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The relation between emotional awareness and hallucinations

and delusions in acute psychiatric inpatients

Mark Serpera,, Howard Berenbaum b

aDepartment of Psychology, Hofstra University, Hofstra University, Hempstead, NY 11549-1350, United States

b Department of Psychology, University of Illinois at Urbana-Champaign, United States

Received 16 October 2007; received in revised form 2 January 2008; accepted 7 January 2008

Available online 13 February 2008

Abstract

Background: Although negative affect has been frequently implicated in the formation of cognitive and perceptual disturbances

ranging from odd perceptions and beliefs to delusions and hallucinations it represents only one of the many aspects of emotional

disturbances that may contribute to psychopathology. Surprisingly, no past research has examined in a psychiatric sample whether

levels of cognitiveperceptual symptoms are associated with levels of emotional awareness (i.e., attention to emotion and clarity of

emotion). In the present study we examined, in an acute psychiatric inpatient sample, the relations between emotional awareness

and the severity of delusions and hallucinations.

Method: Two groups were included: 34 schizophrenia and schizophrenia spectrum disordered inpatients and 30 mood and

substance use disordered inpatients. Patients were assessed on emotional awareness (attention to emotion and emotional clarity)

and severity of psychiatric symptomatology.Results: We found that lower levels of emotional clarity were associated with more severe hallucination ratings in both groups of

patients. Among schizophrenia spectrum patients, lower levels of attention to emotion were also associated with more severe

hallucination ratings. Among mood/substance disorder participants, higher levels of attention to emotion were associated with more

severe delusion ratings, whereas the opposite pattern was found among schizophrenia spectrum participants.

Conclusions: Consistent with the results of past research using college and community samples, we found that diminished

emotional clarity is associated with elevated levels of hallucinations in both mood disorder/substance abuse and schizophrenia

spectrum inpatients. We also found that greater attention to emotion was associated with more severe delusions, though only among

the mood disorder/substance use group. The present research findings support the role of emotional awareness in hallucination

formation and suggest that the factors that contribute to delusions in schizophrenia spectrum patients differ, in part, from the factors

that contribute to delusion formation in other groups of individuals.

2008 Elsevier B.V. All rights reserved.

Keywords: Delusions; Hallucinations; Emotional awareness

1. Introduction

Dating back to Bleuler (1911/1950), psychopatholo-

gists have posited that schizophrenia symptoms are

related to disturbed emotional processes. That emo-

tional processes may play an important role in the

Available online at www.sciencedirect.com

Schizophrenia Research 101 (2008) 195200www.elsevier.com/locate/schres

Corresponding author. Tel.: +1 516 463 5837; fax: +1 516 463 6052.

E-mail address: [email protected] (M. Serper).

0920-9964/$ - see front matter 2008 Elsevier B.V. All rights reserved.doi:10.1016/j.schres.2008.01.012
mailto:[email protected]://dx.doi.org/10.1016/j.schres.2008.01.012http://dx.doi.org/10.1016/j.schres.2008.01.012mailto:[email protected]


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development of cognitive perceptual disturbances is

consistent with the evidence that emotions play a sig-

nificant role in influencing judgments, decision making,

and behaviors (e.g., Clore et al., 2001; Lowenstein et al.,

2001; Kahneman et al., 1999; Kahneman, 2003). Along

these lines, a recent study found delusion-prone indivi-duals demonstrated reasoning biases only during condi-

tions when information presented was emotionally salient

(Warman and Martin, 2006). While many past investiga-

tors have found individuals with schizophrenia make

decisions more quickly and with less information than

non-patient controls (e.g., Young and Bentall, 1997), it is

not surprising that reasoning biases appear to be more

prominent when information is emotionally salient

(Dudley et al., 1998; McGuire et al., 2001).

A great deal of theorizing and research has linked

elevated levels of unpleasant emotions with cognitive

perceptual disturbances, ranging from odd perceptions

and beliefs to delusions and hallucinations (e.g., Bentall et

al., 2001; Freeman et al., 2001). Unpleasant emotion,

however, represents only one of many aspects of emo-

tional disturbances than may contribute to psychopathol-

ogy (Berenbaum et al., 2003). The present research

examined facets of emotion other than unpleasant affect.

Specifically, it focused on two facets of emotional

awareness, attention to emotions and clarity of emotions.

Individuals vary in the degree to which they value and pay

attention to their own emotional state. Such individual

differences, labeled attention to emotions, refers to thedegree to which individuals notice, think about, and

monitor their mood states. Clarity of emotions refers to an

individual's ability to comprehend their emotions,

discriminate among their feelings, and know what they

feel. In other words, clarity of emotions can be described

as an individual's ability to identify, explain and discern

particular emotions. Attention to and clarity of emotion

are distinct from other facets of emotional experience such

as absorption, intensity and emotional expression (e.g.,

Berenbaum et al., 2003; Gohm and Clore, 2000; 2002).

The results of past research have supported the notionthat cognitive perceptual disturbances are associated

with patterns of emotional awareness. Kerns (2005), for

example, found that college students with unusually

high levels of positive schizotypy symptoms reported

paying more attention to their emotions than did control

participants. Relatedly, Kerns and Berenbaum (2000)

found, in the context of a word pronunciation task, that

college students who had unusually high levels of odd

beliefs and perceptions were more strongly influenced

than were control participants by the emotional valence

of prime words. Berenbaum et al. (2006) found that both

college students and adults from the community who

had elevated levels of cognitiveperceptual symptoms

of schizotypal personality disorder reported paying

more attention to their emotions.

Diminished clarity of emotions has also been found

to be associated with cognitiveperceptual disturbances.

In a sample of women recruited from the community,Berenbaum et al. (2003) found that higher levels of

cognitiveperceptual symptoms of schizotypal person-

ality disorder tended to be associated with diminished

clarity of emotions. Similarly, in a sample of women

participating in a weight loss program, Bach et al.

(1994) found that those women who had higher levels of

schizotypal symptoms tended to report greater difficulty

identifying their emotions. Kerns (2005) found that

college students with unusually high levels of positive

schizotypy symptoms reported lower levels of emo-

tional clarity than did control participants. Finally,Berenbaum et al. (2006) found that elevated levels of

cognitiveperceptual symptoms of schizotypal person-

ality disorder were associated with diminished clarity of

emotions among college students but not among adults

recruited from the community.

There has been a remarkable dearth of research

examining emotional awareness and psychotic symp-

toms in psychiatric patients. Cedro et al. (2001) found

that compared with non-psychiatric controls, outpatients

with schizophrenia reported greater difficulty identify-

ing their emotions and a more externally oriented think-

ing style (which is the inverse of attention to emotion).In a small sample of outpatients with schizophrenia,

Stanghellini and Ricca (1995) found that individuals

with nonparanoid schizophrenia reported greater diffi-

culty identifying their emotions and a more externally

oriented thinking style (i.e., less attention to emotion)

than did individuals with paranoid schizophrenia; un-

fortunately, the authors did not describe clearly how

they assigned patients to these two groups, though it

appeared to be based on the relative preponderance of

negative vs. positive symptoms. Maggini et al. (2002)

found that in a sample of outpatients with schizophrenia,those who had greater symptoms of depersonalization

reported greater difficulty identifying their emotions and

a more externally oriented thinking style (i.e., less

attention to emotion).

Surprisingly, no past research has examined in a

psychiatric sample whether levels of cognitivepercep-

tual symptoms are associated with levels of emotional

awareness. Based on the results of past research with

non-clinical samples, we hypothesized that greater at-

tention to emotion and diminished clarity of emotion

would be associated with higher levels of both

hallucinations and delusions. We tested these hypotheses

196 M. Serper, H. Berenbaum / Schizophrenia Research 101 (2008) 195200


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in acute psychiatric inpatient samples. Because of the

possibility that the associations between psychotic

symptoms and emotional awareness might vary depend-

ing on the nature of the psychiatric disturbance, we

examined the associations separately in two types of

patients presenting for treatment those with schizophrenia spectrum disorders and those with psychiatric

disturbances stemming for problems with mood and/or

substance use.

2. Methods

2.1. Participants

The participants were 64 individuals, 34 schizophre-

nia spectrum disordered patients (79% male) and 30

mood and substance use disordered patients (57% male).All of the participants were residing on an acute

psychiatric inpatient unit at the time of the study. They

ranged in age from 19 to 57 (M=36.4, SD=11.0 for the

schizophrenia spectrum group; M=37.4, SD=11.4, for

the mood disorder/substance abuse group). The partici-

pants belonged to the following racial/ethnic groups:

African American (55.8% of the schizophrenia spectrum

patients; 23.3% of the mood/substance patients), Cau-

casian/White (14.7% of the schizophrenia spectrum

patients; 50% of the mood/substance patients), Hispanic/

Latino (14.7% of the schizophrenia spectrum patients;

13.3% of the mood/substance disordered patients), andAsian American or other (14.7 of the schizophrenia

spectrum patients and 13.3% of the mood/substance

disordered patients).

In terms of educational attainment, 34% completed

middle school or some high school, 23% had high school,

23% completed a GED, 15% had some college and 5%

completed a college degree (M=12.9 years of educa-

tion, SD= 1.3 for the schizophrenia spectrum group;

M= 13.2 years of education, SD= 1.5 for the mood/

substance group). With regard to employment status, 91%

of the schizophrenia spectrum patients were unemployedand 73.3% of the mood/substance disordered patients

were unemployed at the time of this study.

No significant diagnostic group differences were found

between the two groups in terms of age, education, gen-

der, or employment status. Chi-square analyses revealed

significant group differences in racial/ethnic composition

(2 =13.1, df= 4, pb .05), with greater African American

group membership in the schizophrenia group and

significantly greater Caucasian/White group membership

in the mood/substance disordered group.

DSM-IV (American Psychiatric Association, 1994)

diagnoses were established for each patient using a best

estimate approach combining information from patients'

medical records, collaborative information when avail-

able, and clinical interview. The specific diagnoses of

participants in the schizophrenia spectrum group were

as follows: schizophrenia: 17; schizoaffective disorder:

10; psychotic disorder NOS: 6; delusional disorder: 1.The specific diagnoses of participants in the mood

disorder/substance abuse group were as follows: bipolar

disorder: 14; major depressive disorder: 5; mood

disorder NOS: 5; substance abuse: 2; substance induced

mood disorder: 3; substance induced psychotic disorder:

1.1 All patients were receiving psychotropic medication

including antipsychotic and/or anti-depressive medica-

tion at the time of assessment.

In terms of delusion and hallucination frequencies

in our sample, 85.7% of the schizophrenia spectrum

patients and 86.7% of the mood and substance use dis-ordered patients were positive for delusions at the time of

assessment (PANSS itemN2), while 71.4% of the

schizophrenia spectrum patients and 50% of the mood

and substance use disordered patients were positive for

hallucinations (PANSS itemN2).

2.2. Measures

2.2.1. Emotional awareness

The Toronto Alexithymia Scale (TAS; Bagby et

al., 1994) was used to measure emotional awareness.

Based on previous research (e.g., Coffey et al., 2003;Gohm and Clore, 2000), emotional clarity was

measured using the 7-item TAS difficulty identifying

emotions subscale (e.g., I have feelings that I can't

quite identify and When I am upset, I don't know if I

am sad, frightened, or angry; =.86), and attention to

emotion was measured using the 8-item TAS externally

oriented thinking subscale (e.g., Being in touch with

emotions is essential and I find examination of my

feelings useful in solving personal problems; =.43).

The TAS scales were rescored so that higher scores on

the Identification scale reflected greater levels of clarityof emotions, and higher scores on the Externally

Oriented Thinking scale reflected greater levels of

attention to emotions.

2.2.2. Psychiatric symptoms

Psychiatric symptoms were measured using the Positive

and Negative Syndrome Scale for Schizophrenia (PANSS;

Kay et al., 1987). The PANSS was conducted by research

1 Excluding the participant with substance-induced psychotic

disorder, or including him in the schizophrenia spectrum group didnot appreciably change the results.

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Contrary to expectations, among schizophrenia spec-

trum disorder participants, lower levels of attention to

emotion were associated with more severe hallucination

ratings. As expected, among mood/substance disorder

participants, higher levels of attention to emotion were

associated with more severe delusion ratings. In contrast,among the schizophrenia spectrum disorder participants,

attention to emotion was not significantly associated

with delusions. In fact, delusions were associated with

attention to emotions in the opposite direction among the

two groups, and the magnitude of the difference in

correlations was statistically significant, z=2.66, pb .01

(2-tailed). As expected, it was not the case that emotional

awareness was associated with all positive symptoms;

conceptual disorganization was not significantly asso-

ciated with either attention to or clarity of emotions

among either group of patients.

3.4. Emotional awareness, psychosis and general

psychopathology

Finally, we computed partial correlations to examine

whether the significant correlations noted above might

merely reflect shared variance with general psycho-

pathology. When removing shared variance with general

psychopathology, lower levels of emotional clarity

continued to be associated with more severe hallucina-

tions, though the correlation was no longer statistically

significant among the schizophrenia spectrum disorder participants (among mood/substance disorder partici-

pants: r= .36, pb .05; among schizophrenia spectrum

disorder participants: r= .28, p =.12).

Among schizophrenia spectrum disorder participants,

lower levels of attention to emotion continued to be

significantly associated with more severe hallucinations

(r= .36, pb .05). Among mood/substance disorder

participants, higher levels of attention to emotion

continued to be associated with more severe delusions

(r=.44, pb .05).

4. Discussion

The results of the present study indicate that

emotional awareness is associated with hospitalized

patients' delusions and hallucinations. Past research

with college students and community residents has also

found that peculiar perceptions and beliefs are asso-

ciated with individual differences in emotional aware-

ness (e.g., Berenbaum et al., 2006). Given the

importance of emotions for guiding judgments and

behavior, it should not be surprising that individual

differences in attention to and clarity of emotions are

associated with both psychotic-like experiences and

full-blown psychotic symptoms.

In both groups of patients, we found that lower levels

of emotional clarity were associated with more severe

hallucination ratings. These findings are consistent with

the results of most past research, which has found thatdiminished emotional clarity is associated with elevated

levels of cognitive perceptual symptoms in college

student and community samples (e.g., Berenbaum et al.,

2003; Kerns, 2005). We also found that among the

schizophrenia spectrum patients, lower levels of attention

to emotion were associated with more severe hallucina-

tion ratings. Kot and Serper (2002) found evidence sup-

porting a sensory conditioning mechanism underlying

hallucinatory experiences in schizophrenia patients, and

postulated that heightened conditioned emotional

responses may trigger conditioned hallucinatory behavior.Such conditioned emotional responses, possibly exacer-

bated by a lack of clarity concerning one's emotions, may

lead to both hallucinatory behavior and a disinclination to

actively attend to one's emotions.

We found that greater attention to emotion was

associated with more severe delusions, though only

among the mood disorder/substance use group. In fact,

we found that the association between delusions and

attention to emotion differed significantly between the

two groups. Past research with college student and com-

munity sample participants has consistently found that

greater attention to emotion is associated with higherlevels of odd and magical thinking. Thus, the results of

the present research suggest that the factors that con-

tribute to delusions in schizophrenia spectrum patients

differ, at least in part, from the factors that contribute to

peculiar beliefs and even delusions in other groups of

individuals. It will be important for future research to test

whether these group differences reflect group differences

in the types of delusions (e.g., mood congruent vs. mood

incongruent, bizarre vs. non-bizarre). It is possible, for

example, that when individuals are experiencing clini-

cally significant distress, paying a lot of attention toemotions leads to mood-congruent delusions.

We have two reasons to believe that individual dif-

ferences in emotional awareness are specifically asso-

ciated with hallucinations and delusions. First, emotional

awareness was not significantly associated with con-

ceptual disorganization ratings. Second, emotional aware-

ness continued, for the most part, to be associated with

hallucinations and delusions even after taking into

account shared variance with general psychopathology.

There are at least two reasons why additional research

is clearly needed. First, although the scale we used to

measure attention to emotions has often been found to

199M. Serper, H. Berenbaum / Schizophrenia Research 101 (2008) 195200


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have relatively low internal consistency [Gohm and Clore

(2000) reported an average alpha of .65], it was

particularly low in the present study. Consequently, it is

possible that we under-estimated the strength of associa-

tion between attention to emotions and our symptom

measures. Second, although we hypothesize that patternsof emotional awareness can contribute to the development

of hallucinations and delusions (especially the latter), we

must acknowledge that this is speculation on our part

given that our data are correlational in nature. It is also

quite plausible that the formation of hallucinations and

delusions contribute to changes in emotional awareness. It

will be important for future research to test these

alternative possibilities by examining emotional aware-

ness and delusions and hallucinations longitudinally. In

terms of clinical implications, the present results clearly

suggest that examination of emotional awareness vari-ables have important implications for the etiology and

treatment of hallucinations and delusions in patients with

severe and persistent mental illness.

Role of Funding Source

This investigation was not funded by an external granting agency.

Contributors

Both authors designed the study and wrote the protocol, as well as

undertook the statistical analyses, and co-wrote the manuscript. Both

authors contributed to and have approved the final manuscript.

Conflict of Interest

Both authors declare that they have no conflicts of interest.

Acknowledgments

We gratefully acknowledge Andrew Corso, M.A. and Ryan

Quirk, M.A. for their help with the subject recruitment and clinical

assessments.

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