اختلال در نظم احساسات در اسکیزوفرنی:تشدید کاهش یافته ابراز هیجانی با بلانت عاطفی

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.

Introduction Abnormalities in the experience, expression, and recognition of affect are well documented in schizophrenia (Aleman and Kahn, 2005 and 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 abnormalities is evident clinically as blunted affect, characterized by markedly reduced emotional expressivity, alongside apparently normal emotional experiences (Berenbaum and Oltmanns, 1992 and 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). 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 and 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.

3. Results Self-report amusement data are presented in Table 1. Data related to self-report in the experimental conditions 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 > .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 > .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 > .05). Table 1. Means and SDs for self-ratings of amusement across the different experimental conditions Control group SCZ group (n = 30) (n = 29) M SD M SD Amusing clips Expression 5.7 1.76 4.3 3.20 Suppression 5.1 2.77 4.2 2.80 Amplification 4.7 2.22 3.5 2.91 Neutral clips Time 1 2.2 1.93 1.4 1.72 Time 2 1.9 1.94 1.5 2.11 Time 3 1.9 2.15 1.0 1.94 Note: SCZ refers to schizophrenia. The rating scale ranges from 0 (not at all/none) to 8 (extremely/a great deal). Table options 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 < .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 > .05). 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 High responders HC group SCZ group HC group SCZ group (n = 4) (n = 12) (n = 26) (n = 17) M SD M SD M SD M SD Age (years) 35.5 8.19 36.7 11.1 34.6 10.35 32.6 7.64 Education (years) 12.4 1.60 12.0 1.56 13.7 2.28 13.1 2.85 Gender (% male) 50 33 54 53 Age at SCZ onset (years) – – 21.9 4.34 – – 21.2 4.00 Duration of SCZ (years) – – 14.7 10.54 – – 10.9 7.82 Primary diagnosis (%) Schizophrenia – – 83.3 – – – 76.5 – Schizoaffective disorder – – 16.7 – – – 23.5 – SAPS Total – – 5.6 4.67 – – 5.8 4.19 Hallucinations – – 1.8 1.99 – – 2.0 2.00 Delusions – – 2.5 1.88 – – 2.3 1.69 Bizarre behavior – – 0.6 1.17 – – 0.7 1.05 Positive FTD – – 0.7 1.16 – – 0.8 1.35 SANS Total – – 8.1 3.90 – – 7.3 4.66 Affective blunting – – 1.9 1.38 – – 1.7 1.31 Alogia – – 1.1 1.31 – – 0.8 1.30 Avolition – – 1.8 1.80 – – 1.9 1.20 Anhedonia – – 2.7 1.44 – – 2.0 1.58 Attention – – 0.6 1.17 – – 0.9 1.11 Medications (% receiving)a Clozapine – – 67 – – 76 Olanzapine – – 0 – – 18 Risperidone – – 17 – – 12 Quetiapine – – 8 – – 0 Amisupride – – 25 – – 24 Aripiprazole – – 17 – – 12 CPZ equivalents (mg) – – 393.5 228.69 – – 398.1 268.30 Cognitive functioning WASI Total 103.8 10.87 86.3 6.43 105.0 11.70 89.7 15.86 Vocabulary 54.8 12.55 41.0 8.30 52.2 8.02 40.0 11.04 Block design 54.5 11.24 42.1 7.19 54.5 8.73 47.6 11.20 Similarities 53.0 5.86 42.3 8.48 50.5 6.06 41.1 9.89 Matrices 45.5 5.45 42.3 7.09 53.9 10.86 45.9 12.11 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. Table options 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 “low-response” 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 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 > .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 > .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. Table 3. Self-rated and behaviorally rated positive and negative to the neutral video clips Schizophrenia group Control group High responders Low responders (n = 30) (n = 17) (n = 12) M SD M SD M SD Negative emotions Neutral clip 1 Self-rating 0.1 0.19 0.5 0.60 0.1 0.13 Behavioral 0.9 0.81 1.0 0.80 1.2 0.75 Neutral clip 2 Self-rating 0.1 0.21 0.5 0.91 0.1 0.28 Behavioral 1.0 0.78 0.9 0.75 1.1 0.86 Neutral clip 3 Self-rating 0.1 0.21 0.1 0.23 0.1 0.25 Behavioral 1.1 0.92 0.9 0.78 1.1 0.70 Positive emotions Neutral clip 1 Self-rating 3.7 1.41 3.0 1.72 1.5 1.86 Behavioral 1.7 1.19 1.1 1.41 1.0 0.99 Neutral clip 2 Self-rating 3.4 1.64 3.5 1.49 1.8 2.26 Behavioral 1.9 1.13 1.5 1.41 1.1 1.77 Neutral clip 3 Self-rating 3.3 1.56 3.1 1.33 1.8 1.54 Behavioral 1.6 1.21 1.5 1.35 0.5 0.99 Note: The trends shown in this table are unchanged if the four “low-response” participants are omitted from the control group. Table options 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) 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 > .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. 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 SCZ group Inferential statistics Effect size (n = 26) (n = 17) M SD M SD t df p d Expression Self-rating 6.0 1.37 6.1 2.28 0.04 41 .971 0.01 Behavioral 4.0 1.93 3.6 2.31 0.59 41 .560 0.18 Suppression Self-rating 5.6 2.44 5.8 1.98 0.35 41 .729 0.10 Behavioral 2.2 2.16 1.8 1.85 0.69 41 .496 0.22 Amplification Self-rating 5.3 1.67 4.8 2.72 0.73 41 .473 0.23 Behavioral 4.7 1.40 3.5 2.15 2.19 41 .035 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). Table options 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 indicated that, for both groups, behavioral expression of emotion was significantly reduced during the suppression condition (t = 4.99, df = 25, p < .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 single strongest contributor to this relationship (r = −.49; p < .05). 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 CPZe Total Hallucinations Delusions Bizarre behavior Positive FTD Total Affective blunting Alogia Avolition Anhedonia Attention Expression .18 .16 .40 −.32 .07 −.21 −.26 −.09 −.04 −.06 −.35 −.23 Suppression .15 −.17 .12 .20 .19 −.17 −.32 −.30 .14 .01 −.17 .04 Amplification .45 .55⁎ .27 .07 .19 −.50⁎ −.49⁎ −.47⁎ −.04 −.32 −.46 .14 ⁎P < 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.