Facial Emotion Recognition Ability in Individuals with Remitted Schizophrenia in Comparison to Healthy Population: A Cross-Sectional Study

Abstract

Background:

Facial emotion recognition is one of the significant domains of social cognition that underlie social interactions. These deficits can influence the functional outcome in individuals with schizophrenia by impairing judgment toward others and reducing their capability to function. We aimed to assess the facial emotion recognition deficits in individuals with schizophrenia in comparison to healthy individuals and find their association with clinical and demographic profiles.

Methods:

This cross-sectional study compared individuals with schizophrenia in a stable remitted phase of illness to an age, gender, and education-matched healthy population, including 30 participants in each group. The assessment was done using Addenbrooke’s Cognitive Examination (ACE-III), AIIMS Facial Toolbox for Emotion Recognition (AFTER), and the Positive and Negative Syndrome Scale (PANSS). Intergroup comparison was done using the Independent sample t-test, and the association of facial emotional deficit with any clinical or demographic factor was analyzed using Pearson’s correlation.

Results:

The schizophrenia group performed significantly worse than healthy controls on identifying positive and negative emotions except for happiness. The time to recognize emotion was also found to be significantly more in the schizophrenia group than in controls. Also, significant cognitive deficits were found in the schizophrenia group in comparison to the healthy population. Negative emotions were found to be more correlated to psychopathology.

Conclusion:

Individuals with schizophrenia appear to have a stable deficit in facial emotion recognition (more in negative emotions). Cognitive deficits are seen more in individuals with schizophrenia as compared to healthy populations, even in their stable phase of illness.

Keywords

Emotion facial emotion schizophrenia social cognition psychosis cognition

Key Messages:

Facial emotion recognition deficits persist in individuals with schizophrenia even after symptom remission.

Differences are observable in both positive and negative emotion recognition between schizophrenia and the healthy population.

Negative emotions appear to be more correlated to psychopathology in schizophrenia.

Cognitive functioning is poorer even in a stable state of schizophrenia compared to a healthy population.

Study Highlights:

Individuals with schizophrenia have social cognitive deficits in the form of faulty emotion recognition even in a remitted state.

Emotion recognition deficits exist both in the form of accuracy and the time to identify the emotion.

Cognitive deficits persist in remitted schizophrenia.

Schizophrenia is one of the most debilitating psychiatric illnesses, which significantly affects both individuals and society by causing impairment in socialization, loss of employment, and impaired ability to lead a life without support. It is a chronic illness with varied psychopathology—positive symptoms (delusions and hallucinations), negative symptoms (anhedonia, asocial, alogia, and avolition), and cognitive symptoms (both social and nonsocial). The negative and cognitive symptoms have more deteriorating outcomes with chronic course and have long-term effects on social interaction.¹ Cognitive impairments are one of the most distinct features of schizophrenia, which affects almost 98% of the individual.² Nonsocial cognition or neuro-cognitive domains comprise speed of processing, verbal learning and memory, visuospatial learning and memory, working memory, attention/vigilance, reasoning, and problem-solving. In contrast, the social cognition domain comprises emotion processing, social perception, attribution bias/style, and theory of mind. Social cognition indicates the psychological means involved in perceiving, encoding, storing, retrieving, and regulating information about the individual and people around them in the context of social interactions.³

Social cognition has a significant role in causing poor functioning in schizophrenia and has a comparatively stronger influence on community functioning (a direct indicator of everyday functioning).⁴ It is, therefore, gaining research interest, as it appears to be one of the treatable determinants of functional outcome. In addition, a better understanding of this social cognition would provide possibilities for targeted recovery-focused interventions. Furthermore, social cognition is also a trait factor that precedes the onset of illness, according to the research. Therefore, studying in this area may also offer a better insight into the cause of the illness.³

The most studied aspects of social cognition in schizophrenia include mentalizing and emotion processing. Mentalizing is defined as the ability to infer the intentions, dispositions, emotions, and beliefs of others, including whether they are sincere, sarcastic, or deceptive.⁵ Emotion processing means to perceive and use emotions adaptively, with facial emotion perception being the most frequently studied aspect in this area. Facial emotion recognition partially facilitates the association between cognitive and social functioning. Individuals with schizophrenia have been reported to have deficits in facial emotion processing and abnormal neurological responses to emotional stimuli.¹

Most studies on the determination of emotional deficits in schizophrenia have utilized Western standardized instruments. Culture strongly influences emotions and thus should have an impact on emotion recognition, too.⁶ There has been some work done in non-Western countries in this aspect utilizing culture-sensitive emotion recognition tools. Studies on Chinese patients with schizophrenia have shown that they recognize both positive (joy) and negative emotions (sadness, fear, disgust, and anger) worse than healthy controls.^7,8 These deficits are more pronounced in individuals with deficit-type schizophrenia, characterized by persistent primary negative symptoms. However, Korean studies report alterations in negative emotion recognition but found no significant differences in recognizing positive emotions like joy.⁹ Other than poor accuracy in identification, the response times for the recognition of contempt, sadness, and neutral emotion have been found to be delayed.⁹ The abnormal performance has been found to correlate with alterations in the culmen of the cerebellum anterior lobe in schizophrenia.¹⁰ When assessed for interpreting facial expressions with ambiguous valence, a longer time was taken by individuals with schizophrenia for recognizing surprise, suggesting the importance of background information to be considered during assessment.¹¹ Recent studies report that the pattern of emotion misidentification in schizophrenia is similar to healthy individuals, and the accuracy of facial emotion recognition is negatively correlated to the age of illness onset.¹² Researchers also reported a negative correlation of emotion recognition to negative symptoms but not to positive symptoms. A meta-analysis of Chinese studies reported significant facial emotion recognition impairments for the six basic facial emotions (happiness, sadness, fear, disgust, anger, and surprise), as well as for contempt, calmness, and neutral facial expressions.¹³

While there are few studies from the Indian sub-continent on this aspect,¹⁴ there is scarce literature utilizing culture-sensitive facial emotion recognition tools.^15,16 Some of these studies lacked a comparative healthy control group,^17,18 or had a small sample size.¹⁹ Recently, more robust databases for emotion recognition that are culturally sensitive for India have been reported.²⁰ Therefore, we attempted to use a standardized Indian database of facial emotion recognition to increase the authenticity of previous findings. Moreover, to build upon previous literature, this study incorporated healthy individuals for comparison, adequately powered the study, and correlated emotion deficits with neuro-cognition, clinical, and demographic profiles to delineate factors affecting this ability. To avoid the effects of the acute state of illness, we recruited individuals in their stable phase of illness.

Methods

This cross-sectional study compared individuals with schizophrenia (n = 30) to age, gender, and education-matched healthy individuals (n = 30) at a tertiary care hospital in North India from September 2023 to March 2024. Before initiating the study, the Institute Ethics Committee (IEC/2023/CC-274) approved it.

Participants

Individuals between the age group of 18 to 50 years diagnosed with schizophrenia as per the Diagnostic and Statistical Manual (DSM 5), with the ability to read and write in Hindi or English, clinically stable (defined as item scores of ≤3 in each category of Positive and Negative Syndrome Scale (PANSS)), on stable medication dose for at least 6 weeks (if on oral treatment) or 12 weeks (if on depot injections), and with a minimum illness duration of one year with no hospitalization or electroconvulsive therapy received in the previous 12 weeks were included in the case group. Since previous literature has reported the impact of age and gender on emotion recognition ability,^21,22 we chose the younger adult group to maintain homogeneity in the sample. A healthy control population (age, gender, and education matched) was also recruited from the outpatient clinic at the Department of Psychiatry (from among staff or caregivers) and was screened by a clinician for the absence of any psychiatric illness and included in the control group.

Individuals were excluded from either group if there was the presence of comorbid substance use disorder (except nicotine and caffeine) within the last one year, a history of neurological illness (such as seizure disorder, head injury, stroke, or neurodegenerative disease), any uncontrolled medical condition, any significant visual or hearing impairment or intellectual disability excluded by measuring performance intelligence quotient (IQ) on Vineland Social Maturity Scale (VSMS). Individuals providing written informed consent were enrolled in the study.

Sample Size

The sample size required in each arm of the study was calculated based on a previous similar study design.²³ With 90% power and 95% confidence interval (CI), the minimum sample size for each arm was calculated as 25. Considering the attrition rate and to make the group even smaller with a 1:1 distribution, the sample size was increased to 30 in each group. Purposive sampling was conducted for participant recruitment in both groups.

Instruments

A semi-structured proforma was used to assess the socio-demographic and clinical details of the participants.

PANSS: This 30-item Likert scale evaluates the symptom severity in schizophrenia on 3 subscales for positive symptoms (delusions and hallucination), negative symptoms (anhedonia, asocial, alogia, avolition), and general psychopathology.²⁴ It constitutes 7 items for the positive scale, 7 for the negative scale, and 16 for the general psychopathology scale. The total score ranges from 7 to 49 for positive and negative scales and 16 to 112 for the general psychopathology scale.

Addenbrooke’s Cognitive Examination (ACE-III): It is a neuropsychological test used to identify cognitive impairment.²⁵ The scale consists of 19 activities, which test five cognitive domains: attention, memory, fluency, language, and visuospatial processing. Each domain is scored to give a total score out of 100 (18 points for attention, 26 for memory, 14 for fluency, 26 for language, and 16 for visuospatial processing). The score needs to be interpreted in the context of the individual‘s overall history and examination. However, a score of 88 and above is considered normal; below 83 is abnormal, and between 83 and 87 is inconclusive. It is available in English and Hindi language.

All India Institute of Medical Sciences (AIIMS) Facial Toolbox for Emotion Recognition (AFTER): This is a facial expression database for emotion recognition that was developed and standardized for use in the Indian population.²⁰ It has eight expressions (happiness, sadness, disgust, fear, surprise, anger, contempt, and neutral) provided by professionals in drama. Each emotion includes 11 colored static pictures in the original tool. We chose four images from each emotion that had the highest average hit rate for recognition. The participants were provided free choices for recognizing the expression in an image from the list of the above eight emotions. The answer was labeled as one of the four responses—correct, incorrect, no response, or recognized as any other emotion. Permission was obtained from the author before using the tool.

Medication Adherence Rating Scale (MARS): This is a type of adherence scale with 10 questions.²⁶ It assesses an individual’s behavior or attitude toward their medication during the past week.

Statistical Analysis

Data was analyzed using Statistical Product and Service Solutions version 29 (SPSS Inc, IBM, United States). Categorical variables are presented in frequency (percentage), and continuous variables are presented as mean ± standard deviation (SD) or median with interquartile range (IQR). Intergroup comparison was done for the socio-demographic parameters, cognitive functioning, and emotion recognition using the Independent Student t-test and chi-squared test for continuous and categorical variables, respectively. Levene’s test for equality of variances was performed to observe homogeneity of variance for continuous variables. Pearson’s correlation was done to observe the association of socio-demographic or clinical factors with facial emotion recognition in either group. A p-value of less than .05 was considered significant. Correction for multiple comparisons among the groups was done using Bonferroni adjustment (p = .05/number of comparisons).

Results

Sociodemographic Parameters

The mean age of participants in the schizophrenia group was comparable to healthy individuals (39.30 ± 5.39 years and 39.30 ± 5.19 years, respectively, p = 1.00). With equal gender distribution among the groups, most of the participants were males (57%), belonged to a Hindu nuclear family, and were from an urban community (Table 1). More than 50% of participants in the schizophrenia group were unemployed, whereas about 33% were unemployed in the healthy group. Though not significant, separation/divorce was more commonly observed in the schizophrenia group.

Table 1.

Intergroup Comparison of Sociodemographic Parameters.

		Schizophrenia Group (n = 30) Frequency (%)	Healthy Group (n = 30) Frequency (%)	Chi-squared Value
Gender	Male	17 (56.7)	17 (56.7)	–
Gender	Female	13 (43.3)	13 (43.3)	–
Education	Primary	4 (13.3)	3 (10)	0.65
	Secondary	21 (70)	24 (80)
	Graduate	5 (16.7)	3 (10)
Occupation	Unemployed	17 (56.7)	10 (33.3)	0.62
	Self-employed	2 (6.7)	7 (23.3)
	Private job	9 (30)	13 43.3)
	Government job	2 (6.7)	–
Religion	Hindu	28 (93.3)	28 (93.3)	0.26
	Muslim	2 (6.7)	–
	Christian	–	2 (6.7)
Residential state	Delhi	26 (86.7)	25 (83.3)	0.24
	U.P.	1 (3.3)	4 (13.3)
	Haryana	3 (10)	1 (3.3)
Residence	Urban	30 (100)	30 (100)	–
Residence	Rural	0 (0)	0 (0)	–
Family type	Nuclear	26 (86.7)	29 (96.7)	0.35
Family type	Joint	4 (13.3)	1 (3.3)	0.35
Socioeconomic status	Lower	7 (23.3)	2 (6.7)25	0.56
	Middle	21 (70)	28 (93.3)
	Upper	2 (6.7)	–
Marital status	Married	25 (83.3)	29 (96.7)	0.43
Marital status	Separated	5 (26.7)	1 (3.3)	0.43

*p<.05.

Clinical Details

The mean age of illness onset was 31.70 ± 7.12 years among cases. The median duration of illness was 84 (84) months, and the median duration of treatment was 36 (56) months. About 83.3% of participants had a continuous course of illness, while the rest (16.7%) had an episodic course. About 83.3% of participants had no medical comorbidity, while the rest (16.7%) had hypothyroidism and type II diabetes. About 96.7% of participants did not report any positive symptoms, 20% reported having negative symptoms in the form of decreased social interaction, and 36.7% of participants reported cognitive symptoms mostly in the form of forgetfulness. None of the participants reported any affective symptoms. The mean score of PANSS positive symptom dimension was 7.47 ± 0.86; of PANSS negative symptom dimension was 7.70 ± 1.17; of PANSS General psychopathology dimension was 17.03 ± 0.80; and of PANSS Total was 32.20 ± 1.40.

All the participants in the schizophrenia group were on monotherapy, with a variable distribution of antipsychotic medication—olanzapine (n = 8), risperidone (n = 16), lurasidone (n = 1), clozapine (n = 2), aripiprazole (n = 2), and cariprazine (n = 1). On the assessment of treatment adherence, about 86.7% of participants were adherent to the treatment, and the rest (13.3%) were relatively adherent.

Cognitive Functioning

In comparison to the healthy controls, participants in the schizophrenia group performed poorly on all the parameters of ACE-III: attention, memory, fluency, language, visuospatial, and the total score (Table 2). Except for the language, all other ACE-III domains, including total scores, were found to be significantly different even after the Bonferroni adjustment.

Table 2.

Intergroup Comparison of the ACE Parameters.

ACE Parameters	Schizophrenia Group Mean ± SD	Healthy Group Mean ± SD	t^a	df	MD	95% CI
ACE Parameters	Schizophrenia Group Mean ± SD	Healthy Group Mean ± SD	t^a	df	MD	Lower	Upper
Attention	12.93 ± 2.50	15.43 ± 1.92	4.33**	58	2.50	1.34	3.65
Memory	13.70 ± 6.53	19.23 ± 3.87	3.98**	47.14^b	5.53	2.74	8.32
Fluency	7.70 ± 3.53	11.20 ± 2.41	4.48**	51.20^#	3.50	1.93	5.06
Language	22.87 ± 2.38	24.37 ± 2.84	2.21*	58	1.50	0.14	2.85
Visuospatial	11.63 ± 3.00	14.20 ± 1.29	4.30**	39.47^#	2.56	1.36	3.77
Total	68.50 ± 15.03	84.67 ± 7.76	5.23**	43.44^#	16.16	9.93	22.39

^aIndependent sample t-test.

^bCorrected for significant values after Levene’s test for equality of variances (p<.05).

*p<.05.

**p <.01 with Bonferroni adjustment (p = .05/5 = .01).

ACE: Addenbrooke’s Cognitive Examination, CI: confidence interval, df: degrees of freedom, MD: mean difference, SD: standard deviation.

Emotion Recognition

The average hit rates for the emotions were higher in healthy individuals than those in the schizophrenia group for all emotions (sadness—96.66 vs. 60.83%, disgust—67.5 vs. 30%, fear—94.17 vs. 59.17%, surprise—67.5 vs. 37.5%, anger—87.5 vs. 70%, contempt—28.33 vs. 12.5%, and neutral—57.5 vs. 40.83%, respectively) except for happiness for which both groups had 100% recognition.

As shown in Table 3, except for happiness and neutral images, individuals in the schizophrenia group were able to recognize a significantly lesser number of images of all other emotions—anger (t = 2.36, p = .02), contempt (t = 2.52, p = .01), disgust (t = 4.58, p < .001), sadness (t = 5.81, p < .001), surprise (t = 3.54, p = .001), and fear (t = 4.99, p < .001). The contempt images were less recognizable than other emotion images in both groups. All the participants in both groups were able to identify each of the happiness emotion images. Neutral images were more recognized by healthy participants but were marginally significant than the schizophrenia group (t = 1.66, p = .05). It was also observed that the schizophrenia group took comparatively more time than the healthy group in emotion identification, with significant differences observed for all emotions except happiness. The differences remained significant when corrected for multiple comparisons for recognition and response time for disgust, sadness, surprise, and fear images (p < .003).

Table 3.

Intergroup Comparison of the Facial Emotion Recognition Parameters.

After Parameters	Schizophrenia Group Mean ± SD	Healthy Group Mean ± SD	t^a	df	MD	95% CI
After Parameters	Schizophrenia Group Mean ± SD	Healthy Group Mean ± SD	t^a	df	MD	Lower	Upper
Anger rec	2.80 ± 1.27	3.50 ± 1.00	2.36*	58	0.70	0.10	1.29
Anger rec time (sec)	50.46 ± 11.98	43.50 ± 12.26	–2.22*	58	–6.95	–13.22	–0.69
Contempt rec	0.50 ± 0.63	1.13 ± 1.22	2.52*	43.34^b	0.63	0.12	1.14
Contempt rec time (sec)	47.04 ± 10.51	39.74 ± 10.11	–2.74**	58	–7.29	–12.62	–1.96
Disgust rec	1.20 ± 1.27	2.70 ± 1.26	4.58***	58	1.50	0.84	2.15
Disgust rec time (sec)	50.78 ± 9.21	42.27± 9.50	–3.52***	58	–8.50	–13.34	–3.67
Happy rec	4.00 ± 0.00	4.00 ± 0.00	–	–	–	–	–
Happy rec time (sec)	19.11 ± 4.74	17.31 ± 4.57	–1.49	58	–1.80	–4.21	0.60
Neutral rec	1.63 ± 1.54	2.30 ± 1.55	1.66	58	0.66	–0.13	1.46
Neutral rec time (sec)	54.68 ± 8.60	48.88 ± 9.61	–2.46*	58	–5.79	–10.51	–1.08
Sad rec	2.43 ± 1.27	3.87 ± 0.43	5.81***	35.60^b	1.43	0.93	1.93
Sad rec time (sec)	57.17 ± 3.60	51.58 ± 4.62	–5.22***	58	–5.59	–7.73	–3.45
Surprise rec	1.50 ± 1.07	2.70 ± 1.51	3.54***	52.34^b	1.20	0.52	1.88
Surprise rec time (sec)	59.01 ± 6.79	47.44 ± 9.21	–5.53***	58	–11.56	–15.75	–7.38
Fear rec	2.37 ± 1.45	3.77 ± 0.50	4.99***	35.90^b	1.40	0.83	1.96
Fear rec time (sec)	45.32 ± 11.43	36.42 ± 7.83	–3.51***	58	–8.90	–13.96	–3.83

^aIndependent sample t-test.

^bCorrected for significant values after Levene’s test for equality of variances (p<.05).

*p<.05.

**p<.01.

***p<.001 with Bonferroni adjustment (p = .05/16 = .003).

CI: confidence interval, df: degrees of freedom, MD: mean difference, Rec: recognition, SD: standard deviation.

In the schizophrenia group, disgust and sadness recognition time were more in females than males (disgust recognition time: t = 3.21, df = 25.35, p = .004, mean difference [MD] = 8.94, 95% CI = 14.68–3.20; sadness recognition time: t = 1.95, df = 28, p = .03, MD = 2.48, 95% CI = 5.08–0.11). No other gender differences were observed in either schizophrenia or healthy groups. After correcting for multiple comparisons (p < .003), no gender difference was noted in either group.

Due to very low scoring for recognition and time to recognize, contempt emotion was not analyzed for the correlation matrix (Table 4). The number of anger images recognized was negatively correlated with PANSS positive dimension (r = –0.44), PANSS total scores (r = –0.40), and fluency domain of ACE-III (r = –0.39). The number of disgust images recognized was positively correlated with PANSS Negative dimension (r = 0.36) but negatively with PANSS General Psychopathology scores (r = –0.37). Neutral image recognition was positively correlated with the visuospatial domain of ACE-III (r = 0.46) and ACE-III total scores (r = 0.42). Surprise image recognition was negatively correlated with PANSS Total scores (r = –0.43). No other significant correlation was noted for any emotion recognition with other sociodemographic or clinical parameters.

The time taken to recognize disgust was negatively correlated with the age of the participant at the onset of illness (r = –0.45) and PANSS general psychopathology scores (r = –0.46). The time taken to recognize surprise was positively correlated with the age at illness onset (r = 0.40) and negatively correlated with fluency domain (r = –0.47), visuospatial domain (r = –0.38), and ACE-III total scores (r = –0.36). No significant correlation was observed in the time taken for emotion recognition for the rest of the emotions with other socio-demographic or clinical parameters (Table 4).

Table 4.

Correlation of Clinical Parameters to AFTER Variables.

Parameters	Age	Age at Onset	PANSS Positive Dimension	PANSS Negative Dimension	PANSS GP	PANSS Total	Attention	Memory	Fluency	Language	Visuo- spatial	ACE Total
Anger recognition	–0.20	–0.03	–0.44*	0.05	–0.22	–0.40*	0.12	–0.30	–0.39*	–0.13	–0.24	–0.24
Anger recognition time (sec)	0.15	–0.05	–0.06	0.26	–0.32	–0.05	0.04	–0.05	–.09	–0.12	–0.03	–0.03
Disgust recognition	0.01	–0.01	–0.02	0.36*	–0.37*	0.05	–0.12	–0.09	–0.07	–0.21	–0.10	–0.07
Disgust recognition time (sec)	–0.23	–0.45*	0.02	0.08	–0.46**	–0.16	0.06	0.06	0.22	–0.03	0.15	0.13
Neutral recognition	0.10	–0.26	0.10	0.16	–0.34	–0.04	0.36	0.35	0.21	0.23	0.46*	0.42*
Neutral recognition time (sec)	0.26	0.16	0.04	0.05	0.11	0.13	–0.01	–0.13	–0.31	–0.10	–0.14	–0.19
Sad recognition	–0.27	–0.04	0.15	–0.25	0.11	0.08	–0.20	–0.21	–0.10	–0.26	–0.30	–0.29
Sad recognition time (sec)	–0.01	0.07	–0.12	0.11	–0.24	–0.13	–0.23	–0.30	–0.24	–0.35	–0.31	–0.36*
Surprise recognition	–0.20	–0.19	–0.26	–0.31	–0.06	–0.43*	0.21	0.10	0.30	.32	0.21	0.21
Surprise recognition time (sec)	0.24	0.40*	–0.16	0.00	0.18	0.00	–0.06	–0.30	–0.47**	–0.27	–0.38*	–0.36*
Fear recognition	0.03	–0.11	–0.22	–0.07	0.22	–0.05	–0.01	0.09	0.23	0.24	0.15	0.22
Fear recognition time (sec)	0.23	–0.17	0.12	0.17	–0.25	0.06	0.10	0.07	0.20	0.13	0.21	0.15

*Correlation is significant at the 0.05 level (2-tailed).

**Correlation is significant at the 0.01 level (2-tailed).

ACE: Addenbrooke’s Cognitive Examination, AFTER: AIIMS Facial Toolbox for Emotion Recognition, GP: General Psychopathology, PANSS: Positive and Negative Syndrome Scale.

Discussion

This study investigated one of the important aspects of the social cognition domain, that is, facial emotion deficit in individuals with schizophrenia in their stable phase of illness, and compared it to healthy individuals. In line with the established literature, our findings replicate the previous observations and found a significantly higher deficit in facial emotion recognition in the schizophrenia group compared to healthy individuals both in accuracy and reaction time.²⁷

It was observed that the schizophrenia group performed worse in the identification of all the emotions except happiness emotion, in agreement with previous literature.^27,28 An Indian study reported similar findings, but they found significant differences for only negative emotion recognition when compared with healthy individuals.²⁸ In contrast, in this study, a significant difference was observed in both positive and negative emotion recognition (disgust, sadness, surprise, and fear). The reason for this difference could be due to the use of different facial emotional tools and phases of the illness of schizophrenia in the studies.

Several studies have reported quicker response time with more accuracy in the identification of happiness emotion, the concept being mentioned as an advantage effect in happiness face recognition.²⁹ This study also validated these findings. It extended the report to show that both the healthy group and the schizophrenia group identified maximum pictures, taking the least amount of time to identify. Previous studies have reported fear to be the least identified emotion, followed by disgust, sadness, and anger.³⁰ In our study, though, negative emotions were identified with difficulty, disgust, and contempt, which showed the worst performance (accuracy and response time). In this study, the ascending order of recognition pattern was for contempt, disgust, surprise, neutral, and then positive emotions in both groups. Meta-analysis suggests that individuals having schizophrenia have more difficulty in identifying the negative and neutral emotions in comparison to the positive emotions.¹ Literature has mentioned fear to be misinterpreted as anger, linking it to paranoid ideation,³¹ which was not found in our study. The reason could be the individual being in a stable phase of illness in this study.

Existing literature is still inconsistent, with no strong indication of a deficit of a particular emotion in schizophrenia.³² Our study also confirmed these findings and observed facial recognition of negative emotion being affected more in comparison to positive emotions. Researchers have reported comparatively poorer performance of negative emotion (anger and fearfulness, whereas in our study, disgust, and contempt) and the highest performance on happiness face recognition.³³ Neurobiological research has implicated abnormal amygdala activation in individuals with schizophrenia for these facial emotion deficits.³⁴ Walker and colleagues also proposed the avoidance behavior of schizophrenia patients toward stimuli that induce negative emotion, leading to a greater deficit in negative emotions.³⁵ Another explanation given for the differential response between the positive and negative facial emotions is that positive emotions are generally easier to recognize and, therefore, have a lesser bearing on the illness; such differential discrimination is less prominent in healthy individuals (as also noted in this study except for emotion recognition of disgust which was performed poorly by either group) because of the nearly best performance in the majority of the task, that is, ceiling effect.³⁶

Studies have explained increased reaction time in schizophrenia to be related to their arousal response to the cues or due to the aberrant emotional salience.¹¹ This may suggest that emotion recognition deficits seen in schizophrenia are not specific to any of the emotion types but a general perceptual impairment in processing facial emotion expression information.³⁷ Neuroimaging studies have given evidence for this correlation and showed defects in the areas of the frontotemporal region, leading to a deficit in the neurocognitive domain and emotion processing in individuals with schizophrenia.³⁸ As indicated in previous research, the schizophrenia group performed worse in all the parameters of cognitive functioning compared to healthy controls. Only neutral and negative emotions (surprise, anger) were mildly correlated to cognitive scores among the schizophrenia group. Meta-analysis has reported impairment in emotion recognition to be linked with cognitive deficits in different domains like attention, memory, fluency, and language. However, results are still lacking in pointing to a specific cognitive domain.³⁹ With the stricter criteria, language does not appear to differentiate schizophrenia from healthy individuals. Thus, its link with facial emotion recognition deficits could be less than that of other cognitive domains. However, the small sample size in this study may have been less powerful in portraying the discriminating ability.

Most of the previous research has reported male gender overrepresentation. For this reason, we included similar profiles in both groups (schizophrenia and healthy). Furthermore, we tried regulating both groups in terms of gender, age, and education in demographic profiles to eliminate the confounding factors influencing emotion recognition. This study found no gender difference in the accuracy of facial emotion recognition in either schizophrenia or healthy groups. Previous literature also reports no gender difference in facial emotion perception.^40,41 These findings are indicative that recognition of facial emotions is generally performed badly irrespective of gender in schizophrenia. There are still discrepancies in gender-specific facial emotion deficit, with few studies showing an inclination toward males having more deficit in recognition of negative emotions due to higher propensity of substance use in them.⁴² This study excluded the influence of substance in emotion recognition by not including such cases in the study.

Individuals having an earlier age of illness onset were found to have more ease in identifying surprise but had difficulty with identifying disgust emotion. A few studies have shown a correlation between increased age and worsening facial emotion recognition abilities in patients with schizophrenia. Although few researchers have found neutral emotion recognition in favor of the younger age group,⁴³ have not yet noted strong evidence to show the effect of emotion recognition with age. Reasons explained in the literature are cognitive decline with age and the long-term effect of the illness or the psychotropic drugs leading to cognitive decline.^29,44,45

Facial emotion recognition deficits have been consistently demonstrated in individuals with schizophrenia, and arguments are going on for this characteristic to be a trait phenomenon.⁴⁶ Constant emotion recognition deficits have been reported during different phases of illness in schizophrenia in comparison to healthy individuals.⁴⁵ We found a mild correlation of negative emotions (anger, disgust, and surprise) to PANSS scores that could indicate that psychopathology and severity of the disorder might have some role in the identification of facial emotions even in the stable phase of illness with more impact of severity of illness on negative emotions. Researchers have observed similar findings showing the severity of the illness to be an influencing factor in the quality of facial emotion recognition.³³ Researchers have hypothesized specific impairment in recognition of negative emotions to be attributable to social-emotional processing disturbance existing even before the onset of the illness. They might not be related to the symptomatology or misattribution phenomenon.⁴⁷ These recognition deficits appeared to be independent of the general cognitive deficits observed in schizophrenia.⁴⁸ Another reason explained is a hypodopaminergic state in the prefrontal cortex affecting both neurocognition and social cognition (facial recognition being one of its important components).⁴³ Facial emotion recognition deficit has also been linked with the misprocessing of visual stimuli,⁴⁹ or deficit in the top-down control of visual stimuli processing.⁵⁰ Two theoretical concepts have been postulated to explain the decoding of the facial emotion deficit in schizophrenia—first, due to a general perceptual deficit for understanding facial features and second, due to difficulty in comprehending facial emotional cues leading to emotion-specific deficit. This study showed findings that inclined toward the latter theory with a deficit more in negative emotions.⁵¹

This study is limited in generalizability owing to its small sample size, cross-sectional design, and lack of data preceding illness onset that may have affected emotion recognition deficits like personality factors. Since all the patients were on antipsychotic medications, the impact of medicines on emotion recognition could not be ascertained. The strength of the study was the use of AFTER, an emotion recognition tool validated in the Indian population. Most of the Indian data on facial emotion recognition deficits till now was based on the tool validated for the Western population. To remove the confounding factors influencing emotion recognition, sample collection was robust, with groups matching for age, gender, and education. IQ assessment was also done in all the subjects to overcome the influence of general cognitive decline/deficit on facial emotion recognition, as suggested in previous literature.⁵² The assessment was done in stable remitted individuals, paving the way to discern emotion recognition deficit as a trait marker in schizophrenia. Moreover, we analyzed the potential factors that could influence this ability, such as the severity or duration of the symptoms and dimensions of psychopathology, among other clinical variables.

Further evaluation of factors contributing to these emotion recognition deficits in terms of neurocognitive impairments and neuroimaging correlates in a larger population of schizophrenia, preferably comparing medication naïve to those on various treatment modalities, should be explored in the future. The impact of facial emotion deficits on individual social and work environments, impacting features such as empathy and stress, should be studied in the future to analyze the significance of the assessment of social cognition in schizophrenia.

Conclusion

This study found that individuals with schizophrenia present with social cognition deficits in the form of emotion recognition even when clinically remitted. The deficit is both in the form of accuracy in identifying the emotion and in the time needed to identify the emotion. Negative emotions were found to have a worse impact in comparison to positive emotions, with happiness emotions being the least impacted. Cognitive decline persists in schizophrenia patients in comparison to healthy individuals even in their remission phase of the illness, though their impact on emotion recognition needs to be more studied.

Supplemental Material

Supplemental material for this article is available online.

Footnotes

Acknowledgements

The authors thank the patients and their caregivers for participating in this study.

I assume full responsibility for the entire content of the manuscript and confirm that no part has been generated by any artificial intelligence (AI) tool.

Author Statement

This work was entirely conducted by the authors and is being submitted for publication in the journal. I transfer all copyright ownership of the enclosed manuscript to the journal on behalf of all authors. I warrant that this article is original and has not been in part or in whole simultaneously submitted to or published in another journal or has been presented in any conference.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Declaration Regarding the Use of Generative AI

None used.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Informed Consent—Case Reports/Clinical Images

The study was approved by the Institutional Ethics Committee of the VMMC and Safdarjung Hospital, New Delhi, India (IEC/2023/CC-274).

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