Schizophrenia Research 142 (2012) 58–64

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Schizophrenia Research
journal homepage: www.elsevier.com/locate/schres

How specific are emotional deficits? A comparison of empathic abilities in

schizophrenia, bipolar and depressed patients
Birgit Derntl a, b, c,⁎, Eva-Maria Seidel a, Frank Schneider b, c, Ute Habel b, c
a
Faculty of Psychology, University of Vienna, Vienna, Austria
b
Department of Psychiatry, Psychotherapy, and Psychosomatics, Medical School, RWTH Aachen University, Aachen, Germany
c
JARA-BRAIN Jülich Aachen Research Alliance, Translational Brain Medicine, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Empathy is a rather elaborated human ability and several recent studies highlight significant impairments in
Received 21 May 2012 patients suffering from psychiatric disorders, such as schizophrenia, bipolar disorder or major depression.
Received in revised form 7 September 2012 Therefore, the present study aimed at comparing behavioral empathy performance in schizophrenia, bipolar
Accepted 28 September 2012
and depressed patients with healthy controls. All subjects performed three tasks tapping the core compo-
Available online 30 October 2012
nents of empathy: emotion recognition, emotional perspective taking and affective responsiveness. Groups
Keywords:
were matched for age, gender, and verbal intelligence.
Empathy Data analysis revealed three main findings: First, schizophrenia patients showed the strongest impairment in
Emotional competencies empathic performance followed by bipolar patients while depressed patients performed similar to controls in
Schizophrenia most tasks, except for affective responsiveness. Second, a significant association between clinical character-
Bipolar disorder istics and empathy performance was only apparent in depression, indicating worse affective responsiveness
Depression with stronger symptom severity and longer duration of illness. Third, self-report data indicate that particular-
ly bipolar patients describe themselves as less empathic, reporting less empathic concern and less perspec-
tive taking.
Taken together, this study constitutes the first approach to directly compare specificity of empathic deficits in
severe psychiatric disorders. Our results suggest disorder-specific impairments in emotional competencies
that enable better characterization of the patient groups investigated and indicate different psychotherapeu-
tic interventions.
© 2012 Elsevier B.V. All rights reserved.

1. Introduction Vignemont and Singer, 2006). As a fundamental interpersonal phe-

While several studies compared neurocognitive functioning be-
tween patients suffering from schizophrenia, bipolar disorder or
major depression (e.g., Simonsen et al., 2009, 2010; Zanelli et al.,
2010; Tuulio-Henriksson et al., 2011), little is known about the speci-
ficity of emotional competencies in these major psychiatric disorders.
Addington and Addington (1998) compared emotion recognition per-
formance of schizophrenia and bipolar disorder patients and observed
significantly poorer performance in schizophrenia patients, however
patient groups were not matched for age, gender and education. Little
is known about disorder-specific deficits in other emotional com-
petencies such as empathic abilities, despite their relevance for suc-
cessful social interaction. Correctly inferring emotional states and
intentions via the observation of others' behavior is a prerequisite
for successful social interaction and increase social coherence (De
⁎ Corresponding author at: Department of Psychiatry, Psychotherapy and Psychosomatics,
Medical School, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany.
Tel.: +49 241 8085729; fax: +49 241 8082401.
E-mail address: bderntl@ukaachen.de (B. Derntl).
nomenon, empathy plays a vital role in all social interactions, and
thus, deficits in empathic behavior may lead to social dysfunctions, in-
cluding those that characterize major psychiatric disorders (Segrin,
2000; Blair, 2005; Henry et al., 2008).
According to most models we differentiate three core components
of empathy (Decety and Jackson, 2004): 1) recognizing emotions in
facial expressions, speech or behavior (gestic), 2) affectively respond-
ing to emotional states of others (affective empathy), and 3) taking
over the perspective of another person, though the distinction be-
tween self and other remains intact (cognitive empathy, e.g., Ickes,
2003). Please see also Fig. 1 for illustration of the three components.
The majority of previous studies in all three patient groups focused
on emotion recognition and at least for schizophrenia and bipolar
patients studies consistently demonstrated a difficulty of patients to
infer the correct emotion from a facial expression (bipolar: e.g., Derntl
et al., 2009a; Hoertnagl et al., 2011; schizophrenia: e.g., Schneider
et al., 2006; Kohler et al., 2010). In depression, however, given the lim-
ited evidence, results are somewhat mixed (Wright et al., 2009;
Anderson et al., 2011). According to a recent meta-analysis including
40 studies in depression (Bourke et al., 2010) there is some consistency

0920-9964/$ – see front matter © 2012 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.schres.2012.09.020
 B. Derntl et al. / Schizophrenia Research 142 (2012) 58–64 59

Table 1
Sociodemographic information on schizophrenia (SZP), bipolar (BDP), depressed
(MDP) and healthy control participants (CON). Mean values are presented and stan-
dard deviations are listed in parentheses. All participants were matched for age, gen-
der, and (premorbid) verbal intelligence and patient samples did not differ in their
duration of illness.

SZP BDP MDP CON p-value

(n = 24) (n = 24) (n = 24) (n = 24)

Fig. 1. Illustration of the three core components of empathy according to Decety and Gender 12:12 12:12 12:12 12:12 –
Jackson (2004). Age (years) 40.1 (8.7) 44.0 (9.8) 41.1 (10.6) 39.9 (10.0) 0.445
Verbal IQ 107.7 (12.7) 108.9 (14.5) 109.0 (13.4) 111.3 (9.7) 0.807
Age of onset 28.9 (9.2) 37.9 (9.6) 32.1 (9.8) – 0.010
in that depressed patients show a negative response bias towards sad- Illness duration 11.5 (7.6) 7.8 (5.4) 8.2 (7.8) – 0.148

ness, such that neutral or ambiguous stimuli are evaluated as sad.

Regarding cognitive and affective empathy, results are less consis-
tent. While schizophrenia patients show a significant deficit in both
abilities (Shamay-Tsoory et al., 2007; Bora et al., 2008; Langdon and
Ward, 2009), euthymic bipolar patients show no significant impair-
ment (Montag et al., 2010) but report lower levels of cognitive em-
pathy and higher levels of personal distress (Cusi et al., 2010). In
depression, Thoma et al. (2011) reported no significant behavioral
deficit in cognitive and affective empathy but higher self-reported em-
pathy scores, mainly driven by increased personal distress scores.
Directly comparing patient's performance with controls' in all
three components, schizophrenia patients showed a significant gener-
al impairment (Derntl et al., 2009b), while bipolar patients exhibited a
deficit in emotion recognition and affective empathy (Seidel et al.,
2012).
Taken together, previous results indicate emotional dysfunctions in
all three major psychiatric disorders, which may be associated with dif-
ficulties in social functioning (schizophrenia: Sparks et al., 2010; Smith
et al., 2012; bipolar: Hoertnagl et al., 2011; depression: Cusi et al., 2011).
It remains unclear, however, if these dysfunctions characterize psychi-
atric patients in general or whether there are disorder-specific patterns,
which in turn could have implications for treatment strategies.
Therefore, the present study is the first attempt to directly compare
performance regarding three different core components of empathy in
patients suffering from schizophrenia, bipolar disorder and major de-
pression. Based on the previous findings on emotional abilities, we hy-
pothesized worst performance in schizophrenia patients, particularly
in emotion recognition (cf. Addington and Addington, 1998). More-
over, we analyzed whether groups show distinct self-report descrip-
tions and investigated the impact of symptom severity on emotional
performance.
2. Methods
2.1. Sample
from the in- and outpatient units of the Department of Psychiatry, Psy-
chosomatic and Psychotherapy, University of Regensburg, Germany,
and the Department of Psychiatry and Psychotherapy I, University
Hospital Ulm, Weißenau, Germany. Depressed patients were recruited
from the in- and outpatient units of the Department of Psychiatry, Psy-
chotherapy and Psychosomatics, Medical School, RWTH Aachen
University, Germany and the Department of Psychiatry and Psycho-
therapy I, University Hospital Ulm, Weißenau, Germany. Symptom se-
verity in schizophrenia patients was measured with the Positive and
Negative Syndrome Scale (PANSS, Kay et al., 1987), in bipolar patients
affective symptoms were assessed using the Young Mania Rating Scale
(Young et al., 1978) and the Montgomery Asberg Depression Rating
Scale (Montgomery and Asberg, 1979) and in depressed patients the
Beck Depression Inventory (BDI, Beck et al., 1961) and the 17-item
version of the Hamilton Depression Rating Scale (HAMD, Hamilton,
1960) were used. Moreover, all SZP patients received atypical antipsy-
chotic medication except for one patient who was treated with both
atypical and typical agents. BDP were taking the prescribed medica-
tion to ensure mood stabilization (antidepressant n = 2, neuroleptic
n = 3, mood-stabilizer n = 7, antidepressants + neuroleptic n = 3,
antidepressant + mood-stabilizer n = 1, mood-stabilizer + neurolep-
tic n = 6, combination of all three n = 2). Eight DP were unmedicated
at the time of testing, the other 14 were all taking antidepressant
medication except for one patient who received antidepressants and
neuroleptics.
All subjects gave written informed consent prior to the start of the
study. Procedures have been approved by local ethics committees in
Aachen, Ulm and Regensburg.
All participants completed a test tapping crystallized verbal intel-
ligence (MWT-B, Lehrl, 1996), as a measure of premorbid crystallized
verbal intelligence and the German version of the Interpersonal Reac-
tivity Index (IRI, Davis, 1983; German version: Paulus, 2009) as a self-
report measure of empathic abilities.

We relied on data of 24 schizophrenia patients (SZP; 12 females) 2.2. Empathy tasks

meeting the DSM-IV criteria for schizophrenia (confirmed via struc-
tured clinical interview, SCID, Wittchen et al., 1997) that have been
published previously (Derntl et al., 2009b). Twenty-four bipolar pa-
tients (BDP; 12 females) meeting the DSM-IV criteria for bipolar I
or bipolar II disorder (again confirmed via structured interview,
MINI, Sheehan et al., 1998) have been included. A recent publication
(Seidel et al., 2012) relies partly on the sample presented here. Addi-
tionally, 24 patients fulfilling the criteria for major depression (MDP;
12 females) and 24 healthy controls (CON; 12 females) were recruited
and participated in this study. All subjects were matched for age, gen-
der and (premorbid) verbal intelligence as can be seen in Table 1. Ex-
clusion criteria for all subjects were substance abuse within the last
six months, no neurological and no (other) psychiatric disorder (as
assessed via structured clinical interviews). Schizophrenia patients
were recruited from the in- and outpatient units of the Department
of Psychiatry, Psychotherapy and Psychosomatics, Medical School,
RWTH Aachen University, Germany. Bipolar patients were recruited
All participants performed the following three tasks:
2.2.1. Emotion recognition and age discrimination
60 colored Caucasian facial identities (Gur et al., 2002) depicting
five basic emotions (happiness, sadness, anger, fear, disgust) and neu-
tral expressions were presented maximally for 4 s. Half of the stimuli
were used for emotion recognition, the other half for the age discrim-
ination control task. For emotion recognition subjects had to deter-
mine the correct emotion by selecting from two emotion categories.
For age recognition, subjects had to judge, which of two age decades
was closer to the poser's age.
2.2.2. Emotional perspective taking
Participants viewed 60 pictures each presented for 4 s depicting
scenes showing two Caucasians involved in social interaction there-
by portraying five basic emotions and neutral scenes (10 stimuli per
60 B. Derntl et al. / Schizophrenia Research 142 (2012) 58–64
condition). The face of one person was masked and participants were
asked to infer the corresponding emotional expression of the masked
face that would fit the emotional situation. Responses were made by
selecting between two different emotional facial expressions or a
neutral expression presented after each scene. Facial alternatives
were taken from the same stimulus set described above. One option
was correct and the other was selected at random from all other
choices. Again, scores were calculated as percent of items judged cor-
rectly and reaction times were assessed.
2.2.3. Affective responsiveness
We presented 150 short written sentences describing real-life sit-
uations, which are likely to induce basic emotions (the same emo-
tions as described above), and situations that were emotionally
neutral (25 stimuli per condition). Participants were asked to imagine
how they would feel if they were experiencing those situations. Stim-
uli were presented for 4 s and response format was the same as for
emotional perspective taking. Response format was kept maximally
similar across tasks allowing comparisons between tasks, i.e. differ-
ences could be traced back to different task requirements not to dif-
ferent response formats. Similar to both other tasks, percent correct
and reaction times were calculated and used for data analysis. Order
of tasks was pseudo-counterbalanced in that the emotion recognition
task was always presented first. However, the perspective taking task
and the affective responsiveness task were counterbalanced in that
half of the participants completed the perspective taking task first,
the other half the affective responsiveness task.
2.3. Statistical analysis
Statistical analyses were performed using SPSS 18.0 and level of
significance was set at p = .05. Percent correct was analyzed using
Generalized Estimating Equations (GEE; SPSS command GENLIN)
accounting for non-normality of the dependent measures and/or
violations of sphericity. For each empathy task, a full-factorial model
was computed with emotion as within-subject factor, and group (SZP
vs. BDP vs. MDP vs. CON) as between-subject factor. Analyses of emo-
tional perspective taking and affective responsiveness tasks further
included performance on emotion recognition and the respective other
task as covariates to control for influences of response format on results
and influences of the tasks on each other. Emotion recognition as inves-
tigated in our study using an explicit emotion recognition task consti-
tutes the basic ability that underlies all higher empathic components,
such as perspective taking and affective responsiveness. Therefore we
suggested a unidirectional influence since neither perspective taking
nor affective responsiveness is possible or adequate, if the corresponding
emotion is not recognized correctly. To compare overall performance
between the groups, we computed an additional model using GEE with
task (3 levels) as within-subject factor, and group as between-subject
factor.
Reaction times were analyzed for each task using repeated-measures
ANOVAs with emotion as within-subject factor and group as between-
subject factor. Moreover, to compare performance across tasks, we per-
formed an additional repeated-measures ANOVA with task as within-
subject factor and group as between-subject factor. Whenever violations
of sphericity occurred, Greenhouse–Geisser corrected degrees of free-
dom and p-values are reported. Post hoc comparisons of the ANOVAs
are Bonferroni corrected. Results of reaction time analyses are presented
in the Supplementary material.
Group differences in the empathy questionnaire were assessed
using univariate ANOVAs with group as fixed factor. Correlations be-
tween accuracy measures of the empathy paradigms, symptom sever-
ity scores, duration of illness, and self-report scores were computed
using non-parametric methods (Spearman rank correlation).
3. Results
3.1. Empathy tasks
Fig. 2 illustrates mean performance of the four groups in the sep-
arate empathy tasks and Table 2 lists mean scores and standard
deviations.
For emotion recognition, GEE accuracy analysis revealed a signifi-
cant effect of group (Wald-χ2 = 8.694, df = 3, p = 0.034) with CON out-
performing SZP (p= 0.017), BDP (p= 0.044) and a similar trend for
MDP (p= 0.059). A significant main effect of emotion (Wald-χ2 =
91.252, df=5, p b 0.001) but no significant emotion-by-group interac-
tion (Wald-χ2 =19.484, df= 15, p = 0.193) emerged. Post hoc analysis
of the significant emotion effect showed highest accuracy for happy
conditions (happy vs. disgust/fear/sad: p b 0.001; happy vs. anger: p =
0.008; happy vs. neutral: p = 0.023) followed by neutral, anger, fear,
disgust and sad conditions.
Controlling for emotion recognition and affective responsiveness per-
formance, we observed a significant main effect of group (Wald-χ2=
22.522, df= 3, p b 0.001) with SZP performing worse than CON
(pb 0.001), MDP (pb 0.001) and BDP (p= 0.029), while the other
three groups did not differ (CON vs. MDP: p = 1; CON vs. BDP: p = 1;
MDP vs. BDP: p = 0.702) in emotional perspective taking. A signifi-
cant main effect of emotion (Wald-χ2 = 154.81, df= 5, pb 0.001) but
no significant emotion-by-group interaction (Wald-χ2 = 11.837, df=
15, p = 0.691) emerged. Post hoc analysis of the significant emotion ef-
fect showed highest accuracy for happy conditions (happy vs. disgust/
fear/sad: p b 0.001; happy vs. anger: p = 0.001, happy vs. neutral: p =
0.007) followed by neutral, anger, disgust, fear and sad conditions.
Controlling for emotion recognition and perspective taking perfor-
mance, a highly significant group effect (Wald-χ2 = 646.378, df = 3,
p b 0.001) occurred for affective responsiveness. CON outperformed
SZP (p b 0.001), BDP (p b 0.001) and MDP (p b 0.01). SZP performed
worse than BDP (p = 0.008) and MDP (p b 0.001), while BDP and
MDP did not differ (p = 0.202). A significant main effect of emotion
(Wald-χ2 = 1944.317, df = 5, p b 0.001) and a significant group-by-
emotion interaction occurred (Wald-χ2 = 53.879, df = 15, p b 0.001).
Emotion-specific post hoc GEE models demonstrated significant
group effects for all negative emotions and neutral conditions (all
p-values b 0.002) while no group effect occurred for happiness (p =
0.643). SZP performed worse for all emotions compared to CON (all
p-values b 0.001) and MDP (all p-values b 0.037), while a significant
difference to BDP only emerged for anger, fear, and sad stimuli (all
p-values b 0.028). BDP differed from CON in responsiveness to disgust
(p = 0.049), neutral (p = 0.037), and sad stimuli (p = 0.003) but not in
anger (p = 0.173) or fear processing (p = 0.051). Interestingly, MDP
did not differ from CON in the emotion-specific post hoc tests (all
p-values > 0.069) but showed significantly better performance than
BDP for sad stimuli (p = 0.029), while for all other emotions no signif-
icant difference emerged (all p-values > 0.091).
Comparing the overall accuracy across all tasks revealed a significant
task effect (Wald-χ2 = 202.376, df= 3, p b 0.001) with lowest accuracy
in affective responsiveness and highest in emotional perspective taking.
A significant group effect (Wald-χ2 = 45.911, df= 3, p b 0.001) oc-
curred with CON outperforming SZP (pb 0.001) and BDP (p=0.005).
There was only a trend for a difference between MDP (p= 0.059) and
CON. SZP performed worse than BDP (p=0.042) and MDP (pb 0.001)
while BDP and MDP (p= 0.306) did not differ. A significant task-by-
group interaction was observed (Wald-χ2 = 55.941, df= 9, p b 0.001),
mirroring the task-specific analysis presented above.
3.2. Empathy self-report
We observed a significant group difference (F(3,89) = 3.010, p =
0.035) in the self-report empathy sum-score with lower scores in
BDP compared to CON (p = 0.009) and MDP (p = 0.019). There was
 B. Derntl et al. / Schizophrenia Research 142 (2012) 58–64 61

Fig. 2. Performance (percent correct) for the three empathy tasks separately for each group. Direct comparison revealed significant differences between clinical groups and controls.
Significant differences are marked with an asterisk. Note that equal performance of participants sometimes might be covered by only one data point.

a significant group effect regarding the subscale fantasy (F(3,89) =
3.614, p = 0.016) with SZP showing lower scores than CON (p =
0.005) and BDP (p = 0.008), but no difference compared to MDP
(p = 0.071). Regarding the subscale perspective taking, the main ef-
fect of group (F(3,89)=9.828, pb 0.001) was triggered by BDP scoring
lower than all other groups (all p-valuesb 0.001). The group effect re-
garding personal distress (F(3,89) =2.937, p= 0.038) was driven by
CON scoring lower than all patient groups (SZP: p=0.010, MDP: p=
0.018, BDP: p=0.036). For empathic concern, we observed a group dif-
ference (F(3,89)=2.774, p=0.046) due to BDP scoring lower than CON
(p=0.031) and MDP (p=0.009). Mean scores are presented in Table 3.
Correlation of behavioral performance (accuracy) and self-report
data revealed no significant association in any of the groups (SZP: all
p > 0.063; BDP: all p > 0.166; MDP: all p > 0.062; CON: all p > 0.096).
3.3. Clinical characteristics
Symptom severity scores in MDP correlated with accuracy in affective
responsiveness (BDI: rho=−0.482, p=0.009; HAMD: rho=−0.412,
p=0.045), however, MADRS scores or YMRS scores in BDP were not
correlated to accuracy in any of our empathy tasks (all
p-values>0.061). Correlation analysis with PANSS scores and perfor-
mance in the empathy tasks revealed no significant results for SZP,
too (p> 0.071).
Regarding duration of illness, only MDP showed a significant neg-
ative association with affective responsiveness scores (rho = − 0.421,
p = 0.029) indicating worse performance with longer duration. How-
ever, for both other patient groups no significant association with du-
ration of illness emerged (both p > 0.072).

Table 2
Emotion-specific and total mean percent correct (and standard deviations in parentheses) for each task and each group.

Anger Disgust Fear Happiness Sadness Neutral Total

Schizophrenia patients
Emotion recognition 78.3 (20.4) 75.0 (24.5) 75.8 (23.6) 93.3 (12.7) 66.7 (18.3) 89.2 (16.7) 79.7 (12.2)
Perspective taking 67.6 (23.9) 60.9 (18.1) 64.7 (15.6) 84.3 (12.4) 73.4 (22.9) 76.5 (16.7) 71.4 (9.8)
Affective responsiveness 66.3 (18.0) 78.8 (15.6) 74.6 (15.1) 91.1 (10.9) 73.4 (11.0) 87.0 (14.1) 78.5 (10.3)

Bipolar disorder patients

Emotion recognition 85.8 (22.4) 82.5 (17.0) 80.8 (18.2) 92.5 (14.2) 67.5 (22.7) 86.7 (19.3) 82.6 (10.1)
Perspective taking 75.5 (18.5) 64.2 (17.2) 74.5 (19.8) 92.9 (11.2) 78.2 (17.8) 81.3 (19.0) 77.8 (12.3)
Affective responsiveness 84.2 (20.2) 87.1 (15.2) 81.3 (15.4) 94.2 (12.5) 82.3 (15.1) 89.2 (12.8) 87.7 (11.9)

Major depression patients

Emotion recognition 86.7 (21.0) 80.8 (22.4) 84.2 (16.7) 91.7 (15.5) 71.7 (20.4) 77.5 (27.2) 82.1 (13.6)
Perspective taking 75.5 (16.7) 71.7 (13.1) 80.0 (12.9) 92.9 (8.1) 85.0 (13.6) 87.9 (13.5) 82.2 (7.3)
Affective responsiveness 89.2 (11.8) 85.0 (12.7) 90.0 (9.7) 89.6 (16.1) 87.1 (8.3) 94.2 (12.0) 89.2 (7.6)

Controls
Emotion recognition 92.5 (14.2) 80.0 (18.7) 87.5 (16.5) 95.8 (10.2) 76.7 (14.0) 92.5 (15.4) 87.4 (6.3)
Perspective taking 74.1 (15.3) 72.8 (17.2) 75.9 (15.3) 95.0 (7.2) 84.7 (17.9) 84.6 (16.7) 82.8 (8.7)
Affective responsiveness 90.8 (13.8) 94.2 (9.7) 97.5 (4.4) 100 (0.0) 92.5 (7.9) 99.6 (2.0) 95.8 (4.2)
62 B. Derntl et al. / Schizophrenia Research 142 (2012) 58–64

Table 3 SZP performed similar to CON and showed even faster response
Means and standard deviations for the self-reported empathic abilities using the times than MDP and BDP across all three tasks. Regarding self-
German version of the Interpersonal Reactivity Index.
reported empathy, SZP did not differ from MDP in any subscale but
SZP BDP MDP CON showed lower fantasy scores than CON and BDP. Interestingly, SZP
SPF fantasy 12.0 (3.0) 14.8 (3.5) 13.8 (3.8) 14.9 (3.1) did not report a perspective taking impairment paralleling results in
SPF perspective taking 14.9 (2.5) 12.0 (3.6) 15.7 (2.1) 15.6 (1.6) first-episode SZP (Achim et al., 2011) but contrasting data from sever-
SPF empathic concern 14.7 (2.8) 13.7 (2.7) 15.8 (2.5) 15.4 (1.9) al previous studies on chronic SZP patients (e.g., Smith et al., 2012; for
SPF personal distress 11.9 (2.4) 11.6 (2.8) 11.8 (3.2) 9.8 (2.4)
meta-analysis see Achim et al., 2011). All three clinical groups
SPF empathy 42.8 (7.2) 40.6 (8.1) 45.3 (5.6) 45.9 (4.5)
SPF total 30.9 (7.4) 28.8 (8.7) 33.5 (5.5) 36.0 (5.3) reported higher personal distress levels than CON, mirroring prior re-
sults (e.g., Cusi et al., 2010; Achim et al., 2011). Recently, Simonsen et
Note: SPF = Saarbrückener Persönlichkeitsfragebogen by Paulus (2009) (German ver-
sion of Interpersonal Reactivity Index, IRI, Davis, 1983).
al. (2010) reported a significant discrepancy between clinician-rated
psychosocial functioning and self-report data in SZP indicating that
patients have poorer insight into their functional level than other pa-
4. Discussion tients, resulting in high self-ratings for social functioning. Based on the
observed discrepancy between significantly decreased accuracy but
This study examined disorder-specificity of emotional deficits in preserved reaction time data, unimpaired self-ratings in perspective
three groups of psychiatric patients compared to healthy controls, all taking and empathic concern, as well as findings from Simonsen et
matched for age, gender, and verbal intelligence. Emotional dysfunc- al. (2010), we speculate that SZP might not be fully aware of their se-
tions have been reported for different psychiatric conditions and vere empathic deficit which should be further explored in future
have been associated with social functioning in general. What remains studies.
unclear is how specific these dysfunctions are and how they character- Our findings of worse performance in SZP parallel those from stud-
ize certain patient groups. ies exploring neurocognitive functioning (attention, executive function,
To probe disorder-specificity of specific emotional competencies, processing speed, memory, etc.) in these patients (cf. Reichenberg et al.,
we applied three tasks measuring emotion recognition, emotional 2009; Simonsen et al., 2009, 2010; Zanelli et al., 2010; Harvey, 2011;
perspective taking, and affective responsiveness in patients diagnosed Tuulio-Henriksson et al., 2011). Those studies also showed stronger im-
with schizophrenia (SZP), bipolar disorder (BDP), or major depression pairments in SZP on all cognitive domains compared to patients with af-
(MDP) and healthy controls (CON). There were three main findings. fective disorders. These findings support the notion that schizophrenia
First, SZP presented the most severe empathy impairment followed has the most severe impact on general human abilities, including cogni-
by BDP while MDP performed similar to CON in most tasks, except tion and emotional functioning.
for affective responsiveness. Second, a significant association between
clinical characteristics and empathy performance was only apparent in 4.2. Difficulties in affective responsiveness are associated with severity
MDP while no correlations emerged for SZP and BDP. In MDP, affective indicators in MDP
responsiveness performance was significantly negatively correlated
with symptom severity as well as with duration of illness. Third, MDP seem to be characterized by a significant deficit only in affec-
self-report data indicate that particularly BDP describe themselves as tive responsiveness compared to CON, which was negatively correlated
less empathic than all other groups, reporting less empathic concern with BDI scores and illness duration. Our data did not show any associ-
and less perspective taking. These results have several implications. ation between clinical characteristics (symptom severity, age of onset,
duration of illness) and behavioral empathy in SZP and BDP, thereby
4.1. Patients with SZP show the strongest impairment in behavioral supporting previous findings (SZP: Lee et al., 2004; Brüne, 2005; BDP:
empathy performance Bora et al., 2005; Wolf et al., 2010). The affective responsiveness task
targets generation and experience of basic emotions and MDP per-
Behavioral deficits in specific empathy components, such as emo- formed better with less symptom severity. Although we observed im-
tion recognition, have been reported for all three patient groups (SZP: pairments in affective responsiveness in SZP and BDP, too, and patient
Schneider et al., 2006; Kohler et al., 2010; BDP: Derntl et al., 2009a; groups showed similar illness duration, their deficits seem less associat-
Kohler et al., 2011; MDP: Bourke et al., 2010; Kohler et al., 2011). Pre- ed with clinical characteristics and thus more state-independent. A
viously, we reported a more general emotional deficit in SZP compris- similar impact of symptom severity only in the depressed sample (com-
ing all core components (Derntl et al., 2009b) and a specific deficit in pared to BDP and SCZ) has also been shown for neurocognitive deficits
emotion recognition and affective responsiveness in BDP (Seidel et (cf. Tuulio-Henriksson et al., 2011), further supporting the notion
al., 2012). However, in these previous studies we compared patients that cognitive and socio-emotional impairments in MDP are strongly
with matched healthy controls. But only the comparison with other state-dependent.
clinical samples who are also medicated, hospitalized, and have com-
parable duration of illness' can delineate which deficits are specific for 4.3. Discrepancy between actual performance and self-report data
which disorder and what may be a general dysfunction in all major in BDP
psychiatric conditions.
Our results indicate that SZP are characterized by a pronounced In BDP we observed a more differentiated pattern. BDP showed
impairment in all empathy tasks including general face processing significantly reduced accuracy in emotion recognition and affective
and thus extend previous findings comparing facial affect recognition responsiveness compared to CON, while they performed similar to
in SZP and BDP (Addington and Addington, 1998). Notably, SZP show MDP and showed significantly better emotional perspective taking
a particular deficit in emotional perspective taking and affective re- compared to SZP. Hence, our data not only support previous findings
sponsiveness when compared to both other clinical samples. Hence, on deficient emotion recognition accuracy in BDP (e.g., Derntl et al.,
the ability to quickly infer an emotional state of another person by tak- 2009a; Hoertnagl et al., 2011), but also indicate that these patients
ing the social context and people's behavior into account (here emo- have problems putting themselves in a certain extrinsic emotional
tional perspective taking) as well as the ability to put oneself in a condition. However, the unimpaired perspective taking performance
certain extrinsic emotional condition (here affective responsiveness) indicates that BDP seem to profit from contextual information when
seem specifically dysfunctional in SZP. Interestingly, these difficulties interpreting the emotional meaning of a social situation compared
are not reflected in reaction times (see supplementary material), as to inferring emotions from facial displays only.
 B. Derntl et al. / Schizophrenia Research 142 (2012) 58–64
Analysis of self-report data revealed that all patients reported
higher distress ratings than CON, which has been reported in previous
studies (SZP: Montag et al., 2007; Smith et al., 2012; BDP: Cusi et al.,
2010, MDP: Cusi et al., 2011). Interestingly, BDP described themselves
as less empathic, reporting less empathic concern and less perspec-
tive taking. Particularly their self-reported lack of perspective taking
compared to both other patient groups stands in strong contrast
with their unaffected behavioral performance. BDP showed similar
performance as MDP and CON and outperformed SZP. In a previous
study by Simonsen et al. (2010), BDP rated their psychosocial func-
tioning worse than clinicians did and authors argue that BDP might
be more susceptible to compare themselves with unimpaired peers,
thus expecting a higher level of functioning.
Self-report data in general may provide limited access to the exact
nature and extent of empathic impairments and are subject to re-
sponse tendencies. Although important, relying on self-reports only
is not sufficient to characterize empathic abilities and deficits, thus
behavioral tasks are advantageous here (Dimaggio et al., 2008).
5. Limitations
While this study provides important new insights into disorder-
specific emotional competencies, i.e. empathic behavior, several meth-
odological constraints have to be acknowledged. The sample sizes are
small preventing, e.g. analysis of the impact of diagnostic subgroups
on empathic abilities. Particularly regarding BDP, previous data indicate
that BDP types I and II might not only differ in cognitive abilities
(Martinez-Aran et al., 2008; Simonsen et al., 2009) but also in emotional
capacities (cf. Derntl et al., 2009a). Exploratory analysis revealed no
group differences for any of the tasks (all p >.499), however, sample
sizes (BPI: n = 13, BPII: n = 11) were far too small and further studies
should address this issue in larger samples. A previous meta-analysis
also indicated that history of psychotic episodes worsens cognitive per-
formance in bipolar patients (Bora et al., 2010). While we gathered this
information in SZP and MDP patients, data from BDP were not complete
in this regard thereby preventing analysis of the impact of history of
psychotic episodes on emotional performance. Additionally, most pa-
tients were medicated and most of them were chronic patients. Howev-
er, results from a recent meta-analysis showed no significant effect of
medication on emotional experience in SZP (Cohen and Minor, 2010).
Moreover, several longitudinal studies observed no significant effect
of drug treatment on emotion deficits in SZP (e.g., Harvey et al., 2006),
thereby suggesting that socio-emotional impairments seem to be
quite independent from pharmacological treatment. A recent meta-
analysis on social cognition deficits in BDP also reports no significant as-
sociations between medication and patient-control effect size differ-
ences (Samamé et al., 2012). Contrary, previous studies in MDP show
that antidepressants normalize face emotion recognition independent
of mood state (Anderson et al., 2011), supporting the hypothesis that
antidepressants alter emotional processing rather than having direct
effects on mood (Harmer, 2010). Nevertheless, this study was not
designed to investigate the impact of medication on empathic abilities
and we cannot exclude the influence of medication on the observed
performance in our patient samples.
6. Conclusion
Notwithstanding these limitations, this study highlights that SZP
are particularly characterized by a severe impairment in emotional
perspective taking and affective responsiveness, when compared
with healthy controls and patients suffering from affective disorders
(BDP and MDP). Looking at clinical characteristics, we observed a sig-
nificant association between symptom severity, duration of illness
and performance in affective responsiveness in MDP, pointing to a
state-dependent dysfunction, while no such relation emerged for
BDP and SZP. Regarding self-report data on empathic abilities, BDP
63
rate themselves as significantly less empathic compared to SZP,
MDP, and CON thereby reflecting recent findings on a self-report
bias regarding psychosocial functioning in this clinical sample.
Taken together, this study showed that analysis of specificity of
empathic deficits helps to better characterize emotional deficits in pa-
tients suffering from severe psychiatric disorders. Moreover, our data
provide input for disorder-specific psychotherapeutic treatment. Con-
sistent with previous reports, our data clearly support the need of spe-
cific training programs to improve high-level emotional competencies
particularly in SZP going beyond emotion recognition training. In BDP,
therapists should encourage patients to correct their negative self-
evaluation as regards to empathic competencies especially by relying
on accurate perspective taking in complex social situations as a partic-
ular resource.
Role of funding source
Funding for this study was provided by the IZKF grant TVN70 to U.H. The IZKF had
no further role in study design, in the collection, analysis and interpretation of data, in
the writing of the report, and in the decision to submit the paper for publication.
Contributors
BD and UH designed the study. BD and EMS acquired the data and performed data
analysis. BD, EMS, and UH wrote the manuscript and FS helped with discussion and in-
terpretation of data. All authors approved the final version of the manuscript.
Conflict of interest
All authors declare no conflict of interest.
Acknowledgments
B.D., F.S. and U.H. were supported by the German Research Foundation (DFG: IRTG
1328; Ha3202/7-1) and authors B.D., E-M.S. and U.H. were supported by the Austrian
Science Fund (FWF: P23533). U.H. and F.S. were also supported by the Initiative and
Networking Fund of the Helmholtz Association (Helmholtz Alliance for Mental Health
in an Ageing Society).
Appendix A. Supplementary data
Supplementary data to this article can be found online at http://
dx.doi.org/10.1016/j.schres.2012.09.020.
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