Neuropsychology

2011, Vol. 25, No. 1, 131136

2010 American Psychological Association

0894-4105/10/$12.00 DOI: 10.1037/a0020752

BRIEF REPORT

Specific Impairments of Emotion Perception in Multiple Sclerosis

Louise H. Phillips

Julie D. Henry

University of Aberdeen

University of New South Wales

Clare Scott

Fiona Summers and Maggie Whyte

University of Aberdeen

Aberdeen Royal Infirmary

Moira Cook
University of Aberdeen
Objective: Multiple sclerosis (MS) often results in demyelination of a network of frontal-subcortical
tracts involved in processing emotional information. We investigated the effect of MS on the ability to
identify emotional and nonemotional information from static and dynamic stimuli and determined
whether difficulties in emotion perception related to quality of life. Method: 32 MS and 33 control
participants, matched for age and education, identified emotions and nonemotional information from
static images of faces and dynamic videos of people interacting. They also completed cognitive
assessment and quality of life ratings. Results: On the static face perception tasks, participants with MS
performed more poorly than healthy controls on emotion perception, t(63) 3.30, p .01, d .83, but
not identity perception, t(63) 1.18, d .30. For the dynamic tasks, the MS group were impaired on
emotion perception, t(63) 3.41, p .001, d .86, but not age/gender perception, t(63) 0.15, d
.04. Ratings of social and psychological aspects of quality of life in MS were related to emotion
perception scores, controlling for disease severity and duration, age, depression, and cognitive function,
with r2 ranging from .17 to .24. Conclusions: These results indicate a specific deficit in decoding static
and dynamic information about emotion in MS, as compared to nonemotional information. There were
specific relationships between emotion perception problems and poor social and psychological quality of
life, indicating that emotional skills should be considered when evaluating functioning in MS.
Keywords: multiple sclerosis, emotion perception, quality of life

(Beatty, Orbelo, Sorocco, & Ross, 2003) and pictures of facial

expressions (Beatty et al., 1989). Henry et al. (2009) reported that
people with MS performed more poorly than matched controls in
identifying facial expressions of the basic emotions of fear and
anger, as well as having difficulties in identifying more complex
emotional states, such as hostility and interest, from pictures
of the eye region in a test designed to assess theory of mind.
These effects of MS on emotion perception might reflect a
specific problem in the processing of affective information or,
instead, more general changes in perceptual and cognitive processing. Beatty et al. (2003) reported that the problems in processing
prosodic information about emotions in MS were unrelated to
peripheral hearing loss, depression, or cognitive impairment. In
contrast, Beatty et al. (1989) reported that a group of MS patients
were impaired at both emotional and nonemotional tasks of face
processing, indicating a more general difficulty with the perceptual
demands of perceiving emotions from faces. Henry et al. (2009)
found that problems with emotion perception in MS were correlated with some measures of cognitive performance: particularly
processing speed and executive functioning. This suggests that
emotion perception difficulties may reflect more general information-processing impairments in MS.
In the current study, we directly investigated whether problems
in emotion perception in MS were specific to the affective elements of the task by matching emotion perception tasks to control
conditions with similar perceptual and cognitive demands but no

Multiple sclerosis (MS) is an inflammatory brain disorder.

While much is known of cognitive impairment in MS, such as
slowed processing and executive dysfunction (Kalmar, Gaudino,
Moore, Halper, & Deluca, 2008), there has been less research on
emotional skills. As emotional skills are essential for interpersonal
interaction and social communication, it is important to understand
the effects of MS on these functions. MS is associated with
disconnection in the frontal-subcortical brain tracts known to be
involved in the processing of emotional signals (Adolphs,
Damasio, Tranel, Cooper, & Damasio, 2000; Ruffman, Henry,
Livingstone, & Phillips, 2008). There is some evidence that MS
can influence emotion perception, with studies identifying significant impairment in decoding emotional states from prosodic cues

This article was published Online First November 22, 2010.

Louise H. Phillips, School of Psychology, University of Aberdeen; Julie
D. Henry, School of Psychology, University of New South Wales; Clare
Scott, School of Psychology, University of Aberdeen; Fiona Summers and
Maggie Whyte, Aberdeen Royal Infirmary; Moira Cook, School of Psychology, University of Aberdeen.
This research was funded by Tenovus, Scotland.
Correspondence concerning this article should be addressed to Louise H.
Phillips, School of Psychology, College of Life Sciences and Medicine,
University of Aberdeen, Aberdeen, Scotland, United Kingdom, AB24
2UB. E-mail: louise.phillips@abdn.ac.uk
131

132

BRIEF REPORT

requirement to process emotional information. This allows a

clearer delineation of whether effects of MS on emotion perception
tasks are specific to decoding emotions or instead reflect perceptual difficulties inherent in processing information about people.
Two different measures of emotion perception were included. The
first, the Ekman and Friesen photographs of facial expressions, is
the most commonly used measure of emotion perception in neuropsychological studies. A control task based on recognizing facial
identity from photographs was also used. The second emotion
perception task used dynamic stimuli. Although the majority of
studies into emotion perception use photographs of emotions, in
everyday life emotional expressions are fleeting and dynamic
(Ambadar, Schooler, & Cohn, 2005). It is important to establish
whether any effects of MS upon emotion perception extend to
more naturalistic, dynamic visual stimuli. In the current study,
participants labeled emotions from brief video clips of interpersonal interactions (Sullivan & Ruffman, 2004). A control task was
also administered which required age and gender judgments from
the same dynamic stimuli. We also explored the role of cognitive
function and depression in the effects of MS on emotion perception.
Efficiently identifying other peoples emotions is critical for
interpersonal functioning, with difficulties in understanding others emotions linked to lower social competence (Bornhofen &
McDonald, 2008), communication skills (Spell & Frank, 2000),
and quality of life (Phillips, Scott, Henry, Mowat, & Bell, 2010).
It has been suggested that emotion perception difficulties in MS
might adversely affect social interactions (Beatty et al., 2003), but
this has not been directly tested to date. MS impacts on many
domains of well-being, including social and psychological functioning (Chopra, Herrman, & Kennedy, 2008). In the current study,
we assessed multiple domains of quality of life and tested the
specificity of relationships between emotion perception and aspects of well-being.
This study, therefore, had three aims. The first was to investigate
whether MS was associated with impaired ability to decode both
static and dynamic representations of emotion. Second, we tested
whether the influence of MS on emotion perception was specific to
the affective processing required by the tasks. The final aim was to
test the hypothesis that problems with emotion perception in MS
would relate to social and psychological aspects of quality of life,
controlling for disease severity, cognition and age. In contrast,
measures of disease severity, which traditionally focus on motor
symptoms, should relate to physical aspects of self-rated quality of
life.

those with progressive disease variants were not. None of the

participants was undergoing a relapse during testing. Participants
mean score on a researcher-rated variant of the Disease Steps
measure of MS severity (Hohol, Orav, & Weiner, 1995) was 2.22
(SD 1.68), with scores spanning the maximum range on this
measure from 0 (normal) to 6 (confined to wheelchair). The
Disease Steps correlates strongly (r .96) with the physicianencoded Kurzke Expanded Disability Status Scale (EDSS; Hohol
et al., 1995; Kurtzke, 1983).
Control participants (n 33; 24 female) were recruited from the
general community via advertisements and word of mouth. They
ranged in age from 27 to 60 years (M 44.4, SD 9.8). The MS
group ranged in age from 27 to 66 years (M 44.0, SD 9.2).
The mean age in years of the two groups did not differ significantly, t(63) 0.17, d 0.04. The two groups also did not
significantly differ in years of education (for the control group,
M 16.7 years, SD 3.5, the MS group, M 15.3, SD 3.4,
t(63) 1.61, d 0.40). Participants also completed the Hospital
Anxiety and Depression scales (HADS; Zigmond & Snaith, 1983),
see Table 1.
Grampian National Health Service Local Research Ethics Committee granted ethical approval, and all participants provided informed consent. Exclusion criteria for both groups included (a)
history of neurological disease (other than MS for the MS participants); (b) history of major psychiatric illness; (c) presence or
premorbid history of alcohol or drug abuse; (d) severe motor
disturbances, current optic neuritis, or other visual deficit which
would interfere with testing.

SD

SD

Methods

74.31
83.63
64.62
64.45

9.84
7.35
11.29
12.84

81.64
85.73
73.48
64.96

7.97
6.99
9.64
14.06

59.37
60.42
69.49
72.36
40.84
88.59
7.25
5.56
5.22

19.64
18.02
19.94
13.38
16.15
14.10
1.92
3.78
4.63

87.12
69.95
78.28
78.60
48.94
96.21
7.33
5.27
2.18

11.19
12.40
12.83
8.53
13.75
4.34
1.95
2.29
2.01

Participants
The National Health Service Grampian MS Research Database
was used to recruit 32 participants with MS (28 female). All
participants met McDonald criteria for MS (McDonald et al.,
2001), as assessed by a neurologist, including lesions present on
MRI. The mean time since clinical diagnosis was 7.87 years
(SD 5.48), and 27 of the participants had the relapsing-remitting
form of the illness, while two had the primary and three the
secondary progressive form, as ascertained by a neurologist. The
majority of relapsing-remitting patients (21 out of 27) were taking
disease-modifying medication (primarily beta interferon), while

Measures
Each participant completed the FAS letter fluency task (words
beginning with F, A, and S for one minute each), which is known
to tap both speed of processing and executive functioning and to be
Table 1
Descriptive Statistics for Measures of Emotion Perception,
Control Tasks of Identity and Age/Gender Judgments, Quality
of Life, Cognition, and Mood in Participants With MS
and Controls
MS group

% Accuracy on emotion and

control tasks
Emotion static
Identity static
Emotion dynamic
Age/gender dynamic
WHOQoL Domain Score
QoL Physical
QoL Psychological
QoL Social
QoL Environmental
FAS Fluency total score
SART go nogo (% correct)
Delayed recall
HADS-Anxiety
HADS-Depression

Indicates a group difference at p .05.

Control group

at p .01.

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BRIEF REPORT

among the most sensitive neuropsychological measures to cognitive impairment in MS (Henry & Beatty, 2006). Participants also
completed the memory task from the Screening Examination for
Cognitive Impairment (SEFCI; Beatty et al., 1995). A list of 10
words was read out, and participants were asked to recall as many
as possible. Three such learning trials were given. About 10
minutes after the last learning trial, a single delayed-recall trial was
given; performance on this was the dependent measure of interest.
A final cognitive task was the Sustained Attention to Response
Task (SART, Robertson, Manly, Andrade, Baddeley, & Yiend,
1997), which is a variant of the Go NoGo task measuring attentional control and inhibitory skill. Participants completed 100
trials, for each a single digit was displayed on a computer screen.
On the appearance of a number, the task was to press the spacebar
as quickly as possible and say the digit out loud, except when the
number was 3 or 9 (20% of trials), where the instruction was to
withhold making any response. Performance was recorded in terms
of the percentage of 3 or 9 trials where responses were correctly
withheld.
Participants completed the following tasks, with presentation
order of the emotion and control tasks counterbalanced.
Static images of facial emotion task. This test consisted
of 48 photographs from the standard set of Ekman facial expressions, computer morphed to vary the emotional intensity portrayed
(Young, Perret, Calder, Sprengelmeyer, & Ekman, 2002). The
depicted expressions were fear, surprise, anger, disgust, happiness,
and sadness, each displayed by four different individuals (two
male and two female). Four faces displaying each emotion were
presented at 100% emotion intensity, and four at 75% emotion
intensity. Each was presented on a computer screen accompanied
by the six emotion labels and the task was to select the label that
best described the expression. The order of the photographs was
randomized, and percentage accuracy of performance was assessed.
Static identity perception photograph task. The Benton facial identity recognition test (Benton, Hamsher, Varney, & Spreen,
1983) was included to assess nonemotional aspects of facial perception. Participants were presented with a target face situated
above an array of test faces and had to identify which of the test
faces was the same person as the target face. Percentage accuracy
of identification was recorded.
Dynamic emotion perception video task. This task (Slessor,
Phillips, & Bull, 2007) consisted of 16 silent 5-s color video clips
adapted from Sullivan and Ruffman (2004), portraying characters
interacting. Each clip was surrounded by four possible options
describing emotional states, such as frustrated, excited, annoyed,
and bored. The options were visible before, during, and after the
video clip. Participants were instructed to choose the word which
best described the feelings of the person in the video. It was clear
from the angle of filming which character participants were expected to judge.
Dynamic age and gender perception video task. Using the
same video clips as in the dynamic emotion perception task,
participants saw a video clip and had to choose the option that best
described the age and gender of the key character (e.g., Male
40 50, Female 40 50, Female 50 60, Male 50 60). As before,
the options appeared before, during, and after the video clip. This
control task has previously been used to explore the specificity of
mental state labeling problems (Slessor et al., 2007).

World Health Organization quality of life questionnaire

(WHOQoL-BREF; Skevington, Lofty, & OConnell, 2004).
At the end of the session participants completed this quality of life
measure, which required them to rate various aspects of their QoL
over the previous two weeks. Four distinct domains of QoL (Physical, Psychological, Social, Environmental) were assessed using 24
questions. Higher scores represent better QoL, with scores calculated on a 0 100 scale. The WHOQoL-BREF domain scores have
good construct and discriminant validity, as well as acceptable
reliability and sensitivity to health improvements (Skevington et
al., 2004).

Results
Performance on the emotion and control tasks are shown in
Table 1. The effects of participant group and task type (emotion vs.
identity) on the static face perception tasks were examined using a
mixed design ANOVA. There was an effect of task, F(1,
63) 41.7, p .001, 2p .398, with the identity perception task
performed better than the emotion perception task. Overall, the MS
group performed more poorly than the control group, F(1,
63) 7.50, p .01, 2p .106, but this was qualified by a
group task interaction, F(1, 63) 6.33, p .05, 2p .091. To
explore this interaction, independent samples t tests investigating
group differences in each of the tasks were carried out. These
revealed significantly worse emotion perception performance
among those with MS compared to controls, t(63) 3.30, p .01,
d .83, but no group effect on identity perception, t(63) 1.18,
d .30.
The next analysis investigated the effects of participant group
and task type (emotion vs. age/gender) on the video perception
tasks. There was an effect of task, F(1, 63) 4.77, p .05, 2p
.070, with the emotion perception task performed better than the
age/gender task. Overall, the MS group performed more poorly
than the control group, F(1, 63) 4.38, p .05, 2p .065, but
this was again qualified by a group task interaction, F(1,
63) 4.40, p .05, 2p .065. To explore this interaction, t tests
investigating group differences in each of the tasks were carried
out. These again revealed worse emotion perception performance
among those with MS compared to controls, t(63) 3.41, p
.001, d .86, but no group effect on age/gender perception,
t(63) 0.15, d .04.
MS and control groups differed in their FAS fluency performance, t(63) 2.18, p .05, d 0.55, with the patient group
producing fewer words, see Table 1 for descriptive statistics. The
groups also differed in scores on the SART Go NoGo task, with
the MS group making more inhibitory errors, t(63) 2.96, p
.01, d 0.75. However, the groups did not significantly differ on
the delayed recall memory score, t(63) 0.17, d 0.04. Descriptive information shown in Table 1 indicates that those with MS
were more depressed, t(63) 3.45, p .001, d 0.87, but not
more anxious, t(63) 0.37, d 0.09, than controls. In order to
test whether the effect of MS on emotion perception might be
related to slower and less efficient cognitive processing and levels
of depression, partial correlations accounting for these measures
were calculated. Point biserial correlations between group membership (control/MS) and emotion perception were r .384 for
the static and r .394 for the dynamic tasks, both ps .01.
These correlations were reduced but remained significant once

134

BRIEF REPORT

variance due to all three cognitive tasks and depression was

controlled (rp .292 and .279, respectively; both ps .05).
Quality of life in the sample is described in Table 1, and t tests
revealed that people with MS rated their quality of life as poorer
than controls in all domains of functioning: physical, t(63) 7.03,
p .01, d 1.77; psychological, t(63) 2.49, p .05, d .63;
social, t(63) 2.36, p .05, d .60; and environmental,
t(63) 2.25, p .05, d .57. To explore whether problems in
emotion perception related to indicators of quality of life in those
with MS, correlations were carried out, see Table 2. Both measures
of emotion perception were strongly related to psychological and
social domains of quality of life but did not correlate with the
physical domain of the WHO-QoL. Perceiving emotions from
videos also predicted the environmental domain of quality of life.
Disease severity was not correlated with emotion perception or
most domains of quality of life. However, there was a substantial
correlation between ratings of disease severity and physical aspects of well-being. In order to test whether the relationships
between emotion perception and quality of life might reflect more
general variance in disease severity and duration, age, and cognition, partial correlations were carried out (Table 2, bottom rows).
Relationships between emotion perception and quality of life remained significant when these variables were partialed out. In
terms of effect size, measures of emotion perception and quality of
life (controlling for the factors listed above) shared between 17 and
24% of variance (r2 ranging from .171.240).
To explore whether the results obtained might be influenced by
including a small number of participants with progressive MS in
the sample, all the analyses reported above were also repeated in
only the subsample of participants with relapsing-remitting MS
(n 27), and the same pattern of results was found.

Discussion
The current results indicated that MS caused impairment in the
ability to process emotional information from both static and
dynamic images, building on previous research indicating effects
of MS on emotion perception from photographs of faces (Beatty et

al., 1989; Henry et al., 2009). Problems in decoding dynamic

interpersonal information about emotions, as displayed in the
current video task, is likely to be particularly important in everyday interactions. The current evidence indicates that this group
difference was specific to processing emotional information because there was no effect of MS on the ability to perceive information about identity, age, or gender from static or dynamic social
images. It is important to note that this pattern of results cannot be
explained in terms of ceiling effects on the nonemotional control
tasks. Also, group differences in emotion perception remained
when variance due to cognitive functioning and depression was
partialed out. This indicates that impairment in decoding emotions
in MS cannot be explained solely in terms of the perceptual and
cognitive load of emotion recognition tests. However, the emotion
and control tasks in the current study were not perfectly matched
for difficulty, and it is important in future research to explore other
methods of separating out affective from cognitive components of
emotion perception tasks (see, e.g., Clark, Neargarder, & CroninGolomb, 2008, for a novel method to do this).
It was predicted that difficulties in perceiving emotional information would relate to well-being in those with MS. There were
specific and substantial correlations between emotion perception
performance and psychological and social aspects of quality of
life. Further, partial correlations indicated that these relationships
could not be explained in terms of variance in age, disease severity, or cognition. Indeed, severity of disease did not correlate with
emotion perception measures or psychological and social aspects
of quality of life. In contrast, while disease severity correlated
significantly with physical aspects of quality of life, emotion
perception did not. These findings suggest that physical-motor
problems and emotional processing problems have quite different relationships with quality of life for people with MS. Most
measures of disease severity in MS focus solely on physical
symptoms of the disease. The current data reinforce the importance
of also assessing a range of cognitive and emotional skills when
gauging the functional problems likely to arise from MS (Phillips et
al., 2009).

Table 2
Correlations Between Measures of Emotion Perception, Quality of Life, Disease Severity and
Cognition in Participants With MS (N 32). Quality of Life Domains Are Physical (Phys),
Psychological (Psych), Social (Soc), and Environmental (Environ). Partial Correlations Between
Emotion Perception and Quality of Life, Controlling for Disease Severity and Duration, Age,
and Cognitive Function (Fluency, SART, Delayed Recall) are Also Reported
WHO-QoL domain
Phys
Emotion measure
Faces
Videos
Severity
Partial correlation with emotion measure
Faces
Videos

.042
.163
.476
.007
.197

Psych
.405
.494
.175
.413
.490

Soc

Environ

Disease severity

.508
.457
.277

.153
.469
.283

.086
.035

.422
.416

.004
.467

Note. Partial correlations of WHO-QoL domains with emotion measures, controlling for severity and duration
of disease, age, and cognition.

p .05. p .01.

BRIEF REPORT

It has previously been argued that in comparison to progressive

forms of MS, those with the relapsing-remitting form of the disease
may show relatively spared ability to process emotional information
from faces (Beatty et al., 1989). The current sample consisted of
predominantly those with relapsing-remitting MS and showed clearly
impaired performance on emotion perception. When analyses were
repeated excluding those with progressive MS, the same significant
pattern of results reported above was found: specific deficits in emotion perception but not identity or gender/age perception and correlations between problems in emotion perception and quality of life in
those with relapsing-remitting MS.
One limitation of the present study was the absence of detailed
information about lesion volume and distribution in the MS participants tested. Given changes in white matter and cortical gray
matter in MS, and the wide variation in foci of demyelinating
lesions (Filley, 2005; Tedeschi et al., 2005), it would be useful for
future research to directly identify links between neural changes in
MS and emotion perception through the use of both structural and
functional neuroimaging. Studies combining neuroimaging with
behavioral assessment are assisting understanding of other problems like memory deficits in MS (Bobholz et al., 2006; Benedict,
Ramasamy, Munschauer, Weinstock-Gutman, & Zivadinov, 2009).
Of particular interest would be longitudinal evidence of correlates
between the changing pathology and symptoms associated with the
relapsing-remitting form of the disease and emotional processing
ability. A further limitation of the present work was the lack of
formal assessment of visual acuity and perception in the sample.
These issues should be explored in future work, along with a more
detailed and sophisticated assessment of the role of disease severity, cognitive function, and processing speed in the effects of MS
on emotion perception.
In sum, this study provided evidence that people with MS are
impaired in decoding emotional information from static and dynamic visual stimuli. These problems appear specific to emotion
processing and do not extend to other person perception tasks, such
as making judgments about identity, age, and gender information.
Difficulties in emotion perception showed strong and specific
correlations with psychological and social aspects of quality of life
in MS. This indicates the importance of assessing cognitive and
emotional abilities in people with MS, as these skills may have a
significant impact on quality of life even in those without severe
physical symptoms.

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Received June 8, 2009

Revision received June 1, 2010
Accepted June 9, 2010