Review article
The effect of antipsychotic medication on facial affect recognition in schizophrenia: A review

https://doi.org/10.1016/j.psychres.2008.07.025Get rights and content

Abstract

Patients with schizophrenia suffer from impairments in facial affect recognition and social functioning. Since antipsychotic medication affects different areas in the brain, they may also affect target areas involved in emotional processing mechanisms. In this article, we review the findings of the effect of antipsychotic medication on facial affect recognition in schizophrenia. We searched PubMed for articles in English with the keywords schizophrenia, facial, affect, emotion, antipsychotic and medication, published till January 2008. Eight relevant articles were found describing original studies. No substantial improvements in facial affect recognition were found after treatment with either typical or atypical antipsychotic drugs. Facial affect recognition was not related to neuropsychological functioning, and it was unclear whether improvement of symptom severity was related to performance on the facial affect recognition tasks. It is recommended that future research should focus on measuring social skills and social functioning more directly, and by investigating the effects of additional behavioural treatments on facial affect recognition and social functioning relative to treatment with antipsychotic medication alone.

Introduction

Three broad types of symptoms characterise schizophrenia: psychotic symptoms, cognitive impairment and negative symptoms (Mueser and McGurk, 2004). Negative symptoms are deficit states in which basic emotional and behavioural processes are diminished or absent. Negative symptoms (Fitzgerald et al., 2003) and cognitive impairment (Green et al., 2000) are strongly associated with functional impairment, including impairment in community living and work, as well as a limited quality of life. In addition, several investigators have found a deficit in facial affect recognition in schizophrenia (Walker et al., 1981, Feinberg et al., 1986, Heimberg et al., 1992, Mandal et al., 1998, Edwards et al., 2002), which may be related to the impairments in social functioning, work functioning and independent living (Mueser et al., 1996, Hooker and Park, 2002, Kee et al., 2003, Addington et al., 2006, Couture et al., 2006, Trémeau, 2006). However, it is still unclear whether the impairment in affect perception is a specific emotional deficit or whether it is related to a more generalised impairment in perception and attention (Bozikas et al., 2004).

It has previously been found that medication-free patients with schizophrenia and individuals at risk for developing a psychosis are impaired in their ability to recognise emotional facial expressions (Kerr and Neale, 1993, Addington et al., 2008). However, most patients with schizophrenia use antipsychotic medication. Therefore, it is important to investigate the effects of antipsychotic medication on facial affect recognition.

The main targets of most atypical antipsychotic agents are the dopaminergic and serotonergic systems, which are extensively distributed throughout the mesocorticolimbic regions (amygdala, hippocampus, thalamus and anterior cingulate) and the frontal cortical area, known to be implicated in emotional processing (Takahashi et al., 2005). Adolphs (2002) reviewed the neural systems necessary for recognising emotion in healthy individuals and distinguished two different processes: first, the perceptual processing (identifying) of facial features and second, the recognition of the emotional meaning. Adolphs (2002) discovered that the perceptual processing of emotional expressions involves visual cortical regions, and there is evidence that the fusiform gyrus is necessary to represent the static features of faces and identification, whereas the superior temporal gyrus is responsible for representing the dynamic features of faces. In schizophrenia, disturbances in neuronal activity during emotion recognition are found in the amygdala, the fusiform and the mid-occipital gyrus (Taylor et al., 2002, Johnston et al., 2005, Holt et al., 2006). In a review on abnormal brain functioning during emotional stimulation, Phillips et al. (2003) concluded that patients with schizophrenia showed impaired responses of the amygdala, anterior insula, and ventral striatum, regions that are part of the ventral system which is involved in the identification of the emotional significance of a stimulus, overt displays of emotions and autonomic responses to emotion-eliciting stimuli, that is, the more basic responses to these stimuli. Thus, the disturbances in these areas found in schizophrenia could contribute to difficulties in identifying emotional facial expressions. The aim of this review is to investigate whether antipsychotic medication is able to improve facial affect recognition in patients with schizophrenia.

Two previous reviews have been published regarding emotion perception and antipsychotic treatment. Mueser et al. (1997) reviewed three studies, all using the same outcome measures, with different sample characteristics in terms of chronicity of the illness and medication status (on/off medication). Unfortunately, Mueser et al. (1997) did not compare the different antipsychotics and their effects on facial affect recognition. Pinkham et al. (2007) only briefly described some studies that have investigated the effects of antipsychotic treatment of affect perception, but they do not give an extensive overview of these studies. The aim of the present review is to compare studies that investigated the effect of different antipsychotic agents on facial affect recognition in schizophrenia.

Section snippets

Methods

We searched PubMed for articles in English published till January 2008. The keywords we used were schizophrenia, facial, affect, emotion, antipsychotic and medication. We excluded editorials and letters, and studies that did not explicitly investigate the effects of antipsychotic medication on facial affect recognition.

We calculated effect sizes (Cohen's d; Cohen, 1992) where possible, either by using the reported means and standard deviations of the relevant tests, or by converting the

Results

Using the search terms ‘schizophrenia’, ‘facial’, ‘emotion’ and ‘antipsychotic’ resulted in a list of 29 articles, of which seven were useful for the present review (Lewis and Garver, 1995, Kee et al., 1998, Williams et al., 2003, Herbener et al., 2005, Harvey et al., 2006, Sergi et al., 2007, Fakra et al., in press). Using the search terms ‘schizophrenia’, ‘facial’, ‘emotion’ and ‘medication’ resulted in a list of 26 articles, of which five were useful (Gaebel and Wölwer, 1992, Kee et al., 1998

Discussion

This review was performed to compare studies that investigated the effects of antipsychotic medication on facial affect recognition in schizophrenia. Eight studies were eligible to be included in the present review.

Acknowledgements

The authors wish to thank the three anonymous reviewers for their constructive commentary during the preparation of this review article.

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