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Brief Report   |    
Effects of Antipsychotic Treatment on Emotion Perception Deficits in First-Episode Schizophrenia
Ellen S. Herbener, Ph.D.; S. Kristian Hill, Ph.D.; Robert W. Marvin, M.D.; John A. Sweeney, Ph.D.
Am J Psychiatry 2005;162:1746-1748. doi:10.1176/appi.ajp.162.9.1746
Abstract

OBJECTIVE: The authors evaluated emotion perception in acutely ill patients experiencing a first episode of schizophrenia. They also investigated the effects of antipsychotic medication on emotion perception. METHOD: Tests of the ability to perceive and discriminate emotional expressions from the Penn Computerized Neuropsychological Battery were given to 13 patients experiencing their first episode of schizophrenia. Patients were also assessed with the Positive and Negative Syndrome Scale. The patients were tested while they were unmedicated and again following clinical stabilization. Healthy individuals were evaluated over a similar time interval. RESULTS: Patients with first-episode schizophrenia demonstrated impairments in emotion perception before treatment and no significant improvement after treatment. Emotion perception deficits were correlated with negative symptoms after clinical stabilization. CONCLUSIONS: Deficits in emotion perception are present at illness onset in schizophrenia and show minimal response to effective antipsychotic treatment.

Abstract Teaser
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Cognitive deficits are typically present at the onset of schizophrenia and show limited responsiveness to treatment (1, 2). However, it remains to be established whether emotional processing deficits are present at illness onset and whether antipsychotic treatment reduces such deficits. The current study addresses these issues by assessing emotion recognition in patients with first-episode schizophrenia before and after treatment.

Subjects were recruited from the University of Illinois Medical Center. Thirteen patients experiencing their first episode of schizophrenia were diagnosed by using the Structured Clinical Interview for DSM-IV (SCID) (3). These patients had received 4 or fewer weeks of treatment with antipsychotic medication in their lifetime and had been unmedicated for at least 5 days before testing. Potential subjects were excluded if there was a history of substantial head injury, substance dependence, or systemic or neurological disorders that might affect symptom presentation or cognitive performance. After description of the study, written informed consent was obtained from all participating subjects.

Following baseline testing (described in the next two paragraphs), patients began treatment with risperidone (mean dose=3.38 mg, SD=2.01). Four individuals who were not responsive to risperidone or suffered substantial side effects were stabilized with alternate medications (one with ziprasidone 140 mg, one with aripiprazole 30 mg, and two with haloperidol at a mean dose 4.5 mg, SD=0.71). Subjects completed a second testing session when they were clinically stable (mean=31.3 days later, SD=8.35).

At the time of each testing, symptoms were assessed by using the Positive and Negative Syndrome Scale (4). SCID and Positive and Negative Syndrome Scale ratings were completed by trained clinicians with established reliability (kappa ≥0.75) who had no knowledge of task performance. Thirteen healthy subjects were recruited who did not meet criteria for any axis I disorder according to SCID results. These comparison subjects did not differ from the patient group in sex distribution, age, or parental education.

All subjects completed tests of the ability to perceive and discriminate emotional expressions from the Penn Computerized Neuropsychological Battery (5, 6). The emotional acuity task requires individuals to rate 40 black-and-white pictures of adult faces along a 7-point continuum of emotional intensity (happy to sad). The emotion differentiation task requires individuals to identify which of two faces in 40 pairs of black-and-white photographs shows more intense emotion. Data were converted to z scores by using means and standard deviations from normative data collected by the University of Pennsylvania group (6). Subjects also completed the two-subtest version of the Wechsler Abbreviated Scale of Intelligence (7) to evaluate general intellectual function.

At the baseline assessment, patients with schizophrenia performed more poorly than healthy subjects on both the emotional acuity task (F=24.63, df=1, 24, p<0.001) and the emotional differentiation task (happy condition: F=20.73, df=1, 24, p<0.001, and sad condition: F=12.35, df=1, 24, p=0.002).

There was a robust decrease in symptom scores in the patient group from baseline to follow-up (positive symptoms: t=7.187, df=12, p<0.001; negative symptoms: t=3.241, df=12, p<0.01). There was no significant improvement on any of the emotion tasks after treatment (F1). The effect sizes for change in emotion task performance after treatment were very small (emotional acuity task partial η2=0.001; emotion differentiation task happy condition partial η2=0.001, emotion differentiation task sad condition partial η2=0.01). Clinical improvement was unrelated to change in emotion task performance in the patients with schizophrenia (all p>0.20).

After treatment, negative symptom scores were highly correlated with performance impairments on the emotional acuity task in the patients with schizophrenia (r=–0.70, N=13, p<0.01). Positive symptom severity was not significantly correlated with task performance at either testing. When the analyses described here were repeated with IQ as a covariate, the same effects were observed.

Deficits in emotional processing have long been considered a core deficit in schizophrenia (8). The results of the current study indicate that individuals with schizophrenia demonstrate deficits in emotional processing even at their first psychotic episode. Furthermore, these deficits were not significantly reduced by effective treatment with antipsychotic medication. Although the severity of emotional processing deficits was minimally related to symptom presentation during acute illness, these deficits were strongly linked to negative symptom severity after clinical stabilization. Because medication effectively reduced some aspects of negative symptoms, it may be that residual core persistent negative symptoms have a stronger linkage to emotional processing deficits.

The number of patients in the current study is limited, which reduced the power of the analyses. However, effect sizes of treatment on emotion task performance were so low that it is unlikely that statistical power considerations were responsible for the failure to identify improvement after treatment. Nonetheless, additional research with larger groups of subjects will be important to address this issue as well as whether other factors, such as chronicity of illness, may also influence these relationships.

Previous studies assessing medication effects on emotion perception have typically compared performance during treatment with atypical and conventional antipsychotic medications and found better performance with atypical antipsychotics (9, 10). Treatment studies assessing other aspects of cognitive performance in schizophrenia have also demonstrated somewhat better performance with atypical antipsychotics than conventional antipsychotic medications (11, 12). In the few studies comparing cognitive performance between unmedicated and medicated states in first-episode patients (1, 13), researchers have reported modest improvements in cognitive performance in select areas of functioning with atypical antipsychotic treatment. Schuepbach et al. (13) found that a decrease in negative symptoms with treatment was correlated with cognitive improvement and that persistent negative symptoms were associated with ongoing cognitive deficits.

The current data suggest that deficits in emotion perception are not significantly improved with effective atypical antipsychotic medication. Further, because emotion perception deficits were correlated after stabilization with negative symptoms, they may be another domain of deficit related to poorer functional outcome. Thus, they appear to represent an important target for clinical intervention.

Received June 21, 2004; revision received Sept. 22, 2004; accepted Nov. 8, 2004. From the Center for Cognitive Medicine, Department of Psychiatry, University of Illinois at Chicago. Address correspondence and reprint requests to Dr. Herbener, Cognitive Medicine, Department of Psychiatry, University of Illinois at Chicago, 912 S. Wood St., Chicago, IL 60612; eherbener@psych.uic.edu (e-mail). Supported by a grant from the National Alliance for Research on Schizophrenia and Depression (Dr. Herbener) and NIMH grants MH-067223 (Dr. Herbener) and MH-62134 (Dr. Sweeney).

 
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Figure 1.

Performance of Patients With First-Episode Schizophrenia and Healthy Comparison Subjects on the Penn Computerized Neuropsychological Battery Emotional Acuity and Emotion Differentiation Tasks at Baseline and Follow-Upa

aPatients with schizophrenia were medication free at baseline; follow-up testing was done when they were clinically stable with medication.

Hill SK, Schuepbach D, Herbener ES, Keshavan MS, Sweeney JA: Pretreatment and longitudinal studies of neuropsychological deficits in antipsychotic-naive patients with schizophrenia. Schizophr Res  2004; 68:49–63
[PubMed]
[CrossRef]
 
Hoff AL, Sakuma M, Wieneke M, Horon R, Kushner M, DeLisi LE: Longitudinal neuropsychological follow-up study of patients with first-episode schizophrenia. Am J Psychiatry  1999; 156:1336–1341
[PubMed]
 
Spitzer RL, Williams JBW, Gibbon M, First MB: Structured Clinical Interview for DSM-IV (SCID). New York, New York State Psychiatric Institute, Biometrics Research, 1995
 
Kay SR, Opler LA, Fiszbein A: Positive and Negative Syndrome Scale (PANSS). North Tonawanda, NY, Multi-Health Systems, 1986
 
Erwin RJ, Gur RC, Gur RE, Smailis J, Skolnick B: Facial emotion discrimination, 1: task construction and behavioral findings in normal subjects. Psychiatry Res  1992; 42:231–240
[PubMed]
[CrossRef]
 
Gur RC: The Computerized Neuropsychological Battery (CNP) of the Brain Behavior Laboratory at the University of Pennsylvania. http:// html
 
Wechsler Abbreviated Scale of Intelligence. San Antonio, Tex, Psychological Corp (Harcourt), 1999
 
Bleuler E: Dementia Praecox or the Group of Schizophrenias (1911). Translated by Zinkin J. New York, International Universities Press, 1950
 
Kee KS, Kern RS, Marshall BD Jr, Green MF: Risperidone versus haloperidol for perception of emotion in treatment-resistant schizophrenia: preliminary findings. Schizophr Res  1998; 31:159–165
[PubMed]
[CrossRef]
 
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]
[CrossRef]
 
Green MF, Marshall BD Jr, Wirshing WC, Ames D, Marder SR, McGurk S, Kern RS, Mintz J: Does risperidone improve verbal working memory in treatment-resistant schizophrenia? Am J Psychiatry  1997; 154:799–804
[PubMed]
 
Keefe RSE, Silva SG, Perkins DO, Lieberman JA: The effects of atypical antipsychotic drugs on neurocognitive impairment in schizophrenia: a review and meta-analysis. Schizophr Bull  1999; 25:201–222
[PubMed]
 
Schuepbach D, Keshavan MS, Kmiec JA, Sweeney JA: Negative symptom resolution and improvements in specific cognitive deficits after acute treatment in first-episode schizophrenia. Schizophr Res  2002; 53:249–261
[PubMed]
[CrossRef]
 

Figure 1.

Performance of Patients With First-Episode Schizophrenia and Healthy Comparison Subjects on the Penn Computerized Neuropsychological Battery Emotional Acuity and Emotion Differentiation Tasks at Baseline and Follow-Upa

aPatients with schizophrenia were medication free at baseline; follow-up testing was done when they were clinically stable with medication.

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References

Hill SK, Schuepbach D, Herbener ES, Keshavan MS, Sweeney JA: Pretreatment and longitudinal studies of neuropsychological deficits in antipsychotic-naive patients with schizophrenia. Schizophr Res  2004; 68:49–63
[PubMed]
[CrossRef]
 
Hoff AL, Sakuma M, Wieneke M, Horon R, Kushner M, DeLisi LE: Longitudinal neuropsychological follow-up study of patients with first-episode schizophrenia. Am J Psychiatry  1999; 156:1336–1341
[PubMed]
 
Spitzer RL, Williams JBW, Gibbon M, First MB: Structured Clinical Interview for DSM-IV (SCID). New York, New York State Psychiatric Institute, Biometrics Research, 1995
 
Kay SR, Opler LA, Fiszbein A: Positive and Negative Syndrome Scale (PANSS). North Tonawanda, NY, Multi-Health Systems, 1986
 
Erwin RJ, Gur RC, Gur RE, Smailis J, Skolnick B: Facial emotion discrimination, 1: task construction and behavioral findings in normal subjects. Psychiatry Res  1992; 42:231–240
[PubMed]
[CrossRef]
 
Gur RC: The Computerized Neuropsychological Battery (CNP) of the Brain Behavior Laboratory at the University of Pennsylvania. http:// html
 
Wechsler Abbreviated Scale of Intelligence. San Antonio, Tex, Psychological Corp (Harcourt), 1999
 
Bleuler E: Dementia Praecox or the Group of Schizophrenias (1911). Translated by Zinkin J. New York, International Universities Press, 1950
 
Kee KS, Kern RS, Marshall BD Jr, Green MF: Risperidone versus haloperidol for perception of emotion in treatment-resistant schizophrenia: preliminary findings. Schizophr Res  1998; 31:159–165
[PubMed]
[CrossRef]
 
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]
[CrossRef]
 
Green MF, Marshall BD Jr, Wirshing WC, Ames D, Marder SR, McGurk S, Kern RS, Mintz J: Does risperidone improve verbal working memory in treatment-resistant schizophrenia? Am J Psychiatry  1997; 154:799–804
[PubMed]
 
Keefe RSE, Silva SG, Perkins DO, Lieberman JA: The effects of atypical antipsychotic drugs on neurocognitive impairment in schizophrenia: a review and meta-analysis. Schizophr Bull  1999; 25:201–222
[PubMed]
 
Schuepbach D, Keshavan MS, Kmiec JA, Sweeney JA: Negative symptom resolution and improvements in specific cognitive deficits after acute treatment in first-episode schizophrenia. Schizophr Res  2002; 53:249–261
[PubMed]
[CrossRef]
 
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