A path model investigation of neurocognition, theory of mind, social competence, negative symptoms and real-world functioning in schizophrenia

Problems in real-world functioning are pervasive in schizophrenia and much recent effort has been devoted to uncovering factors which contribute to poor functioning. The goal of this study was to examine the role of four such factors: social cognition (theory of mind), neurocognition, negative symptoms, and functional capacity (social competence). 178 individuals with schizophrenia or schizoaffective disorder completed measures of theory of mind, neurocognition, negative symptoms, social competence, and self-reported functioning. Path models sought to determine the relationships among these variables. Theory of mind as indexed by the Hinting Task partially mediated the relationship between neurocognition and social competence, and negative symptoms and social competence demonstrated significant direct paths with self-reported functioning. Study results suggest theory of mind serves as an important mediator in addition to previously investigated social cognitive domains of emotional and social perception. The current study also highlights the need to determine variables which mediate the relationship between functional capacity and real-world functioning.     

Emotion and Theory of Mind in Schizophrenia—Investigating the Role of the Cerebellum

Social cognitive dysfunction, including deficits in facial emotion recognition and theory of mind, is a core feature of schizophrenia and more strongly predicts functional outcome than neurocognition alone. Although traditionally considered to play an important role in motor coordination, the cerebellum has been suggested to play a role in emotion processing and theory of mind, and also shows structural and functional abnormalities in schizophrenia. The aim of this systematic review was to investigate the specific role of the cerebellum in emotion and theory of mind deficits in schizophrenia using previously published functional neuroimaging studies. PubMed and PsycINFO were used to search for all functional neuroimaging studies reporting altered cerebellum activity in schizophrenia patients during emotion processing or theory of mind tasks, published until December 2014. Overall, 14 functional neuroimaging studies were retrieved. Most emotion studies reported lower cerebellum activity in schizophrenia patients relative to healthy controls. In contrast, the theory of mind studies reported mixed findings. Altered activity was observed across several posterior cerebellar regions involved in emotion and cognition. Weaker cerebellum activity in schizophrenia patients relative to healthy controls during emotion processing may contribute to blunted affect and reduced ability to recognise emotion in others. This research could be expanded by examining the relationship between cerebellum function, symptomatology and behaviour, and examining cerebellum functional connectivity in patients during emotion and theory of mind tasks.     

Social brain dysfunctions in schizophrenia: a review of neuroimaging studies

Several studies have indicated that schizophrenic patients show impaired performance in various aspects of social cognition, including theory of mind, emotion processing, and agency judgments. Neuroimaging studies that have compared patients and healthy subjects during such mental activity indicate an abnormal hemodynamic response in the medial prefrontal cortex, the prefrontal cortex, the amygdala, the inferior parietal lobe, i.e., a set of regions known to be critically involved in social cognition. This paper addresses a number of issues raised by schizophrenia research into theory of mind, emotion perception and self-agency with regards to the neural systems that mediate social cognition. In healthy subjects, typical brain patterns are associated with theory of mind, emotion perception and self-agency; some activated clusters overlap, while others are distinct. For instance, activations in the paracingulate gyrus are almost systematically associated with theory of mind tasks, while the amygdala is mainly involved in emotion perception tasks. Additional foci are frequently found activated during those tasks: superior temporal sulcus, inferior frontal area. Moreover, the inferior parietal lobe is thought to contribute to agency judgments. In the light of the data on brain abnormalities and neurochemical dysfunctions in schizophrenia, we discuss the interaction of social cognitive dysfunction with the supposed information processing abnormalities caused by dopamine dysregulation.     

Social brain dysfunctions in schizophrenia: A review of neuroimaging studies

Several studies have indicated that schizophrenic patients show impaired performance in various aspects of social cognition, including theory of mind, emotion processing, and agency judgments. Neuroimaging studies that have compared patients and healthy subjects during such mental activity indicate an abnormal hemodynamic response in the medial prefrontal cortex, the prefrontal cortex, the amygdala, the inferior parietal lobe, i.e., a set of regions known to be critically involved in social cognition. This paper addresses a number of issues raised by schizophrenia research into theory of mind, emotion perception and self-agency with regards to the neural systems that mediate social cognition. In healthy subjects, typical brain patterns are associated with theory of mind, emotion perception and self-agency; some activated clusters overlap, while others are distinct. For instance, activations in the paracingulate gyrus are almost systematically associated with theory of mind tasks, while the amygdala is mainly involved in emotion perception tasks. Additional foci are frequently found activated during those tasks: superior temporal sulcus, inferior frontal area. Moreover, the inferior parietal lobe is thought to contribute to agency judgments. In the light of the data on brain abnormalities and neurochemical dysfunctions in schizophrenia, we discuss the interaction of social cognitive dysfunction with the supposed information processing abnormalities caused by dopamine dysregulation.     

Social cognition in schizophrenia: an overview

The purpose of this column is to provide an overview of social cognition in schizophrenia. The column begins with a short introduction to social cognition. Then, we describe the application of social cognition to the study of schizophrenia, with an emphasis on key domains (i.e., emotion perception, Theory of Mind, and attributional style). We conclude the column by discussing the relationship of social cognition to neurocognition, negative symptoms, and functioning, with an eye toward strategies for improving social cognition in schizophrenia.     

Theory of mind, neurocognition, and functional status in schizotypy

The present study is the first to concurrently examine social cognition, neurocognition, and social functioning in psychometric schizotypes. Screening of 2108 undergraduates with the Schizotypal Personality Questionnaire-Brief (SPQ-B) identified 52 persons high in schizotypy and 40 persons low in schizotypy. All participants were administered a test battery designed to assess two elements of neurocognition, verbal secondary memory (California Verbal Learning Test) and executive functioning (Wisconsin Card Sorting Test), two elements of social cognition, emotion perception (The Awareness of Social Inference Test-Part 1) and theory of mind (The Awareness of Social Inference Test-Parts 2 and 3), and social functioning (Social Adjustment Scale-Self Report). Although the persons with high schizotypy were impaired in social functioning relative to the persons with low schizotypy, they were not impaired in theory of mind, emotion perception, verbal secondary memory, or executive functioning. Theory of mind and verbal secondary memory were correlated in persons with high schizotypy. The present findings suggest that psychometric schizotypes are not impaired in the domains of social cognition and neurocognition examined.     

Neurocognitive predictors of social cognition in remitted schizophrenia

Knowledge of how specific neurocognition (NC) abilities predict social cognition (SC) in schizophrenia has potential to guide novel integrated cognitive-remediation therapies. The scope of studies conducted in this field is limited as they have not examined a comprehensive set of SC domains and they employ small sample sizes of heterogeneous patient groups. We studied a broad range of NC (sustained attention, processing speed, verbal/visual memory and visual processing/encoding, cognitive flexibility and planning) and SC [different levels of theory of mind (ToM)], attributional bias, emotion recognition and social perception] abilities in 170 remitted schizophrenia patients. Multivariate regression analyses revealed attention and planning as predictors of 1st order ToM. Memory encoding was the strongest predictor of 2nd order ToM. Faux-pas recognition, social perception and emotion recognition were influenced by a combination of cognitive flexibility and memory encoding abilities. Overall, NC predicted anywhere between ~4% and 40% of variance observed in specific SC sub-dimensions of attributional bias (4%), 1st order (19%) and 2nd order (12%) theory of mind, faux-pas recognition (28%), social perception (29%) and emotion recognition (39%). Individual SC abilities are predicted by distinctive as well as shared NC abilities. These findings have important implications for integrated cognitive remediation.     

Emotion recognition, 'theory of mind,' and social behavior in schizophrenia

Several studies have demonstrated that patients with schizophrenia are impaired in recognizing emotions from facial expressions and in appreciating other people's mental states--the latter commonly referred to as 'theory of mind.' The question as to how social cognitive skills relate to patients' actual social behavior is, however, largely unanswered. This study examined emotion recognition, 'theory of mind,' and social behavior in schizophrenia. Emotion recognition, 'theory of mind,' executive functioning, 'crystallized' verbal intelligence, psychopathology, and social behavior were assessed in patients with schizophrenia compared with a healthy control group. Patients were significantly impaired on all tasks involving executive functioning, emotion recognition, and 'theory of mind.' Impaired executive functioning did, however, only partially account for the deficits in social perception and social cognition. Social perception and cognition in schizophrenia predicted the odds of being a patient significantly better than nonsocial cognition. Severe social behavioral abnormalities were linked to the duration of the illness, and even more so to 'theory of mind' deficits. Considering impaired social perception and social cognition significantly contributes to the understanding of social behavioral problems in schizophrenia.     

Théorie de l’esprit : un médiateur entre symptômes et fonctionnement dans la schizophrénie ?

This literature review aimed to summarize the scientific knowledge concerning the links between psychosocial functioning and social cognition. Social cognition, and particularly Theory of Mind, is strongly disturbed in patients with schizophrenia. There were strong arguments that psychosocial functioning was more strongly associated with Theory of Mind than with neurocognition (defined as nonsocial information processing in contrast to social cognition). The functional capacity mediated this influence. Moreover, longitudinal studies suggested a unidirectional causal pathway with primary neurocognitive disorders leading to secondary deficits in social cognition, which in turn led to disturbances in psychosocial functioning. Studies using structural equation modelling showed that positive, negative and disorganization symptoms were associated with disturbances in psychosocial functioning. Regarding negative symptoms and disorganization, the influences were mediated by social cognition. The influence of positive symptoms on psychosocial functioning was independent of social cognition. This literature review suggests that social cognitive remediation in patients with should improve the psychosocial functioning in patients with schizophrenia.     

Social Cognition and Interaction Training (SCIT) for inpatients with schizophrenia spectrum disorders: preliminary findings

Individuals with schizophrenia exhibit consistent deficits in social cognition such as emotion perception, attributional style, and theory of mind, which may be targets of psychosocial treatments. Previous intervention studies have typically focused on only one aspect of social cognition and have not assessed generalization of treatment to improvements in social functioning. This paper describes preliminary data from a new group-based treatment, Social Cognition and Interaction Training (SCIT), aimed at improving social cognition in schizophrenia. Eighteen inpatients with schizophrenia spectrum disorders completed SCIT and were compared with 10 inpatients who completed a coping skills group. Participants were assessed at pre-test and post-test on measures of emotion and social perception, theory of mind, attributional style (e.g., blame, hostility, and aggression), cognitive flexibility, and social relationships. We also collected data on the frequency of aggressive incidents on the treatment ward. The results showed that compared to the control group, SCIT participants improved on all of the social cognitive measures and showed better self-reported social relationships and fewer aggressive incidents on the treatment unit at post-test. Importantly, this change was independent of changes in clinical symptoms over time and supports the unique role of SCIT in improving social cognitive deficits in schizophrenia.     

Deficits in Domains of Social Cognition in Schizophrenia: A Meta-Analysis of the Empirical Evidence

Objective: Social cognition is strongly associated with functional outcome in schizophrenia, making it an important target for treatment. Our goal was to examine the average magnitude of differences between schizophrenia patients (SCs) and normal comparison (NCs) patients across multiple domains of social cognition recognized by the recent NIMH consensus statement: theory of mind (ToM), social perception, social knowledge, attributional bias, emotion perception, and emotion processing. Method: We conducted a meta-analysis of peer-reviewed studies of social cognition in schizophrenia, published between 1980 and November, 2011. Results: 112 studies reporting results from 3908 SCs and 3570 NCs met our inclusion criteria. SCs performed worse than NCs across all domains, with large effects for social perception (g = 1.04), ToM (g = 0.96), emotion perception (g = 0.89), and emotion processing (g = 0.88). Regression analyses showed that statistically significant heterogeneity in effects within domains was not explained by age, education, or gender. Greater deficits in social and emotion perception were associated with inpatient status, and greater deficits in emotion processing were associated with longer illness duration. Conclusions: Despite the limitations of existing studies, including lack of standardization or psychometric validation of measures, the evidence for deficits across multiple social cognitive domains in schizophrenia is clear. Future research should examine the role of neurobiological and psychosocial factors in models linking various aspects of deficit in schizophrenia, including social cognition, in order to identify targets for intervention.     

Social Cognition Deficits Among Individuals at Familial High Risk for Schizophrenia

Social cognition in young relatives of schizophrenia probands (N = 70) and healthy controls (N = 63) was assessed using the Penn Emotion Recognition Test-40 to examine the presence of social cognitive deficits in individuals at risk for the disorder. Measures of neurocognitive function and prodromal psychopathology were collected to assess the cognitive and clinical correlates of social cognitive impairments in at-risk relatives. Results indicated that when compared with healthy controls, individuals at familial high risk for schizophrenia were significantly more likely to overattribute emotions to neutral faces, with such individuals frequently misinterpreting neutral faces as negative. In addition, at-risk individuals had significantly greater reaction times when completing emotion recognition tasks, regardless of valence. Impairments in neurocognition were largely independent of social cognitive performance, and emotion recognition impairments persisted after adjusting for deficits in neurocognitive function. Further, social cognitive impairments in the interpretation of neutral faces were significantly associated with greater positive and general prodromal psychopathology, whereas neurocognitive impairments were only associated with disorganization. These results suggest that impairments in social cognition may be unique endophenotypes for schizophrenia.     

Cognitive functioning related to quality of life in schizophrenia

The present study compared the cognitive function of patients with schizophrenia to that of healthy subjects, and investigated the relationships between cognitive function and quality of life (QOL). Participants consisted of 53 patients meeting DSM-IV criteria for schizophrenia and 31 normal controls. All participants completed a neuropsychological test battery assessing executive function, verbal memory, and social knowledge. QOL was rated using the Schizophrenia Quality of Life Scale. Patients with schizophrenia showed lower performance across various cognitive measures of memory, including the Sentence Memory Test, the Verbal Learning Test, and the Script Test, as well as the Rule Shift Cards Test of executive function. Multiple regression analyses were used to evaluate the neuropsychological measures and clinical symptoms to predict QOL. The QOL total score, the social initiative score or the empathy score were significantly predicted by the Script or/and the Sentence Memory. Neuropsychological functioning was unrelated to most QOL scores in the presence of clinical symptoms, while ability of empathy in the QOL was predicted by performance of the Sentence Memory Test. These results demonstrated patients with schizophrenia have deficits in executive function, memory and learning, and social knowledge, and that social knowledge and memory are related to QOL. Thus, in patients with schizophrenia, deficits in social knowledge appear to be associated with current QOL in general, and specifically with the capacity for empathy and social initiative.     

A multidimensional assessment of social cognition in psychometrically defined schizotypy

Individuals with schizophrenia exhibit impairments in multiple social cognitive domains. There is evidence that these impairments may be trait-related vulnerability markers for schizophrenia. However, the literature focusing on individuals vulnerable to developing schizophrenia-spectrum disorders, referred to as schizotypy, has produced inconsistent findings. This study's primary aim was to provide a more comprehensive understanding of social cognitive functioning within schizotypy than previous studies by employing a broad array of measures to assess multiple social cognitive domains, and examine how these domains relate to specific schizotypy traits (i.e., positive, negative, and disorganized) and Quality of Life (QOL). Facial emotion recognition, Theory of Mind (ToM), and aspects of emotional intelligence related to regulating one's own emotions (emotion management) and other's emotions (social management) were measured. Individuals with psychometrically defined schizotypy (n=36) and controls (n=26) were examined. The schizotypy group performed significantly worse than controls on facial emotion recognition, ToM, and emotion management, but not social management. Generally speaking, poorer social cognition performance was not a function of specific schizotypy traits. However, negative traits were associated with poorer facial emotion recognition, and disorganized traits were associated with better social management. Facial emotion recognition was associated with QOL in the schizotypy group.     

Nonverbal Social Communication and Gesture Control in Schizophrenia

Schizophrenia patients are severely impaired in nonverbal communication, including social perception and gesture production. However, the impact of nonverbal social perception on gestural behavior remains unknown, as is the contribution of negative symptoms, working memory, and abnormal motor behavior. Thus, the study tested whether poor nonverbal social perception was related to impaired gesture performance, gestural knowledge, or motor abnormalities. Forty-six patients with schizophrenia (80%), schizophreniform (15%), or schizoaffective disorder (5%) and 44 healthy controls matched for age, gender, and education were included. Participants completed 4 tasks on nonverbal communication including nonverbal social perception, gesture performance, gesture recognition, and tool use. In addition, they underwent comprehensive clinical and motor assessments. Patients presented impaired nonverbal communication in all tasks compared with controls. Furthermore, in contrast to controls, performance in patients was highly correlated between tasks, not explained by supramodal cognitive deficits such as working memory. Schizophrenia patients with impaired gesture performance also demonstrated poor nonverbal social perception, gestural knowledge, and tool use. Importantly, motor/frontal abnormalities negatively mediated the strong association between nonverbal social perception and gesture performance. The factors negative symptoms and antipsychotic dosage were unrelated to the nonverbal tasks. The study confirmed a generalized nonverbal communication deficit in schizophrenia. Specifically, the findings suggested that nonverbal social perception in schizophrenia has a relevant impact on gestural impairment beyond the negative influence of motor/frontal abnormalities.Key words: social cognition, negative symptoms, pantomime, imitation     

Facial emotion perception in Chinese patients with schizophrenia and non-psychotic first-degree relatives

Although there is a consensus that patients with schizophrenia have certain deficits in perceiving and expressing facial emotions, previous studies of facial emotion perception in schizophrenia do not present consistent results. The objective of this study was to explore facial emotion perception deficits in Chinese patients with schizophrenia and their non-psychotic first-degree relatives. Sixty-nine patients with schizophrenia, 56 of their first-degree relatives (33 parents and 23 siblings), and 92 healthy controls (67 younger healthy controls matched to the patients and siblings, and 25 older healthy controls matched to the parents) completed a set of facial emotion perception tasks, including facial emotion discrimination, identification, intensity, valence, and corresponding face identification tasks. The results demonstrated that patients with schizophrenia performed significantly worse than their siblings and younger healthy controls in accuracy in a variety of facial emotion perception tasks, whereas the siblings of the patients performed as well as the corresponding younger healthy controls in all of the facial emotion perception tasks. Patients with schizophrenia also showed significantly reduced speed than younger healthy controls, while siblings of patients did not demonstrate significant differences with both patients and younger healthy controls in speed. Meanwhile, we also found that parents of the schizophrenia patients performed significantly worse than the corresponding older healthy controls in accuracy in terms of facial emotion identification, valence, and the composite index of the facial discrimination, identification, intensity and valence tasks. Moreover, no significant differences were found between the parents of patients and older healthy controls in speed after controlling the years of education and IQ. Taken together, the results suggest that facial emotion perception deficits may serve as potential endophenotypes for schizophrenia.     

Social cognition in schizophrenia, Part 1: performance across phase of illness

Social cognitive impairments are consistently reported in schizophrenia and are associated with functional outcome. We currently know very little about whether these impairments are stable over the course of illness. In the current study, 3 different aspects of social cognition were assessed (emotion processing, Theory of Mind [ToM], and social relationship perception) at 3 distinct developmental phases of illness: prodromal, first episode, and chronic. In this cross-sectional study, participants included 50 individuals with the prodromal risk syndrome for psychosis and 34 demographically comparable controls, 81 first-episode schizophrenia patients and 46 demographically comparable controls, and 53 chronic schizophrenia patients and 47 demographically comparable controls. Outcome measures included total and subtest scores on 3 specialized measures of social cognition: (1) emotion processing assessed with the Mayer-Salovey-Caruso Emotional Intelligence Test, (2) ToM assessed with The Awareness of Social Inference Test, and (3) social relationship perception assessed the Relationships Across Domains Test. Social cognitive performance was impaired across all domains of social cognition and in all clinical samples. Group differences in performance were comparable across phase of illness, with no evidence of progression or improvement. Age had no significant effect on performance for either the clinical or the comparison groups. The findings suggest that social cognition in these 3 domains fits a stable pattern that has outcome and treatment implications. An accompanying article prospectively examines the longitudinal stability of social cognition and prediction of functional outcome in the first-episode sample.     

Social cognitive skills training in schizophrenia: an initial efficacy study of stabilized outpatients

Social cognitive deficits are promising treatment targets for new interventions to improve functional outcome in schizophrenia. A few preliminary studies of inpatients support the feasibility of improving social cognition through psychosocial interventions. This clinical trial evaluated a new 12-session social cognitive skills training program designed to address four aspects of social cognition (affect perception, social perception, attributional style, Theory of Mind) in outpatients with psychosis, a population for whom such interventions will likely be very useful. Thirty-one clinically stabilized outpatients were randomly assigned to a social cognition skills training intervention or a time-matched control condition (illness self-management and relapse prevention skills training), and completed pre- and post-treatment assessments of social cognition, neurocognition, and symptoms. The social cognition group demonstrated a large, significant improvement in facial affect perception, which was not present in the control group. This improvement was independent of changes in basic neurocognitive functioning or symptoms. Results support the efficacy of a social cognitive intervention for community-dwelling outpatients and encourage further development of this treatment approach to achieve broader improvements in social cognition and generalization of treatment gains.     

Predictive Factors of Social Functioning in Patients with Schizophrenia: Exploration for the Best Combination of Variables Using Data Mining

Objective

This study aimed to use data mining to explore the significantly contributing variables to good social functioning in schizophrenia patients.

Methods

The study cohort comprised 67 schizophrenia patients on stable medication. A total of 51 variables (6 demographic data, 3 illness history, 22 social cognition, 16 neurocognition, 4 psychiatric symptoms) were input into a data-mining decision tree using the Answer Tree program to find the pathway for the best social functioning.

Results

Several contributing factors for good social functioning were found. Continuous attention was the strongest contributing factor. Three variables involving best social functioning included good continuous attention, good theory of mind (TOM), and low sensitivity of disgust emotion.

Conclusion

Our results confirmed the mediating roles of social cognition between neurocognition and functional outcomes, and suggested that social cognition can significantly predict social functioning in schizophrenia patients.     

Social cognition of schizophrenia: bridging gap between brain science and psychosocial intervention

The concept and assessment tools for social cognition of schizophrenia were reviewed in order to bridge the gap between brain cognitive science and psycho-social intervention. Social cognition as well as neuro-cognition strongly influences social functioning, and the impact of neuro-cognition is mediated by social cognition. Neuronal networks of personal identification, facial perception, emotional identification, eye contact, "theory of mind", mutual communication, and the decision-making process have been clarified recently. The results of face discrimination and emotion recognition tasks show impairment in persons with schizophrenia as compared with healthy controls, especially fear, dislike, and sad recognition tasks. It might be difficult for them to link ambiguous stimuli with specific emotions, and they have a tendency to recognize uncomfortable emotions easily. "Jumping to conclusions" tendency (JTC) was identified in previous research on delusion. JTC develops from information uptake bias and confidence bias, and they might be thought to be trait and state. Social problem-solving is the skill to use social cognition to comprehensively adjust to specific social situations, and processing skills of social problem-solving are related to divergent thinking. Rating scales and the results of previous studies on emotion recognition, social perception, attribution style, and "theory of mind" were summarized. Furthermore, psycho-social interventions to improve emotion recognition directly, JTC, and divergent thinking were reported. Interventions aiming at improving social cognition or meta-cognition directly have been recently developed, which might improve some components of social functioning that used to be difficult to improve. These concepts of social cognition and researches on brain science, assessment tools, and intervention methods would clarify the mechanisms of the effects of psycho-social interventions, improve their methodology, and help to develop new aspects of intervention.