Emotional Response to Humour Perception and Gelotophobia Among Healthy Individuals and Patients with Schizophrenia and Depression, with Signs of a High Clinical Risk of Psychosis

Introduction. Investigating early changes in the emotional sphere within the schizophrenia course is a perspective direction in clinical psychology and psychiatry. Intactness of positive emotions, in particular, humour perception, may be a very important resource for patients. At the same time, humour perception is very sensitive to pathological conditions, such as the fear of being laughed at, known as gelotophobia. Those with gelotophobia perceive laughter as dangerous, rather than pleasant, and they can hardly distinguish between teasing and ridicule. Gelotophobia was confirmed to be expressed among people with mental disorders. Nonetheless, knowledge relating to the fear of being laughed at, was mostly generated among the non-clinical samples. Objectives. Thus, the aim of the study was to provide more clinical data on gelotophobia manifestations associated with schizophrenia spectrum disorders; the emotional response and facial expression of patients with gelotophobia were studied, in particular, regarding their perception of humour, including during the early stages of disorders, by comparison with healthy individuals. Methods. n=30 controls and n=32 patients with schizophrenia and with depression with signs of a high clinical risk of psychosis took part. Two short videos, comic and neutral, were shown to the participants, while videotaping their facial expression, followed each by a self-reported measure of emotional responses. Participants also completed the State-Trait Anxiety Inventory, the PhoPhiKat30 and the Toronto Alexithymia Scale. Results. Gelotophobia was significantly higher within the clinical group. It correlated with a lower frequency of grins among the patients during the comic video, while this was not the case in the control group. Gelotophobia was related to state and trait anxiety in both groups, but only in the clinical group did state anxiety increase after watching the comic video. Gelotophobia correlated with alexithymia and was twice higher among the patients compared to the controls. Conclusion. Thus, gelotophobia has not only quantitative, but also qualitative specifics in patients with schizophrenia, and those with depression with signs of a clinically high risk of psychosis, compared to healthy controls.


INTRODUCTION
According to many scholars, the recognition and expression of emotions that are the basis of nonverbal communication, reflect a decrease in the ability to process and apply social information, which leads to social incompetence. 1 These disorders are more common for schizophrenia spectrum disorders than affective disorders. 2 The socio-emotional deficit is also related to a poor functional outcome for patients, with a high clinical risk of psychosis. 3 Humour perception may be regarded as a strong marker of emotional expression disorder or intactness. Patients with schizophrenia exhibited significant and substantial deficits in humour recognition, compared to the patients with depression and anxiety, 4,5 while patients with affective disorders demonstrated a greater decrease in laughter expression, compared to those with schizophrenia spectrum disorders and the healthy controls. 5 All the aforementioned groups of patients have difficulties in relation to humour comprehension. 6 The inability to orient in social interactions involving humour and laughter, may lead to negative emotional reactions to humour, including an increased fear of being laughed at -gelotophobia. 7 Gelotophobia is defined as the pathological fear of becoming an object of ridicule, initially regarded as a form of social phobia. 7  Proyer used prototypical statements of individuals with gelotophobia, collected from clinical practice, to elaborate on the first self-reported gelotophobia scale -the Geloph. 9 Using this first version of the questionnaire they empirically separated a group of clinically-diagnosed gelotophobic patients (provided by M. Titze) from the groups of shame-based and nonshame-based "depressed neurotics", as defined by Nathanson, 10 and normal controls. 11 Subsequently, the gelotophobia scale has been revised several times, 12 and the modern instrument, the PhoPhiKat<30> includes two additional gelotophobia subscales, such as gelotophilia (the joy of being an object of laughter) and katagelasticism (the joy of laughing at others). 13 From this point, the concept of the fear of being laughed at, became an area of interest, and has been studied in many countries and in many languages. In a multi-national study by R. Proyer et al. the data from 73 countries and 42 languages were analysed altogether. 14 Gelotophobia has maladaptive characteristics: conviction in one's own ridiculousness, perception of laughter as a threat, increased anxiety and shame, stiffness and timidity, sensitivity and social isolation in extreme cases. 15-17 Gelotophobic people are very observant in social situations and become easily suspicious of the laughter of others. They can hardly distinguish between happy, joyful and derisive kinds of laughter, and cannot experience laughter as relaxing or positive, only as a means of aggression. They tend to interpret even benevolent or neutral kinds of humour-related situations as threatening. 15 Among the general population, the frequency of gelotophobia ranges from 5% to 12% in different countries, and from 7% to 15% in Russia. [16][17][18] The first data regarding the emotional response and expression of people with gelotophobia were provided by W. Ruch et al. 15 They discovered that people with gelotophobia automatically respond to smiling and laughing faces with a facial expression of contempt, rather than the more natural and normative reaction of smiling back. Gelotophobic people also tend to perceive others' smiles as less joyful and more contemptuous; they do not experience positive emotions watching smiling faces, in the same way as other people. 19 Thus, gelotophobia may not only distort the perception of the target of laughter and the motives of laughter, but also constitutes an emotional response to humour in general, in a wide range of humour-related situations.
M. Titze discussed gelotophobia in relation to sociophobia and shame-bound anxiety, although regarded it as a relatively independent phenomenon. 8 Recent empirical studies have confirmed the high correlation between the fear of being laughed at, and social anxiety. 20-22 Gelotophobia also occurs more often in patients with avoidant personality disorder, moreover, all patients with both social anxiety and avoidant personality disorder were also defined as gelotophobic. 21 Based on this, the fear of being laughed at was regarded as a possible additional diagnostic criterion for these disorders.

MATERIAL AND METHODS
1) The stimulus video material consisted of two clips -the comic and the neutral clips. The videos were compiled from short clips taken from the YouTube platform.
Fragments of each video were selected in such a way, so as to be very similar in terms of duration, brightness, quality, as well as format (only horizontal orientation).
Each of the two videos lasted around three minutes. The participants were to rate each of the statements on a four-point Likert scale (from "completely disagree" to "fully agree").

4) We also used the Scale of Prodromal Symptoms
(SOPS) 33 to assess attenuated prodromal symptoms, the

Expressive reactions
Mean rank comparisons, using the Mann-Whitney criterion showed, that in the control group, the subjects  Table 1

Gelotophobia and alexithymia
Not surprisingly, the Mann-Whitney test revealed that higher levels of alexithymia, measured by the Toronto Alexithymia Scale, were more common among the patients than the healthy participants (mean ranks 1240 and 713, respectively, W = 248.000; Z = -3.270; p = 0.001). Figure 1 demonstrates the distribution of the alexithymia levels in the two groups.
Gelotophobia correlated with alexithymia in both groups, but in the clinical group, the Spearman coefficient was almost twice higher (r = 0.746; p = 0.0001) than in the control group (r = 0.490; p = 0.006).

DISCUSSION
In the group of healthy participants, the comic video No correlations in any of the groups were found between gelotophobia and reported emotions after watching the videos. Thus, the comic video did not result in more fear, shame, anxiety or anger, as one might hypothesize. It is worthy of note, however, that the scale of emotions was a self-reported measure, therefore, could be more influenced by the tendency to control oneself and to reveal more socially desirable results.
Gelotophobia was associated with trait anxiety in all the groups with a particularly significant connection in the control group. At the same time, watching the comic video increased state anxiety among the patients only, while this did not differ among the control group.
Gelotophobia correlated with an increase in state anxiety relating to the comic video in all the groups: the higher the gelotophobia, the higher the increase in anxiety. However, in the group with depression with a high clinical risk, the connection did not reach a level of significance. Thus, the perception of humour and laughter, even regarding such innocent and safe topics as pets' humour, evoked an increase in anxiety among those with gelotophobia.
As expected, gelotophobia was related to the level of alexithymia in both groups, but in the clinical group, it was almost twice higher than in the control group.
Thus, the difficulty of understanding and expressing one's own emotions, as well as understanding the feelings of others, could be one of the psychological mechanisms underlying gelotophobia among these patients.
Overall, the results led to the conclusion that gelotophobia in mentally ill people, in particular, those suffering from schizophrenia spectrum disorders, has specific differences, compared to the fear of being laughed at among healthy individuals. The differences are not just quantitative, but also qualitative, and they may crucially distort humour and laughter perception, along with the behavioural reaction to humour in these patients. Gelotophobia was related to trait anxiety in both groups, but only in the clinical group was it associated with increased state anxiety, measured both before and after watching the comic video. Thus, the study provides evidence that humour perception, even of an innocent nature, may evoke anxiety among patients with schizophrenia spectrum disorders, which is related to gelotophobia.

CONCLUSIONS
Unsurprisingly, alexithymia was higher among the patients, and gelotophobia was associated with it.
Nonetheless, it is interesting that this association was twice higher among patients compared to the controls.
Thereby, gelotophobia has not only quantitative, but also qualitative specifics in patients with schizophrenia spectrum disorders, compared to healthy controls, and it is related to an emotional response to humour perception.

Limitations
The present study has several limitations. Firstly, due to organizational issues, the clinical group consisted only of male participants. Further research with female patients is needed to clarify possible gender differences.
Secondly, the study lacked technical equipment, for example, with the help of specialized computer programs it could be possible to register the facial expression of the participants more accurately. Thirdly, all the patients were assessed after antipsychotic treatment and, despite the low intensity of the side effects, the higher dosage in patients with first psychosis could also influence the difference between groups.