What kind of emotional problems might you expect to see with a brain injury and the relevance

Back to main page

Please check out the following website for a wonderful YouTube video on Living with a TBI.  http://www.youtube.com/watch?v=FgtHvBF4t-E

Please check back for a more reader-friendly, basic description of the information on this page.

Emotional Problems of People with Brain Injury

  • Over- emotional (expression) --> aggression, depression, lability, inappropriate behavior
  • Under-emotional  (expression) --> flat affect, flat personality (no enjoyment)
  • Problems feeling/experiencing  emotions --> problems knowing how to behave; problems with decision making; unaffected by consequences
  • Problems identifying their emotions --> confusion; don't know how to act
  • Problems expressing emotions (verbally and nonverbally)  --> flat affect; trouble communicating feelings and needs
  • Problems identifying others' emotions --> misunderstand people; inappropriate behavior; does not respond to others's needs (unable to show empathy)

Since various areas of the brain are important for different emotional processes (generating, feeling, conceptualizing, and controlling emotions) it only makes sense that an injury to the brain could have a fairly significant impact on one or more aspects of emotional processing.  It is not uncommon that people with brain injury have emotional problems.  People with brain injury often experience many behavioral problems, and consequently have very poor social outcomes.  It is plausible that many of the behavioral problems have to do with impairments of processing and understanding their own and others' emotions.  Some people with brain injury have been found to be overly emotional and cannot seem to control their emotions.  They can easily fly off the handle at anything.  This is probably because the part of the brain that controls emotions (most likely the left ventromedial prefrontal cortex) is damaged.  It is the area of the brain that helps us to reason through our emotions and the consequences of our actions.  It helps to control the impulsive actions that are often stirred by our primitive limbic system (automatic reaction to emotional stimuli and events).  Others seem to be under-emotional, and appear to be unaffected by anything (flat).  Nothing excites them, nothing upsets them. This is usually the result of damage to the right hemisphere, cingulate cortex, limbic system, or areas that are involved in arousal.  Other people with brain injury could have difficulty recognizing their own emotions.  This could be because they aren't feeling any physiological changes in the body either because those changes didn't happen, or because the part of the brain that processes these feelings is damaged (somatosensory cortex).  It could also be because the have damage to the part of the brain that helps them to understand those emotions and relate them to similar situations (ventral medial prefrontal cortex).   People with brain injury may also have problems recognizing how others are feeling, usually due to an impairment in recognizing nonverbal cues of emotions (facial expressions, vocal expressions, gestures, postures) or being able to infer emotions from the context of a situation.   When they can't tell how someone is feeling, they don't know how to act, or act inappropriately.  They often perceive others to be uncaring, indifferent, or confused.  Others will misread people and assume that person is angry when if fact they are not.  Consequently, they (person with injury) begin to get defensive and start acting out.  This behavior (acting out) will then cause the other person to really become angry as they don't know or understand why the person with the injury is overreacting about. This can create tremendous relationship problems.  

 

Traumatic Brain Injury and Impaired Emotion Recognition

 Written by Dawn Neumann,  Barry Willer, and Barbra Zupan

The ability to identify emotions in others is considered to be essential for the engagement of successful social interactions1,2.  Studies have demonstrated that persons who have endured a traumatic brain injury (TBI) have more difficulty recognizing emotions in others when compared to their uninjured counterparts3-15.  Although the prevalence of this deficit in TBI has not yet been tracked, it appears to be a very relevant concern.  First, the aforementioned studies compared representative samples of persons with TBI to healthy persons.  The fact that these studies found representative groups of persons with TBI to be impaired at determining affect, suggests that emotion recognition must be a relatively common problem for persons with TBI. Furthermore, informal reports from Milders et al., and Segalowitz et al. calculated between 50 to 66% of their participants with TBI to perform at least one standard deviation below the norm on standardized tests of facial affect recognition.  These findings are not unsurprising given that the neuroanatomical structures involved in emotion recognition are considered to be very susceptible to damage when a TBI occurs16.  These structures include areas within the prefrontal, parietal, and temporal lobes as well as the amygdala, anterior and posterior cingulate, ventral striatum, insula and other structures and connections to and within the limbic system17-21.

There are several different types of social cues that we could used to identify how someone is feeling.  One process involves attending to nonverbal cues of affect such as facial expressions, voice (pitch, loudness, tempo and pause) and postures22.  Another method involves making an inference about how someone would feel given the circumstances and social context.  People with TBI are often impaired at using nonverbal cues and social inferencing to recognize emotions in others and this is a significant concern.    

Studies have demonstrated that persons with TBI, as a group, have more difficulty than their healthy peers at using facial expressions to recognize emotion3-15,23.  Impaired facial affect recognition is problematic since facial expression is a primary means of communicating emotion among humans5.  Consequently, limitations in determining facial affect can severely limit one’s ability to interpret how others are feeling all together.  It has been suggested that a decreased ability to read nonverbal cues of affect may result in inappropriate behaviors24 and have a negative impact on social relationships25.  A study by Milders and colleagues found poor social outcomes for a group of participants with TBI who also had impaired affect recogntion10.  They showed that persons with TBI not only had difficulty recognizing facial and vocal expressions of emotion, but also had significantly decreased social integration and negative changes in social behavior since their injury.  However, they did not investigate whether these two outcomes were correlated.  Other studies have frequently demonstrated that the social outcomes for many  persons with TBI are often very grim26-32.  While there may be many reasons why a person with TBI might have poor social behavior and outcomes, studies suggest that poor facial affect recognition may be an important contributory factor24,25.

Several studies have also indicated that persons with TBI have difficulty making social inferences to determine how others are feeling7,33.   These studies demonstrated that persons with TBI were generally impaired at determining characters’ feelings, thoughts, and intentions even when they had the necessary contextual information.  This impairment may also present many challenges for persons with the TBI, since there are various circumstances when nonverbal cues are limited (e.g., during a phone conversation), unavailable (e.g. person trying to hide how they feel) or incorrect (sarcasm).  In these circumstances, a person must rely solely on correctly comprehending the context under which the emotion is occurring.  Making inferences based on context involves a complicated set of cognitive tasks. For instance, events such as being fired from a job are typically associated with a specific emotion (anger).  Nevertheless, to form correct assumptions about someone’s emotional reaction, additional information is required.  Wierzbicka 34 suggests that we need to know the person’s wants and beliefs regarding the situation or event in order to correctly infer emotion. For example, if the person who was fired wanted to leave his job he might be happy rather than angry. 

 

Despite the findings that many persons with TBI are impaired at identifying emotions, only one study has been published that looked at training to improve facial affect recognition in this population (Guerico).  Unfortunately, this study was methodologically flawed in that they trained their three participants with the same faces that were used for testing.  Consequently, one could not conclude that the participants in that study learned how to recognize facial affect, only that they learned to associate specific emotions to specific faces.  Despite the fact that this area of research is so understudied, the need for this type of research has not gone unnoticed.  Several researchers have stressed the importance of identifying techniques that are capable of enhancing affect recognition and social skills in persons with TBI6,8. 

  

Background 

            The Brain Injury Association of America has reported that annually, 1.5 million Americans sustain a TBI.  It has further been approximated that 5.3 million Americans have incurred disabilities that result from a TBI.   According to the Brain Injury Association of America Board of Directors, TBI is defined as “an insult to the brain, not of a degenerative or congenital nature but caused by an external physical force, that may produce a diminished or altered state of consciousness, which results in an impairment of cognitive abilities or physical functioning. It can also result in the disturbance of behavioral or emotional functioning. These impairments may be either temporary or permanent and cause partial or total functional disability or psychosocial maladjustment.”35  Given this definition, a TBI is defined by how someone incurs damage to the brain.  TBI’s are typically acquired via motor vehicle accidents (MVA’s), falls, and physical assaults including blunt trauma or gunshot wounds to the head.  They do not include stroke, tumors, anoxia or hypoxia, toxins or meningitis.  Depending on how the damage occurs, it may be classified as a “penetration” or “diffuse axonal injury” (DAI).   A penetration injury occurs when an object pierces the brain, which tends to cause damage that is more localized to a particular structure, relative to diffuse axonal injuries.35  A DAI is when nerve tissues in the brain are torn due to the brain hitting against the skull.  DAI injuries are often the result of a MVA and generally cause more global damage.35  Depending on the areas damaged, both penetration and diffuse axonal injuries may lead to impaired affect recognition.  

 

TBI: Identifying Affect from Nonverbal Communication

            There are numerous studies demonstrating that persons with TBI have significantly more difficulty recognizing nonverbal cues of affect than their uninjured counterparts[3-13,15,23].    

 

Facial Affect Recognition

            Green, Turner and Thompson[3], found that people with TBI were impaired at identifying and discriminating emotions from pictures of faces when compared to uninjured participants.  These researchers first asked participants to select the emotional label that best described the facial expressions presented.  Participants were then asked to determine if two faces portrayed the ‘same’ or ‘different’ emotion.  The results demonstrated that participants with TBI were significantly impaired on both tasks. The subjects with brain injury not only had a problem identifying the emotion expressed, but also had difficulty perceiving the similarities and differences when comparing emotional states.  Their inability to determine similar versus different emotional expressions suggest that people with TBI had trouble interpreting the emotional implication of the different facial characteristics. 

Several studies have suggested that impaired facial affect recognition centers on the ability to differentiate negative emotions.  These studies show that identifying negative facial expressions is a more difficult task for people with TBI than recognizing positive emotions[4,5,36].  Hopkins et al.[4] had participants with and without TBI identify affect from faces and found that the individuals with TBI were impaired at recognizing negative emotions such as sadness, anger and fear.  Both groups were equally successful at recognizing positive emotions.  Similar findings in regard to negative emotions were reported by Jackson and Moffat[5].  Jackson and Moffat5 investigated the ability of persons with and without closed head injuries (CHI) to recognize emotions from photographs depicting a variety of facial expressions.  They assessed participants’ ability to identify the following emotions: happiness, disgust, pensiveness, anger, fear, sadness, surprise, self-satisfied, bored and neutral.  The results demonstrated that persons with CHI were significantly impaired at recognizing the emotions of disgust, anger, and boredom compared to controls.  Hopkins et al.[4] also found that participants with TBI had decreased electrodermal activity compared to controls when viewing faces with negative emotions.  This suggests that people with TBI do not process negative facial expressions in the same way that people without TBI do.  

            One factor that distinguishes affect recognition for people with TBI and those without is the difference in their ability to identify obvious emotional expressions.  Spell and Frank[8] demonstrated that people with TBI were not able to recognize emotions from obvious facial expressions as accurately as their uninjured counterparts.  In this research individuals with TBI and matched controls were asked to determine emotions from both subtle and obvious facial expressions. The group with TBI had significantly more difficulty recognizing obvious emotions than the control group.  This distinction was not noted for subtle expressions of emotion.

 

Vocal Affect Recognition

Studies by Marquardt et al.6, Spell and Frank8 and Milders et al.10also found that in addition to impaired facial affect, many participants with TBI also had significant difficulty recognizing emotions from vocal expressions.  In these studies, persons with and without TBI were presented with vocal expressions and asked to identify the emotion being conveyed.  Compared to their uninjured counterparts, persons with TBI were notably impaired at determining emotions from the vocal expressions.  Furthermore, Marquardt et al. demonstrated that persons with TBI not only had difficulty identifying vocal expressions of emotion, but were also impaired at mimicking/or expressing those emotions.  In order to test this, they had participants repeat a sentence with the same emotion portrayed by an instructor.  The results indicated that persons with TBI were only 79% accurate at imitating a vocal emotion, compared to 100% accuracy for controls.  Not all people with facial affect recognition impairments have impaired vocal affect recognition and vice versa (ref).  However, there appears to be a link between the two, as demonstrated by Hornak and colleagues (ref).   According to Hornak et al., common neuroanatomical structures, such as the ventral medial prefrontal cortex are utilized when determining emotion from both facial and vocal expressions.  Therefore, it is worth noting both deficits and exploring any possible connections between both types of affect recognition.  More detail on this matter will be discussed in the theory and neuroanatomical sections.   

 

Affect Recognition from Facial or Vocal Expression versus Linguistic Content

Researchers have demonstrated that when contradictory multiple cues of emotion are presented, persons with TBI judged emotions based on the explicit content of a sentence, rather than inferring emotions from facial or vocal expressions6.   In this study, Marquardt and colleagues6 presented participants with emotionally laden sentences that were accompanied with facial and vocal cues.  The facial and vocal intonations were either congruent or incongruent with the emotional content of the sentence.  In the congruent conditions, the intonation and facial expression were consistent with the content of the sentence.  In contrast, the incongruent condition presented an intonation and facial expression that were not consistent with the sentence content.   For each condition, participants were asked to identify the emotion.  The results demonstrated that in the incongruous condition, participants with TBI more frequently identified emotion based on the content of the sentence and not the tone or facial expression, compared to controls.  This suggests that persons with TBI use explicit content to determine emotion, rather than nonverbal cues of emotion.  This has significant implications since people often say things they do not mean, especially when using sarcasm. 

 

Affect Recognition and Dynamic, Multiple Nonverbal Cues

            Some studies demonstrate that impaired affect recognition in people with TBI is not just limited to static photos or isolated information.  Researchers have found that there is a relationship in the ability to recognize static versus dynamic expressions of emotion[37].  Consequently, emotion recognition for people with TBI has also been found to be affected when viewing dynamic stimuli[7,9,38].  Turkstra, McDonald, and DePompei[9] had adolescents with and without TBI identify emotions expressed by actors on videotape.  The actors in the videotape used several nonverbal cues including facial expressions to portray different emotions.  The authors found that relative to their uninjured peers, adolescents with TBI had significant deficits in interpreting the emotions played out by the actors.  Similar to Turkstra and colleagues9, McDonald and Flanagan7 were interested in the ability of participants with TBI “to interpret the mental state of others” (p.574).  This skill is often referred to as theory of mind (ToM).  They used The Awareness of Social Inference Test (TASIT) to measure ToM in persons with and without TBI. One of the subtests of TASIT, the Emotional Evaluation Test (EET), tests the ability to infer what others feel (ie. judge emotions).  Participants with TBI were impaired at identifying all emotions on the EET portion of the TASIT. These findings are important because the dynamic stimuli portrayed in the videos are more similar to what people observe in everyday interactions.

 

Affect Recognition and Behavior

Research by Milders et al.[10] provides a link between emotion recognition and a person’s behavior.  They measured the ability of persons with TBI to identify facial and vocal affect, in addition to assessing their social behavior.   Although the authors did not test if there was a direct relationship, they found that many of the persons with TBI who were impaired at identifying facial and vocal expressions of emotions, also had increased behavioral problems after their injury.  These behavioral problems included depression, interpreting gestures, inappropriateness and indifference. 

 

TBI: Using Social Context to Infer Emotions 

Another source of information by which emotions are inferred is through social context39. Social context can help lead a person to an accurate interpretation of the situation through the use of inferencing, particularly when facial affect cues are absent or subtle.  Understanding a social situation and how that interacts with one’s beliefs is vital for determining the emotion someone would feel in a given situation40,41.  This is especially so for people with TBI, who may have difficulty interpreting facial expressions and therefore would rely on other cues to determine an emotion.  This idea is supported by Marquardt and colleagues6 who found that people with TBI are more likely to judge emotions based on the explicit content of a sentence rather than the facial expressions or vocal intonations that accompany them.  As stated earlier, when there is inconsistency between the content of a sentence and the manner in which the sentence is delivered and/or the accompanied facial expression, individuals with TBI relied on the explicit content.  In conclusion, they attributed more importance to information explicitly stated than they do to a person’s facial or vocal expression when determining emotions. 

Using only explicit information to determine how someone is feeling can lead to errors, especially in the case of sarcasm.  Inconsistency between explicit information and social context, facial, and vocal expressions describes exactly what happens when sarcasm is being used.  When someone sarcastically says, “Thanks for your help”, the statement will probably be accompanied by a facial and vocal expression that implies that the person is not really grateful.  If only explicit information (“Thanks for your help”) is used to determine meaning in this situation, one will conclude that the person is really is grateful.  This interpretation would lead a person to incorrectly conclude that the person is also happy.   A study by Channon et al.42 demonstrated that persons with TBI had trouble inferring a person’s intended meaning from sarcastic comments.  They presented participants with scenarios depicting a social context that was followed immediately by either a sincere or sarcastic comment from one of the characters in the scenario.  The authors found that participants with TBI had difficulty interpreting sarcastic comments in comparison to control participants.  Since sarcasm requires the use of inference in social contexts, this study suggests that individuals with TBI have difficulty using social context to infer the indirect meaning of a comment.  Instead, individuals with TBI focus on the literal meanings of the words and sentences43. 

            It is probable that participants’ with TBI have difficulty interpreting sarcasm because of their inability to use implicit information to determine emotions.  Nonverbal cues such as facial or vocal expressions or the context of the situation are implicit pieces of information requiring a person to infer how someone is feeling.   Ferstl and colleagues44 studied reading comprehension in persons with brain injury when they were presented with stories composed of implicit and explicit information about emotions.  They determined that participants with brain injury had difficulty making inferences from implicit information. They compared three groups of patients according to localization of the lesion to age-matched controls. The groups included stroke patients with right hemisphere brain damage, stroke patients with left hemisphere brain damage and patients with TBI (diffuse damage).  Patients with damage to the right hemisphere and those with diffuse TBI were found to have significant difficulty understanding implicit information.  They had no difficulty comprehending explicit details.  These results suggest that people with TBI had difficulty making inferences and therefore difficulty with everyday discourse.  In a related study, Ferstl et al45 demonstrated that the ventromedial prefrontal cortex is activated while reading simple stories depicting emotional content. Given the susceptibility of this area of the prefrontal cortex during a TBI, one would expect that individuals with TBI will have significant difficulty inferring emotions based on contextual clues.

            As discussed earlier, McDonald and Flanagan7 also tested the ability of persons with and without TBI to make social inferences.  They used The Awareness of Social Inference Test (TASIT) to assess participants’ ability to infer the feelings, thoughts, and intentions of characters under a variety of circumstances.  It was concluded that participants with TBI had difficulty interpreting contextual cues in order to infer emotions and understand people’s beliefs and intentions. Consequently, these participants were not able to apply explicit contextual information, or infer implicit information about a situation to determine peoples’ feelings and beliefs.

  

Review of brain injury and emotion

TBI and Emotion Recognition.ppt

Improving Emotion Recognition in Persons with TBI.ppt

 

References

1.         Phillips ML, Drevets WC, Rauch SL, Lane R. Neurobiology of emotion perception I: The neural basis of normal emotion perception. Biol Psychiatry 2003;54(5):504-14.

2.         Ogai M, Matsumoto H, Suzuki K, Ozawa F, Fukuda R, Uchiyama I, Suckling J, Isoda H, Mori N, Takei N. fMRI study of recognition of facial expressions in high-functioning autistic patients. Neuroreport 2003;14(4):559-63.

3.         Green REA, Turner GR, Thompson WF. Deficits in facial emotion perception in adults with recent traumatic brain injury. Neuropsychologia 2004;42(2):133-141.

4.         Hopkins MJ, Dywan J, Segalowitz SJ. Altered electrodermal response to facial expression after closed head injury. Brain Injury 2002;16(3):245-257.

5.         Jackson HF, Moffat NJ. Impaired emotional recognition following severe head injury. Cortex 1987;23:293-300.

6.         Marquardt TP, Rios-Brown M, Richburg T. Comprehension and expression of affective sentences in traumatic brain injury. Aphasiology 2001;15(10-11):1091-1101.

7.         McDonald S, Flanagan S. Social perception deficits after traumatic brain injury: Interaction between emotion recognition, mentalizing ability, and social communication. Neuropsychology 2004;18(3):572-579.

8.         Spell LA, Frank E. Recognition of nonverbal communication of affect following traumatic brain injury. Journal of Nonverbal Behavior 2000;24(4):285-300.

9.         Turkstra LS, McDonald S, DePompei R. Social information processing in adolescents: data from normally developing adolescents and preliminary data from their peers with traumatic brain injury. J Head Trauma Rehabil 2001;16(5):469-83.

10.       Milders M, Fuchs S, Crawford JR. Neuropsychological impairments and changes in emotional and social behaviour following severe traumatic brain injury. Journal of Clinical and Experimental Neuropsychology 2003;25(2):157-172.

11.       Hornak J, Rolls ET, Wade D. Face and voice expression identification in patients with emotional and behavioural changes following ventral frontal lobe damage. Neuropsychologia 1996;34(4):247-61.

12.       Guercio JM, Podolska-Schroeder H, Rehfeldt RA. Using stimulus equivalence technology to teach emotion recognition to adults with acquired brain injury. Brain Injury 2004;18(6):593-601.

13.       Borgaro S, Prigatano GP., Kwasnica C., Alcott S., N. aC. Disturbances in affective communication following brain injury. Brain Injury 2004;18(1):33-9.

14.       Mcmurray PJ. The effect of traumatic brain injury on the ability to recognize emotional

facial expression and prosody. . Dissertation Abstracts International: Section B: The Sciences & Engineering. 2001;61(9-B).

15.       McDonald S. Putting communication disorders in context after traumatic brain injury. Aphasiology 2000;14(4).

16.       Novack T. TBI Facts and Stats. 1999. Last accessed on May 6, 2005. http://www.neuroskills.com/index.shtml?main=/tbi/injury.html.

17.       Calder AJ, Keane J, Lawrence AD, Manes F. Impaired recognition of anger following damage to the ventral striatum. Brain 2004;127(Pt 9):1958-69.

18.       Critchley HD, Daly E, Phillips M, Brammer M, Bullmore ET, Williams S, Van Amelsvoort T, Robertson DM, David A, Murphy DG. Explicit and implicit neural mechanisms for processing of social information from facial expressions: a functional magnetic resonance imaging study. Human Brain Mapping 2000;9:93-105.

19.       Hornak J, Bramham J, Rolls ET, Morris RG, O'Doherty J, Bullock PR, Polkey CE. Changes in emotion after circumscribed surgical lesions of the orbitofrontal and cingulate cortices. Brain 2003;126(Pt 7):1691-712.

20.       Ishai A, Schmidt CF, Boesiger P. Face perception is mediated by a distributed cortical network. Brain Res Bull 2005;67(1-2):87-93.

21.       Ochsner KN, Bunge SA, Gross JJ, Gabrieli JD. Rethinking feelings: an FMRI study of the cognitive regulation of emotion. J Cogn Neurosci 2002;14(8):1215-29.

22.       Minskoff EH. Teaching approach for developing nonverbal communication skills in students with social perception deficits: Part I. The basic approach and body language clues. J Learn Disabil 1980;13(3):118-24.

23.       Croker V, McDonald S. Recognition of emotion from facial expression following traumatic brain injury. Brain Inj 2005;19(10):787-99.

24.       Rolls ET, Hornak J, Wade D, McGrath J. Emotion-related learning in patients with social and emotional changes associated with frontal lobe damage. J Neurol Neurosurg Psychiatry 1994;57(12):1518-24.

25.       Nowicki S, Duke MP. Individual-Differences in the Nonverbal-Communication of Affect - the Diagnostic-Analysis of Nonverbal Accuracy Scale. Journal of Nonverbal Behavior 1994;18(1):9-35.

26.       Elsass L, Kinsella G. Social interaction following severe closed head injury. Psychol Med 1987;17(1):67-78.

27.       Dawson DR, Chipman M. The disablement experienced by traumatically brain-injured adults living in the community. Brain Inj 1995;9(4):339-53.

28.       Dikmen S, Machamer J, Temkin N. Psychosocial Outcome in Patients with Moderate to Severe Head-Injury - 2-Year Follow-Up. Brain Injury 1993;7(2):113-124.

29.       Hoofien D, Gilboa A, Vakil E, Donovick PJ. Traumatic brain injury (TBI) 10-20 years later: a comprehensive outcome study of psychiatric symptomatology, cognitive abilities and psychosocial functioning. Brain Injury 2001;15(3):189-209.

30.       Oddy M, Coughlan T, Tyerman A, Jenkins D. Social-Adjustment after Closed Head-Injury - a Further Follow-up 7 Years after Injury. Journal of Neurology Neurosurgery and Psychiatry 1985;48(6):564-568.

31.       Sbordone RJ, Liter JC, Pettlerjennings P. Recovery of Function Following Severe Traumatic Brain Injury - a Retrospective 10-Year Follow-Up. Brain Injury 1995;9(3):285-299.

32.       Tate RL, Broe GA. Psychosocial adjustment after traumatic brain injury: what are the important variables? Psychological Medicine 1999;29(3):713-725.

33.       Dennis M, Barnes, M., Wilkinson, M., , and Humphreys R. How Children with Head Injury Represent Real and Deceptive Emotion in Short Narratives. Brain and Language 1998;61:450–483.

34.       Wierzbicka A. Defining emotion concepts. Cognitive Science 1992;16:539–581.

35.       Directors BIABo. Traumatic Brain Injury http://www.biausa.org/Pages/types_of_brain_injury.html. 1986; Last accessed January 10, 2006

36.       Kucharska-Pietura K, Phillips ML, Gernand W, David AS. Perception of emotions from faces and voices following unilateral brain damage. Neuropsychologia 2003;41(8):1082-90.

37.       McDonald S, Saunders JC. Differential impairment in recognition of emotion across different media in people with severe traumatic brain injury. J Int Neuropsychol Soc 2005;11(4):392-9.

38.       McDonald SaS, J. . Differential impairment in recognition of emotion across different media in people with severe traumatic brain injury. Journal of the International Neuropsychological Society 2005;11(4):392-399.

39.       McDonald S, Flanagan S, Rollins J, Kinch J. TASIT: A new clinical tool for assessing social perception after traumatic brain injury. J Head Trauma Rehabil 2003;18(3):219-38.

40.       Weiner BG, S.; Stern, P.; and Lawson, M. Using affective cues to infer causal thoughts.  . Developmental Psychology 1982;18(2):278-286.

41.       Thompson RA. Development of children’s inferences of emotions of others. Developmental Psychology 1987;23(1):124-131.

42.       Channon S, Pellijeff, A., and Rule, A. Social cognition after head injury: sarcasm and theory of mind. Brain and Language 2005;93:123-134.

43.       Ferstl EC, Guthke T, von Cramon DY. Text comprehension after brain injury: left prefrontal lesions affect inference processes. Neuropsychology 2002;16(3):292-308.

44.       Ferstl EC, Walther, K., Guthke, T., and Von Crammon, D. Y. Assessment of story comprehension deficits after brain damage. Journal of Clinical and Experimental Neuropsychology 2005;27:367-384.

45.       Ferstl EC, Rinck M, von Cramon DY. Emotional and temporal aspects of situation model processing during text comprehension: an event-related fMRI study. J Cogn Neurosci 2005;17(5):724-39.

46.       Adolphs R, Gosselin F, Buchanan TW, Tranel D, Schyns P, Damasio AR. A mechanism for impaired fear recognition after amygdala damage. Nature 2005;433(7021):68-72.

47.       Adolphs R, Damasio H, Tranel D, Cooper G, Damasio AR. A role for somatosensory cortices in the visual recognition of emotion as revealed by three-dimensional lesion mapping. J Neurosci 2000;20(7):2683-90.

48.       Haxby JV, Hoffman EA, Gobbini MI. The distributed human neural system for face perception. Trends Cogn Sci 2000;4(6):223-233.

49.       Tarr MJ, Gauthier I. FFA: a flexible fusiform area for subordinate-level visual processing automatized by expertise. Nat Neurosci 2000;3(8):764-9.

50.       Schultz RT, Gauthier I, Klin A, Fulbright RK, Anderson AW, Volkmar F, Skudlarski P, Lacadie C, Cohen DJ, Gore JC. Abnormal ventral temporal cortical activity during face discrimination among individuals with autism and Asperger syndrome. Arch Gen Psychiatry 2000;57(4):331-40.

51.       Blair RJ, Morris JS, Frith CD, Perrett DI, Dolan RJ. Dissociable neural responses to facial expressions of sadness and anger. Brain 1999;122 ( Pt 5):883-93.

52.       Hoffman EA, Haxby JV. Distinct representations of eye gaze and identity in the distributed human neural system for face perception. Nature 2000;3(1):80-84.

53.       Adolphs R, Damasio H, Tranel D, Damasio AR. Cortical systems for the recognition of emotion in facial expressions. J Neurosci 1996;16(23):7678-87.

54.       Adolphs R, Tranel D, Damasio H. Emotion recognition from faces and prosody following temporal lobectomy. Neuropsychology 2001;15(3):396-404.

55.       James W. What is an emotion? Mind 1884;9:188-205.

56.       Strack F, Martin LL, Stepper S. Inhibiting and Facilitating Conditions of the Human Smile - a Nonobtrusive Test of the Facial Feedback Hypothesis. Journal of Personality and Social Psychology 1988;54(5):768-777.

57.       Anderson AK, Phelps EA. Perceiving emotion: There's more than meets the eye. Curr Biol 2000;10(15):R551-4.

58.       Damasio A. Descartes' Error : Emotion, Reason, and the Human Brain New York: HarperCollins Publishers Inc; 1994.

59.       Adolphs R, Tranel D, Damasio AR. Dissociable neural systems for recognizing emotions. Brain Cogn 2003;52(1):61-9.

60.       Dolan RJ, Fletcher P, Morris J, Kapur N, Deakin JF, Frith CD. Neural activation during covert processing of positive emotional facial expressions. Neuroimage 1996;4(3 Pt 1):194-200.

61.       Vuilleumier P, Armony JL, Driver J, Dolan RJ. Effects of attention and emotion on face processing in the human brain: an event-related fMRI study. Neuron 2001;30(3):829-41.

62.       Lane RD, Reiman EM, Axelrod B, Yun LS, Holmes A, Schwartz GE. Neural correlates of levels of emotional awareness. Evidence of an interaction between emotion and attention in the anterior cingulate cortex. J Cogn Neurosci 1998;10(4):525-35.

63.       Lee GP, Bechara A, Adolphs R, Arena J, Meador KJ, Loring DW, Smith JR. Clinical and physiological effects of stereotaxic bilateral amygdalotomy for intractable aggression. J Neuropsychiatry Clin Neurosci 1998;10(4):413-20.

64.       Misslin R. The defense system of fear: behavior and neurocircuitry. Neurophysiol Clin 2003;33(2):55-66.

65.       Adolphs R, Tranel D, Damasio A. The human amygdala in social judgment. Nature 1998;393(6684):470-474.

66.       Broks P, Young AW, Maratos EJ, Coffey PJ, Calder AJ, Isaac CL, Mayes AR, Hodges JR, Montaldi D, Cezayirli E and others. Face processing impairments after encephalitis: amygdala damage and recognition of fear. Neuropsychologia 1998;36(1):59-70.

67.       Scott SK, Young AW, Calder AJ, Hellawell DJ, Aggleton JP, Johnson M. Impaired auditory recognition of fear and anger following bilateral amygdala lesions. Nature 1997;385(6613):254-7.

68.       Vuilleumier P. Cognitive science: staring fear in the face. Nature 2005;433(7021):22-3.

69.       Piggot J, Kwon H, Mobbs D, Blasey C, Lotspeich L, Menon V, Bookheimer S, Reiss AL. Emotional attribution in high-functioning individuals with autistic spectrum disorder: a functional imaging study. J Am Acad Child Adolesc Psychiatry 2004;43(4):473-80.

70.       Hall GB, Szechtman H, Nahmias C. Enhanced salience and emotion recognition in Autism: a PET study. Am J Psychiatry 2003;160(8):1439-41.

71.       Weeks SJ, Hobson RP. The Salience of Facial Expression for Autistic-Children. Journal of Child Psychology and Psychiatry and Allied Disciplines 1987;28(1):137-152.

72.       Macdonald H, Rutter M, Howlin P, Rios P, Leconteur A, Evered C, Folstein S. Recognition and Expression of Emotional Cues by Autistic and Normal Adults. Journal of Child Psychology and Psychiatry and Allied Disciplines 1989;30(6):865-877.

73.       Hobson RP, Ouston J, Lee A. Whats in a Face - the Case of Autism. British Journal of Psychology 1988;79:441-453.

74.       Happe F, Ehlers S, Fletcher P, Frith U, Johansson M, Gillberg C, Dolan R, Frackowiak R, Frith C. 'Theory of mind' in the brain. Evidence from a PET scan study of Asperger syndrome. Neuroreport 1996;8(1):197-201.

75.       Critchley HD, Daly EM, Bullmore ET, Williams SC, Van Amelsvoort T, Robertson DM, Rowe A, Phillips M, McAlonan G, Howlin P and others. The functional neuroanatomy of social behaviour: changes in cerebral blood flow when people with autistic disorder process facial expressions. Brain 2000;123 ( Pt 11):2203-12.

76.       Baron-Cohen S, Ring HA, Wheelwright S, Bullmore ET, Brammer MJ, Simmons A, Williams SCR. Social intelligence in the normal and autistic brain: an fMRI study. European Journal of Neuroscience 1999;11(6):1891-1898.

77.       Aylward EH, Minshew NJ, Goldstein G, Honeycutt NA, Augustine AM, Yates KO, Barta PE, Pearlson GD. MRI volumes of amygdala and hippocampus in non-mentally retarded autistic adolescents and adults. Neurology 1999;53(9):2145-50.

78.       Voelbel GT, Hamstra J, Locascio G, Patel N, Patel P, Bates ME, Pandina G, Hendren R. The relationship between amygdala volume with face recognition and face emotion: a comparative study of children with Asperger's Syndrome and bipolar disorder. Archives of Clinical Neuropsychology 2003;18(7):719-719.

79.       Hubl D, Bolte S, Feineis-Matthews S, Lanfermann H, Federspiel A, Strik W, Poustka F, Dierks T. Functional imbalance of visual pathways indicates alternative face processing strategies in autism. Neurology 2003;61(9):1232-7.

80.       Silver H, Goodman C, Knoll G, Isakov V. Brief emotion training improves recognition of facial emotions in chronic schizophrenia. A pilot study. Psychiatry Res 2004;128(2):147-54.

81.       Penn DL, Combs D. Modification of affect perception deficits in schizophrenia. Schizophr Res 2000;46(2-3):217-29.

82.       Kohler CG, Turner TH, Bilker WB, Brensinger CM, Siegel SJ, Kanes SJ, Gur RE, Gur RC. Facial emotion recognition in schizophrenia: intensity effects and error pattern. Am J Psychiatry 2003;160(10):1768-74.

83.       Gur RE, Turetsky BI, Cowell PE, Finkelman C, Maany V, Grossman RI, Arnold SE, Bilker WB, Gur RC. Temporolimbic volume reductions in schizophrenia. Archives of General Psychiatry 2000;57(8):769-775.

84.       Stafford N. Can emotions be taught to a low functioning autistic child? Early Child Development and Care 2000;154:105-126.

85.       Grinspan D, Hemphill A, Nowicki S, Jr. Improving the ability of elementary school-age children to identify emotion in facial expression. J Genet Psychol 2003;164(1):88-100.

86.       Williams TI. A social skills group for autistic children. J Autism Dev Disord 1989;19(1):143-55.

87.       Silver M, Oakes P. Evaluation of a new computer intervention to teach people with autism or asperger syndrome to recognize and predict emotions in others. Autism 2001;5(3):299-316.

88.       Bolte S, Feineis-Matthews S, Leber S, Dierks T, Hubl D, Poustka F. The development and evaluation of a computer-based program to test and to teach the recognition of facial affect. Int J Circumpolar Health 2002;61 Suppl 2:61-8.

89.       Bölte S, Hubl D, Feineis-Matthews S, Prvulovic D, Dierks T, And Poustka HG. A Functional MRI Study of Computer-Aided

Emotion Recognition Training in Autism. 2005.

90.       Sack AT, Hubl D, Prvulovic D, Formisano E, Jandl M, Zanella FE, Maurer K, Goebel R, Dierks T, Linden DEJ. The experimental combination of rTMS and fMRI reveals the functional relevance of parietal cortex for visuospatial functions (vol 13, pg 85, 2002). Cognitive Brain Research 2002;14(2):307-307.

91.       Wojciulik E, Kanwisher N. The generality of parietal involvement in visual attention. Neuron 1999;23(4):747-764.

92.       Erwin RJ, Gur RC, Gur RE, Skolnick B, Mawhinneyhee M, Smailis J. Facial Emotion Discrimination .1. Task Construction and Behavioral Findings in Normal Subjects. Psychiatry Research 1992;42(3):231-240.

93.       Kohler CG, Bilker W, Hagendoorn M, Gur RE, Gur RC. Emotion recognition deficit in schizophrenia: association with symptomatology and cognition. Biol Psychiatry 2000;48(2):127-36.

94.       Riley GA, Sotiriou D, and, Jaspal S. Which is more effective in promoting implicit and explicit memory: The method of vanishing cues or errorless learning without fading? Neuropsychological Rehabilitation Jul 2004;Vol 14(3):257-283.

95.       Glisky EL. Computer-assisted instruction for patients with traumatic brain injury: Teaching of domain-specific knowledge. Journal of Head Trauma Rehabilitation Sep 1992;Vol 7(3):1-12.

96.       Braun CMJ, Baribeau JMC, Ethier M, Guerette R, Proulx R. Emotional Facial Expressive and Discriminative Performance and Lateralization in Normal Young-Adults. Cortex 1988;24(1):77-90.

97.       Asthana HS, Mandal MK, Khurana H, and Haque-Nizamie S. Visuospatial and affect recognition deficit in depression. Journal of Affective Disorders 1998;48(1):57-62.

98.       Beck AT, Steer RA. Internal Consistencies of the Original and Revised Beck Depression Inventory. Journal of Clinical Psychology 1984;40(6):1365-1367.

99.       Albert ML. Simple Test of Visual Neglect. Neurology 1973;23(6):658-664.

100.     Benton AL, Hamsher K, Varney Nea. Contributions to neuropsychological assessment. New York: Oxford University Press; 1983.

101.     Stevens J. Applied multivariate statistics for the social sciences. Mawah, NJ: Lawrence Erlbaum Associates; 2002.

102.     Nowicki S, Jr., Carton J. The measurement of emotional intensity from facial expressions. J Soc Psychol 1993;133(5):749-50.

103.     Measuring cue perception: Assessment of reliability and validity. . McIntire KA, Danforth MM, and Schneider HG. 1997.

104.     Spell LA. Recognition of the nonverbal communication of affect following traumatic brain injury. . 1997.

105.     Verbeek P. Peacemaking in young children. . 1996.

106.     Nowicki S. A study of the DANVA AP in college students.  . 1995.

107.     Lane RD, Quinlan DM, Schwartz GE, Walker PA, Zeitlin SB. The Levels of Emotional Awareness Scale: a cognitive-developmental measure of emotion. J Pers Assess 1990;55(1-2):124-34.

108.     Gur RC, Sara, R.,  Hagendoorn, M., Marom, O., Hughett, P., Macy, L., Turner, T., Bajcsy, R., Posner, A. and  Gur, R.E. A method for obtaining 3-dimensional facial expressions and its standardization for use in neurocognitive studies Journal of Neuroscience Methods 2002;115(2):137-143.

109.     Knowlton BJ, Squire LR, and Gluck MA. Probabilistic classification learning in amnesia. Learn Mem 1994;1:106-120.

110.     Silver H, Shlomo N. Perception of facial emotions in chronic schizophrenia does not correlate with negative symptoms but correlates with cognitive and motor dysfunction. Schizophr Res 2001;52(3):265-73.