Alexithymia and personality disorder functioning styles in paranoid schizophrenia

Alexithymia in Schizophrenia and Psychosis Vulnerability: A Systematic Review and Meta-Analysis

AIMS

Disturbances involving impairments in experience and expression of affect are frequently identified in schizophrenia samples. Alexithymia underlies cognitive impairments in identification and expression of affect, further implicated in affect dysregulation. The current review aimed to systematically review the literature and estimate the strength of associations between alexithymia and schizophrenia phenomenology.

METHOD

A systematic review and meta-analysis identified 67 studies involving measures of alexithymia in psychosis. All studies were assessed for quality and publication bias. Overall, data from 47 studies were suitable for meta-analysis.

RESULTS

Alexithymia and schizophrenia were consistently positively associated with a large effect size (k = 11). Compared to control groups, a schizophrenia diagnosis was positively associated with large magnitude effects for difficulties in identifying feelings (k = 18) and moderate effect sizes for difficulties in describing feelings (k = 17) and externally oriented thinking (k = 11). Data from community samples indicated moderate associations between subclinical negative symptoms and difficulties in identifying and describing feelings (k = 4) and a small association between positive symptoms and difficulties in identifying feelings (k = 5).

CONCLUSIONS

Alexithymia and schizophrenia are strongly associated. However, methodological issues limit the establishment of directionality in these associations. The majority of studies use cross-sectional designs reliant on self-report assessments which may result in over-estimation of the reported effect sizes. Future research could conceptualize alexithymia as a stress-reactive multidimensional construct, and modeling dynamic relationships between alexithymia, psychological distress, and schizophrenia phenomenology should incorporate confounders such as gender, age, and neurocognition.

Predicting emotions across schizotypy levels

Successfully navigating the social world requires making accurate predictions about others. Individual differences in emotion prediction-the ability to predict someone's subsequent emotion given their current emotional state-can lead to variability in social success. In this study (N = 1024) we found evidence that individuals with heightened schizotypy displayed worse emotion prediction accuracy. This difficulty with emotion prediction was associated with increased loneliness, diminished social support, and smaller social networks, partially mediating some of the social difficulties in individuals with heightened schizotypy. Individuals with heightened schizotypy showed disruptions to key sources of affective information, meaning they had less reliable information about how emotions work when making emotion predictions. Specifically, their own emotion experiences were less typical, and their perception of others' emotions was less accurate. These findings highlight emotion prediction as a key social cognitive construct that should be considered in future research for individuals across the schizophrenia spectrum.

Examining the relationship between Theory of Mind functions and emotional and mindful awareness in schizophrenia patients

This study was conducted to determine the relationship between the Theory of Mind functions and the emotional and mindful awareness of schizophrenia patients. The sample of the study consisted of 118 schizophrenia patients who were attending the Community Mental Health Center. The data were collected with the Sociodemographic Data Form, Dokuz Eylül Theory of Mind Scale (DETMS), Toronto Alexithymia Scale (TAS), and Mindful Awareness Scale (MAAS). As well as demographic analysis, Pearson Correlation Analysis, and Regression Analysis were used to analyze the study data. The schizophrenia patients received 4.86 ± 2.66 points from DETMS, 51.89 ± 14.29 points from MAAS, and 57.91 ± 12.37 points from TAS. A significant relationship was detected between DETMS, MAAS, and TAS total scores (p < 0.05). As the DETMS score increased, the TAS score decreased and the MAAS score increased. It was found that the TAS score was an effective predictor of Theory of Mind, but the MAAS score was not a significant predictor of Theory of Mind (R = 0.310, R2adjusted = 0.080, F(2.115) = 6.102; p = 0.003). The TAS score explained 8 % of the variation in the Theory of Mind. As a result of the study, it was found that the Theory of Mind functions of schizophrenia patients were at low levels, half of the patients had alexithymia, and their mindful awareness levels were close to the average. It can be argued that emotional awareness is an effective variable in the Theory of Mind. As individuals' Theory of Mind functions increase, their alexithymia levels decrease and mindful awareness increases.

Quantifying abnormal emotion processing: A novel computational assessment method and application in schizophrenia

Abnormal emotion processing is a core feature of schizophrenia spectrum disorders (SSDs) that encompasses multiple operations. While deficits in some areas have been well-characterized, we understand less about abnormalities in the emotion processing that happens through language, which is highly relevant for social life. Here, we introduce a novel method using deep learning to estimate emotion processing rapidly from spoken language, testing this approach in male-identified patients with SSDs (n = 37) and healthy controls (n = 51). Using free responses to evocative stimuli, we derived a measure of appropriateness, or "emotional alignment" (EA). We examined psychometric characteristics of EA and its sensitivity to a single-dose challenge of oxytocin, a neuropeptide shown to enhance the salience of socioemotional information in SSDs. Patients showed impaired EA relative to controls, and impairment correlated with poorer social cognitive skill and more severe motivation and pleasure deficits. Adding EA to a logistic regression model with language-based measures of formal thought disorder (FTD) improved classification of patients versus controls. Lastly, oxytocin administration improved EA but not FTD among patients. While additional validation work is needed, these initial results suggest that an automated assay using spoken language may be a promising approach to assess emotion processing in SSDs.

Impaired emotional awareness is associated with childhood maltreatment exposure and positive symptoms in schizophrenia

Objectives

Evidence suggests that emotional awareness-the ability to identify and label emotions-may be impaired in schizophrenia and related to positive symptom severity. Exposure to childhood maltreatment is a risk factor for both low emotional awareness and positive symptoms.

Methods

The current investigation examines associations between a performance-based measure of emotional awareness, positive symptom severity, and childhood maltreatment exposure in 44 individuals with a schizophrenia-spectrum disorder and 48 healthy comparison participants using the electronic Levels of Emotional Awareness Scale (eLEAS), Positive and Negative Syndrome Scale (PANSS) and Childhood Trauma Questionnaire (CTQ).

Results

Patients demonstrated significant deficits in emotional awareness overall, which was true for both self and others. In patients, lower emotional awareness was significantly associated with more severe positive symptoms. Emotional awareness was significantly impaired in patients with schizophrenia with self-reported maltreatment exposure, relative to other groups. Severity of maltreatment was not significantly associated with emotional awareness or positive symptoms when looking continuously, and there was no significant indirect effect.

Conclusion

These data suggest that emotional awareness impairments observed in schizophrenia may be exacerbated by exposure to childhood maltreatment, possibly putting individuals at greater risk for experiencing positive symptoms of psychosis.

Gender difference in association between clinical symptoms and alexithymia in chronic schizophrenia: A large sample study based on Chinese Han population

BACKGROUND

Alexithymia, a prevalent social cognitive impairment in schizophrenia, remains insufficiently studied. Though some studies propose a link between alexithymia and clinical symptoms of schizophrenia, this connection lacks consistent confirmation. Additionally, there is limited research on gender difference in alexithymia among schizophrenia patients. To fill this gap, our study aimed to conduct a large-sample survey of Chinese Han patients with chronic schizophrenia to explore whether there are gender differences between clinical symptoms and alexithymia.

METHODS

We obtained sociodemographic characteristics of 987 schizophrenia patients, measured their clinical symptoms using the Positive and Negative Syndrome Scale (PANSS), and assessed their self-reported alexithymia using the Toronto Alexithymia Scale (TAS-20).

RESULTS

In patients with chronic schizophrenia, the prevalence of alexithymia did not differ between genders (male: 35.51 % vs. female: 26.91 %, P = 0.018). Correlation and linear regression analyses revealed that PANSS scores and TAS-20 scores were widely correlated in both male and female patients. In particular, multiple linear regression analysis showed that the TAS total score was positively correlated with negative symptoms and cognitive symptoms in male patients, while it was positively correlated with negative symptoms and depressive symptoms in female patients.

CONCLUSION

Our study suggests that the prevalence of alexithymia in patients with chronic schizophrenia does not differ between genders. Negative symptoms are related to the TAS-20 total score in both male and female patients, while cognitive symptoms are only related to the TAS-20 total score in male patients, and depressive symptoms are only related to the TAS-20 total score in female patients.

The percentage and clinical correlates of alexithymia in stable patients with schizophrenia

Alexithymia is a common, but less-recognized affective deficit in patients with schizophrenia. To date, no definitive conclusions have been drawn about the relationship between alexithymia and the clinical symptoms or their clinical correlates, particularly in stable patients with schizophrenia. The purpose of this study was to investigate the link between alexithymia and psychopathological symptoms, as well as any associated correlates, in stable patients with schizophrenia. A total of 435 Chinese patients with schizophrenia were recruited. The Positive and Negative Symptoms Scale (PANSS) was used to evaluate each patient's psychopathological symptoms. The Toronto Alexithymia Scale (TAS-20) was used to measure alexithymia. The percentage of alexithymia was 35.2% in stable patients with schizophrenia. Compared to non-alexithymia patients, patients with alexithymia had higher PANSS total scores, negative subscores, depressive subscores, and cognitive subscores (all p < 0.05). Multivariate regression analysis revealed that the following variables were positively associated with TAS-20 total scores: PANSS negative subscores (β = 0.274, t = 3.198, p = 0.001) and PANSS depressive subscores (β = 0.366, t = 2.500, p = 0.013). Education years (β = - 0.453, t = - 2.824, p = 0.005) was negatively associated with TAS-20 total scores. Our results suggest that the percentage of alexithymia was relatively higher in stable patients with schizophrenia. Education levels, negative symptoms, and depressive symptoms were independently associated with alexithymia in this specific population.

Social Elite in Imperial China: Their Destinies as Documented by the Historical Literature and Their Personality as Defined by the Contemporary Five-Factor Model

Background: The association between personality and life outcome has been widely studied in Western countries, and one might question whether the association exists in China. The official documentation from the Twenty-Six Histories of Imperial China, which presents life-long data on the social elite, may offer a convenient way to realize this effort. Meanwhile, a possible association might help identify competent personalities and offer treatment hints for personality disorders or other psychiatric deviations worldwide. Methods: Based on these historical records (about 618–1911 AD) on 18 social elite groups with long longevity (Macrobian group) and 30 with normal lifespans (Control group), we assessed personality traits/facets using the revised NEO Personality Inventory (NEO-PI-R) and destiny using the Destiny Evaluation Questionnaire (DEQ). Results: Compared to the Controls, the Macrobian group scored higher on the DEQ’s Health and Destiny in General and lower on the NEO-PI-R traits Openness to Experience and Extraversion and facets such as Openness to Fantasy, Openness to Aesthetics, Openness to Feelings, Excitement-Seeking, and Self-Consciousness. In the Macrobian group, the Trust and Compliance facets predicted the DEQ’s Family and Marriage and Social Relationships aspects, respectively; Conscientiousness and its facets Dutifulness, Self-Discipline, and Competence predicted Family and Marriage, Career Achievement, and Destiny in General, respectively; and the Self-Consciousness facet predicted worse performance in Career Achievement, Family and Marriage, and Social Relationships and the Depression facet of Destiny in General. In the Control group, Openness to Feelings positively and Anxiety negatively predicted Health. Conclusions: Less self-focused attention and more interdependence between individuals were beneficial to several aspects of individual destiny in Imperial China, which might be profound for the individual career development and clinical treatment of personality disorders in contemporary society.

A bottom-up model of functional outcome in schizophrenia

Schizophrenia results in poor functional outcomes owing to numerous factors. This study provides the first test of a bottom-up causal model of functional outcome in schizophrenia, using neurocognition, vocal emotional cognition, alexithymia, and negative symptoms as predictors of functional outcome. We investigated a cross-sectional sample of 135 individuals with schizophrenia and 78 controls. Using a series of structural equation modelling analyses, a single pathway was generated among scores from the MATRICS Consensus Cognitive Battery (MCCB), vocal emotion recognition test, Toronto Alexithymia Scale (TAS), Brief Negative Symptom Scale, and the Personal and Social Performance Scale. The scores for each dimension of the MCCB in the schizophrenia group were significantly lower than that in the control group. The recognition accuracy for different emotions (anger, disgust, fear, sadness, surprise, and satire, but not calm was significantly lower in the schizophrenia group than in the control group. Moreover, the scores on the three dimensions of TAS were significantly higher in the schizophrenia group than in the control group. On path analysis modelling, the proposed bottom-up causal model showed a strong fit with the data and formed a single pathway, from neurocognition to vocal emotional cognition, to alexithymia, to negative symptoms, and to poor functional outcomes. The study results strongly support the proposed bottom-up causal model of functional outcome in schizophrenia. The model could be used to better understand the causal factors related to the functional outcome, as well as for the development of intervention strategies to improve functional outcomes in schizophrenia.

What are the specificities of social cognition in schizophrenia? A cluster-analytic study comparing schizophrenia with the general population

While social cognition (SC) is widely recognized as being impaired in schizophrenia, little is known about the potential heterogeneity in individuals' functioning. Using a wide range of SC measures and a cluster-analytic approach, we compared SC profiles in the general population and in people with schizophrenia. A total of 131 healthy controls and 101 participants with schizophrenia were included. Groups were compared on sociodemographic, neurocognition, anxiety and depressive mood variables. Three profiles were identified in healthy controls: one with good SC abilities (Homogeneous SC group) and two with specific weaknesses in complex Facial Emotion Recognition (Low FER group) or Affective Theory of Mind (Low AToM group). However, these patterns were not found in participants with schizophrenia, who were characterized rather by levels of SC functioning (i.e., Low, Medium and High SC groups). Importantly, while the High SC group (47.9% of the sample) exhibited normal performances, the two others were underpinned by different pathological processes (i.e., alexithymia for Medium SC group or neurocognition dysfunctioning for Low SC group). These results have important implications for future research as well as for clinical practice regarding assessment methodology and therapeutic interventions.

Cognitive mechanisms of alexithymia in schizophrenia: Investigating the role of basic neurocognitive functioning and cognitive biases

Alexithymia is an important but poorly understood emotional deficit in schizophrenia. We aimed at investigating the role of basic cognitive functions, cognitive biases, and symptom severity in alexithymia among patients with schizophrenia. Sixty patients (31 females) with schizophrenia were assessed with standardized clinical interviews for symptom severity. Cognitive functioning was assessed with neuropsychological tests. A self-report scale (Davos Assessment of Cognitive Biases, DACOBS), as well as two experimental tasks assessing jumping to conclusions (the Fish task) and source monitoring (Action memory task), were used to investigate cognitive biases. Alexithymia was assessed with the Toronto Alexithymia Scale (TAS-20). Alexithymia was related to the severity of hallucinations but not delusions. Patients with a lifetime history of more psychotic symptoms had higher alexithymia. Alexithymia has broad relationships with different cognitive biases, especially in the self-reported measure. These relationships were not affected by neurocognition and symtpoms severity. In particular, difficulties in identification of feelings were related to various cognitive biases. Dysfunctional information processing can thus be considered as potential psychological correlates of alexithymia. The theoretical and clinical implications of our findings are discussed.

The Role of Metacognitive Self-Reflectivity in Emotional Awareness and Subjective Indices of Recovery in Schizophrenia

Emotional awareness deficits in people with schizophrenia have been linked to poorer objective outcomes, but no work has investigated the relationship between emotional awareness and subjective recovery indices or metacognitive self-reflectivity. The authors hypothesized that increased emotional awareness would be associated with greater self-esteem, hope, and self-reflectivity and that self-reflectivity would moderate links between emotional awareness and self-esteem and hope-such that significant relationships would only be observed at lower levels of self-reflectivity. Participants were 56 people with schizophrenia spectrum disorders. Correlations revealed that better emotional awareness was significantly associated with increased self-esteem and hope but not self-reflectivity. Self-reflectivity moderated the relationship between emotional awareness and self-esteem but not hope. Overall, findings suggest that emotional awareness may affect self-esteem for those low in self-reflectivity, but other factors may be important for those with greater self-reflectivity. Results emphasize the importance of interventions tailored to enhance self-reflective capacity in clients with schizophrenia.

The impact of emotion awareness and regulation on social functioning in individuals at clinical high risk for psychosis

BACKGROUND

Social functioning (SF) difficulties are ubiquitous among individuals at clinical high risk for psychosis (CHR), but it is not yet clear why. One possibility is suggested by the observation that effective SF requires adaptive emotion awareness and regulation. Previous reports have documented deficits in emotion awareness and regulation in individuals with schizophrenia, and have shown that such deficits predicted SF. However, it is unknown whether these deficits are present prior to the onset of psychosis or whether they are linked to SF in CHR individuals.

METHOD

We conducted a cross-sectional comparison of emotion awareness and regulation in 54 individuals at CHR, 87 with schizophrenia and 50 healthy controls (HC). Then, within the CHR group, we examined links between emotion awareness, emotion regulation and SF as indexed by the Global Functioning Scale: Social (Cornblatt et al. 2007).

RESULTS

Group comparisons indicated significant differences between HC and the two clinical groups in their ability to identify and describe feelings, as well as the use of suppression and reappraisal emotion-regulation strategies. Specifically, the CHR and schizophrenia groups displayed comparable deficits in all domains of emotion awareness and emotion regulation. A hierarchical multiple regression analysis indicated that difficulties describing feelings accounted for 23.2% of the SF variance.

CONCLUSIONS

The results indicate that CHR individuals display substantial emotion awareness and emotion-regulation deficits, at severity comparable with those observed in individuals with schizophrenia. Such deficits, in particular difficulties describing feelings, predate the onset of psychosis and contribute significantly to poor SF in this population.

Cognitive alexithymia is associated with the degree of risk for psychosis

Alexithymia is a personality construct denoting emotion processing problems. It has been suggested to encompass two dimensions: a cognitive and affective dimension. The cognitive dimension is characterized by difficulties in identifying, verbalizing and analyzing emotions, while the affective dimension reflects the level of emotional arousal and imagination. Alexithymia has been previously proposed as a risk factor for developing psychosis. More specifically, the two alexithymia dimensions might be differentially related to the vulnerability for psychosis. Therefore, we examined the two dimensions of alexithymia, measured with the BVAQ in 94 siblings of patients with schizophrenia, 52 subjects at ultra-high risk (UHR) for developing psychosis, 38 patients with schizophrenia and 109 healthy controls. The results revealed that siblings and patients had higher levels of cognitive alexithymia compared to controls. In addition, subjects at UHR for psychosis had even higher levels of cognitive alexithymia compared to the siblings. The levels of affective alexithymia in siblings and patients were equal to controls. However, UHR individuals had significantly lower levels of affective alexithymia (i.e. higher levels of emotional arousal and fantasizing) compared to controls. Alexithymia was further related to subclinical levels of negative and depressive symptoms. These findings indicate that alexithymia varies parametrically with the degree of risk for psychosis. More specifically, a type-II alexithymia pattern, with high levels of cognitive alexithymia and normal or low levels of affective alexithymia, might be a vulnerability factor for psychosis.

Maladaptive personality traits increase subjectively during the course of schizophrenia spectrum disorders

We assessed both current maladaptive personality traits (MPTs) and, retrospectively, premorbid MPTs in patients with schizophrenia spectrum disorders (SSDs). This was to examine whether the patients had the impression that their personality had changed and which traits were affected. We also wanted to determine whether the perceived changes could be explained by SSD psychopathology. MPTs were assessed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnoses, axis II disorders, screening questionnaire and interview, integrating questions on subjective estimation of premorbid MPTs in moderately ill SSD patients. Forty-five patients were included. Premorbid MPTs were remembered as significantly less pronounced than current MPTs for the whole spectrum of personality traits (p < 0.001). Antisocial traits had worsened significantly less (p < 0.001), and borderline and obsessive-compulsive traits had worsened significantly more (both p < 0.01) than the mean increase. Associations between MPT increase and SSD psychopathology were significant for schizotypal, avoidant, and depressive traits. According to the patients' retrospective assessment, MPTs increased through onset and course of SSDs. Memory bias, depressed mood, and SSD symptoms alone could not sufficiently explain these differences. Subjective MPT increase may play a role for the patients' concept of illness, quality of life, and adherence to therapeutic interventions. It should be addressed in SSD treatment.

Subjective well-being, but not subjective mental functioning shows positive associations with neuropsychological performance in schizophrenia-spectrum disorders

OBJECTIVE

To assess the association of subjective quality of life as measured by the Subjective Well-being under Neuroleptic Treatment questionnaire (SWN-K) with neuropsychological functioning; to address interactions with the SWN-K domain mental functioning as a measure of subjective cognitive dysfunction; and to examine the interaction of subjective well-being and psychopathology ratings.

METHODS

Forty-five patients diagnosed with schizophrenia spectrum disorder (SSD) were assessed regarding subjective well-being (SWN-K), neuropsychological impairment, and psychopathology (Brief Psychiatric Rating Scale; BPRS).

RESULTS

After controlling for multiple comparisons, SWN-K total score showed significant positive correlations with concentration/attention (r=.498), working memory (r=.537), verbal memory (r=.522), and global cognition (r=.459). No correlations of SWN mental functioning and neuropsychological impairment remained significant after Bonferroni correction. Correlations between SWN-K subscales and neuropsychological functioning were generally positive, indicating higher subjective well-being in patients with better neurocognition. In multivariate analyses, global cognition was a significant predictor (p=.011), accounting for 19.7% of SWN total score variance. Adding BPRS total score as predictor (p=.054) explained an additional 6.9% of SWN-K variance. Linear regression analyses with SWN-K mental functioning as dependent variable did not yield statistically significant models.

CONCLUSION

Subjective well-being and objective neuropsychological functioning show only moderate associations and can be seen as largely independent parameters. In particular, subjective mental functioning cannot serve as a proxy for objective neuropsychological testing.

Depression and insight in schizophrenia: comparisons of levels of deficits in social cognition and metacognition and internalized stigma across three profiles

While research has paradoxically linked insight to greater emotional distress and depression in schizophrenia, little is known why and for whom insight can result in depression. One possibility is that internalized stigma and deficits in social cognition and metacognition are risk factors for insight to convert to depression. To explore this possibility we assessed insight, depression, internalized stigma, social cognition and metacognition for sixty five persons with schizophrenia spectrum disorders. We then performed a cluster analysis based on insight and depression scores. Three groups were produced by the cluster analysis: Good insight/Mild depression (n=22); Fair insight/Moderate depression (n=26) and Poor insight/Minimal depression (n=17). As predicted, ANOVA comparing groups revealed the three groups differed in social cognition, and the metacognitive mastery aspect of metacognition. Those with fair insight and moderate depression reported more internalized stigma than those with poor insight and minimal depression. Persons with good insight and mild depression had higher levels of social cognition and metacognitive mastery than the other two groups. These differences persisted when controlling for neurocognition and symptom severity. These findings point to the possibility that future research should examine whether bolstering metacognitive and social cognitive capacities may have a protective effect as persons are assisted to achieve insight.

Emotion awareness and regulation in individuals with schizophrenia: Implications for social functioning

Successful social functioning requires adaptive forms of emotion awareness and regulation. However, despite well-documented deficits in social functioning in individuals with schizophrenia, little is known about emotion awareness and regulation in this population. Therefore, we compared emotion awareness and regulation in individuals with schizophrenia and healthy controls, and then, within the schizophrenia group, we examined their impact on social functioning. Forty-four individuals with schizophrenia and 20 healthy controls completed measures of emotion awareness, emotion regulation, and social functioning, in addition to control measures, including neurocognitive functioning. Compared to controls, individuals with schizophrenia displayed significant deficits describing and identifying their emotions and used significantly less reappraisal and more suppression to regulate their emotions. Among the schizophrenia group, better social functioning was associated with the ability to identify, and in particular to describe emotions, better emotion management, as well as greater use of reappraisal and less use of suppression. A hierarchical multiple regression analysis indicated that, after controlling for age and neurocognition, difficulties describing feelings accounted for 35% of the social functioning variance. The present study highlights the importance of emotion awareness and regulation in schizophrenia, pointing to their substantial influence on social functioning above and beyond the impact of neurocognitive functioning.