Patients with Stable Schizophrenia Struggle to Recognize Negative Facial Emotions

A recent study showed that individuals in a stable phase of schizophrenia tend to be more likely to have a deficit in facial emotion recognition than healthy individuals.1

“Negative emotions were found to have a worse impact in comparison to positive emotions, with happiness emotions being the least impacted,” wrote investigators, led by Shaily Mina, MD, from the department of psychiatry at VMMC and Safdarjung Hospital, in India.

Facial emotion recognition plays a significant role in social interactions, and a deficit in recognizing facial emotions can impair an individual’s judgment toward others. Many studies have examined the deficit in facial emotion recognition among patients with schizophrenia.2 In a cross-sectional study, investigators sought to assess the facial emotion recognition deficits in individuals with schizophrenia compared with healthy individuals.1 They also aimed to evaluate the association between deficits in facial emotion recognition and clinical and demographic profiles.

The study included participants aged 18 – 50 years with a schizophrenia diagnosis based on the DSM-5. Participants were clinically stable, defined as item scores of ≤ 3 in each category of the Positive and Negative Syndrome Scale (PANSS), and on a stable medication dose for ≥ 6 weeks if on oral treatment or 12 weeks if on injections. Moreover, participants had schizophrenia for ≥ 1 year (mean duration: 84 months) with no hospitalization or electroconvulsive therapy received in the previous 12 weeks.

The mean age of illness onset was 31.70 ± 7.12 years among patients with schizophrenia. Approximately 83.3% of participants had a continuous course of illness and 16.7% had an episodic course. Most (83.3%) had no medical comorbidity, although 16.7% had hypothyroidism and type 2 diabetes.

Among individuals with schizophrenia, 96.7% did not report any positive symptoms, 20% reported negative symptoms (reduced social interaction), and 36.7% reported cognitive symptoms (forgetfulness). The mean PANSS total score was 32.20 ± 1.40, with scores of 7.47 ± 0.86 for the positive symptom dimension, 7.70 ± 1.17 for the negative symptom dimension, and 17.03 ± 0.80 for general psychopathology dimension. All participants with schizophrenia were on monotherapy, either olanzapine (n = 8), risperidone (n = 16), lurasidone (n = 1), clozapine (n = 2), aripiprazole (n = 2), or cariprazine (n = 1).

Investigators compared participants with schizophrenia (n = 30; mean age: 39.30 ± 5.39 years) with age, gender, and education-matched healthy controls (n = 30; mean age: 39.30 ± 5.19 years) who were recruited from an outpatient clinic and screened for the absence of any psychiatric illness. Most participants were male (57%), belonged to a Hindu nuclear family, and were from an urban community. Participants were excluded from either group if they had a comorbid substance use disorder (excluding nicotine and caffeine) within the last year, a history of neurological disease, any uncontrolled medical condition, any significant visual or hearing impairment, or intellectual disability.

The research took place at a tertiary care hospital in North India from September 2023 to March 2024. Assessments included the Addenbrooke’s Cognitive Examination (ACE-III), All India Institute of Medical Sciences (AIIMS) Facial Toolbox for Emotion Recognition (AFTER), the Positive and Negative Syndrome Scale (PANSS), and Medication Adherence Rating Scale (MARS).

The schizophrenia arm performed significantly worse than healthy controls at identifying positive and negative emotions, excluding happiness for which both arms got 100% recognition:

• Sadness (60.83 vs 96.66%; P < .001)
• Disgust (30% vs 67.5%; P < .001)
• Fear (59.17% vs 94.14%; P < .001)
• Surprise (37.5% vs 67.5%; P = .001)
• Anger (70% vs 87.5%; P = .02)
• Contempt (12.5% vs 28.33%; P = .01)
• Neutral (40.83% vs 57.5%)

Individuals with schizophrenia also took significantly longer to recognize emotion than the controls. Additionally, females with schizophrenia took longer to recognize disgust (disgust recognition time: t = 3.21, df = 25.35; P = .004, mean difference [MD], 8.94; 95% CI, 14.68–3.20) and sadness (t = 1.95, df = 28, P = .03; MD, 2.48; 95% CI, 5.08–0.11) than males. No other gender differences were observed in either the schizophrenia or healthy arms.

Investigators saw anger recognition negatively correlated with PANSS positive symptoms, total scores, and ACE-III fluency. Disgust recognition positively correlated with PANSS negative symptoms but negatively with general psychopathology. Surprise recognition negatively correlated with PANSS total scores.

“We found a mild correlation of negative emotions (anger, disgust, and surprise) to PANSS scores that could indicate that psychopathology and severity of the disorder might have some role in the identification of facial emotions even in the stable phase of illness with more impact of severity of illness on negative emotions,” investigators wrote.

References

1. Mina S, Chaudhary S. Facial Emotion Recognition Ability in Individuals with Remitted Schizophrenia in Comparison to Healthy Population: A Cross-Sectional Study. Indian J Psychol Med. 2025 Jan 2:02537176241299371. doi: 10.1177/02537176241299371. Epub ahead of print. PMID: 39759442; PMCID: PMC11694268.
2. Gao Z, Zhao W, Liu S, Liu Z, Yang C, Xu Y. Facial Emotion Recognition in Schizophrenia. Front Psychiatry. 2021 May 4;12:633717. doi: 10.3389/fpsyt.2021.633717. PMID: 34017272; PMCID: PMC8129182.