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Perceptions of social dominance through facial emotion expressions in

euthymic patients with bipolar I disorder

Sung Hwa Kim, Vin Ryu, Ra Yeon Ha, Su Jin Lee, Hyun-Sang Cho

PII: S0010-440X(15)30071-7

DOI: doi:10.1016/j.comppsych.2016.01.012

Reference: YCOMP 51624

To appear in: Comprehensive Psychiatry

Please cite this article as: Kim Sung Hwa, Ryu Vin, Ha Ra Yeon, Lee Su Jin,Cho Hyun-Sang, Perceptions of social dominance through facial emotion expressionsin euthymic patients with bipolar I disorder, Comprehensive Psychiatry (2016), doi:10.1016/j.comppsych.2016.01.012

This is a PDF file of an unedited manuscript that has been accepted for publication.As a service to our customers we are providing this early version of the manuscript.The manuscript will undergo copyediting, typesetting, and review of the resulting proofbefore it is published in its final form. Please note that during the production processerrors may be discovered which could affect the content, and all legal disclaimers thatapply to the journal pertain.

http://dx.doi.org/10.1016/j.comppsych.2016.01.012http://dx.doi.org/10.1016/j.comppsych.2016.01.012http://dx.doi.org/10.1016/j.comppsych.2016.01.012http://dx.doi.org/10.1016/j.comppsych.2016.01.012

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Title: Perceptions of social dominance through facial emotion expressions in euthymic

patients with bipolar I disorder

Sung Hwa Kima,b; Vin Ryuc; Ra Yeon Had; Su Jin Leeb; Hyun-Sang Choa,b*

aDepartment of Psychiatry, Yonsei University College of Medicine, Seoul, Republic of Korea

bInstitute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul,

Republic of Korea

cDepartment of Psychiatry, Seoul National Hospital, Seoul, Republic of Korea

dDepartment of Psychiatry, Seoul Bukbu Hospital, Seoul, South Korea

*Corresponding author

Hyun-Sang Cho, MD, PhD

Department of Psychiatry, College of Medicine, Yonsei University

50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea

Tel: +82.2.2228.1587, Fax: +82.2.313.0891

Email: chs0225@yuhs.ac

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Abstract

The ability to accurately perceive dominance in the social hierarchy is important for

successful social interactions. However, little is known about dominance perception of

emotional stimuli in bipolar disorder. The aim of this study was to investigate the perception

of social dominance in patients with bipolar I disorder in response to six facial emotional

expressions. Participants included 35 euthymic patients and 45 healthy controls. Bipolar

patients showed a lower perception of social dominance based on anger, disgust, fear, and

neutral facial emotional expressions compared to healthy controls. A negative correlation was

observed between motivation to pursue goals or residual manic symptoms and perceived

dominance of negative facial emotions such as anger, disgust, and fear in bipolar patients.

These results suggest that bipolar patients have an altered perception of social dominance that

might result in poor interpersonal functioning. Training of appropriate dominance perception

using various emotional stimuli may be helpful in improving social relationships for

individuals with bipolar disorder.

Keywords:Social dominance; Facial emotion; Bipolar disorder; Euthymia

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1. Introduction

Interpersonal relationships may be divided into two systems: the social dominance system

and the social inhibition system [1]. The function of the social dominance system is to

recognize social hierarchy in order to successfully compete with people in a more dominant

position [2]. The social hierarchy is important in interpersonal relationships in that it

promotes knowledge of ones own place in the hierarchy and eventually it could bring

appropriate social behavior through behavioral inhibition [3,4]. Recently, comprehensive

studies of social hierarchy across species revealed that recognizing social hierarchy is

associated with a neural network system that is distinct from other social cognition [5].

In interpersonal relationships, social status can be inferred from multiple visual cues, such

as facial features, posture, gender, age, and facial expressions [6-8]. Facial emotional stimuli

are important because they provide information about the social hierarchy and regulate both

the affective state and emotional behavior in response to stimuli [9]. For example, an

individual who expresses approach-related emotions (e.g., anger) may increase perceived

power, whereas an individual who shows inhibition-related emotions (e.g., sadness) may

decrease perceived power [10]. In addition, facial expressions of happy and angry are seen as

assertive, dominant, and controlling, whereas expressions of fear and sadness are perceived

as submissive, incompetent, and in need of help [8]. In healthy humans, neutral expressions

are considered as high social dominance because neutral faces provide the impression ofhaving the ability to handle the situation and reacting non-emotionally to the an event [8,10].

Additionally, neutral emotions expressed by males are rated as more dominant than those

expressed by females [8]. Facial features such as a square jaw, low brow position, and male

gender may be perceived as a high social dominance [8,11,12]. When people are faced with

dominant cues, they flexibly adopt either dominant or submissive behavior through

comparing their self-status against other dominance cues [13]. People with a low sense of

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power are more attentive to dominant people and social threats, whereas individuals with a

high sense of power are more attentive to rewarding aspects of social interactions [1,14].

According to reports that examined the perception of social dominance in individuals with a

social anxiety disorder, facial emotions like anger, contempt, disgust, and fear were

associated with a negative view of dominance (e.g., harsh, threatening) and emotions like

happiness were associated with a positive view of dominance (e.g., accepting) [15,16].

Socially anxious individuals perceived themselves as low in the social hierarchy, engaged in

negative social comparisons [17], and were particularly hypersensitive to dominance stimuli

such as angry facial expressions [18]. Depressed people also felt defeated and tended to show

submissive behaviors in response to dominant stimuli [19,20]. Patients with schizophrenia

have impairments in various social cognitive processes including social perception with

materials generating social cues [21]. Subjects with ventromedial prefrontal cortical lesions

showed subtle, abnormal judgments of social dominance using static facial stimuli [22]. So

abnormal dominance perception or recognition can be observed in specific psychiatric

disorders and these impairments of dominance perception may lead to problems in

interpersonal relationships or social adaptation.

Bipolar disorder is characterized by alternating cycles of manic and depressive episodes,

interspersed with euthymic periods. During a manic episode, patients show approach

behaviors such as excessive goal pursuit with overly confidence and less regard toconsequences. Manic symptoms and impairments of social functioning may be caused, in part,

by underlying deficits in social cognitive functions, such as the perception of potential danger

cues [23]. During the euthymic period, bipolar patients still tend to think highly of themselves

in comparison to others and set ambitious goals [24,25]. As for cognitive vulnerability in

euthymic states, bipolar patients also showed higher levels of dysfunctional attitudes,

particularly related to need for social perfectionism and approval than healthy controls [26].

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Studies on facial emotional processing revealed mixed results, but some studies among them

reported altered recognition of facial emotions [27]. Moreover, altered reactivity in the

prefrontal cortices, including the ventrolateral and ventromedial regions, appears to be

involved in deficits of emotional processing and regulation in bipolar disorder [28]. Therefore,

these abnormalities in cognitive and emotional processing may lead to the potential alteration

in the dominance perception in patients with bipolar disorder.

In this study, we investigated the perception of social dominance in response to emotional

stimuli in patients with bipolar I disorder. Using facial expressions of six different emotions,

including neutral stimuli, we compared the levels of dominance perception in euthymic

bipolar patients to healthy control subjects.

2. Methods

2.1. Participants

Thirty-five euthymic bipolar I patients were recruited from psychiatric clinics at Severance

Mental Health Hospital of the Yonsei University Health System. Bipolar disorder was

diagnosed by two psychiatrists based on clinical interviews and using the criteria for bipolar

disorder in the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV)

[29]. Patients diagnoses were briefly confirmed using the Mini-International

Neuropsychiatric Interview (MINI) [30] by two psychiatrists (S.H.K and H.S.C). Patientswith schizoaffective disorder, severe personality disorder, recent substance abuse, history of

head trauma, or any other Axis I disorder were excluded. Forty-five healthy control subjects

were selected from the local community via advertisement and screened by using the MINI to

exclude neurological disease and other major psychiatric disease. This research was approved

by the Institutional Review Board of Severance Mental Health Hospital, and written informed

consent was obtained from all participants.

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2.2. Materials

We presented 24 Japanese facial emotional expressions from the JACFEE (Japanese and

Caucasian Facial Expression of Emotion) [39]. Except for surprised facial expressions, the

facial stimuli consisted of five basic emotions (happy, anger, disgust, fear, and sad) and

neutral faces. Each emotional expression was composed of two male and two female actors.

Different actors were used for each emotion and did not overlap. Because facial features such

as hairstyle, jaw form, and facial rounding may influence the perception of social dominance

[11], facial hair and blemishes were removed and all faces were unified into an oval annulus

using Adobe Photoshop. Skin tone was expressed in black and white on a black background

to put the most focus on the emotional expression of the face. Faces were presented centrally

on a 13-inch laptop computer screen at a size of 275 420 pixels, and at a viewing distance

of approximately 60 cm. Facial emotional expressions were presented in a randomized order.

Participants were instructed to look carefully at each facial emotional expression and rate

their perceived dominance for each emotion until they pressed key for next facial stimuli.

To estimate dominance, the translated version of 7-point dominance scale developed by

Hess [8] (Insecure-Assertive, Placid-Forceful, Non-controlling-Controlling, Submissive-

Dominant) was used. The item Placid-Forceful was excluded because the translated

meaning of the Korean words was unclear when the dominance scale was preliminarily

conducted on seven normal persons. The remaining items were combined into an overalldominance scale (N = 80, Cronbachs = 0.78). Participants rated each face on three 7 point-

Likert scales ranging from 3 to 3 with opposite descriptions (i.e., 3 = very insecure; 3 =

very assertive). Thus, higher positive scores were considered to reflect higher levels of

perceived social dominance, and lower negative scores were regarded as greater levels of

perceived social submissiveness.

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2.3. Statistical analysis

The sociodemographic and clinical characteristics of the bipolar patient and healthy control

groups were compared using a Chi-square test and an independent Students ttest. Perceived

dominance scores were analyzed by three-way analysis of variance (ANOVA) to assess

effects of group, gender of the participant, and facial emotional expressions. Post-hoc

analyses were conducted in 2 ways by using Bonferroni correction method, due to non-

significant gender of the participant effect: (1) assessing group effects within each facial

emotional expressions and (2) comparing perceived dominance scores for the five emotional

expressions with the neutral expressions (happy vs. neutral, anger vs. neutral, disgust vs.

neutral, fear vs. neutral, and sad vs. neutral) for each group separately. .

Lastly, Pearsons correlation was used to estimate the correlation between the clinical

characteristics and perceived dominance scores in bipolar patients. All of the above statistical

analyses were conducted with SPSS Statistics, version 19.0.

3. Results

For perceived dominance, there were no significant main effect of gender of the participant

(F[1,456] = 0.31, p = 0.575) or significant interactions (group emotion gender of the

participant,F[5,456] = 0.36,p= 0.877; group gender of the participant, F[1,456] = 0.97,p

= 0.326; emotion gender of the participant, F[5, 456]=0.13, p=0.986) when including thegender of the participants. As a result, this factor (gender of the participant) dropped from

further analysis. A two-way group by emotion ANOVA revealed significant effects of group

(F[1,948] = 20.34, p

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disgust (p neutral, p neutral,p neutral,p

= 0.010; sad < neutral,p

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of fear. There was a negative correlation (r = 0.34, p = 0.047) between YMRS and

dominance ratings of fear. However, these data did not reveal any significant correlations

when we employed a critical p-value of 0.006 to correct for multiple testing using

Bonferronis method.

4. Discussion

In the present study, bipolar patients showed noticeably lower perceptions of social

dominance based on anger, disgust, fear, and neutral facial emotional expressions compared

to healthy controls. However, there were no significant differences in the dominance

perception of happy and sad emotions between bipolar patients and controls. To our

knowledge, this is the first study to investigate the social dominance perception using facial

emotional expressions in bipolar I patients.

This lower dominance perception of negative emotions may be related to impairment of

emotional processing and regulation that is observed in individuals with bipolar disorder.

Although it was long believed that deficits of facial emotion recognition remit during the

euthymic status of bipolar disorder, growing evidence suggests that these impairments persist

during the euthymic state [40,41]. A meta-analytic study reported small, but significant effect

sizes for facial emotion recognition in euthymic bipolar disorder [42], in which euthymic

bipolar patients were found to have enhanced or impaired recognition of negative emotions,especially fear and disgust [43-45]. In another study, several negative facial emotions were

misrecognized as other emotions in remitted bipolar patients in comparison to healthy

controls [46]. Patients with bipolar disorder also exhibited selective impaired with negative,

but not positive, emotional maintenance when compared to healthy controls [47]. Individuals

with bipolar disorder were also more likely to ruminate about a positive affect and engage in

risk-taking behaviors when faced with a negative affect [48]. These difficulties with

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experiencing negative emotions may result in overlooking dominance in negative facial

expressions. Euthymic bipolar patients showed a greater use of suppression and reappraisal,

indicating difficulty with regulating emotions [49]. Another possible explanation is that

impaired attention in bipolar disorder [50,51] might influence lower dominance perceptions

in response to negative emotional facial expressions. Schizophrenia patients showed a

significant association between attention processes and facial emotion recognition [52,53].

Similarly, for bipolar patients, altered dominance perception may be associated with impaired

attention to details of facial expressions. Taken together, altered recognition or maintenance

of negative emotions, difficulties with regulating emotion, and deficits in attention may lead

to a decreased perception of dominance in response to these emotions.

To the best of our knowledge, there has been no investigation of dominance perception in

response to facial expressions among patients with depression or bipolar depression. Only

one study directly rated the perceived dominance to anger, neutral, and happy facial

expressions in individuals who had high or low social anxiety [54]. The results revealed no

differences among groups; however, the participants (i.e., students) only had speech fear, and

their anxiety was thus not as severe as patients with social anxiety disorder. Studies that

measured dominance indirectly using faces have shown that patients with social anxiety

disorder are hypervigilant to negative facial expressions and that they have an attentional bias

to social threats [55-57]. For example, patients with social anxiety disorder, who viewthemselves as less dominant, perceive angry faces as challenges to dominance contest [58].

Patients with social anxiety disorder rated angry faces as more arousing and as more

unpleasant than controls [59]. In addition, participants with anxiety disorder reported elevated

emotional reactivity for facial expressions of anger or contempt [60].

In healthy individuals, the dorsolateral and ventrolateral prefrontal cortices, which are

associated with the regulation of socio-emotional responses and behavioral inhibition,

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respectively, are activated when faced with dominant persons [3,5,61]. Likewise, altered

functioning or connectivity, including ventrolateral prefrontal cortex and amygdala, have

been observed during emotion processing and emotion regulation in individuals with bipolar

disorder [28]. These altered neural activities may contribute to the emotional dysregulation

and differences in dominance perception in patients with bipolar disorder.

There were no between-group differences in the dominance perception of happy and sad

emotions in this study. It has been reported that happy and sad facial emotions have a lower

arousal than do fear, anger, and disgust in healthy people [62,63]. Low arousal faces are more

emotionally ambiguous and appear to be related to an active affective system including

amygdala and prefrontal cortex [63]. So this relatively low arousal might lead to no group

differences in the dominance perception. Additionally, cultural differences might influence

dominance perception. For example, Westerners perceived happy expressions as higher in

dominance than neutral expressions [8]. However, no differences in dominance perception

were found between happy and neutral faces in either bipolar patients or healthy controls in

this study.

Interestingly, bipolar patients demonstrated not only a significantly lower dominance

perception of neutral facial expressions but also perceived excessive submissiveness of

neutral expressions compared to controls. The neutral facial expressions may be rated as

negative in some circumstances by healthy persons [64], but bipolar patients reported morefear and showed greater limbic hyperactivation when viewing neutral faces compared with

controls [65]. Bipolar patients also perceived neutral faces as negative when experiencing a

high emotional state [66]. As a result, these altered interpretations of neutral expressions

might contribute to different dominance perceptions in individuals with bipolar disorder.

Although female gender expressions signaled lower dominance than expressions in males,

no significant interactions involving gender were observed in this study. Male expressers

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were perceived as higher dominant than female ones because the morphological cues were

more typical for men than for women in healthy participants [67]. In our study, facial shape

was unified into an oval annulus; therefore, the gender effect on perceived dominance may

have been attenuated.

Negative correlations between residual manic symptoms (YMRS) or drive subscale and the

dominance perception of anger, disgust, and fear were found in patients with bipolar disorder.

Also, low BIS scores were related to lower dominance perception of fear in bipolar patients.

Drive is a subscale of the BAS that regulates approach motivation and goal-directed behavior,

whereas BIS measures the tendency to regulate with anxiety in response to fear stimuli [36].

Individuals with social anxiety disorder view themselves as inferior and incapable of

adequately competing with others; they also tend to be more hypervigilant or anxious toward

dominant stimuli [17,68]. On the other hand, bipolar patients, who have hypomanic

symptoms and high drive scores, might view themselves as capable of adequately competing

with others, exhibiting and fearless responses to facial cues that suggest danger [23,69].

Therefore, bipolar patients who have residual manic symptoms, high goal pursuit, and low

BIS might have a lower dominance perception of emotions such as anger, disgust, and fear.

However, these results should be interpreted carefully, as the statistically significance did not

appear when applying the conservative threshold.

The ability to accurately perceive and make inferences about the emotions of other people iscritical to interpersonal and social relationships [70]. In individuals with schizophrenia,

improvements in perception of facial emotion were shown in response to a training program

[71], and this has led to improvements in social relationships [72]. Therefore, training of

appropriate dominance perceptions using various emotional stimuli or situation might be

helpful in improving social functioning in individuals with bipolar disorder.

The limitations of this research are the following: First, sample size was relatively small and

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a single site was used for recruitment; therefore, this preliminary study should be replicated

in larger samples. Second, bipolar patients have been taking mood stabilizers and/or

antipsychotics. While we cannot completely exclude the medication effects, we did not find

any significant correlations between the level of dominance perception of each emotion and

medications (mood stabilizers or neuroleptic doses) in the patient group (all p>0.06). Third,

our study focused on facial emotions for dominance perception. Although we unified the

faces, it will be necessary to investigate the contributions of specific facial features and body

postures or gestures to ratings of dominance. Fourth, we did not assess the reasons why the

participants judged the emotional faces as more dominant or more submissive. As a result,

further study will be needed to determine a direct cause of altered dominance perception in

bipolar disorder. Fifth, the difference in perceived dominance between bipolar patients and

healthy controls was modest. Thus, these effects might have had a subtle influence on real-

world behavior. Sixth, given that patients with any other Axis I disorder were excluded, our

bipolar patients constituted a relatively pure sample; Thus, it may not have been

representative of general patients with bipolar disorder who have high rates of comorbid

substance use or anxiety disorders [73]. In addition, we did not directly measure the

participantsself-esteem or their own sense of social dominance. Further study will be needed

to determine the relationship between self-esteem and perceived dominance. Moreover, even

though we measured dominance scores by using Likert scales, future research would considerusing a visual analog scale for increasing sensitivity and decreasing anchoring on specific

values. Lastly, this was a cross-sectional study. Although lower dominance perception may be

a trait factor observed during the euthymic state in those with bipolar disorder, an

investigation into its longitudinal changes during the disease course is needed.

Despite these limitations, this research is the first of our knowledge to study the perception

of social dominance in euthymic bipolar patients. Bipolar patients showed a significantly

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lower perception of social dominance in negative, threatening stimuli compared to normal

participants. This research is important because decreased dominance perception may be

related to impaired social and occupational functioning and potential components of its

treatment training in patients with bipolar disorder. This study also provides a foundation for

future research, focusing on neurobiological or brain imaging of dominance perception in

individuals with bipolar disorder.

Acknowledgements

This study was supported by a faculty research grant (No. 6-2013-0169) of Yonsei

University College of Medicine.

Conflicts of interest

All authors declare that they have no conflicts of interest.

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Figure 1. Perceived dominance scores to each emotion for bipolar patients and healthy

controls, with standard error bars. * :p

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Figure 1

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Table 1.Demographic and clinical characteristics of subjectsBipolar Control t or p-value

(n=35) (n=45)

Age 35.710.3 32.88.5 1.37 0.17Gender (M/F) 20/15 21/24 0.87 0.35

Education (years) 11.71.7 12.11.4 -1.23 0.22

Estimated IQ 107.911.6 111.811.6 -1.46 0.15

No. admission 3.93.7 -

Duration of illness (years) 9.88.8 -

YMRS 3.84.8 0.71.0 3.65