A Swedish study has found that people with psychotic spectrum disorders struggle more with recognising emotions in others than healthy individuals, and those with a history of interpersonal aggression fare worst. The researchers compared three groups: individuals with psychotic spectrum disorders and aggression history, those with psychotic spectrum disorders but no aggression history, and healthy controls.
Recognising others’ emotions is vital for social interaction, as facial expressions, tone of voice and body movements provide crucial clues about how others feel. When these signals are misunderstood, communication can break down and inappropriate responses may follow.
Difficulties with emotion recognition are common across psychotic spectrum disorders, which in this study included schizophrenia, schizoaffective disorder, delusional disorder and bipolar disorder with psychotic features. Prior research has shown trouble identifying emotions from faces, voices and body movements, often more pronounced for negative emotions but present for positive ones as well.
The study, led by Gabriela Gavalova of Karolinska Institutet, investigated how well people with psychotic spectrum disorders recognise a broad range of emotions conveyed dynamically through facial, vocal and bodily expressions. Participants were allocated to three groups: those with PSD and a history of interpersonal aggression, those with PSD but no aggression history, and healthy individuals.
The researchers hypothesised that misclassification would be greatest in the PSD with aggression group, intermediate in the PSD without aggression group, and lowest in healthy controls.
The sample comprised 79 people with psychotic spectrum disorders and a history of interpersonal aggression, recruited from Forensic Psychiatry Stockholm; 72 people with PSD but no aggression, recruited at psychiatric outpatient clinics in Stockholm; and 86 healthy individuals recruited via Sweden’s State Person Address Registry. Groups were matched for age and gender, with men constituting between 69% and 75% of each group and average ages ranging from 35 to 39. Participants with PSD had been clinically stable, with no changes in medication for at least three months before testing.
Most participants with PSD had schizophrenia (79% in the aggression group and 86% in the non-aggression group). Information about aggression-related acts came from crime reports, forensic assessments, hospital records and self-reports. Aggressive acts were defined as threats to life, assault, grievous bodily harm or murder/manslaughter; about half of the aggression group had assaulted others, and about a third had been convicted of grievous bodily harm.
The groups differed in other ways as well. More than three-quarters of the aggression group had a history of alcohol or substance abuse, compared with about a third of the non-aggression group and 7% of healthy participants. Education levels also differed, with more than half of the aggression group not progressing beyond primary school, compared with 15% of the non-aggression group. The aggression group also scored lower on a measure of fluid intelligence.
Participants underwent psychiatric screening, a fluid intelligence test (Matrix Reasoning subtest of WAIS-IV) and a psychomotor speed test. They also completed a task assessing knowledge of emotion terms by selecting synonyms for 14 emotion words. The Emotion Recognition Assessment in Multiple modalities (ERAM) asked participants to watch and listen to short clips of actors expressing 12 emotions through faces, voices and bodies while uttering nonsense sentences. Clips were shown as video only, audio only, or video with sound, and participants chose the emotion from a list of 12.
As anticipated, those with PSD and an aggression history performed the worst. Across emotions, accuracy ranged from 25% for despair to 54% for anger. Those with PSD but no aggression history fared better, with accuracy from 29% for despair to 66% for anger, while healthy participants performed best, from 39% to 68%.
All groups performed well above chance, and the gaps between groups were similar across emotions and across video, audio and combined presentations, suggesting the difficulties reflected broad cognitive and perceptual challenges rather than emotion-specific or sensory-specific problems. Emotions were best recognised when both video and sound were present.
A distinctive finding was in the error pattern: the aggression group misread negative emotions as positive in 14% of cases, about 1.2 times more often than the non-aggression group and twice as often as healthy participants. The authors suggest such errors could blunt recognition of social cues that might otherwise curb escalating interactions.
Within the PSD groups, fluid intelligence and understanding of emotion words were the strongest predictors of emotion recognition, followed by gender (women outperforming men) and educational attainment. A history of substance abuse was linked to better performance once other factors were accounted for, a result the authors caution may be a statistical artefact. Importantly, a history of aggression still predicted poorer emotion recognition after adjustment, though it explained only about 2% of the additional variation in performance.
In summary, individuals with PSD and a history of interpersonal aggression exhibit more pronounced deficits in emotion recognition than those with PSD alone. This underscores the potential value of incorporating emotion recognition assessment and training into clinical interventions to reduce aggression risk and improve social functioning in individuals with PSD, the study authors concluded.
The researchers note that the study cannot establish causality. Differences in education, intelligence and substance use histories between groups, as well as other unmeasured factors, may influence results. Participants were tested while clinically stable, so findings may not reflect emotion recognition during acute psychosis or agitation. The stimuli were acted expressions provided by white European actors, developed in Switzerland, which may be interpreted differently by people from other backgrounds.
The paper, “Emotion recognition misclassification patterns in individuals with psychotic spectrum disorders and history of interpersonal aggression,” lists Gabriela Gavalova and colleagues as authors.
