Noh Mask Test for schizophreniaS. Minoshita et al.

Blackwell Science, LtdOxford, UKPCNPsychiatry and Clinical Neurosciences1323-13162005 Blackwell Science Pty LtdFebruary 2005591410Original Article

Psychiatry and Clinical Neurosciences (2005), 59, 410

Regular Article

Recognition of affect in facial expression using the Noh Mask Test: Comparison of individuals with schizophrenia and normal controls
SEIKO MINOSHITA, phd,1 NOBUAKI MORITA, md, phd,2 TOSHIYUKI YAMASHITA, phd,3 MAIKO YOSHIKAWA, md, phd,4 TADASHI KIKUCHI, phd5 AND SHINJI SATOH, md, phd2
1

Department of Psychology, Kawamura Gakuen Womans University, Abiko, Chiba, 2Graduate School of Comprehensive Human Sciences and 5Institutes of Psychology, University of Tsukuba, Tsukuba, Ibaraki, 3 Tokyo Metropolitan Institute of Technology, Graduate School of Engineering, Intelligent Systems, Hino and 4 Department of Human Studies, Faculty of Human Studies, Musashino University, Nishitokyo, Tokyo, Japan

Abstract

The purpose of the present study was to compare facial expression recognition in individuals with schizophrenia and normal controls using the Noh Mask Test. Fifteen men with schizophrenia and 15 normal controls were presented with a photograph of a Noh mask rotated either upward or downward from the neutral front-facing position, and an emotion label, and were requested to judge whether the expression of the mask was congruent with the indicated emotion. Using multidimensional scaling, the facial expression of the Noh mask recognized by the patients and the healthy controls was analyzed in 3-D: (i) RejectionAttention; (ii) PleasantUnpleasant; and (iii) AwakeningRelaxation. Individuals with schizophrenia had difculty recognizing that others had intentions of harming them. The Noh Mask Test was found to be useful in discriminating between individuals with schizophrenia and controls in the recognition of facial expression (discriminant ratio: 99.9%). discrimination test, multidimensional scaling, Noh Mask, recognition of facial expression, schizophrenia.

Key words

INTRODUCTION
In recent years, considerable research has investigated the perceptual disturbances of individuals with schizophrenia. Many studies exploring facial expression recognition in these individuals have utilized recognition tasks involving the identication of basic emotions, such as happiness, surprise, fear, sadness, disgust, and anger.16 However, the appreciation of subtle affect has been found to be more important than the recognition of these basic emotions for emotional interactions in daily living,7 and recognition of subtle affect has been found to be impaired in

Correspondence address: Dr Seiko Minoshita, Department of Psychology, Kawamura Gakuen Womans University, 1133 Sageto Abiko, Chiba 270-1138, Japan. Email: mino@os.rim.or.jp Received 29 May 2003; revised 2 June 2004; accepted 13 June 2004.

patients with schizophrenia.8 A number of studies have employed neutral facial emotion stimuli using different methodologies, including functional magnetic resonance imaging (fMRI), event-related potentials (ERP) and electroencephalography (EEG).914 The current study was designed to explore the recognition of subtle affective expression in individuals with schizophrenia. Previous studies have presented patients with line drawings or photographs of human faces, but such stimuli are not without problems.1517 Specically, when line drawings are employed, the facial expression may not realistically portray the facial expression evident on the human face. When photographs of human faces are used, personal characteristics of the models may confound the results. Such confounds include familiarity with the stimulus face and the examinees preferences for certain types of faces. The current study employed photographs of a Noh mask rotated to different angles as stimuli for

Noh Mask Test for schizophrenia

the assessment of facial expression recognition in an effort to minimize the mentioned difculties. A Noh mask is a mask worn by the leading dancer or protagonist in a Noh play, a well-known traditional Japanese performing art. These masks combine elements of the human face in typical patterns, and their expressions are considered to represent rich and diverse human emotions.18 The facial expressions of the female masks change, depending on the angle from which they are viewed. These masks are designed to express conicting emotions, in that when the face looks up, the mouth appears as a chevron, expressing unpleasantness, but when the face looks down, the mouth expresses pleasantness but the eyebrows and eyes are slanted inward to express unpleasantness. Therefore, the participants may need sophisticated judgment to handle the contradictory information imparted by the mask, in contrast to the largely consistent information evident on an actual persons face or a line drawing of a face. Given that the mechanisms involved in the recognition of the Noh mask and the human face are not known, there may be some argument as to whether they may be regarded as analogous. However, in a previous study we administered a recognition task using photographs of a Noh mask as the stimuli,19 and, via factor analysis, were able to extract factors similar to those extracted in studies that employed human facial expression as the stimuli.20 We have endeavored to create effective tools for the measurement of the cognitive aspects of facial expression in mentally challenged individuals for 10 years, with the result being the creation of a facial expression cognition test. The stimuli of the test were created by having professional photographs taken of a Noh mask from the Taisho Era (19121926). The mask was xed to a rotation stand, and the angle was changed sequentially by 1 between shots, with a full lighting system that allowed every small change in facial expression to show.19 We then analyzed the responses of healthy controls to the mask by using factor analysis, and found the features obtained in the Noh Mask Test, and then extracted the emotion labels to be used in the test to rene the method of the Noh Mask Test.21 The results of this method were then compared with ndings of the YatabeGilford personality test (YG; specically as they relate to the anger scale), and we investigated the relationship between self-feeling and facial expression recognition.22,23 We also analyzed the ambiguity of the facial expressions of the Noh mask using a fuzzy reasoning method to determine the possibility of creating tools for a cross-cultural exchange.24 As aforementioned, we examined previous analysis methods and experimental procedures.

METHODS Participants
Fifteen men with schizophrenia and 15 healthy male controls participated in the present study. Individuals in the patient group were diagnosed with chronic schizophrenia according to Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) criteria, and were being treated as inpatients or outpatients at a mental hospital when they participated in the present study.25,26 Mean age of the patient group was 33.2 years (SD = 11.0 years), mean number of years of education was 12.3 years (SD = 1.7 years), mean age at onset was 23.5 years (SD = 5.2 years), mean dose of chlorpromazine was 247.2 mg (SD = 39.3 mg), and mean Brief Psychotic Rating Scale (BPRS) rating was 11.3 (SD = 7.4). Individuals in the control group were screened for mental illness using the DSM-IV. Mean age was 31.6 years (SD = 9.7 years), and mean number of years of education was 19.3 years (SD = 2.4 years). All participants gave informed consent to participate in the study.

Apparatus and stimuli

Stimuli were presented to the participants using a computer on a 17-in cathode ray tube (CRT) against a black background. Each trial consisted of the presentation of an emotion label, followed by a xation point, and nally a photograph of the Noh mask rotated to one of 15 different angles. Twelve emotion labels, specically those factors extracted in a previous study, were used in the present study: (i) surprise; (ii) sadness; (iii) happiness; (iv) interest; (v) composure; (vi) hope; (vii) shyness; (viii) curse; (ix) absence; (x) pride; (xi) ecstasy; and (xii) uncanniness.21 Fifteen images of a Noh mask rotated from 50 downward to 48 upward from the neutral position (down50, down40, down30, down20, down10, down6, down2, front, up2, up6, up10, up20, up30, up40, and up48) were used.21

Procedure
The participants considered the photograph of a Noh mask in conjunction with the presented emotion label and judged whether the expression of the mask was congruent with the indicated emotion. Practice trials consisted of the presentation of three mask images for each emotion label, and test trials consisted of 15 mask images for each emotion label. The three mask images for the practice trials were selected from among the 15 test trial mask images. During the rst and second practice trials, two participants from the healthy control group requested elabo-

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ration of the meaning of the emotion labels, while ve participants from the patient group requested assistance with the meaning of the emotions. Also, some participants from both groups were uncertain about how to press the keys until the second practice trial. In the third practice trial, however, all the participants executed the test without hesitation. One patient had no difculty during the practice trials but discontinued the test in progress, stating, I want to stop the test because Im tired. In each trial, an emotion label was presented for 500 ms, followed by a xation point presented for 500 ms, followed by the photograph of the Noh mask, which remained on-screen until the participants made their judgment of emotionmask congruence by pressing the corresponding key. Subjects were instructed to consider the emotion label and Noh mask image presented in each trial and to press the yes key when they felt that the Noh mask image expressed the presented emotion and the no key when they felt that it did not. Each participant completed 180 trials (12 emotion labels 15 mask images). Completion of all trials took approximately 30 min for individuals in the control group and approximately 40 min for individuals in the patient group.

RESULTS Plot of the results of the two groups of Noh Mask Test
The value of SSTRESS as a 2-D solution was 0.287, while the value of SSTRESS was 0.161 when it was mapped in 3-D coordinates. We selected 3-D analysis, because SSTRESS (Stress by Youngs formula) was improved markedly and interpretation was easier. The graphs in Figs 1,2 show the plots on 2-D coordinates. Using 1-D analysis, we examined the rates of emotional afrmation of the positive high scores of controls (C) for different positions of the Noh mask (down, d; up, u): Cd50, Cd40, Sd50, and Cd30 [where the number (50, 40 etc.) refers to the angle in degrees] and the negative high scores of Cu06, Cu10, Cu02, and Cd02. We found that the afrmation rate of the positive high score image was high in Curse while that for the negative high score image was high in Interest. Thus, we named the 1-D scale as AttentionRejection. Using 2-D analysis, we examined the rates of emotional afrmation of the positive high scores of schizophrenia patients (S) for Noh mask positions of Sd30, Sd40, Sd50, and Sd10 and the negative high scores of Cu30, Cu40, Cu50, and Cu20. We found that the afrmation rates of the positive high score images were high in Composure, Hope, and Shyness while those of the negative high score images were high in Uncanniness, Surprise, Sadness, and Curse. Thus, we named the 2-D scale PleasantUnpleasant. Using 3-D analysis, we examined the rates of emotional afrmation of the positive high scores of Cd20, Cd30, Cd06, and Cd10 and the negative high scores of Su30, Su40, Su50, and Su20. We found that the afrmation rates of the positive high score images were high in Composure, Interest, Happiness, Hope, and Shyness while those of the negative high score images were high in Surprise, Ecstasy, Composure, and Uncanniness. Thus, we named the 3-D scale as AwakeningRelaxation.

Analysis method Plots for assessment of stimulative images by the multidimensional scaling method to investigate the plot of recognition of facial expression
The disparity matrix was given to route the number of all pairs of judgments concerning the 30 stimulation images by the multidimensional scaling program, alscal.27 As we analyzed the image of the Noh mask for each group by angle, the results for each item were treated as data points, therefore total data points were as high as 30 persons 12 items = 360 (apparent). The data matrix shape was symmetrical at 30 30 data items. The model option chosen was Euclid.

Differential diagnosis
The discriminate analysis was performed by entering all items (12 labels and 15 photos), seven affect labels [(i) surprise; (ii) sadness; (iii) happiness; (iv) composure; (v) shyness; (vi) absence; and (vii) uncanniness], which are basic affect labels (iiii) and have signicant differences between schizophrenia and normal controls (ivvii), and nine photographs (down40, down30, down20, down10, front, up10, up20, up30, up40), three labels [(i) surprise; (ii) sadness; (iii) happiness], which are basic affect labels, and nine photographs.

Differential diagnosis Plot of the results of two the groups of Noh Mask Test
The discriminant analysis was performed entering all items into the equation to raise the discriminant ratio to 99.9%. We are able to achieve a determinant ratio of 99.9% using a modied version of seven affect labels [(i) surprise; (ii) sadness; (iii) happiness; (iv) composure; (v) shyness; (vi) absence; and (vii) uncanniness] and nine photos (down40, down30, down20, down10, front, up10, up20, up30, up40) out of the original item

Noh Mask Test for schizophrenia

Unpleasant-Pleasant

2.0
Sd30 Sd10 Sd02 Sfront Sd20 Cd10 Su10 Cd06 Sd06 Su06 Cd02 Su02 Cfront Cu06 Cu02 Sd40 Cd20 Su30 Sd50 Cd30 Su40 Su50 Cd40 Cd50

1.0

Su20

0.0

-1.0

Cu10 Cu20 Cu40 Cu50

-2.0

Cu30

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-3.0 -2 -1 0 1 2 3 Schizophrenia(S) Control(C)

Dimension 1

Attention-Rejection

Figure 1. Multidimensional scale plots of the reaction of control group and schizophrenia group for Noh mask stimulus (dimension1, dimension2). The stimulus images were plotted in a nearly circular pattern in 2-D coordinates (mapped with the rst dimension as the X axis and the second dimension as the Y axis) in the controls, but in a semicircular pattern with the unpleasant side attened in the patients. Cu10, images presented to healthy controls with an upward angle of 10; Cd20, image presented to healthy controls with a downward angle of 20; Su30, image presented to schizophrenia patients with an upward angle of 30; Sd40, image presented to schizophrenia patients with a downward angle of 40.

set. Utilizing this reduced set of stimuli would reduce the amount of time required to complete the Noh Mask Test.

DISCUSSION Plot of the results of the two groups of Noh Mask Test
These results agree with the PleasantUnpleasant, AttentionRejection, and AwakeningRelaxation factors described in the facial expression circle model presented by Schlosberg, and are consistent with the major dimensions of emotion recognition obtained by dimensional evaluation methods in the study of facial expressions.2830

In Fig. 1, the plotted stimulative images created a nearly circular pattern using 2-D coordinates (mapped with the rst dimension as the X axis and the second dimension as the Y axis) in the controls. In contrast, the plotted images created a semicircular pattern, with the unpleasant side attened, in the patients. This suggests that patients with schizophrenia have difculty perceiving unpleasantness and attention of facial expressions on a Noh mask and tend to infer pleasantness and attention instead. In other words, patients with schizophrenia may have difculty in recognizing others ill-wishes towards them. This result may be consistent with the nding that patients with schizophrenia have difculty recognizing unpleasant emotions, which has been documented using imaging technology such as fMRI.31

S. Minoshita et al.

2.0 1.5 1.0

.5

Awakening-Relaxation

Cd20 Cd06 Cd30 Cd10 Cd40 Cd02 Cu02 Cfront Sd50 Cd50 Cu10 Cu30 Cu20 Cu40 Sd06 Cu50 Schizophrenia Control Su50 Su40 Su30 -1.0 -.5 0.0 .5 Su20 Su06 Su02 Su10 Sfront Sd02 Cu06 Sd20

Sd40 Sd30

This technique may be applied to social skill training (SST) by pointing out to individuals with schizophrenia their tendency to distort facial expressions of others, which may affect their social interactions in daily living.

Sd10

0.0 -.5 -1.0 -1.5

Differential diagnosis
In recent years, there have been many attempts to differentiate healthy controls from schizophrenia patients based on the difference in their ability to recognize facial expressions. However, no previous study was able to produce the high rate (99.9% accuracy) of classication achieved in the current study. While many studies of the recognition of facial expression have utilized photographs of human faces and line drawings, the present research used Noh masks that combine ethnic and cultural information. Unlike stimulated images, which represent emphasized or simplied humor, and which have been in the form of human photographs or line drawings in the past, Noh masks represent facial expressions that are more complicated and provide inconsistent information. The high discriminability rate achieved in the present study may be attributed to the inherent ambiguity present in Noh masks that present complicated and subtle emotions. The ambiguity of Noh masks may shed light upon the pathology of schizophrenia patients in the same manner in which projective tests, such as the Rorschach test, draw out dysfunction in individuals with mental illness. Previous ndings by the author revealed that the Rorschach test was better than any other procedure in differentiating between disease type, while the Noh Mask Test was the best predictor of employment status 4 years later. In that study, we did not utilize a forced-choice method of selecting the emotional label.35 Instead, we asked participants whether a certain facial expression looked so or did not look so. We thought that this method was useful for participants to reply yes by taking reection into account when the participants felt that a certain facial expression did not clearly look so.

Dimension 3

-2.0 -2.5

-2.0
Dimension 2

-1.5

1.0

1.5

Pleasant-Unpleasant

Figure 2. Multidimensional scale plots of the reaction of the control group and schizophrenia group for Noh mask stimulus (dimension2, dimension3). The plotted stimulative images for schizophrenia and control groups showed that those two groups were divided clearly. Cu10, image presented to healthy controls with an upward angle of 10; Cd20, image presented to healthy controls with a downward angle of 20; Su30, image presented to schizophrenia patients with an upward angle of 30; Sd40, image presented to schizophrenia patients with a downward angle of 40.

Also, the plotted stimulative images for the patient and control groups, depicted in Fig. 1, suggest that the interpretation of the facial expression varied most when the mask was facing front (i.e. not rotated upward or downward). The clues available to the participants in the present study for interpretation of expressions were the angle of inclination of the mask and protrusions and depressions of the face with consequent shadows. The inclination of the Noh mask images was not changed at even intervals in the present study; the changes were smaller near the neutral front position (up6down6) and larger in the upturned (up50up10) or down-turned (down 10 down50) positions. When the participants perceived the expressions of the Noh Mask near the front, the information from mask inclination was limited, and the protrusions and depressions of the face and resultant shadows were the only types of information available. Therefore, it could be argued that the vagueness of the stimuli was increased in this position, and that the expression of the Noh mask image became subtler. The controls perceived subtle differences from the contrast of shadows, while the patients did not perceive the subtle differences. The results of the present study also are considered to support the reports that patients with schizophrenia are poor in perceiving vague stimuli.3234

Future tasks
Given the results of the current research and the burden load on the patients, future research would be best accomplished using a shortened version of the Noh Mask Test. We plan to increase the number of participants to conrm the reliability and validity of the Noh Mask Test, and also plan to collect data for a number of other disorders. We already have conducted comparisons with a persons facial stimulative images and line drawings for the healthy controls.36 Also, comparison

Noh Mask Test for schizophrenia

with other facial stimulative images is being carried for patients with schizophrenia.

CONCLUSION
Using the Noh Mask Test, we were able to demonstrate differences in the ability to recognize facial expression in patients with schizophrenia versus controls. Three dimensions were extracted using the multidimensional scaling method. The plots of the control group and the patient group suggested that healthy participants perceived emotions such as pleasantness, attention and tension from the Noh mask images. In contrast, patients with schizophrenia perceived emotions such as unpleasantness, attention and sleep relatively frequently. The possibility of using the Noh Mask Test as a diagnostic instrument for schizophrenia is proposed.

ACKNOWLEDGMENT
This study was supported by Grant-in-Aid for Scientic Research (C) No.10835002, No.12670922 in Japan.

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