Edited by: Noah James Sasson, The University of Texas at Dallas, United States
Reviewed by: Xiaohua Liu, Shanghai Jiao Tong University, China; Margherita Bechi, San Raffaele Hospital (IRCCS), Italy
*Correspondence: Felicity V. Larson,
This article was submitted to Schizophrenia, a section of the journal Frontiers in Psychiatry
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
There is a recognized increase in vulnerability to psychosis in autistic people (AP). However, the construct of psychosis (particularly schizophrenia) contains several distinct factors, making understanding the relationship between autism and psychosis complex. Previous research has suggested that affective lability may be particularly related to psychotic experiences for AP who have experienced psychosis (AP-P). There is also a suggestion that psychosis might be a state of extreme (over)empathizing, perhaps related to emotional processes.
We recruited three groups: AP-P (N = 23), a group of AP who had not experienced psychosis (AP-NP; N = 59) and a neurotypical control group (NC, N = 41). Participants completed measures of autistic traits, schizotypal traits (as a proxy for psychosis-proneness), emotional processes, and perspective taking (as a proxy for the type of empathizing most theoretically likely to be linked to psychosis). As well as comparisons between groups, regression analyses were used to understand the influence of dependent variables on schizotypal traits.
We found that AP-P had significantly higher rates of schizotypy (positive and disorganized), as well as higher rates of emotional difficulties. Across all groups, affective lability had a positive and significant association with positive and disorganized schizotypal traits. Differences in perspective taking between groups were small and generally non-significant, particularly in adjusted comparisons; additionally, its impact on schizotypy was small and non-significant.
Our findings suggest that positive and disorganized schizotypy, in particular, have a relationship with affective lability. This, in turn, supports the idea of emotional processes as related to the development of schizotypal traits and psychosis across all individuals, regardless of autism diagnostic status. We found no evidence of empathy relating to any subscale of schizotypy, or the total schizotypy score. We contend that emotional processes should be considered in exploration of the relationship between autism and schizotypy in future. This may help to explain some of the findings of overlap between these constructs in previous research. Factors known to affect neurodevelopment of emotion systems such as history of early trauma, challenges during pregnancy and birth, and early childhood experiences of adversity during critical windows of development need further consideration in future research.
Autism spectrum disorders (ASDs) are life-long neurodevelopmental conditions affecting an individual’s perception of, and interaction with, the world (
Chisholm and colleagues (
In order to understand the relationship between ASD and psychosis, researchers have attempted to map ASD traits and psychotic traits into the same conceptual ‘space’. A personality construct called schizotypy has been used as a proxy for ‘psychosis-proneness’ (
Using factor analysis, two of the largest studies in this area drew differing conclusions about the relationship between autistic and schizotypal traits. Dinsdale et al. (
A factor that may be involved in the relationship between schizotypal and autistic traits is empathy. Empathy is a complex skill that involves predicting and reacting to how you believe another person will feel. It has been conceptualized as having broadly two factors: cognitive empathy (broadly, this is defined as understanding other people’s perspectives); and affective empathy (colloquially, feeling for another person). The diametric model of ASD and schizophrenia suggests that increased empathy may be linked to increased risk of psychosis, through a mechanism of overly empathizing with the perceived contents of others’ minds (
In order to contribute to better understanding of this area, and the potential interactions between emotion regulation difficulties, affective lability, schizotypy, and autistic traits, we have attempted to investigate these concepts in the same theoretical space. The following hypotheses were tested:
H1. AP-P will use less effective emotion regulation strategies and report more affective lability than AP-NP
H2. AP-P will be better at perspective taking than AP-NP
H3. Schizotypal traits will be higher in AP with a history of psychosis (AP-P) compared with AP who have no history of psychosis (AP-NP)
H4. Emotion regulation difficulties and affective lability will be associated with higher schizotypal scores across participant groups
Ethical approval for the study was given by the North of Scotland NHS Research Ethics Committee in January 2016. The study was conducted between January 2016 and April 2017.
An observational study comparing self-reported measures of autistic traits, schizotypal traits, and emotional processes between participant groups. Participants were recruited either
Participants were all adults (aged 18 or older), and were required to have English as their first language. They were recruited to three groups.
Recruited
Consisted of:
participants invited from previous research (
new participants self-identified through the ARC database.
Participants from the ARC database were screened using the Diagnostic Interview for Psychosis (DIP-DM) (
A total of 23 participants were recruited from both sources.
Participants were recruited through social media advertising. Participants were not formally screened, but were asked to confirm they had neither history of ASD diagnosis nor any significant mental health history. A total of 41 participants were recruited.
The following self-report measures were used:
Questionnaire of Cognitive and Affective Empathy (QCAE) (
All participants were asked their age and gender. No other demographics were collected.
Data were analyzed using R (R Core Team).
Initially, the AP-NP, AP-P and NC groups were compared in terms of gender, age and the measures introduced in
To begin examining our hypotheses, unadjusted comparisons of affective and empathy measures between groups were conducted as outlined in
Linear regression models were used to look for adjusted relationships with SPQ-BR scales (Total and all subscales). In these models, the following independent variables were included: Participant Group; Gender; Age; AQ Total; ALS-18 Total; ERQ-9 Cognition Reappraisal; ERQ-9 Emotion Suppression; QCAE Perspective Taking. In each regression, multicollinearity was examined using variation inflation factors (VIFs).
For each regression, a key area of interest was the potential interaction between Participant Group and each of the dependent variables. To explore these interactions, we fitted a series of models that extended each base regression with all possible combinations of (first order) interactions between Group and other dependent variables. Fitted models were compared using the second-order Akaike Information Criterion (AICc) (
Where interactions were fitted, the Effects (
Having conducted the analysis outlined in the above sections, affective lability was highlighted as a key factor. Thus, we repeated the analyses described in
Pearson’s correlation coefficient (r) was used as the primary measure of effect size. Generally, Pearson’s r was calculated from t-statistics (
Group sizes, descriptive statistics and tests of differences between groups (including confidence intervals, p-values and effect sizes) are reported in
Descriptive statistics.
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N= | 59 | 23 | 41 | |||||||||||||
Gender (% W) | 56% | 26% | 61% | Fisher’s | 0.28 | 0.08 | 0.88 |
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0.33 | Fisher’s |
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– | ||||
Age (years) | 44.3 | 12.8 | 33.5 | 11.0 | 31.5 | 9.4 | t(47) = 3.8 | 10.9 | 5.1 | 16.6 |
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0.49 | F(2,120) = 17.4 |
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0.47 | |
AQ Total | 39.0 | 8.2 | 31.0 | 9.9 | 19.4 | 9.1 | t(35) = 3.4 | 8.0 | 3.3 | 12.7 |
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0.51 | F(2,120) = 59.3 |
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0.71 | |
SPQ-BR Total | 71.8 | 16.6 | 77.6 | 21.7 | 52.3 | 20.0 | t(33) = −1.2 | −5.8 | −16.0 | 4.4 | 0.256 | 0.20 | F(2,120) = 18 |
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0.48 | |
SPQ-BR Positive | 20.6 | 9.2 | 29.1 | 13.4 | 15.2 | 9.1 | t(30) = −2.8 | −8.5 | −14.7 | −2.3 |
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0.45 | F(2,120) = 14.1 |
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0.44 | |
SPQ-BR Negative | 28.4 | 7.6 | 26.8 | 8.1 | 19.4 | 8.9 | t(38) = 0.8 | 1.6 | −2.3 | 5.6 | 0.414 | 0.13 | F(2,120) = 15.6 |
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0.46 | |
SPQ-BR Disorganized | 22.7 | 6.1 | 21.7 | 4.7 | 17.8 | 7.3 | t(51) = 0.9 | 1.1 | −1.5 | 3.6 | 0.398 | 0.12 | F(2,120) = 7.6 |
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0.34 | |
ALS-18 Total | 19.2 | 13.3 | 26.0 | 10.8 | 17.8 | 12.8 | t(49) = −2.4 | −6.8 | −12.5 | −1.1 |
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0.32 | F(2,120) = 3.3 |
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0.23 | |
ALS-18 Anxiety/Depression | 6.3 | 4.3 | 8.3 | 4.3 | 5.9 | 5.0 | t(40) = −1.9 | −2.0 | −4.2 | 0.1 | 0.065 | 0.29 | F(2,120) = 2.3 | 0.104 | 0.19 | |
ALS-18 Depression/Elation | 8.9 | 6.6 | 11.9 | 4.9 | 9.0 | 6.8 | t(54) = −2.2 | −3.0 | −5.6 | −0.3 |
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0.29 | F(2,120) = 2 | 0.142 | 0.18 | |
ALS-18 Anger | 3.9 | 4.2 | 5.7 | 4.2 | 3.0 | 3.5 | t(40) = −1.8 | −1.8 | −3.9 | 0.3 | 0.088 | 0.27 | F(2,120) = 3.6 |
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0.24 | |
ERQ-9 Cognitive Reappraisal | 22.3 | 7.0 | 19.7 | 6.4 | 22.0 | 6.4 | t(44) = 1.6 | 2.6 | −0.6 | 5.9 | 0.110 | 0.24 | F(2,120) = 1.3 | 0.270 | 0.15 | |
ERQ-9 Emotion Suppression | 16.3 | 6.4 | 17.3 | 5.9 | 14.5 | 5.7 | t(43) = −0.7 | −1.0 | −4.0 | 2.0 | 0.500 | 0.10 | F(2,120) = 1.8 | 0.171 | 0.17 | |
QCAE Perspective Taking | 20.3 | 7.0 | 22.2 | 6.7 | 29.2 | 5.8 | t(42) = −1.2 | −2.0 | −5.3 | 1.4 | 0.246 | 0.18 | F(2,120) = 23.1 |
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0.53 |
Means, standard deviation (SD) by participant group and comparisons between (i) AP groups (Fisher’s exact test/two-sample t-test) and (ii) all three groups (Fisher’s exact test/ANOVA).
Bold/italic p-values indicate significant differences at the 5% level.
AP-NP, Autistic people with no psychosis; AP-P, Autistic people with psychosis; NC, Neurotypical controls; Stats. Comp, Statistical comparison; OR/diff, Odds ratio/difference; LCI/UCI, Lower/upper 95% confidence interval; W, Women; SPQ-BR, Schizotypal Personality Questionnaire; ALS-18, Affective lability scale-18; ERQ-9, Emotional regulation questionnaire-9; QCAE, Questionnaire of cognitive and affective lability. There are two separate sets of comparisons: the first compares the AP groups (middle set of columns) and the second compares all three groups (last set of columns).
Gender split was similar between AP-NP and NC groups; however, there were significantly (proportionately) fewer women in AP-P compared to AP-NP. The AP-NP group was significantly older than the AP-P and NC groups. A large and significant difference in AQ scores was found between AP-NP and AP-P. As would be expected, the NC group had the lowest AQ score. Between AP-NP and AP-P groups, across SPQ-BR scales, the only significant difference was found on the Positive scale. NC had the lowest means across all SPQ-BR scales. The same differences between groups were found in the equivalent non-parametric analysis reported in
Detailed unadjusted comparisons of these measures are given in
Detailed adjusted comparisons of these measures are given in
Fitted regressions on ALS-18 Total, ERQ-9 and QCAE scales.
Variable | Cat. level | Adjusted comparison regressions (n = 123) | |||||||||||||||||||
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ALS-18 Total (adjusted R² = 0.43) | ERQ-9 Cognitive Reappraisal (adjusted R² = 0.08) | ERQ-9 Emotion Suppression (adjusted R² = 0.43) | QCAE Perspective Taking(adjusted R² = 0.67) | ||||||||||||||||||
b | 95% CI | P-value | r | B | 95% CI | P-value | r | b | 95% CI | P-value | r | b | 95% CI | P-value | r | ||||||
Intercept | – | −6.0 | −26.7 | 14.7 | 0.567 | 0.054 | 11.6 | −1.8 | 25.0 | 0.090 | 0.160 | 4.7 | −5.0 | 14.4 | 0.343 | 0.090 | 37.0 | 30.8 | 43.3 |
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0.743 |
Participant Group* | AP-P | 3.4 | −2.6 | 9.3 | 0.266 | 0.105 | −2.1 | −6.0 | 1.8 | 0.289 | 0.101 | 0.7 | −2.1 | 3.5 | 0.626 | 0.046 | −2.3 | −5.0 | 0.3 | 0.086 | 0.162 |
NC | 7.1 | 1.1 | 13.1 |
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0.218 | −0.7 | −4.7 | 3.3 | 0.723 | 0.034 | 2.4 | −0.5 | 5.2 | 0.105 | 0.153 | −1.4 | -4.1 | 1.4 | 0.330 | 0.092 | |
Gender† | W | 0.9 | −3.0 | 4.9 | 0.636 | 0.045 | 0.1 | −2.5 | 2.7 | 0.945 | 0.007 | −2.4 | −4.2 | −0.6 |
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0.247 | 0.8 | −1.0 | 2.5 | 0.392 | 0.081 |
Age (years) | – | −0.2 | −0.3 | 0.0 |
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0.213 | 0.0 | −0.1 | 0.1 | 0.534 | 0.059 | 0.0 | −0.1 | 0.1 | 0.659 | 0.042 | 0.0 | -0.1 | 0.1 | 0.984 | 0.002 |
AQ Total | – | 0.4 | 0.1 | 0.7 |
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0.211 | 0.1 | −0.1 | 0.3 | 0.484 | 0.067 | 0.0 | −0.1 | 0.2 | 0.683 | 0.039 | −0.5 | −0.6 | −0.3 |
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0.569 |
SPQ-BR Positive | – | 0.5 | 0.3 | 0.7 |
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0.406 | 0.1 | 0.0 | 0.3 | 0.122 | 0.146 | 0.0 | −0.1 | 0.1 | 0.411 | 0.078 | 0.1 | 0.0 | 0.2 | 0.243 | 0.111 |
SPQ-BR Negative | – | 0.0 | −0.3 | 0.4 | 0.826 | 0.021 | 0.0 | −0.2 | 0.2 | 0.953 | 0.006 | 0.5 | 0.3 | 0.6 |
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0.503 | −0.1 | −0.3 | 0.0 | 0.122 | 0.146 |
SPQ-BR Disorganized | – | 0.4 | 0.1 | 0.7 |
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0.236 | 0.1 | −0.2 | 0.3 | 0.632 | 0.045 | −0.2 | −0.3 | 0.0 |
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0.195 | −0.1 | −0.2 | 0.1 | 0.508 | 0.063 |
ALS-18 Total | – | −0.1 | −0.3 | 0.0 |
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0.215 | 0.0 | −0.1 | 0.1 | 0.894 | 0.013 | 0.0 | 0.0 | 0.1 | 0.354 | 0.088 | |||||
ERQ-9 Cognitive Reappraisal | – | −0.3 | −0.6 | 0.0 |
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0.215 | 0.0 | −0.2 | 0.1 | 0.580 | 0.053 | 0.2 | 0.0 | 0.3 |
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0.224 | |||||
ERQ-9 Emotion Suppression | – | 0.0 | −0.4 | 0.4 | 0.894 | 0.013 | −0.1 | −0.3 | 0.2 | 0.580 | 0.053 | 0.1 | −0.1 | 0.2 | 0.554 | 0.056 | |||||
QCAE Perspective Taking | – | 0.2 | −0.2 | 0.6 | 0.354 | 0.088 | 0.3 | 0.1 | 0.6 |
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0.224 | 0.1 | −0.1 | 0.3 | 0.554 | 0.056 |
Bold/italic p-values indicate significant terms at the 5% level. Gray cells indicate that the corresponding term has not been included in the regression. Cat., Categorical; SPQ-BR, Schizotypal Personality Questionnaire; CI, Confidence interval; AP-P, Autistic people with psychosis; NC, Neurotypical controls; W, Woman; AQ, Autism quotient; ALS-18, Affective lability scale-18; ERQ-9, Emotional regulation questionnaire-9; QCAE, Questionnaire of cognitive and affective lability. *‘AP-NP’ group taken as reference level. †‘Man’ taken as reference level.
Regression models within two of the best AICc for each SPQ-BR scale (Total, Positive, Negative and Disorganized) are shown in
The fit of the final models is given in
Fitted Schizotypal regressions.
Variable | Cat. level | SPQ-BR regressions (n = 123) | |||||||||||||||||||
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Total (adjusted R² = 0.61) | Positive (adjusted R² = 0.41) | Negative (adjusted R² = 0.68) | Disorganized (adjusted R² = 0.28) | ||||||||||||||||||
b | 95% CI | P-value | r | b | 95% CI | P-value | r | b | 95% CI | P-value | r | b | 95% CI | P-value | r | ||||||
Intercept | – | 18.9 | −8.0 | 45.8 | 0.167 | 0.130 | −4.2 | −21.5 | 13.0 | 0.629 | 0.045 | 7.7 | −2.7 | 18.2 | 0.144 | 0.137 | 15.4 | 4.0 | 26.8 | 0.009 | 0.244 |
Participant Group* | AP-P | 6.2 | −1.7 | 14.0 | 0.122 | 0.145 | 6.7 | 1.6 | 11.7 |
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0.240 | 0.2 | −2.8 | 3.2 | 0.895 | 0.012 | −0.7 | −4.0 | 2.6 | 0.673 | 0.040 |
NC | −4.7 | −12.9 | 3.6 | 0.265 | 0.105 | −3.6 | −8.9 | 1.7 | 0.178 | 0.126 | −0.1 | −3.3 | 3.1 | 0.946 | 0.006 | −0.9 | −4.4 | 2.5 | 0.595 | 0.050 | |
Gender† | Woman | −1.1 | −6.4 | 4.2 | 0.672 | 0.040 | −0.5 | −3.8 | 2.9 | 0.790 | 0.025 | 0.0 | −2.0 | 2.1 | 0.979 | 0.002 | −0.7 | −2.9 | 1.5 | 0.535 | 0.058 |
Age (years) | – | 0.1 | −0.2 | 0.3 | 0.545 | 0.057 | 0.1 | −0.1 | 0.2 | 0.356 | 0.087 | 0.0 | −0.1 | 0.1 | 0.740 | 0.031 | 0.0 | −0.1 | 0.1 | 0.740 | 0.031 |
AQ Total | – | 0.5 | 0.1 | 1.0 |
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0.221 | 0.0 | −0.2 | 0.3 | 0.728 | 0.033 | 0.3 | 0.2 | 0.5 |
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0.345 | 0.2 | 0.0 | 0.3 | 0.115 | 0.148 |
ALS-18 Total | – | 0.7 | 0.5 | 0.9 |
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0.505 | 0.4 | 0.3 | 0.5 |
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0.484 | 0.1 | 0.0 | 0.2 | 0.058 | 0.177 | 0.2 | 0.1 | 0.3 |
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0.354 |
ERQ-9 Cognitive Reappraisal | – | 0.3 | −0.1 | 0.7 | 0.118 | 0.147 | 0.2 | 0.0 | 0.5 | 0.090 | 0.159 | 0.0 | −0.1 | 0.2 | 0.706 | 0.036 | 0.1 | −0.1 | 0.2 | 0.432 | 0.074 |
ERQ-9 Emotion Suppression | – | 0.7 | 0.3 | 1.2 |
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0.291 | 0.3 | 0.0 | 0.6 |
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0.187 | 0.6 | 0.4 | 0.7 |
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0.517 | −0.1 | −0.3 | 0.1 | 0.198 | 0.121 |
QCAE Perspective Taking | – | −0.1 | −0.7 | 0.4 | 0.691 | 0.037 | 0.1 | −0.2 | 0.5 | 0.453 | 0.071 | −0.2 | −0.4 | 0.1 | 0.143 | 0.137 | −0.1 | −0.3 | 0.1 | 0.465 | 0.069 |
Bold/italic p-values indicate significant terms at the 5% level. Cat., Categorical; SPQ-BR, Schizotypal Personality Questionnaire; CI, Confidence interval; AP-P, Autistic people with psychosis; NC, Neurotypical controls; AQ, Autism quotient; ALS-18, Affective lability scale-18; ERQ-9, Emotional regulation questionnaire-9; QCAE, Questionnaire of cognitive and affective lability. *’AP-NP’ group taken as reference level. †’Man’ taken as reference level.
Between groups, schizotypy differences are minimal. For total schizotypy, there was a significant difference between NC and AP-P, with AP-P scoring approximately 11 units higher. On positive schizotypy, AP-P scored significantly higher than both AP-NP and NC. Other group differences were small and non-significant.
Across Positive, Negative and Disorganized scales, AQTotal was only significantly associated with negative schizotypy. This was the second largest effect on the Negative scale, and likely drives the significant relationship with AQTotal on the Total scale.
ALS-18 Total had a significant and the largest impact within each of the Positive and Disorganized scales. Accordingly, ALS-total significantly impacts on SPQ-BR Total and has the largest impact thereon. ERQ-9 Emotion Suppression had a significant effect on the Positive and Negative scales, and had the third and largest impact on these respectively. These relationships likely drive the significant impact of ERQ-9 Emotion Suppression on SPQ-BR Total.
There were no significant relationships between the SPQ-BR subscales and gender, age, ERQ-9 Cognitive Reappraisal, or QCAE Perspective Taking respectively.
With no interactions with Participant Group, we had no evidence for effects noted above differing by Participant Group (however, this is
Unadjusted comparisons between groups on the three ALS-18 subscales are detailed in
Adjusted comparisons between groups on the three ALS-18 subscales are detailed in
Regressions relating the ALS-18 subscales to SPQ-BR measures, alongside other variables, are reported in
Fitted Schizotypal regressions with ALS-18 subscales.
Variable | Cat. level | SPQ-BR regressions (with ALS-18 subscales) (n = 123) | ||||||||||||||||||||
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Total (adjusted R² = 0.62) | Positive (adjusted R² = 0.41) | Negative (adjusted R² = 0.74) | Disorganized (adjusted R² = 0.32) | |||||||||||||||||||
b | 95% CI | P-value | r | b | 95% CI | P-value | r | b | 95% CI | P-value | r | b | 95% CI | P-value | r | |||||||
Intercept | – | 16.5 | −11.2 | 44.2 | 0.239 | 0.112 | −3.1 | −21.0 | 14.9 | 0.734 | 0.032 | 5.3 | −6.2 | 16.9 | 0.359 | 0.089 | 10.9 | −0.6 | 22.4 | 0.063 | 0.175 | |
Participant Group* | AP-P | 6.1 | −1.8 | 13.9 | 0.131 | 0.143 | 6.3 | 1.2 | 11.4 |
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0.226 | 6.0 | −3.1 | 15.1 | 0.196 | 0.125 | 0.0 | −3.2 | 3.3 | 0.978 | 0.003 | |
NC | −4.9 | −13.1 | 3.4 | 0.242 | 0.111 | −4.0 | −9.3 | 1.4 | 0.145 | 0.138 | −9.9 | −17.4 | −2.5 |
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0.248 | −0.3 | −3.8 | 3.1 | 0.851 | 0.018 | ||
Gender† | Woman | −2.6 | −8.1 | 2.9 | 0.348 | 0.089 | −0.9 | −4.4 | 2.6 | 0.619 | 0.047 | −0.9 | −2.8 | 1.1 | 0.380 | 0.085 | −0.9 | −3.2 | 1.4 | 0.441 | 0.073 | |
Age (years) | – | 0.1 | −0.1 | 0.3 | 0.476 | 0.068 | 0.1 | −0.1 | 0.2 | 0.401 | 0.080 | 0.0 | −0.1 | 0.1 | 0.900 | 0.012 | 0.0 | −0.1 | 0.1 | 0.425 | 0.076 | |
AQ total | – | 0.6 | 0.1 | 1.0 |
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0.225 | 0.0 | −0.3 | 0.3 | 0.857 | 0.017 | 0.4 | 0.2 | 0.6 |
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0.400 | 0.2 | 0.0 | 0.4 |
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0.212 | |
ALS-18 Anxiety/Depression | – | 1.3 | 0.5 | 2.1 |
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0.295 | 0.7 | 0.2 | 1.2 |
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0.245 | 0.6 | 0.3 | 0.8 |
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0.364 | 0.1 | −0.3 | 0.4 | 0.726 | 0.033 | |
ALS-18 Depression/Elation | – | 0.6 | 0.1 | 1.2 |
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0.223 | 0.3 | −0.1 | 0.6 | 0.107 | 0.153 | −0.1 | −0.3 | 0.1 | 0.210 | 0.121 | 0.5 | 0.2 | 0.7 |
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0.364 | |
ALS-18 Anger | – | 0.0 | −0.7 | 0.8 | 0.919 | 0.010 | 0.3 | −0.2 | 0.9 | 0.184 | 0.126 | −0.3 | −0.6 | 0.1 | 0.145 | 0.140 | −0.2 | −0.5 | 0.2 | 0.302 | 0.098 | |
ERQ-9 Cognitive Reappraisal | – | 0.3 | −0.1 | 0.7 | 0.089 | 0.161 | 0.2 | 0.0 | 0.5 | 0.082 | 0.164 | 0.0 | −0.2 | 0.2 | 0.794 | 0.025 | 0.1 | −0.1 | 0.2 | 0.392 | 0.081 | |
ERQ-9 Emotion Suppression | – | 0.7 | 0.3 | 1.2 |
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0.282 | 0.3 | 0.0 | 0.6 |
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0.188 | 0.6 | 0.4 | 0.7 |
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0.540 | −0.2 | −0.3 | 0.0 | 0.105 | 0.153 | |
QCAE Perspective Taking | – | −0.1 | −0.6 | 0.5 | 0.820 | 0.022 | 0.1 | −0.2 | 0.5 | 0.492 | 0.065 | −0.1 | −0.3 | 0.1 | 0.441 | 0.075 | 0.0 | −0.3 | 0.2 | 0.811 | 0.023 | |
Participant Group × |
AP-P:Anger | −0.3 | −0.9 | 0.3 | 0.304 | 0.099 | ||||||||||||||||
NC : Anger | 0.7 | 0.2 | 1.3 |
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0.263 | |||||||||||||||||
Participant Group × |
AP-P:ERQ-9 CR | −0.2 | −0.6 | 0.2 | 0.338 | 0.093 | ||||||||||||||||
NC : ERQ-9 CR | 0.4 | 0.1 | 0.7 |
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0.226 |
Bold/italic p-values indicate significant terms at the 5% level. Cat., Categorical; SPQ-BR, Schizotypal Personality Questionnaire; CI, Confidence interval; AP-P, Autistic people with psychosis; NC, Neurotypical controls; AQ, Autism quotient; ALS-18, Affective lability scale-18; ERQ-9, Emotional regulation questionnaire-9; QCAE, Questionnaire of cognitive and affective lability; CR, Cognitive reappraisal. *‘AP-NP’ group taken as reference level. †‘Man’ taken as reference level.
Fitted interactions between participant group and ALS-18 Anger in SPQ-BR Negative regression with ALS-18 subscales (see
Our study set out to examine whether there was a role for emotional factors to explain existing known relationships between ASD traits and schizotypal traits. In particular, we were interested in the role of emotion regulation, affective lability, and perspective taking/empathy in understanding the relationship between these constructs. Our results replicated those found in previous research in terms of the relationship between AP and NC groups on variables such as schizotypal traits, autistic traits, and empathy. We tested four novel hypotheses, finding that affective processes do appear to contribute to the model of interaction between schizotypal and autistic traits, but our results were not fully conclusive. Taking each hypothesis in turn:
While in the uncorrected analysis the AP-P group reported significantly greater affective lability, particularly shifts between elation and depression, this difference was not found in the adjusted model. There was no effect found of group on emotion regulation strategy usage, either helpful or unhelpful, and the results provide no corroboration for this hypothesis. However, there is significant gender imbalance between groups, with the AP-P group having proportionally fewer women than the AP-NP group, which may have impacted our ability to identify differences even having controlled for gender. Female AP are known to present differently to male AP in multiple ways (
We found no evidence to support this hypothesis. While AP in general reported worse perspective taking in our study than NC, there was no significant difference between AP groups. This combined with the results of H3, suggest that the psychotic experiences of AP-P are not linked with high levels of empathizing after the onset and resolution of their acute episodes of mental ill-health. We cannot say whether their self-reported empathizing skills would have been at the time of their illness. It is also possible that our study was under-powered to detect differences, as previous research has shown differences between AP-P and AP-NP in empathizing, using a different measure (
While this was not true for overall schizotypal traits, it was supported for Positive Schizotypy. Both autistic groups had higher mean levels of schizotypy across the three subscales (Positive, Negative, and Disorganized) than NC, although not all of these comparisons were statistically significant.
The premise of this hypothesis is that emotional processes are involved with or impacted by schizotypy, regardless of other factors. This hypothesis was supported. Affective lability has a significant and positive association with overall schizotypy (as one increases, so does the other); further, this is also the strongest association with schizotypy among the variables considered here (r = 0.5, a large effect). This suggests an important relationship between these constructs. Exploratory analysis of the subscales of the ALS-18 suggests that different affective processes may be related to different schizotypal traits. For example, we found that switches between anxiety and depression (ALS-18 anxiety/depression) were more strongly associated with Positive and Negative schizotypy. Switches between depression and elation associated more with Disorganized schizotypy. We also found that, as predicted, Emotional Suppression is significantly associated with greater overall schizotypy, and specifically Positive and Negative schizotypy.
It is important to note that the relationship between emotional processes and negative schizotypy is complex and appears to be affected by the presence of an ASD diagnosis. The two group by measure interactions that we found in the analyses both related to negative schizotypy, and in both cases, the AP groups showed a different relationship between affective lability, emotion regulation, and negative schizotypy, when compared to NC. This suggests that there may be something fundamentally different in the way that AP report experiencing and managing anger. It is also interesting to consider how AP, who show more negative schizotypal traits, report better use of an emotion regulation strategy that relies on logically appraising the situation (Cognitive Reappraisal). The finding may indicate a specific relevance of or different understanding of the descriptions of Cognitive Reappraisal between AP and NC, for example. This requires further investigation.
Potentially impacting on generalizability, this study’s sample sizes were small. This was partially a by-product of selecting a rare dual diagnostic group such as AP-P, and also the nature of the study as exploratory investigation of a novel hypothesis. The sample size particularly impacts on the statistical power to detect interactions. Conclusions, particularly based on interactions, should be interpreted with caution given the small sample size. It may be helpful to consider our results as preliminary in light of these limitations, and further research is clearly required to confirm and expand on them.
Recruitment methods varied between groups, potentially introducing bias: for example, mental status relating to autism and psychosis were retrospectively determined, which may produce bias and impact on the results of the study. Additionally, further screening of individuals may have been useful: AP-NP and NC groups were not screened, and so may have mis-represented their diagnostic status. Psychopathology screening would have helped rule out other confounding relationships. However, additional screening would have added to participant burden and so may have not been as useful as hoped as we are not aware of evidence to suggest research participants have been found to under-represent their mental health status.
Given the limitations of the small sample and limited screening, but the interesting relationships highlighted, future research replicating these results would be valuable. Increased screening of participants to confirm group diagnoses and rule out general psychopathology would help reduce bias from unmeasured confounders. Controlling for additional demographic variables may also further reduce bias. Other designs—such as matching—might also be considered.
As found in previous research, there appears to be a complex relationship between negative schizotypy, disorganized schizotypy, and autistic traits, and our results have suggested that these traits correlate with emotional processing differences. Future studies would benefit from comparing AP-P to other populations with psychosis to further understanding in this area.
It seems plausible to us that emotional processes, particularly affective lability, add to the model of relationship between autistic and schizotypal constructs. To our knowledge, these factors have not previously been considered in this research field. Lability involving anxious emotional states is associated with positive and negative schizotypy, while lability involving elated emotional states is associated with disorganized schizotypy, suggesting that different emotional experiences may give rise to or be caused by different patterns of thought or behavior. AP as a whole in our study reported significantly higher negative schizotypal traits than NC, replicating previous findings. However, this difference was complicated by interactions with euthymia/anger lability and use of cognitive reappraisal as an emotion regulation strategy, which require further research to replicate and explore further.
Clinically, we would hypothesize that individuals with emotion regulation difficulties and affective lability are likely to be those with either underlying neurobiological differences and/or histories of traumatic experiences such as difficulties during pregnancy/birth [e.g. (
We believe that our finding could be considered a development of the stress-vulnerability theory of psychosis (
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
The study involved human participants and was reviewed and approved by North of Scotland NHS Research Ethics Committee. All patients/participants provided informed consent to participate in this study, either written or electronic.
FL led design of the study, with contributions from AW, SW, RR, and KC. FL gathered the data. AW conducted data analysis in collaboration with FL. All authors contributed to the article and approved the submitted version.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
We would like to thank all of the participants in this research who gave so generously of their time to help further understanding in this area. This work would not be possible without them. We are also grateful for the support the Autism Research Centre showed towards this project in allowing us to approach volunteers from their database and ask them to take part in the study.
AW’s involvement with the work presented here was supported by the National Institute of Health Research (NIHR) Applied Research Collaboration East of England (ARC EoE) program. This research was also supported by the NIHR Cambridge Biomedical Research Centre. In particular, we wish to thank Dr. Simon R White for his statistical advice and support. The views expressed are those of the authors and not necessarily those of the NIHR, NHS or the Department of Health and Social Care.
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