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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 61-66

A comparative study of facial emotion recognition pattern and its determinants in patients of alcohol dependence syndrome versus matching controls


1 Department of Psychiatry, Narayana Medical College, Nellore, Andhra Pradesh, India
2 Department of Psychiatry, Acsr Medical College, Nellore, Andhra Pradesh, India
3 Department of Physiology, Kims, Amalapuram, Andhra Pradesh, India

Date of Submission02-Dec-2020
Date of Decision11-Feb-2021
Date of Acceptance12-Feb-2021
Date of Web Publication15-Apr-2021

Correspondence Address:
Dr. Ananda Reddy Endreddy
Associate Professor, Department of Psychiatry, Narayana Medical College and Hospital, Chinta Reddy Palem, Nellore, Andhra Pradesh - 524 003
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_136_20

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  Abstract 


Background: Facial emotional recognition plays a pivotal role in human interactions and behavior. Long-term alcohol use leads to brain dysfunction that causes impairment in social cognitive abilities including facial emotional recognition. Objectives: Our study was aimed to assess the facial emotional recognition pattern in patients with alcohol dependence syndrome (ADS) and compared with that of matching controls and to study the sociodemographic and clinical correlates of facial emotional recognition in ADS. Setting and Design: This cross-sectional study was conducted at a tertiary care teaching hospital for a period of 1½ years. Fifty participants having ADS and fifty controls were included in the study. Materials and Methods: Fifty participants having ADS and fifty controls were included in the study. In the group with ADS, a semi-structured pro forma was used to collect the sociodemographic and clinical profile. Rating scales such as Severity of Alcohol Dependence Questionnaire, the Clinical Institute Withdrawal Assessment for Alcohol scale-revised, and facial emotion recognition test (FERT) were administered. For the control group, FERT was administered after collecting the data regarding sociodemographic profile and clinical variables. Results: It was observed a significant impairment in FERT scores in individuals having ADS (mean score = 19.93 ± 7.67) when compared to the control population (mean score = 32.73 ± 4.96T-test = −10.86; P < 0.001). Lower scores on FERT were observed in persons with severe alcohol dependence (one-way ANOVA = 41.79, P < 0.001). Post hoc Tukey testing showed the difference between groups having moderate-to-severe dependence (P < 0.001) and mild-to-severe dependence (P < 0.001). Conclusions: Significant impairment in facial emotional recognition skills were observed in patients having ADS. The subjects in ADS group were able to identify happy and angry emotions better while facing difficulties in identifying sad and fear full stimulus.

Keywords: Alcohol, dependence, facial emotion recognition test, social cognition


How to cite this article:
Rajesh CL, Endreddy AR, Shaik S, Venu Gopala Raju S V. A comparative study of facial emotion recognition pattern and its determinants in patients of alcohol dependence syndrome versus matching controls. Ann Indian Psychiatry 2021;5:61-6

How to cite this URL:
Rajesh CL, Endreddy AR, Shaik S, Venu Gopala Raju S V. A comparative study of facial emotion recognition pattern and its determinants in patients of alcohol dependence syndrome versus matching controls. Ann Indian Psychiatry [serial online] 2021 [cited 2021 Jul 25];5:61-6. Available from: https://www.anip.co.in/text.asp?2021/5/1/68/313752




  Introduction Top


Alcohol dependence has resulted in serious public health issues worldwide, and more than 3 million deaths were occurring worldwide every year.[1] Many deleterious consequences of associated violence, effects on families, default on social role, and financial burden also exist with the alcohol abuse.[2] Chronic alcohol abuse leads to alteration in brain structures and function.[3],[4] Impairments in social cognitive abilities occur in alcohol dependence.[5] Emotional processing deficits perpetuate alcohol use and lead to relapse in individuals who use it as a pathological coping mechanism.[6]

Facial emotion recognition skills form a vital tool in an individual's social interactions and behavior.[7] Facial emotion recognition requires the synchronized activity of multiple brain areas, predominantly the right fusiform gyrus, and it has been described as the face area of the human brain.[8],[9] Emotional inputs involving the prefrontal circuits were implicated in decision-making, executive functioning, and regulation of affective reactions.[10] In alcohol dependence syndrome (ADS), many cognitive domains such as working memory, attention-span, and social cognition deficits arise due to the damage and dysfunction involving the prefrontal cortices.[11],[12] Impairment in neurocognitive functions had some correlation with treatment implications.[13]

ADS patients are known to have a negative impact on multiple facets of the affected individual and family life.[14] Impairment in facial emotional recognition skills have been reported in patients with the ADS which results in poor communication, interpersonal problems, problems at workplace, familial dispute, and poor quality of life.[15] Literature also reveals impaired facial emotion recognition in long-term alcohol use. Faces depicting fear and anger were mostly recognized as the higher intensity of emotions.[16],[17],[18],[19],[20] Maintaining abstinence revealed facial emotion recognition deficits and irreversible neurotoxic effects of alcohol.[21]

Facial emotional expressions also aid as communicative tools in expressing intentions during day-to-day social and interpersonal interactions.[22] Emotion recognition has thus got significance from an evolutionary biology point of view as well from infancy to adults.[23] Existing literature reports that chronic alcohol use leads to impairment in emotion recognition and other social cognitive abilities. However, the association between facial emotion recognition deficits and factors pertaining to alcohol use such as patterns of drinking, the severity, quantity, and duration of alcohol use have not been studied in detail hence in this study was attempted to study the association between facial emotional recognition scores and various sociodemographic and clinical parameters.


  Materials and Methods Top


The present study was aimed to assess the facial-emotion recognition pattern in patients with ADS and compared it with that of matching controls and to study the sociodemographic and clinical correlates of facial-emotional recognition in ADS. This study was a cross-sectional study conducted in the admitted patients of the Department of Psychiatry, Narayana Medical College and Hospital, between July 2018 and December 2019, among the patients of ADS. A purposive sampling technique was adopted for the recruitment of study subjects. Obtained IEC approval and informed consent were taken from study subjects.

Inclusion and exclusion criteria: patients with ADS, willing to give consent for the study, and aged between 18 and 60 years were included as cases. Individuals without ADS, age group 18–60 years, and willing to give consent were included as controls. Patients within withdrawal state as defined by CIWA-Ar, with a history of comorbid psychiatric illness, intellectual disability, debilitating medical illness, and comorbid substance use other than tobacco were excluded from the study.

Tools for assessment

  1. Semi-structured pro forma for collecting the sociodemographic data
  2. Modified Kuppuswamy Socioeconomic status scale: This scale was one of the established determinants of health. Modified Kuppuswamy socioeconomic status scale was an important tool in hospital- and community-based research in India, which was proposed in 1972. The main limitation of this scale was an overemphasis on income rather than on educational and occupational factors. Socioeconomic status was classified into five classes based on the score obtained on this scale[24]
  3. Severity of Alcohol Dependence Questionnaire (SADQ): This scale had 20-item questionnaires used to measure the severity of alcohol dependence score >30 indicates severe dependence, 16–30 moderate dependence, and score <16 indicates mild dependence[25]
  4. The Clinical Institute Withdrawal Assessment for Alcohol Scale-revised (CIWA-Ar): The scale was used to assess the severity of alcohol withdrawal and developed from 18 items CIWA-Ar. For administration of scale requires 5 min. A patient scoring <10 indicates mild withdrawal, 11–15 indicates moderate, and more than 15 indicates severe withdrawal[26]
  5. Facial emotion recognition test (FERT): FERT includes colored photographs of facial emotional expressions that include evoked or felt emotions such as happy, angry, fearful, sad, and neutral stimuli. There are low-intensity and high-intensity expressions for each emotion. There were eight faces for each of the five categories amounting to a total of forty faces to be decoded. The average testing time for this task was 5–10 min for comparison of control subjects and patients.[27]


Procedure

A total of 100 participants, including fifty cases and fifty matched controls meeting the inclusion and exclusion criteria, were included in the study. Subjects were diagnosed with alcohol-dependent syndrome based on International Statistical Classification of Disease-10 criteria. CIWA-Ar and SADQ were administered in this group of cases. In the post detoxification phase, while they were in the in-patient de-addiction ward, 3 weeks after their last drink. The presence of withdrawal symptoms was excluded by administering the CIWA-Ar. Before the administration of the FERT, the participants were shown ten photographs depicting the happy, angry, fearful, sad, and neutral stimuli. The FERT was administered to the patients having ADS and the matched control group. Data were analyzed using SPSS 25 (IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.), and the descriptive statistics were used to summarize the baseline sociodemographic variables. The continuous variables were summarized as mean and standard deviation. Independent t-test was used to analyze any significant difference in the facial-emotion recognition score between the two groups. The association between various sociodemographic and clinical variables were studied using the Chi-square/Fisher's exact test. Wilcoxon matched pair test was performed to know the significant difference in emotion scores.


  Results Top


Fifty patients having ADS and 50 age- and sex-matched control subjects were included in the study. Mean age of the sample was 38.97 years with a standard deviation of 10.5. The details of the sociodemographic variables of participants are as given below.[Table 1]
Table 1: Details of the sociodemographic variables of the participants

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The estimated mean and standard deviation of facial emotion recognition pattern score for the alcohol group was observed as 19.93 (standard deviation [SD] 7.67) and in the control group 32.73 (SD 4.96). Results were interpreted as in alcohol group subjects able to identify around 50% of facial emotion patterns, while control was able to identify 80% of the facial emotions. The maximum score possible was 40. Higher scores indicate better performance in facial emotion recognition task. On the study sample, independent sample t-test was performed to know the significance of the data between the two groups. It was observed a statistically significant difference between the two groups (P < 0.001) [Table 2].
Table 2: Mean facial emotion recognition scores, comparison between the alcohol-dependent and control group

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In order to study the association of various sociodemographic and clinical variables, Chi-square/Fischer's exact test was done. It was observed that, among sociodemographic variables, family history of alcohol use group was found to be statistically significant (P < 0.001). Among the clinical variables, comorbid illness affecting the nervous system, gastrointestinal system, and genitourinary system were found to be significant (P < 0.001) [Table 3].
Table 3: Depicting details of family history and comorbidities in study subjects

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Based on the severity of alcohol use, the alcohol-dependent group was divided into mild, moderate, and severe on the severity of the alcohol-dependent questionnaire. Average scores of the mean and standard deviation of facial emotion recognition pattern scores were 29.80 (SD = 2.78), 25.50 (SD = 3.54), and 14.73 (SD = 5.90). It means that mild subgroup of alcohol dependence was able to interpret 30 faces, whereas the moderate group identified 26 and severe group 15, respectively. To estimate whether there is a statistically significant difference among two groups based on number of years of alcohol dependence, independent sample t-test was performed. It was observed that there is a statistically significant difference (P < 0.001) in the group having alcohol dependence since more than 5 years had significantly lower scores on the FERT [Table 4].
Table 4: The mean facial emotion recognition scores of alcohol group based on the severity, pattern, and duration of alcohol dependence in years

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The individuals having alcohol dependence were categorized into three groups, 1 – continuous use, 2 – binge drinking (is a pattern of drinking that brings a person's blood alcohol concentration to 0.08 g/dl or above), 3 – uses alcohol on <4 days. It was observed that the average scores for individuals having continuous use, binge pattern, and alcohol use on <4 days per week; were respectively 16.70 (SD = 7.30), 22.52 (SD = 6.12), and 28.67 (SD = 3.72). It means individuals having daily drinking were able to correctly decode an average of 17 out of the total 40 faces presented to them when compared to a total of 23 and 29 out of 40 faces in other subgroups [Table 4].

To estimate the median and interquartile range for the average number of mild and extreme intensity emotions by subjects of both groups, Wilcoxon-matched pair test was done.

It was found that there was a significant difference (P < 0.001), in the median and interquartile range for the average number of mild and extreme intensity emotions by subjects of both groups with the Wilcoxon matched-pair test [Table 5].
Table 5: Facial emotion recognition scores for mild and extreme emotions

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  Discussion Top


In our study, the participants having alcohol dependence did not differ from the control group in terms of various socio-demographic variables. Individuals from both groups had similar educational and occupational statuses. Their socioeconomic status, religion, habitat, and marital status were comparable. It was observed in studies done by French et al.,[28] Frigerio et al.,[29] and Hoffmann et al.,[30] reported comparable baseline sociodemographic details similar to our study.

In our study, it was observed that the mean score on the FERT was significantly lower for the alcohol-dependent group. The average facial emotion recognition score was around 19.93 (SD = 7.67) in the alcohol dependence group and 32.73 (SD = 4.96) in the control group. The individuals having ADS were able to identify only around 50% of the facial emotional patterns presented before them, similar results were reported by Donadon and Osório[31] and Maurage et al.[32]

It was observed in our study that participants belonging to both the groups identified extreme intensity emotions better than mild intensity emotions (alcohol group – Wilcoxon-matched pair test – 6.76 (P < 0.001); control group – Wilcoxon-matched pair test – 6.36 (P < 0.001); similar results were reported in the study done by Carmona-Perera et al.[33] and O'Daly et al.[34]

In our study, participants of the alcohol dependence group were able to identify happy and sad faces better, while they had difficulty in decoding fear and disgust emotions as well as neutral faces. Likewise, studies were done by Maurage et al.[32] and Donadon and Osório Fde,[10] reported difficulty in decoding fear and disgust emotions by participants having ADS. Enhanced perception of fearful stimuli was reported in the study done by Townshend and Duka.[35] Our study reported a significant association between the severity of alcohol dependence and facial emotion recognition scores (FERS). It was observed that the average (FERS) score for individuals having mild, moderate, and severe alcohol dependence were 29.80 (SD = 2.78), 25.50 (SD = 3.54), and 14.73 (SD = 5.90), respectively. The findings of our study are in accordance to findings of study done by kumar et .al,.[36]

In our study, the average FERS score for individuals having continuous use of alcohol, binge pattern, and the group with alcohol use on <4 days per week was 16.70 (SD = 7.30), 22.52 (SD = 6.12), and 28.67 (SD = 3.72), respectively. Individuals having daily drinking had significantly lower scores on the emotion scoring task (one-way ANOVA = 10.66, [P < 0.001]). A study was done by Kornreich et al.[37] reported similar findings to our study and also concluded that prolonged abstinence from alcohol use was associated with improved emotion recognition.

A study by Noble and Weimer[38] reported that a longer duration of alcohol use was associated with neurological changes that impaired the emotion recognition capabilities in a person having ADS. Our study also explored the association between alcohol use in dependence patterns and FERS. It was observed that participants having alcohol dependence for more than 5 years had significantly reduced scores on FERT (14.81, [SD = 6.74]) when compared to the individuals who had alcohol dependence for <5-year duration (23.85, [SD = 5.85]), t-test = 0.95 (P < 0.001). It suggests worsening of impairments in emotion recognition skills with increasing duration of alcohol dependence.

The family history of substance dependence was compared among both the groups; it was observed that the participants having ADS had a strong family history of substance abuse, which was a finding that had been replicated in studies done by Cservenka et al.[39] and Spadoni et al.[40] Family history again is a strong pointer toward genetic influence on alcohol dependence in a study by McCrady et al.[41]

In our study we had examined the occurrence of medical comorbidities in both the alcohol-dependent and control groups. The rate of medical comorbidities involving the nervous system, genitourinary system, and gastrointestinal system was found to be considerably higher among the participants belonging to the alcohol-dependent group as per the results derived from our study; these findings were comparable with the findings of studies done by Arackal and Benegal[42] and Lieber.[43]


  Conclusions Top


In ADS patients, there is a significant impairment in the facial-emotion recognition scores in individuals having ADS. Individuals having more quantity of alcohol per day and more years of alcohol use in dependence pattern exhibited deficits in emotion recognition. These patients were able to identify better with happy and angry emotions when compared to sad and fear stimulus. The impairment in emotion recognition will definitely impact the quality of life and social life of a patient with alcohol dependence.

Future directions

Emotion recognition training is involved in the treatment of alcohol-dependent individuals, along with the social skills training program. Future studies exploring the change in facial-emotion recognition scores in alcohol-dependent individuals after training emotion recognition skills may be done.

Limitations

  1. Owing to practical concerns, we had to resort to a cross-sectional design of the study. A follow-up study would have been more informative
  2. We have included the four basic emotional categories along with neutral expressions. Studies exploring complex emotions may be done
  3. The entire sample has been collected from a group of people attending the treatment facilities at a tertiary care center, so the results cannot apply to the general population
  4. Ethnicity of images is limitation of our study.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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