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Emotion dysregulation in schizophrenia: Reduced amplification of emotional expression is associated with emotional blunting
Schizophrenia Research 95 (2007) 197 – 204 www.elsevier.com/locate/schres
Emotion dysregulation in schizophrenia: Reduced amplification of emotional expression is associated with emotional blunting Julie D. Henry a,⁎, Melissa J. Green b , Amber de Lucia a , Corinne Restuccia a , Skye McDonald a , Maryanne O'Donnell c a
b
School of Psychology, University of New South Wales, Sydney, NSW 2052 Australia School of Psychiatry, University of New South Wales & Black Dog Institute, Prince of Wales Hospital, Sydney, NSW 2031 Australia c Director of Clinical Services, Kiloh Centre, Prince of Wales Hospital, Sydney, NSW 2031 Australia Received 26 March 2007; received in revised form 29 May 2007; accepted 6 June 2007 Available online 13 July 2007
Abstract A prominent emotional disturbance in schizophrenia is clinically evident in blunted affect, often observed as reduced emotional expressivity alongside the individual's report of normal or heightened emotional experience. It has been suggested that this disjunction between the experience and expression of emotion may reflect problems with the regulation of emotional expression. The present study thus set out to examine the capacity to engage in particular emotion regulatory strategies, and specifically, the ability to amplify the emotional expression of an experienced emotion (‘amplification’) or suppress the emotional expression of an experienced emotion (‘suppression’) whilst watching film clips selected to elicit amusement. Twenty nine participants with schizophrenia and 30 demographically matched non-clinical controls were asked to watch three different amusing film clips, whilst engaging in different regulatory strategies. The results indicate that participants with schizophrenia have difficulties with the amplification (but not suppression) of emotion expressive behavior. These difficulties are significantly correlated with total negative symptoms experienced, particularly emotional blunting. © 2007 Elsevier B.V. All rights reserved. Keywords: Schizophrenia; Emotion regulation emotional blunting; Emotional expression; Amplification
1. Introduction Abnormalities in the experience, expression, and recognition of affect are well documented in schizophrenia (Aleman and Kahn, 2005; Ellgring and Smith, 1998), and substantially reduce the potential for effective vocational and interpersonal functioning (Aghevli et al., 2003). The most prominent of these emotional abnormal⁎ Corresponding author. Tel.: +61 2 9385 3936; fax: +61 2 9385 3641. E-mail address: [email protected] (J.D. Henry). 0920-9964/$ - see front matter © 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.schres.2007.06.002
ities is evident clinically as blunted affect, characterized by markedly reduced emotional expressivity, alongside apparently normal emotional experiences (Berenbaum and Oltmanns, 1992; Kirkpatrick and Fischer, 2006). Blunted affect is observed from the earliest stages of illness, and often continues in chronic stages following the amelioration of active psychotic symptoms with psychopharmacological treatment (Gur et al., 2006). Blunted affect in schizophrenia has been particularly linked to social behavioral abnormalities, and predicts poor outcome (Dworkin et al., 1998).
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It has recently been proposed that the disjunction between experience and expression of affect that characterizes blunted affect may be attributable to emotion dysregulation. In a prominent theoretical account of emotion regulation Gross (2001, 2007) argues that response-focused emotion regulatory strategies occur after the emotion response has been triggered, and require management of the ongoing emotional experience, expression and physiological responses. Typical examples 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). One hypothesis is that blunted affect may reflect abnormal suppression of emotional responses that otherwise cause excessive load upon an overly sensitive physiological system (Ellgring and Smith, 1998). However, Kring and Werner (2004) argue that suppression of expressive behavior is usually associated with increased autonomic nervous system activity. Although patients with schizophrenia have demonstrated greater skin conductance reactivity to emotional films, despite being less facially expressive and experiencing comparable levels of emotion relative to healthy controls, increased physiological activity is also observed in response to neutral films (Kring and Neale, 1996). This pattern of findings is therefore inconsistent with the argument that over-use of suppression may be responsible for the disjunction between affective experience and behavior. Kring and Werner (2004) have suggested instead that the discrepancy may be attributable to impaired up-regulation of emotional expression. The present study will be the first to directly investigate whether individuals with schizophrenia are impaired in their capacity to suppress (down-regulate) or amplify (up-regulate) expressive emotional behavior. Whilst the modulation of both positive and negative emotion expression behavior is clearly of enormous adaptive significance (Gross and Levenson, 1997), given that anhedonia (the decreased capacity to experience pleasure, in both physical and social– interpersonal domains) is regarded as a core feature of schizophrenia, the present study focused on capacity to up- and down-regulate positive emotion expressive behavior, and specifically, amusement. It is predicted that whilst the ability to down-regulate (suppress) emotional reactions to positive emotional events will be spared in schizophrenia, the ability to up-regulate (amplify) emotional experience will be disrupted. It is further predicted that difficulties with amplification will be related to emotional blunting.
2. Method All procedures were approved by the Human Research Ethics Committee of the South Eastern Sydney Area Health Service. 2.1. Participants Twenty nine participants were recruited from outpatient and rehabilitation clinics in Sydney. Diagnoses of schizophrenia (n = 23) or schizoaffective disorder (n = 6) were made by treating psychiatrists according to the Diagnostic and Statistical Manual of Mental Disorders IV (American Psychiatric Association, 2004). Volunteers were self-referred via waiting room advertisements or by their health care providers. All participants were aged over 18, medicated, and in a stable phase of illness. Thirty age-, education-, gender-matched controls were recruited via advertisements placed in local newspapers. Exclusion criteria for all participants were neurological disorder, severe alcohol/drug abuse and inability to communicate adequately. 2.2. Baseline assessment Wechsler's Abbreviated Scale of Intelligence (WASI; Wechsler, 1999) was used to provide a brief index of current intelligence and includes four subtests (Vocabulary, Block Design, Similarities, and Matrix Reasoning). The age-standardized scores based on performance on these sub-scales were calculated to provide an estimate of current intelligence. The Scale for the Assessment of Negative Symptoms (SANS; Andreasen, 1983) and the Scale for the Assessment of Positive Symptoms (SAPS; Andreasen, 1984) were used to assess current positive and negative symptoms in the clinical group. 2.3. Emotion regulation manipulation Four amusement film clips were selected from pilot work involving 14 film clips selected from comedy shows and movies. This piloting involved asking 28 adults to watch each of the clips and self-rate each for level of disgust, anger, happiness, sadness, amusement, confusion, interest, fear, surprise, anxiety and overall pleasantness. The four film clips selected were found to elicit high, comparable levels of amusement (and the related emotions of happiness and pleasantness), but only minimal elicitation of each of the other emotions. The clips selected involved (i) a television presenter reporting the news, but being forced to say a series of silly things, (ii) a person singing an amusing love song,
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(iii) a person making jokes about their experiences with a chiropractor and (iv) a public speaker forgetting to remove their microphone before they go to the toilet, with all the resultant noises broadcast to a live audience. Each of these film clips was an average of 2 min 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). 2.4. Procedure 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: Expression (control condition). Participants were randomly assigned to watch one of the amusing film clips, presented in a counterbalanced order. In the expression 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 experimental conditions was also counterbalanced across participants. 5. Amusement 2: Suppression. “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”.
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6. Neutral film clip 3. 7. Amusement 3: Amplification. “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.” 8. Demographic questionnaire, WASI, SAPS and SANS. Emotion Response Forms were adapted from those used in previous research (Rottenberg et al., in press). 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 specific emotions (disgust, anger, happiness, sadness, amusement, confusion, interest, fear, surprise and anxiety). An overall rating of positive affect was calculated by calculating the average rating of happiness and amusement; an overall rating of negative affect was obtained by calculating the average rating of disgust, anger, sadness, fear and anxiety. Two community volunteers who had received no formal training in any psychology or psychiatry related discipline were paid to act as independent raters, 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 using a rating form developed for the present study based on the Emotional Behavior Coding System (Gross and Levenson, 1993). Facial and behavioral expressions were not independently evaluated, but were assessed together to derive an overall rating of behavioral expression of amusement, as well as other aspects of emotional responding, such as level of positive and negative emotions expressed. The rating scale used for coding behavioral expressions was identical to the scale used for the rating of self-report, and thus values on this scale ranged from 0 to 8, with higher scores indicative of greater levels of expressed emotion. For the behavioral ratings of amusement, Pearson product-moment correlations for the two raters were .84 for the expression condition, .86 for the suppression condition, and .82 for the amplification condition. Mean scores collapsed across the two coders were therefore calculated. 3. Results Self-report amusement data are presented in Table 1. Data related to self-report in the experimental conditions
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Table 1 Means and SDs for self-ratings of amusement across the different experimental conditions
Amusing clips Expression Suppression Amplification Neutral clips Time 1 Time 2 Time 3
Control group (n = 30)
SCZ group (n = 29)
M
SD
M
SD
5.7 5.1 4.7
1.76 2.77 2.22
4.3 4.2 3.5
3.20 2.80 2.91
2.2 1.9 1.9
1.93 1.94 2.15
1.4 1.5 1.0
1.72 2.11 1.94
Note: SCZ refers to schizophrenia. The rating scale ranges from 0 (not at all/none) to 8 (extremely/a great deal).
were analyzed with a 1 × 3 mixed ANOVA design, with the between subjects variable of schizophrenia status and the within subjects variable of emotion regulation condition (expression, suppression, amplification). These two variables did not significantly interact (p N .05), and there was no significant main effect of emotion regulation condition, indicating that level of reported amusement in the expression, suppression and amplification conditions did not differ significantly (p N .05). However, there was a main effect of group, F(1, 57) = 4.50, p = .038, indicating that participants with schizophrenia self-reported significantly less amusement relative to controls. To provide baseline comparison standards, these analyses were repeated with the between subjects variable of schizophrenia status and the within subjects variable of neutral video (Time 1, Time 2 or Time 3). Neither main effect was significant nor did these two variables significantly interact (all ps N .05). Since the primary focus of the present study was to assess how schizophrenia affects the ability to regulate the emotional experience of amusement, an essential prerequisite for inclusion in the emotion regulation analyses was that each participant find the target film clips amusing. Given the noted lack of interaction between group status and self-reported affect in the three emotion regulation conditions, self-rated amusement across the three conditions was collapsed in order to quantify average level of emotional responding. Sixteen participants' average self-rating was 3 or less (12 participants with schizophrenia and 4 controls), indicating that these “low-response” participants found the film clips, on average, to be less than ‘somewhat’ amusing. These participants were thus excluded from all analyses relating to the emotion regulation manipulation, leaving
a final sample size of 17 “high-response” participants with schizophrenia and 26 “high-response” controls for the emotion regulation analyses. Exploratory analyses across the total schizophrenia sample (n = 29), indicated that of the clinical variables, only the anhedonia dimension of the SANS was a significant correlate of level of endorsed amusement (r = − .37; p b .05). Demographic and clinical information relating to the “high-response” and “low-response” participant groups is presented in Table 2. Although all individuals in the “high-response” and “low-response” schizophrenia groups were receiving antipsychotic medication, there was considerable variability with respect to the different types and combinations of drugs being taken (see Table 2). Antipsychotic drugs differ in potency, and these differences in potency are typically expressed as differences in chlorpromazine equivalence (CPZe).1 Importantly, the “high-response” and “low-response” groups did not differ with respect to CPZe (398.1 and 393.5 mg, respectively; t = 0.48, df = 27, p = .962). It should also be noted that controlling for CPZe did not alter any of the results reported in the present study. Independent samples t-tests indicated that the two schizophrenia sub-groups also did not differ significantly with respect to any of the demographic variables, indices of psychopathology or performance on any of the cognitive measures reported in Table 2 (all ps N .05). To further characterize the “high-response” and “low-response” schizophrenia sub-groups, Table 3 provides descriptive statistics for the self- and behavioral-ratings of positive and negative affect in response to the neutral video clips for each of these groups in addition to the control group. It can be seen that self- and behavioral ratings of negative affect are equivalent for the three groups. However, there is a trend for the “lowresponse” schizophrenia group to report less positive affect. To compare the two schizophrenia sub-groups, these data were analyzed with a series of 1 × 3 mixed ANOVAs, with the between subjects variable of schizophrenia response (high, low) and the within subjects variable of neutral video (Time 1, Time 2 or 1 Whilst this conversion is more controversial as applied to atypical antipsychotics (see; Taylor et al., 2003), it is nevertheless useful for assessing broad trends across patient groups. Humberstone et al.'s (2003) guidelines provided conversion equivalents for all drugs taken by participants in the present study, with the exception of amisulpride and aripiprazole, for which The Maudsley 2003 Prescribing Guidelines (Taylor et al., 2003) were used to calculate CPZe, based on the minimum recommended doses of these drugs. Thus, since a minimum dose of 200 mg for chlorpromazine, 400 mg for amisulpride, and 15 mg of aripiprazole is recommended, a conversion ratio of 1:2 and 1:.075 was used for these drugs, respectively.
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Table 2 Baseline characteristics of the healthy control (HC) and schizophrenia (SCZ) participants who were high or low responders to the amusing videoclips Characteristic
Low responders HC group (n = 4) M
Age (years) Education (years) Gender (% male) Age at SCZ onset (years) Duration of SCZ (years) Primary diagnosis (%) Schizophrenia Schizoaffective disorder SAPS Total Hallucinations Delusions Bizarre behavior Positive FTD SANS Total Affective blunting Alogia Avolition Anhedonia Attention Medications (% receiving) a Clozapine Olanzapine Risperidone Quetiapine Amisupride Aripiprazole CPZ equivalents (mg) Cognitive functioning WASI Total Vocabulary Block design Similarities Matrices
High responders SCZ group (n = 12)
SD 8.19 1.60
M
HC group (n = 26) SD
SCZ group (n = 17)
M
SD
34.6 13.7 54 – –
10.35 2.28 – –
32.6 13.1 53 21.2 10.9
– –
– –
76.5 23.5
4.67 1.99 1.88 1.17 1.16
– – – – –
– – – – –
5.8 2.0 2.3 0.7 0.8
4.19 2.00 1.69 1.05 1.35
3.90 1.38 1.31 1.80 1.44 1.17
– – – – – –
– – – – – –
7.3 1.7 0.8 1.9 2.0 0.9
4.66 1.31 1.30 1.20 1.58 1.11
67 0 17 8 25 17 393.5
228.69
– – – – – – –
– – – – – – –
76 18 12 0 24 12 398.1
268.30
86.3 41.0 42.1 42.3 42.3
6.43 8.30 7.19 8.48 7.09
105.0 52.2 54.5 50.5 53.9
11.70 8.02 8.73 6.06 10.86
89.7 40.0 47.6 41.1 45.9
15.86 11.04 11.20 9.89 12.11
35.5 12.4 50 – –
– –
36.7 12.0 33 21.9 14.7
– –
– –
83.3 16.7
– – – – –
– – – – –
5.6 1.8 2.5 0.6 0.7
– – – – – –
– – – – – –
8.1 1.9 1.1 1.8 2.7 0.6
– – – – – – –
– – – – – – –
103.8 54.8 54.5 53.0 45.5
10.87 12.55 11.24 5.86 5.45
11.1 1.56 4.34 10.54 – –
M
SD 7.64 2.85 4.00 7.82 – –
Note: SANS refers to The Scale for the Assessment of Negative Symptoms; SAPS refers to The Scale for the Assessment of Positive Symptoms. WASI refers to the Wechsler's Abbreviated Scale of Intelligence. a Many of the schizophrenia participants were receiving more than one medication. In particular, approximately one third of the participants who were taking olanzapine, clozapine or risperidone were also taking either amisulpride or aripiprazole.
Time 3). For self-reported negative affect, behaviorally rated negative affect and behaviorally rated positive affect, these analyses indicated that none of the main effects or interactions were significant (all ps N .05). However, for self-rated positive affect, whilst the main effect of neutral video time, and interaction between video time and group did not attain significance (both ps N .05), there was a significant main effect of group, F(1, 27) = 8.52, p = .007. Thus, the participants with schizophrenia who were categorized as low responders based on their affective responses to the amusing
videoclips, also report less positive affect in response to the neutral videoclips. 3.1. Emotion regulation analyses Since, as noted previously, an essential prerequisite for inclusion in the emotion regulation analyses was that each participant find the target film clips amusing all “low-response” participants were excluded from analyses relating to the emotion regulation manipulation. The “high-response” participants with schizophrenia (n = 17)
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Table 3 Self-rated and behaviorally rated positive and negative to the neutral video clips Schizophrenia group Control group (n = 30)
Negative emotions Neutral clip 1 Neutral clip 2 Neutral clip 3
Positive emotions Neutral clip 1 Neutral clip 2 Neutral clip 3
High responders (n = 17)
Low responders (n = 12)
M
SD
M
SD
M
SD
Self-rating Behavioral Self-rating Behavioral Self-rating Behavioral
0.1 0.9 0.1 1.0 0.1 1.1
0.19 0.81 0.21 0.78 0.21 0.92
0.5 1.0 0.5 0.9 0.1 0.9
0.60 0.80 0.91 0.75 0.23 0.78
0.1 1.2 0.1 1.1 0.1 1.1
0.13 0.75 0.28 0.86 0.25 0.70
Self-rating Behavioral Self-rating Behavioral Self-rating Behavioral
3.7 1.7 3.4 1.9 3.3 1.6
1.41 1.19 1.64 1.13 1.56 1.21
3.0 1.1 3.5 1.5 3.1 1.5
1.72 1.41 1.49 1.41 1.33 1.35
1.5 1.0 1.8 1.1 1.8 0.5
1.86 0.99 2.26 1.77 1.54 0.99
Note: The trends shown in this table are unchanged if the four “low-response” participants are omitted from the control group.
indicated that, for both groups, behavioral expression of emotion was significantly reduced during the suppression condition (t = 4.99, df = 25, p b .001 for controls; t = 2.75, df = 16, p = .014 for individuals with schizophrenia). However, whilst for the control group the comparison of behavioral expression during the amplification condition relative to behavioral expression during the expression condition attained significance (t = 2.13, df = 25, p = .043), this was not true for the schizophrenia group (t = 0.13, df = 16, p = .897). Finally, correlations between clinical ratings of psychopathology and CPZe, with behavioral ratings of expressed amusement in the three experimental conditions are reported in Table 5. It can be seen that CPZe was not significantly related to behavioral ratings of amusement. Whilst amount of emotion expressed during the amplification condition was significantly correlated with the total SANS score, emotional blunting was the
and healthy controls (n = 26) who contributed to the emotion regulation analyses did not differ significantly with regard to age, education or gender (all ps N .05), but did differ significantly with regard to overall cognitive functioning (t = 3.05, df = 41, p = .004). Table 4 summarizes mean levels of self-rated and behaviorally rated amusement for these schizophrenia and control participants for each of the three conditions. It can be seen that for all three conditions, the two groups do not differ with regard to self-rated amusement. Whilst behavioral expression of emotion is lower for the schizophrenia group across all three conditions, it is only for the amplification condition that this difference attains significance. Within-group comparisons focused on comparing behavioral expression of amusement during each of the regulation conditions with behavioral expression of amusement during the baseline (expression) condition
Table 4 Between-group analyses focused on self- and behavioral-ratings for levels of amusement across the three conditions for the high responders Control group (n = 26)
Expression Suppression Amplification
Self-rating Behavioral Self-rating Behavioral Self-rating Behavioral
SCZ group (n = 17)
Inferential statistics
Effect size
M
SD
M
SD
t
df
p
d
6.0 4.0 5.6 2.2 5.3 4.7
1.37 1.93 2.44 2.16 1.67 1.40
6.1 3.6 5.8 1.8 4.8 3.5
2.28 2.31 1.98 1.85 2.72 2.15
0.04 0.59 0.35 0.69 0.73 2.19
41 41 41 41 41 41
.971 .560 .729 .496 .473 .035
0.01 0.18 0.10 0.22 0.23 0.69
Note: SCZ refers to schizophrenia. Cohen (1988) defines effect sizes of 0.2 as small, 0.5 as medium, and 0.8 as large).
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Table 5 Correlations between behavioral ratings of expressivity in the three regulation conditions with psychopathology ratings and chlorpromazine equivalents (CPZe) for the high-responders with schizophrenia (n = 17) Condition
SAPS
SAPS
Total Hallucinations Delusions Bizarre behavior Expression .18 Suppression .15 Amplification .45
.16 −.17 .55⁎
.40 .12 .27
−.32 .20 .07
CPZe
Positive FTD
Total
Affective blunting
.07 .19 .19
−.21 −.26 −.17 −.32 −.50⁎ −.49⁎
Alogia Avolition Anhedonia Attention −.09 −.30 −.47⁎
−.04 .14 −.04
−.06 .01 −.32
−.35 −.17 −.46
−.23 .04 .14
⁎P b 0.05. Note; SAPS refers to the Scale for the Assessment of Positive Symptoms; SANS refers to the Scale for the Assessment of Negative Symptoms; FTD refers to Formal Thought Disorder.
single strongest contributor to this relationship (r = −.49; p b .05). 4. Discussion The present results indicated that both schizophrenia and control participants were able to effectively implement the strategy of suppression. In contrast, during the amplification condition, only control (but not schizophrenia) 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 (expression) condition, participants with schizophrenia (like controls) showed evidence of effective suppression of emotion expressive behavior. However, for the amplification condition effective upregulation of emotion expressive behavior was only observed for the control group. The subjective experience of affect did not differ for either of the emotion regulation conditions, or during the baseline expression condition, and thus the group differences identified cannot be attributed to differences in the intensity of emotion experienced. These findings are therefore consistent with the proposal that the disjunction between the experience and expression of affect associated with schizophrenia may reflect a specific deficit upregulating emotion expressive behavior (Kring and Werner, 2004). Consistent with this possibility, behavioral expression in the amplification condition was significantly correlated with degree of emotional blunting. As noted previously, blunted affect is present in the majority of patients with schizophrenia, exhibits longitudinal stability and is predictive of poor prognosis (Berenbaum and Oltmanns, 1992; Gur et al., 2006). These findings provide the first empirical evidence for emotion dysregulation as a potential mechanism underpinning emotional blunting, and highlight the need for further research to clarify the nature of emotion regulation disturbances in schizophrenia.
Nevertheless, it is important to note several potential limitations to the interpretation of these data. Firstly, interpretation of results from the between-group analyses is limited by the fact that the difference between the two groups for the amplification condition only just attained significance, and multiple comparisons were made without correction for an inflated Type I error rate. Thus, although the magnitude of this between-group effect size was moderate to large, and was entirely consistent with the results of the within-group analyses, the robustness of these findings remains to be demonstrated. Additionally, although schizophrenia and control groups were equated for subjectively experienced affect for the emotion regulation analyses, this was only achieved by excluding all participants who did not find the film clips at least ‘somewhat’ amusing. An important caveat arising from this process is that the omission of “low-response” schizophrenia participants may have resulted in the exclusion of schizophrenia patients with potentially the most severe emotion regulation difficulties. Indeed, these patients reported lower levels of positive affect even in response to neutral video clips, relative to their “high-response” counterparts, and inspection of the mean ratings on individuals SANS items suggests that this group may be more impaired in their capacity to experience pleasure generally (see SANS Anhedonia item, Table 2). However, we also note that the “low-response” sub-group did not differ from “high-response” patients with respect to clinical ratings of blunted affect, which was found to be associated with deficits amplifying behavioral expressions of amusement in schizophrenia patients, in this study. It is therefore unfortunate that the methodological design of this study precluded the analysis of the “low responding” schizophrenia patients, since these patients clearly demonstrate an aberrant experience of affect that may also reflect emotion regulatory dysfunction. Future research should therefore employ alternative strategies to examine emotion regulatory processes in chronic ‘low emotional responding’ schizophrenia patients.
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Finally, whilst the present results provide the first evidence that capacity to amplify positive emotion expressive behavior may be disrupted in schizophrenia, Gross and Levenson (1997) suggest 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 ability of schizophrenia patients to regulate negative emotions, particularly since the dysregulation of worry processes and anxiety may be pertinent to the formation of delusional symptoms (Freeman and Garety, 1999). Additionally, in the present study only behavioralexpressive emotion regulation was investigated. Whilst this form of emotion regulation has particular importance for schizophrenia given that blunted affect is a core feature of the disorder, future research should also examine the modulation of other aspects of emotional responses (such as physiological arousal), and the capacity of schizophrenia patients to implement cognitively-focused emotion regulation strategies (e.g., cognitive reframing or reappraisal). Role of the Funding Source Funding for this study was provided by an Australia Research Council grant awarded to Henry and McDonald (DP0663182). The Australian Research Council had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. Contributors Julie Henry designed the study, conducted the statistical analyses and wrote the first draft of the manuscript. Melissa Green assisted with conceptual issues related to the study design, and also made a substantial contribution in writing the manuscript. Amber de Lucia and Corinne Restuccia recruited participants and conducted the experimental testing. Skye McDonald assisted with conceptual issues related to the study design. Maryanne O'Donnell assisted with participant recruitment. All authors contributed to and have approved the final manuscript. Conflict of Interest There are no actual or potential conflicts of interests with respect to the authors' involvement in this manuscript. Acknowledgement The authors acknowledge the Research Register of the Schizophrenia Research Institute, Australia, for assisting with the recruitment of the volunteers participating in this research, as well as the participants themselves.
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American Psychiatric Association, 2004. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. [Washington DC]. Andreasen, N.C., 1983. Scale for the Assessment of Negative Symptoms (SANS). University of Iowa, Iowa City. Andreasen, N.C., 1984. Scale for the Assessment of Positive Symptoms (SAPS). University of Iowa, Iowa City. Berenbaum, H., Oltmanns, T.F., 1992. Emotional experience and expression in schizophrenia and depression. J. Abnorm. Psychology 101, 37–44. Cohen, J., 1988. Statistical Power Analysis for the Behavioral Sciences. Lawrence Erlbaum Associates, Hillsdale, New Jersey. Denmaree, H.A., Schmeichel, B.J., Robinson, J.L., Everhart, D.E., 2004. Behavioural, affective, and physiological effects of negative and positive emotional exaggeration. Cogn. Emot. 18, 1079–1097. Dworkin, R.H., Oster, H., Clark, S.C., White, S.R., 1998. Affective expression and affective experience in schizophrenia. In: Lenzenweger, M.F., Dworkin, R.H. (Eds.), Origins and Development of Schizophrenia. American Psychological Association, Washington DC. Ellgring, H., Smith, M., 1998. Affect regulation during psychosis. In: Flack, J.D., Laird, J.D. (Eds.), Emotions in psychopathology — theory and research. Oxford University Press. Freeman, D., Garety, P.A., 1999. Worry, worry processes and dimensions of delusions: an exploratory investigation of a role for anxiety processes in the maintenance of delusional distress. Behav. Cogn. Psychother. 27, 47–62. Gross, J.J., 2001. Emotion regulation in adulthood: timing is everything. Curr. Dir. Psychol. Sci. 10, 214–219. Gross, J.J., Levenson, R.W., 1993. Emotional suppression: physiology, self-report, and expressive behaviour. J. Pers. Soc. Psychol. 64, 970–986. Gross, J.J., Levenson, R.W., 1995. Emotion elicitation using films. Cogn. Emot. 9, 87–108. Gross, J.J., Levenson, R.W., 1997. Hiding feelings: the acute effects of inhibiting negative and positive emotion. J. Abnorm. Psychology 106, 95–103. Gur, R.E., Kohler, C.G., Ragland, J.D., Siegel, S.J., Lesko, K., Bilker, W.B., et al., 2006. Flat affect in schizophrenia: relation to emotion processing and neurocognitive measures. Schizophr. Bull. 32, 279–287. Humberstone, V., Wheeler, A., Lambert, T., 2003. An audit of outpatient antipsychotic usage in the three health sectors of Auckland, New Zealand. Aust. N. Z. J. Psychiatry 38, 240–245. Kirkpatrick, B., Fischer, B., 2006. Subdomains within the negative symptoms of schizophrenia: commentary. Schizophr. Bull. 32, 246–249. Kring, A.M., Neale, J.M., 1996. Do schizophrenics show a disjunctive relationship among expressive, experiential, and psychophysiological components of emotion? J. Abnorm. Psychology 105, 249–257. Kring, A.M., Werner, K.H., 2004. Emotion regulation in psychopathology. In: Philippot, P., Feldman, R.S. (Eds.), The Regulation of Emotion. LEA, New York, pp. 359–385. Rottenberg, J., Ray, R.D., Gross, J.J., in press. Emotion elicitation using films. In: Coan, J.A., Allen, J.J.B.J.A. (Eds.) The handbook of emotion elicitation and assessment. Oxford University Press, New York. Taylor, D., Paton, C., Kerwin, R., 2003. The Maudsley 2003 Prescribing Guidelines. Martin Dunitz, London, UK. Wechsler, D., 1999. Wechsler Abbreviated Scale of Intelligence (WASI). The Psychological Association, USA.
Emotion dysregulation in schizophrenia: Reduced amplification of emotional expression is associated with emotional blunting Julie D. Henry a,⁎, Melissa J. Green b , Amber de Lucia a , Corinne Restuccia a , Skye McDonald a , Maryanne O'Donnell c a
b
School of Psychology, University of New South Wales, Sydney, NSW 2052 Australia School of Psychiatry, University of New South Wales & Black Dog Institute, Prince of Wales Hospital, Sydney, NSW 2031 Australia c Director of Clinical Services, Kiloh Centre, Prince of Wales Hospital, Sydney, NSW 2031 Australia Received 26 March 2007; received in revised form 29 May 2007; accepted 6 June 2007 Available online 13 July 2007
Abstract A prominent emotional disturbance in schizophrenia is clinically evident in blunted affect, often observed as reduced emotional expressivity alongside the individual's report of normal or heightened emotional experience. It has been suggested that this disjunction between the experience and expression of emotion may reflect problems with the regulation of emotional expression. The present study thus set out to examine the capacity to engage in particular emotion regulatory strategies, and specifically, the ability to amplify the emotional expression of an experienced emotion (‘amplification’) or suppress the emotional expression of an experienced emotion (‘suppression’) whilst watching film clips selected to elicit amusement. Twenty nine participants with schizophrenia and 30 demographically matched non-clinical controls were asked to watch three different amusing film clips, whilst engaging in different regulatory strategies. The results indicate that participants with schizophrenia have difficulties with the amplification (but not suppression) of emotion expressive behavior. These difficulties are significantly correlated with total negative symptoms experienced, particularly emotional blunting. © 2007 Elsevier B.V. All rights reserved. Keywords: Schizophrenia; Emotion regulation emotional blunting; Emotional expression; Amplification
1. Introduction Abnormalities in the experience, expression, and recognition of affect are well documented in schizophrenia (Aleman and Kahn, 2005; Ellgring and Smith, 1998), and substantially reduce the potential for effective vocational and interpersonal functioning (Aghevli et al., 2003). The most prominent of these emotional abnormal⁎ Corresponding author. Tel.: +61 2 9385 3936; fax: +61 2 9385 3641. E-mail address: [email protected] (J.D. Henry). 0920-9964/$ - see front matter © 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.schres.2007.06.002
ities is evident clinically as blunted affect, characterized by markedly reduced emotional expressivity, alongside apparently normal emotional experiences (Berenbaum and Oltmanns, 1992; Kirkpatrick and Fischer, 2006). Blunted affect is observed from the earliest stages of illness, and often continues in chronic stages following the amelioration of active psychotic symptoms with psychopharmacological treatment (Gur et al., 2006). Blunted affect in schizophrenia has been particularly linked to social behavioral abnormalities, and predicts poor outcome (Dworkin et al., 1998).
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It has recently been proposed that the disjunction between experience and expression of affect that characterizes blunted affect may be attributable to emotion dysregulation. In a prominent theoretical account of emotion regulation Gross (2001, 2007) argues that response-focused emotion regulatory strategies occur after the emotion response has been triggered, and require management of the ongoing emotional experience, expression and physiological responses. Typical examples 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). One hypothesis is that blunted affect may reflect abnormal suppression of emotional responses that otherwise cause excessive load upon an overly sensitive physiological system (Ellgring and Smith, 1998). However, Kring and Werner (2004) argue that suppression of expressive behavior is usually associated with increased autonomic nervous system activity. Although patients with schizophrenia have demonstrated greater skin conductance reactivity to emotional films, despite being less facially expressive and experiencing comparable levels of emotion relative to healthy controls, increased physiological activity is also observed in response to neutral films (Kring and Neale, 1996). This pattern of findings is therefore inconsistent with the argument that over-use of suppression may be responsible for the disjunction between affective experience and behavior. Kring and Werner (2004) have suggested instead that the discrepancy may be attributable to impaired up-regulation of emotional expression. The present study will be the first to directly investigate whether individuals with schizophrenia are impaired in their capacity to suppress (down-regulate) or amplify (up-regulate) expressive emotional behavior. Whilst the modulation of both positive and negative emotion expression behavior is clearly of enormous adaptive significance (Gross and Levenson, 1997), given that anhedonia (the decreased capacity to experience pleasure, in both physical and social– interpersonal domains) is regarded as a core feature of schizophrenia, the present study focused on capacity to up- and down-regulate positive emotion expressive behavior, and specifically, amusement. It is predicted that whilst the ability to down-regulate (suppress) emotional reactions to positive emotional events will be spared in schizophrenia, the ability to up-regulate (amplify) emotional experience will be disrupted. It is further predicted that difficulties with amplification will be related to emotional blunting.
2. Method All procedures were approved by the Human Research Ethics Committee of the South Eastern Sydney Area Health Service. 2.1. Participants Twenty nine participants were recruited from outpatient and rehabilitation clinics in Sydney. Diagnoses of schizophrenia (n = 23) or schizoaffective disorder (n = 6) were made by treating psychiatrists according to the Diagnostic and Statistical Manual of Mental Disorders IV (American Psychiatric Association, 2004). Volunteers were self-referred via waiting room advertisements or by their health care providers. All participants were aged over 18, medicated, and in a stable phase of illness. Thirty age-, education-, gender-matched controls were recruited via advertisements placed in local newspapers. Exclusion criteria for all participants were neurological disorder, severe alcohol/drug abuse and inability to communicate adequately. 2.2. Baseline assessment Wechsler's Abbreviated Scale of Intelligence (WASI; Wechsler, 1999) was used to provide a brief index of current intelligence and includes four subtests (Vocabulary, Block Design, Similarities, and Matrix Reasoning). The age-standardized scores based on performance on these sub-scales were calculated to provide an estimate of current intelligence. The Scale for the Assessment of Negative Symptoms (SANS; Andreasen, 1983) and the Scale for the Assessment of Positive Symptoms (SAPS; Andreasen, 1984) were used to assess current positive and negative symptoms in the clinical group. 2.3. Emotion regulation manipulation Four amusement film clips were selected from pilot work involving 14 film clips selected from comedy shows and movies. This piloting involved asking 28 adults to watch each of the clips and self-rate each for level of disgust, anger, happiness, sadness, amusement, confusion, interest, fear, surprise, anxiety and overall pleasantness. The four film clips selected were found to elicit high, comparable levels of amusement (and the related emotions of happiness and pleasantness), but only minimal elicitation of each of the other emotions. The clips selected involved (i) a television presenter reporting the news, but being forced to say a series of silly things, (ii) a person singing an amusing love song,
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(iii) a person making jokes about their experiences with a chiropractor and (iv) a public speaker forgetting to remove their microphone before they go to the toilet, with all the resultant noises broadcast to a live audience. Each of these film clips was an average of 2 min 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). 2.4. Procedure 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: Expression (control condition). Participants were randomly assigned to watch one of the amusing film clips, presented in a counterbalanced order. In the expression 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 experimental conditions was also counterbalanced across participants. 5. Amusement 2: Suppression. “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”.
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6. Neutral film clip 3. 7. Amusement 3: Amplification. “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.” 8. Demographic questionnaire, WASI, SAPS and SANS. Emotion Response Forms were adapted from those used in previous research (Rottenberg et al., in press). 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 specific emotions (disgust, anger, happiness, sadness, amusement, confusion, interest, fear, surprise and anxiety). An overall rating of positive affect was calculated by calculating the average rating of happiness and amusement; an overall rating of negative affect was obtained by calculating the average rating of disgust, anger, sadness, fear and anxiety. Two community volunteers who had received no formal training in any psychology or psychiatry related discipline were paid to act as independent raters, 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 using a rating form developed for the present study based on the Emotional Behavior Coding System (Gross and Levenson, 1993). Facial and behavioral expressions were not independently evaluated, but were assessed together to derive an overall rating of behavioral expression of amusement, as well as other aspects of emotional responding, such as level of positive and negative emotions expressed. The rating scale used for coding behavioral expressions was identical to the scale used for the rating of self-report, and thus values on this scale ranged from 0 to 8, with higher scores indicative of greater levels of expressed emotion. For the behavioral ratings of amusement, Pearson product-moment correlations for the two raters were .84 for the expression condition, .86 for the suppression condition, and .82 for the amplification condition. Mean scores collapsed across the two coders were therefore calculated. 3. Results Self-report amusement data are presented in Table 1. Data related to self-report in the experimental conditions
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Table 1 Means and SDs for self-ratings of amusement across the different experimental conditions
Amusing clips Expression Suppression Amplification Neutral clips Time 1 Time 2 Time 3
Control group (n = 30)
SCZ group (n = 29)
M
SD
M
SD
5.7 5.1 4.7
1.76 2.77 2.22
4.3 4.2 3.5
3.20 2.80 2.91
2.2 1.9 1.9
1.93 1.94 2.15
1.4 1.5 1.0
1.72 2.11 1.94
Note: SCZ refers to schizophrenia. The rating scale ranges from 0 (not at all/none) to 8 (extremely/a great deal).
were analyzed with a 1 × 3 mixed ANOVA design, with the between subjects variable of schizophrenia status and the within subjects variable of emotion regulation condition (expression, suppression, amplification). These two variables did not significantly interact (p N .05), and there was no significant main effect of emotion regulation condition, indicating that level of reported amusement in the expression, suppression and amplification conditions did not differ significantly (p N .05). However, there was a main effect of group, F(1, 57) = 4.50, p = .038, indicating that participants with schizophrenia self-reported significantly less amusement relative to controls. To provide baseline comparison standards, these analyses were repeated with the between subjects variable of schizophrenia status and the within subjects variable of neutral video (Time 1, Time 2 or Time 3). Neither main effect was significant nor did these two variables significantly interact (all ps N .05). Since the primary focus of the present study was to assess how schizophrenia affects the ability to regulate the emotional experience of amusement, an essential prerequisite for inclusion in the emotion regulation analyses was that each participant find the target film clips amusing. Given the noted lack of interaction between group status and self-reported affect in the three emotion regulation conditions, self-rated amusement across the three conditions was collapsed in order to quantify average level of emotional responding. Sixteen participants' average self-rating was 3 or less (12 participants with schizophrenia and 4 controls), indicating that these “low-response” participants found the film clips, on average, to be less than ‘somewhat’ amusing. These participants were thus excluded from all analyses relating to the emotion regulation manipulation, leaving
a final sample size of 17 “high-response” participants with schizophrenia and 26 “high-response” controls for the emotion regulation analyses. Exploratory analyses across the total schizophrenia sample (n = 29), indicated that of the clinical variables, only the anhedonia dimension of the SANS was a significant correlate of level of endorsed amusement (r = − .37; p b .05). Demographic and clinical information relating to the “high-response” and “low-response” participant groups is presented in Table 2. Although all individuals in the “high-response” and “low-response” schizophrenia groups were receiving antipsychotic medication, there was considerable variability with respect to the different types and combinations of drugs being taken (see Table 2). Antipsychotic drugs differ in potency, and these differences in potency are typically expressed as differences in chlorpromazine equivalence (CPZe).1 Importantly, the “high-response” and “low-response” groups did not differ with respect to CPZe (398.1 and 393.5 mg, respectively; t = 0.48, df = 27, p = .962). It should also be noted that controlling for CPZe did not alter any of the results reported in the present study. Independent samples t-tests indicated that the two schizophrenia sub-groups also did not differ significantly with respect to any of the demographic variables, indices of psychopathology or performance on any of the cognitive measures reported in Table 2 (all ps N .05). To further characterize the “high-response” and “low-response” schizophrenia sub-groups, Table 3 provides descriptive statistics for the self- and behavioral-ratings of positive and negative affect in response to the neutral video clips for each of these groups in addition to the control group. It can be seen that self- and behavioral ratings of negative affect are equivalent for the three groups. However, there is a trend for the “lowresponse” schizophrenia group to report less positive affect. To compare the two schizophrenia sub-groups, these data were analyzed with a series of 1 × 3 mixed ANOVAs, with the between subjects variable of schizophrenia response (high, low) and the within subjects variable of neutral video (Time 1, Time 2 or 1 Whilst this conversion is more controversial as applied to atypical antipsychotics (see; Taylor et al., 2003), it is nevertheless useful for assessing broad trends across patient groups. Humberstone et al.'s (2003) guidelines provided conversion equivalents for all drugs taken by participants in the present study, with the exception of amisulpride and aripiprazole, for which The Maudsley 2003 Prescribing Guidelines (Taylor et al., 2003) were used to calculate CPZe, based on the minimum recommended doses of these drugs. Thus, since a minimum dose of 200 mg for chlorpromazine, 400 mg for amisulpride, and 15 mg of aripiprazole is recommended, a conversion ratio of 1:2 and 1:.075 was used for these drugs, respectively.
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Table 2 Baseline characteristics of the healthy control (HC) and schizophrenia (SCZ) participants who were high or low responders to the amusing videoclips Characteristic
Low responders HC group (n = 4) M
Age (years) Education (years) Gender (% male) Age at SCZ onset (years) Duration of SCZ (years) Primary diagnosis (%) Schizophrenia Schizoaffective disorder SAPS Total Hallucinations Delusions Bizarre behavior Positive FTD SANS Total Affective blunting Alogia Avolition Anhedonia Attention Medications (% receiving) a Clozapine Olanzapine Risperidone Quetiapine Amisupride Aripiprazole CPZ equivalents (mg) Cognitive functioning WASI Total Vocabulary Block design Similarities Matrices
High responders SCZ group (n = 12)
SD 8.19 1.60
M
HC group (n = 26) SD
SCZ group (n = 17)
M
SD
34.6 13.7 54 – –
10.35 2.28 – –
32.6 13.1 53 21.2 10.9
– –
– –
76.5 23.5
4.67 1.99 1.88 1.17 1.16
– – – – –
– – – – –
5.8 2.0 2.3 0.7 0.8
4.19 2.00 1.69 1.05 1.35
3.90 1.38 1.31 1.80 1.44 1.17
– – – – – –
– – – – – –
7.3 1.7 0.8 1.9 2.0 0.9
4.66 1.31 1.30 1.20 1.58 1.11
67 0 17 8 25 17 393.5
228.69
– – – – – – –
– – – – – – –
76 18 12 0 24 12 398.1
268.30
86.3 41.0 42.1 42.3 42.3
6.43 8.30 7.19 8.48 7.09
105.0 52.2 54.5 50.5 53.9
11.70 8.02 8.73 6.06 10.86
89.7 40.0 47.6 41.1 45.9
15.86 11.04 11.20 9.89 12.11
35.5 12.4 50 – –
– –
36.7 12.0 33 21.9 14.7
– –
– –
83.3 16.7
– – – – –
– – – – –
5.6 1.8 2.5 0.6 0.7
– – – – – –
– – – – – –
8.1 1.9 1.1 1.8 2.7 0.6
– – – – – – –
– – – – – – –
103.8 54.8 54.5 53.0 45.5
10.87 12.55 11.24 5.86 5.45
11.1 1.56 4.34 10.54 – –
M
SD 7.64 2.85 4.00 7.82 – –
Note: SANS refers to The Scale for the Assessment of Negative Symptoms; SAPS refers to The Scale for the Assessment of Positive Symptoms. WASI refers to the Wechsler's Abbreviated Scale of Intelligence. a Many of the schizophrenia participants were receiving more than one medication. In particular, approximately one third of the participants who were taking olanzapine, clozapine or risperidone were also taking either amisulpride or aripiprazole.
Time 3). For self-reported negative affect, behaviorally rated negative affect and behaviorally rated positive affect, these analyses indicated that none of the main effects or interactions were significant (all ps N .05). However, for self-rated positive affect, whilst the main effect of neutral video time, and interaction between video time and group did not attain significance (both ps N .05), there was a significant main effect of group, F(1, 27) = 8.52, p = .007. Thus, the participants with schizophrenia who were categorized as low responders based on their affective responses to the amusing
videoclips, also report less positive affect in response to the neutral videoclips. 3.1. Emotion regulation analyses Since, as noted previously, an essential prerequisite for inclusion in the emotion regulation analyses was that each participant find the target film clips amusing all “low-response” participants were excluded from analyses relating to the emotion regulation manipulation. The “high-response” participants with schizophrenia (n = 17)
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Table 3 Self-rated and behaviorally rated positive and negative to the neutral video clips Schizophrenia group Control group (n = 30)
Negative emotions Neutral clip 1 Neutral clip 2 Neutral clip 3
Positive emotions Neutral clip 1 Neutral clip 2 Neutral clip 3
High responders (n = 17)
Low responders (n = 12)
M
SD
M
SD
M
SD
Self-rating Behavioral Self-rating Behavioral Self-rating Behavioral
0.1 0.9 0.1 1.0 0.1 1.1
0.19 0.81 0.21 0.78 0.21 0.92
0.5 1.0 0.5 0.9 0.1 0.9
0.60 0.80 0.91 0.75 0.23 0.78
0.1 1.2 0.1 1.1 0.1 1.1
0.13 0.75 0.28 0.86 0.25 0.70
Self-rating Behavioral Self-rating Behavioral Self-rating Behavioral
3.7 1.7 3.4 1.9 3.3 1.6
1.41 1.19 1.64 1.13 1.56 1.21
3.0 1.1 3.5 1.5 3.1 1.5
1.72 1.41 1.49 1.41 1.33 1.35
1.5 1.0 1.8 1.1 1.8 0.5
1.86 0.99 2.26 1.77 1.54 0.99
Note: The trends shown in this table are unchanged if the four “low-response” participants are omitted from the control group.
indicated that, for both groups, behavioral expression of emotion was significantly reduced during the suppression condition (t = 4.99, df = 25, p b .001 for controls; t = 2.75, df = 16, p = .014 for individuals with schizophrenia). However, whilst for the control group the comparison of behavioral expression during the amplification condition relative to behavioral expression during the expression condition attained significance (t = 2.13, df = 25, p = .043), this was not true for the schizophrenia group (t = 0.13, df = 16, p = .897). Finally, correlations between clinical ratings of psychopathology and CPZe, with behavioral ratings of expressed amusement in the three experimental conditions are reported in Table 5. It can be seen that CPZe was not significantly related to behavioral ratings of amusement. Whilst amount of emotion expressed during the amplification condition was significantly correlated with the total SANS score, emotional blunting was the
and healthy controls (n = 26) who contributed to the emotion regulation analyses did not differ significantly with regard to age, education or gender (all ps N .05), but did differ significantly with regard to overall cognitive functioning (t = 3.05, df = 41, p = .004). Table 4 summarizes mean levels of self-rated and behaviorally rated amusement for these schizophrenia and control participants for each of the three conditions. It can be seen that for all three conditions, the two groups do not differ with regard to self-rated amusement. Whilst behavioral expression of emotion is lower for the schizophrenia group across all three conditions, it is only for the amplification condition that this difference attains significance. Within-group comparisons focused on comparing behavioral expression of amusement during each of the regulation conditions with behavioral expression of amusement during the baseline (expression) condition
Table 4 Between-group analyses focused on self- and behavioral-ratings for levels of amusement across the three conditions for the high responders Control group (n = 26)
Expression Suppression Amplification
Self-rating Behavioral Self-rating Behavioral Self-rating Behavioral
SCZ group (n = 17)
Inferential statistics
Effect size
M
SD
M
SD
t
df
p
d
6.0 4.0 5.6 2.2 5.3 4.7
1.37 1.93 2.44 2.16 1.67 1.40
6.1 3.6 5.8 1.8 4.8 3.5
2.28 2.31 1.98 1.85 2.72 2.15
0.04 0.59 0.35 0.69 0.73 2.19
41 41 41 41 41 41
.971 .560 .729 .496 .473 .035
0.01 0.18 0.10 0.22 0.23 0.69
Note: SCZ refers to schizophrenia. Cohen (1988) defines effect sizes of 0.2 as small, 0.5 as medium, and 0.8 as large).
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Table 5 Correlations between behavioral ratings of expressivity in the three regulation conditions with psychopathology ratings and chlorpromazine equivalents (CPZe) for the high-responders with schizophrenia (n = 17) Condition
SAPS
SAPS
Total Hallucinations Delusions Bizarre behavior Expression .18 Suppression .15 Amplification .45
.16 −.17 .55⁎
.40 .12 .27
−.32 .20 .07
CPZe
Positive FTD
Total
Affective blunting
.07 .19 .19
−.21 −.26 −.17 −.32 −.50⁎ −.49⁎
Alogia Avolition Anhedonia Attention −.09 −.30 −.47⁎
−.04 .14 −.04
−.06 .01 −.32
−.35 −.17 −.46
−.23 .04 .14
⁎P b 0.05. Note; SAPS refers to the Scale for the Assessment of Positive Symptoms; SANS refers to the Scale for the Assessment of Negative Symptoms; FTD refers to Formal Thought Disorder.
single strongest contributor to this relationship (r = −.49; p b .05). 4. Discussion The present results indicated that both schizophrenia and control participants were able to effectively implement the strategy of suppression. In contrast, during the amplification condition, only control (but not schizophrenia) 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 (expression) condition, participants with schizophrenia (like controls) showed evidence of effective suppression of emotion expressive behavior. However, for the amplification condition effective upregulation of emotion expressive behavior was only observed for the control group. The subjective experience of affect did not differ for either of the emotion regulation conditions, or during the baseline expression condition, and thus the group differences identified cannot be attributed to differences in the intensity of emotion experienced. These findings are therefore consistent with the proposal that the disjunction between the experience and expression of affect associated with schizophrenia may reflect a specific deficit upregulating emotion expressive behavior (Kring and Werner, 2004). Consistent with this possibility, behavioral expression in the amplification condition was significantly correlated with degree of emotional blunting. As noted previously, blunted affect is present in the majority of patients with schizophrenia, exhibits longitudinal stability and is predictive of poor prognosis (Berenbaum and Oltmanns, 1992; Gur et al., 2006). These findings provide the first empirical evidence for emotion dysregulation as a potential mechanism underpinning emotional blunting, and highlight the need for further research to clarify the nature of emotion regulation disturbances in schizophrenia.
Nevertheless, it is important to note several potential limitations to the interpretation of these data. Firstly, interpretation of results from the between-group analyses is limited by the fact that the difference between the two groups for the amplification condition only just attained significance, and multiple comparisons were made without correction for an inflated Type I error rate. Thus, although the magnitude of this between-group effect size was moderate to large, and was entirely consistent with the results of the within-group analyses, the robustness of these findings remains to be demonstrated. Additionally, although schizophrenia and control groups were equated for subjectively experienced affect for the emotion regulation analyses, this was only achieved by excluding all participants who did not find the film clips at least ‘somewhat’ amusing. An important caveat arising from this process is that the omission of “low-response” schizophrenia participants may have resulted in the exclusion of schizophrenia patients with potentially the most severe emotion regulation difficulties. Indeed, these patients reported lower levels of positive affect even in response to neutral video clips, relative to their “high-response” counterparts, and inspection of the mean ratings on individuals SANS items suggests that this group may be more impaired in their capacity to experience pleasure generally (see SANS Anhedonia item, Table 2). However, we also note that the “low-response” sub-group did not differ from “high-response” patients with respect to clinical ratings of blunted affect, which was found to be associated with deficits amplifying behavioral expressions of amusement in schizophrenia patients, in this study. It is therefore unfortunate that the methodological design of this study precluded the analysis of the “low responding” schizophrenia patients, since these patients clearly demonstrate an aberrant experience of affect that may also reflect emotion regulatory dysfunction. Future research should therefore employ alternative strategies to examine emotion regulatory processes in chronic ‘low emotional responding’ schizophrenia patients.
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Finally, whilst the present results provide the first evidence that capacity to amplify positive emotion expressive behavior may be disrupted in schizophrenia, Gross and Levenson (1997) suggest 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 ability of schizophrenia patients to regulate negative emotions, particularly since the dysregulation of worry processes and anxiety may be pertinent to the formation of delusional symptoms (Freeman and Garety, 1999). Additionally, in the present study only behavioralexpressive emotion regulation was investigated. Whilst this form of emotion regulation has particular importance for schizophrenia given that blunted affect is a core feature of the disorder, future research should also examine the modulation of other aspects of emotional responses (such as physiological arousal), and the capacity of schizophrenia patients to implement cognitively-focused emotion regulation strategies (e.g., cognitive reframing or reappraisal). Role of the Funding Source Funding for this study was provided by an Australia Research Council grant awarded to Henry and McDonald (DP0663182). The Australian Research Council had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. Contributors Julie Henry designed the study, conducted the statistical analyses and wrote the first draft of the manuscript. Melissa Green assisted with conceptual issues related to the study design, and also made a substantial contribution in writing the manuscript. Amber de Lucia and Corinne Restuccia recruited participants and conducted the experimental testing. Skye McDonald assisted with conceptual issues related to the study design. Maryanne O'Donnell assisted with participant recruitment. All authors contributed to and have approved the final manuscript. Conflict of Interest There are no actual or potential conflicts of interests with respect to the authors' involvement in this manuscript. Acknowledgement The authors acknowledge the Research Register of the Schizophrenia Research Institute, Australia, for assisting with the recruitment of the volunteers participating in this research, as well as the participants themselves.
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