The Role of Attention in Affect Perception:
An Examination of Mir sky's Four Factor Model
of Attention in Chronic Schizophrenia
by Dennis R. Combs and Wm. Drew Qouvier
Abstract
Attentional skills among people with schizophrenia
may be related to deficits in affect perception. Such
deficits can dramatically inhibit appropriate social
functioning. We examined attention and affect percep-
tion in a sample of 65 people diagnosed with chronic
schizophrenia. We used Mirsky's four factor model of
attention to assess attentional functioning. To measure
affect perception, we used two reliable measures of
emotion recognition, the Bell-Lysaker Emotion
Recognition Test and the Face Emotion Identification
Test. Multiple regression analysis showed that all four
attentional factors and a diagnosis of paranoid schizo-
phrenia were significantly predictive of affect percep-
tion scores. In contrast, psychiatric symptoms, medica-
tion levels, demographic variables, verbal fluency, and
face recognition scores were not predictive of affect
perception scores. The four factors of attention
accounted for 78 percent of the variance in affect per-
ception scores. These results emphasize the role that
attentional abilities play in affect perception for people
with schizophrenia.
Keywords: Attention, affect perception, schizo-
phrenia, social functioning.
Schizophrenia Bulletin, 30(4):727-738, 2004.
Many researchers believe that schizophrenia is essentially
a social-cognitive disorder (Bellack 1992; Penn and
Mueser 1996; Penn et al. 1997; Kohler et al. 2000).
People diagnosed with schizophrenia demonstrate various
social impairments such as poor affect perception, defi-
cient social skills, decreased recognition of nonverbal
cues, and social competence deficits (Bellack 1992; Salem
et al. 1996; Penn et al. 1997). Schizophrenia has also been
associated with a range of information-processing and
neuropsychological deficits (Saykin et al. 1991, 1994;
Schwartz et al. 1992; Zalewski et al. 1998), and some
researchers believe that problems in cognitive functioning
may affect people's ability to learn, exhibit, and express
727
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social skills and behaviors (Morrison et al. 1988ft; Bellack
1992; Penn et al. 1997, 2000). Researchers have become
increasingly interested in the possible link between infor-
mation processing and social functioning (Bellack 1992;
Cornblatt et al. 1992; Freedman et al. 1998; Bellack et al.
1999; Penn et al. 2000; Addington et al. 2001). However,
studies examining this relationship are few and have been
inconsistent in their findings regarding which cognitive
variables are linked to adaptive social functioning (Green
1996).
One aspect of social behavior needing further study is
the ability to perceive and identify another person's affec-
tive or emotional state (affect perception). Many empiri-
cal studies have shown consistent deficits in affect percep-
tion among those diagnosed with schizophrenia
(Doughtery et al. 1974; Muzekari and Bates 1977; Novic
et al. 1984; Cramer et al. 1989; Archer et al. 1992; Kerr
and Neale 1993; Schneider et al. 1995; Salem et al. 1996;
Mandal et al. 1998; Penn and Combs 2000; Penn et al.
2000), and some researchers believe that these deficits are
the most debilitating of all the social impairments found
in schizophrenia (Morrison et al. 1988ft) These findings
raise the question of what variables contribute to these
deficits.
Deficits in affect perception and other social behav-
iors may stem from cognitive impairments associated
with schizophrenia (Bellack 1992; Green 1993;
Addington and Addington 1998; Mandal et al. 1998;
Morrison et al. 1988ft). Bellack (1992) stated that success-
fully completing most social perception tasks requires
substantial cognitive demands. A better understanding of
the relationship between information-processing abilities
and affect perception may lead to a better understanding
of the characteristics of the disorder. In fact, several stud-
ies have found that affect-perception skills were related to
adaptive social functioning and social skills in both inpa-
Send reprint requests to Dr. D.R. Combs, University of Tulsa, Lorton
Hall, Room 303, 600 S. College, Tulsa, OK 74104; e-mail: dennis-
combs@utulsa.edu.
Schizophrenia Bulletin, Vol. 30, No. 4, 2004
tient and outpatient settings (Penn et al. 1996; Mueser et
al. 1996; Ihnen et al. 1998).
Emerging evidence indicates that a particular cogni-
tive variable, attention, may be an important component
of affect perception. Theoretically, deficient attentional
skills could impair affect perception by interfering with
the ability to attend to and decode facial stimuli (Bellack
1992; Addington and Addington 1998; Mandal et al.
1998; Morrison et al. 1988fc). Bruce and Young (1986)
posited an important role for visual attention in face
recognition and in affect/expression analysis. This theory
was empirically demonstrated in a series of studies by
Phillips and David (1997, 1998) in which people with
delusions scanned more nonrelevant areas of the face.
Thus, affect perception requires that people select which
parts of the face to attend to and then maintain their atten-
tion to collect important information about another's emo-
tional state (Green 1996; Bryson et al. 1997; Addington
and Addington 1998; Morrison et al. 1988a). Quite sim-
ply, if a person cannot fully attend to facial stimuli, then
his or her capacity to decode and interpret emotional
expressions will be concomitantly impaired.
Several empirical studies have examined the role of
neuropsychological variables in affect perception. An
examination of these studies showed consistent evidence
that attention was a key variable in affect perception
(Bryson et al. 1997; Addington and Addington 1998; Kee
et al. 1998; Kohler et al. 2000)—arguably more important
than memory, learning, motor functioning, and reasoning.
Furthermore, because attention is a necessary precursor
for processing incoming information, attention problems
can affect many other higher order cognitive abilities
(Mapou 1995).
Although attention may be a crucial factor in affect
perception (Archer et al. 1992; Kerr and Neale 1993;
Bryson et al. 1997; Mandal et al. 1998), only a few stud-
ies have specifically examined the aforementioned link
between attention and affect perception. Bryson et al.
(1997), Addington and Addington (1998), Kee et al.
(1998), and Kohler et al. (2001) have all found some sup-
port for the role of attention in affect perception, although
not all studies agree on its importance (Schneider et al.
1995; Morrison et al. 1988a). Specifically, attention span,
the ability to shift attention, and sustained attention have
all been found to be related to affect perception scores.
However, these studies used unvalidated attentional mea-
sures, and these measures were not selected based on cur-
rent theoretical models of attentional functioning (i.e.,
Mirskyetal. 1991).
In sum, theoretical and research evidence suggests
that attention may be important in affect perception
(Morrison et al. 1988b; Bellack 1992; Bryson et al. 1997;
Mandal et al. 1998). To identify different emotional states,
728
D.R. Combs and Wm. D. Gouvier
facial information must be attended to and perceived
(Bellack 1992). Various research studies on affect percep-
tion have stated that attentional problems may be respon-
sible for the observed deficits, but only a few have
explored this topic empirically. Attention should be
assessed in a way that is consistent with research on the
multifactorial nature of the attentional process (Solhberg
and Mateer 1989; Mirsky et al. 1991). Finally, the rela-
tionship between attention and affect perception could
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have implications for the cognitive rehabilitation of these
deficits (Hogarty and Flesher 1992; Green 1996). The
study of attention in affect perception therefore has
important theoretical, empirical, and clinical merit.
The purpose of this study was to explore the relation-
ship between affect perception and attention in a sample
of people with chronic schizophrenia using Mirsky's four
factor model of attention. Mirsky et al. (1991) identified
four factors of attention (Shift, Sustain, Encode, and
Focus-Execute) based on a Principal Components
Analysis (PCA) of common neuropsychological mea-
sures. The four factor model of attention has been repli-
cated in other samples of people with chronic schizophre-
nia (Steinhauer et al. 1991; Kremen et al. 1992). Previous
research findings suggest that the Sustain, Shift, and
Encode factors will best predict affect perception scores.
In addition, because there is evidence that people with
paranoid schizophrenia show improved affect perception
scores, the relationship between diagnostic subtype and
affect perception was also examined (Kline et al. 1992;
Lewis and Garver 1995). Finally, two other neurocogni-
tive measures (verbal fluency and general face perception)
were included to examine what role, if any, these skills
play in affect perception.
Method
Participants. The participants were 65 people diagnosed
with chronic schizophrenia who were recruited from two
large State psychiatric hospital settings in Louisiana:
Southeast Louisiana State Hospital and the Eastern
Louisiana Mental Health System. Both settings are ter-
tiary care treatment centers for people with chronic men-
tal illness. Table 1 summarizes participant demographic
and clinical characteristics. A total of 36 males and 29
females participated in the study. By ethnicity, 17 were
Caucasian, 47 were African-American, and 1 was Asian-
American. There was no difference in the gender and eth-
nic makeup of the total sample, x2 (2) = 1.3, p = 0.50.
Comparison tests did not reveal any differences in atten-
tional or affect perception measures based on gender, eth-
nicity, or hospital site. To be eligible for the study, partici-
pants were required to have a DSM-IV diagnosis of
The Role of Attention in Affect Perception Schizophrenia Bulletin, Vol. 30, No. 4, 2004

Table 1. Summary of participant demographics

Eastern Southeast
Louisiana Mental Louisiana State
Total sample Health System Hospital
Variable mean (SD) mean (SD) mean (SD)
Age (yrs) 40.7 (7.9) 41.0(8.0) 40.2 (8.0)
Education (yrs) 11.2(1.7) 11.1 (1.8) 11.5(1.6)
Gender (n)

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Male 36 24 12
Female 29 19 10
Ethnicity (n)
Caucasian 17 10 7
African-American 47 32 15
Other 1 1 0
SCID-I/P diagnosis (n)
Paranoid schizophrenia 40 25 15
Undifferentiated schizophrenia 8 6 2
Disorganized schizophrenia 4 2 2
Schizoaffective disorder 13 10 3
CPZ equivalents (mg/d)1 854.0 (494.5) 864.2 (534.7) 834.0(415.8)
Antipsychotic medication type (n)
Typical 15 105
Atypical 34 18 16
Combination 16 15 1
Anticholingeric medication (%) 36 44 22
BPRS total score 53.8 (5.9) 54.3 (6.0) 52.8 (5.8)
AIMS score 0.17(0.57) 0.21 (0.64) 0.09 (0.43)
Length of illness (mos) 218.8(97.7) 220.5(102.9) 216.5(88.9)
Length of stay (wks) 86.0(110.7) 84.4(123.4) 89.2 (82.9)
Hospital admits (n) 11.1 (17.3) 13.6(20.8) 6.4(4.1)
WRAT-III, reading 79.8 (9.0) 79.4 (8.6) 80.7(10.0)
Note.—AIMS = Abnormal Involuntary Movement Scale; BPRS = Brief Psychiatric Rating Scale; CPZ = chlorpromazine; SCID-I/P =
Structured Clinical Interview for DSM-IV; WRAT-III = Wide Range Achievement Test III.
1
Medication dosages were converted to chlorpromazine equivalents.

schizophrenia, schizoaffective disorder, or psychotic dis-
order not otherwise specified. All participants were
assessed using the Structured Clinical Interview for the
DSM-IV (SCID-I/P; First et al. 1995) to confirm diagno-
sis of schizophrenia. To examine the effects of diagnostic
subtype on affect perception, two groups were formed: A
paranoid group (paranoid schizophrenia) and a nonpara-
noid group (disorganized, undifferentiated, and schizoaf-
fective). Psychiatric symptomatology was assessed using
the Brief Psychiatric Rating Scale (BPRS; Lukoff et al.
1986). Tardive dyskinesia symptoms were assessed by a
review of Abnormal Involuntary Movement Scale (AIMS)
scores conducted by hospital staff. Data on type and
dosage of antipsychotic medication were collected, and
medication dosages were converted into standardized
chlorpromazine equivalents (see Lehman and Steinwachs
1998 and Bezchlibnyk-Butler and Jeffries 2002 for CPZ
conversion rates).
Participants who had documented substance abuse
problems were required to be in remission or in a con-
trolled environment for 3 months before participating.
Substance abuse problems were ruled out by a review of
substance screening tests on admission and by the
SCID-I/P substance abuse module. Other exclusion crite-
ria included having a documented neurological condition
(e.g., stroke, traumatic brain injury, or seizure disorder),

729
Schizophrenia Bulletin, Vol. 30, No. 4, 2004
being too disorganized to give consent or complete the
protocol, being deemed unsuitable for inclusion by hospi-
tal staff, or reading level below the fourth-grade level as
assessed by the Wide Range Achievement Test III
(WRAT-III) reading test (Wilkinson 1993).
Procedure for Selection of Participants. Participants
were selected using a methodology employed in previous
research studies in these settings (Penn and Combs 2000;
Penn et al. 2000). Potential participants first received a
general overview of the study. Next, a list of all people
with diagnoses that met study eligibility criteria was con-
structed from the hospital roster. Participants either volun-
teered to take part in the study after the general overview
or were identified (based on diagnosis) and approached
for participation. One person refused to participate in the
study, and two people refused to continue testing. In all
three cases, the subject became disorganized, psychotic,
and confused.
Demographic and Clinical Measures. A basic demo-
graphic questionnaire was used to obtain background
information for each participant (e.g., length of illness,
duration of current stay, number of inpatient hospitaliza-
tions, AIMS score, and medication type and dosage). This
information was obtained from hospital records and an
interview with the participant.
The SCID-I/P was used to derive a clinical psychiatric
diagnosis based on the DSM-IV system (First et al. 1995).
The BPRS assessed each participant's current level of
symptomatology over the previous 1- to 2-week period
(Lukoff et al. 1986). The BPRS contains 24 items (rated
on a scale of 1 to 7) that cover a range of psychiatric
symptoms. The BPRS can be broken down into four fac-
tor scores: anergia, affect, thought disorder, and disorgani-
zation (Mueser et al. 1997). The principal investigator
was reliability trained on the BPRS and SCID-I/P (Penn
and Combs 2000; Penn et al. 2000). The WRAT-III
(Wilkinson 1993) reading subtest was used to screen par-
ticipants for problems in reading.
Measures of Attention. The measures of attention used
in this study were selected based on Mirsky's four factor
model of attention: Focus-Execute, Encode, Sustain, and
Shift (Mirsky et al. 1991, 1995). The Shift factor was
composed of scores from the Wisconsin Card Sorting Test
(WCST; Heaton 1981). WCST variables of interest were
percentage correct, number of errors, and categories com-
pleted. The person must be able to disengage or shift
attention from the previous response to the new set (e.g.,
color to form), which may be different from the reason-
ing/problem-solving aspects of the test (Mirsky et al.
730
D.R. Combs and Wm. D. Gouvier
1995; Spreen and Strauss 1998). A computerized version
of the WCST was used for ease of examination. The
Sustain factor was based on scores from the conventional
version of the Continuous Performance Test (CPT;
obtained from the University of California at Los
Angeles), which required the person to respond by click-
ing a mouse button each time the number "0" appeared
(Nuechterlein 1991). Of the 480 total numbers presented,
only 120 were targets. Variables of interest from the CPT
included number of hits, total number of errors (misses
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and false alarms), and mean reaction time (Mirsky et al.
1991, 1995; Kremen et al. 1992). The CPT also provided
a sensitivity index (d'; based on signal detection theory),
which measured the person's sensitivity to correctly
respond to targets and ignore distracter numbers. The
Focus-Execute factor was based on scores from the Trail
Making Test (Reitan and Davison 1974; time in seconds)
and Digit Symbol-Coding subtest (number correct) from
the WAIS-III. The final factor, Encode, was based on
scores from the Digit-Span subtest (number correct) and
Arithmetic subtest (number correct) of the WAIS-III.
Affect Perception Measures
Bell-Lysaker Emotion Recognition Test (BLERT).
The BLERT is a 21-item videotaped presentation of seven
different emotional states: happiness, sadness, anger, fear,
disgust, surprise, and no emotion (Bell et al. 1997; Bryson
et al. 1997). Each emotional state was presented for 10
seconds, and the subject had to decide which affective
state was presented. Each emotion was displayed by a
male actor who recited a series of three standard mono-
logues concerning his job. The BLERT total score (range
0 to 21) was used in the analyses. The BLERT has good
categorical stability data (K = 0.76) and test-retest stability
(5-month test-retest reliability was 0.76). The BLERT also
has good discriminant and convergent validity (Bell et al.
1997; Bryson et al. 1997). In the present study, the inter-
nal consistency for this scale was 0.79.
Face Emotion Identification Test (FEIT). The
FEIT was developed by Kerr and Neale (1993) using still
photograph pictures taken from the work of Ekman
(1976) and Izard (1971) and based on the generalized
deficit model (Chapman and Chapman 1973, 1978). The
FEIT consists of 19 (score range 0 to 19) videotaped pic-
tures of six different emotional states: happiness, sadness,
anger, surprised, afraid, and ashamed. The FEIT was
developed as an affect perception test with acceptable
reliability and validity. Previous reliability results showed
an internal consistency value ranging from 0.56 to 0.71
(Kerr and Neale 1993). Comparable reliability results
were replicated in another study using a similar state hos-
pital sample (Penn et al. 2000). The FEIT has demon-
strated good discriminant and convergent validity (Kerr
The Role of Attention in Affect Perception Schizophrenia Bulletin, Vol. 30, No. 4, 2004

and Neale 1993). In the present study, the internal consis-
tency for this scale was 0.75.
Other Neurocognitive Measures. To evaluate the person's
verbal fluency, the Controlled Oral Word Association test
(COWAt; Benton et al. 1994; Spreen and Strauss 1998) was
administered. The test evaluates whether deficits in emotion
recognition might be due to problems in general verbal flu-
ency (language production) that might prevent the subject
Results
Summary Scores and Correlations. Summary scores
for the attentional, affect perception, and cognitive mea-
sures are presented in table 2. These scores are reported as
raw scores (Mirsky et al. 1991). In addition, correlations
between affect perception and the demographic and clini-
cal variables can be found in table 3. Variables signifi-
cantly correlated with affect perception included the

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from generating the names for different emotions (Chen et
al. 2000). The COWA requires the person to verbally gener-
ate as many items beginning with the letters F, A, and S as
possible in 60 seconds, and a total score across all three let-
ters was computed. The short form of the Benton Test of
Facial Recognition (TFR; Benton et al. 1983) was adminis-
tered as a control measure for the affect perception tasks.
The test presented 27 pictures of different faces that the per-
son matched in identity to a target face. Because the test
controlled for the emotional content of the faces, it could
serve as a pure face recognition test. The TFR has been used
in previous studies to compare face perception and affect
recognition (Salem et al. 1996; Penn et al. 2000).
COWAT (r = 0.326, p = 0.002), the TFR (r = 0.450, p =
0.0001), BPRS total score (r = -0.329, p = 0.008), and
psychiatric subtype diagnosis (r = -0.295, p = 0.008).
Multiple Regression Analysis. We conducted a stepwise
multiple regression analysis to determine which factor of
attention was most predictive of affect perception scores.
Predictor variables were the four factor scores generated
from the PCA and other study variables related to affect
perception scores (table 3). The BPRS total score,
COWAt score, TFR score, and diagnostic subtype (para-

General Procedures. The main component of the study

was the administration of the measures of attention and
Table 2. Summary scores on attentional,
neurocognitive, and affect perception measures1
affect perception. The measures of attention were admin-
istered individually and randomized before administra- Variable Mean (SD)
tion. The CPT and WCST were administered using a com- Trails A (sec) 60.9 (21.4)
puterized testing format. These were followed by the
COWAt and the TFR. Finally, the affect perception mea- Trails B (sec) 144.2(57.9)
sures (BLERT and FEIT) were administered. Each partici- Digit Symbol Coding 33.6(13.3)
pant was compensated $5 for time and effort after com- Arithmetic 9.7 (2.2)
pleting the entire study protocol. The research protocol
took approximately 1.5 to 2 hours to complete, and ample Digit Span 12.3(2.5)
rest periods and breaks were provided to reduce the stress CPT
and fatigue associated with intensive testing. Hits (n) 101.0(28.2)
Errors (n) 30.9 (40.2)
Data Analytic Plan. The statistical analysis begins with Reaction time (ms) 455.6(132.7)
summary scores based on the attentional and cognitive <f index score 3.6(1.5)
measures, followed by correlations between affect per- WCST
ception and the demographic and clinical variables. Correct (%) 59.4 ( - )
Because Mirsky's four factor model has been replicated Errors (n) 49.7(21.0)
previously, and because the attentional factors found in Categories completed 3.4 (2.0)
this study (Shift, Sustain, Encode, and Focus-Execute)
COWAt 25.4 (4.5)
were very similar to Mirsky's, the derivation of the fac-
tors using PCA is not reported. The factor scores com- TFR (0-54) 43.9 (4.5)
puted from the PCA were used a predictor variables in BLERT (0-21) 12.1 (4.4)
the subsequent regression analyses. The dependent vari-
FEIT (0-19) 11.2(3.7)
able of interest is a standardized affect perception score
composed of scores from the BLERT and FEIT. To deter- Note.—BLERT = Bell-Lysaker Emotion Recognition Test; COWAt =
Controlled Oral Word Association test; CPT = Continuous
mine which attentional factors were related to affect per- Performance Test; FEIT = Facial Emotion Identification Test; TFR =
ception scores, we conducted a stepwise multiple regres- Test of Facial Recognition; WCST = Wisconsin Card Sorting Test.
sion analysis. 1
All scores are reported as raw scores.

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Schizophrenia Bulletin, Vol. 30, No. 4, 2004 D.R. Combs and Wm. D. Gouvier

Table 3. Correlations between demographic, Overall, the four factors of attention and psychiatric
clinical, and affect perception variables diagnosis accounted for 81 percent of the variance in
Variable Affect perception score
affect perception scores. The four factors of attention
(correlation coefficient) accounted for 78 percent of the variance in affect percep-
tion scores and diagnostic subtype accounted for 3 percent
Age (yrs) -0.20 of the variance. The Shift factor had the highest predictive
Education 0.24 value (34.6%) followed by Encode (18.5%), Focus-
Facial recognition 0.45* Execute (14.7%), and Sustain (9.7%) factors. Examining
Verbal fluency 0.37* the effect of diagnosis revealed that participants with

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1
Diagnosis -0.29*
BPRS total -0.32*
Length of illness
(mos) -0.20
Length of stay
(wks) -0.15
Hospitalizations (n) -0.24
AIMS -0.21
Medication dose
(CPZ equivalent) -0.02
2
Medication type 0.03
Note.—AIMS = Abnormal Involuntary Movement Scale BPRS =
Brief Psychiatric Rating Scale; CPZ = chlorpromazine.
1
Diagnosis was dummy coded as paranoid versus nonparanoid.
dedication type was coded as typical versus atypical.
*p<0.05
noid versus nonparanoid) were included as additional pre-
dictor variables. Note that when people with schizoaffec-
tive disorder (n - 13) were removed from the diagnosis
variable, the results were unchanged.
A composite affect perception score (based on
BLERT and FEIT) was the dependent variable in this
analysis. This composite total score represented a more
global, comprehensive measure of affect perception.
Because scores from the BLERT and FEIT were found to
be highly correlated (r - 0.85, p = 0.0001), the two affect
perception scores were converted into standardized z
scores based on sample means, and a composite affect
perception score was computed (mean z scores from
BLERT and FEIT). The conversion of these scores into z
scores was needed to make the two measures comparable
(see Salem et al. 1996 for a similar procedure) because
the BLERT and FEIT have different numbers of test items
and have different presentation formats (the BLERT has
an audiovisual format and the FEIT is visual only). No
differences in the regression results existed when the
FEIT and BLERT were analyzed separately. The results of
the stepwise multiple regression analysis are presented in
table 4.
paranoid schizophrenia had higher affect perception
scores than participants with nonparanoid schizophrenia,
F (1,63) = 7.3, p - 0.009. There were no differences in
BPRS total or factor scores between the paranoid and
nonparanoid groups. The other variables (COWAT, TFR,
and BPRS) were not included in the stepwise analysis.1
Supplementary Analysis. To determine whether atten-
tion was also important in face recognition, the four atten-
tional factors were regressed against scores from the TFR.
The four attentional factors predicted 20 percent of the
variance in TFR scores (r - 0.45, r2 = 0.20) compared
with 78 percent in the affect perception scores. The
Focus-Execute factor was the only significant predictor
variable (r[64] = -2.0, p = 0.04).
Discussion
The stepwise multiple regression analysis showed that all
four factors of attention, along with diagnostic subtype,
were significantly related to affect perception scores. The
Shift and Encode factors were found to be the strongest
predictors of affect perception performance. The Focus-
Execute and Sustain factors were also significant predic-
tors but accounted for less variance. The four attentional
factors accounted for 78 percent of the variance in affect
perception scores. The attentional variables predicted
emotion perception scores beyond that accounted for by
general face perception, which suggests that basic face
perception was not a significant factor for the affect per-
ception task. In addition, the lack of a relationship with
verbal fluency suggests that problems with affect percep-
tion are not related to verbal fluency deficits. No effect on
affect perception was found for the BPRS symptoms
scores, which will be discussed in more detail below.
Furthermore, the attentional factors were found to be min-
1
A direct regression analysis was conducted to examine the problems
associated with stepwise regression methods because of the elimination
of important variables, which share variance with the selected predictors
(Thompson 1995). BPRS, TFR, and COWA were still not found to be
significant predictors and did not account for any appreciable variance in
affect perception scores.

732
The Role of Attention in Affect Perception
Table 4. Stepwise Regression Analysis Results1
Step/variable r A/ 2
1. Shift 0.597 0.356
2. Encode 0.736 0.541
3. Focus-Execute 0.830 0.689
4. Sustain 0.887 0.786
5. Diagnosis 0.905 0.819
1
Excluded variables in this analysis were the Brief Psychiatric Rating Scale total score, Controlled Oral Word Association Test, and the
Benton Test of Facial Recognition; Diagnosis was dummy coded as paranoid versus nonparanoid.
' p< 0.005; **p< 0.001
imally predictive of face recognition scores (supplemen-
tary analysis), which suggests that attention may be more
important in affect perception and less important for gen-
eral face recognition (Kohler et al. 2001). The Focus-
Execute factor was the only attentional variable predictive
of face recognition. This result may be due to the
demands of the test, in which the subject must select
(focus) the target face and then respond (execute).
Bryson et al. (1997) and Kee et al. (1998) presented
similar evidence that encoding skills, sustained attention,
and the ability to shift attention were related to affect per-
ception scores. Note that in the Bryson et al. study (1997),
cognitive-attentional variables accounted for only 34 per-
cent of the variance in affect perception as measured by
the BLERT. The attentional variables used in the present
study accounted for much more variance (78% versus
34%). The finding that participants with paranoid schizo-
phrenia showed better affect perception scores is consis-
tent with the results of Kline et al. (1992), Lewis and
Garver (1995), and Toomey et al. (2002). Magaro (1981)
and Strauss (1993) argued that people with paranoid
schizophrenia have more intact cognitive abilities than
people with nonparanoid schizophrenia. Because no dif-
ferences in psychiatric symptoms on the BPRS existed
between the paranoid and nonparanoid participants, we
speculate that cognitive factors (which were not directly
assessed) may be a source of the differences found in this
study.
Surprisingly, no empirical relationship existed
between affect perception and current psychiatric symp-
toms (positive and negative), medication type or dosage,
demographic, or other illness-related variables (table 3),
suggesting that the affect perception scores found in this
study may not be an artifact of these variables. Regarding
illness-related variables, one study showed that a higher
the number of hospitalizations was paradoxically associ-
ated with better FEIT scores (Salem et al. 1996), whereas
another study showed that the length of the current treat-
ment episode was inversely correlated with the FEIT
(Mueser et al. 1996). This present study did not find any
733
Schizophrenia Bulletin, Vol. 30, No. 4, 2004
P f Zero order
0.346 0.581 10.4" 0.597
0.185 0.400 7.0" 0.430
0.147 -0.393 -7.0" -0.384
0.097 0.303 5.4" 0.312
0.030 -0.186 -3.3* -0.295
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association between length of illness or length of current
treatment episode and affect perception scores. Previous
research studies showed a modest association between
affect perception and psychiatric symptoms, with negative
symptoms associated with lower affect perception scores
and more visual-spatial processing deficits (Borod et al.
1993; Kohler et al. 2000; Penn et al. 2000; Strauss 1993;
Schneider et al. 1995). Although the BPRS total score was
initially correlated with affect perception scores in the
present study, its influence was better accounted for by the
attentional and diagnostic variables. Researchers have
hypothesized that the link between negative symptoms
and poor affect perception stems from lower social func-
tioning and poorer premorbid adjustment or the presence
of structural brain impairments. However, not all studies
have shown an association between negative symptoms
and affect perception scores (Salem et al. 1996; Toomey
et al. 2002), and currently the role of symptoms in affect
perception remains unclear. Finally, and somewhat sur-
prisingly, no relationship between affect perception and
medication type or dosage was found. Many believe that
the newer atypical antipsychotic medications may
improve cognitive abilities (Nagamoto et al. 1996;
Meltzer and McGurk 1999), which may in turn improve
affect perception (Green 1996; Stip and Lussier 1996).
However, research on this topic is limited (Toomey et al.
2002), and it is not known if the improvement in affect
perception is due to indirect enhancement of cognitive
abilities (e.g., attention or working memory) or affect per-
ception directly. Conflicting evidence exists on whether
traditional antipsychotic medications improve cognitive
abilities (Allen et al. 1997; Sweeney et al. 1991) and the
effects on affect perception may be dose related (Corrigan
and Penn 1995).
How Does Attention Affect Emotion Perception? The
results of this study showed that all four factors of atten-
tion were significantly related to affect perception scores.
A proposed theoretical model on the relationship between
attention and affect perception, which suggests how atten-
Schizophrenia Bulletin, Vol. 30, No. 4, 2004
tional problems might lead to impairments in affect per-
ception, is presented below.
First, because affect perception is a dynamic process
and subject to constant change, the ability to shift atten-
tion from one facial expression to another is valuable.
People impaired in this aspect of attention may become
stuck on one particular emotion, and miss subsequent
shifts in emotion. This study showed that the Shift factor
is most predictive of affect perception scores and is
arguably the most important of the four factors. Second,
the ability to sustain attention over time may be important
because people must constantly follow social dialogue to
detect changes in emotional states. A person who con-
stantly looks away and does not stay focused on the con-
versation at hand is more likely to miss important social
and emotional cues. Bryson et al. (1997) argued that sus-
tained attention leaves people ready to detect important
aspects of emotion. Third, encoding of the entire face (and
possibly other body cues) may also be important because
narrowly focusing on a certain aspect of the face (e.g.,
only the eyes or mouth) may lead to the wrong conclusion
regarding the expressed emotion. The effect of encoding
can be seen in a study by Mandal and Palchoudhury
(1989) in which persons with schizophrenia made more
errors in affect perception when shown pictures of the
whole face (more complex encoding) than shown only
parts of the face.
The influence of the Focus-Execute factor of atten-
tion is more difficult to define. This factor is very simi-
lar to processing speed. The important aspects of this
factor are (1) the ability to identify an important feature
(to focus) and (2) the ability to respond to it (to exe-
cute). Those with delusions and schizophrenia tend to
examine more nonrelevant areas of the face (Phillips
and David 1997, 1998; Quirk 2000). Thus the person
may not be focusing on the most relevant areas of the
face to obtain the most information. The ability of the
motor system to generate emotionally appropriate
responses (through speech or nonverbal cues) is another
key component of this factor. Even when participants in
this study knew the correct emotion presented on the
tape, that information may have been lost, or the emo-
tion changed, if they did not respond quickly. Socially,
if a person engaged in conversation does not respond
(or is slow to respond) to an emotion, the other person
may lose interest, become upset, or end the interaction.
A study by Mandal and Rai (1987) showed that people
with schizophrenia were slower to identify emotional
pictures than a group of people with anxiety disorders
and a control group.
Each attentional factor arguably could impair affect
perception. A summary of the proposed theoretical rela-
tionship between attention and affect perception adopted
734
D.R. Combs and Wm. D. Gouvier
in this study can be found in figure 1. The fact that all four
factors of attention were related to affect perception sug-
gests that this skill can become impaired in many areas in
people with schizophrenia.
Limitations. Sample size is a concern for the multiple
regression analysis. Multiple regression procedures
should have a participant-to-variable ratio of at least
10:1 to ensure an appropriate degree of generalization
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(Diekoff 1992). For this study, the number of variables
in the regression (8) was relatively acceptable to the
number of participants (n = 65). In addition, the combi-
nation of the attentional measures (via PCA) into four
independent factors further reduced the number of vari-
ables in the multiple regression analysis and provided
orthogonality among the attentional factors (Diekoff
1992).
The sample has several limitations. First, the present
study did not include a control group of normal people.
Recent findings by Kohler et al. (2000) showed that cog-
nitive variables in normal people have little relationship
to affect perception and face-recognition performance,
but a relationship between cognition and affect percep-
tion did exist for people with schizophrenia. Because
cognition and affect perception may not be related in
normal people, having a control group may be of little
benefit to understanding the link between attention and
affect perception in schizophrenia, in which cognitive
deficits are more prominent (See Bryson et al. 1997 and
Kee et al. 1998 for similar designs). Second, the sample
used in this study could be placed at the severe end of
the illness continuum based on length of current treat-
ment, length of illness, and reading scores. The results of
this study may differ from other studies with less
impaired participants.
Some argue that affect perception tasks may be
designed to highlight attentional problems in this popu-
lation by having brief exposure times and reducing the
number of visual and verbal cues available to the person
(Bellack et al. 1996, 1999). In this study, the emotional
stimuli were presented for brief periods of time (10 to 15
seconds), but the regression results of the BLERT (with
cues/verbal material) and the FEIT (without cues) were
similar. Therefore, even though stimulus presentation
times were brief (which may be ecologically valid for
emotional expression), there were no differences regard-
ing the role of attention for the BLERT and the FEIT.
Finally, the measures of attention used in this study
cannot be considered pure measures of attention; they
most likely involve other cognitive abilities as well. In
fact, most psychological measures require a combination
of abilities for successful completion (Spreen and
Strauss 1998). For example, the WCST has aspects of
The Role of Attention in Affect Perception Schizophrenia Bulletin, Vol. 30, No. 4, 2004

Figure 1. Theoretical model of the relationship between attention and affect perception

Impact on
Affect Perception

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Cannot Shift to Different
Shift Emotions

Cannot Sustain
Sustain Attention to the Face

Attention
Slow to respond to
emotions
Examine non-relevant
Focus-Execute
areas of the face

Cannot take in
all features of the
Encode face

attention, problem solving, motor skills, and abstract
reasoning (Spreen and Strauss 1998). Mirsky et al.
(1991) stated that difference between shifting attention
and executive functioning (conceptual reasoning and
flexibility) are unclear at present, but both have been
linked to the frontal cortex. According to Posner and
Petersen (1990), the Shift function is more related to eye
movements produced in the superior colliculus than to
frontal cortex functioning. Although the measures used
in this study have significant attentional components,
they do have other aspects that should be considered in
the interpretation of these findings.
This study provided evidence for the role of atten-
tional variables in affect perception. All four factors of
attention were significantly related to affect perception
scores. More information is needed to clarify the complex
relationship between cognitive variables, symptoms, and
medication factors in affect perception. Each factor likely
affects the others, and empirical research could help
uncover their individual and combined effects. This study
represents a first step in understanding how a single cog-
nitive skill, attention, can affect social functioning. We
hope that future studies will further refine our understand-
ing of attention and affect perception.

735
Schizophrenia Bulletin, Vol. 30, No. 4, 2004
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