Effects of Training of Affect Recognition on the recognition and visual exploration of emotional faces in schizophrenia

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Abstract

Background

Schizophrenia patients have impairments in facial affect recognition and display scanpath abnormalities during the visual exploration of faces. These abnormalities are characterized by fewer fixations on salient feature areas and longer fixation durations. The present study investigated whether social–cognitive remediation not only improves performance in facial affect recognition but also normalizes patients' gaze behavior while looking at faces.

Methods

Within a 2 × 2-design (group × time), 16 schizophrenia patients and 16 healthy controls performed a facial affect recognition task with concomitant infrared oculography at baseline (T0) and after six weeks (T1). Between the measurements, patients completed the Training of Affect Recognition (TAR) program. The influence of the training on facial affect recognition (percent of correct answers) and gaze behavior (number and mean duration of fixations into salient or non-salient facial areas) was assessed.

Results

In line with former studies, at baseline patients showed poorer facial affect recognition than controls and aberrant scanpaths, and after TAR facial affect recognition was improved. Concomitant with improvements in performance, the number of fixations in feature areas (‘mouth’) increased while fixations in non-feature areas (‘white space’) decreased. However, the change in fixation behavior did not correlate with the improvement in performance.

Conclusions

After TAR, patients pay more attention to facial areas that contain information about a displayed emotion. Although this may contribute to the improved performance, the lack of a statistical correlation implies that this factor is not sufficient to explain the underlying mechanism of the treatment effect.

Introduction

Impairments in facial affect recognition are one of the most often replicated neuropsychological findings in schizophrenia (Trémeau, 2006, Morris et al., 2009, Kohler et al., 2010) and have been identified as a significant factor contributing to poor social and community functioning (Lee et al., 2004, Couture et al., 2006, Pinkham et al., 2008). Deficits in facial affect recognition occur in first and multi-episode schizophrenia (Edwards et al., 2001, Addington et al., 2006) and are already present in individuals at clinical high risk for psychosis (Addington et al., 2008, Amminger et al., 2012a, Amminger et al., 2012b, Wölwer et al., 2012) and in healthy relatives of schizophrenia patients (Kee et al., 2004, Bediou et al., 2007, Eack et al., 2010). For this reason, an involvement of impaired facial affect recognition as a vulnerability factor (Bediou et al., 2007) or putative endophenotype (Gur et al., 2007) in the etiopathogenesis of schizophrenia is discussed.

A better understanding of the underlying neurocognitive abnormalities is necessary in order to generate adequate treatment strategies or improve already existing approaches that focus on impaired facial affect recognition (Wölwer et al., 2010). The analysis of visual scanpaths (patterns of eye movements and foveal fixations) provides an objective, real-time behavioral correlate of neurocognitive strategies that individuals employ while viewing face stimuli (Manor et al., 1999, Williams et al., 1999). In general, people scan the salient regions of a face (i.e. eyes, nose, and mouth) in an inverted triangular pattern (Groner et al., 1984). Patients diagnosed with schizophrenia and other psychotic disorders show abnormalities in the visual exploration of faces (and other stimuli) characterized by fewer fixations of longer average durations and a tendency to avoid salient facial features (Streit et al., 1997, Williams et al., 1999, Loughland et al., 2002b, Green et al., 2003, Bestelmeyer et al., 2006, Benson et al., 2007, Lee et al., 2010), for review see Toh et al. (2011). Because of the stability of these atypical scanpaths in schizophrenia patients, their role as a potential trait marker was already discussed by several authors (Loughland et al., 2002a, Loughland et al., 2004, Marsh and Williams, 2006, Beedie et al., 2011).

Despite the apparent relationship between scanpath abnormalities on the one hand and deficits in facial affect recognition on the other, whether and how these characteristics relate to each other remains unresolved, since only a few studies have investigated both in the same paradigm (Rosse et al., 1998, Schwartz et al., 1999, Loughland et al., 2004, Campbell et al., 2010). One way of investigating the relationship between divergent gaze patterns and impaired facial affect recognition in schizophrenia is to enhance performance with social–cognitive remediation programs that specifically target the correct decoding of facial emotions (Penn and Combs, 2000, Silver and Oakes, 2001, Frommann et al., 2003) and to assess concomitant changes in the visual exploration of facial stimuli. This approach would also help to uncover the mechanisms of change of such interventions.

In a study by Russell et al. (2008), after patients had been successfully trained with the computer-based Micro-Expression Training Tool (METT) they showed an overall increase in visual attention towards facial feature areas (i.e. eyes, nose, and mouth), i.e. improvements in facial affect recognition were associated with an increase in the number of fixations and the time spent viewing these feature areas. Nevertheless, correlations between accuracy and gaze parameters were only significant before the training, not afterwards. Since these were the first findings on the influence of a targeted social–cognitive remediation program on the visual exploration of faces in schizophrenia patients, the present study aimed to add evidence to this field by using a different kind of training program that is based on more implicit strategies rather than the explicit attention shaping processes applied in the METT. We investigated the impact of the six-week Training of Affect Recognition (TAR) (Frommann et al., 2003) on gaze behavior in schizophrenia patients by means of concurrent measurements of performance and visual exploration before (baseline T0) and after (T1) the training. A non-treated healthy control group was assessed twice within six weeks as well. We expected significant interactions between the factors ‘group’ and ‘time’ regarding (1) the performance in facial affect recognition and (2) the number and average duration of fixations in non-salient ‘white space’ and facial feature areas.

Section snippets

Design

A 2 × 2 design comprised the quasi-experimental between-subjects factor ‘group’ (schizophrenia patients vs. healthy controls) and the within-subjects factor ‘time’ (measurement at baseline T0 and after six weeks T1). The dependent variables were performance in the affect recognition task (percent of correct answers) and the number and mean duration of fixations in white space and the relevant feature areas. The study was approved by the ethics committee of the University of Düsseldorf and

Affect recognition performance

Analyses of the performance data calculated over all seven emotional states revealed significant main effects for the factors ‘group’ (F(1,30) = 10.470, p = .003) and ‘time’ (F(1,30) = 13.571, p < .001), as well as a significant ‘group’ × ‘time’ interaction of F(1,30) = 6.353, p = .017. Patients at T1 performed significantly better than they did themselves at T0 (T(1,15) =  3.497, p = .003) and before TAR, healthy controls performed significantly better in affect recognition than patients (T(1,30) = 3.938, p < .001)

Discussion

In order to gain deeper insights into the mechanisms of effect of social cognitive remediation focused on facial affect recognition impairments, the present study investigated the influence of the TAR (Frommann et al., 2003, Wölwer et al., 2005) on the abnormal gaze strategies in schizophrenia patients. These gaze strategies have proven to be stable characteristics in the course of the disorder (Streit et al., 1997, Beedie et al., 2011, Toh et al., 2011). In line with the literature (Wölwer et

Conclusion

The present study supports the hypothesis that a targeted and successful training of facial affect recognition via implicit attention shaping also leads to a change in the visual exploration of faces in schizophrenia. The missing correlation between the investigated parameters implies that the application of a certain exploration strategy is not the only factor that contributes to good facial affect recognition. Other factors, such as a change in early attentional processes, certainly play a

Role of funding source

The project Training of Affect Recognition (TAR): Remediation of impairments in facial affect recognition and its psychophysiological correlates in schizophrenia was funded (grant number 9772459) by the Commission for Research of the Medical Faculty of the Heinrich Heine University Düsseldorf.

Contributors

Authors Stroth and Wölwer designed the study and wrote the protocol. Authors Stroth and Drusch conducted the measurements before and after the Training of Affect Recognition, which was developed by the authors Frommann and Wölwer. Author Drusch undertook the statistical analysis and wrote the first draft of the manuscript, which was revised by the authors Wölwer, Stroth and Kamp. All authors contributed to and have approved the final manuscript.

Conflict of interest

All authors declare that they have no conflicts of interest.

Acknowledgments

The authors thank Agnes Lowe for her successful participation in the training; Jacquie Klesing, Board-certified Editor in the Life Sciences (ELS), for the editing assistance with the manuscript; and Heike Sievering, Nathalie Raths, and Clarissa Schmitz for their support in data collection and analysis. Special thanks go to Petra Pitters for her valuable work during the whole study procedure.

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