Wolfgang Wölwer

Remediation of impairments in facial affect recognition in schizophrenia: Efficacy and specificity of a new training program

OBJECTIVE Schizophrenia patients often exhibit impairments in facial affect recognition which contribute to their poor social functioning. These impairments are stable in the course of the disorder and seem not to be affected by conventional treatment. The present study investigates the efficacy and specificity of a new training program for the remediation of such impairments. METHOD A newly developed training program tackling affect recognition (TAR) was compared with a cognitive remediation training program (CRT) and treatment as usual (TAU) within a randomized three group pre-post design in n=77 post-acute schizophrenia patients. The TAR is a computer-aided 12-session program focussing on facial affect recognition, whereas the CRT aims to improve attention, memory and executive functioning. Facial affect recognition, face recognition, and neurocognitive performance were assessed before (T0) and after (T1) the six week training phase. During the training period all patients received antipsychotic medication. RESULTS Patients under TAR significantly improved in facial affect recognition, with recognition performance after training approaching the level of healthy controls from former studies. Patients under CRT and those without special training (TAU) did not improve in affect recognition, though patients under CRT improved in verbal memory functions. CONCLUSION According to these results, remediation of disturbed facial affect recognition in schizophrenia patients is possible, but not achievable with a traditional cognitive rehabilitation program such as the CRT. Instead, functional specialized remediation programs such as the newly developed TAR are a more suitable option.

Neurophysiological correlates of the recognition of facial expressions of emotion as revealed by magnetoencephalography

MEG correlates of the recognition of facial expressions of emotion were studied in four healthy volunteers. Subjects performed a facial emotion recognition task and a control task involving recognition of complex objects including faces. Facial emotion recognition activated inferior frontal cortex, amygdala and different parts of temporal cortex in a relatively consistent time sequence. The characteristics of these activations were clearly different from those recorded during the control task. Most interesting was the fact that faces evoked different MEG responses as a function of task demands, i.e., the activations recorded during facial emotion recognition were different from those recorded during simple face recognition in the control task. These findings support the assumption that MEG is able to specifically identify the activation pattern of the brain when recognition of the emotional expression of a face is performed.

Early detection and secondary prevention of psychosis: facts and visions.

Abstract.As effective and practical approaches to primary and universal prevention of psychosis are lacking, intervention efforts are targeted at the early stages of schizophrenia to prevent (by way of secondary prevention) or postpone psychosis onset, reduce severity of illness or at least ameliorate the social consequences involved. Early intervention requires early detection and early recognition (diagnosis) of persons at risk and early prediction of psychosis. Within the German Research Network on Schizophrenia (GRNS) awareness programmes are being carried out in several German cities, and these efforts are already improving utilisation of early-recognition and early-prediction services by at risk persons. The empirical basis of developing a two-step early-recognition inventory and strategies of application will be discussed. This instrument is supplemented by a set of cognitive tests, prospectively validated in the GRNS. Results from preliminary analysis of data covering a two-year period demonstrate that the inventory and the cognitive tests are readily accepted. When used for screening in non-specialist settings and at the next level, i. e. at early-recognition centres, they seem to permit identification of at-risk persons. Early intervention is being tested 1) in a randomised controlled multi-centre trial consisting of a specially developed cognitive-behavioural therapy in the early (prepsychotic) prodromal state and 2) on additional treatment with appropriate doses of amisulpride in the late prodromal (early psychotic) state. Preliminary data from Study 1 covering 16.3 months show significantly fewer transitions to psychosis and from Study 2 reduced positive and negative symptoms and improved global functioning compared with controls who had received normal clinical treatment. As a result, both the early-recognition inventory plus cognitive tests and the two therapy strategies are feasible. We hope that the favourable trend indicated by the preliminary data will be confirmed in the final analysis planned for 2005 and the objective of implementing effective and practical secondary prevention of psychosis and its consequences will be attained.

Remediation of facial affect recognition impairments in patients with schizophrenia: a new training program

Impairments in facial affect recognition are trait-like characteristics in schizophrenia and might contribute to poor social functioning. A special Training of Affect Recognition program was developed, which shows a good feasibility and promising treatment effects. The specificity of these effects can now be demonstrated in a control group design.

Facial-affect recognition and visual scanning behaviour in the course of schizophrenia

The performance of schizophrenic in-patients in facial expression identification was assessed in an acute phase and in a partly remitted phase of the illness. During visual exploration of the face stimuli, the patients eye movements were recorded using an infrared-corneal-reflection technique. Compared to healthy controls, patients demonstrated a significant deficit in facial-affect recognition. In addition, schizophrenics differed from controls in several eye movement parameters such as length of mean scan path and mean duration of fixation. Both the facial-affect recognition deficit and the eye movement abnormalities remained stable over time. However, performance in facial-affect recognition and eye movement abnormalities were not correlated. Patients with flattened affect showed relatively selective scan pattern characteristics. In contrast, affective flattening was not correlated with performance in facial-affect recognition. Dosage of neuroleptic medication did not affect the results. The main findings of the study suggest that schizophrenia is associated with disturbances in primarily unrelated neurocognitive operations mediating visuomotor processing and facial expression analysis. Given their time stability, the disturbances might have a trait-like character.

Facial affect recognition in the course of schizophrenia.

Deficits in facial affect recognition have been shown repeatedly in schizophrenia. However, the stability of this deficit over time remains to be clarified. A total of 36 remitted, 32 acutely ill schizophrenic patients and 21 healthy volunteers participated in a cross-sectional and longitudinal study. All subjects were assessed twice within 4 weeks (acute schizophrenics and normal controls), or 12 weeks, respectively (remitted schizophrenics). Subjects had to identify six basic emotions from corresponding facial expressions shown as photographs on a video screen. Both acute and remitted schizophrenics demonstrated a stable deficit over time in facial affect recognition unrelated to psychopathology and medication. This suggests that deficits in facial affect recognition in schizophrenia reflect a trait-like, rather than a state-dependent, characteristic.

Neuropsychological Profiles in Different At-Risk States of Psychosis: Executive Control Impairment in the Early—and Additional Memory Dysfunction in the Late—Prodromal State

Impairments in neuropsychological functioning have been described in subjects clinically at high risk for psychosis, but the specific cognitive deficits in different clinical high-risk groups remain to be elucidated. The German Research Network on Schizophrenia employs a heuristic 2-stage model: a putatively late prodromal state (LPS), characterized by the onset of attenuated positive or brief psychotic symptoms, and an early prodromal state (EPS), mainly characterized by the presence of basic symptoms, which are predictive for psychosis within the next 10 years. A total of 205 subjects met the criteria for either an EPS or an LPS of psychosis and were assessed with a comprehensive neuropsychological test battery. Neurocognitive profiles of high-risk groups were compared with data of 87 healthy controls comparable with regard to gender, age, and premorbid verbal IQ. Patients in the LPS were impaired in all neurocognitive domains (memory/learning, executive control/processing speed, and working memory) examined, with memory being the worst. Deficits were less pronounced in patients in the EPS, with a specific deficit in the executive control/processing speed domain. Consistent with a progressive neurodevelopmental disorder, some cognitive abilities were already impaired in patients in the EPS, followed by further deterioration in the LPS. Specifically, deficits in executive control functioning were related to the presence of basic symptoms, indicating a vulnerability for psychosis. Memory deficits were associated with the onset of psychotic symptoms indicating further disease progression in the trajectory to psychosis and, thus, may be useful in predicting psychosis and targeting early intervention.

Negative Symptoms of Schizophrenia as Primary Target of Cognitive Behavioral Therapy: Results of the Randomized Clinical TONES Study

Clinical studies on cognitive behavioral therapy (CBT) that include schizophrenia patients primarily on the basis of negative symptoms are uncommon. However, those studies are necessary to assess the efficacy of CBT on negative symptoms. This article first gives an overview of CBT on negative symptoms and discusses the methodological problems of selecting an adequate control group. Furthermore, the article describes a clinical study (the TONES-Study, ISRCTN 25455020), which aims to investigate whether CBT is specifically efficacious for the reduction of negative symptoms. This multicenter randomized clinical trial comparing CBT with cognitive remediation (CR) for control of nonspecific effects is depicted in detail. In our trial, schizophrenia patients (n = 198) participated in manualized individual outpatient treatments. Primary outcome is the negative syndrome assessed with the positive and negative syndrome scale, analyzed with multilevel linear mixed models. Patients in both groups moderately improved regarding the primary endpoint. However, against expectation, there was no difference between the groups after treatment in the intention to treat as well as in the per-protocol analysis. In conclusion, psychotherapeutic intervention may be useful for the reduction of negative symptoms. However, there is no indication for specific effects of CBT compared with CR.

Time course of regional brain activations during facial emotion recognition in humans

Recognition of facial expressions of emotions is very important for communication and social cognition. Neuroimaging studies showed that numerous brain regions participate in this complex function. To study spatiotemporal aspects of the neural representation of facial emotion recognition we recorded neuromagnetic activity in 12 healthy individuals by means of a whole head magnetoencephalography system. Source reconstructions revealed that several cortical and subcortical brain regions produced strong neural activity in response to emotional faces at latencies between 100 and 360 ms that were much stronger than those to neutral as well as to blurred faces. Orbitofrontal cortex and amygdala showed affect-related activity at short latencies already within 180 ms after stimulus onset. Some of the emotion-responsive regions were repeatedly activated during the stimulus presentation period pointing to the assumption that these reactivations represent indicators of a distributed interacting circuitry.

Electrophysiological correlates of emotional and structural face processing in humans.

In order to study brain potentials related to decoding of facial expressions of emotions and those, related to basic perception of faces 16 right-handed subjects performed tasks on facial emotion recognition and perception of blurred faces and objects. Electroencephalograph (EEG) recordings during performance of the tasks revealed similar event-related potentials during the presentation of faces at 120 and 170 ms after stimulus onset in both of the tasks but significant differences in amplitudes between 180 and 300 ms. Whereas faces in the emotion recognition task produced high amplitudes in that latency range, potentials in response to faces in the blurred object condition were virtually absent. These data point to the assumption that decoding of facial expressions starts early in the brain and might be processed separately from basic stages of face perception.