Download Diminished Emotionality and Social Functioning in Schizophrenia

ORIGINAL ARTICLES
Diminished Emotionality and Social Functioning
in Schizophrenia
Alex S. Cohen, PhD,* Thomas J. Dinzeo, MA,* Tasha M. Nienow, PhD,* Doug A. Smith, MD,†
Beth Singer, BA,† and Nancy M. Docherty, PhD*
Abstract: There is indirect evidence to suggest that a subgroup of
patients with schizophrenia exhibit a diminished capacity to experience both positive and negative emotions. To date however, no
studies have focused specifically on this diminished emotionality
(DE). The main objective of the present project was to determine
whether patients with self-reported DE differed from other patients
in level of social functioning, physical and social anhedonia, and
negative/deficit symptoms. Seventy-three state hospital patients with
DSM-IV diagnosed schizophrenia and 22 nonpsychiatric controls
were examined. Results provided mixed support for the present
hypotheses. Patients with self-reported DE (N ⫽ 10) versus those
without (N ⫽ 63) had poorer social functioning, similar levels of
physical and social anhedonia, and significantly less severe negative/
deficit symptoms. Moreover, there was a substantial amount of
discrepancy between patients’ self-reported levels of emotionality
and the ratings of their emotionality as made by trained observers.
Implications of these results are discussed.
Key Words: Schizophrenia, emotion, social, deficit, negative.
(J Nerv Ment Dis 2005;193: 796 – 802)
T
he link between emotional abnormalities and social functioning deficits in patients with schizophrenia is a topic of
recent empirical attention. Generally speaking, the results
from this body of literature suggest that decreased levels of
positive and increased levels of negative emotions are associated with poorer social functioning. For example, decreased
levels of positive emotions, including decreased levels of trait
positive affectivity (PA) and increased levels of physical and
social anhedonia, have been associated with poor social
functioning (Blanchard et al., 1998; Goldstein, 1987). Increased levels of negative emotions, notably social anxiety
(Blanchard et al., 1998; Goldstein, 1987) and trait negative
affectivity (NA; Blanchard et al., 1998; Goldstein, 1987;
*Department of Psychology, Kent State University, Kent, Ohio; and †Northcoast Behavioral Healthcare System, Northfield, Ohio.
Supported by National Institute of Mental Health grants MH58783 and
MH57151 to Dr. Docherty.
Send reprint requests to Alex S. Cohen, PhD, University of Maryland,
Department of Psychology, College Park, MD 20742.
Copyright © 2005 by Lippincott Williams & Wilkins
ISSN: 0022-3018/05/19312-0796
DOI: 10.1097/01.nmd.0000188973.09809.80
796
Koivumaa-Honkanen et al., 1999; Sands and Harrow, 1999),
also have been associated with poorer social functioning.
However, it is important to note that schizophrenia is a
heterogeneous disorder with significant differences across
patients in symptomatic presentation, pathophysiological processes, and clinical course. There is evidence to suggest that
a subgroup of patients with schizophrenia experiences diminished levels of both positive and negative emotions (Kirkpatrick et al., 1989), and that these patients have poorer social
functioning compared with other patients (Fenton and McGlashan, 1994; Horan and Blanchard, 2003). To date, no
studies that we are aware of have focused exclusively on this
diminished emotionality (DE) as a pathological process. The
main objective of the present project was to determine
whether patients with self-reported DE had poorer social
functioning compared with other patients.
With a few exceptions, investigations of the deficit
syndrome have provided support for the notion that a subgroup of patients experiences DE. The deficit syndrome is
theorized to be a pathophysiologically distinct form of
schizophrenia, diagnosed based on the presence of at least
two of six enduring (occurring for at least 1 year) and
idiopathic (not the result of medication, depression, or environmental factors) negative symptoms. Patients with the
deficit syndrome report having higher levels of self-reported
physical anhedonia (Horan and Blanchard, 2003; Kirkpatrick
and Buchanan, 1990; Loas et al., 1996) and lower levels of
self-reported trait PA (Horan and Blanchard, 2003) than
patients with nondeficit schizophrenia. Patients with the deficit syndrome have also tended to receive less severe clinical
ratings of negative emotions, including depression, guilt,
anxiety, hostility (Kirkpatrick et al., 1993, 1994; Tek et al.,
2001), suicidality (Fenton and McGlashan, 1994), and suspiciousness (Kirkpatrick et al., 1996). It is noteworthy that one
study found that self-reported levels of trait NA did not differ
between deficit and nondeficit patients (Horan and Blanchard,
2003). With respect to laboratory investigations of emotionality, deficit versus nondeficit patients have reported experiencing lower levels of stress during a stress-induction procedure (Cohen and Docherty, 2004) and have evidenced lower
levels of speech disorder reactivity (Cohen et al, 2003) when
discussing stressful memories. However, Earnst and Kring
(1999) reported that deficit versus nondeficit patients did not
differ in self-reported emotional experience following the presentation of emotionally evocative stimuli. In some ways, find-
The Journal of Nervous and Mental Disease • Volume 193, Number 12, December 2005
The Journal of Nervous and Mental Disease • Volume 193, Number 12, December 2005
ings that deficit patients have lower levels of emotionality
compared with other patients are tautological because one criterion for the deficit syndrome diagnosis is an enduring diminished capacity to experience emotion (Kirkpatrick et al., 1989).
Nonetheless, the deficit syndrome literature generally supports
the notion that attenuations of both positive and negative emotions occur within a subset of patients with schizophrenia.
Although the deficit syndrome is the product of an
attempt to reduce the heterogeneity of schizophrenia pathology in study samples, there is reason to suspect that there may
be substantial heterogeneity within the deficit syndrome,
particularly with respect to whether deficit patients experience DE. Diagnosis of the deficit syndrome is based on the
presence of at least two of six symptoms, so it is possible for
individuals who do not exhibit DE to be included in the
deficit syndrome group. In a study by Bryson et al. (1998),
only half of those patients assigned to the deficit syndrome
group were rated as having DE. Furthermore, a recent unpublished factor analysis of the Schedule for Deficit Syndrome, the gold standard instrument used to diagnose the
deficit syndrome, suggested that the emotion related symptoms, including flat affect, DE, and poverty of speech, comprised a different factor from the other deficit symptoms,
which include curbed interests, diminished sense of purpose,
and diminished social drive.1 Thus, it is clear that the overlap
between the deficit syndrome and DE is moderate at best.
The present project examined social functioning in
patients who self-reported experiencing diminished levels of
emotionality. Three groups, including patients with DE, patients without DE, and nonpsychiatric controls were compared on measures of social functioning and physical and
social anhedonia. We hypothesized that DE patients, identified by low scores on measures of both trait PA and NA,
would have poorer social functioning and would report having more social and physical anhedonia than the other two
groups. We also compared deficit symptom severity between
DE and non-DE patients with the expectation that DE patients
would have more severe deficit symptoms. Additionally, we
examined whether the significant relationships between trait
PA and NA, social and physical anhedonia, and social functioning that have been found in prior patient samples (Blanchard et al., 1998) would replicate in a sample comprised of
state psychiatric hospital inpatients.
METHODS
Participants
Patients
The patient group consisted of 73 volunteers from an
inpatient psychiatric state hospital who met DSM-IV (American Psychiatric Association, 1994) criteria for schizophrenia
or schizoaffective disorder based on information obtained
from the patients’ medical records and the Schedule for
Affective Disorders and Schizophrenia (SADS; Endicott and
Spitzer, 1978). The majority of these patients were hospitalized under a forensic status (i.e., forensic evaluation, restoration of competency to stand trail, or a criminal finding of
not guilty by reason of insanity). Exclusion criteria included
© 2005 Lippincott Williams & Wilkins
Diminished Emotionality
the following: Global Assessment of Functioning rating
(American Psychiatric Association, 1994) below 30, evidence
of mental retardation, history of organic disorder or significant head trauma (requiring overnight hospitalization),
DSM-IV current alcohol or drug abuse, or a significant
history of alcohol or drug abuse or dependence sufficient to
suggest the possibility of substance related organic damage.
The descriptive data and intellectual functioning scores for
the patients are presented in Table 1.
Controls
The control group consisted of 22 Kent State University
support staff. Controls were matched to the patient group in
terms of age, gender, and parental combined Socio Economic
Index (Hauser and Warren, 1996) scores. Matching was done
by group, not based on individual cases. Controls were
excluded if they met DSM-IV criteria for any psychotic or
substance use disorder, or if they had a history suggestive of
the possibility of organic damage, as discussed. The descriptive data and intellectual functioning scores for the controls
are presented in Table 1.
Procedures
Trait Positive and Negative Affectivity
Trait PA and NA scales from the Multidimensional
Personality Questionnaire (MPQ; Tellegen, 1982) were used.
Items from the PA and NA scales were presented to the
participants in a quasi-random order in the same questionnaire, and scores from both scales were converted to T-score
format using the norms provided in the administration manual
(Tellegen, 1982). Both the PA and NA scales had adequate
internal consistency (coefficient ␣ values ⬎ 0.85) in the
present study. Twenty-two controls and 73 patients completed the MPQ scales.
Diminished Emotionality
Diminished emotionality was identified using the trait
PA and NA scale scores. The present study explored DE as a
categorical variable, as past research exploring DE within the
larger context of the deficit syndrome has suggested that the
deficit syndrome is a distinct group within schizophrenia (see
introduction for elaboration on this topic). The MPQ has been
used primarily as a research tool, so there are no clear
guidelines for differentiating clinically significant from nonsignificant scores. Our a priori plan was for all individuals
with T scores of 40 or below on both the PA and NA scales
to be included in the DE group. Although there was no formal
precedent for using cutoff scores of 40, these criteria seemed
appropriate because a T score 1 SD below the mean has been
considered a low score on other commonly used personality
instruments such as the MMPI-2 (e.g., Graham, 1999). However, using these criteria, no patients would have been included in the DE group. For the present study, we looked at
those subjects in our sample who were closest to our original
criteria. All subjects with a T score of 45 or below on both the
PA and NA scales were included in the DE group, while all
other subjects were included in the non-DE group. Using this
modified criterion, 10 patients were included in the DE group.
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The Journal of Nervous and Mental Disease • Volume 193, Number 12, December 2005
Cohen et al.
TABLE 1. Patients With Diminished Emotionality (DE; N ⫽ 10) Versus Those Without (Non-DE; N ⫽ 63) Versus Controls
(N ⫽ 22) on Descriptive, SEI, Intellectual Functioning (IQ), Global Assessment of Functioning (GAF), and Clinical and
Medication Data, With Means ⫾ SDs
Group
Measure
Descriptive Variable
Age
Education
Parents’ combined SEIa
IQb
% Male
% Caucasian
Total time in hospital (wk)c
Age of first treatment (y)
GAFa,d
Positive syndromee
Negative syndromec,f
Disorganization syndromee
Medications
% On atypical antipsychotics
% On antidepressants
% On mood stabilizers
Group Comparison of DE,
Non-DE, and Control
Groups Post
Hoc ⴝ Scheffé
All Patients
DE
Non-DE
Controls
41.67 ⫾ 8.61
11.89 ⫾ 1.90
63.04 ⫾ 24.54
80.40 ⫾ 10.46
75%
36%
55.02 ⫾ 89.11
20.08 ⫾ 89.11
40.88 ⫾ 8.08
5.84 ⫾ 2.99
4.90 ⫾ 2.63
4.16 ⫾ 2.05
45.60 ⫾ 7.09
12.60 ⫾ 2.59
66.35 ⫾ 37.48
85.80 ⫾ 10.81
80%
40%
91.75 ⫾ 128.03
23.50 ⫾ 7.47
43.30 ⫾ 7.92
4.90 ⫾ 2.77
3.70 ⫾ .95
4.70 ⫾ 2.79
40.97 ⫾ 8.83
11.78 ⫾ 1.76
62.88 ⫾ 2.92
79.73 ⫾ 10.15
73%
35%
50.78 ⫾ 83.12
19.57 ⫾ 6.03
40.57 ⫾ 8.13
5.90 ⫾ 2.97
5.11 ⫾ 2.78
4.03 ⫾ 1.90
38.95 ⫾ 10.89
14.14 ⫾ 1.49
59.30 ⫾ 21.30
101.36 ⫾ 11.19
68%
59%
—
—
—
—
—
DE ⫽ Non ⫽ Con
DE† ⫽ Non* ⬍ Con
DE ⫽ Non ⫽ Con
DE* ⫽ Non* ⬍ Con
DE ⫽ Non ⫽ Cong
DE ⫽ Non ⫽ Cong
DE ⫽ Non
DE ⬎ Non†
DE ⫽ Non
DE ⫽ Non
DE ⬍ Non**
DE ⫽ Non
85%
8%
42%
100%
10%
50%
85%
8%
41%
—
—
—
DE ⫽ Nong
DE ⫽ Nong
DE ⫽ Nong
p value ⬍ 0.10; *p value ⬍ 0.05; **p value ⬍ .01.
Higher scores reflect better functioning.
In standard scale format (mean ⫽ 100, SD ⫽ 15), non-DE N ⫽ 60.
c
Scores were log-transformed to correct for excessive skew before comparison.
d
GAF ⫽ scale 0 –90 (DSM; American Psychiatric Association, 1994).
e
Higher scores reflect more severe symptomatology.
f
The variances of the DE and non-DE group were significantly different (Levene test F ⫽ 5.25; p ⬍ 0.05), so a t test for unequal variances was used.
g 2
␹ value.
†
a
b
Social Functioning
Social functioning was measured using the Social
Functioning Scale (SFS; Birchwood et al., 1990). The SFS is
a 79-item questionnaire that assesses seven distinct yet highly
correlated domains of social behavior: social engagement
(e.g., time spent with others, reactions to strangers), interpersonal behavior (e.g., number of friends), independence-performance (e.g., performance of skills necessary for independent living), recreational activities (e.g., time spent pursuing
hobbies, interests, pastimes), prosocial behavior (e.g., engagement in social activities), independence-competence
(e.g., ability to perform skills necessary for independent
living), and employment/occupation (e.g., engagement in
productive employment). The present study computed total
social functioning scores by summing the seven individual
subscale scores. The SFS has been shown to have acceptable
coefficient ␣ values (.80), sensitivity, and construct validity
in patients with schizophrenia and nonpsychiatric controls
(Birchwood et al., 1990).
Social and Physical Anhedonia
Social and physical anhedonia were assessed using the
revised Social Anhedonia Scale (SAS) and the Physical
Anhedonia Scale (PAS; Chapman et al., 1976). The SAS is
designed to measure deficits in social pleasure (e.g., sociality,
talking, competition), whereas the PAS is designed to measure deficits in the capacity to experience physical pleasures
798
(e.g., eating, movement, touching, smell, sex). Both the SAS
and the PAS have demonstrated adequate reliability (coefficient ␣ values ⬎0.79; test-retest reliability ⬎0.74) in studies
of both patients (Blanchard et al., 1998) and nonpsychiatric
populations (Chapman et al., 1976). The Chapman infrequency scale was administered to assess the validity of
participants’ responses on the SAS and PAS scales. Individuals who responded positively to three or more infrequency
items were excluded from the present study, as was done in
several studies that have used the Chapman scales (Blanchard
et al., 1994; Gooding et al., 2002). The items from the
infrequency, SAS, and PAS scales were combined in a
quasi-random order and presented to participants as a single
questionnaire. Twenty-two controls and 72 patients completed the anhedonia measures, although 19 of these patients
had infrequency scores of 3 or more and were not included in
any of the analyses.
Schedule for the Deficit Syndrome
The symptoms of the deficit syndrome were measured
using the Schedule for the Deficit Syndrome (SDS; Kirkpatrick et al., 1989). The SDS is a semistructured interview
designed to assess six enduring (lasting ⬎1 year) and idiopathic negative symptoms: restricted affect, diminished emotional range, poverty of speech, curbed interests, diminished
sense of purpose, and diminished social drive. Each of the six
deficit symptoms are rated on a scale from 0 to 4, with higher
© 2005 Lippincott Williams & Wilkins
The Journal of Nervous and Mental Disease • Volume 193, Number 12, December 2005
scores reflecting greater severity. To meet criteria for the
deficit syndrome, an individual must demonstrate a moderate
or higher level of severity on at least two of these deficit
symptoms, as evidenced by a score of 2 or above. Ratings
were made based on information obtained during the interview as well as from behavioral observations and from staff
and medical records.
Schedule for the Deficit Syndrome ratings were made
by one of three graduate-level researchers, each of whom was
trained by one of the SDS’s authors (Brian Kirkpatrick).
Intraclass Correlation Coefficient (ICC) values for the six
individual subscales of the SDS were acceptable (range ⫽
.74 –.90), and ␬ values for deficit/nondeficit group categorization were adequate (range ⫽ .60 –1.00) across the three
raters based on independent review of the videotaped SADS/
SDS interviews of 10 of the patients. To avoid false positives,
the videotapes of all potential deficit cases were reviewed by
the researcher with the most familiarity with the deficit
syndrome (Alex Cohen) and were discussed with the other
researchers until group consensus was obtained. These ratings were done blind to subjects’ performance on the emotion
and social functioning measures. SDS data were available for
70 of the patients.
Positive, Negative, and Disorganization Syndromes
The Brief Psychiatric Rating Scale (BPRS; Lukoff et
al., 1986) was used to assess patients’ symptom severity. The
positive syndrome was computed by summing the unusual
thought content and hallucinatory behavior item scores. The
negative syndrome score was computed by summing the flat
affect, emotional withdrawal, and motor retardation item
scores. The disorganization syndrome scores were computed
by summing the conceptual disorganization and bizarre behavior BPRS item scores. BPRS ratings were made by one of
three graduate-level researchers who demonstrated adequate
reliability based on 10 videotaped SADS/SDS interviews
(ICC values for the positive 关ICC ⫽ .94兴, negative 关ICC ⫽
.85兴, and disorganization 关ICC ⫽ .78兴).
Intellectual Functioning (IQ)
Estimated IQ scores were derived from the Shipley
Institute of Living scales (revised manual; Zachary et al.,
1985). This scale has been found to be highly correlated with
full-scale WAIS-R IQ scores (⬎.79; Frisch and Jessop,
1989).
Present Analyses
The analyses were conducted in three steps. First, DE
patients, non-DE patients, and controls were compared on the
social functioning, physical and social anhedonia, and trait
NA and PA scores using five separate one-way ANOVA
tests. Scheffé post hoc tests were used to examine betweengroup differences. We hypothesized that DE patients would
have poorer social functioning and more severe levels of
physical and social anhedonia compared with both non-DE
patients and controls. Additionally, we predicted that both
patient groups would have lower trait PA scores compared
with controls, and that non-DE patients would have higher
trait NA scores than controls. Second, we compared the DE
© 2005 Lippincott Williams & Wilkins
Diminished Emotionality
and non-DE patient groups on the six individual deficit
symptom subscale scores from the SDS with the expectation
that DE patients would have worse deficit symptom scores on
each of the subscales. Finally, we computed bivariate correlations between the social functioning, physical and social
anhedonia, and trait PA and NA scores to replicate prior
research. We hypothesized that poorer social functioning
would be associated with increased anhedonia, decreased trait
PA, and increased trait NA levels. All results reported are
two-tailed.
RESULTS
Means and SDs were computed and compared among
the DE, non-DE, and control groups for the descriptive data
and intellectual functioning variables. Symptom, clinical, and
medication data were also compared between the DE and
non-DE groups. Nearly all of the distributions of these variables had skew values less than 1.5, suggesting that parametric statistics were appropriate for comparisons. To compensate for excessive skew in the total time in hospital and
negative syndrome severity scores, these two variables were
log-transformed. The results, which are presented in Table 1,
suggest that the three groups were similar in terms of age,
parental Socio Economic Index scores, and gender and ethnic
composition. Controls had significantly higher levels of education and higher levels of intellectual functioning than
either of the patient groups. The DE and non-DE groups were
not statistically different on any of the descriptive, intellectual or general functioning, or medication variables. Surprisingly, DE patients had significantly less severe negative
symptoms compared with non-DE patients, but the two
groups did not differ in positive or disorganization syndrome
scores. DE patients also had slightly older age of first treatment compared with other patients at a trend level. In sum,
the DE group was similar to the non-DE group in most
respects, although they were healthier in terms of their severity of negative symptomatology.
Emotion and Social Functioning
Means and SDs for the social functioning,2 physical
and social anhedonia, and trait PA and NA scores were
computed and compared between the DE, non-DE and control groups using a one-way ANOVA. For each of these
measures, increasing scores reflect a higher intensity of that
phenomenon. The skew values for each of these variables
was less than 1.5, suggesting that parametric statistics were
appropriate for group analysis. These results are presented in
Table 2. There was a significant between-group main effect
for each of the variables, including social functioning
(F 关2,89兴 ⫽ 51.65; p ⬍ 0.01), NA (F 关2,92兴 ⫽ 4.17; p ⬍
0.05), PA (F 关2,92兴 ⫽ 6.71; p ⬍ 0.01), social anhedonia
(F 关2,71兴 ⫽ 3.96; p ⬍ 0.05), and physical anhedonia
(F 关2,71兴 ⫽ 4.94; p ⬍ 0.05) measures. Post hoc analyses were
then conducted using Scheffé tests. These results suggest that,
as hypothesized, DE patients had poorer social functioning
than either non-DE patients or controls. However, DE patients did not differ from non-DE or controls on social
anhedonia or physical anhedonia scores. Non-DE patients
reported experiencing significantly higher levels of trait PA
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Cohen et al.
TABLE 2. Patients With Diminished Emotionality (DE; N ⫽ 10) Versus Those Without (NonDE; N ⫽ 63) Versus With Controls (N ⫽ 22) on Social and Emotion Functioning Variables, With
Means ⫾ SDs
Group
Measure Descriptive
Variable
a
Social functioning
Positive affectivityb
Negative affectivityb
Social anhedoniab,c
Physical anhedoniab,c
DE
Non-DE
Controls
Group Comparison of DE,
Non-DE, and Control
Groups Post
Hoc ⴝ Scheffé
101.00 ⫾ 16.23
40.30 ⫾ 3.53
41.10 ⫾ 3.54
11.00 ⫾ 4.93
15.71 ⫾ 5.56
116.90 ⫾ 20.36
48.73 ⫾ 11.61
48.41 ⫾ 6.67
14.56 ⫾ 6.67
16.69 ⫾ 7.42
160.05 ⫾ 13.01
52.50 ⫾ 10.31
42.27 ⫾ 8.54
10.23 ⫾ 5.51
11.36 ⫾ 5.92
DE* ⬍ Non* ⬍ Con
DE* ⬍ Non* ⫽ Con
DE ⫽ Non† ⬎ Con
DE ⫽ Non* ⬎ Con
DE ⫽ Non* ⬎ Con
Patients
p value ⬍ 0.10; *p value ⬍ 0.05.
Higher scores reflect better social functioning.
Higher scores reflect a greater severity of symptomatology.
c
DE group N ⫽ 7; non-DE group N ⫽ 45.
†
a
b
than DE patients, and DE patients did not significantly differ
from non-DE patients or controls on the trait NA measure.
Patients with DE versus those without were then compared on the individual subscales from the SFS. Given that
these analyses were underpowered due to the DE group
having only 10 subjects, we excluded controls from these
analyses to increase the power. DE (m ⫾ SD ⫽ 12.40 ⫾ 4.40)
versus non-DE (m ⫾ SD ⫽ 17.18 ⫾ 6.13) patients had
significantly fewer recreational interests (t ⫽ 2.36; p ⬍ 0.05),
and DE (m ⫾ SD ⫽ 11.40 ⫾ 5.72) versus non-DE (m ⫾
SD ⫽ 17.05 ⫾ 8.46) patients engaged in significantly fewer
prosocial behaviors (t ⫽ 2.03; p ⬍ 0.05). DE patients (m ⫾
SD ⫽ 17.50 ⫾ 5.23) also had lower independence performance scores than non-DE patients (m ⫾ SD ⫽ 21.94 ⫾
7.11) at a trend level (t ⫽ 1.89; p ⬍ 0.10), but the two groups
did not significantly differ on the social engagement, interpersonal behavior, independence competence, or employment/occupational subscales. Thus, DE patients tended to
engage in fewer recreational activities, fewer prosocial activities, and to a lesser extent, fewer independent activities than
non-DE patients.
Deficit Symptom Ratings: DE Versus Non-DE
Eight of the patients, approximately 11% of the sample,
met criteria for the deficit syndrome, suggesting that it was a
relatively low occurring phenomenon in the present sample.
None of the patients with self-reported DE from the MPQ met
criteria for the deficit syndrome.
Patients with DE versus those without were compared
on the six deficit syndrome subscale ratings and the total SDS
scores. Four of the six SDS subscale ratings had skew values
less than 1.5, suggesting that parametric statistics were appropriate for these group comparisons. The SDS ratings of
diminished capacity to experience emotions and poverty of
speech exhibited excessive positive skew, so a Kendell’s ␶ B
test statistic was computed and used to determine whether the
groups were different on these variables. These results are
presented in Table 3. Patients with DE versus patients without had significantly less restricted affect, greater emotional
range, less poverty of speech, more social drive, and a trend
for more sense of purpose and lower overall deficit syndrome
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TABLE 3. Patients With DE (DE; N ⫽ 10) Versus Those
Without (Non-DE; N ⫽ 61) on the Individual Deficit
Syndrome Ratings and Total Schedule for Deficit Syndrome
Ratings With Means ⫾ SDs
Patients
Deficit Symptom
Restricted affecta
Diminished emotional
rangea
Poverty of speecha
Curbing of interestsa
Diminished sense of
purposea
Diminished social
drivea
Total scorea
a
Group
p
Comparison Value
DE
Non-DE
.10 ⫾ .32
.10 ⫾ .32
.73 ⫾ 1.08
.45 ⫾ .70
3.74c
.19b
0.00
0.04
.00 ⫾ .00
.28 ⫾ .64
.60 ⫾ .84
.88 ⫾ 1.11
.70 ⫾ 1.06 1.53 ⫾ 1.36
.18b
.77c
2.20c
0.01
0.44
0.04
.11 ⫾ .32
4.44c
0.00
2.29c
0.03
.82 ⫾ .98
1.60 ⫾ 1.96 4.63 ⫾ 4.10
Higher scores reflect a greater severity of symptomatology.
Kendell’s ␶ B value.
T value.
b
c
scores. This suggests that patients with self-reported DE
generally had significantly lower levels of deficit symptoms.
Interestingly, 37% (22 of 70) of the patients in the present study
were rated as having at least some level of DE from the
diminished capacity to experience emotions on the SDS. However, only one of the patients with (MPQ) self-reported DE was
rated as having any level of diminished emotionality on the
interview-rated deficit syndrome scale. Thus, there was substantial discrepancy between patients’ self-report of their emotions
and ratings of their emotionality as coded by trained observers.
Social Functioning and Emotion Variables for
Patients as a Group
To replicate prior research, bivariate correlations were
computed between the social functioning, physical and social
anhedonia, and trait PA and NA variables. As hypothesized,
social functioning scores were significantly associated with
physical anhedonia scores (r 关52兴 ⫽ ⫺.29; p ⬍ 0.05). Social
functioning and social anhedonia were correlated at the trend
level (r 关52兴 ⫽ ⫺.26; p ⬍ 0.10). Contrary to expectations,
© 2005 Lippincott Williams & Wilkins
The Journal of Nervous and Mental Disease • Volume 193, Number 12, December 2005
social functioning was not significantly associated with trait
NA (r 关73兴 ⫽ ⫺.16; NS) or PA (r 关73兴 ⫽ .19; NS) scores. It
is important to note that these correlations were in the
direction that was expected. For the most part however,
results from Blanchard et al. (1998) and Horan and Blanchard
(2003) were not replicated in this study.
DISCUSSION
Prior research has provided indirect evidence suggesting that a subgroup of patients has a diminished capacity to
experience both positive and negative emotions, poorer social
functioning, and more severe negative/deficit and anhedonia
symptoms than other patients. Findings from the present
study provide mixed support for these ideas. Approximately
14% of the patients self-reported experiencing DE, and these
patients tended to have poorer social functioning than other
patients. However, patients with DE versus those without had
significantly less severe negative and deficit symptoms and
similar levels of physical and social anhedonia. It seems
paradoxical that DE patients were as healthy as or healthier
than other patients in most respects, yet had poorer overall
social functioning.
With respect to understanding the potential relationship
between DE and social functioning impairments, it is important
to keep in mind that each of the patients was living in a
restrictive state hospital inpatient setting. It is possible that
differences between patients on a third variable (e.g., patients’
level of involvement in treatment, level of privileges) were
responsible for causing both DE and lower social functioning
scores. For example, patients with few privileges may have had
limited opportunities for engaging in social and vocational
activities. Similarly, the emotionally evocative experiences that
these patients experienced may have been limited, leading to
reduced levels of self-reported emotionality. However, it seems
unlikely that DE and social functioning deficits were solely the
results of environmental variables given that DE patients also
had significantly less severe negative and deficit syndrome
scores. A more cogent possibility is that, for certain patients, DE
and social functioning impairments manifested in reaction to
environmental factors. Perhaps certain healthier patients tended
to feel more constrained or have more difficulty adapting to
some aspects of the hospital environment. These patients might
have withdrawn emotionally from the hospital milieu by limiting
their engagement in social activities. Preliminary findings from
this study offer some support for this notion because many of the
social functioning deficits associated with DE tended to reflect
reduced participation in ward activities rather than a reduced
level of skill in social functioning. For example, the DE and
non-DE groups had equivalent levels of independent living skills
and vocational functioning, and similar numbers of peer and
intimate friendships. Rather, DE patients were engaging in fewer
prosocial activities, such as going to classes or meetings, fewer
recreational activities, and, to a lesser extent, fewer independent
living activities. In sum, while the causal relationship between
DE and social functioning impairments are, at present, unclear,
findings from this study suggest that certain patients may be at
increased risk for developing DE and concomitant social functioning deficits.
© 2005 Lippincott Williams & Wilkins
Diminished Emotionality
The present findings are important for our understanding of how emotional dysfunctions differ across different
forms of schizophrenia. It is well accepted that patients, as a
group, do not report experiencing diminished levels of state
emotionality (Kring and Neale, 1996). Even patients with
prominent flat affect report levels of emotional experience
similar to those reported by patients without flat affect (Kring
et al., 1993), suggesting that while patients may appear
emotionless, they actually experience normal levels of emotions. However, the present findings suggest that a subgroup
of patients reports experiencing low levels of emotionality
even though they appear to others to have normal levels of
affect and emotion. This suggests that while certain patients
appear emotionally expressive, they actually may be limited
in the emotions that they are experiencing.
Some limitations of the present project warrant mention.
First, given the possibility that both DE and social functioning
impairments were present, in part, due to the restrictive nature of
the treatment setting, it is unclear whether DE would have
occurred in a less restrictive environment. Moreover, we did not
assess patients’ forensic status, so it is possible that there were
differences between the forensic and nonforensic patients in
their level of emotion or social functioning impairments. It is
noteworthy that subjects in the present sample had better social
functioning than a sample of stable outpatients (Birchwood et
al., 1990). Nonetheless, it is unclear to what extent the present
findings generalize to patients in other settings. Second, none of
the patients met criteria using the more stringent a priori– defined
DE cutoff scores. It is unclear to what degree DE, defined using
the post hoc– defined cutoff scores, could be considered abnormal, because these scores fell within the normal range of
emotional functioning. It is important to point out that while
patients’ mean PA scores have been found to be in the lower part
of the normal range, mean NA scores have been nearly 1.5 SDs
above the population-normed mean (Bagby et al., 1997). Thus,
patients having low scores on both NA and PA is unusual.
Moreover, clinically meaningful differences between the DE
and non-DE groups were found using the post hoc– defined
cutoff scores. Finally, the analyses that examined self-reported
DE were underpowered because DE occurred with little frequency in this sample. It is possible that a larger DE sample size
would have yielded stronger results.
In contrast to two prior studies (e.g., Blanchard et al.,
1998; Horan and Blanchard, 2003), neither trait positive nor
negative affectivity scores were significantly associated with
social functioning impairments. Unfortunately, it was impossible to compare directly the mean NA and PA scores
between the studies, because the other studies used similar,
but different, NA and PA scales. For example, Blanchard et
al. (1998) used an abbreviated version of the NA and PA
scales from the MPQ. It was possible to determine that
patients in the present sample were generally reporting less
NA and more PA than patients in the prior study. Patients in
the present study endorsed approximately 37% of the NA
questions (mean ⫽ 8.49 of 23 questions), whereas patients in
previous studies endorsed approximately 56% (mean ⫽ 7.81
of 14 questions; Blanchard et al., 1998) and 51% (mean ⫽
14.34 of 28 questions; Horan and Blanchard, 2003) of the NA
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The Journal of Nervous and Mental Disease • Volume 193, Number 12, December 2005
Cohen et al.
questions. Similarly, patients in the present study endorsed
approximately 82% of the PA questions (mean ⫽ 18.77 of 23
questions), whereas patients in previous studies have endorsed approximately 57% (mean ⫽ 6.32 of 11 questions;
Blanchard et al., 1998) and 65% (mean ⫽ 17.79 of 27
questions; Horan and Blanchard, 2003) of the PA questions.
Thus, it seems a reasonable supposition that the relatively low
correlations between NA, PA, and social functioning were, at
least in part, a function of the present study’s patients having
healthier emotion levels. This is the first study to examine
simultaneously anhedonia and trait affectivity in a sample of
chronic inpatients, and it possible that sample differences
contributed to this lack of replication.
CONCLUSION
Based on the results of this study, the answer to the
question “Does DE meaningfully characterize a subgroup of
patients with schizophrenia?” is still unclear. Nonetheless, given
the potential relationship between deficits in emotional experience and social functioning impairments, DE appears to be a
promising construct for further research. The next step in examining DE would be to understand why there was virtually no
overlap between the self-reported and interviewer-rated measures of DE. Ultimately, a better understanding of how emotional deficits manifest differently across patients can inform
efforts to identify valid and meaningful subtypes of schizophrenia, and can improve psychosocial rehabilitation treatments
aimed at improving social functioning of patients.
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END NOTES
1
Kimhy D, Yale S, Goetz R, McFarr L, Malaspina D.
Independent Factors Comprise the Schizophrenia Deficit
Syndrome. Manuscript submitted for publication.
2
The SFS scores of the present study’s patients had a
mean approximately 1 SD above that of a normative sample
of 334 stable outpatients (m ⫾ SD ⫽ 102.76 ⫾ 9.78;
Birchwood et al., 1990). Thus, even though the patients in the
present study were relatively chronic inpatients, they tended
to have a higher level of social functioning compared to
outpatients. This finding was unexpected, and the reasons
underlying it are unclear. It is noteworthy that patient participation in ward activities was generally encouraged by hospital staff. Thus, the modest increase in social functioning
seen in the present sample could reflect treatment effects.
© 2005 Lippincott Williams & Wilkins