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Schizophr Bull. Sep 2010; 36(5): 1009–1019.
Published online Mar 27, 2009. doi:  10.1093/schbul/sbn192
PMCID: PMC2930336
Facial Emotion Perception in Schizophrenia: A Meta-analytic Review
Christian G. Kohler,1,2 Jeffrey B. Walker,2 Elizabeth A. Martin,2 Kristin M. Healey,2 and Paul J. Moberg2
2Schizophrenia Research Center, Department of Psychiatry; University of Pennsylvania School of Medicine, Philadelphia, PA
1To whom correspondence should be addressed; Neuropsychiatry Section, Department of Psychiatry, 10th Floor, Gates Building, University of Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104; tel: 215-614-0161, fax: 215-662-7903, e-mail: kohler/at/upenn.edu.
Objectives: A considerable body of literature has reported on emotion perception deficits and the relevance to clinical symptoms and social functioning in schizophrenia. Studies published between 1970–2007 were examined regarding emotion perception abilities between patient and control groups and potential methodological, demographic, and clinical moderators. Data Sources and Review: Eighty-six studies were identified through a computerized literature search of the MEDLINE, PsychINFO, and PubMed databases. A quality of reporting of meta-analysis standard was followed in the extraction of relevant studies and data. Data on emotion perception, methodology, demographic and clinical characteristics, and antipsychotic medication status were compiled and analyzed using Comprehensive Meta-analysis Version 2.0 (Borenstein M, Hedges L, Higgins J and Rothstein H. Comprehensive Meta-analysis. 2. Englewood, NJ: Biostat; 2005). Results: The meta-analysis revealed a large deficit in emotion perception in schizophrenia, irrespective of task type, and several factors that moderated the observed impairment. Illness-related factors included current hospitalization and—in part—clinical symptoms and antipsychotic treatment. Demographic factors included patient age and gender in controls but not race. Conclusion: Emotion perception impairment in schizophrenia represents a robust finding in schizophrenia that appears to be moderated by certain clinical and demographic factors. Future directions for research on emotion perception are discussed.
Keywords: schizophrenia, meta-analysis, emotion perception
Although most efforts to examine behavioral deficits in schizophrenia have focused on neurocognition, the past 25 years have seen a growing literature on emotion perception deficits in schizophrenia (reviews by Edwards et al,1 Mandal et al,2 and Morrison et al3) and in the larger domain of social cognition,4,5 which is defined as the ability to process and apply social information. Recognition of facial expressions of emotions is instrumental constituent of nonverbal communication, and several studies in schizophrenia have underscored that emotion perception abilities are related to social competence610 and predict later work functioning and independent living.11 In addition, emotion perception is more affected in schizophrenia compared with psychiatric control groups, such as mood disorders.1214
Reviews of early studies3 showed that results were limited by small sample sizes consisting of mostly inpatients with prolonged hospitalizations and the use of diverse nonstandardized stimuli. Study designs improved considerably in the 1990s1,2 with employment of standardized tasks, exclusion criteria, and inclusion of in- and outpatient groups that with respect to demographic and clinical characteristics are more representative of schizophrenia. The qualitative review by Edwards et al1 of studies published prior to 2000 details the need to attend to numerous demographic, task, and illness-related variables that can interfere with accurate emotion perception. Among others, duration of illness, negative symptoms, medication levels, outpatient vs inpatient status, stage of illness, and schizophrenia subtypes were identified as potential and unexamined variables that contribute to emotion perception impairment and warrant further attention.
In general, task designs within emotion perception studies can be separated into those that focus on identification of specific emotions and those that differentiate between intensities of emotion expressions. Identification tasks rely on choosing a qualitative label, usually from a limited number of choices, to the picture of a facial expression. Differentiation tasks require judgment regarding differences in emotion expressions—typically of 2 visual stimuli—without necessary identification of the emotion. Numerous studies have employed both identification and differentiation tasks, based on the possibility that the different tasks yield differential impairment. While early investigations included nonstandardized emotional stimuli, many subsequent studies employed face stimuli developed by Ekman and Friesen15 or Gur et al.16 The black and white stimuli created by Ekman and Friesen15 consist of posed facial expressions of universally recognized emotions, including happiness, sadness, anger, fear, disgust, and surprise. Pictures are of mostly middle-aged Caucasian posers, with more recent inclusion of Asian but not African American or Hispanic posers. The stimuli of Gur et al16 include color faces expressing happy, sad, angry, fearful, and disgusted emotions in posed and evoked conditions, across adult age groups and different ethnicities. Very few studies have failed to elucidate emotion impairment in schizophrenia, and the argument has been made that methodology and task design, rather than emotion perception abilities, may account for group differences seen.17
Most9,1822, but not all,17,23 cross-sectional studies have shown an association between illness severity, positive and negative symptoms of schizophrenia, and emotion perception abilities that may be further medicated by chronicity of illness.8 Potentially, the issue between clinical parameters and perception abilities can be more decisively investigated in a longitudinal design. Several studies12,2426 with short-term follow-up in acutely ill patients have revealed that standard treatment, including antipsychotics, and resultant response do not appreciably improve performance on emotion perception suggesting a trait-like deficit. On the other hand, specific application of emotion remediation has been found to be beneficial.27
While the vast majority of studies on facial emotion perception establish the existence of impairment in schizophrenia, potential factors related to task design and sample characteristics that may influence published findings remain to be better understood. We conducted a comprehensive meta-analysis of the existing studies on emotion perception in schizophrenia with the aim to quantify the magnitude of deficit seen in facial emotion perception and to identify variables that may moderate the impairment in schizophrenia. Specifically, the selection of variables was based on (1) the majority of facial emotion perception studies being based on tasks of emotion identification or differentiation, (2) findings in the existing literature that implicate certain clinical variables, ie, symptoms, hospitalization status, and illness duration with emotion perception abilities, (3) findings in the existing literature that implicate certain demographic variables, ie, age, gender, ethnicity, with emotion perception abilities, and (4) adequate representation of the potential variables within the extant literature to allow for meaningful comparisons.
Because most studies that employed tasks that measured emotion identification or differentiation reported on emotion perception in general, we did not anticipate finding a differential effect related to task. The lack of test design affecting performance may indicate that although the task types may overlap with different aspects of cognition, emotion identification and differentiation tasks tap the general domain of facial emotion perception to a similar extent.
We examined relatedness for clinical factors, in particular diagnosis of schizophrenia vs inclusion of schizoaffective disorder, hospitalization status, duration of illness, and clinical symptoms, and we anticipated that emotion perception deficits in schizophrenia show association with characteristic clinical symptoms but are not clearly related to diagnosis, stabilization of psychosis, or to deterioration with prolonged duration of illness. Similarly, based on the limited effect of antipsychotics on cognition, we did not expect the meta-analysis to reveal clear effects associated with antipsychotic treatment, ie, related to being on antipsychotic and type and dosage.
Studies that have described demographic factors associated with emotion perception were performed on large sample sizes. In healthy controls, subtle effects of age, gender, and race have been associated with perception ability.2831 Considering group characteristics that commonly included age ranges between 18 and 65 years, male predominance, and limited inclusion of participants with different ethnicities, we were not confident to find a clear association between emotion perception and demographics between and within groups. Nevertheless, investigation of demographic characteristics may prove informative in elucidating that the effect of the clinical condition on emotion perception outweighs demographic influences.
Search Strategy
Studies were identified through a computerized literature search of the MEDLINE, PsychINFO, and PubMed databases from 1970 through August 2007 using the keywords “emotion, affect -perception, -recognition, -identification, -differentiation, -discrimination, social cognition, - perception, and schizophrenia and schizoaffective disorder.” In addition, a thorough manual search was performed using cross-references from original articles and reviews. The search was limited to English language publications and studies of humans only. For further consideration, articles included information about performance measures and relevant statistical information that permitted application of meta-analytical procedures.
Data Extraction
Eligible studies focused on formal tests of facial emotion identification and emotion differentiation in patients with schizophrenia and healthy participants. Facial emotion identification tasks were defined as tests that required ascribing a qualitative label, usually from a limited number of choices, to the picture of a facial expression. Facial emotion differentiation tasks required judgment regarding differences in emotion expressions without necessary identification of the emotion. A quality of reporting of meta-analysis standard32 was followed in the extraction of relevant studies and data. Potential studies were initially reviewed for possible inclusion by 3 authors (C.G.K., E.A.M., J.B.W.) based on the aforementioned criteria. Relevant data for meta-analytic analysis, including statistical values on differences in emotion perception, and information on task type (emotion identification or differentiation), clinical characteristics (diagnosis, inpatient status, age at onset, duration, number of hospitalizations, clinical symptoms), antipsychotics (medication status and type and dosage), and demographic characteristics (age, gender, education, race of participant) were subsequently extracted and tabulated independently by 2 authors (J.B.W. and P.J.M.). Disagreements were resolved by discussion and consensus.
Statistical Analyses
Comprehensive Meta-analysis Version 2.033 was used for the analysis. The mean difference in scores between studies reporting contrasts of schizophrenia patients and healthy controls on measures of facial emotion identification or differentiation was standardized by calculating Cohen d, the difference between the 2 raw means divided by the pooled SD. In order to control for study differences in sample size when mean effect sizes were computed, studies were weighted according to their inverse variance estimates. Effect sizes are typically categorized as small (d = 0.2), medium (d = 0.5), or large (d ≥ 0.8) based on these methods.34 In order to determine whether mean effect sizes were statistically significant, the CI and z transformation of the effect size were used. The Cochran Q statistic was utilized to assess homogeneity of the effect sizes across studies for each facial emotion domain.35 The significance level of the mean effect sizes was computed using fixed-effects linear models except when the Q statistic revealed significant within-group heterogeneity, in which case a random-effects model was used. The pooled estimates by the random-effects model did not differ significantly from those obtained by the fixed-effects model. The presented results are according to the latter. Possible effect size moderators were examined in those domains with significant heterogeneity, based on the Q statistic and meta-regression techniques. Cohen d values are provided for categorical moderating variables and are based on group comparisons but not for continuous moderating variables, where Cohen d values are based on unit of measure comparisons (ie, Scheduled Assessment of Positive Symptoms [SAPS] scores, % gender, etc) and do not yield information that can be easily interpreted. Analysis of facial emotion perception differences was performed including all eligible studies. Publication bias was assessed graphically using a funnel plot and mathematically using an adjusted rank correlation test, according to the methods of Begg and Mazumdar36 and Egger et al.37 Further analysis included comparison of studies grouped by task design and those reporting on relevant demographic and clinical characteristics and antipsychotic status.
Search Results
Out of 91 articles examined in detail, 53 articles totaling 86 studies were identified that reported the results of comparative studies of facial emotion identification and differentiation6,8,9,12,1923,26,3880 employing photographic images of emotion expressions. Thirty-eight articles were excluded for reasons of lack of control groups (N = 13),11,18,8191 lack of data or statistics that precluded meta-analysis (N = 11),13,92101 and tests that included ratings for friendliness/pleasantness or evaluation of video scenes (N = 8)3,17,102107 because these tasks did not necessarily focus on perception of facial emotions and other reasons (N = 6).9,27,108111
Overall Meta-analysis Results
Analysis of facial identification and differentiation impairment collapsed across the entire sample revealed a large overall effect size (N = 3822, d = −0.91, 95% CI = −0.97 < δ < −0.84) that was significantly heterogeneous (QB[76] = 295.7, P < .001). Evidence of publication bias was observed, as indicated by an asymmetric funnel plot and a significant Begg test (P = .005, 1 tailed) and Egger test (P = .003, 1 tailed). In light of this finding, we calculated a fail-safe N, which revealed that 9538 “null” studies would have to be located and included in order to nullify the observed effect. Effect sizes for the individual studies included in the meta-analysis are illustrated in figure 1. To further probe the variability among effect sizes, we proceeded to analyze psychometric, clinical, and demographic variables that might explain this heterogeneity.
Fig. 1.
Fig. 1.
Individual Effect Sizes (Cohen d and 95% CIs) for Emotion Perception Studies.
Task Type
Examination of experimental tasks used to probe facial emotion perception revealed that all tasks could be broken down into tests tapping the domains of facial emotion identification or differentiation. Comparisons of effect sizes for studies examining facial affect identification (N = 59 studies, d = −0.89, 95% CI = −1.05 < δ < −0.75) and differentiation (N = 27 studies, d = −1.09, 95% CI = −1.29 < δ < −0.89) revealed large performance deficits that did not differ significantly from each other (QB[33] = 2.46, P = .117) (figure 2). For the remainder of the analyses, the 2 test domains were collapsed into a single variable and are collectively referred to as “facial emotion perception.”
Fig. 2.
Fig. 2.
Effect Sizes (Cohen d and 95% CI) for Facial Emotion Identification and Differentiation Deficits.
Clinical Characteristics
Diagnosis
Studies were either comprised of a sole diagnosis of schizophrenia or a mix of patients with schizophrenia and schizoaffective disorder. Effect sizes for the schizophrenia diagnosis (N = 71 studies, d = −0.98, 95% CI = −1.12 < δ < −0.85) and the mixed diagnoses (N = 15 studies (d = −0.85, 95% CI = −1.09 < δ < −0.61) were very large and did not differ significantly from each other (QB[33] = 0.90, P = .34). Although of interest, there were too few studies (N = 2)38,47 examining first-episode patients to allow for meaningful comparisons.
Inpatient/Outpatient Status
Patient samples ranged from inclusion of inpatients (N = 38 studies) and outpatients (N = 26 studies) to mixed groups (N = 8 studies). Analysis of facial emotion perception deficits for the 3 status classifications revealed significant heterogeneity of effect sizes (QB[1] = 19.65, P < .001) (figure 3). Post hoc analysis revealed that inpatients (d = −1.20, 95% CI = −1.30 < δ < −1.10) were more impaired than both outpatients (d = −0.70, 95% CI = −0.80 < δ < −0.60) (QB[33] = 16.01, P < .001) and the mixed group (d = −0.58, 95% CI = −0.76 < δ < −0.39) (QB[33] = 10.57, P < .01) but did not indicate a difference between outpatients and the mixed group (QB[33] = 0.37, P = .55).
Fig. 3.
Fig. 3.
Effect Sizes (Cohen d and 95% CI) for Facial Emotion Perception Deficits in Schizophrenia Patients by Study Setting (ie, Inpatients, Outpatients, and Mixed).
Age of Onset/Duration
Schizophrenia patients varied throughout the sample with regard to their age at onset and the duration of illness. The age of onset (N = 16 studies, mean ± SD = 23.3 ± 1.68) was shown to significantly moderate effect sizes, relating a later age of onset to greater impairment (Z = −2.79, P = .006). In contrast, duration of illness (N = 43 studies, mean years ± SD = 10.3 ± 4.34) was not significantly associated with effect size on tasks of emotion perception (Z = 0.42, P = .67).
Hospitalizations
The total number of past and present hospitalizations of the patients (N = 26 studies) did not appear to have a significant impact on obtained effect sizes (Z = −1.54, P = .12).
Clinical Characteristics
For clinical symptom assessment, results were mixed and based on the instruments employed. Studies that employed the Scheduled Assessment of Negative Symptoms (SANS112) and SAPS113 analysis revealed significant relationships between facial emotion perception effect sizes and SANS scores (N = 20 studies, Z = −4.13, P < .001) as well as SAPS scores (N = 18 studies, Z = −4.48, P < .001), relating higher levels of negative or positive symptoms to greater deficit in the ability to perceive facial affect. However, heterogeneity could not be explained by positive (N = 16 studies, Z = 1.03, P = .30), negative (N = 16 studies, Z = −1.44, P = .15), or overall symptom scores (N = 11 studies, Z = −1.27, P = .20), as measured by the Positive and Negative Syndrome Scale.114 Finally, measurements of general psychopathology obtained by the Brief Psychiatric Rating Scale (BPRS115) revealed a significant relationship with effect sizes (Z = −3.08, P = .002), but the latter finding is tentative due to limited BPRS data (N = 6 studies).
Antipsychotics
Medication Status
In order to assess possible influences of antipsychotics on the observed effect sizes, studies were classified as including (1) medicated (N = 57 studies), (2) unmedicated (N = 2 studies), or (3) mixed (medicated and unmedicated) (N = 20 studies) samples. Homogeneity analysis revealed significant variability among effect sizes (QB[1] = 11.76, P < .01); unmedicated patients (d = −0.141, 95% CI = −0.9 < δ < −0.18) were the most impaired, followed by medicated patients (d = −1.00, 95% CI = −1.10 < δ < −0.86), and then the mixed group (d = −0.73, 95% CI = −0.89 < δ < −0.58) (figure 4). Post hoc contrasts revealed that medicated patients did not differ from unmedicated patients (QB[33] = 3.02, P = .082). The mixed group was significantly less impaired than both the medicated (QB[33] = 6.17, P < .05) and the unmedicated patients (QB[33] = 8.35, P < .01). It should be noted, however, that data for unmedicated patients consisted of only 2 studies; thus, analysis involving this moderator variable classification should be considered tentative.
Fig. 4.
Fig. 4.
Effect Sizes (Cohen d and 95% CI) for Facial Emotion Perception Deficits in Schizophrenia Patients by Medication Status (ie, Medicated, Unmedicated, and Mixed).
Medication Type
Medicated patients were further subdivided into those using first-generation antipsychotics (FGAs) (N = 25 studies) or second-generation antipsychotics (SGAs) (N = 7 studies) and mixed groups (N = 22 studies). Effect sizes for these 3 groups were found to be heterogeneous (QB[1] = 9.35, P < .01). Post hoc contrasts revealed that FGA groups (d = −1.10, 95% CI = −1.30 < δ < −0.91) showed greater impairment in facial emotion perception relative to SGA groups (d = −0.63, 95% CI = −0.87 < δ < −0.38) (QB[33] = 9.00, P < .01) and mixed groups (d = −0.82, 95% CI = −1.00 < δ < −0.62) (QB[33] = 4.12, P < .05). Contrasts between patients on SGA and mixed groups, however, were not significant (QB[33] = 2.64, P = .10) (figure 5).
Fig. 5.
Fig. 5.
Effect Sizes (Cohen d and 95% CI) for Facial Emotion Perception Deficits in Schizophrenia Patients by Type of Antipsychotic Medication (ie, First Generation, Second Generation, and Mixed).
Chlorpromazine Equivalents
To further probe the effect of antipsychotics on facial emotion perception, we analyzed the relationship between effect sizes and chlorpromazine equivalents (N = 47 studies) and found a marginal, but nonsignificant, relationship between higher chlorpromazine dosage and greater degree of impairment on tests of facial emotion perception (Z = −1.67, P = .10).
Demographic Characteristics
Age
Both the average age of controls (N = 81 studies) and the average age of patients were examined (N = 84 studies). Analysis revealed a strong relationship between greater age in both patients (Z = −5.25, P < .001) and healthy controls (Z = −2.98, P < .01) and facial emotion perception impairment.
Gender
The effect of gender was analyzed by comparing both the percentages of male controls (N = 80 studies) and male patients (N = 81 studies) to effect sizes. The percentage of male controls showed a relationship with effect sizes (Z = 3.53, P < .001), indicating that samples with more male controls were related to less impairment in facial emotion perception in schizophrenia. However, the percentage of male patients did not appear to moderate effect sizes in schizophrenia (Z = 1.58, P = .11).
Education
We then sought to determine if education had an impact on facial emotion perception. Analysis showed that education levels of controls (N = 66 studies) were not significantly related to effect sizes (Z = −0.44, P = .66). Similarly, analyses of education levels of the patient group (N = 66 studies) revealed no significant association between this moderator and effect size (Z = 1.62, P = .10).
Race
The last demographic variable investigated was race, identified by the percentage of Caucasians within control (N = 48 studies) and patient groups (N = 53 studies). Effect sizes were moderated by the percentage of Caucasian controls at a trend level (Z = −1.90, P = .058). In contrast, no relationship between the percentage of Caucasian patients and effect size was seen (Z = −1.01, P = .31).
Over the past 25 years, a considerable body of literature has established the presence of emotion perception impairment in schizophrenia that affects quality of life and psychosocial functioning. Generalizability of the findings has been limited by the diversity of tasks employed and diversity in clinical and demographic characteristics of patient groups. While emotion perception impairment in schizophrenia has been well documented, it is questionable whether a differential deficit116 can be demonstrated against the more general impairment in facial processing.9,19,23,39,47,53,69,117 Among other reasons, impaired emotion perception may be related to the tendency of persons with schizophrenia to visually scan features of the face that are not important in the expression of a particular emotion, as has been shown with computerized procedures.62,118
As anticipated, the results of the current meta-analysis, which spanned the literature from 1970–2007 and included 86 studies, revealed a large deficit in emotion perception in patients with schizophrenia relative to healthy participants (ie, d = −0.91, 95% CI = −0.97 < δ < −0.84). The effect size of emotion perception impairment was significantly heterogeneous indicating the presence of methodological, illness-related, and demographic factors that moderate the severity of impairment seen in schizophrenia groups, specifically including hospitalization status, age at onset, negative and positive symptoms, medication status, and current age. Results of this meta-analysis can be grouped into findings that—given the existing literature and posted hypotheses—were expected, indeterminate findings that did not clearly confirm our hypotheses, and unexpected findings that ran counter to our hypotheses. Expected findings were those related to overall impairment, methodology, diagnostic status, and demographics of age, gender, race, and education. On the basis of most studies reporting on emotion perception impairment in schizophrenia, the overall effect size confirmed these results and was measured as large. In general, emotion perception tasks can be separated into those that rely on identification or differentiation. Identification tasks are based on choosing a qualitative label with greater reliance on language and semantic skills, while differentiation tasks require judgment regarding differences in emotion expressions and may be more dependent on visual analysis and spatial skills. Our results support that emotion identification and differentiation are independent of “top-down” mechanisms and have limited relationship to neurocognitive aspects of the tasks.
Examining clinical characteristics revealed no effect for diagnosis of schizophrenia compared with schizoaffective disorder in line with current assumptions that the 2 disorders are not viewed as distinct with respect to symptoms, outcome, and cognition. Several demographic characteristics influenced the findings, including age in patients and controls and race and gender in controls. Increased age of patients and controls was associated with greater impairment in support of age-related decline in emotion perception abilities.30 Male gender in controls lessened the impairment found in patient groups, but male gender in patients did not moderate group differences. Evidence exists that men may have more difficulties in emotion perception31 compared with women. Within the meta-analysis, the gender-related finding remained isolated to controls, and the effect of illness in patients may supersede any gender-related differences. The effect of race on emotion perception abilities has received considerable attention, and while it has been proposed that universal emotions are equally recognized across ethnic groups, recent studies support an own-race bias28 that may be moderated by mood states.29 In this meta-analysis, race of participants was summarized as Caucasian and non-Caucasian, and a potential moderating effect on emotion perception was limited to a trend level of race in controls. In the majority of studies, race of emotion perception stimuli was not described or included Caucasian subjects only, limiting statistical power to confirm a possible own-race effect. Reports that specifically investigated this issue in healthy persons found an advantage for emotion perception in own-race faces28 that is moderated by familiarity,119 and this finding has been extended to schizophrenia.83,120,121 Lastly, level of education failed to significantly moderate emotion perception findings. Because education can be viewed as a proxy measure of general cognition, the lack of association supports that neurocognition and social cognition represent largely independent functions.
Indeterminate findings included those involving measures of illness severity and antipsychotic treatment, while the finding for age at onset was unexpected. Previous longitudinal studies that lasted between weeks to 1 year showed lack of emotion perception improvement in acutely ill patients12,25,26 and indicated the potential unrelatedness of emotion perception abilities and clinical status in schizophrenia, similar to what has been shown for neurocognition.122 Within the meta-analysis, clinical moderators that indicate illness severity, including being hospitalized at the time of testing and some clinical symptom measurements, but not duration of illness, showed adverse effects on emotion perception abilities. Clinical symptoms were only characterized in about half of the studies, and some, but not all, measurements of negative, positive, and general symptoms were related to emotion perception abilities. Recent investigations on schizophrenia subtypes reported on paranoid patients to be highly accurate in recognition of genuine rather than posed emotion expressions123 or less impaired than other subtypes.110 Unfortunately, clinical descriptors within the published studies on static images did not allow further investigation of this relationship.
The results of examining effects of antipsychotics on emotion perception were limited by the small sample size of unmedicated patients who were most impaired. However, the notion of untreated illness exerting effects on emotion perception was not supported by comparison of studies that included mixed samples and medicated samples, where medicated samples performed worse. Within the medicated sample, patients on FGA were more impaired than patients on SGA. The literature on possible effects of antipsychotics on cognition in persons with acute and chronic schizophrenia remains in evolution but may indicate a greater beneficial effect124 associated with SGAs compared with FGAs.
The single unexpected effect involved the association between later age at onset and greater emotion perception impairment, which is contrary to our understanding about the association between onset of illness with clinical symptoms and cognition. It must be noted that limitations involving meta-analytic procedures include the descriptive nature of the analysis and the inability to more fully examine directional mechanisms underlying results. It is therefore quite possible that studies reporting on groups with later onset of illness differed in another measure that itself related to worse emotion perception abilities. This mechanism may also play a role in the indeterminate findings regarding clinical symptoms and antipsychotics.
In conclusion, to our knowledge, this is the first comprehensive meta-analysis examining facial emotion perception in schizophrenia and the moderating effects of illness-related and demographic factors. Further investigations may clarify the association of emotion perception with clinical aspects of schizophrenia, including the relationship between specific illness-related characteristics, such as first episode and subtype, on performance; emotion perception changes as the result of treatment and stabilization beyond acute psychosis, and emotion perception as a possible endophenotype related to genetic risk125,126 and emergence of psychosis.127
Funding
National Institute of Mental Health (MH01839 to C.G.K.).
Acknowledgments
We have no financial or conflict of interest to disclose.
1. Edwards J, Jackson HJ, Pattison PE. Emotion recognition via facial expression and affective prosody in schizophrenia: a methodological review. Clin Psychol Rev. 2002;22:789–832. [PubMed]
2. Mandal MK, Pandey R, Prasad AB. Facial expressions of emotions and schizophrenia: a review. Schizophr Bull. 1998;24:399–412. [PubMed]
3. Morrison RL, Bellack AS, Bashore TR. Perception of emotion among schizophrenic patients. J Psychopathol Behav Assess. 1988;10:319–332.
4. Couture SM, Penn DL, Roberts DL. The functional significance of social cognition in schizophrenia: a review. Schizophr Bull. 2006;32:S44–S63. [PMC free article] [PubMed]
5. Penn DL, Corrigan PW, Bentall RP, Racenstein JM, Newman L. Social cognition in schizophrenia. Psychol Bull. 1997;121:114–132. [PubMed]
6. Hooker C, Park S. Emotion processing and its relationship to social functioning in schizophrenia patients. Psychiatry Res. 2002;112:41–50. [PubMed]
7. Ihnen GH, Penn DL, Corrigan PW, Martin J. Social perception and social skill in schizophrenia. Psychiatry Res. 1998;80:275–286. [PubMed]
8. Mueser KT, Doonan R, Penn DL, et al. Emotion recognition and social competence in chronic schizophrenia. J Abnorm Psychol. 1996;105:271–275. [PubMed]
9. Penn DL, Combs DR, Ritchie M, et al. Emotion recognition in schizophrenia: further investigation of generalized versus specific deficit models. J Abnorm Psychol. 2000;109:512–516. [PubMed]
10. Vauth R, Rüsch N, Wirtz M, Corrigan PW. Does social cognition influence the relation between neurocognitive deficits and vocational functioning in schizophrenia? Psychiatry Res. 2004;128:155–165. [PubMed]
11. Kee KS, Green MF, Mintz JM, Brekke JS. Is emotion processing a predictor of functional outcome in schizophrenia? Schizophr Bull. 2003;29:487–497. [PubMed]
12. Addington J, Addington D. Facial affect recognition and information processing in schizophrenia and bipolar disorder. Schizophr Res. 1998;32:171–181. [PubMed]
13. Gaebel W, Wolwer W. Facial expression and emotional face recognition in schizophrenia and depression. Eur Arch Psychiatry Clin Neurosci. 1992;242:46–52. [PubMed]
14. Mikhailova ES, Vladimirova TV, Iznack AF, Tsusulkovskaya EJ, Sushko NV. Abnormal recognition of facial expression of emotions in depressed patients with major depression disorder and schizotypal personality disorder. Biol Psychiatry. 1996;40:697–705. [PubMed]
15. Ekman P, Friesen WV. Manual of the Facial Action Coding System (FACS) Palo Alto, Calif: Consulting Psychologists Press; 1978.
16. Gur RC, Sara R, Hagendoorn M, et al. A method for obtaining 3-dimensional facial expressions and its standardization for use in neurocognitive studies. J Neurosci Methods. 2002;115:137–143. [PubMed]
17. Bellack AS, Blanchard JJ, Mueser KT. Cue availability and affect perception in schizophrenia. Schizophr Bull. 1996;22:535–544. [PubMed]
18. Bryson G, Bell M, Lysaker P. Affect recognition in schizophrenia: a function of global impairment or a specific cognitive deficit. Psychiatry Res. 1997;71:105–113. [PubMed]
19. Kohler CG, Bilker W, Hagendoorn M, Gur RE, Gur RC. Emotion recognition deficit in schizophrenia: association with symptomatology and cognition. Biol Psychiatry. 2000;48:127–136. [PubMed]
20. Kohler CG, Turner TH, Bilker WB, et al. Facial emotion recognition in schizophrenia: intensity effects and error pattern. Am J Psychiatry. 2003;160:1768–1774. [PubMed]
21. Mandal MK, Jain A, Haque-Nizamie S, Weiss U, Schneider F. Generality and specificity of emotion-recognition deficit in schizophrenic patients with positive and negative symptoms. Psychiatry Res. 1999;87:39–46. [PubMed]
22. Schneider F, Gur RC, Gur RE, Shtasel DL. Emotional processing in schizophrenia: neurobehavioral probes in relation to psychopathology. Schizophr Res. 1995;17:67–75. [PubMed]
23. Salem JE, Kring AM, Kerr SL. More evidence for generalized poor performance in facial emotion perception in schizophrenia. J Abnorm Psychol. 1996;105:480–483. [PubMed]
24. Harvey PD, Patterson TL, Potter LS, Zhong K, Brecher M. Improvement in social competence with short-term atypical antipsychotic treatment: a randomized, double-blind comparison of quetiapine verus risperidone for social competence, social cognition, and neuropsychological functioning. Am J Psychiatry. 2006;163:1918–1925. [PubMed]
25. Herbener ES, Hill SK, Marvin RW, Sweeney JA. Effects of antipsychotic treatment on emotion perception deficits in first-episode schizophrenia. Am J Psychiatry. 2005;162:1746–1748. [PubMed]
26. Wolwer W, Streit M, Polzer U, Gaebel W. Facial affect recognition in the course of schizophrenia. Eur Arch Psychiatry Clin Neurosci. 1996;246:165–170. [PubMed]
27. Wolwer W, Frommann N, Halfmann S, Piaszek A, Streit M, Gaebel W. Remediation of impairments in facial affect recognition in schizophrenia: efficacy and specificity of a new training program. Schizophr Res. 2005;80:295–303. [PubMed]
28. Elfenbein HA, Ambady N. On the universality and cultural specificity of emotion recognition: a meta-analysis. Psychol Bull. 2002;128:203–235. [PubMed]
29. Johnson KJ, Frederickson BL. “We all look the same to me”: positive emotions eliminate own-race in face recognition. Psychol Sci. 2005;16:875–881. [PMC free article] [PubMed]
30. McDowell CL, Harrison DW, Demaree HA. Is the right hemisphere decline in the perception of emotion a function of aging? Int J Neurosci. 1994;79:1–11. [PubMed]
31. Merten J. Culture, gender, and the recognition of the basic emotions. Psychologia. 2005;48:306–316.
32. Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses. Lancet. 1999;354:1896–1900. [PubMed]
33. Borenstein M, Hedges L, Higgins J, Rothstein H, editors. Comprehensive Meta-analysis. 2. Englewood, NJ: Biostat; 2005.
34. Cohen J. Statistical Power Analysis for the Behavioral Sciences. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.
35. Hedges LV, Olkin I. Statistical Methods for Meta-Analysis. New York, NY: Academic Press; 1985.
36. Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994;50:1088–1101. [PubMed]
37. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315:629–634. [PMC free article] [PubMed]
38. Addington J, Saeedi H, Addington D. Facial affect recognition: a mediator between cognitive and social functioning in psychosis? Schizophr Res. 2006;85:142–150. [PubMed]
39. Archer J, Hay DC, Young AW. Movement, face processing and schizophrenia: evidence of a differential deficit in expression analysis. Br J Clin Psychol. 1994;33(pt 4):517–528. [PubMed]
40. Bediou B, Franck N, Saoud M, et al. Effects of emotion and identity on facial affect processing in schizophrenia. Psychiatry Res. 2005;133:149–157. [PubMed]
41. Bigelow NO, Paradiso S, Adolphs R, et al. Perception of socially relevant stimuli in schizophrenia. Schizophr Res. 2006;83:257–267. [PubMed]
42. Bolte S, Poustka F. The recognition of facial affect in autistic and schizophrenic subjects and their first-degree relatives. Psychol Med. 2003;33:907–915. [PubMed]
43. Borod JC, Martin CC, Alpert M, Brozgold A, Welkowitz J. Perception of facial emotion in schizophrenic and right brain-damaged patients. J Nerv Ment Dis. 1993;181:494–502. [PubMed]
44. Brune M. Emotion recognition, ‘theory of mind,’ and social behavior in schizophrenia. Psychiatry Res. 2005;133:135–147. [PubMed]
45. Burch JW. Typicality range deficit in schizophrenics’ recognition of emotion in faces. J Clin Psychol. 1995;51:140–152. [PubMed]
46. Chambon V, Baudouin JY, Franck N. The role of configural information in facial emotion recognition in schizophrenia. Neuropsychologia. 2006;44:2437–2444. [PubMed]
47. Edwards J, Pattison PE, Jackson HJ, Wales RJ. Facial affect and affective prosody recognition in first-episode schizophrenia. Schizophr Res. 2001;48:235–253. [PubMed]
48. Feinberg TE, Rifkin A, Schaffer C, Walker E. Facial discrimination and emotional recognition in schizophrenia and affective disorders. Arch Gen Psychiatry. 1986;43:276–279. [PubMed]
49. Habel U, Krasenbrink I, Bowi U, Ott G, Schneider F. A special role of negative emotion in children and adolescents with schizophrenia and other psychoses. Psychiatry Res. 2006;145:9–19. [PubMed]
50. Hall J, Harris JM, Sprengelmeyer R, et al. Social cognition and face processing in schizophrenia. Br J Psychiatry. 2004;185:169–170. [PubMed]
51. Heimberg C, Gur RE, Erwin RJ, Shtasel DL, Gur RC. Facial emotion discrimination: III. Behavioral findings in schizophrenia. Psychiatry Res. 1992;42:253–265. [PubMed]
52. Johnston PJ, Devir H, Karayanidis F. Facial emotion processing in schizophrenia: no evidence for a deficit specific to negative emotions in a differential deficit design. Psychiatry Res. 2006;143:51–61. [PubMed]
53. Kerr SL, Neale JM. Emotion perception in schizophrenia: specific deficit or further evidence of generalized poor performance? J Abnorm Psychol. 1993;102:312–318. [PubMed]
54. Kline JS, Smith JE, Ellis HC. Paranoid and nonparanoid schizophrenic processing of facially displayed affect. J Psychiatr Res. 1992;26:169–182. [PubMed]
55. Kosmidis MH, Bozikas VP, Giannakou M, Anezoulaki D, Fantie BD, Karavatos A. Impaired emotion perception in schizophrenia: a differential deficit. Psychiatry Res. 2007;149:279–284. [PubMed]
56. Kubota Y, Querel C, Pelion F, et al. Facial affect recognition in pre-lingually deaf people with schizophrenia. Schizophr Res. 2003;61:265–270. [PubMed]
57. Kucharska-Pietura K, David AS, Masiak M, Phillips ML. Perception of facial and vocal affect by people with schizophrenia in early and late stages of illness. Br J Psychiatry. 2005;187:523–528. [PubMed]
58. Leentjens AF, Wielaert SM, van Harskamp F, Wilmink FW. Disturbances of affective prosody in patients with schizophrenia; a cross sectional study. J Neurol Neurosurg Psychiatry. 1998;64:375–378. [PMC free article] [PubMed]
59. Leitman DI, Foxe JJ, Butler PD, Saperstein A, Revheim N, Javitt DC. Sensory contributions to impaired prosodic processing in schizophrenia. Biol Psychiatry. 2005;58:56–61. [PubMed]
60. Leppanen JM, Niehaus DJ, Koen L, Du Toit E, Schoeman R, Emsley R. Emotional face processing deficit in schizophrenia: a replication study in a South African Xhosa population. Schizophr Res. 2006;84:323–330. [PubMed]
61. Lewis SF, Garver DL. Treatment and diagnostic subtype in facial affect recognition in schizophrenia. J Psychiatr Res. 1994;29:5–11. [PubMed]
62. Loughland CM, Williams LM, Gordon E. Visual scanpaths to positive and negative facial emotions in an outpatient schizophrenia sample. Schizophr Res. 2002;55:159–170. [PubMed]
63. Loughland CM, Williams LM, Harris AW. Visual scanpath dysfunction in first-degree relatives of schizophrenia probands: evidence for a vulnerability marker? Schizophr Res. 2004;67:11–21. [PubMed]
64. Mandal MK. Decoding of facial emotions, in terms of expressiveness, by schizophrenics and depressives. Psychiatry. 1987;50:371–376. [PubMed]
65. Mandal MK, Gewali H. Identification of brief presentations of facial expressions of affect in schizophrenics. Int J Psychol. 1989;24:605–616. [PubMed]
66. Mandal MK, Palchoudhury S. Identifying the components of facial emotion and schizophrenia. Psychopathology. 1989;22:295–300. [PubMed]
67. Martin F, Baudouin JY, Tiberghien G, Franck N. Processing emotional expression and facial identity in schizophrenia. Psychiatry Res. 2005;134:43–53. [PubMed]
68. Muzekari LH, Bates ME. Judgment of emotion among chronic schizophrenics. J Clin Psychol. 1977;33:662–666. [PubMed]
69. Novic J, Luchins DJ, Perline R. Facial affect recognition in schizophrenia. Is there a differential deficit? Br J Psychiatry. 1984;144:533–537. [PubMed]
70. Sachs G, Steger-Wuchse D, Kryspin-Exner I, Gur RC, Katschnig H. Facial recognition deficits and cognition in schizophrenia. Schizophr Res. 2004;68:27–35. [PubMed]
71. Schneider F, Gur RC, Koch K, et al. Impairment in the specificity of emotion processing in schizophrenia. Am J Psychiatry. 2006;163:442–447. [PubMed]
72. Scholten MR, Aleman A, Montagne B, Kahn RS. Schizophrenia and processing of facial emotions: sex matters. Schizophr Res. 2005;78:61–67. [PubMed]
73. Streit M, Ioannides A, Sinnemann T, et al. Disturbed facial affect recognition in patients with schizophrenia associated with hypoactivity in distributed brain regions: a magnetoencephalographic study. Am J Psychiatry. 2001;158:1429–1436. [PubMed]
74. Tomlinson EK, Jones CA, Johnston RA, Meaden A, Wink B. Facial emotion recognition from moving and static point-light images in schizophrenia. Schizophr Res. 2006;85:96–105. [PubMed]
75. Turetsky BI, Kohler CG, Indersmitten T, Bhati MT, Charbonnier D, Gur RC. Facial emotion recognition in schizophrenia: when and why does it go awry? Schizophr Res. 2007;94:253–263. [PMC free article] [PubMed]
76. Van't Wout M, Aleman A, Kessels RP, Cahn W, de Haan EH, Kahn RS. Exploring the nature of facial affect processing deficits in schizophrenia. Psychiatry Res. 2007;150:227–235. [PubMed]
77. Walker E, Marwit SJ, Emory E. A cross-sectional study of emotion recognition in schizophrenics. J Abnorm Psychol. 1980;89:428–436. [PubMed]
78. Walker E, McGuire M, Bettes B. Recognition and identification of facial stimuli by schizophrenics and patients with affective disorders. Br J Clin Psychol. 1984;23(pt 1):37–44. [PubMed]
79. Weniger G, Lange C, Ruther E, Irle E. Differential impairments of facial affect recognition in schizophrenia subtypes and major depression. Psychiatry Res. 2004;128:135–146. [PubMed]
80. Williams LM, Loughland CM, Green MJ, Harris AW, Gordon E. Emotion perception in schizophrenia: an eye movement study comparing the effectiveness of risperidone vs. haloperidol. Psychiatry Res. 2003;120:13–27. [PubMed]
81. Bell M, Bryson G, Greig T, Corcoran C, Wexler BE. Neurocognitive enhancement therapy with work therapy: effects on neuropsychological test performance. Arch Gen Psychiatry. 2001;58:763–768. [PubMed]
82. Bozikas VP, Kosmidis MH, Anezoulaki D, Giannakou M, Karavatos A. Relationship of affect recognition with psychopathology and cognitive performance in schizophrenia. J Int Neuropsychol Soc. 2004;10:549–558. [PubMed]
83. Brekke JS, Nakagami E, Kee KS, Green MF. Cross-ethnic differences in perception of emotion in schizophrenia. Schizophr Res. 2005;77:289–298. [PubMed]
84. Bryson G, Bell M, Kaplan E, Greig T, Lysaker P. Affect recognition in deficit syndrome schizophrenia. Psychiatry Res. 1998;77:113–120. [PubMed]
85. Combs DR, Gouvier WD. The role of attention in affect perception: an examination of Mirsky's four factor model of attention in chronic schizophrenia. Schizophr Bull. 2004;30:727–738. [PubMed]
86. Fiszdon JM, Richardson R, Greig T, Bell MD. A comparison of basic and social cognition between schizophrenia and schizoaffective disorder. Schizophr Res. 2007;91:117–121. [PubMed]
87. Fullam R, Dolan M. Emotional information processing in violent patients with schizophrenia: association with psychopathy and symptomatology. Psychiatry Res. 2006;141:29–37. [PubMed]
88. Kee KS, Kern RS, Green MF. Perception of emotion and neurocognitive functioning in schizophrenia: what's the link? Psychiatry Res. 1998;81:57–65. [PubMed]
89. Penn DL, Spaulding W, Reed D, Sullivan M. The relationship of social cognition to ward behavior in chronic schizophrenia. Schizophr Res. 1996;20:327–335. [PubMed]
90. Silver H, Shlomo N, Turner TH, Gur RC. Perception of happy and sad facial expressions in chronic schizophrenia: evidence for two evaluative systems. Schizophr Res. 2002;55:171–177. [PubMed]
91. Weiss EM, Kohler CG, Brensinger CM, et al. Gender differences in facial emotion recognition in persons with chronic schizophrenia. Eur Psychiatry. 2007;22:116–122. [PubMed]
92. Baudouin JY, Martin F, Tiberghien G, Verlut I, Franck N. Selective attention to facial emotion and identity in schizophrenia. Neuropsychologia. 2002;40:503–511. [PubMed]
93. Borod JC, Alpert M, Brozgold A, et al. A preliminary comparison of flat affect schizophrenics and brain-damaged patients on measures of affective processing. J Commun Disord. 1989;22:93–104. [PubMed]
94. Gessler S, Cutting JC, Frith CD, Weinman J. Schizophrenic inability to judge facial emotion: a controlled study. Br J Clin Psychol. 1989;28:19–29. [PubMed]
95. Hermann MJ, Reif A, Jabs BE, Jacob C, Fallgatter AJ. Facial affect decoding in schizophrenic disorders: a study using event-related potentials. Psychiatry Res. 2006;141:247–252. [PubMed]
96. Johnston PJ, Stojanov W, Devir H, Schall U. Functional MRI of facial emotion recognition deficits in schizophrenia and their electrophysiological correlates. Eur J Neurosci. 2005;22:1221–1232. [PubMed]
97. Joseph PL, Sturgeon DA, Leff J. The perception of emotion by schizophrenic patients. Br J Psychiatry. 1992;161:603–609. [PubMed]
98. Kee KS, Horan WP, Wynn JK, Mintz JM, Green MF. An analysis of categorical perception of facial emotion in schizophrenia. Schizophr Res. 2006;87:228–237. [PubMed]
99. Loughland CM, Williams LM, Gordon E. Schizophrenia and affective disorder show different visual scanning behavior for faces: a trait versus state-based distinction? Biol Psychiatry. 2002;52:338–348. [PubMed]
100. Shaw RJ, Dong M, Lim KO, Faustam WO, Pouget ER, Alpert M. The relationship between affect expression and affect recognition in schizophrenia. Schizophr Res. 1999;37:245–250. [PubMed]
101. Streit M, Wolwer W, Gaebel W. Facial-affect recognition and visual scanning behaviour in the course of schizophrenia. Schizophr Res. 1997;24:311–317. [PubMed]
102. Bell M, Bryson G, Lysaker P. Positive and negative affect recognition in schizophrenia: a comparison with substance abuse and normal control subjects. Psychiatry Res. 1997;73:73–82. [PubMed]
103. Bellack AS, Mueser KT, Wade J, Sayers S, Morrison RL. The ability of schizophrenics to perceive and cope with negative affect. Br J Psychiatry. 1992;160:473–480. [PubMed]
104. Cramer P, Weegmann M, O'Neil M. Schizophrenia and the perception of emotions. How accurately do schizophrenics judge the emotional states of others. Br J Psychiatry. 1989;155:225–228. [PubMed]
105. Cutting JC. Judgement of emotional expression in schizophrenics. Br J Psychiatry. 1981;139:1–6. [PubMed]
106. Lysaker P, Wickett AM, Lancaster RS, Davis LW. Neurocognitive deficits and history of childhood abuse in schizophrenia spectrum disorders: associations with Cluster B personality traits. Schizophr Res. 2004;68:87–94. [PubMed]
107. Nienow TM, Docherty NM, Cohen AS, Dinzeo TJ. Attentional dysfunction, social perception, and social competence: what is the nature of the relationship? J Abnorm Psychol. 2006;115:408–417. [PubMed]
108. Frommann N, Streit M, Wolwer W. Remediation of facial affect recognition impairments in patients with schizophrenia: a new training program. Psychiatry Res. 2003;117:281–284. [PubMed]
109. Johnston PJ, McCabe K, Schall U. Differential susceptibility to performance degradation across categories of facial emotion–a model confirmation. Biol Psychiatry. 2003;63:45–58. [PubMed]
110. Nelson AL, Combs DR, Penn DL, Basso MR. Subtypes of social perception deficits in schizophrenia. Schizophr Res. 2007;94:139–147. [PubMed]
111. Zuroff DC, Colussy SA. Emotion recognition in schizophrenic and depressed inpatients. J Clin Psychol. 1986;42:411–417. [PubMed]
112. Andreasen NC. The Scale for the Assessment of Negative Symptoms (SANS) Iowa City, Iowa: The University of Iowa; 1984.
113. Andreasen NC. The Scale for the Assessment of Positive Symptoms (SAPS) Iowa City, Iowa: The University of Iowa; 1984.
114. Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull. 1987;13:261–276. [PubMed]
115. Overall JE, Gorham DR. The Brief Psychiatric Rating Scale. Psychol Rep. 1962;10:799–812.
116. Chapman LJ, Chapman JP. The measurement of differential deficit. J Psychiatr Res. 1978;14:303–311. [PubMed]
117. Johnston PJ, Katsikitis M, Carr VJ. A generalized deficit can account for problems in facial emotion recognition in schizophrenia. Biol Psychol. 2001;58:203–227. [PubMed]
118. Sasson N, Tsuchiya N, Hurley R, et al. Orienting to social stimuli differentiates social cognitive impairment in autismand schizophrenia. Neuropsychologia. 2007;45:2580–2588. [PMC free article] [PubMed]
119. Elfenbein HA, Ambady N. When familiarity breeds accuracy: cultural exposure and facial emotion recognition. J Pers Soc Psychol. 2003;85:276–290. [PubMed]
120. Habel U, Gur RC, Mandal MK, Salloum JB, Gur RE, Schneider F. Emotional processing in schizophrenia across cultures: standardized measures of discrimination and experience. Schizophr Res. 2000;42:57–66. [PubMed]
121. Pinkham AE, Sasson NJ, Calkins ME, et al. The other-race effect in face processing among African-American and Caucasian individuals with schizophrenia. Am J Psychiatry. 2008;165:639–645. [PubMed]
122. Keefe RS, Bilder RM, Harvey PD, et al. Baseline neurocognitive deficits in the CATIE schizophrenia trial. Neuropsychopharmacology. 2006;31:2033–2046. [PubMed]
123. Davis PJ, Gibson MG. Recognition of posed and genuine facial expressions of emotion in paranoid and nonparanoid schizophrenia. J Abnorm Psychol. 2000;109:445–450. [PubMed]
124. Keefe RS, Seidman LJ, Christensen BK, et al. Long-term neurocognitive effects of olanzapine or low-dose haloperidol in first episode psychosis. Biol Psychiatry. 2006;59:97–105. [PubMed]
125. Bediou B, Asri F, Brunelin J, et al. Emotion recognition and genetic vulnerability to schizophrenia. Br J Psychiatry. 2007;191:126–130. [PubMed]
126. Pinkham AE, Penn DL, Perkins DO, Graham KA, Siegel M. Emotion perception and social skill over the course of psychosis: a comparison of individuals “at-risk” for psychosis and individuals with early and chronic schizophrenia spectrum illness. Cogn Neuropsychiatry. 2007;12:198–212. [PubMed]
127. Addington J, Penn D, Woods SW, Addington D, Perkins DO. Facial affect recognition in individuals at clinical high risk for psychosis. Br J Psychiatry. 2008;192:67–68. [PMC free article] [PubMed]
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