Generalized deficit in all core components of empathy in schizophrenia

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Abstract

Empathy is a multidimensional construct composed of several components such as emotion recognition, emotional perspective taking and affective responsiveness. Patients with schizophrenia demonstrate deficits in several domains of emotion processing and perspective taking, thus suggesting a dysfunctional emotional competence.

We assessed empathic abilities via three paradigms measuring emotion recognition, perspective taking and affective responsiveness as well as self-report empathy questionnaires in 24 (12 females, 12 males) schizophrenia patients meeting the DSM-IV criteria for schizophrenia and 24 matched healthy volunteers. Patients were recruited from the Department of Psychiatry and Psychotherapy, RWTH Aachen University and healthy volunteers were recruited via advertisement. Groups were matched for age, gender and parental education.

Data analysis indicates a significant empathic deficit in patients, reflected in worse performance in all three domains. This deficit was only partly reflected in the self-report empathy questionnaires. Comparing the different tasks, emotional perspective taking was the most difficult task for all subjects and symptomatology worsened affective responsiveness.

Schizophrenia patients not only struggle to correctly identify emotions, but also have difficulties in spontaneously simulating another person's subjective world (perspective taking) and might not be able to respond adequately in terms of their own emotional experience (affective responsiveness), which are not caused by emotion perception deficits. The results suggest that all domains of empathy are affected in schizophrenia and have to be addressed independently in behavioral therapies, thereby offering a possibility to improve socio-occupational life.

Introduction

The ability to communicate and understand intentions and feelings, and perceive the emotional states of others as well as in oneself is a vital skill. Similarities in our responses upon perceiving the emotions of others may in a broader sense be the basis for prosocial behavior, inhibition of antisocial tendencies and thus the prerequisite of social societies.

Empathy and empathic behavior have various definitions, likely due to the complexity of the construct (Preston and de Waal, 2002, De Vignemont and Singer, 2006, Gallese, 2003). However, according to most models three core components can be derived (Decety and Jackson, 2004): 1) The ability to recognize emotions in oneself and others via facial expressions, speech or behavior, 2) affective responsiveness, i.e. sharing of emotional states with others by experiencing similar emotions to others while being conscious that this is a simulation and not one's own emotion, and 3) emotional perspective taking, describing the competency to take the perspective of another person, while the distinction between self and other remains intact.

Correctly inferring emotional states and intentions via the observation of others' behavior are prerequisites for successful social interaction and increase social coherence (De Vignemont and Singer, 2006). Deficits in this fundamental competency are typically associated with poor social functioning as demonstrated by previous findings in patients with psychiatric disorders, e.g. autism (Frith and Frith, 2001). In schizophrenia, social interaction deficits are described as a core feature of the disorder and typically add to the deviant social behavior (Brüne, 2005). Bota and Ricci (2007) even propose application of empathy measures “as a method of identification of the debut of the prodrome of schizophrenia”. The clinical and social relevance of such impairments has been shown in a prospective study on functional as well as social outcome (Kee et al., 2003). This is further corroborated by findings from Penn et al. (1997) who demonstrated that statistically social cognition measures may better distinguish between patients and healthy controls than neurocognitive measures. Moreover, a deficit in so-called theory of mind (ToM) tasks has been reported frequently for schizophrenia patients (e.g., Frith, 2004). ToM refers to the ability to recognize beliefs and intentions of other people and to be able to interpret them correctly (Premack and Woodruff, 1978). It is also described as “mentalising”, when correct inferences of the intentions and beliefs of others are used to predict and control behavior (Corcoran et al., 1997).

Concerning emotional processing, an emotion recognition deficit is well documented in schizophrenia patients (e.g., Schneider et al., 2006, Van et al., 2007, Mandal et al., 1998 for review) however, less is known about the other two empathy components in schizophrenia patients. Emotional empathic abilities have only been scarcely investigated in schizophrenia as experimental paradigms for assessing empathy are relatively rare and most studies resort to questionnaire measures (Lee et al., 2004) reporting severe dysfunctions in schizophrenia patients (Bora et al., 2008). Only two previous studies have reported significant differences in self-reported affective responsiveness in schizophrenia patients (Shamay-Tsoory et al., 2007a, Shamay-Tsoory et al., 2007b). Regarding emotional perspective taking, recent publications indicate a significant impairment of schizophrenia patients using an affective ToM paradigm (Shamay-Tsoory et al., 2007a, Shamay-Tsoory et al., 2007c), where subjects had to infer mental states based on gaze cues in a cartoon outline. Langdon et al. (2006) demonstrated a significant deficit in cognitive empathy in schizophrenia patients who performed significantly worse in the emotion attribution task, whereas surprisingly no significant impairment occurred for emotion identification. These findings are further supported by recent results from Montag et al. (2007) demonstrating significant differences between patients and controls with respect to perspective taking and personal distress using a self-report questionnaire that were not related to psychopathological status.

Despite the potential shortcomings of some studies e.g., small numbers of test trials and stimuli or sole reliance on self-report measures, these findings indicate that deficits in social cognition characterize and stigmatize schizophrenia patients. It is currently unknown whether these deficits are prominent for all empathy components or whether deficits in one component influence those in the other domains.

Therefore, we assessed the three defining components of empathy in schizophrenia patients and matched healthy controls, enabling more detailed and exact analyses of these emotional competencies, their interactions and possible dysfunctions in patients. Based on prior results (Langdon et al., 2006, Montag et al., 2007, Shamay-Tsoory et al., 2007b, Van et al., 2007), we hypothesized impairments of patients in all empathy components, which could not be explained sufficiently by dysfunctions in just one component. Moreover, we assumed that this deficit in empathic abilities cannot be fully explained by cognitive impairments. In light of findings of inverse correlations between psychopathology and affective ToM performance (Shamay-Tsoory et al., 2007b) and self-report measures (Bora et al., 2008, Shamay-Tsoory et al., 2007a) we further hypothesized an association between psychopathology and empathic deficits. Moreover, we expected positive correlations between the self-report empathy questionnaires and the performance in the empathy tasks.

Section snippets

Sample

Twenty-four schizophrenia patients meeting the DSM-IV criteria for schizophrenia and 24 healthy controls matched for gender, age and parental education participated in this study. All subjects were Caucasian. Exclusion criteria included: no substance abuse for the last six months and no (other) psychiatric or neurological illness based on the German version of the Structured Clinical Interview (SCID, Wittchen et al., 1998). Symptom severity in patients was assessed with the Positive and

Emotion recognition

The GEE analysis for percent correct revealed a significant main effect of group (Wald-χ2 = 6.031, df = 1, p = .014) with lower performance for patients (mean = 81.2%) than controls (mean = 87%) and a significant main effect of emotion (Wald-χ2 = 66.355, df = 5, p < .001). Accuracy was highest for happiness and lowest for sadness. No significant main effect of gender (Wald-χ2 = .280, df = 1, p = .597) and no significant interactions (all p > .335) occurred.

Analysis for reaction times revealed a significant emotion

Discussion

The aim of the study was to explore dysfunctional affective and cognitive components of empathic abilities in schizophrenia patients and to compare patients' performance with results from well-matched healthy controls. As hypothesized, schizophrenia patients were impaired in all empathy related functions, suggesting a severe emotional deficit, not only in emotion recognition but also in emotional perspective taking and affective responsiveness. However, the emotion recognition deficit is not

Conclusion

Our results fully support the assumption by Langdon et al. (2008), who speculate that schizophrenia patients are impaired in their capacity to spontaneously simulate another person's subjective world, i.e. they cannot empathetically appreciate the likely content of another person's mind in order to take appropriate account of that other person's feelings. Furthermore, our findings even indicate a much broader emotional deficit characterized by reduced emotion recognition accuracy and impaired

Role of funding source

Funding for this study was provided by the IZKF grant TVN70 to U.H. The IZKF had no further role in study design, in the collection, analysis and interpretation of data, in the writing of the report, and in the decision to submit the paper for publication.

Contributors

Authors B.D., D.F. and U.H. designed the study and wrote the protocol. Authors B.D., A.H., T.K.T. tested the subjects. Authors B.D., A.F. und U.H. undertook the statistical analysis and wrote the first draft of the manuscript. Authors D.F. und F.S. helped with interpretation of data. All authors contributed to and have approved the final manuscript.

Conflict of interest

All authors declare no conflict of interest.

Acknowledgements

B.D. and A.F. were supported by the Interdisciplinary Centre for Clinical Research (IZKF, TVN70 to U.H.). B.D. and U.H. were further supported by the German Research Foundation (DFG, KFO 112) and the International Research and Training Group (IRTG 1328, DFG).

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