Perception of facial emotion in adults with bipolar or unipolar depression and controls

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Abstract

Previous research indicates that patients with depression display deficits in their ability to perceive emotions. However, few studies have used animated facial stimuli or explored sensitivity to facial expressions in depressed individuals. Moreover, limited research is available on facial processing in unipolar versus bipolar depression. In this study, 34 patients with DSM-IV major depressive disorder (MDD), 21 patients with DSM-IV bipolar disorder (BPD) in the depressed phase, and 24 never-depressed controls completed the Emotional Expression Multimorph Task, which presents facial emotions in gradations from neutral to 100% emotional expression (happy, sad, surprised, fearful, angry, and disgusted). Groups were compared in terms of sensitivity and accuracy in identifying emotions. Our preliminary findings suggest that subjects with bipolar depression may have emotional processing abnormalities relative to controls.

Introduction

Depression is associated with impairments in judging facial expressions, a crucial part of social interaction. Such deficits may offer an explanation for the decreased psychosocial functioning that many people with depression experience as their symptoms become more severe (Judd et al., 2005, Judd et al., 2000). Previous studies noted that patients with unipolar and bipolar depression are less accurate than controls at identifying facial expressions (Derntl et al., 2009, Gray et al., 2006, Gur et al., 1992, Leppanen et al., 2004, Persad and Polivy, 1993, Rubinow and Post, 1992, Surguladze et al., 2004), an impairment that could be due to difficulty in attending to salient facial features when viewing faces (Loughland et al., 2002).

Several studies have indicated that these deficits reflect a negative bias in perception, where happy faces are interpreted as neutral, and neutral faces are interpreted as sad (Gur et al., 1992, Leppanen et al., 2004, Surguladze et al., 2004, Yoon et al., 2009). Subjects with unipolar depression also appear to be slower to detect positive facial expressions than healthy volunteers (Suslow et al., 2004). Moreover, the way that patients view negative emotions corresponds with the course of their illness. Individuals with unipolar depression who perceive high levels of negative emotions when viewing faces tend to have a course of illness characterized by greater severity of depression, persistence of symptoms, and likelihood of relapse (Bouhuys et al., 1999, Hale, 1998). However, one study found that even after remission, patients with a history of recurrent depression displayed impaired sensitivity to happy faces as compared to controls (LeMoult et al., 2009).

In terms of bipolar disorder (BPD), studies have found that patients are less accurate at identifying certain emotions. For instance, subjects with BPD were less accurate than controls in identifying surprised (Bozikas et al., 2007, Summers et al., 2006) and fearful facial expressions (Bozikas et al., 2007). Other studies found generalized deficits in recognizing expressions as opposed to emotion-specific impairments. Subjects with bipolar depression were less accurate at identifying emotional expressions overall as compared to controls, (Gray et al., 2006). In addition, generalized impairments were found in euthymic BPD patients as well, suggesting a trait deficit in emotional processing (Bozikas et al., 2006, Derntl et al., 2009).

Traditionally, tasks that assess emotion perception use static facial stimuli representing happy, sad, and neutral expressions. These tasks, however, fail to emulate the range of emotions and the varying intensity of expression that people experience in real-life situations. Preliminary evidence suggests that tasks incorporating a wider variety of facial expressions reveal a deficit across emotions (Asthana et al., 1998, Persad and Polivy, 1993). Recently, researchers started to use forms of animated facial stimuli displaying various intensities, providing a more realistic and sensitive measure of emotion perception (Gray et al., 2006, Rich et al., 2008b, Summers et al., 2006, Venn et al., 2004).

Animated facial stimuli allow researchers to measure sensitivity to facial expressions, which represents an important aspect of social interaction. While several studies have explored sensitivity in BPD, very few have used animated facial stimuli with unipolar depression. Preliminary findings for BPD indicate that euthymic adults do not display impaired sensitivity (Venn et al., 2004); however, during the depressed phase of BPD, patients exhibited reduced sensitivity in recognizing certain emotions (Gray et al., 2006, Summers et al., 2006). However, findings have been inconsistent regarding which emotions are pertinent to this deficit. Although a reduced sensitivity to happiness is consistently reported, the results vary for negative emotions. One study found no deficit for negative emotions (Gray et al., 2006), whereas another study discovered a deficit in identifying disgusted and fearful faces, but not sad faces (Rich et al., 2008b). Summers et al. (2006) found that a group of individuals with bipolar depression were less likely to identify angry faces than the euthymic BPD group. Given the variation in findings, more research is clearly needed to decipher the nature of the deficit.

Although most studies exploring sensitivity to facial expressions have been conducted in individuals with BPD, preliminary results suggest deficits in this area for Major Depressive Disorder (MDD) as well. Gur et al. (1992) found that BPD and MDD subjects with higher negative affect displayed more impaired sensitivity to sad faces. Surguladze et al. (2004) found that individuals with MDD tended to mislabel mildly happy faces. However, these studies used static as opposed to animated facial expressions, which might influence the nature of the results. To our knowledge, few studies have compared the perception of facial emotion in individuals with unipolar versus bipolar depression, and the studies that included both unipolar and bipolar participants did not analyze the data separately for each diagnostic group (Gur et al., 1992, Rubinow and Post, 1992).

This study used animated facial stimuli to compare the accuracy and sensitivity of emotion perception between individuals with unipolar and bipolar depression as well as controls. We hypothesized that the MDD and BPD groups would exhibit an overall decreased sensitivity to emotional faces compared to controls. Moreover, we predicted that these groups would be less accurate than the control group when labeling emotions.

Section snippets

Subjects

Participants were recruited from ongoing studies at the National Institute of Mental Health (NIMH). The subjects met DSM-IV criteria for MDD (n = 34) or BPD I or II, depressed phase (n = 21) as determined by the Structured Clinical Interview for Axis I DSM-IV Disorders–Patient Version (SCID-P) (First et al., 2001). All participants were free of acute medical illnesses, current psychotic features, and substance abuse or dependence for the past three months. The subjects with unipolar depression

Results

The groups were similar in age, IQ, and sex (see Table 1). As expected, the control group exhibited less depression than the patient groups.

The linear mixed model for the morph level reached on the first response showed significant main effects for diagnosis, emotion, and trial, but no interactions (see Table 2 and Fig. 1). The BPD group required a more intense facial expression to make a first response than controls (p = .03), but there were no differences between the unipolar and BPD groups (p

Discussion

Our results partially support our first hypothesis, namely that the MDD and BPD groups would display impaired sensitivity to all emotional faces as compared to controls. The BPD group exhibited decreased sensitivity to facial expressions in general compared to controls. Specifically, the BPD group required more intense facial expressions before they first responded, and before they correctly identified the emotion. However, no differences were found between the BPD and MDD groups, or between

Funding

Funding for this work was supported by the Intramural Research Program of the National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services (IRP-NIMH-NIH-DHHS) and by a NARSAD Award (CAZ). The NIMH had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the manuscript; or in the decision to submit the paper for publication.

Contributors

Dr. Carlos Zarate, Dr. Brendan Rich, and Kathryn Schaefer conceptualized the study. Kathryn Schaefer and Jacqueline Baumann managed the literature searches and analyses. David Luckenbaugh performed the statistical analysis and Kathryn Schaefer wrote the first draft of the manuscript. All authors contributed to and approved the final manuscript.

Conflict of Interest

All of the authors declare that they have no conflict of interest to disclose, financial or otherwise.

Acknowledgements

We thank Ioline Henter for outstanding editorial assistance.

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