The Authors Reply

THE AUTHORS REPLY Dear Sir: We thank Drs. Ennis and Whelton for their interest in our article (1). While we are aware of the literature indicating facial-affect recognition impairment in schizophrenia (2,3), we did not assess our patient for facial-affect impairment. Our study focused on delusional misidentification in the context of schizophrenia (4). However, the phenomena of delusional misidentification transcends schizophrenia and can be found elsewhere in organic delusional disorders and mood disorders. The preliminary results of recent research suggest that facial-affect recognition may be impaired in some but not all patients who suffer from delusional misidentification (5). The relationship between delusional misidentification, schizophrenia and face processing deficits is unclear even though there appears to be considerable overlap between these groupings. We hypothesize that at least a subgroup of schizophrenics have face recognition processing deficits, including facial-affect recognition impairments that may be intrinsically associated with delusional misidentification, although face processing deficits in schizophrenia may turn out to be a phenomenon independent of delusional misidentification in many instances. Drs. Ennis and Whelton also point out that "the relationship between face recognition, facial-affect recognition and social skills has never been studied in schizophrenia" and believe that such relationships may be of benefit to social skills training programs for schizophrenics. This is a helpful suggestion which, we agree, would benefit those schizophrenic and other psychotic patients who suffer from face processing deficits and related delusional misidentification syndromes. However, our experience with these patients in social settings such as group therapy is that they derive more benefit after both delusional misidentification and face processing deficits subside substantially. We believe that social skills rehabilitation in schizophrenia may be of benefit when these perceptual and delusional problems are taken into account while providing cognitive-type therapy aimed at facilitating greater reality testing in those patients who are beginning to stabilize. There is another aspect of facial-affect recognition that may be important in schizophrenia, particularly in those patients who also suffer from delusional misidentification syndromes in which dangerousness is a prominent concern. A significant number of the dangerous schizophrenics that we have studied who suffer from delusional misidentification also complain of facial distortion in others or misinterpret the affects or intentions of others. These patients report either aggressive ideation or violent behaviour aimed at those whom they misidentify and express fears regarding the misidentified object with distorted or "strange" faces. Some patients suffering from delusional misidentification phenomena have perpetrated serious attacks including homicides (6). We emphasize the issue of dangerousness because delusional misidentification and face (including facial-affect) recognition deficits may be more common among schizophrenics than previously assumed. In conclusion, we agree with Drs. Ennis and Whelton that facialaffect recognition may be a fruitful approach to understanding social visual cognition in schizophrenics and that it may assist social rehabilitative efforts in this disorder. Furthermore, the association between facial-affect recognition and other forms of face processing may be intrinsically associated with delusional misidentification in schizophrenia and other psychoses. Understanding this relationship may further our understanding of the social world of the schizophrenic and may have implications for public safety.