Acta Psychiatr Scand 2007: 116: 263270 All rights reserved DOI: 10.1111/j.1600-0447.2007.00991.

Copyright 2007 The Authors Journal Compilation 2007 Blackwell Munksgaard

ACTA PSYCHIATRICA SCANDINAVICA

The eect of gender on emotion perception in schizophrenia and bipolar disorder

Vaskinn A, Sundet K, Friis S, Simonsen C, Birkens AB, Engh JA, Jonsdottir H, Ringen PA, Opjordsmoen S, Andreassen OA. The eect of gender on emotion perception in schizophrenia and bipolar disorder. Objective: Impaired emotion perception is documented for schizophrenia, but ndings have been mixed for bipolar disorder. In healthy samples females perform better than males. This study compared emotion perception in schizophrenia and bipolar disorder and investigated the eects of gender. Method: Visual (facial pictures) and auditory (sentences) emotional stimuli were presented for identication and discrimination in groups of participants with schizophrenia, bipolar disorder and healthy controls. Results: Visual emotion perception was unimpaired in both clinical groups, but the schizophrenia sample showed reduced auditory emotion perception. Healthy males and male schizophrenia subjects performed worse than their female counterparts, whereas there were no gender dierences within the bipolar group. Conclusion: A disease-specic auditory emotion processing decit was conrmed in schizophrenia, especially for males. Participants with bipolar disorder performed unimpaired.

A. Vaskinn1,2, K. Sundet3, S. Friis1,2, C. Simonsen2,3, A. B. Birkens1,2, J. A. Engh1,2, H. Jnsdttir1,2, P. A. Ringen1,2, S. Opjordsmoen1,2, O. A. Andreassen1,2
Institute of Psychiatry, University of Oslo, Norway, Division of Psychiatry, Ullevl University Hospital, Norway and 3Institute of Psychology, University of Oslo, Norway
2 1

Key words: schizophrenia; bipolar disorder; emotion perception; gender Anja Vaskinn, Division of Psychiatry, Psychosis Research Section TOP, Ullevl University Hospital, building 49, 0407 Oslo, Norway. E-mail: anja.vaskinn@medisin.uio.no

Accepted for publication December 18, 2006

Significant outcomes:

Bipolar disorder was not characterized by emotion perception decits, and schizophrenia had intact visual, but impaired auditory emotion perception. Females performed better than males on emotion perception tests. This held true both for participants with schizophrenia and for healthy controls. When communicating with people with schizophrenia, especially men, clinicians should strive to express emotions in a clear and unambiguous manner.
Limitations:

The number of participants was small, especially in the bipolar group. The study did not include non-emotional control tasks. The effect of medication on emotion perception could not be investigated.

Introduction

Several investigators have reported emotion recognition impairments in schizophrenia as reviewed by Mandal and coworkers (1) and Kohler and Brennan (2). The general conclusion has been that people with schizophrenia do not decode universally recognizable facial emotions as well as healthy controls. Less is known about emotion perception

in bipolar disorder (3). Lembke and Ketter (4) found that subjects with mania performed worse than healthy subjects on recognition of disgusted and fearful faces. Results from the euthymic phase are not consistent. Venn et al. (5) compared subjects with bipolar disorder in a euthymic phase and normal controls and found no signicant dierences, whereas Harmer and colleagues (6) reported enhanced recognition of disgusted 263

Vaskinn et al. facial expressions in the euthymic bipolar group compared with healthy controls. In a study comparing the two disorders, Addington and Addington (7) showed that schizophrenia participants performed worse than both normal controls and participants with bipolar disorder for facial aect recognition, but that even the bipolar group had a decit for facial aect discrimination compared with normal controls. Bellack et al. (8) found no dierences in emotion perception abilities between subjects with schizophrenia, schizoaective disorder and bipolar disorder. Research on emotion perception in healthy normal samples acknowledges an eect of gender, with females performing better than males in both detecting and expressing emotions (9, 10). Few studies have looked at gender dierences in emotion perception in psychiatric samples. Scholten et al. (11) found that for negative facial aect recognition, women performed better than men. They also showed that the control group performed better than schizophrenia subjects, regardless of gender, but with the largest decit seen for males. Bozikas et al. (12) examined perception of aective prosody in participants with schizophrenia and healthy controls. They found that decits were most prevalent in men with schizophrenia.
Aims of the study

It remains unclear whether the emotion perception decit in schizophrenia is disease-specic, or a general characteristic of major mental disorders, and how gender and diagnosis interact in emotion perception. The primary aim of our study was to investigate visual and auditory emotion perception in schizophrenia and bipolar disorder. Secondly, we wanted to examine whether males with either schizophrenia or bipolar disorder have greater emotion perception decits compared with their female counterparts.

group on gender, age and education were recruited to the current control sample. All participants signed informed consent, and the Regional Committee for Medical Research Ethics and the Norwegian Data Inspectorate approved the study. Tests of premorbid IQ (a Norwegian research version of the National Adult Reading Test, NART; 13) and current IQ (Wechsler Abbreviated Scale of Intelligence, WASI; 14) were administered. The Structured Clinical Interview for DSM-IV Axis I disorders, SCID (15), the Global Assessment of Functioning, GAF (Split DSM-IV version; 16) and symptom ratings were administered to the two clinical groups. Psychotic symptoms were rated with the Positive and Negative Syndrome Scale, PANSS (17), and aective symptoms with Young Mania Rating Scale, YMRS (18) and Inventory of Depressive Symptomatology, IDS-C (19). The interrater reliability of the investigators (trained psychiatrists) was good, for the GAF corresponding to an intraclass classication (20) of 0.86, and for the diagnostic categories the overall agreement was 88% with a Kappa of 0.77 (95% CI: 0.60 0.94). Exclusion criteria were traumatic brain injury or neurological disease, IQ below 70 and age below 18 or above 55. Control participants with use/abuse of illicit drugs during the last 3 months, a history of medical and/or psychiatric problems, or severe mental disorder in close relatives were also excluded. In the clinical groups, individuals with a score 6 on any positive subscale item on the PANSS were excluded in order to recruit subjects who were not severely psychotic, as this is expected to interfere with test performance. Only subjects with YMRS scores < 12 and IDS-C scores < 30 were included.
Measures of emotion perception

Material and methods Participants

Eighty-three Caucasian subjects participating in the Norwegian TOP (Thematic Organized Psycho sis Research) study at Ulleval University Hospital in Oslo were included: 31 with schizophrenia, 21 with bipolar I disorder (DSM-IV diagnoses) and 31 healthy controls. The TOP control group was randomly selected from ocial population records for Oslo and Akershus counties and invited through letters to participate. From this larger control sample persons matching the schizophrenia 264

We used the Face/Voice Emotion Identication and Discrimination Test developed by Kerr and Neale (21), which has been shown to be a valid and sensitive measure of the ability to perceive human emotion (22, 23). The Face Emotion test was constructed from photographs developed by Izard (24) and Ekman (25). The pictures show Caucasians posing one of six dierent emotions: happiness, surprise, shame, anger, fear or sadness. In the identication subtest (Face ID) the subject is shown 19 pictures and instructed to tick the column for one of the six alternative emotions. In the discrimination subtest (Face DM) two pictures are shown at the same time, and the subject is asked to state whether the people in the two pictures are expressing the same emotion or not.

Emotion perception in major mental disorder There are 30 picture pairs, of which eight show identical emotions. The Face tests were kept in their original English version, as the posers have the same ethnicity as our Norwegian study sample. The Voice Emotion test has the same structure with one identication task and one discrimination task. In the identication task (Voice ID) the subject listens to one of four short sentences. These are read aloud by an actor expressing one of the same six emotions as in the Face Emotion tests, and the subject is asked to indicate which emotion is being expressed. In the discrimination task (Voice DM) sentences are paired together. The participant hears two sentences, one after the other, and is asked whether or not they express the same emotion. In some instances, these two sentences have identical verbal content. The English sentences were translated directly into Norwegian or, when necessary for keeping the same length as in the original sentences, slightly adapted. The Norwegian version of the Voice ID test consists of 21 items, with emotions distributed in the following manner: anger (four), surprise (ve), happiness (ve), sadness (three), shame (two) and fear (two). The Voice DM has 22 sentence pairs, of which six express identical emotions: anger (two), surprise, happiness, sadness and fear.
Statistical analyses

the four emotion perception measures with diagnostic group and gender as between-subjects factors, and with WASI IQ and age as covariates. When relevant, post-hoc comparisons (one-way univariate ancovas with WASI IQ and age as covariates) were performed in order to decide which of the diagnostic and gender groups diered from each other. Finally, the relationship between emotion perception and clinical variables (illness duration as well as psychotic symptoms for the schizophrenia group and aective symptoms for the bipolar group) was examined with Pearson correlations. Because of the small clinical samples, the relationship between dierent types of medication use and emotion perception was not analyzed.
Results

The Statistical Package for the Social Sciences (spss for Windows, version 12.0; SPSS Inc., Chicago, IL, USA) was used. A multivariate repeated measure analysis of covariance (mancova) was conducted with the four emotion scores as the dependent variables grouped according to modality (visual vs. auditory) and presentation format (discrimination vs. identication) with group (schizophrenia vs. bipolar disorder vs. healthy controls) and gender as the between-subjects factors, and with WASI IQ and age as covariates. The mancova was followed up by multiple twoway analyses of covariance (ancovas) for each of

Demographic data are presented in Table 1. The bipolar group was signicantly older than the other two groups, and the control group had signicantly higher IQ than the schizophrenia group. This was controlled for by ancova when studying group dierences in emotion perception. There were no group dierences on length of education or premorbid IQ. Clinical characteristics are shown in Table 2. Illness duration was longer for the bipolar group than the schizophrenia group, corresponding to the older mean age of bipolar subjects. As expected from the clinical picture, the schizophrenia group had impaired functional capacity (GAF) and increased psychotic symptom load (PANSS) compared with the bipolar group. There were no signicant group dierences for aective symptoms. Two subjects in each clinical group used rst generation antipsychotic medication. All but one of the schizophrenia subjects and close to half the bipolar group used second generation antipsychotics. Three individuals with schizophrenia were using clonazepam in addition to second generation antipsychotic medication. Approximately a third in

Table 1. Demographic data for groups of subjects with schizophrenia or bipolar disorder compared with healthy control subjects Schizophrenia, (n 31) Mean (SD) Bipolar, (n 21) Mean (SD) Controls, (n 31) Mean (SD)

F
ANOVA

P-value (d.f. 2, 80) 0.016 0.070 0.356 0.005 P-value 0.614

Scheffe

Age (years) Education (years) NART (errors) WASI total IQ Gender (male/female)

31.3 12.7 17.0 106.5 20/11

(9.5) (2.3) (7.2) (11.5)

38.1 14.1 14.0 107.8 11/10

(9.3) (2.4) (8.1) (7.8)

30.7 13.7 15.3 114.1 20/11

(9.6) (2.0) (7.7) (8.0)

4.34 2.75 1.05 5.70 v2 (d.f. 2, n 83) 0.98

S, C < B n.s. n.s. S<C

IQ, intelligence quotient; NART, Norwegian research version of the National Adult Reading Test; WASI, Wechsler Abbreviated Scale of Intelligence.

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Table 2. Clinical characteristics in groups of subjects with schizophrenia or bipolar disorder
ANOVA

Schizophrenia Mean (SD) Duration of illness (years) GAF-s GAF-f PANSS Positive Negative General YMRS IDS-C 6.1 (5.1) 46.5 (11.0) 48.1 (10.4) 12.0 15.1 28.1 3.2 13.2 (3.7) (5.6) (5.9) (3.0) (9.0)

Bipolar Mean (SD) 11.5 (10.9) 64.6 (12.9) 61.5 (14.0) 9.3 9.1 23.6 2.8 10.1 (2.9) (2.2) (5.2) (3.7) (7.6)

(d.f. 1,50) F 5.66 29.76 15.92 7.89 21.64 7.87 0.45 2.15 P-value 0.021 < 0.001 < 0.001 0.007 < 0.001 0.007 0.505 0.149 n (%)

n (%) Medication First generation antipsychotics Second generation antipsychotics Mood stabilizers Antidepressants

2 30 3 10

(6.5) (96.8) (9.7) (33.3)

2 (9.1) 10 (45.5) 15 (71.4) 5 (23.8)

GAF, Global Assessment of Functioning; IDS-C, Inventory of Depressive Symptomatology; PANSS, Positive and Negative Syndrome Scale; YMRS, Young Mania Rating Scale.

each group was taking antidepressants, whereas the majority of the bipolar subjects were taking mood stabilizers. The emotion perception performance of the three groups according to gender is reported in Table 3. When controlling for IQ and age, the main eect of presentation format (F 9.53; d.f. 1,75; P 0.003) and the interaction eect of modality presentation format (F 8.82; d.f. 2,75; P 0.004) were signicant. No signicant eect of diagnostic group (F 2.34; d.f. 1,75; P 0.104) or gender (F 2.65; d.f. 1,75; P 0.108) was found. However, the interaction between group gender was signicant (F 3.14;
Table 3. Scores on the emotion perception test for Faces and for Voices according to gender in groups of subjects with schizophrenia or bipolar disorder compared with healthy controls Schizophrenia, (n 31) Mean (SD) Face ID (range 019) Males Females Face DM (range 030) Males Females Voice ID (range 021) Males Females Voice DM (range 022) Males Females 13.2 12.6 14.2 25.7 25.7 25.6 16.2 15.5 17.6 17.7 17.1 18.8 (2.5) (1.8) (3.2) (2.2) (2.1) (2.5) (2.6) (2.0) (3.0) (2.8) (3.0) (1.9) Bipolar, (n 21) Mean (SD) 13.8 14.3 13.3 26.5 26.6 26.4 17.7 18.3 17.0 18.5 19.0 17.9 (2.6) (2.8) (2.4) (2.0) (2.1) (2.1) (2.0) (1.9) (2.1) (2.2) (2.3) (2.0) Controls, (n 31) Mean (SD) 14.0 14.0 14.1 26.4 26.1 27.1 18.3 18.0 18.9 19.3 18.7 20.3 (2.2) (2.4) (1.8) (2.3) (2.3) (2.4) (1.5) (1.5) (1.2) (1.6) (1.5) (1.0)

d.f. 2,75; P 0.049) indicating that dierences in emotion perception between diagnostic groups depend upon gender or that gender dierences depend upon diagnostic group. Follow-up ancovas conrmed that persons with schizophrenia, bipolar disorder and healthy controls did not dier signicantly in their performance on the visual tasks (see Figs 1 and 2) (n.s. on all main and interaction eects). For the auditory identication task, there were signicant eects of diagnostic group (F 4.40; d.f. 1,75; P 0.016), and of the group gender interaction (F 3.85; d.f. 2,75; P 0.026) (see Fig. 3). There was a non-signicant trend for the interaction eect of group gender on the discrimination task (F 3.10; d.f. 2,75; P 0.051) (see Fig. 4). Post-hoc comparisons for the two auditory emotion tasks conrmed that male schizophrenia subjects performed signicantly weaker than healthy males for the identication subtest (P 0.001). Males with schizophrenia also scored signicantly poorer than female schizophrenia subjects for the identication format (P 0.020), as did healthy males for the discrimination format when compared with healthy females (P 0.001). Figures 3 and 4 show that for auditory emotion perception, participants with bipolar disorder
19 # correct (019) Face ID SZ BD HC 16

13

10 Males Females

Fig. 1. Visual emotion identication (Face ID) in males and females with schizophrenia, bipolar disorder and healthy controls.

30
# correct (030)

Face DM

25 SZ BD HC 20
Males Females

ID, identification; DM, discrimination.

Fig. 2. Visual emotion discrimination (Face DM) in males and females with schizophrenia, bipolar disorder and healthy controls.

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Emotion perception in major mental disorder

Voice ID 20 # correct (021)

need replication. However, our study supports the view that emotion perception decits are a core characteristic of schizophrenia and not a general nding in major mental disorders.
SZ BD HC

15

Schizophrenia

10 Males Females

Fig. 3. Auditory emotion identication (Voice ID) in males and females with schizophrenia, bipolar disorder and healthy controls.

SZ

Voice DM

# correct (022)

21

BD HC

19

17

15

Males

Females

Fig. 4. Auditory emotion discrimination (Voice DM) in males and females with schizophrenia, bipolar disorder and healthy controls.

deviated from the pattern observed in schizophrenia subjects and healthy controls, with females having a lower performance than males, albeit not signicantly so. When examining the relationship between symptoms, illness duration and emotion scores, we found one signicant correlation (Pearson r )0.46; P 0.038); i.e. between Face ID and level of depression (IDS-C) in the bipolar group. Degree of mania (YMRS) was not associated with emotion perception in the bipolar group, and neither was level of psychotic symptoms (PANSS) in the schizophrenia group. Illness duration showed no signicant correlation with emotion perception in any of the clinical groups.
Discussion

Our main nding was intact emotion perception in bipolar disorder, and intact visual, but reduced auditory emotion perception in schizophrenia. Secondly, our results indicate that gender interact with diagnosis as shown by females outperforming males in the schizophrenia and healthy control groups, but not for bipolar disorder. The evidence for modality-specic diculties and the interaction eect between gender and diagnosis are weak and

The schizophrenia group showed fewer diculties in emotion perception than previously reported. There are several possible explanations. One has to do with the current sample, which has a higher IQ than what is commonly reported in the schizophrenia literature. We therefore examined the relationship between IQ and emotion perception and found one signicant correlation of moderate size; between Voice ID and WASI total IQ (Pearsons r 0.38, P 0.036). In other words, emotion perception is to some extent related to general cognitive function, and high IQ is probably partly responsible for the high emotion perception scores in our study. But as we found only one such correlation and it was of moderate size, emotion perception cannot be reducible to IQ in this sample. Another reason for the high emotion perception performance in our study may be the cultural bias in emotion perception, with the ethnicity of the poser in the stimuli material having impact on the accuracy of perception. People remember faces from their own ethnic group better than faces from other races (26), and they understand emotional expressions better when they are expressed by a person belonging to the same cultural group (27). This also seems to be the case for schizophrenia (28). Our schizophrenia sample clearly outperforms previous samples; whereas the group in Kerr and Neales (21) original study had an average score of 8.8 on the Face ID, our sample has 13.2, which corresponds to the performance of their normal controls (a mean score of 13.7). However, we carefully selected participants to match the ethnicity of the stimuli material by having only Caucasian perceivers of the Caucasian posers in Kerr and Neales (21) test. Samples from more multi-ethnic countries than Norway often include non-Caucasian participants. In previous studies, the ethnicity of the subjects did not match that of the stimuli material, with for instance 46 Caucasians and 48 non-Caucasians in one study by Kee et al. (23) and 16 Caucasians and 11 non-Caucasians in the original Kerr and Neale (21) sample. As the control group in the last study was not matched with the study group for ethnicity (consisting of 18 Caucasians and ve non-Caucasians), the cultural bias cannot be ruled out as an explanation of the ndings. Hence, part of the 267

Vaskinn et al. emotion perception decits previously reported in schizophrenia could be because of the ethnic bias. A possible explanation for reduced auditory and not visual performance is the general verbal cognitive decit seen in schizophrenia. As language dysfunction seems to be central to schizophrenia (29), a more severe impairment of verbal performance is expected. It is therefore possible that the verbal stimuli were more challenging to people with schizophrenia than the visual tasks. Nonemotional control tasks were not included in the study, making it dicult to answer this question. However, as the groups did not dier in general verbal (NART) or visual (WASI Matrix Reasoning, P 0.150) abilities, we assume that the risk of our results reecting impaired basic visual or auditory processing is minor. An alternative reason for the lack of corresponding ndings for the two emotion modalities could be that the auditory tasks are more sensitive for emotion perception decits. If we use the percentage of correct responses in our control group as an indication of the level of diculty, the tasks seem to be equally dicult. Face ID is the most dicult one with 73% correct responses amongst our controls. The corresponding numbers for the other tasks are: Voice ID (87%), Voice DM (87%) and Face DM (88%). As this points to the Face ID task being most dicult, the lack of group dierences on the Face tasks cannot be explained by visual tasks being easier than the auditory ones. Thus, our results seem to support a hypothesis of modality-specic impairments.
Bipolar disorder

in line with the study of Harmer et al (6), who found enhanced performance in a euthymic sample compared with healthy controls. Either way, although we cannot rule out that mood state has aected the ability to recognize emotions in our bipolar-disorder sample, it has not reduced emotion perception to a level below our healthy controls. In line with the schizophrenia group, the cultural bias and high IQ can be oered as explanations for the high emotion perception performance in the bipolar disorder group. However, there were no signicant associations between IQ and any of the emotion perception measures. This suggests that emotion perception is an ability that is relatively independent of general cognition in bipolar disorder.
Gender

We found no evidence of an emotion perception decit in bipolar disorder. These data are in accordance with the ndings that bipolar disorder in euthymic phase is not characterized by impaired emotion perception (5). Although the group mean corresponds to euthymic phase, eight participants had IDS-C scores within the mild to moderate depressive range, and indeed, there was a signicant relationship between the depression score and visual emotion identication. As the correlation is negative (a higher score on the Face ID is related to a lower score on the IDS-C, or vice versa), it seems that depression has a negative impact on the accuracy of visual emotion identication. Still, the emotion perception performance was not reduced in the bipolar disorder group compared with the control group. Consequently one could speculate that this bipolar disorder sample would have outperformed the healthy controls had they all been tested in a euthymic phase. This would be 268

Gender dierences in emotion perception have largely been ignored in the schizophrenia eld, even though gender dierences in other aspects of the disorder are recognized (30, 31). This is the rst study to investigate gender dierences in emotion perception in schizophrenia and bipolar disorder. As healthy females have better emotion perception performance than healthy males, the same would be expected for the clinical groups. But the group-bygender interaction eect that we found means that the gender eects were dierent in the bipolar group compared with the other two groups. We found a reduced performance in healthy males and in men with schizophrenia, but the expected superiority of females was not seen in bipolar disorder. There were no statistically signicant gender dierences on demographic or clinical variables in the bipolar disorder group, but a tendency for longer duration of illness in females. Some authors have found a relationship between emotion processing and illness duration in schizophrenia (32). It is possible that women with long illness duration could be responsible for the lack of gender dierences in the bipolar sample. One hypothesis derived from this is that some disease characteristics of bipolar disorder compromise the ability to recognize emotions in other people. This is in line with studies that show that neurocognition deteriorates through the course of bipolar illness (33). Even though we found no association between duration of illness and emotion perception, this does not rule out that another clinical characteristic, like number of manic episodes or psychotic symptoms could negatively inuence emotion perception over time. As such data are not included in the current study, these questions remain unsettled. There are gender differences in the presentation of bipolar disorder,

Emotion perception in major mental disorder with females experiencing e.g. both more depressive episodes and rapid cycling than men (34). Thus, another speculation is that emotion perception is more aected in women with bipolar disorder than it is in men with bipolar disorder.
Limitations

As previously mentioned, the study did not include non-emotional control tasks. However, the groups did not dier on the WASI Matrix Reasoning subtest, which we take to imply that they have sucient visuospatial abilities to perform the visual emotion tasks. In addition, no group dierence was found on the NART, and subjects adjusted the volume to a preferred level before the start of the auditory emotion tasks. This indicates that there are no impairments in basic auditory processing interfering with emotion perception performance. Hence, it does not seem likely that our results can be reduced to intact visual, but impaired auditory processing in our schizophrenia sample. An important limitation of our study is the small sample sizes, especially for bipolar disorder. A larger sample may have yielded dierent results for the genders in the bipolar group. Thus, our results need to be replicated. Small sample sizes also limit the number of variables that can be reliably investigated because of low statistical power. Therefore, the eect of dierent psychotropic medication on emotion perception could not be statistically analyzed, and we cannot rule out that the drugs used have inuenced the emotion perception scores. This issue remains unsettled in the literature. A series of studies have shown a relationship between use of antipsychotic medication and improved neurocognition (3537), as well as enhanced emotion perception (38) in schizophrenia, while for bipolar disorder antipsychotics have been found to be associated with impaired neurocognition (39). Unfortunately our study cannot address the question of the impact of psychotropic medication on emotion perception. The emotion perception measure itself can be considered as a limitation. The test includes a relatively low number of positive as compared with negative emotions. Thus, our design does not allow looking at valence or separately at specic emotions. These are interesting research questions, and some studies have shown that schizophrenia samples are selectively impaired for negative emotions (1), although the ndings of a recent study argue against this (40). Diculties in understanding other peoples emotional expressions have real-life consequences. It can lead to misunderstandings and problems in

social interactions that can result in alienation and social isolation. A person, who is perceived by his or her peers as not recognizing or responding to their emotional communication, will not be a preferred partner in social interactions. Emotion perception and social problem-solving are social cognitive abilities. The social brain hypothesis of schizophrenia (41) states that problems with social cognition are a core feature of the disorder. Social cognitive decits are hypothesized to be caused by disruption of neural networks that govern social behaviour. These social brain networks connect cortical frontal, temporal and parietal regions, as well as subcortical structures like the amygdala. Possible cellular correlates of social cognition are the mirror neurons, which are active when one individual observes another individual performing an action, thus constituting an inner representation of that action. Emotion perception decits in schizophrenia may be caused by dysfunctional mirror neurons, but more research is needed to elucidate these hypotheses. In conclusion, our data show intact emotion perception for bipolar disorder and an auditory emotion perception decit for schizophrenia. We have shown that gender plays a role in emotion perception in schizophrenia, and it is our view that gender dierences should be incorporated when examining emotion processing in psychiatric samples.
Acknowledgements
This study was supported by funds from the Norwegian Research Council, grant 147787/320, and the Josef and Haldis Andresens Foundation.

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