Facial expression to emotional stimuli in non-psychotic disorders: A systematic review and meta-analysis

The EmpkinS-EKSpression Reappraisal Training Augmented With Kinesthesia in Depression: One-Armed Feasibility Study

BACKGROUND

Harboring dysfunctional depressogenic cognitions contributes to the development and maintenance of depression. A central goal of cognitive behavioral therapy (CBT) for depression is to invalidate such cognitions via cognitive reappraisal (CR). However, relatively low remission rates and high dropout rates in CBT demonstrate the need for further improvement. Potentially, the effects of CBT could be enhanced by addressing not only dysfunctional depressogenic cognitions but also body states associated with depression. This may be done, for example, by systematically pairing the invalidation of depressogenic cognitions with the performance of antidepressive kinesthesia.

OBJECTIVE

This study aimed to examine the feasibility and clinical potential of a smartphone-based cognitive restructuring task that required users to deliberately perform antidepressive kinesthesia in conjunction with the rejection of depressogenic statements and the affirmation of antidepressive statements. This feasibility study was conducted as a precursor to a large-scale randomized controlled trial.

METHODS

In total, 10 healthy participants engaged in a single 90-120-minute session of smartphone-based CR training. During the training, they completed 2 phases in which they were required to reject 20 depressogenic and affirm 20 antidepressive statements, respectively. Diagnostic assessments were conducted 1 week (T1) before and directly prior (T2) to the training, and again directly posttraining (T3) and at a 2-week follow-up posttraining (T4). Feasibility outcomes assessed at T3 included intervention safety recorded by study therapists, compliance, technical feasibility, usability assessed using the Short Version of the User Experience Questionnaire (UEQ-S), and acceptability assessed using the UEQ-S and self-developed items. Preliminary clinical potential was evaluated via single-item ratings of current depressed and positive mood assessed continuously during the training. Feasibility outcomes were analyzed descriptively, and clinical potential was examined using paired-sample t tests of pre and post ratings of mood at each training phase.

RESULTS

Overall, the results indicated that the training was safe, feasible, and usable (UEQ-S pragmatic quality scale: mean 1.45, SD 0.71). However, acceptance was limited (UEQ-S hedonic quality scale: mean 1.05, SD 0.79). While 80% (8/10) of the participants were generally satisfied with the training, 80% (8/10) would recommend it to a friend, 90% (9/10) found it interesting, and 80% (8/10) rated it as "leading edge," 40% (4/10) to 70% (7/10) did not consider it particularly helpful and 50% (5/10) found it repetitive. Preliminary results regarding clinical potential were promising, with significant increases in positive mood (rejection: Hedges g=0.63; affirmation: Hedges g=0.25), whereas changes in depressed mood were not significant.

CONCLUSIONS

This study evaluated the feasibility and acceptability of a smartphone-based CR training augmented with validating and invalidating kinesthesia. This provided valuable insights for further optimizing the intervention for the subsequent randomized controlled trial, but also potential similar interventions. If future studies confirm their clinical potential, such interventions offer a promising approach to enhancing CBT for depression.

TRIAL REGISTRATION

OSF Registries pw6ma; https://osf.io/pw6ma/.

How facial expressions reveal acute pain in domestic animals with facial pain scales as a diagnostic tool

The growing interest in managing and recognizing pain in animals has led to the search for more sensitive methods to evaluate it, especially because some species conceal any visible changes associated with pain or are not easily assessed. Research has shown that an animal's facial expression changes when exposed to painful stimuli. Thus, developing several pain scales (grimace scales) in species such as horses, cattle, pigs, sheep, donkeys, rabbits, rats, mice, and cats has helped to improve the study of pain in veterinary medicine. The possibility of using facial expression as an indicator of pain is due to the direct relationship between the activation of different regions of the Central Nervous System such as the somatosensory cortex, prefrontal cortex, amygdala, hippocampus, and hypothalamus, and their connections with the motor cortex to elicit motor responses including the movement of facial muscles. The present review aims to discuss the neurobiological association between acute pain and facial expressions in animals. It will analyze the importance of facial expression characterization and the use of grimace scales in farm, companion, and laboratory species.

Reliability and validity of facial expression recognition in the screening of generalized anxiety disorder

INTRODUCTION

Anxiety disorder is one of the most prevalent mental disorders in China. However, there are obvious subjective factors in the current assessment of anxiety disorders, which may lead to certain diagnostic errors. The identification and diagnosis of anxiety disorders can be further improved if objective biological indicators are added in the assessment process. The current research validates facial expression recognition as a screening tool to assist in detecting generalized anxiety disorder.

METHODS

Based on the International Affective Picture System, we constructed an aided diagnostic experimental paradigm and recorded their facial expression. The split-half reliability was displayed by the Pearson correlation heatmap. The paradigm, GAD-7 and HAMA scales were administered to 60 generalized anxiety disorder patients and 60 matched healthy controls to evaluate the criterion-related validity. Additionally, we conducted a diagnostic study by using MINI as a gold standard and calculated ROC analysis to examine the screening performance of the facial expressions.

RESULTS

The heatmap showed very high correlations (r > 0.60, PS < 0.05) along the diagonal of the square heatmap (from the bottom left corner to the top right). The Pearson correlation coefficients between the GAD-7, HAMA and seven facial expressions ranged from -0.35(neutral, P < 0.01) to 0.34(angry, P < 0.01). The intergroup effects of neutral, anger and fear emotions were statistically significant (F = 18.893, P < 0.001; F = 20.535, P < 0.001; F = 9.091, P = 0.003). ROC analysis showed AUC for neutral, angry and scared facial expressions were 0.723, 0.792 and 0.727 respectively.

CONCLUSION

This study constructed a tool for auxiliary screening of GAD patients and provided an objective automatic facial expression recognition method to assist psychological diagnosis.

Affect Expression During Social and Non-Social Contexts in Autistic Young Adults

Autism spectrum disorder (ASD) is characterized by impairments in social affective engagement. The present study uses a mild social stressor task to add to inconclusive past literature concerning differences in affective expressivity between autistic young adults and non-autistic individuals from the general population (GP). Young adults (mean age = 21.5) diagnosed with ASD (n = 18) and a non-autistic comparison group (n = 17) participated in the novel social stress task. Valence (positive/negative) and intensity of facial affect were coded across four observational episodes that alternated between engagement and disengagement of social conversational partner. Results indicated an overall attenuation in expressivity in the ASD group in comparison to the non-autistic group. Mean affect differed between groups, especially in the amount of affective expression. Both groups responded with increased positive expressions during social engagement episodes. The affect difference was driven by a smaller proportion of positive and a greater proportion of neutral affect displays in the ASD group compared to the non-autistic group during these episodes, and less so by negative affect differences. The results suggest that friendly, non-threatening social interactions should not be assumed to be aversive to autistic individuals, and that these individuals may respond to such situations with muted positive valence. These findings are consistent with past reports of decreased expressivity in autistic individuals compared to individuals from the general population, specifically in an ecologically valid social context.

Facing depression: evaluating the efficacy of the EmpkinS-EKSpression reappraisal training augmented with facial expressions - protocol of a randomized controlled trial

BACKGROUND

Dysfunctional depressogenic cognitions are considered a key factor in the etiology and maintenance of depression. In cognitive behavioral therapy (CBT), the current gold-standard psychotherapeutic treatment for depression, cognitive restructuring techniques are employed to address dysfunctional cognitions. However, high drop-out and non-response rates suggest a need to boost the efficacy of CBT for depression. This might be achieved by enhancing the role of emotional and kinesthetic (i.e., body movement perception) features of interventions. Therefore, we aim to evaluate the efficacy of a cognitive restructuring task augmented with the performance of anti-depressive facial expressions in individuals with and without depression. Further, we aim to investigate to what extent kinesthetic markers are intrinsically associated with and, hence, allow for the detection of, depression.

METHODS

In a four-arm, parallel, single-blind, randomized controlled trial (RCT), we will randomize 128 individuals with depression and 128 matched controls without depression to one of four study conditions: (1) a cognitive reappraisal training (CR); (2) CR enhanced with instructions to display anti-depressive facial expressions (CR + AFE); (3) facial muscle training focusing on anti-depressive facial expressions (AFE); and (4) a sham control condition. One week after diagnostic assessment, a single intervention of 90-120-minute duration will be administered, with a subsequent follow-up two weeks later. Depressed mood will serve as primary outcome. Secondary outcomes will include current positive mood, symptoms of depression, current suicidality, dysfunctional attitudes, automatic thoughts, emotional state, kinesthesia (i.e., facial expression, facial muscle activity, body posture), psychophysiological measures (e.g., heart rate (variability), respiration rate (variability), verbal acoustics), as well as feasibility measures (i.e., treatment integrity, compliance, usability, acceptability). Outcomes will be analyzed with multiple methods, such as hierarchical and conventional linear models and machine learning.

DISCUSSION

If shown to be feasible and effective, the inclusion of kinesthesia into both psychotherapeutic diagnostics and interventions may be a pivotal step towards the more prompt, efficient, and targeted treatment of individuals with depression.

TRIAL REGISTRATION

The study was preregistered in the Open Science Framework on August 12, 2022 ( https://osf.io/mswfg/ ) and retrospectively registered in the German Clinical Trials Register on November 25, 2024.

CLINICAL TRIAL NUMBER

DRKS00035577.

Effects of Sleep Quality, Acute Sleep Deprivation, and Napping on Facial Emotion Recognition Accuracy and Speed

Objective

To investigate the effects of sleep quality, sleep deprivation, and napping on facial emotion recognition (FER) accuracy and speed.

Methods

This research included a cross-sectional study (102 qualified participants) and a randomized controlled study (26 in the napping group and 24 in the control group). The stimuli for the FER task were obtained from the Chinese Facial Affective Picture System (CFAPS). Four facial expressions (fearful, disgusted, sad, and angry) were used. The Pittsburgh Sleep Quality Index (PSQI), Self-Rating Anxiety Scale, and Self-Rating Depression Scale were used to measure participants' sleep quality and psychological conditions. In Study 1, FER ability was compared between good and poor sleepers. In Study 2, all participants were sleep-deprived for one night, and completed the FER task before and after sleep deprivation. After different interventions (ie, napping for one hour, or walking around for ten minutes), the participants completed the third FER task.

Results

Study 1: Poor sleepers were able to recognize sad expressions more accurately compared with good sleepers. Study 2: 30-h sleep deprivation had no significant effect on the accuracy (ACC). Napping after sleep deprivation improved the FER ACC of upper-face expressions and marginally significantly improved the FER ACC of disgusted expressions.

Conclusion

Better sleep quality was linked to lower FER accuracy, particularly in recognizing sad expressions, while no significant differences in recognition speed were observed. Additionally, 30 hours of sleep deprivation did not affect FER accuracy, but napping after sleep deprivation improved accuracy for upper-face and marginally for disgusted expressions.

Linking Affect Dynamics and Well-Being: A Novel Methodological Approach for Mental Health

Emotions are dynamic processes; their variability relates to psychological well-being and psychopathology. Affective alterations have been linked to mental diseases like depression, although little is known about how similar patterns occur in healthy individuals. This study investigates the psychophysiological correlations of emotional processing in healthy subjects, specifically exploring the relationship between depressive traits, cognitive distortions, and facial electromyographic (f-EMG) responses during affective transitions. A cohort of 44 healthy participants underwent f-EMG recording while viewing emotional images from the International Affective Picture System (IAPS). Self-report measures included the Beck Depression Inventory (BDI) and the Cognitive Distortion Scale (CDS). Higher BDI scores were associated with increased EMG activity in the corrugator muscle during transitions between positive and negative emotional states. Cognitive distortions such as Catastrophizing, All-or-Nothing Thinking, and Minimization showed significant positive correlations with EMG activity, indicating that individuals with higher levels of these distortions experienced greater facial muscle activation during emotional transitions. This study's results indicate that there is a bidirectional correlation between depressed features and cognitive distortions and alterations in facial emotional processing, even in healthy subjects. Facial EMG in the context of dynamic affective transitions has the potential to be used as a non-invasive method for detecting abnormal emotional reactions at an early stage. This might help in identifying individuals who are at risk of developing depression and guide therapies to prevent its advancement.

Autistic traits and perspective taking in youths with anorexia nervosa: an exploratory clinical and eye tracking study

BACKGROUND

Despite their apparent dissimilarity, Anorexia Nervosa (AN) and Autism Spectrum Disorder (ASD) share many features, especially in terms of social and emotional difficulties. In recent years, empathic abilities in AN have been frequently assessed using self-report measures. Otherwise, the director task (DT) has been used to investigate the ability to take the visual perspective of another individual in a communicative context, using eye-tracking technology. The aim of the current study was to test the presence of autism-relevant features in AN, through: (i) comparing self-reported autistic traits and empathic abilities in a group of young inpatients with AN and age/gender matched healthy controls (HC); (ii) comparing performance on the director paradigm.

METHODS

The participants were females in the age-range between 11 and 18 years: 24 with AN and 23 HC. Autistic traits, empathic abilities, and severity of the eating disorder were respectively measured using: the Autism Quotient (AQ), the Interpersonal Reactivity Index (IRI), and the Eating Disorder Inventory-3 (EDI-3). Both groups performed a computerized task in which a director instructed them to move objects placed on a set of shelves using a mouse, while their eye gaze was tracked. A total of 36 shelf configurations, divided into three categories (with dimensional distractor - with spatial distractor - control), were created.

RESULTS

Subjects with AN showed higher autistic traits than HC. Eye-tracking data revealed that subjects with AN took longer to decide which object to select and where to move it, both in distractor-trials and in control-trials. In the AN group, we found a significant negative correlation between the total score of the AQ and the number of fixations to the irrelevant object in the dimensional control condition -in which the subjects were asked to focus on dimensional aspects of the object (large-small)-.

CONCLUSIONS

Autistic traits were over-represented in a group of young inpatients with AN. Through the use of eye-tracking technology, this exploratory study documented some differences between AN inpatients and HC in their online processes during the perspective taking tasks, which could be considered a target of tailored intervention. A larger sample of patients is needed to confirm these preliminary findings.

Behavioral meaures of psychotic disorders: Using automatic facial coding to detect nonverbal expressions in video

Emotional deficits in psychosis are prevalent and difficult to treat. In particular, much remains unknown about facial expression abnormalities, and a key reason is that expressions are very labor-intensive to code. Automatic facial coding (AFC) can remove this barrier. The current study sought to both provide evidence for the utility of AFC in psychosis for research purposes and to provide evidence that AFC are valid measures of clinical constructs. Changes of facial expressions and head position of participants-39 with schizophrenia/schizoaffective disorder (SZ), 46 with other psychotic disorders (OP), and 108 never psychotic individuals (NP)-were assessed via FaceReader, a commercially available automated facial expression analysis software, using video recorded during a clinical interview. We first examined the behavioral measures of the psychotic disorder groups and tested if they can discriminate between the groups. Next, we evaluated links of behavioral measures with clinical symptoms, controlling for group membership. We found the SZ group was characterized by significantly less variation in neutral expressions, happy expressions, arousal, and head movements compared to NP. These measures discriminated SZ from NP well (AUC = 0.79, sensitivity = 0.79, specificity = 0.67) but discriminated SZ from OP less well (AUC = 0.66, sensitivity = 0.77, specificity = 0.46). We also found significant correlations between clinician-rated symptoms and most behavioral measures (particularly happy expressions, arousal, and head movements). Taken together, these results suggest that AFC can provide useful behavioral measures of psychosis, which could improve research on non-verbal expressions in psychosis and, ultimately, enhance treatment.

Functional social isolation mediates the association between depression and executive function in older women: findings from the Canadian Longitudinal Study on Aging Comprehensive cohort

Depression and social isolation increase risk for executive function declines and are among the top five modifiable risk factors for dementia. However, the interrelationships between depression, social isolation and executive function are not well established. Further evidence is needed to inform strategies to promote executive function and independence in older age. We examined whether social isolation mediated the association between depression and executive function in community-dwelling middle-aged and older adults and whether this association was modified by age and sex. Adults aged 45 to 85 years from the Canadian Longitudinal Study on Aging (CLSA) Comprehensive cohort were followed over three years (complete case analysis, n = 14,133). Baseline depressive symptoms, a history of clinical depression, and functional social isolation (perceived lack of social support) were self-reported. Executive function at follow-up was a composite measure of five cognitive tests. Conditional process analysis assessed the mediating effects of functional social isolation across age group and sex, adjusted for sociodemographic and health covariates. Functional social isolation significantly mediated the association of depressive symptoms (proportion mediated [PM] = 8.0%) or clinical depression (PM = 17.5%) with executive function only among women aged 75+ years. Functional social isolation explains a proportion of the total effect of depressive symptoms or clinical depression on executive function in women aged 75 and older. Although reverse causation cannot be ruled out, our findings suggest that interventions that reduce functional social isolation or depression in older women may promote executive function.

Automating the analysis of facial emotion expression dynamics: A computational framework and application in psychotic disorders

Facial emotion expressions play a central role in interpersonal interactions; these displays are used to predict and influence the behavior of others. Despite their importance, quantifying and analyzing the dynamics of brief facial emotion expressions remains an understudied methodological challenge. Here, we present a method that leverages machine learning and network modeling to assess the dynamics of facial expressions. Using video recordings of clinical interviews, we demonstrate the utility of this approach in a sample of 96 people diagnosed with psychotic disorders and 116 never-psychotic adults. Participants diagnosed with schizophrenia tended to move from neutral expressions to uncommon expressions (e.g., fear, surprise), whereas participants diagnosed with other psychoses (e.g., mood disorders with psychosis) moved toward expressions of sadness. This method has broad applications to the study of normal and altered expressions of emotion and can be integrated with telemedicine to improve psychiatric assessment and treatment.

Multimodal Mental Health Digital Biomarker Analysis From Remote Interviews Using Facial, Vocal, Linguistic, and Cardiovascular Patterns

OBJECTIVE

Psychiatric evaluation suffers from subjectivity and bias, and is hard to scale due to intensive professional training requirements. In this work, we investigated whether behavioral and physiological signals, extracted from tele-video interviews, differ in individuals with psychiatric disorders.

METHODS

Temporal variations in facial expression, vocal expression, linguistic expression, and cardiovascular modulation were extracted from simultaneously recorded audio and video of remote interviews. Averages, standard deviations, and Markovian process-derived statistics of these features were computed from 73 subjects. Four binary classification tasks were defined: detecting 1) any clinically-diagnosed psychiatric disorder, 2) major depressive disorder, 3) self-rated depression, and 4) self-rated anxiety. Each modality was evaluated individually and in combination.

RESULTS

Statistically significant feature differences were found between psychiatric and control subjects. Correlations were found between features and self-rated depression and anxiety scores. Heart rate dynamics provided the best unimodal performance with areas under the receiver-operator curve (AUROCs) of 0.68-0.75 (depending on the classification task). Combining multiple modalities provided AUROCs of 0.72-0.82.

CONCLUSION

Multimodal features extracted from remote interviews revealed informative characteristics of clinically diagnosed and self-rated mental health status.

SIGNIFICANCE

The proposed multimodal approach has the potential to facilitate scalable, remote, and low-cost assessment for low-burden automated mental health services.

High depressive symptomatology reduces emotional reactions to pictures of social interaction

Individuals with severe depressive symptoms present diminished facial expressions compared to healthy individuals. This reduced facial expression, which occurs in most depressive patients could impair social relationships. The current study sought to investigate whether pictures with social interaction cues could elicit different modulations of facial expressions and mood states in individuals with depressive symptoms compared to healthy individuals. A total of 85 individuals were divided into depressive and non-depressive groups based on their beck depression inventory scores. Participants viewed pictures containing neutral (objects), affiliative (people interacting socially), and control (people not interacting) scenes. Electromyographic signals were collected during the entire period of visualization of the blocks, and emotional questionnaires were evaluated after each block to assess sociability and altruism (prosocial states). In non-depressed individuals, affiliative pictures increased the activity of the zygomatic muscle compared to both neutral and control pictures and reduced fear of rejection compared to neutral pictures. During the visualization of the affiliative block, zygomatic major muscle activation was higher and fear of rejection was lower in the non-depressive individuals than in the depressive. These effects reflected the low expressions of smiling and sociability to affiliative pictures in depressive individuals. These findings highlight the importance of smiling and prosocial states in social interactions, especially in these individuals.

The effects of online facial muscle training with resonance vocalization on mental health in postpartum women: A single-arm pilot study

BACKGROUND

Mental health problems among expectant and nursing mothers also affect their infants, partners, and families. While physical activity is a potential method for preventing postpartum depression (PPD), it is difficult for postpartum women to find the time for physical exercise. A recent study reported that improving communication between expectant couples can be used as a preventive intervention for PPD, and a systematic review and meta-analysis recently reported decreased facial emotional expressivity in individuals with different non-psychotic disorders. Therefore, we focused on facial muscle training and its potential as prevention for PPD.

OBJECTIVE

We evaluated the effectiveness of online facial muscle training with resonance vocalization using real-time video conferencing programs on the PPD of postpartum women at 2-3 months.

DESIGN

We recruited 20 postpartum women and used a single-arm, prospective, pre-post design.

METHODS

All subjects participated in 30 min of online facial muscle training with resonance vocalization once a week for 4 weeks. The first and final sessions were performed using a real-time remote chat application, and the second and third sessions were performed on demand. Scores on the Edinburgh Postnatal Depression Scale (EPDS) as an indicator of PPD were used as the primary outcome. Secondary outcomes included the appearance ratio of a happy facial expression, analyzed using FaceReader™; mood, which was measured using a visual analog scale; and stress level, which was measured using a smartwatch.

RESULTS

The training had a significant effect on EPDS, appearance ratio of a happy facial expression, and mood; however, it did not affect physical stress.

CONCLUSIONS

In the future, intervention studies with a higher evidence level, such as a crossover randomized controlled trial, are required.

Multimodal mental health assessment with remote interviews using facial, vocal, linguistic, and cardiovascular patterns

Objective

The current clinical practice of psychiatric evaluation suffers from subjectivity and bias, and requires highly skilled professionals that are often unavailable or unaffordable. Objective digital biomarkers have shown the potential to address these issues. In this work, we investigated whether behavioral and physiological signals, extracted from remote interviews, provided complimentary information for assessing psychiatric disorders.

Methods

Time series of multimodal features were derived from four conceptual modes: facial expression, vocal expression, linguistic expression, and cardiovascular modulation. The features were extracted from simultaneously recorded audio and video of remote interviews using task-specific and foundation models. Averages, standard deviations, and hidden Markov model-derived statistics of these features were computed from 73 subjects. Four binary classification tasks were defined: detecting 1) any clinically-diagnosed psychiatric disorder, 2) major depressive disorder, 3) self-rated depression, and 4) self-rated anxiety. Each modality was evaluated individually and in combination.

Results

Statistically significant feature differences were found between controls and subjects with mental health conditions. Correlations were found between features and self-rated depression and anxiety scores. Visual heart rate dynamics achieved the best unimodal performance with areas under the receiver-operator curve (AUROCs) of 0.68-0.75 (depending on the classification task). Combining multiple modalities achieved AUROCs of 0.72-0.82. Features from task-specific models outperformed features from foundation models.

Conclusion

Multimodal features extracted from remote interviews revealed informative characteristics of clinically diagnosed and self-rated mental health status.

Significance

The proposed multimodal approach has the potential to facilitate objective, remote, and low-cost assessment for low-burden automated mental health services.

Brain functional alterations in patients with anorexia nervosa: A meta-analysis of task-based functional MRI studies

The goal of this study was to discern the neural activation patterns associated with anorexia nervosa (AN) in response to tasks related to body-, food-, emotional-, cognitive-, and reward- processing. A meta-analysis was performed on task-based fMRI studies, revealing that patients with AN showed increased activity in the left superior temporal gyrus and bilaterally in the ACC during a reward-related task. During cognitive-related tasks, patients with AN also showed increased activity in the left superior parietal gyrus, right middle temporal gyrus, but decreased activity in the MCC. Additionally, patients with AN showed increased activity bilaterally in the cerebellum, MCC, and decreased activity bilaterally in the bilateral precuneus/PCC, right middle temporal gyrus, left ACC when they viewed food images. During emotion-related tasks, patients with AN showed increased activity in the left cerebellum, but decreased activity bilaterally in the striatum, right mPFC, and right superior parietal gyrus. Patients with AN also showed increased activity in the right striatum and decreased activity in the right inferior temporal gyrus and bilaterally in the mPFC during body-related tasks. The present meta-analysis provides a comprehensive overview of the patterns of brain activity evoked by task stimuli, thereby augmenting the current comprehension of the pathophysiology in AN.

Positive communication workshops: are they useful for treatment programmes for anorexia nervosa?

Background

Social isolation, loneliness and difficulties in relationships are often described as a core feature of eating disorders. Based on the experimental research, we have designed one-off workshops for patients in inpatients and day care services and evaluated its acceptability and effectiveness using feedback questionnaires.

Methods

This naturalistic project is an evaluation of multiple positive communication workshops. Forty-one participants completed workshop questionnaires, which were provided immediately at the beginning and end of the workshop, including feedback on these one-off groups. The workshops consisted of educational and experiential components. The questionnaire outcomes were evaluated by independent researchers.

Results

All participants were female adults with a mean age of 33 (12.2) and a diagnosis of Anorexia Nervosa (AN; either restrictive or binge-purge subtype). Post-workshop questionnaires showed large effect sizes in the improvement of understanding the importance and confidence in using positive communication strategies.

Discussion

Addressing social communication difficulties in eating disorder treatment programmes adds valuable dimensions to these symptom-based treatments in both inpatient settings and day services, and may provide broader benefits in overall social functioning in patients with AN.

Conclusion

Brief one-off workshops targeting social functioning for patients with eating disorders might be useful complementary input for treatment programmes.

Facial mimicry and metacognitive judgments in emotion recognition are distinctly modulated by social anxiety and autistic traits

Facial mimicry as well as the accurate assessment of one's performance when judging others' emotional expressions have been suggested to inform successful emotion recognition. Differences in the integration of these two information sources might explain alterations in the perception of others' emotions in individuals with Social Anxiety Disorder and individuals on the autism spectrum. Using a non-clinical sample (N = 57), we examined the role of social anxiety and autistic traits in the link between facial mimicry, or confidence in one's performance, and emotion recognition. While participants were presented with videos of spontaneous emotional facial expressions, we measured their facial muscle activity, asked them to label the expressions and indicate their confidence in accurately labelling the expressions. Our results showed that confidence in emotion recognition was lower with higher social anxiety traits even though actual recognition was not related to social anxiety traits. Higher autistic traits, in contrast, were associated with worse recognition, and a weakened link between facial mimicry and performance. Consequently, high social anxiety traits might not affect emotion recognition itself, but the top-down evaluation of own abilities in emotion recognition contexts. High autistic traits, in contrast, may be related to lower integration of sensorimotor simulations, which promote emotion recognition.

Autistic traits distribution in different psychiatric conditions: A cluster analysis on the basis of the Adult Autism Subthreshold Spectrum (AdAS Spectrum) questionnaire

Increasing interest is being paid on full-threshold and sub-threshold autism spectrum conditions among adults. Sub-threshold autistic traits (AT) seem to be distributed in a continuum from the clinical to the general population, being particularly higher among subjects with other psychiatric disorders. The aim of the present study was to evaluate the distribution of AT in a sample of subjects with different psychiatric conditions by means of a cluster analysis on the basis of the score reported to the AdAS Spectrum instrument. A total of 738 subjects recruited by seven Italian Universities were divided in 5 groups depending on the clinical diagnosis: Autism spectrum disorder (ASD), subthreshold ASD symptoms (partial ASD), Bipolar disorder (BD), Feeding and eating disorders (FED), and controls (CTLs). All subjects were assessed with the AdAS Spectrum. The cluster analysis identified 3 clusters: the high, medium and low autism clusters. The Restricted interests and rumination domain reported the highest influence in forming the clusters. The high, medium and low autism clusters were respectively more represented in the ASD, partial ASD and CTL groups. The clusters were represented intermediately in the FED and BD groups, confirming the presence of intermediate levels of AT in these clinical populations.

Insomnia and impacts on facial expression recognition accuracy, intensity and speed: A meta-analysis

Facial expressions provide nonverbal cues that are important for delivering and interpreting human emotions. Previous studies have shown that the ability to interpret facial emotions correctly could be partially impaired in sleep-deprived people. People with insomnia might also suffer from sleep loss, so we assumed that facial expression recognition ability might also be impaired in people with insomnia. Despite a growing body of research exploring insomnia's potential impacts on facial expression recognition, conflicting results have been reported, and no systematic review of this research body has been conducted. In this study, after screening 1100 records identified through database searches, six articles examining insomnia and facial expression recognition ability were included in a quantitative synthesis. The main outcomes were classification accuracy (ACC), reaction time (RT), and intensity rating-the three most studied facial expression processing variables. Subgroup analysis was performed to identify altered perceptions according to the facial expressions of four emotions-happiness, sadness, fear, and anger-used to examine insomnia and emotion recognition. The pooled standard mean differences (SMDs) and corresponding 95% confidence intervals (CIs) demonstrated that facial expression recognition among people with insomnia was less accurate (SMD = -0.30; 95% CI: -0.46, -0.14) and slower (SMD = 0.67; 95% CI: 0.18, -1.15) compared to good sleepers. The classification ACC of fearful expression was lower in the insomnia group (SMD = -0.66; 95% CI: -1.02, -0.30). This meta-analysis was registered using PROSPERO.

Non-verbal social communication in individuals with eating disorders: an ethological analysis in experimental setting

PURPOSE

Evidence that social difficulties promote the development and the maintenance of eating disorders (EDs) derive from self-reported data and only partially from experimental tasks. This study objectively assessed non-verbal behaviors of individuals with EDs in a psycho-social stress scenario.

METHODS

Thirty-one women suffering from EDs (13 with anorexia nervosa and 18 with bulimia nervosa) and 15 healthy women underwent the Trier Social Stress Test (TSST), the paradigm of psycho-social stress, and were videotaped. Throughout the procedure, anxiety feelings were measured by the State-Trait Anxiety Inventory state subscale and saliva samples were collected to evaluate cortisol levels. Non-verbal behaviors were analyzed through the Ethological Coding System for Interviews and were compared between study samples through multivariate analysis of variance. Multivariate regression analyses were performed to assess the association between anxiety, cortisol and behavioral responses to TSST.

RESULTS

Women with EDs showed reduced submissiveness, flight (cutoff from social stimuli) and gesture compared to healthy peers during TSST. Submissiveness and flight behaviors were negatively associated with stress-induced anxiety, while TSST-induced anxiety and cortisol increases were positively associated with looking at the other's face behavior in participants with EDs. In this population, cortisol reactivity was also positively associated with submissiveness and negatively with gesture.

CONCLUSION

Women with EDs showed a hostile and freezing response to acute psycho-social stress: reduced submissiveness and flight may represent strategies to manage social anxiety. These findings confirm that the non-verbal behavior assessment provides complementary information to those derived from traditional measurements and suggests research and clinical implications.

LEVEL OF EVIDENCE I

Evidence obtained from experimental study.

Evaluation of film stimuli for the assessment of social-emotional processing: a pilot study

Background

Difficulties in top-down and bottom-up emotion generation have been proposed to play a key role in the progression of psychiatric disorders. The aim of the current study was to develop more ecologically valid measures of top-down interpretation biases and bottom-up evoked emotional responses.

Methods

A total of 124 healthy female participants aged 18-25 took part in the study. We evaluated two sets of 18 brief film clips. The first set of film clips presented ambiguous social situations designed to examine interpretation biases. Participants provided written interpretations of each ambiguous film clip which were subjected to sentiment analysis. We compared the films in terms of the valence of participants interpretations. The second set of film clips presented neutral and emotionally provoking social scenarios designed to elicit subjective and facial emotional responses. While viewing these film clips participants mood ratings and facial affect were recorded and analysed using exploratory factor analyses.

Results

Most of the 18 ambiguous film clips were interpreted in the expected manner while still retaining some ambiguity. However, participants were more attuned to the negative cues in the ambiguous film clips and three film clips were identified as unambiguous. These films clips were deemed unsuitable for assessing interpretation bias. The exploratory factor analyses of participants' mood ratings and evoked facial affect showed that the positive and negative emotionally provoking film clips formed their own factors as expected. However, there was substantial cross-loading of the neutral film clips when participants' facial expression data was analysed.

Discussion

A subset of the film clips from the two tasks could be used to assess top-down interpretation biases and bottom-up evoked emotional responses. Ambiguous negatively valenced film clips should have more subtle negative cues to avoid ceiling effects and to ensure there is enough room for interpretation.

Genuine and non-genuine smiles in individuals meeting criteria for a clinical high-risk syndrome

AIM

Psychosis is characterized by both alterations in emotional functioning and environmental stressors including bullying victimization. Recent evidence suggests that some alterations in emotional functioning (e.g., blunted positive facial expressions) are already present in the psychosis risk period. Yet, some clinically relevant facial emotions have not been investigated such as genuine smiles (thought to reflect genuine positive emotions) and non-genuine smiles (thought to fake positive or mask negative emotions) in individuals meeting criteria for a clinical high-risk (CHR) syndrome. Further, despite a compelling conceptual basis to suggest a link between affective expression and exposure to environmental stress, to date, no investigations have sought to examine this association. Here, we aim to assess differences between a sample of CHR (N = 65) and control (N = 67) individuals in genuine and non-genuine smiles and associations with bullying victimization.

METHODS

Smiles (i.e., genuine; non-genuine) were objectively coded on a second-by-second basis using the Facial Action Coding System during a digitally recorded clinical interview segment. Bullying victimization was measured via parent report.

RESULTS

Findings revealed that the CHR group (1) showed blunted genuine (but not non-genuine) smiles compared to controls. Moreover, (2) bullying victimization was related to blunted genuine smiles, but not non-genuine smiles.

CONCLUSION

These findings expand our understanding of emotional alterations in this group with implications for diagnosis (highlighting blunted genuine smiles as a specific marker) and etiology (underscoring the role of bullying victimization in the etiology of emotional dysfunction).

Test–Retest Reliability in Automated Emotional Facial Expression Analysis: Exploring FaceReader 8.0 on Data from Typically Developing Children and Children with Autism

Automated emotional facial expression analysis (AEFEA) is used widely in applied research, including the development of screening/diagnostic systems for atypical human neurodevelopmental conditions. The validity of AEFEA systems has been systematically studied, but their test–retest reliability has not been researched thus far. We explored the test–retest reliability of a specific AEFEA software, Noldus FaceReader 8.0 (FR8; by Noldus Information Technology). We collected intensity estimates for 8 repeated emotions through FR8 from facial video recordings of 60 children: 31 typically developing children and 29 children with autism spectrum disorder. Test–retest reliability was imperfect in 20% of cases, affecting a substantial proportion of data points; however, the test–retest differences were small. This shows that the test–retest reliability of FR8 is high but not perfect. A proportion of cases which initially failed to show perfect test–retest reliability reached it in a subsequent analysis by FR8. This suggests that repeated analyses by FR8 can, in some cases, lead to the “stabilization” of emotion intensity datasets. Under ANOVA, the test–retest differences did not influence the pattern of cross-emotion and cross-group effects and interactions. Our study does not question the validity of previous results gained by AEFEA technology, but it shows that further exploration of the test–retest reliability of AEFEA systems is desirable.

Deep learning-based classification of posttraumatic stress disorder and depression following trauma utilizing visual and auditory markers of arousal and mood

BACKGROUND

Visual and auditory signs of patient functioning have long been used for clinical diagnosis, treatment selection, and prognosis. Direct measurement and quantification of these signals can aim to improve the consistency, sensitivity, and scalability of clinical assessment. Currently, we investigate if machine learning-based computer vision (CV), semantic, and acoustic analysis can capture clinical features from free speech responses to a brief interview 1 month post-trauma that accurately classify major depressive disorder (MDD) and posttraumatic stress disorder (PTSD).

METHODS

N = 81 patients admitted to an emergency department (ED) of a Level-1 Trauma Unit following a life-threatening traumatic event participated in an open-ended qualitative interview with a para-professional about their experience 1 month following admission. A deep neural network was utilized to extract facial features of emotion and their intensity, movement parameters, speech prosody, and natural language content. These features were utilized as inputs to classify PTSD and MDD cross-sectionally.

RESULTS

Both video- and audio-based markers contributed to good discriminatory classification accuracy. The algorithm discriminates PTSD status at 1 month after ED admission with an AUC of 0.90 (weighted average precision = 0.83, recall = 0.84, and f1-score = 0.83) as well as depression status at 1 month after ED admission with an AUC of 0.86 (weighted average precision = 0.83, recall = 0.82, and f1-score = 0.82).

CONCLUSIONS

Direct clinical observation during post-trauma free speech using deep learning identifies digital markers that can be utilized to classify MDD and PTSD status.

Computerized analysis of facial expressions in serious mental illness

Blunted facial affect is a transdiagnostic component of Serious Mental Illness (SMI) and is associated with a host of negative outcomes. However, blunted facial affect is a poorly understood phenomenon, with no known cures or treatments. A critical step in better understanding its phenotypic expression involves clarifying which facial expressions are altered in specific ways and under what contexts. The current literature suggests that individuals with SMI show decreased positive facial expressions, but typical, or even increased negative facial expressions during laboratory tasks. While this literature has coalesced around general trends, significantly more nuance is available regarding what components facial expressions are atypical and how those components are associated with increased severity of clinical ratings. The present project leveraged computerized facial analysis to test whether clinician-rated blunted affect is driven by decreases in duration, intensity, or frequency of positive versus other facial expressions during a structured clinical interview. Stable outpatients meeting criteria for SMI (N = 59) were examined. Facial expression did not generally vary as a function of clinical diagnosis. Overall, clinically-rated blunted affect was not associated with positive expressions, but was associated with decreased surprise and increased anger, sadness, and fear expressions. Blunted affect is not a monolithic lack of expressivity, and increased precision in operationally defining it is critical for uncovering its causes and maintaining factors. Our discussion focuses on this effort, and on advancing digital phenotyping of blunted facial affect more generally.

Parent-reported feeding characteristics in children with ASD vs. children who are typically developing

Background

Parents of children with autism spectrum disorders (ASDs) often report that their children have multiple dietary behavior problems than parents of typically developing (TD) children do. This may affect proper nutrition and subsequently adequate growth and development in children with ASD. The current study aimed to assess the feeding behavior in recently diagnosed children with autism spectrum disorders (ASD) ranged in age from 2 to 4 years and compare it with typically developing (TD) children and to explore the relationship between feeding behaviors and autism severity using the Montreal Children’s Hospital Feeding Scale (MCH) and Childhood Autism Rating Scale (CARS), respectively. Parents of 35 preschool children (2–4 years) with ASD completed reports of physical measurements, feeding interview, Childhood Autism Rating Scale (CARS), and Montreal Children’s Hospital Feeding Scale (MCH Feeding-Scale). The collected data from parents of children with ASD were analyzed and compared with 70 typically developed children matched with age and sex.

Results

ASD children showed statistically significantly more problematic feeding behaviors in most of the assessed eating characters compared with TD children, e.g., food neophobia, eating non-food items instead of food, requiring assistance during eating, and feeding avoidance to particular textures and taste. The mean total score of the MCH feeding scale differed significantly between children with ASD and TD children. No correlation was found between the mean total score of the MCH feeding scale and CARS scores.

Conclusion

Our findings revealed a high rate of behavioral feeding problems in children with ASD. Future work will be needed to follow up the feeding behaviors and to develop practical feeding approaches for ASD children to maintain nutritional adequacy.

Autistic characteristics in eating disorders: Treatment adaptations and impact on clinical outcomes

OBJECTIVE

Autistic people with eating disorders (EDs) may have special needs that are not met in standard ED treatment, raising the need for treatment adaptations to accommodate co-existing autism spectrum condition (ASC). Little is currently known about the nature of existing treatment options or adaptations for this population. We conducted a pre-registered systematic review to: (1) identify research articles describing existing interventions for patients with ED and comorbid ASC, and to critically review evidence of their clinical effectiveness and cost-effectiveness (Review 1); (2) review the impact of ASC comorbidity on ED clinical outcomes (Review 2).

METHOD

Peer-reviewed studies published until the end of December 2020 were identified through a systematic search of the electronic databases: Medline, Embase, PsycINFO, Web of Science, CINAHL, Scopus and Cochrane Library.

RESULTS

Only one clinical pathway of treatment adaptations (the 'PEACE' pathway) was identified in Review 1 with early evidence of cost-savings and favourable treatment outcomes. ASC characteristics were shown in Review 2 to have no direct impact on physical outcomes or ED symptoms, but could be associated with higher rates of comorbidities and greater use of intensive ED treatment. Additionally, patients with ASC characteristics may benefit more from individual sessions, rather than group sessions.

CONCLUSIONS

Any new treatments or treatment adaptations may not directly impact on ED symptoms, but may be better able to support the complex needs of the ASC population, thus reducing subsequent need for intensive treatment. Future research is warranted to explore evidence of clinical and cost-effectiveness of interventions for this population.

Feeding and eating problems in children and adolescents with autism: A scoping review

LAY ABSTRACT

Feeding problems, such as picky eating and food avoidance, are common in youth with autism. Other, broader difficulties with feeding and eating (eating disorder symptoms such as restricting food intake or preoccupation with body shape or weight and insistence on specific food presentation) are also common in autistic individuals. Here, we describe the nature and extent of feeding and eating problems in youth with autism. We found no common characteristics (such as severity of autism symptoms) that best describe autistic youth who experience problems with feeding or eating. Almost all studies we reviewed focused on problems with feeding (selective or picky eating), and only a few studies focused on eating disorder symptoms (concern with weight, shape, and/or body image). However, some researchers reported that eating disorder symptoms may occur more often in autistic individuals compared to their peers without autism. Many studies used the terms "feeding" and "eating" problems interchangeably, but understanding the difference between these problems is important for researchers to be consistent, as well as for proper identification and treatment. We suggest future researchers use "eating problems" when behaviors involve preoccupation with food, eating, or body image, and "feeding problems" when this preoccupation is absent. We highlight the importance of understanding whether feeding or eating problems are separate from autism traits, and the role of caregivers and other adults in the child's treatment. Considerations for health-care providers to assist with diagnosis and treatment are also provided.

Current State and Future Directions of Intranasal Delivery Route for Central Nervous System Disorders: A Scientometric and Visualization Analysis

Background: The management of various central nervous system (CNS) disorders has been challenging, due to highly compact blood-brain barrier (BBB) impedes the access of most pharmacological agents to the brain. Among multiple strategies proposed to circumvent this challenge, intranasal delivery route has sparked great interest for brain targeting in the past decades. The aim of this study was to apply scientometric method to estimate the current status and future trends of the field from a holistic perspective.

Methods: All relevant publications during 1998–2020 were retrieved from the Web of Science Core Collection (SCIE, 1998-present). Two different scientometric software including VOS viewer and CiteSpace, and one online platform were used to conduct co-authorship, co-citation, and co-occurrence analysis of journals, countries, institutes, authors, references and keywords.

Results: A total of 2,928 documents, including 2,456 original articles and 472 reviews, were retrieved. Our analysis revealed a significant increasing trend in the total number of scientific publications over the past 2 decades (R² = 0.98). The United States dominated the field, reflecting in the largest amount of publications (971), the highest H-index (99), and extensive international collaboration. Jamia Hamdard contributed to most publications. Frey WH and Illum L were key researchers with the highest number of publications and citations, respectively. The International Journal of Pharmaceutics was the most influential academic journal, and Pharmacology/Pharmacy and Neurosciences/Neurology were the hottest research categories in this field. Based on keywords occurrence analysis, four main topics were identified, and the current research focus of this field has shifted from cluster 4 (pathways and mechanisms of intranasal delivery) to cluster 2 (the study of nasal drug delivery systems), especially the nanostructured and nano-sized carrier systems. Keywords burst detection revealed that the research focus on oxidative stress, drug delivery, neuroinflammation, nanostructured lipid carrier, and formulation deserves our continued attention.

Conclusion: To the authors’ knowledge, this is the first scientometric analysis regarding intranasal delivery research. This study has demonstrated a comprehensive knowledge map, development landscape and future directions of intranasal delivery research, which provides a practical and valuable reference for scholars and policymakers in this field.

Emotion and Psychophysiological Responses During Emotion-Eliciting Film Clips in an Eating Disorders Sample

Background: Greater vulnerability to negative emotions appears associated with the development and maintenance of eating disorders (EDs). A systematic review of psychophysiological studies using emotion-eliciting film clips reveals that there are no studies examining the effect of standardized validated film clips on psychophysiological response across a range of EDs.

Methods: Using standardized validated film clips without ED-specific content, the present study examined self-reported emotions and psychophysiological responses of women with Binge-Eating Disorder (BED; n = 57), Anorexia Nervosa (AN; n = 16), Bulimia Nervosa (BN; n = 34), and Healthy Controls (HCs; n = 26) at Baseline, during Neutral, Sad, Happy, and Fear-inducing film clips, and at Recovery.

Results: Throughout the protocol, the ED groups reported significantly greater sadness and anxiety than HCs. Additionally, the AN group reported more fear, the BED group more frustration, and the BED and BN groups more tension than HCs. Compared to HCs, the BED group reported stronger urges to binge throughout the protocol, whereas BN group reported stronger urges to binge relative to the HC group only at Baseline and Recovery. The BN and BED groups experienced decreased urges to binge during all film clips compared to Baseline. Respiratory Sinus Arrhythmia levels were significantly lower in the BED group compared to HCs and the BN group throughout the protocol.

Discussion: Standardized validated film clips can be used to elicit expected self-reported emotion and skin conductance responses in ED groups, although individuals with EDs compared HCs report greater negative emotions. Interestingly, film clips appeared to reduce urges to binge in binge-eating groups.

Experimental Investigation of Non-Verbal Communication in Eating Disorders

This study aimed to be the first to measure non-verbal communication in 25 eating disorder (ED) and 25 non-ED control participants during a naturalistic social interaction incorporating positive, negative and neutrally-valenced topics. The first hypothesis, that ED participants would show significantly reduced facial emotional expression than controls, was not supported. Supporting the second hypothesis of between-group differences in non-verbal behaviour, ED participants were less likely to lean in towards their interlocutor (d=.81) discussing negatively-valanced topics and were more likely to be positioned upright when discussing positively-valenced topics (d=.1.09) than controls. Irrespective of emotional valence, ED participants positioned their gaze on their interlocutor significantly less (d=.29) and spent more time looking down (d=.54), or away than controls (d=.63). ED participants moved their hands along with speech significantly less (d=.63) and gestured fewer real/hypothetical/imagined images/actions/objects) than controls (d=.57), irrespective of emotional valence. Instead, ED participants indicated discomfort in the social interaction, touching their nose (d=.89) or playing with their nails (d=.95) more often than controls. ED participants, regardless of emotional valence, showed significantly lowered electro-dermal activity (d=.60) than controls, supporting the exploratory hypothesis. People with EDs appear to make less efficient use of non-verbal communication than controls.

Emotion context insensitivity in depression: Toward an integrated and contextualized approach

Major depressive disorder (MDD) is characterized by pervasive mood disturbance as well as deficits in emotional processing, reactivity, and regulation. There is accumulating evidence that MDD is characterized by emotional patterns consistent with environmental disengagement, as reflected in attenuated positive and negative emotional reactivity, consistent with Emotion Context Insensitivity (ECI) theory. However, MDD individuals vary considerably in the extent to which they exhibit specific alterations in patterns of emotional responding. Emotions are complex, multicomponent processes that invoke responses across multiple functional domains and levels of analysis, including subjective experience, behavior, autonomic regulation, cognition, and neural processing. In this article, I review the current state of the literature on emotional responding and MDD from the lens of ECI. I focus on the importance of assessing emotional indices from multiple levels of analysis across development and contexts. I also discuss methodological and measurement issues that may contribute to inconsistent findings. In particular, I emphasize how psychophysiological measures can help elucidate emotional processes that underlie the pathophysiology of MDD as part of an integrated and contextualized approach.

New Technologies as Promising Tools for Assessing Facial Emotion Expressions Impairments in ASD: A Systematic Review

The ability to recognize and express emotions from facial expressions are essential for successful social interactions. Facial Emotion Recognition (FER) and Facial Emotion Expressions (FEEs), both of which seem to be impaired in Autism Spectrum Disorders (ASD) and contribute to socio-communicative difficulties, participate in the diagnostic criteria for ASD. Only a few studies have focused on FEEs processing and the rare behavioral studies of FEEs in ASD have yielded mixed results. Here, we review studies comparing the production of FEEs between participants with ASD and non-ASD control subjects, with a particular focus on the use of automatic facial expression analysis software. A systematic literature search in accordance with the PRISMA statement identified 20 reports published up to August 2020 concerning the use of new technologies to evaluate both spontaneous and voluntary FEEs in participants with ASD. Overall, the results highlight the importance of considering socio-demographic factors and psychiatric co-morbidities which may explain the previous inconsistent findings, particularly regarding quantitative data on spontaneous facial expressions. There is also reported evidence for an inadequacy of FEEs in individuals with ASD in relation to expected emotion, with a lower quality and coordination of facial muscular movements. Spatial and kinematic approaches to characterizing the synchrony, symmetry and complexity of facial muscle movements thus offer clues to identifying and exploring promising new diagnostic targets. These findings have allowed hypothesizing that there may be mismatches between mental representations and the production of FEEs themselves in ASD. Such considerations are in line with the Facial Feedback Hypothesis deficit in ASD as part of the Broken Mirror Theory, with the results suggesting impairments of neural sensory-motor systems involved in processing emotional information and ensuring embodied representations of emotions, which are the basis of human empathy. In conclusion, new technologies are promising tools for evaluating the production of FEEs in individuals with ASD, and controlled studies involving larger samples of patients and where possible confounding factors are considered, should be conducted in order to better understand and counter the difficulties in global emotional processing in ASD.

Electromyographic evidence of reduced emotion mimicry in individuals with a history of non-suicidal self-injury

Engaging in facial emotion mimicry during social interactions encourages empathy and functions as a catalyst for interpersonal bonding. Decreased reflexive mirroring of facial expressions has been observed in individuals with different non-psychotic disorders, relative to healthy controls. Given reports of interpersonal relationship difficulties experienced by those who engage in non-suicidal self-injury (NSSI), it is of interest to explore facial emotion mimicry in individuals with a history of this behaviour (HNSSI). Among other things, this will enable us to better understand their emotion regulation and social interaction challenges. Surface facial electromyography (fEMG) was used to record the reflexive facial mimicry of 30 HNSSI and 30 controls while they passively observed a series of dynamic facial stimuli showing various facial expressions of emotion. Beginning with a neutral expression, the stimuli quickly morphed to one of 6 prototypic emotional expressions (anger, fear, surprise, disgust, happiness, or sadness). Mimicry was assessed by affixing surface electrodes to facial muscles known to exhibit a high degree of electrical activity in response to positive and negative emotions: the corrugator supercilii and the zygomaticus major. HNSSI participants, relative to controls, exhibited significantly less electrical activity in the corrugator muscle in response to viewing angry stimuli, and significantly less of an expected relaxation in muscle activity in response to viewing happy stimuli. Mirroring these results, greater endorsement of social influence as a motivator for engaging in NSSI was associated with less mimicry, and greater endorsement of emotion regulation as a motivator was associated with greater incongruent muscle response when viewing happy faces. These findings lend support to the theory that social interaction difficulties in HNSSI might be related to implicit violations of expected social rules exhibited through facial mimicry nonconformity.

Alexithymia may explain the relationship between autistic traits and eating disorder psychopathology

BACKGROUND

Autistic people are disproportionately vulnerable to anorexia nervosa and other eating disorders (ED), and within the general population, autistic traits correlate with ED psychopathology. A putative mechanism which may underpin this heightened risk is alexithymia, a difficulty identifying and describing emotional states which is observed in both autism and ED. In two experiments with independent non-clinical samples, we explored whether alexithymia might mediate the heightened risk of eating psychopathology in individuals high in autistic traits.

METHODS

Our first experiment used the PROCESS macro for SPSS to examine relationships between alexithymia (measured by the Toronto Alexithymia Scale (TAS-20)), autistic traits (autism quotient (AQ)), and eating psychopathology (Eating Attitudes Test (EAT-26)) in 121 participants. Our second experiment (n = 300) replicated and furthered this analysis by examining moderating effects of sex and controlling for anxiety and depression as covariates. We also included an additional performance-based measure of alexithymia, the Levels of Emotional Awareness Scale (LEAS).

RESULTS

Study 1 suggested that TAS-20 scores mediated the relationship between heightened autistic traits and eating psychopathology. Replication and further scrutiny of this finding, in study 2, revealed that this mediation effect was partial and specific to the female participants in this sample. The mediation effect appeared to be carried by the difficulty identifying feelings subscale of the TAS-20, even when depression and anxiety were controlled for. LEAS scores, however, were not significantly related to autistic traits or eating psychopathology.

LIMITATIONS

Cross-sectional data prevents any conclusions around the direction and causality of relationships between alexithymia, autistic traits, and eating psychopathology (alongside depression and anxiety), necessitating longitudinal research. Our non-clinical sample was predominantly Caucasian undergraduate students, so it remains to be seen if these results would extrapolate to clinical and/or autistic samples. Divergence between the TAS-20 and LEAS raises crucial questions regarding the construct validity of these measures.

CONCLUSIONS

Our findings with respect to autistic traits suggest that alexithymia could partially explain the prevalence of ED in autistic people and may as such be an important consideration in the pathogenesis and treatment of ED in autistic and non-autistic people alike. Further research with clinical samples is critical to explore these ideas. Differences between men and women, furthermore, emphasize the importance of looking for sex-specific as well as generic risk factors in autistic and non-autistic men and women.

Facial Affective Behavior in Borderline Personality Disorder Indicating Two Different Clusters and Their Influence on Inpatient Treatment Outcome: A Preliminary Study

Background

The purpose of the present study was threefold: first, to investigate the facial affective behavior in patients with a borderline personality disorder (BPD); second, to examine whether these patients could be divided into clusters according to facial affective behavior; and third, to test whether these clusters would influence the inpatient treatment outcome.

Methods

Thirty inpatients with BPD were assessed with the Structured Clinical Interviews for DSM-IV Axis I and II Disorders (SCID I, SCID II) and had to complete a series of questionnaires before and directly after the 12-week long inpatient treatment. Facial affective behavior was recorded during the structured interview for personality organization (STIPO) and afterward coded with the emotional facial action coding system (EMFACS). Measures on psychopathology [beck depression inventory (BDI), Spielberger state and trait anxiety inventory (STAI), Spielberger state and trait anger inventory (STAXI), and symptom cheklist-90-revised (SCL-90-R)], interpersonal problems [Inventory of Interpersonal Problems (IIP)], and personality organization [inventory of personality organization (IPO)] were administered.

Results

Cluster analysis before the treatment yielded two groups that differed in general facial expressivity, and regarding the display of anger, contempt, and disgust. The effect sizes of the repeated measures ANOVAs showed that persons with higher scores on the affective facial expressions benefitted more from the treatment in terms of STAI state anxiety, STAXI state and trait anger, IIP total, and the two scales primitive defenses and identity diffusion of the IPO, whereas persons with lower scores benefitted more on the scale IPO reality testing.

Conclusion

Our results indicated some initial trends for the importance of facial affective behavior in patients with BPD and their treatment outcome.

Towards an Improved Understanding of the Anorexia Nervosa and Autism Spectrum Comorbidity: PEACE Pathway Implementation

This paper describes an eating disorder service development pilot project helping clinicians implement evidence-based research for patients with anorexia nervosa and autism spectrum condition comorbidity. Currently, there are no clear guidelines or recommendations for people who have the developmental condition of autism spectrum condition and a comorbid eating disorder. The Maudsley eating disorder team is pioneering a tailored approach of adaptations for this autism and eating disorder comorbidity to improve and adapt evidenced-based treatments and improve the experience for patients, families, and clinicians involved in their care. This paper aims to support the clinical and research community to implement some of the learning and new strategies developed through the PEACE pathway. The authors aim is to collaborate with teams nationally and internationally to scale up the project to benefit patients with this comorbidity.

Automated recognition of spontaneous facial expression in individuals with autism spectrum disorder: parsing response variability

BACKGROUND

Reduction or differences in facial expression are a core diagnostic feature of autism spectrum disorder (ASD), yet evidence regarding the extent of this discrepancy is limited and inconsistent. Use of automated facial expression detection technology enables accurate and efficient tracking of facial expressions that has potential to identify individual response differences.

METHODS

Children and adults with ASD (N = 124) and typically developing (TD, N = 41) were shown short clips of "funny videos." Using automated facial analysis software, we investigated differences between ASD and TD groups and within the ASD group in evidence of facial action unit (AU) activation related to the expression of positive facial expression, in particular, a smile.

RESULTS

Individuals with ASD on average showed less evidence of facial AUs (AU12, AU6) relating to positive facial expression, compared to the TD group (p < .05, r = - 0.17). Using Gaussian mixture model for clustering, we identified two distinct distributions within the ASD group, which were then compared to the TD group. One subgroup (n = 35), termed "over-responsive," expressed more intense positive facial expressions in response to the videos than the TD group (p < .001, r = 0.31). The second subgroup (n = 89), ("under-responsive"), displayed fewer, less intense positive facial expressions in response to videos than the TD group (p < .001; r = - 0.36). The over-responsive subgroup differed from the under-responsive subgroup in age and caregiver-reported impulsivity (p < .05, r = 0.21). Reduced expression in the under-responsive, but not the over-responsive group, was related to caregiver-reported social withdrawal (p < .01, r = - 0.3).

LIMITATIONS

This exploratory study does not account for multiple comparisons, and future work will have to ascertain the strength and reproducibility of all results. Reduced displays of positive facial expressions do not mean individuals with ASD do not experience positive emotions.

CONCLUSIONS

Individuals with ASD differed from the TD group in their facial expressions of positive emotion in response to "funny videos." Identification of subgroups based on response may help in parsing heterogeneity in ASD and enable targeting of treatment based on subtypes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02299700. Registration date: November 24, 2014.

Towards the automatic detection of social biomarkers in autism spectrum disorder: introducing the simulated interaction task (SIT)

Social interaction deficits are evident in many psychiatric conditions and specifically in autism spectrum disorder (ASD), but hard to assess objectively. We present a digital tool to automatically quantify biomarkers of social interaction deficits: the simulated interaction task (SIT), which entails a standardized 7-min simulated dialog via video and the automated analysis of facial expressions, gaze behavior, and voice characteristics. In a study with 37 adults with ASD without intellectual disability and 43 healthy controls, we show the potential of the tool as a diagnostic instrument and for better description of ASD-associated social phenotypes. Using machine-learning tools, we detected individuals with ASD with an accuracy of 73%, sensitivity of 67%, and specificity of 79%, based on their facial expressions and vocal characteristics alone. Especially reduced social smiling and facial mimicry as well as a higher voice fundamental frequency and harmony-to-noise-ratio were characteristic for individuals with ASD. The time-effective and cost-effective computer-based analysis outperformed a majority vote and performed equal to clinical expert ratings.

Cognitive Interpersonal Model for Anorexia Nervosa Revisited: The Perpetuating Factors that Contribute to the Development of the Severe and Enduring Illness

The cognitive interpersonal model was outlined initially in 2006 in a paper describing the valued and visible aspects of anorexia nervosa (Schmidt and Treasure, 2006). In 2013, we summarised many of the cognitive and emotional traits underpinning the model (Treasure and Schmidt, 2013). In this paper, we describe in more detail the perpetuating aspects of the model, which include the inter- and intrapersonal related consequences of isolation, depression, and chronic stress that accumulate in the severe and enduring stage of the illness. Since we developed the model, we have been using it to frame research and development at the Maudsley. We have developed and tested interventions for both patients and close others, refining the model through iterative cycles of model/intervention development in line with the Medical Research Council (MRC) framework for complex interventions. For example, we have defined the consequences of living with the illness on close others (including medical professionals) and characterised the intense emotional reactions and behaviours that follow. For the individual with an eating disorder, these counter-reactions can allow the eating disorder to become entrenched. In addition, the consequent chronic stress from starvation and social pain set in motion processes such as depression, neuroprogression, and neuroadaptation. Thus, anorexia nervosa develops a life of its own that is resistant to treatment. In this paper, we describe the underpinnings of the model and how this can be targeted into treatment.

Mindfulness-Oriented Recovery Enhancement Restructures Reward Processing and Promotes Interoceptive Awareness in Overweight Cancer Survivors: Mechanistic Results From a Stage 1 Randomized Controlled Trial

Introduction: The primary aims of this Stage I pilot randomized controlled trial were to establish the feasibility of integrating exercise and nutrition counseling with Mindfulness-Oriented Recovery Enhancement (MORE), a novel intervention that unites training in mindfulness, reappraisal, and savoring skills to target mechanisms underpinning appetitive dysregulation a pathogenic process that contributes to obesity among cancer survivors; to identify potential therapeutic mechanisms of the MORE intervention; and to obtain effect sizes to power a subsequent Stage II trial. Methods: Female overweight and obese cancer survivors (N = 51; mean age = 57.92 ± 10.04; 88% breast cancer history; 96% white) were randomized to one of two 10-week study treatment conditions: (a) exercise and nutrition counseling or (b) exercise and nutrition counseling plus the MORE intervention. Trial feasibility was assessed via recruitment and retention metrics. Measures of therapeutic mechanisms included self-reported interoceptive awareness, maladaptive eating behaviors, and savoring, as well as natural reward responsiveness and food attentional bias, which were evaluated as psychophysiological mechanisms. Results: Feasibility was demonstrated by 82% of participants who initiated MORE receiving a full dose of the intervention. Linear mixed models revealed that the addition of MORE led to significantly greater increases in indices of interoceptive awareness, savoring, and natural reward responsiveness, and, significantly greater decreases in external eating behaviors and food attentional bias—the latter of which was significantly associated with decreases in waist-to-hip ratio. Path analysis demonstrated that the effect of MORE on reducing food attentional bias was mediated by increased zygomatic electromyographic activation during attention to natural rewards. Conclusions and Implications: MORE may target appetitive dysregulatory mechanisms implicated in obesity by promoting interoceptive awareness and restructuring reward responsiveness.

Ambiguity Processing Bias Induced by Depressed Mood Is Associated with Diminished Pleasantness

Depressed individuals are biased to perceive, interpret, and judge ambiguous cues in a negative/pessimistic manner. Depressed mood can induce and exacerbate these biases, but the underlying mechanisms are not fully understood. We theorize that depressed mood can bias ambiguity processing by altering one's subjective emotional feelings (e.g. pleasantness/unpleasantness) of the cues. This is because when there is limited objective information, individuals often rely on subjective feelings as a source of information for cognitive processing. To test this theory, three groups (induced depression vs. spontaneous depression vs. neutral) were tested in the Judgement Bias Task (JBT), a behavioral assay of ambiguity processing bias. Subjective pleasantness/unpleasantness of cues was measured by facial electromyography (EMG) from the zygomaticus major (ZM, "smiling") and from the corrugator supercilii (CS, "frowning") muscles. As predicted, induced sad mood (vs. neutral mood) yielded a negative bias with a magnitude comparable to that in a spontaneous depressed mood. The facial EMG data indicates that the negative judgement bias induced by depressed mood was associated with a decrease in ZM reactivity (i.e., diminished perceived pleasantness of cues). Our results suggest that depressed mood may bias ambiguity processing by affecting the reward system.

Facial Affect and Interpersonal Affiliation: Displays of Emotion During Relationship Formation in Social Anxiety Disorder

Social anxiety disorder (SAD) often involves difficulty developing relationships. Facial expressions are important in relationship formation, but data are limited regarding facial display production among persons with SAD during social interaction. The current study compared facial displays of individuals diagnosed with SAD (n=41) to control participants (n=24) as they interacted with a confederate; confederates and observers then rated their desire for future interaction with participants. Automated software used the Facial Action Coding System (FACS; Ekman & Friesen, 1978) to classify displays. During portions of the interaction that involved listening to partners, the SAD group smiled less frequently and less intensely than controls, and lower smiling was associated with others' lower desire for future interaction with participants. Diminished positive facial affect in response to interaction partners may disrupt relationship formation in SAD and may serve as an effective treatment target.

Less differentiated facial responses to naturalistic films of another person's emotional expressions in adolescents and adults with High-Functioning Autism Spectrum Disorder

BACKGROUND

Reduced facial expressivity (flat affect) and deficits in nonverbal communicative behaviors are characteristic symptoms of autism spectrum disorder (ASD). Based on the important interpersonal functions of facial emotional responsiveness the present study aimed at a comprehensive and differentiated analysis of perceptible facial behavior in response to another person's naturalistic, dynamic facial expressions of emotion.

METHODS

In a group of 21 adolescent and adult individuals with High-Funtioning autism spectrum disorder (HF-ASD) and in 21 matched healthy controls we examined perceptible facial responses using the whole range of action units of the Facial Action Coding System (FACS) while participants were watching films displaying continuous, dynamic real-life facial expressions of four universal emotions (cheerfulness, anger, sadness, anxiety). The duration of the 80 s films was in the typical range of casual face-to-face interactions.

RESULTS

Overall, the number of congruent facial muscle movements while watching the emotion-laden stimulus films did not differ in the two groups. However, the comprehensive FACS analysis indicated that participants with HF-ASD displayed less differentiated facial responses to the watched emotional expressions.

CONCLUSIONS

The unusual or awkward patterns of facial emotional responses in ASD may hamper the recognition of affect in other people as well as the interaction partner's sense of interpersonal resonance, and thereby lead to social disadvantage in individuals with ASD.