Facial Emotion Identification in Early-Onset and First-Episode Psychosis

Abstract

Psychotic conditions are a major public health concern as service expenditure costs are high, rates of unemployment are elevated, and risk of homelessness is increased. Improvements in the treatment of acute symptoms have resulted in many patients living in the community, which requires the ability to negotiate the social world. Social cognition refers to the set of skills involved in the perception, interpretation and effective use of social information. A fundamental building block of social cognition is the ability to quickly and accurately identify facial expressions of emotion (facial emotion identification: FEI). FEI has been found impaired and stable across time in people suffering from schizophrenia and first-episode psychosis (FEP), as well as in people at ultra-high risk of converting to psychosis and family members of people with psychosis. Taken together, this suggests that the ability to accurately identify facial expressions of emotions may be a trait marker of illness, rather than a consequence of illness. If so, a clearer understanding of the nature of these deficits at the early stages of illness would have implications for our theoretical understanding of the development and maintenance of psychotic illnesses. Furthermore, FEI deficits show cross-sectional and prospective ties with the ability of people with established schizophrenia to function in everyday life. The identification of factors that contribute to social disability in schizophrenia, especially those amenable to change, is a core aim of research. Therefore, an examination of the links between FEI and functioning in early-onset and first-episode psychosis would have implications for the provision of remediation programs aimed at ameliorating functional decline at the early stages of illness. This thesis contains a series of empirical manuscripts that have been published or are to be submitted for publication. This series of manuscripts is preceded by a general introduction to psychosis, schizophrenia, social cognition and FEI (Chapter 1) and a systematic review and meta-analysis of the literature assessing FEIdeficits in EOP and FEP (Chapter 2). This review found that, similar to patients with chronic schizophrenia, patients at the early stages of illness have difficulties accurately identifying facial expressions of emotion. Chapter 3 is an empirical study that aims to address several shortcomings identified in the extant literature. Patients with early-onset psychosis (n= 34, mean age = 14.11, 53% female) and healthy controls (n= 42, mean age 13.80, 51% female) completed a task of FEI that measured accuracy, error pattern and response time. Relative to controls, patients (i) had lower accuracy for identifying facial expressions of emotions, especially fear, anger and disgust, (ii) were more likely to misattribute other emotional expressions as fear or disgust, and (iii) were slower at accurately identifying all facial expressions. FEI accuracy was not significantly correlated with clinical symptoms of psychosis or current functioning. Chapter 4 follows eight of these children and adolescents (mean age = 17.53, 50% female) over time (2 to 4 years) to assess the longitudinal stability of facial emotion identification deficits in early psychosis, with a concurrent consideration of clinical course and functional outcome. Results indicated that, overall, FEI deficits remain stable over time in EOP, despite improvements in real-world functioning and fluctuations in clinical state. Chapter 5 compares FEI in patients with FEP with two different types of psychosis, affective psychoses (FEAP: n= 15, mean age = 19.53, 40% female) and schizophrenia spectrum psychoses (FESz: n= 69, mean age = 20.70, 38% female) to healthy controls (HC: n= 159, mean age = 19.97, 34% female). This is important, as little is known about differential deficits in FEI in specific types of psychosis, especially in patients experiencing their first episode of illness. Patients with FESz displayed more severe and pervasive deficits compared to FEAP. The results of this study suggest a differential impairment in FEI severity and pattern contingent on the type of psychosis. In the final empirical paper (Chapter 6) findings obtained on 6-month follow-up of patients (n= 29, mean age = 20.30, 38% female) with FEP are reported. FEI deficits were found to remain stable over time, with the exception of improvement in the accurate identification of sadness. Significant relationships between impaired baseline emotion identification task performance and poorer longitudinal functional outcomes, in the context of weak associations between baseline clinical symptoms of psychosis and longitudinal functional outcomes, suggests FEI deficits may contribute to social disability in psychotic disorders. In summary, the results of the studies contained in this thesis suggest that (i) FEI deficits are present in EOP and FEP, (ii) these deficits are stable and endure over time, and (iii) are related to long term functioning in FEP. These findings further our theoretical understanding of psychotic disorders by supporting the hypothesis that FEI deficits represent a candidate neurocognitive marker and endophenotype of schizophrenia spectrum disease. These findings underscore the need for detailed investigation of FEI impairment in EOP and FEP and provide support for the provision of social cognitive remediation programs to people at the early stages of illness in the hope of ameliorating long term functional decline.