Number of tables: 3 Number of figures: 1 Emotional facial expression decoding impairment in poly-substance dependent persons: Impact of a history of alcohol dependence. FOISY, Marie-Line1; PHILIPPOT, Pierre2; VERBANCK, Paul3 ; PELC, Isidore4; VAN DER STRATEN,
5 6 Georges ; KORNREICH, Charles
Free University of Brussels, Brugmann Hospital, Belgium.
Authors' notes 1 Dept. of Psychiatry, Free University of Brussels, Brugmann Hospital, Brussels, Belgium. 2 Ph.D, Professor, Dept. of Psychology, Université catholique de Louvain, Louvain-la-Neuve, Belgium. 3 MD, Ph.D, Dept. of Psychiatry, Free University of Brussels, Brugmann Hospital, Brussels, Belgium. 4 MD, Ph.D, Dept. of Psychiatry, Free University of Brussels, Brugmann Hospital, Brussels, Belgium. 5 Trempoline, Châtelet, Belgium. 6
MD, Ph.D, Dept. of Psychiatry, Free University of Brussels, Brugmann Hospital, Brussels,
Belgium. The study presented in this paper has been made possible by grants from the "Fonds de la Recherche Scientifique Médicale Belge" n° 3.4613.01 and by grants from the "Fondation Brugmann". Correspondence regarding this paper should be addressed to Charles Kornreich, Université Libre de Bruxelles, Laboratoire de Psychologie Médicale, CHU Brugmann, Place A. Van Gehuchten, 4, B- 1020 Bruxelles, Belgique. Phone: + 32 2 477 37 10; Fax: + 32 2 4772162. Electronic mail may be sent via the Internet to Marie-Line Foisy "
[email protected]".
1
Abstract Objective: The decoding of emotional facial expressions is impaired in recovering alcoholics and less severely so in opiates dependent persons without alcohol dependence antecedents. This study addressed two complementary questions: (1) How do these decoding deficits change with long-term abstinence during an institutionalized therapeutic program? (2) Do alcohol dependence antecedents constitute a factor impairing a potential recovery? Method: Sixty-five participants (54 men and 11 women) were recruited at a long-stay postdetoxification treatment center. They were assigned to one of four groups depending on (a) whether or not they met alcohol dependence criteria in the past and (b) whether they were on therapeutic stage 1 or stage 2. Stage 1 was defined as being in the first two months of the therapeutic program and stage 2 as being in the long term therapeutic community (i.e. from 2 to 10 months of therapeutic program). The participants were given an emotional facial expression-decoding test consisting of 16 photographs portraying happiness, anger, disgust and fear. Participants were asked to rate the estimated intensity level of each photograph on 8 scales labeled happiness, sadness, fear, anger, disgust, surprise, shame, and contempt, presented successively. A complementary scale assessed the self-estimated difficulty in performing the task. Results: Results show a greater deficit in individuals with substance dependence with past alcoholic dependence compared to former substance-dependent persons who had never met the alcohol dependence criteria according to the DSM-IV. However, there was no effect of long term abstinence on emotion decoding abilities whatever their past dependence. Conclusions: Substance dependence is associated with dysfunctions in emotional facial expression decoding processing, alcohol dependence being linked with more impairments and no improvement after months of abstinence. Key words: Emotion, face, facial, alcoholism, substance-dependence.
2
Introduction. Satisfying and successful interpersonal relationships are partly determined by the ability to accurately interpret non-verbal signals from interaction partners (Carton et al., 1999). Indeed, the capacity to infer accurately the internal state of one’s interaction partner, specifically in terms of emotion, is a very important facet of social skills (Patterson, 1999): Awareness of a partner’s feelings and emotions enables a person to tune their reactions, and to ensure acceptable interpersonal communication. Thus, interpersonal problems might result partly from impaired processing of emotional information related to social interactions. Emotional information is conveyed primarily by facial expressions and affective prosody, a nonlinguistic aspect of speech that conveys emotion and attitude during discourse (Monnot et al., 2001; 2002). In agreement with these theoretical assumptions and the interpersonal difficulties shown by individuals with substance dependence (e.g. Bauer, 1998; Hover and Gaffney, 1991), several studies have shown that recently detoxified alcoholics demonstrate both affective prosody recognition deficits (Monnot et al., 2001; 2002) and emotional facial expression decoding deficits. Patients displayed deficits in the ability to correctly label the displayed emotion and overestimated the intensity of the stimuli compared to normal controls (Kornreich et al., 2001a, 2001b, 2002; Oscar-Berman et al., 1990; Philippot et al., 1999). Further, they needed more intensity to perceive an expression as being present (Frigerio et al., 2002), and displayed different patterns of interpretation of emotion as compared to controls, with a specific bias for hostile emotions (Frigerio et al., 2002; Philippot et al., 1999; Townshend & Duka, 2003). Alcoholics also do not completely recover from these deficits with long-term abstinence. Indeed, a study by Kornreich and colleagues (Kornreich et al., 2001b) showed that decoding accuracy was still deficient, though intensity overestimation was not observed in alcoholics abstinent for at least 2 months. Such results suggest either a resistant toxic effect of alcohol on
3
this ability and/or the presence of the decoding deficit before the dependence develops. Finally, Kornreich et al. (2002) have shown that in alcoholics, facial emotion decoding deficits are linked to interpersonal difficulties. An important issue pertains to whether this emotion-decoding deficit is present in substance dependence in general, or if it is specific to alcoholism. Kornreich et al. (2003) observed that opiate-dependent persons demonstrate more accuracy deficits in emotion decoding than normal controls but that these deficits are not as severe as in alcoholics. Building upon this previous investigation, we have addressed two main complementary questions: (1) How do these decoding deficits evolve with long term abstinence during an institutionalized therapeutic program? (2) Do alcohol dependence antecedents impair potential recovery of this deficit? The findings of Konreich et al. (2003) matched the frequent observation of more severe cognitive impairments in chronic alcoholism than in other psychotropic substance dependence (e.g. Roques, 1999) and more specifically than in opiate-dependence (Weinrieb & O’Brien, 1993). Indeed chronic alcoholism is well known to lead to a series of sequelae, including cardio-vascular or neurological problems (e.g., Gaignard and Kiritze-Topor, 1994; Leonard and Ben Amar, 2000; Valenzuela, 1997), which are not observed, or to a much lesser extent, in the case of dependence on substances other than alcohol. The neuronal alteration due to heavy, chronic alcohol consumption leads to numerous cognitive and neuropsychological impairments (Grant et al., 1987 ; Leckliter and Matarazzo, 1989), including deficits in learning, memory, abstraction, verbal problem solving, perceptual analysis and synthesis, perceptual-motor speed, and speed and accuracy of information processing (Parsons, 1998). With long-term alcohol abstinence, some of these deficits disappear rapidly (Parsons, 1998; Selby and Azrin, 1998), but others remain for a long time and may not completely disappear (Fabian and Parsons, 1983).
4
However, literature exploring the toxic effect of chronic substance dependence, particularly opiate-dependence, on the brain subject is mixed (e.g. Grant et al., 1976; Hill and Mikhael, 1979, Rounsaville et al., 1982; Specka et al., 2000; Zacny, 1995). Opiates do not seem to be neuro-toxic per se (Darke et al., 2000) and psychomotor and cognitive functions are not impaired by the chronic use of morphine, codeine, heroin or methadone (Lombardo et al., 1976; Rousaville et al., 1982; Zacny, 1995; Specka et al., 2000). This contrasts with the wellknown deleterious effects on cognitive functioning of chronic alcohol (Parsons, 1998) or of poly-substance use in patients using, among other substances, alcohol (Selby and Azrin, 1998). Further, opiates are sometimes used for cancer patients’ treatment with little neuropsychological repercussion (O’Neill, 1994). Thus, whether the deficit is present before the dependence develop or not, alcohol could additionally exercise a particularly deleterious influence on emotional facial expression decoding ability in substance dependent persons. Indeed, participants with alcohol dependence, whether they were dependent on other substances including opiates or not, presented the most severe decoding deficits compared to opiate-dependent persons without alcohol dependence antecedents, who demonstrated milder decoding accuracy deficits (Kornreich et al., 2003). The present study included 45 participants of our previous research (Kornreich et al., 2003) investigating whether emotions decoding deficits varied among 5 different groups: recently detoxified alcoholics, opiate-dependent participants under methadone maintenance treatment, detoxified opiate-dependent participants, detoxified subjects with both alcoholism and opiatedependence antecedents, and normal controls- and 20 new participants. The 65 participants were divided in 4 groups depending on (1) whether they had been diagnosed as alcoholics in the past according to DSM-IV criteria and (2) whether they were at the 1st stage (first 2 months) or at the 2nd stage of the therapeutic program.
5
We hypothesized that alcohol-dependence would be associated with more emotional facial expression decoding deficits than opiate-dependence, and that alcohol-dependence antecedents would impair this function’s recovery with abstinence.
Method Participants Sixty-five participants were recruited at a long-stay post-detoxification treatment center (Trempoline, Châtelet, Belgium) characterized by a maximum possible stay of 18 months. This post-detoxification treatment center is located in an underprivileged region in Belgium. It is characterized by community life where tasks (e.g. cooking, gardening, etc.) are shared among groups of 5 to 6 persons. During the entire stay, patients participate in training programs targeting social interactions and emotional skills. Several times each week they meet with staff members and are invited to express themselves regarding their relational and emotional difficulties in the community. The stay at Trempoline is divided in 3 stages: (1) Stage 1: The Therapeutic Accommodating Program (i.e. roughly between the first day until the 60th day of stay) when participants are closely supervised and inserted in a group. During this time it is not permitted to go out of the institution alone; (2) Stage 2: the Therapeutic Community Program (i.e. roughly between the 2nd and 12th month) during which participants are progressively allowed to go out with less and less supervision; (3) Stage 3: the Social Reinsertion Program (i.e. roughly from the 12th month until the end of the program) in which participants are encouraged to find an accommodation to reintegrate into “real” life without substance use (e.g. find an activity, an apartment, etc.).
6
All study participants were diagnosed with opiate-dependence according to DSM-IV criteria (APA, 1994) and were detoxified from all substances (except tobacco). They were not receiving any psychotropic medication at the time of assessment. Forty-two inpatients were at stage 1. Half of these (N=21) met the DSM-IV criteria for alcohol dependence and for opiate-dependence (1-AO) at some time in their lives. The other 21 participants met the DSM-IV criteria for opiate-dependence but had never been alcohol dependent (1-O). Twenty-three of the participants were at stage 2 and 12 met criteria for alcohol-dependence and opiate-dependence (2-AO). The other 11 participants met criteria for opiate-dependence but not for alcohol (2-O). . Abstinence for all study participants was ensured both by staff’s clinical supervision and by frequent urine and/or alcohol breath test controls. As shown in Table 1, the 4 groups were similar in terms of age, sex and education. The length of stay did not differ respectively for participants at stage 1 and participants at stage 2, whether the participants had alcohol dependence or not. -------------------------------------------------------Insert Table 1 about here -------------------------------------------------------Antecedents for substance dependence were recorded when participants reported regular use of one particular substance. A description of the history of dependence as a function of the groups is shown in Table 2. -------------------------------------------------------Insert Table 2 about here -------------------------------------------------------Participants were also assessed on several control measures: depression (Beck Depression Inventory, BDI; Beck et al., 1988), anxiety state (Spieleberger State-Trait Anxiety Inventory,
7
form B, Spielberger, 1983a; 1983b), and interpersonal problems (Inventory of Interpersonal Problems, (Horowitz et al., 1988) IIP, French abbreviated form, Nef and Simon, 1994 unpublished). Table 3 displays the scores of these control measures for the 4 groups of participants. As could have been expected, patients of stage 1 showed higher levels of anxiety, depression, and interpersonal problems than patients of stage 2 who seem to have benefited from longer abstinence and community life. -------------------------------------------------------Insert Table 3 about here -------------------------------------------------------Emotional Facial Expression Test A series of emotional facial expressions constructed by Hess and Blairy (1995) was employed. Specifically, facial expressions of happiness, anger, sadness, disgust, and fear performed by two male and two female Caucasian actors from a series of standardized photographs of faces were used (JACFEE, Matsumoto and Ekman, 1988). Based on the neutral face (0% of emotional intensity) and the full-blown emotional facial expression (100% of emotional intensity) of the same actor, and using the computer program Morph 1.0, a series of intermediate expressions differing in emotional intensity by 10% steps was constructed. From this series, a set of 2 (intensity levels: 30% and 70%) x 4 (emotions: happiness, anger, disgust and sadness) x 2 (actors) stimuli constituted the stimulus material. These 16 stimuli were presented in a random order on an Apple Macintosh PowerBook 1800.
More
information on these stimuli is available in Hess et al. (1997) and Blairy et al. (1999). Full technical details of the procedure for creating stimuli are available from Ursula Hess (University of Quebec at Montreal). We limited the number of expressions presented in order not to overwhelm the subjects. The 30% and 70% intensity levels were chosen as they are more frequently encountered in real-
8
life situations than full-blown expressions. Further, since actors’ gender has not been part of the research questions, it was consequently collapsed across analyses.
Dependent Measures In order to expand upon the four target emotions (happiness, anger, disgust and sadness), participants rated each of the 16 stimuli on 8 seven-point emotional intensity scales: happiness, sadness, fear, anger, disgust, surprise, shame, and contempt. These scales were presented in a random order on the computer screen, below the facial expression. The face remained on the computer screen until all scales were answered. After completion of the emotional intensity scales, participants also rated task difficulty, i.e. how difficult it had seemed for them to guess the emotion portrayed by that specific facial expression. This additional measure was used to evaluate the subjects’ awareness of deficits in decoding emotional expressions. All scales were anchored by "not at all" at one end and "very intensely" at the other. There was a 2 seconds inter-trial interval. Decoding accuracy was defined as the observers' ability to correctly infer the posed emotion. An expression was considered as accurately identified when the emotion scale rated with the highest intensity score on the emotion profile corresponded to the target emotion. An accurately identified expression received a score of 1 and a misidentified expression received a score of 0. Participants’ performance was expressed as the percentage of accurately identified expressions.
Procedure The ULB (Université Libre de Bruxelles) ethical board approved this research project. Participants were first provided with the full details regarding the procedure to be followed and written informed consent was obtained. Then, the participants were informed that their
9
task was to judge the emotion(s) portrayed by a series of stimulus persons. In order to familiarize the participants with the procedure and the use of the computer, they were asked to complete two practice trials during which the experimenter answered questions regarding the judgment task. Participants then completed the procedure individually. After completion of the decoding task, participants were asked to complete anxiety, depression, and interpersonal problems questionnaires. Finally, they completed a demographic questionnaire administrated by the experimenter including variables such as age, gender, education, history of substance dependence for each psychotropic product used, overdoses, head injury history, familial history of alcohol or substance-dependence, and HIV seropositivity (no participant of the study presented an HIV seropositivity).
Data analysis All statistical analyses were conducted by using Statistical Package for the Social Sciences (SPSS), version 11.0 for Windows. All statistical tests were two-tailed and unless otherwise specified, p
