Four participants' average self-rating was three or less (three high and one low schizotypy), indicating that these participants found the film clips, on average, to be less than ‘somewhat’ amusing. Following the procedure used by Henry et al. (2007), these participants were thus excluded from subsequent analyses relating to the emotion regulation manipulation, leaving a final sample of 24 high schizotypy and 26 low schizotypy participants. Behavioral ratings for these participants are also presented in Fig. 1 for each of the three emotion regulation conditions. It should be noted that the results of the statistical analyses for self-reported
3. Results 3.1. Part one: experimental component The first step in the analyses was to examine whether individuals high and low in schizotypy differed with respect to overall cognitive functioning as indexed by the WASI, as well as the specific SPQ-B dimensions. The age-standardized scores based on performance on the WASI did not differ for the high and low schizotypy groups, t(1,52) = 0.39, P = 0.698, but the high schizotypy group presented with significantly elevated schizotypy across all nine component SPQ-B dimensions, including blunted affect (all Ps b 0.001). Self-report positive affect data are presented in Fig. 1 for each of the three emotion regulation conditions.
Fig. 1. Amusement ratings of high and low schizotypal participants for the three emotion regulation conditions (bars represent S.E.s).
J.D. Henry et al. / Psychiatry Research 166 (2009) 116–124 Table 1 Correlations between suppression with measures of negative affect, social functioning, and schizotypal dimensions. Measure Depression Anxiety Stress Scales-21 (DASS-21) DASS-21 depression DASS-21 anxiety Social Functioning Scale (SFS) SFS total
Suppression 0.18⁎⁎ 0.15⁎ −0.31⁎⁎
Schizotypal Personality Questionnaire (SPQ) SPQ total SPQ positive SPQ negative SPQ disorganized
0.30⁎⁎ 0.24⁎⁎ 0.31⁎⁎ 0.15⁎
SPQ subscales Ideas of reference Odd beliefs/magical thinking Unusual perceptual experiences Paranoid ideation Excessive social anxiety No close friends Odd speech Odd/eccentric behaviour Constricted affect
0.11 0.17⁎ 0.27⁎⁎ 0.17⁎ 0.07 0.28⁎⁎ 0.17⁎ 0.07 0.40⁎⁎
⁎P b 0.05; ⁎⁎P b 0.01.
amusement were the same following exclusion of participants who did not find the film clips amusing. As for the self-report data, there was a main effect of emotion regulation condition, F(2,96) = 49.8, P b 0.001, with Post hoc Tukey tests on this main effect again revealing that participants showed greater amusement in both the control and amplification conditions relative to the suppression condition. However, in contrast to the self-report ratings, there was no main effect of schizotypy status, F(1,48) = 1.04, P = 0.314, but schizotypy status and emotion regulation condition did significantly interact, F(2,96) = 3.07, P = 0.041. Post hoc Tukey tests to identify the locus of this interaction effect indicated a significant between-group difference for the amplification, (P = 0.008) but not the control (P = 0.673) or suppression conditions (P = 0.545). Within-group comparisons further indicated that behavioral expression of emotion was reduced during the suppression condition for both groups; t(25)= 6.34, P b 0.001 and t(23) = 4.33, P b 0.001 for the low and high schizotypy groups, respectively. However, while behavioral ratings of amusement were greater in the amplification condition compared to the control condition for the low schizotypy group, t(25) = 2.61, P = 0.015, there was no difference across these two conditions for the high schizotypy group, t(23)= 0.16, P = 0.871.
121
Finally, correlations between psychopathology as indexed by the positive, negative and disorganized subscale scores of the SPQ-B with behavioral ratings of amusement in the three conditions were calculated. None of these SPQ-B dimensions were significantly correlated with behaviorally rated amusement in either the control or suppression conditions (rs ranged between 0.03 and − 0.12, all Ps N 0.05). Positive SPQ-B scores were also unrelated to behavioral ratings in the amplification condition (r = 0.22, P = 0.128). However, negative and disorganized SPQ-B scores were significantly correlated with behavioral ratings in the amplification condition (r = − 0.31, P = 0.029 and r = − 0.31, P = 0.030, respectively), with emotional blunting the single strongest contributor to the association with negative SPQ-B scores (r = 0.34; P = 0.017). 3.2. Part two: individual differences component Correlations between use of suppression with negative affect, social functioning, and schizotypal ratings are reported in Table 1 for the 204 participants who took part in the second component of the study. It can be seen that greater reported use of suppression is associated with significantly increased depression and anxiety, and significantly reduced social functioning (rs = 0.18, 0.15 and − 0.31, respectively). Further, greater use of suppression is associated with higher scores on all nine SPQ subscales, with six of these associations attaining statistical significance. The single largest of these correlations was with constricted affect (r = 0.40). However, presented in Table 2 are the correlations between suppression with each of the individual SPQ items contributing to the constricted affect dimension. It can be seen that four of the eight individual SPQ items Table 2 Correlations between suppression with individual items on the constricted affect schizotypy dimension. Constricted affect item
Suppression
(8) People find me aloof or distant (17) Poor at expressing my feelings by the way I talk and look (26) I rarely laugh and smile (35) My non-verbal communication is poor (43) I am poor at returning social courtesies and gestures (51) I tend to avoid eye contact when conversing with others (68) I do not have an expressive and lively way of speaking (73) I tend to keep my feelings to myself
0.10 0.28⁎⁎
⁎P b 0.05; ⁎⁎P b 0.01. Note: SPQ item number is indicated in parentheses.
0.05 0.17⁎ 0.08 0.07 0.21⁎⁎ 0.55⁎⁎
122
J.D. Henry et al. / Psychiatry Research 166 (2009) 116–124
are significantly correlated with suppression, but most notably SPQ item 73 (r = 0.55). Importantly item 73 specifically asks about suppressive tendencies (“I tend to keep my feelings to myself”), and indeed, is virtually identical to one of the four ERQ suppression items (Item 2: “I keep my emotions to myself”). Thus, SPQ item 73 may be more appropriately regarded as an indicator of the tendency to engage in expressive suppression, and not constricted affect per se. This overlap in item content appears to account for much of the shared variance between the constricted affect and suppression measures. With SPQ item 73 excluded from the constricted affect subscale, the overall correlation with suppression is substantially reduced (r = 0.26), and comparable in magnitude to the associations observed between suppression with the ‘unusual perceptual experiences’ and ‘no close friends’ subscales (rs = 0.27 and 0.28, respectively). It can also be seen that whilst three of the remaining seven SPQ items contributing to the constricted affect dimension were significantly correlated with suppression, the absolute magnitudes of these associations were relatively small (rs ranged between 0.17 and 0.28). 4. Discussion The results from the first component of the present study indicated that both high and low schizotypy participants who were instructed to implement the strategy of suppression did present with reduced emotion expressive behavior. In contrast, during the amplification condition, only the low (but not the high) schizotypy participants were able to exaggerate their behavioral response. It is important to note that these findings were demonstrated both via between- and within-group analyses. Thus, relative to their own behavioral responses in the baseline (control) condition, whilst both groups showed evidence of effective suppression of emotion expressive behavior, for the amplification condition effective up-regulation of emotion expressive behavior was only observed for the low schizotypy group. Further, behavioral expression in the amplification condition was significantly correlated with negative SPQ-B scores, particularly emotional blunting. These findings therefore support the proposal that the disjunction between the experience and expression of affect associated with schizophrenia may at least partially reflect a specific deficit up-regulating emotion expressive behavior (Kring and Werner, 2004). Consistent with other evidence showing expressive suppression to be associated with a diminished experience and expression of positive affect (John and Gross,
2004), participants reported and exhibited less amusement in the suppression condition relative to the control condition. However, of particular interest was the finding that there was a general trend for high schizotypy participants to report a diminished experience of pleasure. As noted previously, it has been argued that anticipatory (but not consummatory) pleasure may be deficient in schizophrenia (Gard et al., 2007; Horan et al., 2006). The finding of reduced consummatory pleasure in the present study may therefore reflect the use of film clip stimuli that were selected to elicit humor. Specifically, schizophrenia is associated with deficits in humor appreciation (Corcoran et al., 1997; Polimeni and Reiss, 2006), which has been attributed to the reliance of humor on basic neurocognitive skills and social competence (Langdon and Coltheart, 2004; Polimeni and Reiss, 2006), both of which are also disrupted in the context of schizotypy (see; Raine, 2006). The hedonic deficit identified in the present study may therefore at least partially reflect the social cognitive demands implicit in humor appreciation. Consistent with this possibility, using the same stimuli and methods, Henry et al. (2007) found some schizophrenia patients presented with an aberrant experience of affect by way of chronically ‘low responding’, and for this group anhedonia was a central presenting feature. Thus, it may be that consummatory pleasure is deficient in schizophrenia and schizotypy for at least some stimuli and contexts (for a discussion of these issues, see Horan et al., 2006). Since the subjective experience of affect differed across the two groups, it might be argued that the group differences identified in behavioral expression cannot be attributed to differences in the intensity of emotion experienced. It is not possible to rule out this possibility. However, importantly, schizotypy status and emotion regulation condition did not interact, indicating that whilst there was a general trend for individuals high in schizotypy to report lower affect, this did not vary as a function of experimental condition. Consequently, the finding of significant group differences in behavioral expression in the amplification (but not the suppression or control conditions), does not seem easily attributed to differences in self-rated affect. As noted previously, Henry et al. (2007) also found evidence for selective impairment of amplification (but not suppression) of emotion expressive behavior for individuals with schizophrenia. However, the generalizability of these results may have been limited by the clinical sample's long duration of illness, and use of antipsychotic medication. By showing that the same (specific) abnormality in emotion expressivity is observed in schizotypal participants drawn from the non-
J.D. Henry et al. / Psychiatry Research 166 (2009) 116–124
clinical population, the present findings indicate that deficits in amplification are not simply a marker of state factors, chronicity, or the influence of illness-related variables such as institutionalization, long-term medication effects or psychosocial deterioration. Thus, whilst previous research of schizotypy has revealed specific emotion abnormalities also characteristic of schizophrenia, including impaired emotion perception, deficits in theory of mind (Langdon and Coltheart, 2004), abnormalities in emotionality (Kerns, 2006) and the processing of emotional information (Kerns, 2005), the present results indicate that these abnormalities extend to the amplification of emotion expressive behavior. These data therefore provide further evidence consistent with the view that schizotypy reflects the continuum of vulnerability towards schizophrenia (see; Claridge, 1990; Raine, 1991). Nevertheless, a caveat that should be acknowledged is that the control group in Study 1 also represented an extreme scoring group, being in the lower 15% of the SPQ-B. It is therefore possible that the aberrant performing group in this study was not the high schizotypy group, but instead the low schizotypy group (who in contrast to the general adult population, may be exhibiting high amplification). Future research is needed to disentangle these possibilities. The results of the second component of the study indicated that greater reported use of suppression was associated with greater social function difficulties, and increased anxiety and depression. These data are consistent with many other individual difference studies involving non-clinical volunteers that demonstrate greater use of suppression to be associated with reduced interpersonal functioning and affective wellbeing (see; John and Gross, 2004; Henry et al., 2008). However, the present study was the first to demonstrate that schizotypy is also a significant correlate of this regulation strategy. As noted previously, considerable study of the structure of the schizotypy construct supports a distinction between positive schizotypy, negative schizotypy and disorganized schizotypy. Whilst it has been suggested that these different facets of schizotypy are associated with dissociable emotion abnormalities (Kerns, 2006; Raine, 2006), in the present study it was found that all three symptom dimensions were significantly correlated with use of suppression, suggesting that schizotypy per se may be associated with increased habitual use of this regulation strategy. Indeed, although constricted affect was the single strongest correlate with reported use of suppression, this appeared to be attributable to overlap in item content between one of the items on each of the two measures – once the item in question was removed from the SPQ, constricted affect was no more strongly correlated with
123
expressive suppression than several other aspects of schizotypy. Further, the remaining individual items on the constricted affect dimension were not consistently associated with reported use of suppression, and where significant correlations were observed, these were relatively small in magnitude. Thus, taken together with the noted significant correlation between affective blunting and expressive behavior in the amplification (but not suppression) condition observed in Study 1, these data suggest that whilst over-use of suppression may contribute to some of the behavioral abnormalities characteristic of blunted affect, it cannot be regarded as the primary mechanism underpinning this disturbance. Instead, specific difficulties with the amplification of emotion expressive behavior may be most relevant to understanding this clinically important symptom. However, in the present study only the ability to regulate positive emotional experience was assessed – as Gross and Levenson (1997) note, there may be important differences between the ability to regulate positive and negative emotions. It is therefore important that future research extends the present findings by examining the relationship between schizotypy and the regulation of negative emotions. Indeed, blunted affect is uniquely predictive of poor prognosis in schizophrenia (Berenbaum and Oltmanns, 1992; Troisi et al., 2007), and whilst the prominence of schizotypal personality characteristics is a better predictor of transition to firstepisode psychosis among individuals with ‘at-risk mental states’ than premorbid adjustment, family history and current symptoms, the individual schizotypy item that optimally predicts transition is blunted affect (Mason et al., 2004). Consequently, mechanisms contributing to blunted affect in schizotypy may prove central to understanding schizophrenia. Acknowledgements This research was supported by grants from the Australian Research Council. References Aghevli, M.A., Blanchard, J.J., Horan, W.P., 2003. The expression and experience of emotion in schizophrenia: a study of social interactions. Psychiatry Research 119, 261–270. Berenbaum, H., Boden, M.T., Baker, J.P., Dizen, M., Thompson, R.J., Abramowitz, A., 2006. Emotional correlates of the different dimensions of schizotypal personality disorder. Journal of Abnormal Psychology 115, 359–368. Berenbaum, H., Oltmanns, T.F., 1992. Emotional experience and expression in schizophrenia and depression. Journal of Abnormal Psychology 101, 37–44.
124
J.D. Henry et al. / Psychiatry Research 166 (2009) 116–124
Birchwood, M., Smith, J., Cochrane, R., Wetton, S., Copestake, S., 1990. The Social Functioning Scale – the development and validation of a new scale. British Journal of Psychiatry 157, 853–859. Claridge, G.S., 1990. Can a disease model of schizophrenia survive? In: Bentall, R.P. (Ed.), Reconstructing Schizophrenia. London, Routledge. Corcoran, R., Chaill, C., Frith, C.D., 1997. The appreciation of visual jokes in people with schizophrenia: a study of ‘mentalizing’ ability. Schizophrenia Resesearch 24, 319–327. Denmaree, H.A., Schmeichel, B.J., Robinson, J.L., Everhart, D.E., 2004. Behavioural, affective, and physiological effects of negative and positive emotional exaggeration. Cognition and Emotion 18, 1079–1097. Gard, D.E., Kring, A.M., Germans Gard, M., Horan, W.P., Green, M.F., 2007. Anhedonia in schizophrenia: distinctions between anticipatory and consummatory pleasure. Schizophrenia Research 93, 253–260. Gross, J.J., 2001. Emotion regulation in adulthood: timing is everything. Current Directions in Psychological Science 10, 214–219. Gross, J.J., Levenson, R.W., 1997. Hiding feelings: The accute effects of inhibiting negative and positive emotion. Journal of Abnormal Psychology 106, 95–103. Gross, J.J., John, O.P., 2003. Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. Journal of Personality and Social Psychology 85, 348–362. Gross, J.J., Levenson, R.W., 1993. Emotional suppression: physiology, self report, and expressive behaviour. Journal of Personality and Social Psychology 64, 970–986. Gross, J.J., Levenson, R.W., 1995. Emotion elicitation using films. Cognition and Emotion 9, 87–108. Henry, J.D., Crawford, J.R., 2005. The short form version of the Depression Anxiety Stress Scales (DASS 21): construct validity and normative data in a large non-clinical sample. British Journal of Clinical Psychology 44, 227–239. Henry, J.D., Green, M.J., De Lucia, A., Restuccia, C., McDonald, S., O'Donnell, M., 2007. Emotion dysregulation in schizophrenia: reduced amplification of emotional expression is associated with emotional blunting. Schizophrenia Research 95, 197–204. Henry, J.D., Rendell, P.G., Green, M.J., McDonald, S., O’Donnell, M., 2008. Emotion regulation in schizophrenia: affective, social and clinical correlates of suppression and reappraisal. Journal of Abnormal Psychology 117, 473–478. Horan, W.P., Green, M.F., Kring, A.M., Nuechterlein, K.H., 2006. Does anhedonia in schizophrenia reflect faulty memory for subjectively experienced emotions? Journal of Abnormal Psychology 115, 496–508. John, O.P., Gross, J.J., 2004. Healthy and unhealthy emotion regulation: personality processes, individual differences, and life span development. Journal of Personality 72, 1301–1334. Kerns, J.G., 2005. Positive schizotypy and emotion processing. Journal of Abnormal Psychology 114, 392–401.
Kerns, J.G., 2006. Schizotypy facets, cognitive control, and emotion. Journal of Abnormal Psychology 115, 418–427. Kirkpatrick, B., Fischer, B., 2006. Subdomains within the negative symptoms of schizophrenia: commentary. Schizophrenia Bulletin 32, 246–249. Kring, A.M., Neale, J.M., 1996. Do schizophrenic patients show a disjunctive relationship among expressive, experiential, and psychophysiological components of emotion? Journal of Abnormal Psychology 105, 249–257. Kring, A.M., Werner, K.H., 2004. Emotion regulation and psychopathology. In: Philippot, P., Feldman, R.S. (Eds.), The Regulation of Emotion. Lawrence Erlbaum. Langdon, R., Coltheart, M., 2004. Recognition of metaphor and irony in young adults: the impact of schizotypal personality traits. Psychiatry Research 125, 9–20. Lenzenweger, M.F., 2006. Schizotypy. An organizing framework for schizophrenia research. Current Directions in Psychological Science 15, 162–166. Lovibond, S.H., Lovibond, P.F., 1995. Manual for the Depression Anxiety Stress Scales. Sydney, Psychology Foundation. Mason, O., Startup, M., Halpin, S., Schall, U., Conrad, A., Carr, V., 2004. Risk factors for transition to first episode psychosis among individuals with ‘at-risk mental states’. Schizophrenia Research 71, 227–237. Polimeni, J., Reiss, J.P., 2006. Humor perception deficits in schizophrenia. Psychiatry Research 141, 229–232. Raine, A., 1991. The SPQ – a scale for the assessment of schizotypal personality based on DSM-III-R criteria. Schizophrenia Bulletin 17, 555–564. Raine, A., 2006. Schizotypal personality: neurodevelopmental and psychosocial trajectories. Annual Review of Clinical Psychology 2, 291–326. Raine, A., Benishay, D., 1995. The SPQ-B: a brief screening instrument for schizotypal personality disorder. Journal of Personality Disorders 9, 346–355. Raine, A., Reynolds, C., Lencz, T., Scerbo, A., Triphon, N., Kim, D., 1994. Cognitive-perceptual, interpersonal, and disorganized features of schizotypal personality. Schizophrenia Bulletin 20, 191–201. Rottenberg, J., Ray, R.R., Gross, J.J., in press. Emotion elicitation using films. In: Coan, J.A., Allen, J.J.B. (Eds.), The Handbook of Emotion Elicitation and Assessment. Oxford University Press, New York. Stirling, J., Barkus, E., Lewis, S., 2007. Hallucination proneness, schizotypy and meta-cognition. Behaviour Research and Therapy 45, 1401–1408. Troisi, A., Pompili, E., Binello, L., Sterpone, A., 2007. Facial expressivity during the clinical interview as a predictor functional disability in schizophrenia. A pilot study. Progress in NeuroPsychopharmacology and Biological Psychiatry 31, 475–481. Wechsler, D., 1999. Wechsler Abbreviated Scale of Intelligence (WASI). Psychological Corporation, San Antonio, TX.
Psychiatry Research 166 (2009) 116 – 124 www.elsevier.com/locate/psychres
Emotion dysregulation and schizotypy Julie D. Henry a,⁎, Melissa J. Green b , Corinne Restuccia a , Amber de Lucia a , Peter G. Rendell c , Skye McDonald a , Jessica R. Grisham a a
b
School of Psychology, University of New South Wales, Sydney, NSW 2052 Australia School of Psychiatry, University of New South Wales and Black Dog Institute, Prince of Wales Hospital, Sydney, NSW 2031 Australia c School of Psychology, Australian Catholic University National, Victoria 3065 Australia Received 19 October 2007; received in revised form 10 January 2008; accepted 16 January 2008
Abstract In schizophrenia, blunted affect has been argued to reflect difficulties with the amplification of emotion expressive behavior. The aim of the present study was to assess whether ostensibly healthy individuals vulnerable to schizophrenia present with similar difficulties. In the first component of the study, 843 non-clinical participants completed the Schizotypal Personality Questionnaire, of which 27 scoring in the upper 15% (high schizotypy group) and 27 scoring in the lower 15% (low schizotypy group) were asked to watch amusing film clips, whilst engaging in different emotion regulatory strategies, and specifically, amplify the expression of an experienced emotion (‘amplification’) or suppress the expression of an experienced emotion (‘suppression’). The results indicate that highly schizotypal participants present with specific difficulties with the amplification (but not suppression) of emotion expressive behavior. These difficulties are significantly correlated with total negative schizotypy, particularly blunted affect. In the second component of the study, an individual differences approach was used to assess the interrelationship between self-reported use of suppression and schizotypy in an independent sample of 204 community volunteers. The results suggest that, although blunted affect is associated with increased use of suppression, it cannot be regarded as the primary mechanism underpinning this disturbance. Implications for understanding blunted affect in schizophrenia and related disorders are discussed. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Schizotypy; Psychosis-proneness; Schizophrenia; Emotion regulation; Emotional blunting
1. Introduction Blunted affect in schizophrenia is characterized by markedly reduced emotion expressivity, alongside apparently normal emotion experience (Berenbaum and Oltmanns, 1992; Kirkpatrick and Fischer, 2006). Thus, although anhedonia is a core clinical feature of the ⁎ Corresponding author. Tel.: +61 2 9385 3936; fax: +61 2 9385 3641. E-mail address: [email protected] (J.D. Henry).
disorder, recent evidence supports a distinction between anticipatory and consummatory (or in-the-moment) pleasure, and suggests that only the former may be deficient (Gard et al., 2007; Horan et al., 2006). Consequently, most participants with schizophrenia exhibit limited outward expression across multiple channels, i.e. face, voice and gestures, and across both negative and positive emotions, despite reported consummatory emotional experience being normal in terms of valence and arousal (Berenbaum and Oltmanns, 1992; Kring and Neale, 1996; Kring and Werner, 2004). Since any discrepancy
0165-1781/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2008.01.007
J.D. Henry et al. / Psychiatry Research 166 (2009) 116–124
between the emotion experienced and the emotion expressed has the potential to cause communicative misunderstandings during social interactions (Aghevli et al., 2003; Troisi et al., 2007), identification of the mechanisms underpinning blunted affect in schizophrenia is of considerable importance. Recent evidence suggests that this clinical feature may at least partially reflect emotion dysregulation (Henry et al., 2007, 2008; Kring and Werner, 2004). A prominent theoretical account of emotion regulation identifies two broad types of regulatory strategy that can be distinguished according to their temporal initiation in relation to the emotional response (Gross, 2001). Antecedentfocused strategies are applied early in the emotion generation process and thus influence not only what is expressed behaviorally but also what is experienced subjectively. In contrast response-focused emotion regulatory strategies occur after the emotion response has been triggered, and require management of the ongoing emotional experience, expression and physiological response. A typical example of the former strategy is reappraisal of the emotion-eliciting situation (i.e. cognitive transformation of the stimulus), while examples of the latter include suppression (the conscious inhibition of ongoing emotion expressive behavior) and amplification, (the behavioral augmentation of an already initiated emotion, see; Denmaree et al., 2004; Gross, 2001; Kring and Werner, 2004). In their model of emotion dysregulation, Kring and Werner (2004) note that dysregulation may not only involve a deficiency in regulatory processes, but also maladaptive use of otherwise intact processes. In the case of schizophrenia, it has therefore been suggested that blunted affect may reflect a deficiency in the regulatory process of amplification. As Kring and Werner (2004) note, suppression of expressive behavior is usually associated with increased autonomic nervous system activity. However, a selective increase in physiological responding to emotional stimuli for individuals with schizophrenia has not been identified. Although patients with schizophrenia have demonstrated greater skin conductance reactivity to emotional films, increased physiological activity is also observed in response to neutral films (Kring and Neale, 1996). Henry et al. (2008) also found that individuals with schizophrenia did not differ from non-clinical volunteers with regard to their reported habitual use of suppression in day to day life. Further, using an experimental methodology in which the regulatory demands of the emotional task were directly manipulated, Henry et al. (2007) found that individuals with schizophrenia demonstrated significant deficits in the behavioral augmentation of an already initiated emotion, or
117
amplification of emotion expressive behavior, and deficits in this capacity were significantly correlated with clinical levels of blunted affect. This suggests that individuals with schizophrenia may not have the capacity to express a level of emotion that is commensurate with their subjective experience, as they experience problems producing outwardly observable displays of experienced emotion (see; Kring and Werner, 2004). The aim of the present study was to test whether individuals who score highly on schizotypy also demonstrate specific disturbances in the behavioral amplification of emotion expression, and whether they differ from their low schizotypy counterparts with respect to their habitual reported use of suppression. ‘Schizotypy’ refers to a range of enduring, biologically determined, personality and cognitive traits that indicate a predisposition to schizophrenia (Claridge, 1990; see also, Lenzenweger, 2006). Research of schizotypy in ostensibly healthy participants and relatives of schizophrenia patients has revealed similar neurological soft signs and impairments on measures of emotional, social and cognitive functioning that are generally intermediate between individuals with schizophrenia and healthy controls (Berenbaum et al., 2006; Raine, 2006). Stirling et al. (2007), for example, found that individuals who scored highly on schizotypy exhibited ‘heightened’ metacognitive processing that was comparable to the patterns reported in individuals who meet diagnostic criteria for schizophrenia. In the current article, a replication of the schizophrenia study of Henry et al. (2007) is reported, but with non-clinical volunteers scoring either high or low on schizotypy as the participants. Thus, an experimental methodology was used in which the regulatory demands of the emotional task were directly manipulated. Whilst the modulation of both positive and negative emotion expression behavior is clearly of enormous adaptive significance (Gross, 2001), given that anhedonia is a core feature of schizophrenia, the present study focused on capacity to up- and down-regulate positive emotion expressive behavior, and specifically, amusement. It was predicted that, as was shown for individuals with schizophrenia, individuals who score highly on the dimension of schizotypy will present with significant deficits in the amplification (but not the suppression) of emotion expressive behavior. Thus, it will be tested whether the ability to use these different regulation strategies is affected by the presence of schizotypal traits. However, in addition, and as per the study of Henry et al. (2008), in the second component of the study, an individual differences approach will be used to assess whether habitual use of suppression differs
118
J.D. Henry et al. / Psychiatry Research 166 (2009) 116–124
systematically in relation to schizotypal characteristics, and in particular, blunted affect. 2. Method 2.1. Participants For the first part of the study (the experimental component), 843 first year psychology students completed the brief version of the Schizotypal Personality Questionnaire (SPQ), which was presented as part of a larger counterbalanced screening package. Fifty-four participants who scored in either the top or the bottom 15% of the distribution of scores were invited to participate in an individual testing session in which the regulatory demands of an emotional task were directly manipulated. The high schizotypy group consisted of 10 male and 17 female participants, with a mean age of 19.4 years (S.D. = 1.08 years). The low schizotypy group consisted of 9 male and 18 female participants, with a mean age of 19.6 years (S.D. = 3.54). The greater number of females to males is consistent with the greater number of female students in the initial screening sample. For the second part of the study (the individual differences component), 204 adults (who were not involved in the initial screening group) were included. These participants were asked to complete various self-report measures focused on schizotypal personality (the full version of the SPQ), as well as measures of emotion regulation, negative affect and social functioning. These participants were either undergraduate students, or community volunteers recruited by the undergraduate students in return for Psychology Course Credit. The mean age of participants was 45.4 years (S.D. = 20.92) and 57.8% were female. On average, participants had completed 15.1 years of education (S.D. = 3.63). Exclusion criteria for all participants were an identifiable neurological disorder, severe alcohol/drug abuse as indexed by self-reported regular use of illicit substances, or regularly drinking to intoxication. Additionally, only participants who were literate and fluent in English were eligible for inclusion. The study was approved by Human Research Ethics at the University of New South Wales. 2.2. Measures and procedure – part one (experimental component) The SPQ-B (Raine and Benishay, 1995) is a 22-item self-report measure of schizotypy that is modeled on the 74-item full version of the SPQ (Raine, 1991), and
measures the same three factors: positive, negative and disorganized schizotypy. The SPQ-B is estimated to have a substantial 2-month test–retest reliability of 0.90, and good criterion validity (mean r = 0.62; Raine and Benishay, 1995). As noted, scores on the SPQ-B were used in the initial screening component of the study to identify high- and low-schizotypes. For part one of the present study, the film clip stimuli and methodology used were identical to that reported in Henry et al. (2007). The amusement film clips used were selected from pilot work involving 14 film clips that had been shown to elicit high, comparable levels of amusement (and the related emotions of happiness and pleasantness), but only minimal elicitation of other unrelated emotions. Each of these film clips was an average of two minutes duration. Four neutral film clips were also chosen from a set of standardized film stimuli previously identified as eliciting little emotion or low levels of contentment (Rottenberg et al., in press). The neutral clips depicted pleasant scenes from a wildlife documentary on Alaska and were used to habituate participants to the setting and to elicit emotions comparable to those experienced at baseline (Gross and Levenson, 1995). See Henry et al. (2007) for further information related to the stimuli. Prior to commencing, participants were informed that they would be video recorded throughout the study. After providing informed consent, the order of testing was as follows: 1. Neutral film clip 1. To establish baseline emotional responding, participants were randomly assigned to watch one of the four neutral film clips (all neutral film clips were counterbalanced). Prior to each neutral clip, participants were instructed; “Please watch the following film clip carefully” and after watching each film clip the Emotion Rating Form described below was completed. 2. Amusement 1: Control condition. Participants were randomly assigned to watch one of the amusing film clips, presented in a counterbalanced order. In the control condition, participants were instructed: “We will now be showing you a short film clip. It is important to us that you watch the film clip carefully” and were asked to respond naturally and spontaneously. 3. Neutral film clip 2 4. Emotion regulation instructions. Prior to the remaining amusement film clips, two sets of instructions were provided which corresponded to the suppression and amplification conditions (see below). In addition to the film clips, the order of the
J.D. Henry et al. / Psychiatry Research 166 (2009) 116–124
5.
6. 7. 8.
experimental conditions was also counterbalanced across participants. Amusement 2: Suppression OR Amplification (counterbalanced). Suppression instructions were as follows; “This time, if you have any feelings as you watch the film clip, please try your best not to let those feelings show. In other words, as you watch the film clip, try to behave in such a way that a person watching you would not know you were feeling anything. To summarize, as you watch the film clip, try to hide your feelings as much as you can”. Amplification instructions were as follows: “This time, if you have any feelings as you watch the film clip, please try your best to let your feelings show. In other words, as you watch the film clip, try to behave in such a way that a person watching you would clearly know what you're feeling. To summarize, as you watch the film clip, show your feelings as much as you can”. Neutral film clip 3. Amusement 3: Suppression OR Amplification (counterbalanced). Demographic questionnaire, Wechsler's Abbreviated Scale of Intelligence (WASI; Wechsler, 1999) to provide a brief index of current intelligence.
Emotion Response Forms were the same as those used in previous research (Henry et al., 2007). Thus, after each film clip, participants rated on a scale from 0 (not at all/none) to 8 (extremely/a great deal) the extent to which they experienced ten emotions (disgust, anger, happiness, sadness, amusement, confusion, interest, fear, surprise and anxiety). Positive affect was used as the dependent measure of emotional experience, and represented a composite score based on the highly intercorrelated items of happiness, amusement, interest and pleasantness. Cronbach's alpha for the total score based on these four items was extremely high, estimated to be 0.82, 0.85 and 0.92 for the control, suppression and amplification conditions, respectively. Two community volunteers who had received no formal training in any psychology or psychiatry related discipline were paid to act as independent raters of behavioral expression of emotion, and were kept blind to the aims of the study, group status, and which regulation condition the participants were in. These raters were trained to code expressions of amusement from both facial and behavioral expressions using a rating form based on the Emotional Behavior Coding System (Gross and Levenson, 1993). This procedure provided an overall rating of behavioral expression of amusement, as well as other aspects of emotional responding, such as level of positive and negative emotions
119
expressed. As per the study of Henry et al. (2007), behavioral ratings of amusement were the dependent measure of interest. Pearson product-moment correlations between behavioral levels of amusement from the two raters were 0.74 for the control condition, 0.80 for the suppression condition, and 0.70 for the amplification condition. Mean scores collapsed across the two coders were therefore used for analyses. 2.3. Measures and procedure – part two (individual differences component) For part two of the study, participants (N = 204) were asked to complete the following measures, which were administered in a counterbalanced order: The SPQ (Raine, 1991) is a 74-item self-report questionnaire with a dichotomous yes/no response format. The SPQ consists of three schizotypy factors (positive, negative and disorganized) and nine sub-factors corresponding with the nine features of Schizotypal Personality Disorder [SPD] based on criteria defined by the DSM-III-R for SPD. The scoring guidelines of Raine et al. (1994) were used to allocate items to each of the three schizotypy dimensions and to derive subscale scores. As a measure of schizotypy, there is evidence that the SPQ has substantial reliability and validity (Raine, 1991; Raine et al., 1994), and in the present study Cronbach's alpha based on the nine subscales was estimated to be 0.76. The Depression Anxiety Stress Scales-21 [DASS-21] (Lovibond and Lovibond, 1995) consists of three sevenitem self-report scales which measure depression, anxiety and stress. A four point severity scale measures the extent to which each state has been experienced over the past week, with higher scores indicative of greater negative affect. There is considerable evidence for the measure's reliability and validity (Henry and Crawford, 2005). In the present study, scores for the Depression and Anxiety subscales were derived; Cronbach's alpha was estimated to be 0.69 and 0.80, respectively. The Suppression scale of the Emotion Regulation Questionnaire [ERQ] (Gross and John, 2003) consists of four questions which focus upon suppression (e.g. “I keep my emotions to myself”). For each item, use of each emotion regulation strategy is rated from 1 (strongly disagree, indicating that the strategy is not frequently used) to 7 (strongly agree, indicating that the strategy is frequently used). The ERQ has acceptable reliability and has been shown to have considerable validity as an index of the constructs it was developed to assess (Gross and John, 2003). In the present study, α was estimated to be 0.74 for the Suppression scale.
120
J.D. Henry et al. / Psychiatry Research 166 (2009) 116–124
The Social Functioning Scale [SFS] (Birchwood et al., 1990) is a 79-item questionnaire that assesses seven domains of social behavior; Social Engagement/ Withdrawal, Interpersonal Communication, IndependencePerformance, Independence-Competence, Recreation, Prosocial Behavior and Employment/Occupation. Scores on all domains with the exception of Employment/Occupation were pooled. This subscale was omitted because of poor correlations with the other subscales, presumably due to the presence of ceiling effects in responding on this subscale. The SFS has been found to demonstrate adequate reliability, sensitivity and construct validity in patients with schizophrenia and non-psychiatric controls (Birchwood et al., 1990). In the present study, Cronbach's alpha based on the six subscales was estimated to be 0.64. 2.4. Analysis In Study 1, the two groups were compared on each of the background measures of interest (WASI and SPQ-B) using independent samples t-tests. Self- and behavioral ratings of affect were assessed using a series of 2 × 3 mixed ANOVA design, with the between subjects variable of schizotypy status (high, low) and the within subjects variable of emotion regulation condition (control, suppression, amplification). Where significant main effects or interactions were identified, these were followed up with appropriate pair wise comparisons to identify the locus of the effect. Correlational analyses were conducted to assess inter-relationships between psychopathology (as indexed by the SPQ-B) and behaviorally rated amusement. In Study 2, correlational analyses were also used to quantify the relationship between expressive suppression, schizotypy, negative affect and social functioning.
There was a main effect of emotion regulation condition, F(2,104) = 6.44, P = 0.002, with Post hoc Tukey tests on this main effect revealing that participants reported greater amusement in both the control and amplification conditions relative to the suppression condition (Ps b 0.05). The main effect of schizotypy status only just failed to attain significance, F(1,52) = 3.67, P = 0.061, indicating that there was a trend for rated positive affect to be generally higher in the low relative to the high schizotypy group. However, importantly, schizotypy status and emotion regulation condition did not interact, F(2,104) = 1.43, P = 0.245. 3.1.1. Regulation of amusement Since the primary focus of the present study was to assess the capacity to regulate the emotional experience of amusement in schizotypy, an essential prerequisite for inclusion in these analyses was that each participant finds the target film clips amusing. Given the noted lack of interaction between-group status and self-reported affect in the three emotion regulation conditions, selfrated positive affect across the three conditions was collapsed in order to quantify average level of emotional responding. Four participants' average self-rating was three or less (three high and one low schizotypy), indicating that these participants found the film clips, on average, to be less than ‘somewhat’ amusing. Following the procedure used by Henry et al. (2007), these participants were thus excluded from subsequent analyses relating to the emotion regulation manipulation, leaving a final sample of 24 high schizotypy and 26 low schizotypy participants. Behavioral ratings for these participants are also presented in Fig. 1 for each of the three emotion regulation conditions. It should be noted that the results of the statistical analyses for self-reported
3. Results 3.1. Part one: experimental component The first step in the analyses was to examine whether individuals high and low in schizotypy differed with respect to overall cognitive functioning as indexed by the WASI, as well as the specific SPQ-B dimensions. The age-standardized scores based on performance on the WASI did not differ for the high and low schizotypy groups, t(1,52) = 0.39, P = 0.698, but the high schizotypy group presented with significantly elevated schizotypy across all nine component SPQ-B dimensions, including blunted affect (all Ps b 0.001). Self-report positive affect data are presented in Fig. 1 for each of the three emotion regulation conditions.
Fig. 1. Amusement ratings of high and low schizotypal participants for the three emotion regulation conditions (bars represent S.E.s).
J.D. Henry et al. / Psychiatry Research 166 (2009) 116–124 Table 1 Correlations between suppression with measures of negative affect, social functioning, and schizotypal dimensions. Measure Depression Anxiety Stress Scales-21 (DASS-21) DASS-21 depression DASS-21 anxiety Social Functioning Scale (SFS) SFS total
Suppression 0.18⁎⁎ 0.15⁎ −0.31⁎⁎
Schizotypal Personality Questionnaire (SPQ) SPQ total SPQ positive SPQ negative SPQ disorganized
0.30⁎⁎ 0.24⁎⁎ 0.31⁎⁎ 0.15⁎
SPQ subscales Ideas of reference Odd beliefs/magical thinking Unusual perceptual experiences Paranoid ideation Excessive social anxiety No close friends Odd speech Odd/eccentric behaviour Constricted affect
0.11 0.17⁎ 0.27⁎⁎ 0.17⁎ 0.07 0.28⁎⁎ 0.17⁎ 0.07 0.40⁎⁎
⁎P b 0.05; ⁎⁎P b 0.01.
amusement were the same following exclusion of participants who did not find the film clips amusing. As for the self-report data, there was a main effect of emotion regulation condition, F(2,96) = 49.8, P b 0.001, with Post hoc Tukey tests on this main effect again revealing that participants showed greater amusement in both the control and amplification conditions relative to the suppression condition. However, in contrast to the self-report ratings, there was no main effect of schizotypy status, F(1,48) = 1.04, P = 0.314, but schizotypy status and emotion regulation condition did significantly interact, F(2,96) = 3.07, P = 0.041. Post hoc Tukey tests to identify the locus of this interaction effect indicated a significant between-group difference for the amplification, (P = 0.008) but not the control (P = 0.673) or suppression conditions (P = 0.545). Within-group comparisons further indicated that behavioral expression of emotion was reduced during the suppression condition for both groups; t(25)= 6.34, P b 0.001 and t(23) = 4.33, P b 0.001 for the low and high schizotypy groups, respectively. However, while behavioral ratings of amusement were greater in the amplification condition compared to the control condition for the low schizotypy group, t(25) = 2.61, P = 0.015, there was no difference across these two conditions for the high schizotypy group, t(23)= 0.16, P = 0.871.
121
Finally, correlations between psychopathology as indexed by the positive, negative and disorganized subscale scores of the SPQ-B with behavioral ratings of amusement in the three conditions were calculated. None of these SPQ-B dimensions were significantly correlated with behaviorally rated amusement in either the control or suppression conditions (rs ranged between 0.03 and − 0.12, all Ps N 0.05). Positive SPQ-B scores were also unrelated to behavioral ratings in the amplification condition (r = 0.22, P = 0.128). However, negative and disorganized SPQ-B scores were significantly correlated with behavioral ratings in the amplification condition (r = − 0.31, P = 0.029 and r = − 0.31, P = 0.030, respectively), with emotional blunting the single strongest contributor to the association with negative SPQ-B scores (r = 0.34; P = 0.017). 3.2. Part two: individual differences component Correlations between use of suppression with negative affect, social functioning, and schizotypal ratings are reported in Table 1 for the 204 participants who took part in the second component of the study. It can be seen that greater reported use of suppression is associated with significantly increased depression and anxiety, and significantly reduced social functioning (rs = 0.18, 0.15 and − 0.31, respectively). Further, greater use of suppression is associated with higher scores on all nine SPQ subscales, with six of these associations attaining statistical significance. The single largest of these correlations was with constricted affect (r = 0.40). However, presented in Table 2 are the correlations between suppression with each of the individual SPQ items contributing to the constricted affect dimension. It can be seen that four of the eight individual SPQ items Table 2 Correlations between suppression with individual items on the constricted affect schizotypy dimension. Constricted affect item
Suppression
(8) People find me aloof or distant (17) Poor at expressing my feelings by the way I talk and look (26) I rarely laugh and smile (35) My non-verbal communication is poor (43) I am poor at returning social courtesies and gestures (51) I tend to avoid eye contact when conversing with others (68) I do not have an expressive and lively way of speaking (73) I tend to keep my feelings to myself
0.10 0.28⁎⁎
⁎P b 0.05; ⁎⁎P b 0.01. Note: SPQ item number is indicated in parentheses.
0.05 0.17⁎ 0.08 0.07 0.21⁎⁎ 0.55⁎⁎
122
J.D. Henry et al. / Psychiatry Research 166 (2009) 116–124
are significantly correlated with suppression, but most notably SPQ item 73 (r = 0.55). Importantly item 73 specifically asks about suppressive tendencies (“I tend to keep my feelings to myself”), and indeed, is virtually identical to one of the four ERQ suppression items (Item 2: “I keep my emotions to myself”). Thus, SPQ item 73 may be more appropriately regarded as an indicator of the tendency to engage in expressive suppression, and not constricted affect per se. This overlap in item content appears to account for much of the shared variance between the constricted affect and suppression measures. With SPQ item 73 excluded from the constricted affect subscale, the overall correlation with suppression is substantially reduced (r = 0.26), and comparable in magnitude to the associations observed between suppression with the ‘unusual perceptual experiences’ and ‘no close friends’ subscales (rs = 0.27 and 0.28, respectively). It can also be seen that whilst three of the remaining seven SPQ items contributing to the constricted affect dimension were significantly correlated with suppression, the absolute magnitudes of these associations were relatively small (rs ranged between 0.17 and 0.28). 4. Discussion The results from the first component of the present study indicated that both high and low schizotypy participants who were instructed to implement the strategy of suppression did present with reduced emotion expressive behavior. In contrast, during the amplification condition, only the low (but not the high) schizotypy participants were able to exaggerate their behavioral response. It is important to note that these findings were demonstrated both via between- and within-group analyses. Thus, relative to their own behavioral responses in the baseline (control) condition, whilst both groups showed evidence of effective suppression of emotion expressive behavior, for the amplification condition effective up-regulation of emotion expressive behavior was only observed for the low schizotypy group. Further, behavioral expression in the amplification condition was significantly correlated with negative SPQ-B scores, particularly emotional blunting. These findings therefore support the proposal that the disjunction between the experience and expression of affect associated with schizophrenia may at least partially reflect a specific deficit up-regulating emotion expressive behavior (Kring and Werner, 2004). Consistent with other evidence showing expressive suppression to be associated with a diminished experience and expression of positive affect (John and Gross,
2004), participants reported and exhibited less amusement in the suppression condition relative to the control condition. However, of particular interest was the finding that there was a general trend for high schizotypy participants to report a diminished experience of pleasure. As noted previously, it has been argued that anticipatory (but not consummatory) pleasure may be deficient in schizophrenia (Gard et al., 2007; Horan et al., 2006). The finding of reduced consummatory pleasure in the present study may therefore reflect the use of film clip stimuli that were selected to elicit humor. Specifically, schizophrenia is associated with deficits in humor appreciation (Corcoran et al., 1997; Polimeni and Reiss, 2006), which has been attributed to the reliance of humor on basic neurocognitive skills and social competence (Langdon and Coltheart, 2004; Polimeni and Reiss, 2006), both of which are also disrupted in the context of schizotypy (see; Raine, 2006). The hedonic deficit identified in the present study may therefore at least partially reflect the social cognitive demands implicit in humor appreciation. Consistent with this possibility, using the same stimuli and methods, Henry et al. (2007) found some schizophrenia patients presented with an aberrant experience of affect by way of chronically ‘low responding’, and for this group anhedonia was a central presenting feature. Thus, it may be that consummatory pleasure is deficient in schizophrenia and schizotypy for at least some stimuli and contexts (for a discussion of these issues, see Horan et al., 2006). Since the subjective experience of affect differed across the two groups, it might be argued that the group differences identified in behavioral expression cannot be attributed to differences in the intensity of emotion experienced. It is not possible to rule out this possibility. However, importantly, schizotypy status and emotion regulation condition did not interact, indicating that whilst there was a general trend for individuals high in schizotypy to report lower affect, this did not vary as a function of experimental condition. Consequently, the finding of significant group differences in behavioral expression in the amplification (but not the suppression or control conditions), does not seem easily attributed to differences in self-rated affect. As noted previously, Henry et al. (2007) also found evidence for selective impairment of amplification (but not suppression) of emotion expressive behavior for individuals with schizophrenia. However, the generalizability of these results may have been limited by the clinical sample's long duration of illness, and use of antipsychotic medication. By showing that the same (specific) abnormality in emotion expressivity is observed in schizotypal participants drawn from the non-
J.D. Henry et al. / Psychiatry Research 166 (2009) 116–124
clinical population, the present findings indicate that deficits in amplification are not simply a marker of state factors, chronicity, or the influence of illness-related variables such as institutionalization, long-term medication effects or psychosocial deterioration. Thus, whilst previous research of schizotypy has revealed specific emotion abnormalities also characteristic of schizophrenia, including impaired emotion perception, deficits in theory of mind (Langdon and Coltheart, 2004), abnormalities in emotionality (Kerns, 2006) and the processing of emotional information (Kerns, 2005), the present results indicate that these abnormalities extend to the amplification of emotion expressive behavior. These data therefore provide further evidence consistent with the view that schizotypy reflects the continuum of vulnerability towards schizophrenia (see; Claridge, 1990; Raine, 1991). Nevertheless, a caveat that should be acknowledged is that the control group in Study 1 also represented an extreme scoring group, being in the lower 15% of the SPQ-B. It is therefore possible that the aberrant performing group in this study was not the high schizotypy group, but instead the low schizotypy group (who in contrast to the general adult population, may be exhibiting high amplification). Future research is needed to disentangle these possibilities. The results of the second component of the study indicated that greater reported use of suppression was associated with greater social function difficulties, and increased anxiety and depression. These data are consistent with many other individual difference studies involving non-clinical volunteers that demonstrate greater use of suppression to be associated with reduced interpersonal functioning and affective wellbeing (see; John and Gross, 2004; Henry et al., 2008). However, the present study was the first to demonstrate that schizotypy is also a significant correlate of this regulation strategy. As noted previously, considerable study of the structure of the schizotypy construct supports a distinction between positive schizotypy, negative schizotypy and disorganized schizotypy. Whilst it has been suggested that these different facets of schizotypy are associated with dissociable emotion abnormalities (Kerns, 2006; Raine, 2006), in the present study it was found that all three symptom dimensions were significantly correlated with use of suppression, suggesting that schizotypy per se may be associated with increased habitual use of this regulation strategy. Indeed, although constricted affect was the single strongest correlate with reported use of suppression, this appeared to be attributable to overlap in item content between one of the items on each of the two measures – once the item in question was removed from the SPQ, constricted affect was no more strongly correlated with
123
expressive suppression than several other aspects of schizotypy. Further, the remaining individual items on the constricted affect dimension were not consistently associated with reported use of suppression, and where significant correlations were observed, these were relatively small in magnitude. Thus, taken together with the noted significant correlation between affective blunting and expressive behavior in the amplification (but not suppression) condition observed in Study 1, these data suggest that whilst over-use of suppression may contribute to some of the behavioral abnormalities characteristic of blunted affect, it cannot be regarded as the primary mechanism underpinning this disturbance. Instead, specific difficulties with the amplification of emotion expressive behavior may be most relevant to understanding this clinically important symptom. However, in the present study only the ability to regulate positive emotional experience was assessed – as Gross and Levenson (1997) note, there may be important differences between the ability to regulate positive and negative emotions. It is therefore important that future research extends the present findings by examining the relationship between schizotypy and the regulation of negative emotions. Indeed, blunted affect is uniquely predictive of poor prognosis in schizophrenia (Berenbaum and Oltmanns, 1992; Troisi et al., 2007), and whilst the prominence of schizotypal personality characteristics is a better predictor of transition to firstepisode psychosis among individuals with ‘at-risk mental states’ than premorbid adjustment, family history and current symptoms, the individual schizotypy item that optimally predicts transition is blunted affect (Mason et al., 2004). Consequently, mechanisms contributing to blunted affect in schizotypy may prove central to understanding schizophrenia. Acknowledgements This research was supported by grants from the Australian Research Council. References Aghevli, M.A., Blanchard, J.J., Horan, W.P., 2003. The expression and experience of emotion in schizophrenia: a study of social interactions. Psychiatry Research 119, 261–270. Berenbaum, H., Boden, M.T., Baker, J.P., Dizen, M., Thompson, R.J., Abramowitz, A., 2006. Emotional correlates of the different dimensions of schizotypal personality disorder. Journal of Abnormal Psychology 115, 359–368. Berenbaum, H., Oltmanns, T.F., 1992. Emotional experience and expression in schizophrenia and depression. Journal of Abnormal Psychology 101, 37–44.
124
J.D. Henry et al. / Psychiatry Research 166 (2009) 116–124
Birchwood, M., Smith, J., Cochrane, R., Wetton, S., Copestake, S., 1990. The Social Functioning Scale – the development and validation of a new scale. British Journal of Psychiatry 157, 853–859. Claridge, G.S., 1990. Can a disease model of schizophrenia survive? In: Bentall, R.P. (Ed.), Reconstructing Schizophrenia. London, Routledge. Corcoran, R., Chaill, C., Frith, C.D., 1997. The appreciation of visual jokes in people with schizophrenia: a study of ‘mentalizing’ ability. Schizophrenia Resesearch 24, 319–327. Denmaree, H.A., Schmeichel, B.J., Robinson, J.L., Everhart, D.E., 2004. Behavioural, affective, and physiological effects of negative and positive emotional exaggeration. Cognition and Emotion 18, 1079–1097. Gard, D.E., Kring, A.M., Germans Gard, M., Horan, W.P., Green, M.F., 2007. Anhedonia in schizophrenia: distinctions between anticipatory and consummatory pleasure. Schizophrenia Research 93, 253–260. Gross, J.J., 2001. Emotion regulation in adulthood: timing is everything. Current Directions in Psychological Science 10, 214–219. Gross, J.J., Levenson, R.W., 1997. Hiding feelings: The accute effects of inhibiting negative and positive emotion. Journal of Abnormal Psychology 106, 95–103. Gross, J.J., John, O.P., 2003. Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. Journal of Personality and Social Psychology 85, 348–362. Gross, J.J., Levenson, R.W., 1993. Emotional suppression: physiology, self report, and expressive behaviour. Journal of Personality and Social Psychology 64, 970–986. Gross, J.J., Levenson, R.W., 1995. Emotion elicitation using films. Cognition and Emotion 9, 87–108. Henry, J.D., Crawford, J.R., 2005. The short form version of the Depression Anxiety Stress Scales (DASS 21): construct validity and normative data in a large non-clinical sample. British Journal of Clinical Psychology 44, 227–239. Henry, J.D., Green, M.J., De Lucia, A., Restuccia, C., McDonald, S., O'Donnell, M., 2007. Emotion dysregulation in schizophrenia: reduced amplification of emotional expression is associated with emotional blunting. Schizophrenia Research 95, 197–204. Henry, J.D., Rendell, P.G., Green, M.J., McDonald, S., O’Donnell, M., 2008. Emotion regulation in schizophrenia: affective, social and clinical correlates of suppression and reappraisal. Journal of Abnormal Psychology 117, 473–478. Horan, W.P., Green, M.F., Kring, A.M., Nuechterlein, K.H., 2006. Does anhedonia in schizophrenia reflect faulty memory for subjectively experienced emotions? Journal of Abnormal Psychology 115, 496–508. John, O.P., Gross, J.J., 2004. Healthy and unhealthy emotion regulation: personality processes, individual differences, and life span development. Journal of Personality 72, 1301–1334. Kerns, J.G., 2005. Positive schizotypy and emotion processing. Journal of Abnormal Psychology 114, 392–401.
Kerns, J.G., 2006. Schizotypy facets, cognitive control, and emotion. Journal of Abnormal Psychology 115, 418–427. Kirkpatrick, B., Fischer, B., 2006. Subdomains within the negative symptoms of schizophrenia: commentary. Schizophrenia Bulletin 32, 246–249. Kring, A.M., Neale, J.M., 1996. Do schizophrenic patients show a disjunctive relationship among expressive, experiential, and psychophysiological components of emotion? Journal of Abnormal Psychology 105, 249–257. Kring, A.M., Werner, K.H., 2004. Emotion regulation and psychopathology. In: Philippot, P., Feldman, R.S. (Eds.), The Regulation of Emotion. Lawrence Erlbaum. Langdon, R., Coltheart, M., 2004. Recognition of metaphor and irony in young adults: the impact of schizotypal personality traits. Psychiatry Research 125, 9–20. Lenzenweger, M.F., 2006. Schizotypy. An organizing framework for schizophrenia research. Current Directions in Psychological Science 15, 162–166. Lovibond, S.H., Lovibond, P.F., 1995. Manual for the Depression Anxiety Stress Scales. Sydney, Psychology Foundation. Mason, O., Startup, M., Halpin, S., Schall, U., Conrad, A., Carr, V., 2004. Risk factors for transition to first episode psychosis among individuals with ‘at-risk mental states’. Schizophrenia Research 71, 227–237. Polimeni, J., Reiss, J.P., 2006. Humor perception deficits in schizophrenia. Psychiatry Research 141, 229–232. Raine, A., 1991. The SPQ – a scale for the assessment of schizotypal personality based on DSM-III-R criteria. Schizophrenia Bulletin 17, 555–564. Raine, A., 2006. Schizotypal personality: neurodevelopmental and psychosocial trajectories. Annual Review of Clinical Psychology 2, 291–326. Raine, A., Benishay, D., 1995. The SPQ-B: a brief screening instrument for schizotypal personality disorder. Journal of Personality Disorders 9, 346–355. Raine, A., Reynolds, C., Lencz, T., Scerbo, A., Triphon, N., Kim, D., 1994. Cognitive-perceptual, interpersonal, and disorganized features of schizotypal personality. Schizophrenia Bulletin 20, 191–201. Rottenberg, J., Ray, R.R., Gross, J.J., in press. Emotion elicitation using films. In: Coan, J.A., Allen, J.J.B. (Eds.), The Handbook of Emotion Elicitation and Assessment. Oxford University Press, New York. Stirling, J., Barkus, E., Lewis, S., 2007. Hallucination proneness, schizotypy and meta-cognition. Behaviour Research and Therapy 45, 1401–1408. Troisi, A., Pompili, E., Binello, L., Sterpone, A., 2007. Facial expressivity during the clinical interview as a predictor functional disability in schizophrenia. A pilot study. Progress in NeuroPsychopharmacology and Biological Psychiatry 31, 475–481. Wechsler, D., 1999. Wechsler Abbreviated Scale of Intelligence (WASI). Psychological Corporation, San Antonio, TX.