Facial Affect Recognition Training Improves Social Outcomes in Psychosis

How Those With Schizophrenia Misinterpret Social Cues
How Those With Schizophrenia Misinterpret Social Cues
Inability to interpret facial expressions may exacerbate psychotic symptoms, either indirectly via social defeat or directly by creating confusing interpersonal experiences.

Researchers have found that in patients with schizophrenia, facial affect recognition difficulties were highly improved by psychological intervention, which may improve an individual’s ability to function socially.

Dr Paul Hutton from the School of Health and Social Care at Edinburgh Napier University and colleagues conducted a meta-analysis of 8 randomized controlled trials that included 300 patients and found that brief, focused psychological interventions led to significant improvements in the ability of patients with psychosis to recognize facial affect [k = 8, N = 300, g = 1.26; 95% CI, 0.92-1.60; I2 41%].1

They also found early evidence that this intervention may not improve psychotic symptoms; however, it may improve social functioning (k = 3, N = 109, g = 0.98; 95% CI, 0.37-1.36; I2 38%).

“Many individuals with psychosis struggle to identify the emotions of other people, which may have a negative impact on their ability to experience social success and well being,” the investigators wrote. “There is also good reason to think this well-established difficulty may exacerbate psychotic symptoms, either indirectly via social defeat or directly via the generation of confusing interpersonal experiences.”

The researchers noted surprise that none of the studies discussed the significant association between difficulties in recognizing facial expressions and psychotic symptoms, despite clear associations between a lack of skill in perceiving emotion and social defeat risk factors in psychosis, such as trauma and migration.

“One particularly influential theory proposes that psychosis develops in response to repeated experiences of social defeat,” the researchers wrote. “This theory helps to account for the well-established findings that childhood adversity, migration, urbanicity, and discrimination are each associated with an increased risk of psychosis, and as well as the more recent finding that adult trauma survivors have an increased risk of developing psychosis.”2-4

Clinical Applicability

The researchers concluded that the improvements seen from facial affect recognition training are encouraging; this relatively simple intervention may improve the ability of patients with psychosis to experience social success.

They also noted that while no effect on psychotic symptoms was seen, the studies that did observe psychotic symptoms measured them soon after the intervention. A longer follow-up time may be necessary to determine whether psychotic symptoms eventually improve, and it may also be beneficial for researchers to consider using measures that are more sensitive to early or subtle evidence of changes.


  • The trials included in the meta-analysis included limited information on randomization procedures, and most of the studies did not report on whether assessors were blinded
  • The quality of the nonrandomized controlled trials was reduced due to sample size
  • There were too few studies to assess for publication bias

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  1. Bordon N, O’Rourke, Hutton P. The feasibility and clinical benefits of improving facial affect recognition impairments in schizophrenia: systematic review and meta-analysis [published online January 14, 2017]. Schizophr Res. 2017; doi:10.1016/j.schres.2017.01.014
  2. Selten JP, van der Ven E, Rutten BP, Cantor-Graae E. The social defeat hypothesis of schizophrenia: an update. Schizophr Bull. 2013;39(6):1180-1186.
  3. Varese F, Smeets F, Drukker R, et al. Childhood adversities increase the risk of psychosis: a meta-analysis of patient-control, prospective- and cross-sectional cohort studies. Schizophr Bull. 2012;38(4):661-671.
  4. Okkels N, Trabjerg B, Arendt M, Pedersen CB. Traumatic stress disorders and risk of subsequent schizophrenia spectrum disorder or bipolar disorder: a nationwide cohort study. Schizophr Bull. 2017;43(1):180-186.