Impairment in emotion perception from body movements in individuals with bipolar I and bipolar II disorder is associated with functional capacity
Vaskinn et al. Int J Bipolar Disord
Impairment in emotion perception from body movements in individuals with bipolar I and bipolar II disorder is associated with functional capacity
Anja Vaskinn 0 1 3
Trine Vik Lagerberg 1 3
Thomas D. Bjella 1 3
Carmen Simonsen 1 2 3
Ole A. Andreassen 1 3 4
Torill Ueland 0 1 3
Kjetil Sundet 0 1 3
0 Department of Psychology, University of Oslo , P.O. Box 1094, Blindern, 0317 Oslo , Norway
1 NORMENT KG Jebsen Centre for Psychosis Research , Oslo
2 Early Intervention in Psychosis Advisory Unit, Oslo University Hospital , Oslo , Norway
3 University Hospital , Oslo , Norway
4 Department of Mental Health and Addiction, Institute of Clinical Medicine, University of Oslo , Oslo , Norway
Background: Individuals with bipolar disorder present with moderate impairments in social cognition during the euthymic state. The impairment extends to theory of mind and to the perception of emotion in faces and voices, but it is unclear if emotion perception from body movements is affected. The main aim of this study was to examine if participants with bipolar disorder perform worse than healthy control participants on a task using point-light displays of human full figures moving in a manner indicative of a basic emotion (angry, happy, sad, fearful, neutral/no emotion). A secondary research question was whether diagnostic subtypes (bipolar I, bipolar II) and history of psychosis impacted on this type of emotion perception. Finally, symptomatic, neurocognitive, and functional correlates of emotion perception from body movements were investigated. Methods: Fifty-three individuals with bipolar I (n = 29) or bipolar II (n = 24) disorder, and 84 healthy control participants were assessed for emotion perception from body movements. The bipolar group also underwent clinical, cognitive, and functional assessment. Research questions were analyzed using analyses of variance and bivariate correlations. Results: The bipolar disorder group differed significantly from healthy control participants for emotion perception from body movements (Cohen's d = 0.40). Analyses of variance yielded no effects of sex, diagnostic subtype (bipolar I, bipolar II), or history of psychosis. There was an effect of emotion, indicating that some emotions are easier to recognize. The lack of a significant group × emotion interaction effect points, however, to this being so regardless of the presence of bipolar disorder. Performance was unrelated to manic and depressive symptom load but showed significant associations with neurocognition and functional capacity. Conclusions: Individuals with bipolar disorder had a small but significant impairment in the ability to perceive emotions from body movement. The impairment was global, i.e., affecting all emotions and equally present for males and females. The impairment was associated with neurocognition and functional capacity, but not symptom load. Our findings identify pathopsychological factors underlying the functional impairment in bipolar disorder and suggest the consideration of social cognition training as part of the treatment for bipolar disorder.
Bipolar disorder; Social cognition; Emotion perception; Body language; Cognition; Psychosis; Functioning; Functional capacity
Although traditionally conceptualized as an affective
disorder, bipolar disorder (BD) is increasingly recognized as
a mental illness also characterized by cognitive
impairments. Whereas the diagnostic criteria continue to
highlight changes in mood and behavior, research shows that
individuals with BD have cognitive impairments (Bora
et al. 2009; Cardenas et al. 2016) that impact
cross-sectionally and longitudinally on function in everyday life
(Baune and Malhi 2015). The cognitive impairments are
less pronounced than in schizophrenia but present in the
same domains (Bortolato et al. 2015). Prevalence rates
of clinically relevant cognitive impairment in BD vary
across studies and domains, but exceed the rates seen in
the general population (Cullen et al. 2016).
Whereas neurocognition has been thoroughly studied,
social cognition in BD has received less attention. Social
cognition has been defined as “the mental operations that
underlie social interactions, including perceiving,
interpreting and generating responses to the intentions,
dispositions and behaviors of others” (Green et al. 2008). Social
cognition encompasses different domains (Pinkham
2014) of which emotion perception and theory of mind
(ToM, i.e., the ability to infer the intentions, dispositions,
or beliefs of others) have been the most commonly
investigated in BD. Individuals with BD present with deficits
for both domains, across illness phase, i.e., in manic,
depressed, or euthymic states (Samamé 2013). Firstly,
according to a systematic review, deficits are more
pronounced for ToM (d = 0.5–0.8) than for emotion
perception (d < 0.5), albeit significantly for both domains
(Samamé et al. 2012), in the euthymic phase. Moreover, a
meta-analysis (Bora et al. 2016) found ToM deficits to be
significantly more pronounced (d = 1.23) in acute phases
(manic or depressed mood). However, reviews and
metaanalyses show that individuals with BD perform
better than persons diagnosed with schizophrenia for both
facial emotion perception and ToM (Bora and Pantelis
2016), especially for complex ToM tasks of a more
ecological valid nature, where individuals with schizophrenia
evidence large deficits (Mitchell and Young 2014).
Within the BD population, results are mixed when it
comes to cognitive differences between diagnostic
subtypes (BD I versus BD II) and the effect of history of
psychosis on cognition (Lewandowski et al. 2011). For
example, in our previous research, we found
neurocognitive performance to depend on history of psychosis, not
diagnostic subtype, in individuals with established BD
I or II disorder (Simonsen et al. 2011), but detected no
neurocognitive differences between psychotic and
nonpsychotic subgroups with first-treatment BD I (Demmo
et al. 2016). For social cognition, there are also divergent
findings. Some studies find worse performance in BD I
compared to BD II (Lembke and Ketter 2002; Derntl et al.
2009); others find similar performance (Martino et al.
2011). A meta-analysis of ToM (Bora et al. 2016) found
the same magnitude of impairment for BD I as for the
whole BD spectrum, as well as a non-significant,
trendlevel association between history of psychosis and ToM
performance. This unresolved issue is probably due to the
large heterogeneity within the BD population, as well as
in study samples.
A key factor related to daily social function is the
perception of emotions in other people. We communicate
emotions by the way we move and talk; and therefore also
perceive emotions in different modalities. Visual
emotion signals can be conveyed in facial expressions (facial
emotion perception) or body movement (body language),
whereas auditory signals are expressed through
prosodic information in vocal expressions (auditory
emotion perception). Most studies have used pictures of faces
expressing one of the six basic emotions to assess
emotion perception. Persons with BD have a moderate deficit
in facial emotion perception (Kohler et al. 2011).
Findings for auditory emotion perception have been mixed.
Some studies have found intact auditory emotion
perception for BD I (Vaskinn et al. 2007; Hoertnagel et al.
2015), whereas others have found limited impairments
for some emotions for either females (Bozikas et al. 2007)
or males (van Reenen and Rossell 2013) with the
disorder. To the best of our knowledge, there are no studies
of emotion perception from body movement in
individuals with BD. This can be assessed with so-called
pointlight displays (PLD). In PLD tasks (Johansson 1973) a
light is connected to different parts of the human body,
or the face, while the person is filmed when moving in
a dark room. Perceivers are able to infer sex (Kozlowski
and Cutting 1977), personality traits (Gunns et al. 2001),
and emotions (Heberlein et al. 2004) from PLDs. We have
previously shown that individuals with schizophrenia,
regardless of sex, have a global deficit in the perception
of emotions from body movement (Vaskinn et al. 2016),
in line with other studies (Couture et al. 2010; Kern et al.
2013; Okruszek et al. 2015).
Being able to detect the emotional state of others has
adaptive interpersonal value. Because BD is
associated with social functional impairments (Simon 2003;
Sanchez-Moreno et al. 2009), it is of interest to
investigate if individuals with the illness have difficulties
detecting emotions from body movements, and if this is related
to functioning. Only a few studies have investigated the
relationship between social cognition and functioning in
BD. One of these found larger social cognition deficits
in a low-functioning compared to a higher functioning
group (Lahera et al. 2012). In another study,
social/emotional processing predicted functional capacity, i.e., the
ability to perform functional tasks in the test laboratory
(Thaler et al. 2014).
In the current study, we have three research aims. Our
first research question relates to whether individuals
with BD have impairments in emotion perception from
body movement (or body language). We investigate
casecontrol differences for overall body language reading, for
body language reading of specific emotions, and if sex
differences are present. We expect that the BD group
will perform significantly worse than the HC group, but
anticipate no sex differences based on our previous
findings using the same test (Vaskinn et al. 2016). In our
second research aim, we investigate if there are differences
between participants with BD I and BD II, and if history
of psychosis is associated with body language reading
performance. Based on the mixed results in the
cognitive literature, we make no hypotheses for this research
aim. The third research aim is to investigate
symptomatic, neurocognitive, and functional correlates of body
language reading performance in participants with BD.
Participants at our research center are only partly and
only mildly symptomatic, and therefore no associations
with symptom load are expected. Because cognition has
been shown to be associated with functional outcome in
bipolar disorder, we predict significant relations between
body language reading and measures of functioning.
Design and participants
This cross-sectional study was conducted as part of the
Thematically Organized Psychosis (TOP) study at the
KG Jebsen NORMENT Centre for Psychosis Research
at the University of Oslo, Norway, from 2013 to 2015.
Individuals with DSM-IV BD I or BD II disorder as well
as HC were included. All participants had an IQ ≥ 70 as
assessed with the Wechsler Abbreviated Scale of
Intelligence (WASI) (Wechsler 2007). The clinical group was
recruited from inpatient and outpatient units at hospitals
in the greater Oslo area and assessed in a clinically stable
state. Diagnostic assessments were undertaken by trained
clinicians using the SCID interview (First et al. 1995). HC
were randomly selected from national statistical records
and invited to participation by letter. Before inclusion,
HC were screened for symptoms of severe mental illness
using the Primary Care Evaluation of Mental Disorders
interview (PRIME-MD: Spitzer et al. 1994) and excluded
from the study if mental, neurological, or somatic
disorder was confirmed or suspected. The study has been
approved by the Regional Committee for Medical
Research Ethics and the Norwegian Data Inspectorate.
All participants signed informed consent after receiving
oral and written information.
Global symptoms were assessed with the Global
Assessment of Functioning-Split version (Pedersen et al. 2007),
symptoms subscale. Depressive symptoms were
measured with the Inventory of Depressive Symptomatology
(IDS-C: Rush et al. 1996) and manic symptoms were
assessed with the Young Mania Rating Scale (YMRS:
Young et al. 1978). The mean depression score of 16.3
(SD = 10.1) indicates mild depression, whereas the
mean mania score of 2.4 (SD = 3.9) indicates a normal
(non-manic state). 43% (n = 23) of the sample was fully
euthymic at the time of testing (IDS-C ≤ 12; YMRS < 8:
Tohen et al. 2009). The defined daily dose (DDD) is the
“assumed average maintenance dose per day for a
psychopharmacological drug used for its main indication
in adults” (World Health Organization 2016). The DDD
for antipsychotic, antiepileptic, and antidepressant
treatment, as well as for lithium treatment was calculated.
Assessment of emotion perception
Body language reading ability was assessed using human
full-figure PLDs. We used Heberlein et al. (2004)
stimuli, as adapted by Couture et al. (2010), but with
Norwegian norms (Vaskinn et al. 2016). This test has been
referred to as Emotional Biological Motion, or EmoBio,
and consists of 22 short clips of PLD walkers. The clips
were shown on a computer screen, and participants
indicated on a piece of paper which emotion was depicted by
ticking the preferred alternative. Emotions were angry,
happy, sad, fearful, or neutral/no emotion. The standard
proportional scoring method was utilized: each response
is given credit based on the proportion of healthy control
participants giving that response. If 60% of healthy
control participants say “happy,” 25% say “sad,” and 15% say
“neutral,” a “happy” response is scored 1 (60/60), a “sad”
response is scored 0.42 (25/60), and a “neutral” response
is scored 0.25 (15/60). This scoring method accepts a
certain degree of variability as normal. Both the overall total
EmoBio score as well as the EmoBio scores for each of
the five emotion categories are used in the current study.
Assessment of cognition
All participants underwent assessments with a battery
consisting of neuropsychological and social cognitive
tests. Current IQ was measured with the 2-test WASI
(Wechsler 2007). Neurocognition was measured with the
MATRICS Consensus Cognitive Battery (MCCB;
Nuechterlein et al. 2009; Mohn et al. 2012). The MCCB includes
the following neuropsychological tests (domain assessed
in parentheses): Trail Making Test A, BACS Symbol
Coding and Category Fluency (speed of processing), Spatial
Span and Letter Number Span (working memory), NAB
Mazes (reasoning and problem-solving), CPT-IP
(attention), Hopkins Verbal Learning Test and Brief Visual
Memory Test (learning and memory). The MCCB social
cognition subtest was excluded because we wanted to
use the MCCB as a measure of non-social cognition. The
test battery was administered by clinical psychologists
trained by specialists in clinical neuropsychology.
Global functioning was assessed with the Global
Assessment of Functioning-Split version (Pedersen et al. 2007),
function subscale. Self-reported social functioning was
measured with the Social Functioning Scale (Birchwood
et al. 1990) which was developed for schizophrenia, but
has been shown to be suitable for use in BD research
(Hellvin et al. 2010). Functional capacity was assessed
with the University of California San Diego
Performance-Based Skills Assessment, brief version (UPSA-B;
Mausbach et al. 2007). This is a role-play test where the
participant is presented with props and asked to solve
everyday tasks. Two modules are administered:
Financial Skills where tasks include counting change and
paying bills, and Communication Skills where a telephone
is used to call for help in an emergency and to change a
doctor’s appointment. The UPSA-B has been adapted
to Norwegian conditions and approved by the original
developers. In the Communication Skills domain, a check
is used in the original version. As checks are no longer
used in Norway, this was exchanged with an invoice.
Further, Norwegian currency and telephone numbers were
Analyses were done using The Statistical Package for the
Social Sciences (IBM SPSS Statistics for Windows,
Version 22.0, IBM Corp, Armonk, NY). Normality of
distributed scores was investigated through histograms
and skewness indices. All EmoBio measures had
negative skewness values with scores clustering at the high
end. The Kolmogorov–Smirnov statistic was
significant (p < 0.001) for all measures. The EmoBio data were
therefore reflected and transformed (log10). An initial
univariate analysis of variance ANOVA looked at
overall case-control differences for the total EmoBio score.
Thereafter, a 2 × 2 × 5 repeated measures ANOVA (or
mixed between within-subjects ANOVA) of the effect
of diagnostic group (HC/BD) and sex (male/female) on
body language reading was conducted. The 5 EmoBio
scores (angry, happy, sad, fearful, neutral) were entered
as dependent variables (within-subjects factor).
Diagnostic group (HC/BD) and sex (male or female) were
the between-subject factors. The impact of history of
psychosis and diagnostic subtype (BD I or BD II) on body
language reading within the BD sample was examined
with a univariate ANOVA with EmoBio total (log
transformed) entered as the dependent variable, and history of
psychosis and diagnostic subtype as fixed factors.
Associations between body language reading and symptoms
(YMRS, IDS-C, and GAF-s), neurocognition (MCCB),
and functioning (GAF-f, SFS, UPSA-B) were investigated
using bivariate correlations (Pearson’s r). The effect of
psychopharmacological treatment on emotion
perception from body movements was examined by conducting
bivariate correlations (Pearson’s r) between EmoBio total
(log-transformed) and DDD of the compound in
question, in participants who used it.
Fifty-three individuals with DSM-IV BD I (n = 29)
or BD II (n = 24) disorder were included, along with
84 HC whose EmoBio data were also used in a
previous paper (Vaskinn et al. 2016). Within the BD sample,
27 participants had a history of psychosis (BD I n = 24;
BD II n = 3), whereas 26 (BD I n = 5; BD II n = 21) had
never experienced psychotic symptoms. See Table 1 for
Table 1 Demographics in participants with bipolar
disorder (BD) and healthy participants (HC), and clinical
features in participants with bipolar disorder (BD)
Mean (SD) Value
Table 2 Scores on the body language reading test (point-light walkers) in participants with bipolar disorder (BD)
and healthy participants (HC) across sex
EmoBio: Emotional Biological Motion
demographic and clinical information. Results on the
EmoBio test are shown in Table 2.
There was a small, but significant difference between
HC and BD participants for the total EmoBio score
(F(1,136) = 4.85, p = 0.029, η2 = 0.03). The Levene test
statistic (4.61, p = 0.034) indicated unequal variances
across groups, but the robust Welch test for equality of
means still yielded a statistically significant group
difference (4.16, p = 0.045). The effect size (Cohen’s d) using
the pooled standard deviation was 0.40. Significant group
differences were seen in the sex distribution and for
intellectual abilities. The diagnostic group difference in
EmoBio performance remained significant after controlling
for sex as a covariate, and sex was therefore kept as a
separate independent variable in the subsequent analysis.
Subtle reductions in IQ are an attribute of BD (Cardenas
et al. 2016) and do not appear by chance due to our study
design. We therefore refrained from controlling for IQ
(Dennis et al. 2009).
In the repeated measures ANOVA across the five
emotions, the main between-subject effect of diagnostic group
was significant (F(1,133) = 5.06, p = 0.026, η2 = 0.04), with
participants with BD performing significantly worse
than HC, corroborating the results of the first ANOVA
for the total score. Further, the main within-subject
effect of emotion was significant (F(4,130) = 12.38, Wilk’s
Lambda = 0.72, p < 0.001, η2 = 0.28), indicating that
performance differed across emotion. This is shown in Fig. 1
where the performance of the two groups (HC and BD)
is depicted. The group × emotion interaction effect was
non-significant (F(4,130) = 1.23, Wilk’s Lambda = 0.96,
p = 0.300, η2 = 0.04), reflected in the similar profile
shape of body language reading performance for HC and
BD participants in Fig. 1. In other words, individuals with
BD are not disproportionally impaired on any one
emotion compared to HC. Neither the main between-subject
Angry Happy Sad Fearful Neutral
Fig. 1 Scores on the body language reading test of sad, fearful,
happy, angry, and neutral point-light walkers in participants with
bipolar disorder (BD) and healthy participants (HC). Result
summary: Individuals with bipolar disorder had a small, but statistically
significant impairment in the ability to perceive emotions from body
movement. The impairment was global and affected all emotions to
the same extent. Error bars correspond to standard deviations for the
effect of sex (F(1,133) = 1.77, p = 0.186, η2 = 0.01) nor any
of the other interaction effects were significant.
The univariate ANOVA within the BD sample yielded
no significant effect of history of psychosis (F(1,49) = 0.30,
p = 0.588, η2 = 0.01) or diagnostic subtype (F(1,49) = 0.05,
p = 0.826, η2 < 0.001) on body language reading
Bivariate associations between body language reading
and measures of symptoms, neurocognition and
functioning in participants with BD were mostly small and
non-significant (see Table 3). There were two exceptions.
Table 3 Bivariate associations (Pearson’s r) between study
variables in individuals with bipolar disorder (n = 53)
a n = 48, b n = 51, c n = 52
EmoBio was moderately associated with neurocognition
(MCCB, r = 0.33), and strongly associated with
functional capacity (UPSA-BN, r = 0.48).
All bivariate associations between dosage of
psychopharmacological treatment and emotion perception from
body movements were non-significant (antipsychotics
r(n = 28) = 0.19, p = 0.335; antiepileptics r(n = 12) = −0.50,
p = 0.099; lithium r(n = 16) = −0.28, p = 0.303;
antidepressants r(n = 11) = 0.46, p = 0.159).
In this study, we found that persons with BD have a small,
but significant impairment in the ability to perceive
emotions from body movement assessed with PLDs. This
impairment was of a global nature, affecting all emotions
to the same degree, and did not depend on participant
sex. Further, the impairment was of a similar magnitude
for individuals with BD I compared to those with BD II
and was not impacted by having experienced psychotic
The degree of impairment for this type of body
language reading is, although present, not as severe as
the one seen for schizophrenia. In our previous work
(Vaskinn et al. 2016), persons with schizophrenia
presented with a larger impairment compared to HC
(Cohen’s d = 0.73) compared to an effect size of 0.40 in
the current BD sample. This aligns with what we know
about the neurocognitive and social cognitive
performance in BD: it is intermediate between HC and
individuals with schizophrenia (Bortolato et al. 2015; Bora and
The magnitude of the impairment also aligns with the
literature on social cognitive performance in different
domains in BD. The performance level is the same as
found for emotion perception using other types of stimuli
during the euthymic phase in BD (d < 0.5: Samamé et al.
2012), but smaller than the deficit found for ToM tasks
(d = 0.5–0.8: Samamé et al. 2012). The stimuli used in
this study are simple, devoid of context and any
information besides the emotional information of moving dots.
It differs from stimuli of ToM tests where complex
interpretation of the mental state (intentions, wishes, desires)
of others is required. Task demand is therefore less, and
the better performance compared to performance on
ToM tasks is expected. It should also be noted that since
there is heterogeneity within our BD sample, as seen in
the standard deviations for the emotion perception task
(see Table 2; Fig. 1), some individuals with BD have intact
Our sample as a whole is probably best characterized
as mildly symptomatic, since less than half of the
sample (43%) were euthymic according to standard criteria
(Tohen et al. 2009). Body language reading performance
was, however, not associated with global, depressive, or
manic symptoms. This finding supports the notion that
social cognitive impairment is a trait characteristic of
the illness. This does not preclude that performance can
be negatively affected by more severe levels of
ongoing symptomatology. Studies of body language
reading from PLDs in major depressive disorder (MDD)
have given results in line with the idea of the “negative
bias” of depression. Loi et al. (2013) found that
currently depressed individuals had lower recognition rates
of happy stimuli compared to individuals in remission
from depression and HC, whereas Kaletsch et al. (2014)
showed that individuals with MDD rated PLD scenes of
human interactions more negatively than did HC. We
cannot rule out that similar results will appear in studies
of BD samples assessed during a mood episode. An
investigation of this issue requires a different study design and
is outside the scope of this article.
Another issue concerning clinical state is the
association between psychopharmacological treatment and
emotion perception performance. Although none of
the associations were statistically significant, the sizes
of the correlation coefficients suggest a strong
relationship for antiepileptic and antidepressant medication
(r = −0.50 and 0.46, respectively). The lack of
statistical significance is probably due to the small sample. We
do not find it likely, however, that our overall finding of
impaired emotion perception in BD is due to the use of
medication. These associations appear in the small
subsample who received this type of psychopharmacological
treatment, corresponding to approximately 20% of the
BD sample (12 and 11 participants for antiepileptic and
antidepressant medication, respectively). Although it is
possible that social cognition performance is affected by
psychopharmacological treatment, it is not likely that it
causes the observed impairments in BD reported in the
literature (Samamé et al. 2012; Bora et al. 2016). A proper
examination of this research question requires a larger
As expected, the performance on this social cognitive
test was, using Cohen’s rules of thumb for interpretation
of the strength of correlation coefficients, moderately
and statistically significantly associated with
neurocognition (performance on the MCCB battery). Others have
also found that neurocognition and social cognition are
related in BD (van Reenen et al. 2014). Although social
cognition and neurocognition are considered to be two
different constructs, they are related (Green et al. 2015).
They encompass similar cognitive processes, but differ
in the type of stimuli (social or non-social). Statistical
modeling in different datasets has found that a separation
between neurocognition and social cognition fit the data
best (Allen et al. 2007; Bell et al. 2009). Further,
neurocognition and social cognition are dependent on partly
separable neural substrates (van Overwalle 2009).
Therefore, neither of these cognitive domains can be reduced
to the other.
Among the functional measures, emotional body
language reading had small and non-significant associations
with global functioning and self-reported social
functioning. However, the association with functioning as
assessed with a role-play task, functional capacity, was
large and statistically significant. This is the same task
that was predicted by an empirically derived
social/emotional processing factor in a previous study of psychotic
BD (Thaler et al. 2014). Our results both align and
differ from the results of that study. Both studies are
consistent with the hypothesis that social cognition predicts
functioning in BD. Thaler et al. (2014) social cognition
factor included complex stimuli, whereas the current
study extends those findings by showing that even basic
social cognition is associated with functioning. Further,
whereas Thaler et al. (2014) only found this relationship
in psychotic BD, our findings imply that this could be the
case in the BD sample as a whole. Our results
corroborate the findings of Lahera et al. (2012) that social
cognition differentiates between low- and high-functioning
individuals with BD. Our results suggest that even small
emotion perception impairments can have negative
functional consequences for individuals with BD. Taken
together, these studies provide accumulating evidence
that impaired social cognition is associated with worse
functioning in BD.
Our findings are in line with an understanding of
emotion perception impairment as a trait characteristic of
BD. Emotions are important social signals, and their
misinterpretation can have negative consequences for
interpersonal functioning. As this can be expected to increase
subjective feelings of stress and social rejection, emotion
perception impairment could impact on the course of
the illness by conferring risk for developing new
affective episodes. Similarly, emotion perception impairment
could be an endophenotype of BD, preceding the onset
of illness (McKinnon et al. 2013). Studies that have found
reduced emotion perception in first-degree healthy
relatives of persons with BD (see for instance Seidel et al.
2012) support such a view. One could therefore speculate
that emotion perception impairment is a vulnerability
factor for developing BD in unaffected individuals, and
for developing new affective episodes in individuals with
Limitations of the study include the lack of a direct
assessment of real-life functioning. Although our
functional capacity measure, the UPSA-B, has ecological
validity in the sense that it assesses real-world behavior,
it is still administered in the test laboratory. Also, in
statistical modeling of the path to functional outcome in
schizophrenia, this measure behaves more like a
measure of ability, with close connections to social cognition,
than as a measure of functional outcome (Green et al.
2012). This could also be the case for BD. A truly
ecological measure of functional outcome would require a
different approach, such as video-ethnography where the
person is video-taped in real life (Bromley et al. 2012).
Another limitation is the current mood state of our
sample. Our research design requires participants to be able
to undergo our assessments, i.e., they are clinically stable.
Testability does not, however, necessarily correspond to
being in a euthymic state. Therefore, our sample is only
partly euthymic. Thus, our research design does not
enable a thorough investigation of the association between
mood state and emotion perception. A further limitation
is the sample size. Other results may appear with larger
samples, for example for BD subgroupings.
In summary, we found a global impairment in the
ability of individuals with BD to perceive emotions from
bodily movement. The impairment was strongly
associated with functional capacity. Our study implies that the
perception of others’ emotions should be made part of
clinical interventions and confirms a role for social
cognition training in the treatment of BD (Lahera et al. 2013).
AV designed the study, adopted the primary measure to Norwegian,
undertook the statistical analyses, and wrote the first draft of the paper. TVL
contributed to drafting the initial version of the manuscript and helped conceive
the study design. TDB aided in statistical analyses. CS, OAA, TU, KS contributed
to study design and to data collection. All authors have critically revised the
manuscript for important intellectual content and approved the final version
of the article. All authors read and approved the final manuscript.
The authors are grateful for the contribution of all participants and for the help
of the clinical and research personnel at the KG Jebsen NORMENT Centre for
Psychosis Research, especially Ibrahim Akkouh, Eivind Bakken, Line Gundersen,
Seyran Khalili, and Ragnhild B. Storli. The authors thank Tiril Østefjells for kind
assistance with figure design.
AV, TVL, TDB, CS, TU, and KS declare that they have no competing interests.
OAA has received speaker honorarium from Lundbeck, GSK, and Otsuka.
Ethics approval and consent to participate
The study was approved by Norway’s Regional Ethics Committee South
East (REC South East) and is completed in accordance with the Helsinki
This work was supported by the Research Council of Norway (Grant No.
223273), the South East Norway Regional Health Authority (Grant No. 201007
to AV and Grant No. 2013123), the KG Jebsen Foundation, the Fulbright
Foundation for Educational Exchange (to AV), and the Department of Psychology,
University of Oslo (to AV).
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