Dawn Neumann

Meta-Analysis of Facial Affect Recognition Difficulties After Traumatic Brain Injury

OBJECTIVE Difficulties in communication and social relationships present a formidable challenge for many people after traumatic brain injury (TBI). These difficulties are likely to be partially attributable to problems with emotion perception. Mounting evidence shows facial affect recognition to be particularly difficult after TBI. However, no attempt has been made to systematically estimate the magnitude of this problem or the frequency with which it occurs. METHOD A meta-analysis is presented examining the magnitude of facial affect recognition difficulties after TBI. From this, the frequency of these impairments in the TBI population is estimated. Effect sizes were calculated from 13 studies that compared adults with moderate to severe TBI to matched healthy controls on static measures of facial affect recognition. RESULTS The studies collectively presented data from 296 adults with TBI and 296 matched controls. The overall weighted mean effect size for the 13 studies was -1.11, indicating people with TBI on average perform about 1.1 SD below healthy peers on measures of facial affect recognition. Based on estimation of the TBI population standard deviation and modeling of likely distribution shape, it is estimated that between 13% and 39% of people with moderate to severe TBI may have significant difficulties with facial affect recognition, depending on the cut-off criterion used. CONCLUSION This is clearly an area that warrants attention, particularly examining techniques for the rehabilitation of these deficits.

Affect Recognition, Empathy, and Dysosmia After Traumatic Brain Injury

OBJECTIVE To investigate if olfaction is associated with affect recognition and empathy deficits after traumatic brain injury (TBI). Prior research has shown that TBI often leads to loss of smell. We hypothesized a relationship with emotion perception, because the neural substrates of the olfactory system overlap with the ventral circuitry of the orbital frontal cortex, which play a critical role in affective responses, such as empathy. DESIGN Comparative study investigating differences between participants with TBI who had impaired olfaction (dysosmia) with those with normal olfaction (normosmia). SETTING Postacute rehabilitation facilities in the United States, Canada, and New Zealand. PARTICIPANTS Participants (N=106) in the current study were a convenience sample of adults with moderate to severe TBI who were tested for olfactory function as part of a larger, related study on affect recognition. On average, participants were 11.5 years postinjury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Olfaction (Brief Smell Identification Test), facial affect recognition (Diagnostic Assessment of Nonverbal Affect 2-Adult Faces [DANVA2-AF]), vocal affect recognition (Diagnostic Assessment of Nonverbal Affect 2-Adult Paralanguage [DANVA2-AP]), emotional inference (Emotional Inference from Stories Test [EIST]), and empathy (Interpersonal Reactivity Index [IRI]). RESULTS Fifty-six percent of participants were dysosmic and only 36% of these participants were aware of their deficit. Participants with dysosmia performed significantly poorer on the DANVA2-AF (P=.003), DANVA2-AP (P=.007), EIST (P=.016), and IRI (P=.013). Medium effect sizes were found for all measures. Dysosmia had a sensitivity value of 86.4% for detecting facial affect recognition impairments and 67.8% for vocal affect recognition impairments. CONCLUSIONS This study shows that olfactory deficits may be indicative of affect recognition impairments and reduced empathy. Early knowledge of affect recognition and empathy deficits would be valuable so that treatment could be implemented predischarge.

The importance of vocal affect to bimodal processing of emotion: Implications for individuals with traumatic brain injury

UNLABELLED Persons with traumatic brain injury (TBI) often have difficulty recognizing emotion in others. This is likely due to difficulties in interpreting non-verbal cues of affect. Although deficits in interpreting facial cues of affect are being widely explored, interpretation of vocal cues of affect has received much less attention. Accurate interpretation of vocal affect cues is important, particularly when facial cues are absent or ambiguous. These cues also contribute to more accurate identification of emotion. The neural substrates of facial and vocal affect recognition appear to be shared, further contributing to improved bimodal processing. This article discusses the importance of vocal affect cues in interpreting emotion. Expression of vocal affect in persons with TBI is also briefly discussed since difficulty in controlling and manipulating vocal cues of emotion when speaking may also contribute to poor social outcomes. A review of the literature in acoustic parameters that contribute to identification and expression of emotions is followed by a discussion on the integration of visual and auditory cues in bimodal processing and the relationship between facial and vocal affect in persons with TBI. LEARNING OUTCOMES Readers will be able to: 1) Identify the parameters primarily used to describe the acoustic characteristics of vocal affect; 2) Describe the acoustic parameters typically associated with Anger, Fear, Happiness and Sadness; 3) Describe the difficulties experienced by persons with TBI in the perception and integration of facial and vocal cues of affect.

A randomized controlled trial of emotion recognition training after traumatic brain injury.

Objective:To examine the effectiveness of 2 affect recognition interventions (Faces and Stories) in people with a traumatic brain injury. Setting:Postacute rehabilitation facilities. Participants:A total of 203 participants with moderate to severe traumatic brain injury were screened; 71 were eligible and randomized to the Faces (n = 24), Stories (n = 23), and Control interventions (n = 24). Participants were an average of 39.8 years of age and 10.3 years postinjury; 74% of participants were male. Design:Randomized controlled trial with immediate, 3-month, and 6-month follow-up posttests. Interventions were 9 hours of computer-based training with a therapist. Measures:Diagnostic Assessment of Nonverbal Accuracy 2-Adult Faces; Emotional Inference From Stories Test; Empathy (Interpersonal Reactivity Index); and Irritability and Aggression (Neuropsychiatric Inventory). Results:The Faces Intervention did significantly better than the Control Intervention on the Diagnostic Assessment of Nonverbal Accuracy 2-Adult Faces (P = .031) posttreatment; no time effect or group interaction was observed. No other significant differences were noted for the Faces Intervention. No significant differences were observed between the Stories and the Control Interventions; however, a significant time effect was found for the Emotional Inference From Stories Test. Conclusion:The Faces Intervention effectively improved facial affect recognition in participants with chronic post–traumatic brain injury, and changes were maintained for 6 months. Future work should focus on generalizing this skill to functional behaviors.

Affect recognition in traumatic brain injury: Responses to unimodal and multimodal media

Objectives:To compare affect recognition by people with and without traumatic brain injury (TBI) for (1) unimodal and context-enriched multimodal media; (2) positive (happy) and negative emotions; and (3) neutral multimodal stimuli. Participants:A total of 60 people with moderate to severe TBI and 60 matched controls. Measures:(1) facial affect, (2) vocal affect, and (3) multimodal affect. Results:Compared with controls, people with TBI scored significantly lower on both unimodal measures but not on the multimodal measure. Within- group comparisons for people with TBI revealed that they were better at recognizing affect from multimodal than unimodal stimuli. As a group, participants with TBI who were categorized as having impaired facial/vocal affect recognition were less accurate at recognizing all emotions, including happy, than unimpaired participants. Neutral stimuli were more poorly identified by participants with TBI than by those with controls. Conclusion:Context-enriched multimodal stimuli may enhance affect recognition for people with TBI. People with TBI who have impaired affect recognition may have problems identifying both positive (happy) and negative expressions. Furthermore, people with TBI may perceive affect when there is none.

The relationship between facial affect recognition and cognitive functioning after traumatic brain injury

Abstract Primary objective: There is considerable evidence suggesting facial affect recognition and cognitive functions are impaired in many people with moderate-to-severe traumatic brain injury (TBI). However, little is known about the relationship between these two domains in the TBI population. Research design: This study investigated the relationship between facial affect recognition and cognitive functioning in 75 adults with moderate-to-severe TBI. Methods and procedures: Participants were administered three facial affect recognition tests and a computerized cognitive test battery that assessed seven cognitive domains. Main outcomes and results: Deficits in facial affect recognition were significantly correlated with impairments in non-verbal memory, working memory, speed of processing, verbal memory and verbal delayed memory. No significant relationship was found between executive dysfunction and facial affect recognition impairments. Non-verbal memory, working memory and speed of processing significantly predicted overall facial affect recognition performance. Conclusions: It is concluded that impairment in several cognitive processes may contribute to facial affect recognition deficits in TBI, in particular non-verbal memory, working memory and speed of processing. Furthermore, executive functioning may not be a critical factor in facial affect recognition, but would most likely be important in deciding what to do once facial affect is perceived. Trial registration: ClinicalTrials.gov identifier: NCT00283153.

Decreased facial expression variability in patients with serious cardiopulmonary disease in the emergency care setting.

Background and objective The hypothesis of the present work derives from clinical experience that suggests that patients who are more ill have less facial expression variability in response to emotional cues. Methods Prospective study of diagnostic accuracy from a convenience sample of adult patients with dyspnoea and chest pain in an emergency department. Patients viewed three stimulus slides on a laptop computer that were intended to evoke a change in facial affect. The computer simultaneously video recorded patients’ facial expressions. Videos were examined by two independent blinded observers who analysed patients’ facial expressions using the Facial Action Coding System (FACS). Patients were followed for predefined serious cardiopulmonary diagnosis (Disease+) within 14 days (acute coronary syndrome, pulmonary embolism, pneumonia, aortic or oesophageal disasters or new cancer). The main analysis compared total FACS scores, and action units of smile, surprise and frown between Disease+ and Disease−. Results Of 50 patients, 8 (16%) were Disease+. The two observers had 92% exact agreement on the FACS score from the first stimulus slide. During stimulus slide 1, the median of all FACS values from Disease+ patients was 3.4 (1st–3rd quartiles 1–6), significantly less than the median of 7 (3–14) from D−patients (p=0.019, Mann–Whitney U). Expression of surprise had the largest difference between Disease+ and Disease−(area under the receiver operating characteristic curve 0.75, 95% CI 0.52 to 0.87). Conclusions With a single visual stimulus, patients with serious cardiopulmonary diseases lacked facial expression variability and surprise affect. Our preliminary findings suggest that stimulus-evoked facial expressions from emergency department patients with cardiopulmonary symptoms might be a useful component of gestalt pretest probability assessment.

Reductions in Alexithymia and Emotion Dysregulation After Training Emotional Self-awareness Following Traumatic Brain Injury: A Phase I Trial

Objectives: To examine the acceptability and initial efficacy of an emotional self-awareness treatment at reducing alexithymia and emotion dysregulation in participants with traumatic brain injury (TBI). Setting: An outpatient rehabilitation hospital. Participants: Seventeen adults with moderate to severe TBI and alexithymia. Time postinjury ranged 1 to 33 years. Design: Within subject design, with 3 assessment times: baseline, posttest, and 2-month follow-up. Intervention: Eight lessons incorporated psychoeducational information and skill-building exercises teaching emotional vocabulary, labeling, and differentiating self-emotions; interoceptive awareness; and distinguishing emotions from thoughts, actions, and sensations. Measures: Toronto Alexithymia Scale-20 (TAS-20); Levels of Emotional Awareness Scale (LEAS); Trait Anxiety Inventory (TAI); Patient Health Questionnaire-9 (PHQ-9); State-Trait Anger Expression Inventory (STAXI); Difficulty With Emotion Regulation Scale (DERS); and Positive and Negative Affect Scale (PANAS). Results: Thirteen participants completed the treatment. Repeated-measures analysis of variance revealed changes on the TAS-20 (P = .003), LEAS (P < .001), TAI (P = .014), STAXI (P = .015), DERS (P = .020), and positive affect (P < .005). Paired t tests indicated significant baseline to posttest improvements on these measures. Gains were maintained at follow-up for the TAS, LEAS, and positive affect. Treatment satisfaction was high. Conclusion: This is the first study published on treating alexithymia post-TBI. Positive changes were identified for emotional self-awareness and emotion regulation; some changes were maintained several months posttreatment. Findings justify advancing to the next investigational phase for this novel intervention.

Recognition of facial and vocal affect following traumatic brain injury

Abstract Objective: Studies of facial affect recognition by people with traumatic brain injury (TBI) have shown this to be a significant problem. Vocal affect recognition also appears to be challenging for this population, but little is known about the degree to which one modality is impaired compared to the other. This study compared facial and vocal affect recognition of high and low intensity emotion expressions in people with moderate-to-severe TBI. Methods: The Diagnostic Analysis of Nonverbal Accuracy-2 (Adult Faces; Voices) was administered to 203 participants with TBI. Results: Adults with TBI identified vocal emotion expressions with greater accuracy than facial emotion expressions. Facial affect recognition impairment was identified in 34% of participants, 22% were classified as having vocal affect recognition impairment and 15% showed impairment in both modalities. Participants were significantly less accurate at identifying low vs high intensity emotion expressions in both modalities. Happy facial expressions were significantly better identified than all other emotions. Errors were distributed across the emotion categories for vocal expressions. Conclusions: The degree of facial affect impairment was significantly greater than vocal affect impairment in this sample of people with moderate-to-severe TBI. Low intensity emotion expressions were particularly problematic and an advantage for positively valenced facial emotion expressions was indicated.

Neurobiological mechanisms associated with facial affect recognition deficits after traumatic brain injury

The neurobiological mechanisms that underlie facial affect recognition deficits after traumatic brain injury (TBI) have not yet been identified. Using functional magnetic resonance imaging (fMRI), study aims were to 1) determine if there are differences in brain activation during facial affect processing in people with TBI who have facial affect recognition impairments (TBI-I) relative to people with TBI and healthy controls who do not have facial affect recognition impairments (TBI-N and HC, respectively); and 2) identify relationships between neural activity and facial affect recognition performance. A facial affect recognition screening task performed outside the scanner was used to determine group classification; TBI patients who performed greater than one standard deviation below normal performance scores were classified as TBI-I, while TBI patients with normal scores were classified as TBI-N. An fMRI facial recognition paradigm was then performed within the 3T environment. Results from 35 participants are reported (TBI-I = 11, TBI-N = 12, and HC = 12). For the fMRI task, TBI-I and TBI-N groups scored significantly lower than the HC group. Blood oxygenation level-dependent (BOLD) signals for facial affect recognition compared to a baseline condition of viewing a scrambled face, revealed lower neural activation in the right fusiform gyrus (FG) in the TBI-I group than the HC group. Right fusiform gyrus activity correlated with accuracy on the facial affect recognition tasks (both within and outside the scanner). Decreased FG activity suggests facial affect recognition deficits after TBI may be the result of impaired holistic face processing. Future directions and clinical implications are discussed.