| | Emotion recognition in Chinese people with schizophreniaReceived 30 December 2004; received in revised form 1 December 2005; accepted 8 March 2006. 1. Introduction  Deficits of emotion recognition have been observed in patients with schizophrenia (Kirkpatrick et al., 1989, Mueser et al., 1996, Addington and Addington, 1998, Bryson et al., 1998, Kring et al., 1999, Davis and Gibson, 2000, Kohler et al., 2000, Penn et al., 2000, Edwards et al., 2001, Baudouin et al., 2002, Hooker and Park, 2002). These deficits have been speculated to be related to the poor social competency of people with schizophrenia (Izard, 1971, Anthony, 1978, Charlesworth, 1982, Kohler et al., 2000). However, the relationships between social functioning deficits and facial recognition or emotion recognition remain inconclusive. Mueser et al. (1996) observed that facial emotion identification/discrimination and facial recognition were related to the social adjustment of patients with schizophrenia. Hooker and Park (2002), on the other hand, reported that emotion recognition, but not facial recognition, was related to social functioning. Prosodic recognition has rarely been studied (Turner, 1964). The findings of previous studies suggest that deficits in both facial recognition and prosodic recognition are associated with schizophrenia (e.g., Baudouin et al., 2002, Edwards et al., 2001, Hooker and Park, 2002, Penn et al., 2000). It would be interesting to see whether patients with schizophrenia were differentially impaired in facial and prosodic recognition along the dimension of Ekman and Friesen's (1975) six basic emotions. Recent evidence has suggested that individuals with nonparanoid schizophrenia display stronger impairments in facial emotion recognition than individuals suffering from paranoid schizophrenia (Kline et al., 1992, Phillips et al., 1999, Weniger et al., 2004). To explain this observation, it has been speculated that there are fundamental differences in the cognitive processing involved in emotion recognition in paranoid and nonparanoid schizophrenia (Kline et al., 1992). Neuropsychological functions appear to be related to emotion recognition. It has been speculated that there is a selective attentional deficit in patients with schizophrenia (Bediou et al., 2005, Chan et al., 2004). Previous studies have investigated the relationship between various neuropsychological variables and scores on tests of emotion recognition (e.g., Addington and Addington, 1998). For example, Bryson et al. (1997) found that the Digit Span Test, the Wisconsin Card Sorting Test (WCST; Heaton, 1981), the Continuous Performance Task (CPT; Loong, 1991), the Wechsler Memory Scale (WMS-Figural; Wechsler, 1987), and the Hopkins Verbal Learning Test (true positive recognition; HVLT; Brandt, 1991) were related to the emotion-recognition task in their study, while others found that overall cognitive ability, as measured by, for example, the Wechsler Adult Intelligence Scale-Revised (WAIS-R; Wechsler, 1982), was not (Bryson et al., 1997, Edwards et al., 2001). Overall, concurrent cognitive abilities in patients with schizophrenia tend to influence their ability to recognize emotions, but the relationship between neuropsychological functioning and emotion recognition in patients with schizophrenia has only been investigated in a few studies that employed a limited number of neuropsychological measures. The objectives of the present study were (1) to verify whether people with schizophrenia would show emotion-recognition deficits, and if such deficits would vary between people with paranoid schizophrenia and those with nonparanoid schizophrenia; and (2) to explore whether any specific neuropsychological components could predict such differential emotion recognition in people with paranoid or nonparanoid schizophrenia. 2. Methods 2.1. Participants Participants comprised 86 people, of whom: 43 belonged to the clinical group and 43 to the normal control group. The Lateral Dominance Test (LDT; a Chinese version adapted from Harris's (1958) Tests of Lateral Dominance) and The Balloons Test (BT; Edgeworth et al., 1998) were administered as screening measures. The participants were matched on visual attention functioning according to their BT-Part B performance, and those with left-hand dominance were excluded from the current study. Written informed consent was obtained from each participant before participation. The two groups were matched on gender composition (21 men and 22 women in each group, χ2(df =1), P>0.05, ns) and age (F(1, 84)=0.032, P=0.859). The general intelligence of the two groups was estimated by the Test of Nonverbal Intelligence-3 (TONI-3; Brown et al., 1997). A significant between-group difference was observed (F(1,84)=44.146, P<0.01). As depression has a significant impact on cognitive function (Lezak, 1995), we used the Beck Depression Inventory-II (BDI; Beck et al., 1996) to ascertain the degree of depression felt by our participants. The scores of the two groups on the BDI differed significantly (F(1,84)=78.977, P<0.01). The neuropsychological test administrators were blind to the participants' schizophrenic classification in the present study. 2.1.1. Clinical group The 43 people with schizophrenia in remission were recruited from an outpatient clinic in a public hospital in Hong Kong. The patients had to meet (DSM-IV-TR; American Psychiatric Association, 2000) criteria for schizophrenia to be included. Patients with organic brain disorder, a history of severe head trauma, or a significant history of drug abuse or alcoholism were excluded from the study. These schizophrenic patients were placed in the paranoid group (n=19) or the nonparanoid (n=24) group according to the diagnosis made by the psychiatrists based on the information obtained in the clinical interview during visits to the out-patient clinics by these patients. The mean duration of illness was 8.90 (S.D.=7.90) years, and the average age of onset of illness was 28.71 (S.D.=8.90) years. The mean number of hospitalizations was 1.77 (S.D.=1.39). The nonparanoid and paranoid schizophrenic patients did not differ in their chronological age (F(1, 41)=3.80, P=0.06). Yet, the patients with paranoid schizophrenia had reached a higher education level than their nonparanoid counterparts (F(1, 41)=10.69, P=0.002). The healthy controls were therefore divided into two groups to match the education levels of the two clinical groups. No difference in the severity of the clinical syndrome, assessed using the Scale for the Assessment of Negative Symptoms (SANS; Andreasen, 1984a) and the Scale for the Assessment of Positive Symptoms (SAPS; Andreasen, 1984b), between the paranoid and nonparanoid groups at the time of examination was observed (P>0.05). Consistent with previous findings (Kerr and Neale, 1993, Mueser et al., 1996, Addington and Addington, 1998), demographics did not seem to be related to emotion recognition in the two groups of schizophrenic patients (e.g., duration of illness, number of admissions, age of onset, age, education level, and SANS and SAPS scores; P>0.05). All the patients were on antipsychotic medication at the time of the study. We did not control for patient medication because those patients who agreed to be withdrawn from their medication were not representative of the clinical population being studied (Spohn and Fitzpatrick, 1980, Silverstein et al., 1996). Killan et al. (1984) concluded in their study that psychotropic medication and its administration regimen did not affect the performance of schizophrenic patients on cognitive tests in any specific manner. Joober et al. (2002) studied the neuropsychological profile of patients with schizophrenia by examining and comparing neuroleptic responder and neuroleptic-nonresponder patients, representing the two extremes of the neuroleptic response spectrum, with healthy controls. Although they performed significantly below the level of the normal subjects, the two schizophrenia groups did not differ from each other on visuo-spatial ability. 2.2. Instruments 2.2.1. Forward Digit Span Test The Forward Digit Span Test (FDST; Wechsler, 1987) is a measure of working memory, or more specifically of the ability to retain short-term verbal materials (Lezak, 1995). The participant's score is derived from the last digit length for which he or she recalled the digits correctly. 2.2.3. Stroop test The Stroop Test (Stroop, 1935) is a common measure of selective attention (e.g., Amador et al., 1998). A previously validated Chinese translation of the Victoria Version of this test was used in the present study (Lee and Chan, 2000). The interference score in the current study was measured by computing the difference between the reaction times in the color–word condition and the word condition (i.e., the color–word reaction time minus the word reaction time). 2.2.4. Symbol Digit Modalities Test The Symbol Digit Modalities Test (SDMT; Smith, 1982) is a measure of switching attention. The score for the oral format was used as a measure of switching attention. This decision was based on the findings of Ponsford and Kinsella (1992), which suggested that the oral format of the SDMT was a better measure of switching attention. 2.2.5. Judgment of Line Orientation Test The Judgment of Line Orientation Test (JLOT; Benton et al., 1983) is used as a test of spatial perception. 2.2.6. Hooper Visual Organization Test The Hooper Visual Organization Test (HVOT; Hooper, 1983) is used as a test of visuo-perceptual organization. 2.2.7. Facial emotion recognition Matsumoto and Ekman's (1988) facial emotion photographs were used in this study (validated in a previous study by Yip and Lee, 2003). The photographs were administered in two different tasks: identification (12 test items) and discrimination (30 test items). For the identification task, the photographs were presented individually for 10 s. The participants were required to indicate which of the six basic emotions was conveyed in each photograph. For the discrimination task, all possible pairs of photographs were formulated and placed side by side in a computer file. Each pair was presented for 10 s, and the participants were asked to indicate which of the two photographs conveyed a particular emotion (e.g., fear). The identification task was always administered before the discrimination task in this study. All test items for this measure were displayed using a personal portable computer. Four subscales were formed by dividing the test stimuli according to the sex of the poser in the photograph and the type of task. Each stimulus in the two tasks was scored in the following manner: when the participant correctly identified the emotion conveyed in a photograph (identification task) or correctly identified the photograph that conveyed a specified emotion (discrimination task), then the participant received a score of 1. Whenever the response was incorrect, a score of 0 was given. Along with the four subscale scores, the total scores for the identification task (FEI) and the discrimination task (FED) were calculated. 2.2.8. Prosodic recognition This measure is composed of a prosody stimulus previously validated with first year undergraduates. It is divided into six subscales according to the type of prosody (sentence versus single word), the gender of the speaker (male versus female), and the type of task involved (identification versus discrimination). For the identification task, the participants were asked to listen to each of 24 test stimuli and indicate which of Ekman and Friesen's (1975) six basic emotions was conveyed. For the discrimination task, the participants were asked to listen to each of 60 pairs of test stimuli (each stimulus being 2 s apart from the next) and then indicate which of the two stimuli conveyed a particular emotion (e.g., happiness). A score of 1 was given for correct responses and 0 for incorrect responses. The total score was calculated by summing all the scores on the individual test items. Again, along with the four subscale scores, the total scores for the identification task (PEI) and the discrimination task (PED) were calculated. 2.3. Statistical analyses The first step was to verify the hypothesis of group difference in facial and prosodic emotion recognition, facial emotion identification (FEI), facial emotion discrimination (FED), prosodic emotion identification (PEI), and prosodic emotion discrimination (PED). Correlation analyses were performed to identify any possible covariate, including TONI-3 and BDI scores. No significant correlation was found for any of the four tasks in the four groups. A multivariate analysis of variance (MANOVA) procedure was therefore performed to examine the between-group difference for the clinical and control groups with the four emotion-recognition scores as dependent variables. The Bonferroni correction procedure was employed to control for Type 1 error in all analyses of variance procedures. The second step was to identify neuropsychological factors that might predict the impaired emotion-recognition ability identified. Correlation analysis was performed to verify suitable covariates. Since no neuropsychological test score significantly correlated with the TONI-3 or BDI scores in all four groups, MANOVA was used in this part of the analysis to test the performance in neuropsychological measures administered (FDST, SDMT-Verbal, SCWT, CTT, DVT, HVOT, and JLOT) between people with nonparanoid and paranoid schizophrenia, as well as their respective matched healthy volunteers. The Bonferroni correction procedure was employed to control for inflated Type I error in all analyses of variance procedures. Those neuropsychological functions that showed significant between-group differences were then entered as predictors in multiple stepwise linear regression analyses for the emotion-recognition deficits observed, if any, for people with paranoid schizophrenia and for those with nonparanoid schizophrenia. 3. Results 3.1. Emotion recognition MANOVA was employed to investigate the between-group differences in emotion recognition. The alpha level was corrected to 0.0125 to control for possible inflated Type I error. After application of the Bonferroni correction procedure, the group main effect was found to be significant (F(4,81)=21.09), P<0.001). This indicated that the participants in the different groups showed significantly varied performance in emotion recognition. Among the four emotion-recognition tasks, a significant group difference was observed in FEI (F(3,82)=6.17, P=0.001), PEI (F(3,82)=15.0, P<0.001) and PED (F(3,82)=5.29, P=0.002), but not in FED (F(3)=0.90, P=0.44). Post hoc comparisons revealed that only patients with nonparanoid schizophrenia performed significantly worse than their healthy counterparts matched for education level in FEI (P=0.002), PEI (P<0.001), and PED (P=0.007), while patients with paranoid schizophrenia were comparable to their respective healthy controls in FEI (P=1.00), PEI (P=0.027) and PED (P=0.715). The performance of patients with nonparanoid schizophrenia was not significantly worse than that of patients with paranoid schizophrenia in FEI, PEI, and PED (P=0.227; P=0.105; P=0.492). The post hoc results are summarized in Table 2. 3.2. Neuropsychological performance MANOVA was performed to examine any between-group differences in neuropsychological abilities including auditory attention (FDST), processing efficiency (SDMT-Verbal), divided attention (CTT), interference control (Stroop Color–Word Test, SCWT-Interference score), sustained attention (DVT-Time), visual organization (HVOT), and visuo-spatial orientation (JLOT). All alpha levels were corrected to 0.0071 to control for inflated Type I error. A group main effect was observed to be significant (F(7,78)=29.43), P<0.001), indicating that, in general, the participants in the present study, including both those with nonparanoid schizophrenia and paranoid schizophrenia, and their respective healthy volunteers, showed a significant difference in the neuropsychological functions measured. A between-group difference was also found in all neuropsychological tests administered: FDST (F(3,82)=6.723, P<0.001), SDMT-Verbal (F(3,82)=37.096, P<0.001), CTT (F(3,82)=17.689, P<0.001), SCWT-Interference score (F(3,82)=10.345, P<0.001), DVT-Time (F(3,82)=12.913, P<0.001), HVOT (F(3,82)=9.320, P<0.001), and JLOT (F(3,82)=30.378, P<0.001). Post hoc comparisons showed that both patients with nonparanoid schizophrenia and those with paranoid schizophrenia performed worse than their healthy counterparts in the SDMT-Verbal (P<0.001) and the JLOT (P<0.001). The patients in the paranoid group performed worse than their healthy counterparts in the SCWT (P<0.001), while such a difference in performance was not observed in patients with nonparanoid schizophrenia. On the other hand, patients with nonparanoid schizophrenia performed worse than their matched controls in the CTT (P<0.001), the DVT-A (P<0.001), and the HVOT (P=0.001). The nonparanoid schizophrenic participants were also found to perform significantly worse than the participants with paranoid schizophrenia in the CTT (P=0.004). Table 3 summarizes the post hoc results of the performances on all neuropsychological tests for all participants. 3.3. Predictors of emotion recognition for people with paranoid or nonparanoid schizophrenia The paranoid and nonparanoid groups were different from each other in their neuropsychological profiles. Therefore, separate multiple stepwise linear regression procedures were conducted, one for each of the two groups. Any neuropsychological component that could predict the different performance in emotion-recognition tasks for different groups of participants was examined. Neuropsychological measures that showed a significant difference in performance between the four groups of participants were selected to predict their scores on emotion-recognition tasks that showed discriminative performance between groups. Specifically, the scores that were entered as variables were those on the SDMT-Verbal, the SCWT, the DVT, the CTT, the HVOT, and the JLOT. Only emotion-recognition tasks that were found to be significantly different between the four groups were analyzed, namely FEI, PEI, and PED. The JLOT was the only significant predictor of FEI for people suffering from nonparanoid schizophrenia (B=0.165, S.E.=0.053, β=0.554, P=0.005). The R2 reached 30.7%. No neuropsychological component that was entered significantly predicted FEI for paranoid schizophrenic patients or for either group of healthy volunteers. For PEI and PED, the CTT was the only significant predictor for nonparanoid schizophrenic patients (B=−0.043, S.E.=0.012, β=−0.599, P=0.002; B=−0.112, S.E.=0.028, β=−0.648, P=0.001). About 36% of PEI and 42% of PED were predicted by the CTT for this group of patients. On the other hand, the SDMT-Verbal significantly predicted PEI and PED for the healthy controls matched with the nonparanoid schizophrenic patients (B=0.773, S.E.=0.364, β=0.412, P=0.045; B=2.152, S.E.=1.011, β=0.413, P=0.045). No significant predictor was identified for either paranoid schizophrenic group or for their healthy counterparts. (Table 4)  | FEI | NPS | PS | NPS-HV | PS-HV | | | SDMT-Verbal | 0.340 | 0.137 | 0.151 | −0.277 | | | CTT | −0.537⁎⁎⁎ | −0.127 | −0.100 | −0.277 | | | SCWT | 0.257 | 0.395⁎ | 0.125 | 0.050 | | | DVT | −0.036 | 0.139 | 0.150 | −0.182 | | | HVOT | 0.335 | 0.091 | 0.021 | −0.224 | | | JLOT | 0.554⁎⁎⁎ | 0.232 | 0.164 | 0.129 | | | | | | | | | | PEI | NPS | PS | NPS-HV | PS-HV | | | SDMT-Verbal | 0.507⁎⁎ | −0.141 | 0.412⁎ | −0.056 | | | CTT | −0.599⁎⁎⁎ | 0.238 | −0.107 | −0.207 | | | SCWT | 0.012 | −0.144 | −0.073 | −0.048 | | | DVT | −0.073 | 0.159 | −0.080 | −0.048 | | | HVOT | 0.459⁎ | 0.041 | 0.006 | 0.081 | | | JLOT | 0.543⁎⁎⁎ | 0.002 | 0.088 | 0.029 | | | | | | | | | | PED | NPS | PS | NPS-HV | PS-HV | | | SDMT-Verbal | 0.506⁎⁎ | −0.203 | 0.413⁎ | −0.236 | | | CTT | −0.648⁎⁎⁎ | 0.184 | −0.113 | −0.246 | | | SCWT | −0.027 | −0.064 | −0.061 | 0.052 | | | DVT | −0.004 | 0.071 | −0.077 | −0.132 | | | HVOT | 0.466⁎ | 0.145 | 0.028 | −0.018 | | | JLOT | 0.556⁎⁎⁎ | −0.100 | 0.126 | 0.056 | | | | |
4. Discussion Consistent with previous findings, those patients suffering from nonparanoid schizophrenia showed worse performance in emotion-recognition tasks than those diagnosed with paranoid schizophrenia (Kline et al., 1992, Phillips et al., 1999, Weniger et al., 2004). Indeed, paranoid schizophrenic patients performed as well as normal controls in all emotion-recognition tasks in the current study. Such differential profiles of impairment were observed in both facial and prosodic emotion recognition. Furthermore, the two schizophrenic subtypes presented with different neuropsychological profiles. Patients with paranoid schizophrenia showed a deficit in interference control, while individuals with nonparanoid schizophrenia were impaired in divided and sustained attention as well as visual organization. Spatial perception (measured by the JLOT) was observed to be the best predictor of facial emotion identification in individuals with nonparanoid schizophrenia, whereas only attentional processing control (measured by the CTT) predicted both prosodic emotion identification and discrimination in nonparanoid schizophrenic patients. 4.1. Emotion recognition among patients with paranoid or nonparanoid schizophrenia It was indeed surprising to observe that patients with paranoid schizophrenia performed as well as their matched healthy controls in all emotion-recognition tasks. Strong impairment in facial emotion-recognition tasks was previously reported in patients with paranoid schizophrenia (Weniger et al., 2004), while emotion-recognition deficits are well documented to be prominent among schizophrenic patients (Kirkpatrick et al., 1989, Mueser et al., 1996, Addington and Addington, 1998, Bryson et al., 1998, Kring et al., 1999, Davis and Gibson, 2000, Kohler et al., 2000, Penn et al., 2000, Edwards et al., 2001). Methodological discrepancies, which are always regarded as a shortcoming in facial emotion perception or recognition research (Mandal and Rai, 1987, Mandal and Palchoudhury, 1989, Edwards et al., 2002), may explain the discrepant findings between the current study and other studies. These methodological discrepancies include subject selection, such as the use of an unmedicated clinical group (Kerr and Neale, 1993), or the choice of schizophrenic participants in their acute first episode schizophrenic state (Edwards et al., 2001) or those with recurrent admissions (Lewis and Garver, 1995, Addington and Addington, 1998). The course of illness progression would have an effect on emotion recognition in people with schizophrenia (Gessler et al., 1989). Furthermore, our clinical participants were in remission, were on psychotic medication, and had a mean illness duration of 8.9 years (S.D.=7.9). Also, the participants were outpatients, who make up the largest subgroup of patients with schizophrenia (Breier, 1995). The highly stabilized nature of our clinical group might be another contributing factor to the absence of a prominent overall facial emotion-recognition deficit among them. Indeed, our results were consistent with studies that found no or only minor emotion-perception deficits in patients at the remission stage or at the later stage of acute hospitalization when the patients' symptoms were stabilized (Bellack et al., 1996, Cutting, 1981, Gessler et al., 1989, Weniger et al., 2004). Another possible explanation for the discrepant findings is cultural differences. Habel et al. (2000) have suggested that although schizophrenia appears quite similar across cultures, some variations in emotion-recognition performance have been observed among different ethnicities. Among the six basic emotions depicted in the JACFEE, anger and fear were shown to have much lower acceptable levels in Chinese culture than happiness, sadness, surprise, and disgust, possibly owing to a less overt expression of negative emotions in accordance with Chinese traditions (Yip and Lee, 2003). Such interchangeable confusion between anger and disgust, and fear and surprise, in both the schizophrenic and control groups could have feasibly counterbalanced the overall performance in the facial emotion-recognition tasks and have contributed to the absence of an overall facial emotion-recognition deficit in the current findings. The findings of the equality of variance analyses indicated that performance in most emotion-recognition tasks (FED, PEI, and PED) among patients with schizophrenia were not homogeneous (F(1, 41)=14.298, P<0.001; F(1, 41)=10.942, P=0.002; F(1, 41)=4.778, P=0.035). A significantly poorer performance in FEI, PEI, and PED was observed among patients diagnosed with nonparanoid schizophrenia. We speculated that a differential emotion-recognition deficit would be presented by people with paranoid or nonparanoid schizophrenia, as suggested by the fact that they had different profiles of performance to their respective matched controls. Furthermore, the findings indicated that only those clinical subjects with nonparanoid schizophrenia showed a deficit in emotion recognition in both facial and prosodic domains. This observation is partially in line with previous conclusions that patients with schizophrenia display more variability in affective prosody task performance than both nonpatients and neurotics (Turner, 1964, Jonsson and Sjöstedt, 1973, Edwards et al., 2002). 4.2. Neuropsychological performance among patients with paranoid or nonparanoid schizophrenia The evidence of differential neuropsychological profiles between patients with paranoid schizophrenia and those with nonparanoid schizophrenia seems to support previous accounts of specific perceptual deficits in different schizophrenic subtypes (Phillips et al., 1999). To the best of our knowledge, we are the first to compare the neuropsychological performances of patients with paranoid and nonparanoid schizophrenia using multiple measures. Both schizophrenic subtypes were impaired in processing efficiency and spatial orientation, which is consistent with and explains previous reports on facial perceptual deficits observed in patients with schizophrenia. Significantly poorer divided and sustained attention, together with a visual organization deficit, highlighted the neuropsychological impairments of nonparanoid schizophrenia in the current study. On the other hand, a deficit in interference control was observed among paranoid schizophrenic individuals. Such a profile may explain why paranoid schizophrenic patients with delusions have been found to have difficulty avoiding nonsalient information, especially threatening cues (Phillips et al., 2002). 4.3. Neuropsychological predictors of emotion recognition Among the neuropsychological factors for which a significant between-group difference was identified, spatial perception (as measured by the JLOT) was the best predictor of facial emotion identification. Attention processing control (as measured by the CCT) was the best predictor of prosodic emotion identification among nonparanoid schizophrenic patients. Imaging studies demonstrated reduced neural responses in the frontal, temporal, and parietal cortical regions of schizophrenic patients during emotion recognition (Phillips et al., 1999, Andreasen et al., 1997). This neuroanatomical feature was speculated to reflect underlying deficits in attention and inefficient processing of sensory information in these patients when performing these tasks. Bearing in mind that spatial perception is a form of sensory information processing, our findings are consistent with the speculation that spatial perception deficits are an important factor affecting performance in emotion recognition for nonparanoid schizophrenic patients. This may further suggest that sensory information-processing inefficiency is associated with and predicts facial emotion identification in this group of patients. Furthermore, divided and sustained attention deficits may also contribute to the prosodic emotion-recognition (identification and discrimination) impairment observed. Divided and auditory attention appears to be an important element in prosodic emotion recognition, which further implies that a prosodic emotion-recognition task demands dichotic or divided processing, for instance, attending to and processing the prosody while at the same time identifying the emotion. Yet, this speculation awaits future research and clarification. No neuropsychological predictor was able to predict performance or any emotion-recognition task, including FEI, PEI, and PED, in the paranoid schizophrenic patients and healthy controls. 4.4. Limitations Despite much effort, we were unable to solicit detailed information about the nonparanoid subtypes of and medications taken by our clinical subjects. We understand that such information may offer significant insight into how best to interpret our findings. It would be worthwhile identifying how nonparanoid subtypes and medications would affect emotion recognition in future research. Due to the small sample sizes in our study and the test length and testing time trade-off (the need to keep the testing time within reasonable limits for our participants), we were unable to identify how each of the six emotion types interacted with the clinical conditions under study. Furthermore, the adoption of a binary scoring method in our emotion-recognition tasks limited the ability to capture subtle differences between the groups studied. Multicenter studies that enable pooling of data obtained from standardized procedures may help increase the size of the samples, which could then help resolve the methodological shortcomings of our study that resulted from various practical constraints. 4.5. Conclusion People with nonparanoid schizophrenia were observed to be impaired in both facial and prosodic emotion recognition. 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Yip and Lee, 2003. 64.Yip JTH, Lee TMC. Cultural differences in facial emotion recognition. Brain and Cognition. 2003;51:169–170. a Applied Cognitive Neuroscience Laboratory, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong b Department of Neurology, The First Hospital of Anhui Medical University, China c Laboratory of Neuropsychology and Laboratory of Cognitive Affective Neuroscience, Department of Psychology, The University of Hong Kong, Hong Kong d Institute of Clinical Neuropsychology, The University of Hong Kong and MacLehose Medical Rehabilitation Centre, Hong Kong  Corresponding author. K610, Laboratory of Neuropsychology and Laboratory of Cognitive Affective Neuroscience, Department of Psychology, The University of Hong Kong, Hong Kong. Tel.: +852 28578394; fax: +852 25408920.
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