Emotional Experience in Patients With Schizophrenia Revisited: Meta-analysis of
Alex S. Cohen1,2and Kyle S. Minor2
2Department of Psychology, Louisiana State University, 206
Audubon Hall Baton Rouge, LA 708080
Our understanding of the emotion deficits in schizophrenia
is limited. Findings from studies employing trait emotion
instruments suggest that patients have attenuated levels
of positive emotion (ie, anhedonia) and increased levels
of negative emotion. Conversely, patients and controls
have not statistically differed in their subjective reactions
to positive or negative valenced stimuli in most laboratory
studies to date. Further obfuscating this issue is the fact
that many of these laboratory studies are underpowered
and a handful of emotion induction studies have found ev-
idence of anhedonia. We conducted a meta-analysis of 26
published studies employing laboratory emotion induction
procedures in patients with schizophrenia and healthy con-
ing their subjective hedonic reactions to the stimuli.
However, they reported experiencing relatively strong
aversion to both positive and neutral stimuli (Hedges D
of demonstrable sample or methodological differences
across studies. Patients’ ability to experience hedonic emo-
tion is preserved, although they also show relatively strong,
laboratory stimuli considered by others to be pleasant or
Key words: schizophrenia/anhedonia/emotion/
The emotional deficits of schizophrenia have long been
considered integral features of the illness.1–4However,
our understanding of these deficits is limited. As yet, it
is clear that many patients evidence an attenuation in
the outward expression of emotion, often referred to
as blunt or flat emotion.5The degree to which their phe-
nomenological experience of emotion is altered is much
less clear. Some theorists have postulated that patients
have a relatively uniform declination in their capacity
to experience nearly all emotion1while others have pro-
posed that schizophrenia is associated with an innate and
diminished capacity to experience hedonic emotion (eg,
anhedonia or hypohedonia) but a heightened experience
of aversive emotion.3In part due to increasing awareness
regarding the importance of emotional functioning
across a wide range of activities6,7and the recognition
that emotional abnormalities are associated with a num-
ber of functional impairments in schizophrenia8,9,10this
issue has seen near-exponential growth in empirical
attention within the last 2 decades.
At the heart of the obscurity over whether patients’
phenomenological experience of emotion is abnormal
concerns the seemingly inconsistent findings from rele-
vant literatures. On one hand, studies comparing patients
with schizophrenia and nonpatient controls on measures
of emotional disposition, such as the Multidimensional
Personality Questionnaire,8,9,11the Minnesota Multi-
phasic Personality Inventory,12the NEO-PI,13and the
Chapman Anhedonia Scales,8,9find that individuals
with schizophrenia report experiencing abnormally low
levels of positive emotion and abnormally high levels
of negative emotion.14Similarly, trained interviewers
evaluating patients using standardized clinical measures
report that patients show high levels of both anhedo-
nia5,10and negative emotion (eg, hostility, guilt, anxiety,
fear15). However, studies employing emotion induction
procedures under controlled laboratory conditions
have generally reported that patients do not differ
from nonpsychiatric controls in their subjective reactions
to emotionally charged stimuli. These studies include 3
seminal works16–18that have used stimuli ranging from
In each of these studies, patient and control groups did
notshowsignificant attenuationsintheir phenomenolog-
ical experience of emotion and in one case, reported
stronger hedonic responses to neutral stimuli.18In sup-
port of these findings, other published studies have
reported similar results.11,19–30
1To whom correspondence should be addressed; e-mail:
Schizophrenia Bulletin vol. 36 no. 1 pp. 143–150, 2010
Advance Access publication on June 17, 2008
? The Author 2008. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.
For permissions, please email: email@example.com.
There are 2 important factors to consider when inter-
preting this body of laboratory emotion induction stud-
ies. First, the majority of these studies employ relatively
small sample sizesthat offer insufficient power fordetect-
ple size of 29 patients was employed across the 3
ical of many schizophrenia studies employing experimen-
tal methodology, limited power may have obscured true
group differences. Second, similarity between patients
and controls in reaction to laboratory stimuli is not ubiq-
uitous across all studies. At least 5 published studies have
reported that patients experienced significantly less po-
tent emotional reaction to laboratory stimuli.31–35Given
theseconsiderations, itseems that acomprehensivemeta-
analysis of the subjective emotion induction literature
might shed somelight on the issue of whether schizophre-
nia is characterized by abnormal phenomenological emo-
tional states under laboratory conditions. This was the
primary goal of the present study.
Search Strategy for the Meta-analysis
In order to identify relevant studies for the meta-
analysis, we conducted a combined MEDLINE and
PsychINFO search for studies published between
1986 and June 2007 having the following terms:
a word base of ‘‘schizophren*’’ and either ‘‘emotional
experience’’ (yielding 80 entries), or ‘‘mood induct*’’
(yielding 7 additional entries). We also reviewed all pub-
lished articles citing Berenbaum and Oltmanns,16Kring
et al,17and Kring and Neale18using a PsychINFO cita-
tion function. This yielded an additional 170 articles. In
all, 257 journal articles were considered for the present
study. Our inclusion criteria included the following: (1)
the article is written or translated in English (15 studies
excluded), (2) the article is an empirical study that is
published in a peer-reviewed journal (57 studies ex-
cluded), (3) the article includes an emotion manipula-
tion broadly defined (68 studies excluded), (4) the
article reports means of patients’ phenomenological ex-
perience of emotion using a self-report scale following
the emotion manipulation (41 studies excluded), and
(5) the article reports data on a patient group diagnosed
with schizophrenia or schizoaffective disorder and com-
pares their emotional experience to a nonpsychiatric
control group (45 studies excluded). Additionally, 5
studies were excluded because they reported data pub-
lished elsewhere. Authors were contacted when missing
data impeded our analyses except in one case,36where
we were able to estimate standard deviation values using
formulas from Hurlburt.37In all, 26 studies were in-
cluded in the present meta-analyses. These studies are
detailed in table 1.
Creation of the Database
Careful consideration was paid to organizing the data
ysis. One notable challenge concerned the variability in
subjective emotion scales used across these studies. Four-
teen of the studies conceptualized positive and negative
emotion as being orthogonal in nature. These studies
employed unipolar scales to separately measure ‘‘he-
donic’’ and ‘‘aversive’’ emotion. Conversely, 12 studies
conceptualized hedonic and aversive emotion as oppos-
and bipolar scales are based on fundamentally different
theories of emotion (ie, ‘‘orthogonal’’ vs ‘‘circumplex’’
models41), we considered them separately in the present
study. We transformed each of these scales so that in-
creasing unipolar scores reflect higher hedonic/aversive
emotion and increasing bipolar scores reflect higher he-
donic emotion. For the present study, hedonic and aver-
sive emotions refer to subjective emotion states following
stimulus presentation. ‘‘Unipolar’’ refers to subjective
both extreme hedonic and aversive emotion on opposing
ends of a continuum. Finally, ‘‘positive’’ refers to stimuli
generally judged to activate neurocircuitry involved in
the phenomenological experience of pleasurable emo-
tions while ‘‘negative’’ refers to stimuli judged to activate
avoidance, threat, sadness, or other negative emotional
states. ‘‘Neutral’’ refers to stimuli regarded as neither
positive nor negative.
When studies presented separate data for multiple
stimuli that were designed to elicit similar emotion, the
means and standard deviations were averaged together.
For one study,16where subjects were presented with
both flavored liquids and film clips, we averaged together
ratings by valence condition (eg, positive condition) and
presented them as a single effect size except for the anal-
yses examining stimulus type (see below). When data
were presented for separate schizophrenia patient groups
(eg, those with blunted affect vs those without), we
weighted their means and standard deviations by sample
size and averaged them together. All measures of vari-
ance were converted to a standard metric (standard de-
viation) to ensure consistency. All data were carefully
checked and rechecked for accuracy.
We used MetaWin statistical package42to conduct our
analyses. Effect size values were independently computed
for each emotion induction condition for each study
using the Hedges D statistic. Cumulative effect sizes
individual effect sizes by their variance scores. The ratio-
nale for this weighting procedure is that the closer a sam-
ple’s effect size approximates that of the population, the
A. S. Cohen & K. S. Minor
smaller the variance of that effect size will be.42Q statis-
tics, basedonchi-squaredistributions, werealso reported
here. The Qtotal, a measure of the total heterogeneity of
individual effect size values within a group were greater
than that predicted by sampling error and the Qbetween,
a measure of variability across mean weighted effect size,
that null finding studies tend to be unpublished—we com-
puted Orwin statistic. This statistic reports the number of
studies with null findings (Hedges D = 0) that would need
to be included in the meta-analysis to reduce the weighted
Table 1. Descriptive Data, ES, and VAR Computed for Unipolar Hedonic, Unipolar Aversive, and Bipolar Emotion Ratings from the
Positive, Negative, and Neutral Emotion Induction Conditions
Patients vs Controls: Unipolar Scales
Control, n% Male
ES 6 VAR:
ES 6 VAR:
ES 6 VAR:
HedonicAversiveHedonic AversiveHedonic Aversive
Habel et al34,a
Earnst et al26,b
Habel et al20,a
Iwase et al25,a
Kring et al18,a
Kring et al17,a
Salem et al19,a
Schneider et al33,a
Schneider et al27,a
Flack et al36,a
Horan et al11,a
Berenbaum et al16,a
Horan et al30,a
Habel et al38,a
?.41 6 .03
?.26 6 .07
?.04 6 .12
?.68 6 .10
.12 6 .09
.63 6 .03.22 6 .03
?.13 6 .03
.14 6 .07
Yes 41-20100 .54 6 .08 .44 6 .08.42 6 .08.39 6 .08
Yes 13-26100 .51 6 .12.22 6 .12.21 6 .12
?.15 6 .12
.71 6 .12
No23-20100.95 6 .10.24 6 .09.08 6 .09.59 6 .101.04 6 .11
No20-20100.70 6 .11.92 6 .11
?.10 6 .10
.94 6 .14
.47 6 .101.28 6 .12.73 6 .11
?.61 6 .13
?.34 6 .05
?.25 6 .16
?.86 6 .09
.39 6 .10
.84 6 .14.60 6 .13——
Yes40-4053.63 6 .05
?.48 6 .05
.68 6 .16
.43 6 .05——
Yes13-13100 1.31 6 .19.17 6 .15
?.17 6 .15
1.14 6 .18
Yes22-29100—.88 6 .09——
Yes36-15 100.61 6 .10.46 6 .10.75 6 .10.07 6 .09 .48 6 .10
Yes43-2051.41 6 .07—
?.48 6 .08
?.32 6 .07
.11 6 .10
.62 6 .07—
?.28 6 .07
.41 6 .07
Yes20-20 501.06 6 .11.76 6 .11.28 6 .10—
Patients vs Controls: Bipolar Scales
Control, n% Male
Hempel et al24,b
Mathews et al21,b
Taylor et al45,b
Taylor et al31,b
Volz et al23,a
Quirk et al22,a
Quirk et al32,a
Burbridge et al39,a
Lee et al35,a
Seok et al40,a
Crespo-Facorro et al28,b
Heerey et al29,a
?.09 6 .07
?.50 6 .08
?.81 6 .15
?1.03 6 .17
?.28 6 .04
?.22 6 .15
?.53 6 .14
.17 6 .04
?.17 6 .07
?.27 6 .07
.03 6 .14
.00 6 .07
Yes27-2867.60 6 .08
?.47 6 .16
.04 6 .04
.42 6 .16
Yes49-4653.16 6 .04
Yes20-10100.33 6 .15.15 6 .15
No30-10100 .79 6 .14
?.32 6 .13
?.11 6 .04
Yes49-4763.03 6 .04
?.13 6 .10
?.85 6 .09
?.64 6 .12
?.04 6 .06
?.03 6 .10
.98 6 .09Yes25-2552.24 6 .08
No18-16 89.12 6 .12—
Yes41-3163.25 6 .06
?.26 6 .06
Note: ES, Effect sizes, VAR, variance scores. Positive effect size values from hedonic and bipolar ratings reflect patients reporting more
euphoria than controls following stimulus presentation. Positive effect size values from aversive ratings reflect patients reporting more
dysphoria than controls following stimulus presentation.
aTask instructions involved having subjects asked to rate their subjective reactions to the stimuli.
bTask instructions involved having subjects rate the stimuli itself.
Emotion in Schizophrenia
mean below a ‘‘small’’ effect size level (defined as .20). All
meta-analyses reported here used random effects models.
The analyses were conducted in 3 steps. First, we com-
subjective emotion following positive, negative, and neu-
tral stimuli for each individual study. Second, we com-
puted weighted mean effect sizes for the positive,
negative, and neutral conditions. Third, we examined
the degree to which variability in these effect sizes across
studies was a function of stimulus type, gender composi-
tion of the sample, and whether the sample was medi-
cated vs unmedicated and outpatient vs inpatient.
individual study. These data are presented in figure 1.
There are several notable findings. First, patient reac-
tions to positive stimuli were highly variable across stud-
ies. In all, 66% of studies (8 of 12) using bipolar scales
and 57% of studies (8 of 14) using unipolar hedonic
scales reported that patient reactions were more dys-
phoric or anhedonic (respectively) than controls at
a small effect size or higher. Second, patients reported
aversive emotion at a small effect size or higher follow-
ing exposure to positive stimuli in nearly all studies (eg,
100% of studies using unipolar aversion scales). Simi-
larly, patients reported aversive emotion at a small effect
size or better in response to neutral stimuli in most stud-
ies (eg, 100% of studies using unipolar aversion scales).
Finally, the effect sizes across studies examining reaction
to negative stimuli were much more variable, although
75% of studies employing unipolar hedonic scales
reported that patients enjoyed the stimuli more than
controls at a small effect size or better.
In 5 of the studies examined here, subjects were specif-
ically asked to rate the stimuli, whereas in the other 21
studies, subjects were asked to rate their experience while
processing the stimuli. One study did not specify its pro-
cedure in this regard. It is not clear how this may have
affected the present results, and comparison of these
groups of studies revealed no statistically significant
(all P values of Qbetween > .05) differences in effect
size, suggesting that this methodological disparity did
not contribute to variable findings across studies.
Patients vs Controls
Table 2 contains the weighted mean effect sizes for
patients vs controls from the positive, negative, and neu-
tral conditions. Patients reported experiencing more
ges D = .72 and ?.33 for unipolar aversion and bipolar
scales, respectively), but there was little evidence of anhe-
donia given that patients and controls did not differ
1.50 1.000.50 0.00
Fig. 1. Patients vs Controls: Effect Sizes Computed for Unipolar Hedonic, Unipolar Aversive, and Bipolar Emotion Ratings from the
Positive, Negative, and Neutral Emotion Induction Conditions. Positive effect size values from hedonic and bipolar ratings reflect patients
reporting more euphoria than controls following stimulus presentation. Positive effect size values from aversive ratings reflect patients
effect sizes. Dark solid line reflects weighted means.
A. S. Cohen & K. S. Minor
in their hedonic appraisal of positive stimuli (Hedges D =
?.16; see table 2). Interpretation of the confidence inter-
vals and Orwin statistics suggest that these effect sizes are
stable. Patients also reported experiencing relatively nor-
mal levels of aversive emotion to negative stimuli. Inter-
estingly, compared with controls, patients reported
experiencing modest increases in both hedonic and aver-
sive emotion to negative and neutral valenced stimuli. In
stimuli comparedwithcontrols. Put anotherway, itseems
that both hedonic and aversive emotions were induced
in patients with schizophrenia when processing positive
or neutral valenced external stimuli.
Effect of Stimuli Type
In order to examine the degree to which stimuli type may
have produced different patient reactions across studies,
we aggregated the studies into 4 groups: those that used
visual stimuli (eg, film clips, picture stills, faces), verbal
stimuli (eg, reading valenced words), gustatory experien-
(eg, maintaining facial gestures, social interactions).
None of the Qbetweenvalues were statistically significant
(all P values > .05). Although this analysis was under-
powered in the sense that not all types of stimuli had rep-
resentation for each comparison, this finding suggests
that there were no demonstrable differences in stimulus
effect across studies.
Patients vs Controls
termine whether patients on antipsychotic medication
showed notable differences in emotion induction effect
sizes from studies (n = 4) which employed unmedicated
patients (2 of which employed unipolar scales and 2 of
which employed bipolar scales) and studies employing
medicated patients (n = 22). There were no significance
of otherwise notable differences. We conducted similar
analyses on studies employing primarily male (n = 11; de-
fined as sample > 90% male) and studies employing
were any demonstrable gender effects. Finally, we com-
pared effect sizes from studies employing outpatient (n =
10), inpatient (n = 8), and mixed/unspecified (n = 8) sam-
ples. None of these comparisons were statistically signif-
icant (all P values of Qbetween> .05).
Consistent with what has been concluded in most labo-
ratory studies (see Introduction), patients with schizo-
phrenia did not show hedonic deficits when processing
laboratory stimuli. However, positive and neutral
valenced stimuli induced relatively high levels of aversive
emotion in patients. Put another way, positive and neu-
tral stimuli appeared to coactivate hedonic and aversive
to demonstrable differences across studies in sample gen-
der composition or study methods.
If patients are not anhedonic in their ‘‘in the moment’’
experience of pleasure, what might explain the emotional
abnormalities characteristic of the disorder? One possi-
ative emotion. As discussed by Horan et al,30elevated
negative emotionality could reflect an emotion regulation
effective inhibiting abilities43,44and have demonstrated
Table 2. Mean Weighted Effect Sizes Computed for the Positive, Negative, and Neutral Emotion Induction Conditions
?.40 to .07
.53 to .91
?.57 to ?.10
.03 to .59
?.03 to .45
?.12 to .36
?.25 to .73
.34 to .93
?.15 to .29
aPositive effect size values mean patients had more hedonic emotion compared with controls.
bPositive effect size values mean patients had more aversive emotion compared with controls.
Emotion in Schizophrenia
pathology in orbitofrontal brain regions45,46—structures
brain regions related to negative emotions (eg, amyg-
dala31,48) and report experiencing high levels of trait neg-
ative affectivity.8,9Taken together, these results suggest
that patients’ trait negative emotionality may be abnor-
An alternate, but not mutually exclusive, way of con-
ceptualizing the abnormal negative emotionality in
schizophrenia involves ‘‘ambivalence.’’ Contemporary
models of personality and emotion posit that positive
and negative emotions reflect distinct neurocircuitry
that gives rise to disparate hedonic- and aversive-based
systems (eg, behavioral activation and inhibition sys-
tems,49the ‘‘evaluative space’’ model,50and emotional
ambivalence51). Recent research suggests that these sys-
tems coactivate when processing certain stimuli that
have simultaneous pleasant and aversive properties.52–54
Ambivalence has proved a valuable construct for under-
standing a broadrange ofbehaviorsand psychopatholog-
ical states.51,55Interestingly, early schizophrenia theorists
heralded ambivalence—defined as a co-occurrence of he-
ture of schizophrenia pathology.3,56The limited empirical
work examining ambivalence in schizophrenia has sug-
gested that it is a useful construct for understanding
ful way to conceptualize abnormal hedonic experiences in
most patients with schizophrenia? Clearly, further re-
search on this topic is needed.
In explaining why patients show anhedonia on subjec-
tive questionnaires and symptom rating scales,5,59it is
flect elevated negative emotion rather than attenuated
positive emotion. These assessment methods typically in-
volve measuring attitudes (eg, ‘‘I like to make long dis-
tance phone calls to friends and family’’ [keyed
false]58) or behaviors (eg, ‘‘I have often enjoyed receiving
ing anhedonia without regard to the underlying cause of
the putative emotional deficit. Not surprisingly, prior re-
search has demonstrated that both the Chapman Anhe-
donia Scale scores and scale for the assessment of
negative ratings significantly correspond to increasing
levels of negative emotions in patients with schizophre-
nia.8,9In sum, it is possible that, obscured by a lack of
are underway. This involves the creation of a new inter-
view-based measure of negative symptoms61,62and the
development of a measure of emotion using computer-
ized analysis of natural speech that holds potential for
differentiating between positive and negative emotion
states. The present findings suggest that separate unipo-
lar assessments, as opposed to a single bipolar scale,
should be used for measuring emotions in individuals
with schizophrenia because bipolar scales mask the po-
tential coactivation of hedonic and aversive emotions.
It is important to entertain the possibility that patients’
capacity to experience pleasure may be impaired in some
capacity not captured by laboratory experiments. First,
some have postulated that patients are impaired in appe-
experiences for future events as is done when completing
trait questionnaires and interviews, but have intact ‘‘con-
summatory’’ experiential systems.63The present findings
support thistheory insofarbecause no evidence of‘‘in the
moment’’ hedonic deficits were revealed. Second, in con-
trast to laboratory studies, which typically assess state
emotions, questionnaire and interview measures presum-
ably tap more stable trait-like phenomena. It is possible
that patients’ capacity for hedonic experience (as elicited
during laboratory studies) may be bounded by similar
asymptotes as controls, but the frequency of these expe-
riences in the real world may be relatively infrequent.
Supporting this notion, patients have shown lower levels
of subjective hedonic experience in studies employing ex-
perience sampling methodology,63–65which involve hav-
weeks at quasi-random times throughout the day. Com-
paring patients and controls using more sophisticated
procedures, eg, using stimuli with varying intensities un-
der varying conditions, would be important for further
clarifying the emotional abnormalities in schizophrenia.
Finally, some have suggested that cognitive impairments
somehow color patients’ memory of hedonic stimuli after
they have initially been processed. That is, the emotional
how the experience is consolidated into long-term mem-
ory or in how it is recalled. Empirical evidence on this
topic is mixed,30,66so further research is needed.
A serious limitation in our current understanding of
with chronic idiopathic negative symptoms (estimated
to be approximately 25%–30% of patients67) are defined,
patients have shown higher levels of questionnaire-
emotions,67although findings from laboratory studies
are more varied. To date, 2 laboratory emotion induction
tions in negative symptom vs other patients68,69while 2
other studies have reported negligible group differen-
ces.16,26Interpretation of these studies is clouded by pro-
found differences in how negative symptoms were
defined across thesestudies.It is noteworthythat anhedo-
nia can reflect a secondary negative symptom—caused by
A. S. Cohen & K. S. Minor
heterogeneous manifestations of the disorder is a crucial
and sorely neglected area of research (see Cohen et al8
for further discussion of this point).
Although sufficient studies have been published to al-
low broad conclusions about patients’ emotional reac-
tions in the laboratory, there are far too few studies to
allow understanding of the effects of stimulus, method-
ological, or patient characteristics. Thus, it is unclear
to what degree emotion reactions vary as a function of
stimulus modality (eg, image still, movie, social interac-
tions, gustatory), task instructions, medication effects,
sex differences, or other patient characteristics (eg, treat-
ment modality). There were some (albeit nonsignificant)
variability across studies in effect sizes, and this could re-
flect influence of any of these variables. Examining the
impact of these variables on emotion abnormalities in
individuals with schizophrenia is an important avenue
for future research.
In summary, the present meta-analysis found little ev-
their ability to experience pleasurable emotion states.
However, patients do show relatively strong aversive
emotions when processing stimuli considered by others
to be pleasant or neutral in tone. We believe that clarify-
crucial to the development of more sophisticated meas-
ures of schizophrenia pathology, as well as efforts to un-
derstand and treat the disorder more generally.
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