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BACKGROUND: Individuals with bipolar disorder (BD) often struggle with emotional regulation and social interactions, partly due to difficulties in accurately recognizing facial emotions. METHODS: From September 2021 to February 2023, 69 BD individuals-comprising 23 with bipolar manic/hypomanic episode (BME), 23 with bipolar depressive episode (BDE), 23 with bipolar euthymic (EUT)-and 23 healthy controls (HCs) were enrolled. Diagnosis adhered to DSM-IV criteria using M.I.N.I 5.0, alongside assessments via Hamilton Depression Scale 17 and Young Manic Rating Scale. Recognition tasks involving 84 facial expression images across six categories. The Wilcoxon rank-sum test compares two groups, while the Kruskal-Wallis test compares multiple groups with subsequent adjusted pairwise comparisons. RESULTS: The overall correct recognition rate of facial expressions in the BD group (79â¯%) was significantly lower than that of the HC group (83â¯%) (P=0.004). Primary differences were noted in neutral (93â¯% vs. 100â¯%, P=0.012) and fear (79â¯% vs. 86â¯%, P=0.023) expressions. Within the BD group, correct recognition rates were 71â¯% for BME, 80â¯% for BDE, and 80â¯% for EUT, all lower than in the HC group. Significant differences in correct recognition rates of neutral, fear, and joy expressions were observed among the four groups (P<0.05), with the BME group exhibiting the lowest rate. Misidentification of facial expressions was more frequent in the BD group compared to the HC group, particularly among negative expressions. CONCLUSION: Patients with BD demonstrate lower correct recognition and higher misidentification rates of facial expressions, with those experiencing manic episodes showing impaired recognition of neutral, joy, and fear expressions.
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A balanced diet is relevant for neuropsychological functioning. We aimed to analyze the association between dietary patterns and neuropsychological outcomes in a sample of healthy adolescents of the Walnuts Smart Snack (WSS) cohort from Barcelona city. We performed principal components analysis (PCA) to determine dietary patterns in the adolescent sample using a food frequency questionnaire (60 items). Multiple linear regression models were performed to analyze the association between PCA dietary patterns with neuropsychological outcomes: Strengths and Difficulties (SDQ) externalizing and internalizing scores, Attention Network Test (ANT) Impulsivity Index and Emotional Recognition Task (ERT) scores. We additionally adjusted the models for child sex, age, body mass index (BMI), physical activity and maternal education. Six dietary patterns were identified in PCA analyses. "low consumption of calorie-dense foods" dietary pattern had a negative association (protective) with the both SDQ outcomes (p value < 0.001) and "Nuts" dietary pattern showed a negative (protective) association with impulsivity index ( ß 1 = -24.60, 95% CI = -36.80, -12.41, p value < 0.001). Overall, our main results suggest that healthy dietary patterns, including higher intakes of "nuts" and a preference of "low consumption of calorie-dense foods" dietary patterns, could provide a beneficial association with neuropsychological functions during the adolescence period. The associations may include improvements of externalizing and internalizing problem symptoms, and impulsivity.
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BACKGROUND/AIM: Many glioma patients struggle to return to work after surgery because of higher brain dysfunction. Although the right frontal lobe has historically been considered functionally silent, reports of performing awake surgery to evaluate higher brain functions in patients with tumors in this area have increased. We present two cases of patients who underwent awake surgery for malignant glioma in the right frontal lobe to preserve emotional recognition and facilitate an early return to work. CASE REPORT: Case 1 was a 48-year-old right-handed woman employed as a nursery school teacher and case 2 was a 21-year-old right-handed man employed in sales. Both had contrast-enhancing right frontal lobe tumors exhibiting high signal intensity on fluid attenuated inversion recovery imaging and underwent awake surgery. During the operation, cortical mapping was performed using the Reading the Mind in the Eyes, calculation, and motor tasks. Resection of sites involved in motor and emotional recognition functions was avoided. In case 1, all regions of high signal intensity were completely resected; in case 2, all regions exhibiting enhancement were resected. Both patients were discharged home without neurological deficits and returned to work within 21 days after surgery. CONCLUSION: It may be important to focus not only on overall survival and progression-free survival in glioma patients, but also on factors associated with life satisfaction, such as time to return to work after surgery and time until work becomes difficult. Awake surgery aimed at preserving higher brain functions is useful and may also improve life satisfaction.
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Neoplasias Encefálicas , Emoções , Lobo Frontal , Glioma , Retorno ao Trabalho , Vigília , Humanos , Glioma/cirurgia , Glioma/psicologia , Glioma/patologia , Feminino , Pessoa de Meia-Idade , Masculino , Neoplasias Encefálicas/cirurgia , Neoplasias Encefálicas/psicologia , Neoplasias Encefálicas/patologia , Lobo Frontal/cirurgia , Lobo Frontal/diagnóstico por imagem , Vigília/fisiologia , Adulto Jovem , Procedimentos Neurocirúrgicos/métodosRESUMO
Introduction: Expressing emotions play a special role in daily communication, and one of the most essential methods in detecting emotions is to detect facial emotional states. Therefore, one of the crucial aspects of the natural human-machine interaction is the recognition of facial expressions and the creation of feedback, according to the perceived emotion. Methods: To implement each part of this model, two main steps have been introduced. The first step is reading the video and converting it to images and preprocessing on them. The next step is to use the combination of 3D convolutional neural network (3DCNN) and learning automata (LA) to classify and detect the rate of facial emotional recognition. The reason for choosing 3DCNN in our model is that no dimension is removed from the images, and considering the temporal information in dynamic images leads to more efficient and better classification. In addition, the training of the 3DCNN network in calculating the backpropagation error is adjusted by LA so that both the efficiency of the proposed model is increased, and the working memory part of the SOAR model can be implemented. Results and discussion: Due to the importance of the topic, this article presents an efficient method for recognizing emotional states from facial images based on a mixed deep learning and cognitive model called SOAR. Among the objectives of the proposed model, it is possible to mention providing a model for learning the time order of frames in the movie and providing a model for better display of visual features, increasing the recognition rate. The accuracy of recognition rate of facial emotional states in the proposed model is 85.3%. To compare the effectiveness of the proposed model with other models, this model has been compared with competing models. By examining the results, we found that the proposed model has a better performance than other models.
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Introduction: The significant role of emotional recognition in the field of human-machine interaction has garnered the attention of many researchers. Emotion recognition based on physiological signals can objectively reflect the most authentic emotional states of humans. However, existing labeled Electroencephalogram (EEG) datasets are often of small scale. Methods: In practical scenarios, a large number of unlabeled EEG signals are easier to obtain. Therefore, this paper adopts self-supervised learning methods to study emotion recognition based on EEG. Specifically, experiments employ three pre-defined tasks to define pseudo-labels and extract features from the inherent structure of the data. Results and discussion: Experimental results indicate that self-supervised learning methods have the capability to learn effective feature representations for downstream tasks without any manual labels.
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The Bio-Radar is herein presented as a non-contact radar system able to capture vital signs remotely without requiring any physical contact with the subject. In this work, the ability to use the proposed system for emotion recognition is verified by comparing its performance on identifying fear, happiness and a neutral condition, with certified measuring equipment. For this purpose, machine learning algorithms were applied to the respiratory and cardiac signals captured simultaneously by the radar and the referenced contact-based system. Following a multiclass identification strategy, one could conclude that both systems present a comparable performance, where the radar might even outperform under specific conditions. Emotion recognition is possible using a radar system, with an accuracy equal to 99.7% and an F1-score of 99.9%. Thus, we demonstrated that it is perfectly possible to use the Bio-Radar system for this purpose, which is able to be operated remotely, avoiding the subject awareness of being monitored and thus providing more authentic reactions.
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Radar , Sinais Vitais , Taxa Respiratória , Algoritmos , Emoções , Processamento de Sinais Assistido por ComputadorRESUMO
BACKGROUND: The brain of major depressive disorder (MDD) is associated with altered functional connectivity (FC) compared to that of healthy individuals when processing positive and negative visual stimuli. Building upon alterations in brain connectivity, some researchers have employed electroencephalography (EEG) to study FC in MDD, aiming to enhance both diagnosis and treatment; however, the results have been inconsistent and the studies involving FC during emotional recognition are limited. This study aims to 1) investigate the effects of MDD on EEG patterns during visual emotional processing, 2) explore the therapeutic effects of antidepressant treatment on brain FC within the first week, and assess whether these effects can be predictive of treatment outcomes four weeks later, and 3) study baseline FC parameter biomarkers that can be used to predict treatment responsiveness in MDD patients. METHODS: This clinical observational study recruited 38 healthy controls (HC) and 48 MDD patients. Patients underwent an EEG exam while looking at validated images of happy and sad faces at week 0 and 1. MDD patients were categorized into treatment responders and non-responders after 4 weeks of treatment. We conducted the FC analysis (node strength (NS), global efficiency (GE), and cluster coefficient (CC)) on HC and MDD patients using graph theoretical analysis. Multivariable linear regression was used to evaluate the influence of MDD on FC compared to HC, while controlling for confounding variables including age, gender, and academic degrees. RESULTS: At week 0 and week 1, MDD patients revealed to have significant reductions in FC parameters (NS, GE and CC) compared to HC. When comparing MDD patients at week 1 post-antidepressant treatment and pre-treatment, no significant differences in FC changes were observed. Multivariable regression revealed a significant negative effect on FC of MDD. Compared to the treatment non-responsive group, the responsive group revealed a significantly higher FC in delta band frequency at baseline. CONCLUSIONS: MDD patient group showed impaired FC during visual emotion-processing and we observed baseline FC parameters to be associated with treatment response at week 4. While signs of FC changes were observed in the brain after a week of treatment, it is possible that one week may still be insufficient to demonstrate significant alterations in the brain. Our results suggest the potential utilization of EEG-based FC as an indicative measure for predicting treatment response and monitoring treatment progress in MDD patients.
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Transtorno Depressivo Maior , Humanos , Imageamento por Ressonância Magnética/métodos , Encéfalo , Emoções/fisiologia , Eletroencefalografia , Antidepressivos/uso terapêuticoRESUMO
The cingulate cortex is a limbic structure involved in multiple functions, including emotional processing, pain, cognition, memory, and spatial orientation. The main goal of this structural Magnetic Resonance Imaging (MRI) study was to investigate whether age affects the cingulate cortex uniformly across its anteroposterior dimensions and determine if the effects of age differ based on sex, hemisphere, and regional cingulate anatomy, in a large cohort of healthy individuals across the adult lifespan. The second objective aimed to explore whether the decline in emotional recognition accuracy and Theory of Mind (ToM) is linked to the potential age-related reductions in the pregenual anterior cingulate (ACC) and anterior midcingulate (MCC) cortices. We recruited 126 healthy participants (18-85 years) for this study. MRI datasets were acquired on a 4.7 T system. The cingulate cortex was manually segmented into the pregenual ACC, anterior MCC, posterior MCC, and posterior cingulate cortex (PCC). We observed negative relationships between the presence and length of the superior cingulate gyrus and bilateral volumes of pregenual ACC and anterior MCC. Age showed negative effects on the volume of all cingulate cortical subregions bilaterally except for the right anterior MCC. Most of the associations between age and the cingulate subregional volumes were linear. We did not find a significant effect of sex on cingulate cortical volumes. However, stronger effects of age were observed in men compared to women. This study also demonstrated that performance on an emotional recognition task was linked to pregenual ACC volume, whist the ToM capabilities were related to the size of pregenual ACC and anterior MCC. These results suggest that the cingulate cortex contributes to emotional recognition ability and ToM across the adult lifespan.
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Giro do Cíngulo , Teoria da Mente , Masculino , Adulto , Humanos , Feminino , Giro do Cíngulo/diagnóstico por imagem , Giro do Cíngulo/anatomia & histologia , Cognição , Imageamento por Ressonância Magnética/métodos , EnvelhecimentoRESUMO
Social cognition (SC) and executive function (EF) have been described as important variables for social functioning and recovery of patients with psychosis. However, the relationship between SC and EF in first-episode psychosis (FEP) deserves further investigation, especially focusing on gender differences. AIMS: To investigate the relationship between EF and different domains of SC in FEP patients and to explore gender differences in the relationship between these domains. METHODS: A cross-sectional study of 191 patients with new-onset psychosis recruited from two multicenter clinical trials. A comprehensive cognitive battery was used to assess SC (Hinting Task, Face Test and IPSAQ) and EF (TMT, WSCT, Stroop Test and digit span - WAIS-III). Pearson correlations and linear regression models were performed. RESULTS: A correlation between Theory of Mind (ToM), Emotional Recognition (ER) and EF was found using the complete sample. Separating the sample by gender showed different association profiles between these variables in women and men. CONCLUSIONS: A relationship between different domains of SC and EF is found. Moreover, women and men presented distinct association profiles between EF and SC. These results should be considered in order to improve the treatment of FEP patients and designing personalized interventions by gender.
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Função Executiva , Transtornos Psicóticos , Cognição Social , Humanos , Masculino , Feminino , Transtornos Psicóticos/psicologia , Transtornos Psicóticos/fisiopatologia , Função Executiva/fisiologia , Estudos Transversais , Adulto , Adulto Jovem , Teoria da Mente , Fatores Sexuais , AdolescenteRESUMO
Rejective parenting is a major antecedent of emotional instability and aggressive behavioral problems. Previous studies have reported that emotional problems, such as depression, anxiety, aggression, and conduct problems in children and adolescents, improve through interventions that enhance emotional recognition competency. In this study, we explored whether the emotional recognition ability levels of individual adolescents moderated the pathway of negative parenting on aggression mediated by depression The moderated mediating effect of emotional recognition competency was investigated through examining 2265 first-year high school students using the 2021 data from the Korean Children and Youth Panel Survey 2018. There was no significant moderating effect on the direct pathway from rejective parenting to aggression. The moderating effect of emotional recognition competency on the indirect pathway leading to aggression through depression in rejective parenting was significant. These results suggest that the ability to correctly understand signals related to the emotions of others can play an important role in reducing depression and aggressive behavior by reducing conflict with people around them and experiencing more support.
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Depressão , Poder Familiar , Criança , Adolescente , Humanos , Emoções , Agressão , AnsiedadeRESUMO
In a recent article, Shepherd and Rippon (2022) investigated the impact of widespread face mask use on emotion recognition. They found that mask-wearing led to reduced accuracy in identifying emotions such as fear, sadness, and disgust when participants were exposed to brief facial stimuli. Their study highlights the significance of masks in concealing facial areas crucial for non-verbal communication, potentially affecting emotional well-being. Here in this comment, we have argued that despite concerns about impaired emotional recognition and social interactions, balancing COVID-19 protection and effective communication is essential. We stress the importance of adhering to mask guidelines while enhancing alternative cues and communication strategies. In public health emergencies like COVID-19, such research should acknowledge the whole complexity and prioritize safety aspects in a manner that prevents controversial issues.
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The role of the human insula in facial emotion recognition is controversially discussed, especially in relation to lesion-location-dependent impairment following stroke. In addition, structural connectivity quantification of important white-matter tracts that link the insula to impairments in facial emotion recognition has not been investigated. In a case-control study, we investigated a group of 29 stroke patients in the chronic stage and 14 healthy age- and gender-matched controls. Lesion location of stroke patients was analysed with voxel-based lesion-symptom mapping. In addition, structural white-matter integrity for tracts between insula regions and their primarily known interconnected brain structures was quantified by tractography-based fractional anisotropy. Our behavioural analyses showed that stroke patients were impaired in the recognition of fearful, angry and happy but not disgusted expressions. Voxel-based lesion mapping revealed that especially lesions centred around the left anterior insula were associated with impaired recognition of emotional facial expressions. The structural integrity of insular white-matter connectivity was decreased for the left hemisphere and impaired recognition accuracy for angry and fearful expressions was associated with specific left-sided insular tracts. Taken together, these findings suggest that a multimodal investigation of structural alterations has the potential to deepen our understanding of emotion recognition impairments after stroke.
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Malevolent creativity (MC) is defined as a manifestation in which people propose to materially, mentally or physically harm themselves or others in a novel manner. Malevolent creative ideation can be inhibited by high moral emotions (i.e. sympathy, guilt and shame) and low negative emotions, which promote prosocial behaviors. Given that the right postcentral gyrus (PCG) is involved in generating sympathy and emotional recognition for others and the right middle frontal gyrus (MFG) is involved in emotional regulation, we suggest that the right PCG and right MFG may play important roles in malevolent creative ideation. In Study 1, we recruited 98 healthy and right-handed college participants (80 females, age = 21.11 ± 2.00 years) and examined the role of the right PCG in malevolent creative ideation using transcranial direct current stimulation (tDCS). The results showed that the accuracy of emotional recognition changed when the right PCG received electrical stimulation. Enhancing the activation of the right PCG reduced MC originality and fluency, whereas inhibiting it increased MC originality and fluency. In Study 2, we recruited 91 healthy and right-handed college participants (74 females, age = 21.22 ± 2.28 years) and examined the role of the right MFG in malevolent creative ideation using tDCS. The results showed no significant difference in malevolent creative performance between the pre- and post-test when electrical stimulation was applied over the right MFG. These findings indicate that enhancing the activation of the right PCG, which is closely correlated with emotional recognition, reduces an individual's malevolent creative ideation.
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Estimulação Transcraniana por Corrente Contínua , Feminino , Humanos , Adulto Jovem , Adulto , Adolescente , Estimulação Transcraniana por Corrente Contínua/métodos , Córtex Somatossensorial , Criatividade , Lobo Frontal/fisiologia , EmoçõesRESUMO
Objective: Juvenile delinquents have deficits in emotional recognition that might play a critical role in the development of aggression. The present study aimed to investigate the effect of emotional recognition training and its consequences on emotional attention and aggression. Methods: Seventy-three male juvenile delinquents were randomly assigned to two groups. One group was the modification group, which received eight days of training on an emotional recognition task. The purpose of the training was to modify interpretative biases in emotion recognition to encourage the perception of happiness over anger in ambiguous expressions. The other group was the waitlist group, which did not perform a task and continued with their usual programme. Before and after the training, participants completed the aggression questionnaire (AQ) and two behavioural tasks, including the emotional recognition task and a visual search task with happy and angry faces as targets. Results: The modification group recognized more faces as happy after emotional recognition training than the waitlist group. Furthermore, the hostility in the modification group decreased significantly. Importantly, emotional recognition training further affected attention to emotional faces as participants responded faster in searching for happy and angry faces after training. Conclusion: Emotional recognition training could modify juvenile delinquents' emotional recognition, enhance their visual attention to emotional faces and reduce hostility.
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Emotion detection is a fundamental component in the field of Affective Computing. Proper recognition of emotions can be useful in improving the interaction between humans and machines, for instance, with regard to designing effective user interfaces. This study aims to understand the relationship between emotion and pupil dilation. The Tobii Pro X3-120 eye tracker was used to collect pupillary responses from 30 participants exposed to content designed to evoke specific emotions. Six different video scenarios were selected and presented to participants, whose pupillary responses were measured while watching the material. In total, 16 data features (8 features per eye) were extracted from the pupillary response distribution during content exposure. Through logistical regression, a maximum of 76% classification accuracy was obtained through the measurement of pupillary response in predicting emotions classified as fear, anger, or surprise. Further research is required to precisely calculate pupil size variations in relation to emotionally evocative input in affective computing applications.
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This paper describes a technique using photographic portraits in medical education to encourage close observation, cultivate empathic curiosity, explore learners' values and beliefs, and to reveal and reflect on fundamental biases. This new and evolving educational method uses the lens of psychotherapy to explore learners' experience of the portrait in a similar way we would discuss a case in psychodynamic supervision. Through close looking and small group engagement, the facilitator creates a space for deeper reflection and collaborative exploration of the therapeutic relationship, with emphasis on countertransference and the role of prior expectations. The exercise strengthens dialectical thinking through perspective-taking, challenging implicit assumptions and fostering cultural humility. Radiologists are taught to look in every corner of the X-ray and to observe each shadow, all while evaluating the entire image. Portraits can be examined in the same way, looking for subtle clues to the personality and history of the subject. Information from other sources confirms, or sometimes profoundly changes, our evaluation. In this example, we use a historical photographic portrait to demonstrate ways of engaging medical learners as they discover common psychotherapeutic approaches. The method has the potential to enhance therapeutic encounters, improve analytical skills and reduce bias.
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Educação Médica , Psiquiatria , Humanos , Currículo , EmpatiaRESUMO
(1) Background: Emotional recognition (ER), the ability to read into others' minds and recognize others' emotional states, is important in social environment adaptation. Recently it has been found that ER difficulties affect patients with multiple sclerosis (pMS) and relate to different gray matter atrophy patterns from secondary progressive (SP-pMS) and relapsing-remitting (RR-pMS). The aim of this study was to compare the performances of the two MS phenotypes on the Reading the Mind in the Eyes test (RMEt) and other cognitive, mood and fatigue measures. We also examined associations between performance on the RMEt and cognitive, mood and fatigue variables. (2) Methods: A total of 43 pMS (27RR-pMS/16SP-pMS) underwent a clinical assessment, the RMEt, the cognitive battery, and completed mood and fatigue questionnaires. Both groups' performances on the RMEt were then correlated with all these measures. (3) Results: the RMEt scores of RR-pMS were significantly correlated with the impairment degree in some cognitive scores. SP-pMS scores correlated mainly with fatigue, anxiety, anger and depression. (4) Conclusions: ER performances relate to cognitive aspects in RR-pMS, whereas mainly to mood outcomes in the SP-pMS group. We can hypothesize that deficits in ER are a further sign of disease progression. Our data support the different roles of cognitive and emotional deficits related to different disease courses and lesional correlates.
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Esclerose Múltipla Crônica Progressiva , Esclerose Múltipla , Humanos , Esclerose Múltipla Crônica Progressiva/complicações , Esclerose Múltipla/complicações , Cognição , Emoções , Fadiga/psicologia , Testes NeuropsicológicosRESUMO
El presente estudio tuvo como objetivo general identificar la asociación entre las alteraciones olfativas y el reconocimiento emocional en un grupo de pacientes con diagnóstico de traumatismo craneoencefálico. Fue desarrollada bajo un enfoque cuantitativo con diseño no experimental, en donde fueron evaluados 10 pacientes con antecedente de trauma craneoencefálico moderado y severo junto a 10 participantes controles sin daño cerebral. Para las variables sexo, edad y escolaridad los resultados fueron muy similares entre los grupos, con edades promedio de 26 años; la población fue predominantemente masculina, y la mayoría tenía grado de educación superior. En las pruebas de reconocimiento emocional, el grupo control logró un desempeño superior al grupo de casos. Adicionalmente, el grupo control logró mejor capacidad en las pruebas olfativas que el grupo de casos. Se encontró una correlación estadísticamente significativa entre los resultados del reconocimiento emocional y la variable olfativa en el grupo de casos, lo que permite identificar el rol que estructuras del sistema cerebral topográfica y funcionalmente pueden estar participando del procesamiento; a su vez, abre perspectivas de estudios a futuro, en especial a modelos de intervención en los grupos clínicos con afectación por el traumatismo craneoencefálico.
The general objective of this study was to "identify the association between emotional recognition and olfactory alterations in a group of patients with SCD". It was developed under a quantitative approach with nonexperimental design, in which 10 patients with a history of moderate and severe cranioencephalic trauma were evaluated along with 10 control participants without brain damage. For the variables sex, age and schooling the results were very similar among the groups, with average ages of 26 years, the population was predominantly male and most had higher education. In the tests of emotional recognition the control group achieved a superior performance to the group of cases. In addition, the control group achieved better capacity in olfactory tests than the group of cases. A statistically significant correlation was found between the emotional recognition results and the olfactory variable in the group of cases, which allows the identification of the role that topographic and functional brain system structures may be involved in processing; In turn, it opens prospects for future studies especially to intervention models in clinical groups affected by head trauma.
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Individuals with broad autism phenotype (BAP) have a tendency not to integrate emotional stimuli with the surrounding context. They have also shown different patterns and abilities in processing positive and negative emotions. This study aimed to examine whether the effect of context on target stimuli could vary depending on the type of target emotion in individuals with BAP. Based on the Broad Autism Phenotype Questionnaire (BAPQ) and Autism-Spectrum Quotient (AQ), 36 individuals with BAP and 33 healthy controls were selected. All the participants performed an overlap-emotional task consisting of six conditions: 2 (congruence: congruent and incongruent) × 3 (emotion: fearful, sad, and happy). Reaction time and accuracy were measured as dependent variables. The results revealed that the individuals with BAP showed no difference in reaction time between the condition of congruence and incongruence, but that the control group was faster to categorize facial expression on the condition of congruence than that of incongruence regardless of the type of target emotion. There were no differences between the two groups in any of the conditions with regard to accuracy. These findings indicate that individuals with BAP tend not to integrate target emotions with contextual information, a feature that could worsen the speed of emotional recognition in individuals with BAP. This study confirmed that the individuals with BAP have different cognition patterns in emotional recognition than the control group.