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.     

Could schizophrenic subjects improve their social cognition abilities only with observation and imitation of social situations?

Schizophrenics display impairments in domains of social cognition such as theory of mind and emotion recognition. Recent studies, showing that the relationship of social cognition abilities with functional outcome is more significant than other neuro-cognitive functions, have considered these abilities as a target for intervention research. This article describes preliminary data from a new group-based study focused on Emotion and ToM Imitation Training (ETIT), an imitation treatment aimed at improving social cognition and social functioning in schizophrenia.

In the present study, 16 outpatients with schizophrenia completed ETIT assessment and were compared with 17 outpatients who participated to a Problem Solving Training group. Participants were assessed at pre- and post-test on measures of emotion recognition, theory of mind, cognition, flexibility and social functioning. We compared the rehabilitation training effects on neuro-physiological activation through the event-related potentials (ERPs) method, which was recorded pre- and post-rehabilitation training. The results showed that when compared to the control group, ETIT participants improved on every social cognitive measure and showed better social functioning at post-test. Improvement in social cognition, in particular in emotion recognition, is also supported by ERP responses: we recorded an increase in electroactivity of medio-frontal areas only after ETIT treatment. Action observation and imitation could be regarded as a new frontier in rehabilitation.     

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.     

Social cognition deficits and the 'ultra high risk' for psychosis population: a review of literature

Aim: A number of risk factors for developing a psychotic disorder have been investigated in the ‘ultra high risk’ (UHR) population, including neurocognitive abilities, social functioning and, more recently, social cognition. We aimed to review the literature on social cognition in the UHR population. Methods: Literature was restricted to English articles and identified using Pubmed, Medline, PsychINFO and CINAHLplus, as well as the reference lists of published studies and reviews. Search terms included social cognition, theory of mind, emotion recognition, attributional style, social knowledge, social perception, ‘at risk mental state’, psychosis prodrome ‘clinical high risk’ and ‘ultra high risk’. Inclusion criteria were an outcome measure of a social cognition task and an UHR population defined by a structured validated instrument. Results: Seven original research articles met the inclusion criteria, one of which was a conference abstract. One of the two studies that assessed theory of mind, two of the four studies that assessed emotion recognition and both the two studies that assessed social perception/knowledge found significant deficits in UHR patients. The single study that assessed attributional bias also reported differences in UHR patients compared with healthy controls. Conclusions: There is limited published literature on social cognitive performance in the UHR population. Despite this, deficits in certain social cognitive abilities do appear to be present, but further research with more reliable cross‐cultural measures is needed. The characterization of social cognitive deficits in the UHR populations may aid in the identification of potential markers for development of a subsequent psychotic disorder, as well as targets for early intervention.     

Cognition sociale dans la schizophrénie et les troubles du spectre de l’autisme : points de convergences et différences fonctionnelles

Introduction

Schizophrenia and autistic spectrum disorder (ASD) are two neurodevelopmental disorders that have different symptom presentations, ages of onset and developmental courses. Both schizophrenia and ASD are characterized by marked deficit in communication, social interactions, affects and emotions. Social cognitive impairments in ASD and schizophrenia were demonstrated separately in both disorders. It was reported that these impairments have direct relation with social deficits of both disorders. The apparent similarity between social cognition impairments in ASD and schizophrenia highlights questions about the existence of common or different neurocognitive mechanisms related to social dysfunctions. In order to examine these questions, the present article provides a comprehensive review of all published studies which directly compare individuals with ASD and schizophrenia on the same cognitive tasks of social cognition.

Social cognitive training for schizophrenia: a meta-analytic investigation of controlled research

A wealth of evidence has revealed that deficits in social cognitive skills (including facial affect recognition (FAR), social cue perception, Theory of Mind (ToM), and attributional style) are evident in schizophrenia and are linked to a variety of domains of functional outcome. In light of these associations, a growing number of studies have attempted to ameliorate these deficits as a means of improving outcome in the disorder through the use of structured behavioral training. This study used quantitative methods of meta-analysis to assess the efficacy of behavioral training programs designed to improve social cognitive function. A total of 19 studies consisting of 692 clients were aggregated from relevant databases. Outcome measures were organized according to whether they were social cognitive tests proximal to the intervention or whether they represented measures of treatment generalization (symptoms, observer-rated community, and institutional function). With respect to social cognitive measures, weighted effect-size analysis revealed that there were moderate-large effects of social cognitive training procedures on FAR (identification, d = 0.71 and discrimination, d = 1.01) and small-moderate effects of training on ToM (d = 0.46), while effects on social cue perception and attributional style were not significant. For measures of generalization, weighted effect-size analysis revealed that there were moderate-large effect on total symptoms (d = 0.68) and observer-rated community and institutional function (d = 0.78). Effects of social cognitive training programs on positive and negative symptoms of schizophrenia were nonsignificant. Moderating variables and implications for future research and treatment development are discussed.     

Social cognition according to cognitive impairment in different clinical phenotypes of multiple sclerosis

The objective of this study is to evaluate the relationship between social cognition (SC) and cognitive impairment in persons with multiple sclerosis (PwMS). A prospective study was conducted in 60 PwMS, 30 with relapsing-remitting MS (RRMS), 15 with secondary progressive MS (SPMS) and 15 with primary progressive MS (PPMS), and in healthy subjects (HS). All subjects were assessed by the Bordeaux Social Cognition Evaluation Protocol (PECS-B) (facial emotion recognition, theory of mind, emotional awareness and cognitive and affective alexithymia), by a large neuropsychological battery and by questionnaires (depression and anxiety). 43.3% of PwMS were impaired for at least one SC test. The proportion of PwMS with at least two impaired SC tests was similar in all three phenotypes (20%). Mean scores differed significantly between PwMS and HS only for the Reading the Mind in the Eyes Test, a test of Theory of Mind (ToM). ANOVA analyses showed an effect of phenotype on emotional awareness scores with lower scores in PPMS as compared to RRMS. ToM performance was significantly correlated (r ² = 0.56) with executive functions, working memory and episodic memory scores. SC impairment was found in all phenotypes and was more prominent in cognitively impaired MS patients. Executive functions, and working and episodic memory performance accounts for approximately 50% of ToM performance. Emotional awareness is more impaired in progressive MS.     

Reduced Mirror Neuron Activity in Schizophrenia and Its Association With Theory of Mind Deficits: Evidence From a Transcranial Magnetic Stimulation Study

Background: The “mirror-neuron system” has been proposed to be a neurophysiological substrate for social cognition (SC) ability. We used transcranial magnetic stimulation (TMS) paradigms to compare putative mirror neuron activity (MNA) in 3 groups: antipsychotic-naive, medicated schizophrenia patients, and healthy comparison subjects. We also explored the association between MNA and SC ability in patients. Methods: Fifty-four consenting right-handed schizophrenia patients (33 antipsychotic naive) and 45 matched healthy comparison subjects completed a TMS experiment to assess putative premotor MNA. We used 4 TMS paradigms of eliciting motor-evoked potentials (MEP) in the right first dorsal interosseous (FDI) muscle. These were applied while the subjects observed a goal-directed action involving the FDI (actual action and its video) and a static image. The difference in the amplitude of the MEP while they observed the static image and the action provided a measure of MNA. Subjects also underwent SC assessments (theory of mind [ToM], emotion processing, and social perception). Results: Two-way repeated measures ANOVA revealed significant group × occasion interaction effect in 3 TMS paradigms, indicating deficient motor facilitation during action observation relative to rest state in antipsychotic-naive schizophrenia patients as compared with the other two groups. Among patients, there were significant direct correlations between measures of MNA and ToM performance. Conclusions: Antipsychotic-naive schizophrenia patients have poorer MNA than medicated patients and healthy controls. Measures of putative MNA had significant and consistent associations with ToM abilities. These findings suggest a possibility of deficient mirror neuron system underlying SC deficits in schizophrenia.Key words: mirror neurons, social cognition, mental state attribution, psychosis, antipsychotic-naive, embodied simulation     

Social cognition as a mediator of cognition and outcome among deaf and hearing people with schizophrenia

It has been suggested in the research literature that facial affect processing (FAP) and theory of mind (ToM) are both potential mediators of the well-established relationship between cognition and functional outcome among people with schizophrenia. The current project tests the mediating potency of these two domains of social cognition among deaf and hearing people with schizophrenia. Sixty-five people (34 deaf, 31 hearing) were assessed using measures of verbal and visual memory, attention, visual processing, FAP, and ToM. The results suggest that each domain of cognition, save vigilance, exerts an effect on functional outcome indirectly through its influence on social cognition. The patterns of mediation varied when the samples were broken down by hearing status and analyzed separately. Namely, the cognitive tasks directly involving linguistic ability (early visual processing [EVP] and word memory) were best mediated by social cognition for hearing subjects. For deaf subjects, the nonlinguistic cognitive tasks (e.g., visual-spatial memory-recall and copy [VSM-recall and VSM-copy]) were best mediated by social cognition. While FAP and ToM were equally effective as mediators for hearing subjects, FAP was a more potent mediator than ToM for deaf subjects. This study extends prior work in the area of social cognition and schizophrenia and indicates that the development of cognitive rehabilitation strategies should include not only interventions targeting specific cognitive abilities, such as attention and memory, but should include an emphasis on social-cognitive domains, including FAP and ToM. Further, deaf and hearing subjects may benefit from interventions addressing aspects of cognition that support linguistic ability, especially as they relate to social cognition.     

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.     

Potential therapeutic avenues to tackle social cognition problems in schizophrenia

Therapeutic strategies for improving social cognition in patients with schizophrenia have shown much promise in improving social functioning, as well as remediating core psychotic symptoms. However, the efficacy of previous interventions has often been limited by the ambiguity and inconsistency of the categorized subdomains of social cognition, including theory of mind, emotion processing, social perception and attributional bias. Recent research in social and cognitive neuroscience has revealed many new issues that could contribute to the development of more integrated approaches for improving social functioning. The application of such neuroscientific work to a therapeutic and diagnostic context is likely to encourage more effective transference of learned skills to real-world social functioning. This article seeks to provide a comprehensive review of previous social cognitive interventions for schizophrenia, highlight some crucial limitations of these and present the relevance of recent advances in neuroscientific research in possible future treatment strategies. It is emphasized that a more integrated and naturalistic approach for improving social functioning with greater sensitivity for neuroscientific findings related to the psychopathology of schizophrenia is warranted.     

Insight in schizophrenia: associations with empathy

Many people with schizophrenia (50–80 %) demonstrate impaired insight, something which has been associated with a poorer outcome. Two types of empathy can be distinguished: affective empathy via shared emotions and cognitive empathy, also referred to as Theory of Mind (ToM). ToM can be subdivided into cognitive ToM (knowledge about beliefs of other people via perspective taking) and affective ToM (knowledge about other people’s emotions via perspective taking). Recent studies show a relationship between Theory of Mind (ToM) and insight. However, the relationship between affective empathy and insight in schizophrenia was not examined previously. This was the aim of the present study. We expected that affective empathy would show a stronger relationship with insight than both cognitive and affective ToM. We assessed forty-six patients with a diagnosis of schizophrenia, and fifty-three healthy controls were assessed with a test battery consisting of tests of social cognition (a self-rating scale for affective empathy, a ToM task assessing both cognitive and affective ToM, and two tests of emotion perception), verbal memory, executive functioning, psychomotor speed, and intelligence. Insight was assessed with item G12 of the PANSS-interview. A regression equation showed that affective empathy made the strongest unique contribution to insight, followed closely by affective ToM. Together, they explained 45 % of the variance in insight. None of the other independent variables made a unique contribution to the prediction of insight. Both affective ToM and affective empathy are associated with insight in schizophrenia. Being able to take empathize with other peoples feeling at both the affective and cognitive level may enhance insight in schizophrenia.     

A closer look at the relationship between the subdomains of social functioning,social cognition and symptomatology in clinically stable patients with schizophrenia

Impairments in social functioning commonly seen in schizophrenia are thought to be mediated by deficits in the domains of social cognition. Some previous research has explored how social cognitive skills and psychotic symptoms are associated with social functioning, however these associations are still under debate. The main aim of this study was to investigate the relationship between different domains of social cognition and psychotic symptomatology, and also to look at the relationships with individual subdomains of social functioning within a clinically stable schizophrenia population. 45 outpatients were recruited and symptoms were assessed with the PANSS, and measures of emotion processing, affective and cognitive theory of mind (ToM), mental state reasoning attributional biases, and social functioning were taken. A correlational analysis was performed with the data. Following this, a regression analysis was used to reveal which domains of social cognition best predicted psychotic symptoms. In this stable group of patients, our results support the suggestion of a likely distinction between affective and cognitive components of ToM. The study also demonstrated that ToM and mental state reasoning were the best predictors of psychotic symptoms. Here we reveal that cognitive ToM had the most widespread relationship with social functioning, across multiple subdomains, while only some specific subdomains of social functioning correlated with other domains of social cognition and symptomatology. Further to this, positive symptoms were associated with much fewer subdomains of social functioning than negative and general symptoms. These findings imply that different aspects of social functioning may be served by different domains of social cognition and symptomatology.     

Social functioning, theory of mind and neurocognition in outpatients with schizophrenia; mental state decoding may be a better predictor of social functioning than mental state reasoning

Few studies have directly investigated the relationship between theory of mind (ToM) deficits and social functioning in schizophrenia. At the same time, the impact of mental state decoding tasks on social dysfunction has also not yet been investigated. In this study, the relationship between theory of mind deficits and social functioning was investigated among 50 patients with schizophrenia. A mental state decoding task known as 'The Eyes test' and a mental state reasoning task 'The Hinting test' were applied to assess ToM abilities, while the Social Functioning Scale (SFS) was used to assess social functioning. Non-ToM neurocognitive tests were also given to the patients. Results of the study show how theory of mind and working memory performances of patients with good functional outcome proved to be significantly better than those of inadequately functioning patients. Results also indicate that performance on the Eyes test was the best predictor of social functioning and that negative symptoms also contributed to poor social functioning. It is concluded in this study that mental state decoding skills appear to be the most important cognitive mediator of social functioning.     

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.     

Theory of mind performance in schizophrenia: diagnostic, symptom, and neuropsychological correlates

The purpose of this study was to explore the relationship between Theory of Mind (ToM) performance and schizophrenia subtype, symptom, and neuropsychological variables. One hundred twenty-eight stable outpatients with schizophrenia or schizoaffective disorder were assessed during the intake phase of a vocational and cognitive rehabilitation study. Results indicate that ToM performance differed significantly by schizophrenia diagnosis, with people diagnosed with disorganized schizophrenia performing the most poorly. Theory of Mind performance was also significantly correlated with measures of thought disorder and verbal memory. Regression analysis revealed that thought disorder and verbal memory measures explained 30% of the variance in ToM scores. Findings suggest that there is theory of mind variance in the schizophrenia population and theory of mind is strongly related to thought disorder, verbal memory, and cognitive disorganization. Contrary to previous reports, ToM was not related to measures of paranoia.     

Oxytocin,Dopamine, and the Amygdala: A Neurofunctional Model of Social Cognitive Deficits in Schizophrenia

Until recently, the social cognitive impairment in schizophrenia has been underappreciated and remains essentially untreated. Deficits in emotional processing, social perception and knowledge, theory of mind, and attributional bias may contribute to functional social cognitive impairments in schizophrenia. The amygdala has been implicated as a key component of social cognitive circuitry in both animal and human studies. In addition, structural and functional studies of schizophrenia reproducibly demonstrate abnormalities in the amygdala and dopaminergic signaling. Finally, the neurohormone oxytocin plays an important role in multiple social behaviors in several mammals, including humans. We propose a model of social cognitive dysfunction in schizophrenia and discuss its therapeutic implications. The model comprises abnormalities in oxytocinergic and dopaminergic signaling in the amygdala that result in impaired emotional salience processing with consequent social cognitive deficits.     

Evidence for theory of mind deficits in euthymic patients with bipolar disorder

OBJECTIVE: i) To investigate the subtle ToM (theory of mind) deficits in euthymic patients with bipolar disorder. ii) To investigate the impact of non-ToM cognitive deficits on ToM abilities. METHOD: Forty-three euthymic patients with bipolar disorder and 30 healthy control subjects were involved in this study. ToM was assessed by the Eyes test and the Hinting task. Both groups were also evaluated with a comprehensive neuropsychological battery including tasks for basic emotion and face recognition. RESULTS: The patient group was impaired on both of the ToM tasks. The patient group also showed impairment in many cognitive tasks including tasks related to sustained attention. CONCLUSION: Even euthymic patients with bipolar disorder may be impaired in advanced ToM tasks. Executive dysfunction and some other cognitives deficits such as basic emotion recognition may be at least partly responsible for this result.     

Are Deficits in the Decoding of Affective Cues and in Mentalizing Abilities Independent?

It has been hypothesized that deficits in theory of mind (ToM) and emotion recognition abilities in subjects with autisticlike disorders are independent. We examined the relationships between deficits in the various social cognitive domains in children with an autistic disorder (N = 20), in children with a pervasive developmental disorder not otherwise specified (PDDNOS) (N = 20), and in psychiatric control (N = 20) and normal children (N = 20). The clinical groups were matched person-to-person on age and verbal IQ. The clinical children were 8–18 years old, the normal children 8–13 years old. The test battery included tasks for the matching and the context recognition of emotional expressions, and a set of first- and second-order ToM tasks. ToM and emotion recognition functioning proved to be better integrated in the non-PDD children than in the PDD children, but also in the PDD children significant correlations were found between ToM and emotion recognition measures.     

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.