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.

Emotional intelligence in schizophrenia.

BACKGROUND: Deficits in emotion perception have been extensively documented in schizophrenia and are associated with poor psychosocial functioning. However, little is known about other aspects of emotion processing that are critical for adaptive functioning. The current study assessed schizophrenia patients' performance on a theoretically-based, well-validated, multidimensional measure of emotional intelligence, the Mayer-Salovey-Caruso Emotional Intelligence Test (Mayer, J.D., Salovey, P., Caruso, D.R., 2002. Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT): User's Manual. Multi-Health Systems, Inc., Toronto, Ontario). METHODS: 50 schizophrenia outpatients and 39 non-psychiatric controls completed the MSCEIT, a performance measure comprised of subtests that assess four components (branches) of emotional intelligence: Identifying, Using, Understanding, and Managing Emotions. Among patients, associations between MSCEIT scores and measures of clinical symptoms as well as functional outcome were evaluated. RESULTS: The MSCEIT demonstrated good psychometric properties in both groups. Schizophrenia patients performed significantly worse than controls on the total MSCEIT score, and on three of the four subtests: Identifying, Understanding, and Managing Emotions. Among patients, lower MSCEIT scores significantly correlated with higher negative and disorganized symptoms, as well as worse community functioning. CONCLUSIONS: The MSCEIT is a useful tool for investigating emotion processing in schizophrenia. Individuals with schizophrenia demonstrate deficits across multiple domains of emotion processing. These deficits have significant links with clinical symptoms of schizophrenia and with how patients function in their daily lives. Further research is required to understand the links between emotional intelligence, clinical symptoms, and functional outcome in schizophrenia.

Development of a measure of relationship perception in schizophrenia.

Relationships Across Domains (RAD) is a new measure of competence in relationship perception that may be used to assess clinically stable persons with schizophrenia and healthy persons. The structure and content of the RAD are grounded in relational models theory, a well-validated theory of social relations. The 75-item RAD contains 25 vignettes and can be administered in approximately 35 min. The RAD requires participants to implicitly identify the relational model of a dyad described in a brief vignette and infer how the members of the dyad are likely to behave in three other social contexts. The RAD demonstrated good internal consistency in schizophrenia outpatients and healthy participants matched to the outpatients in age and education. The schizophrenia outpatients performed more poorly on the RAD than two healthy comparison groups, supporting the ability of the RAD to discriminate between clinical and non-clinical populations. The schizophrenia patients' performance on the RAD was moderately related to reading ability and several domains of community functioning.

The challenges of ecological validity in the measurement of social perception in schizophrenia.

Ecological validity may be substantiated by verisimilitude (the stimuli and cognitive processing of a test resemble the stimuli and cognitive processing required in everyday life) and/or veridicality (a test is statistically associated with everyday life functioning). The Interpersonal Perception Task uses real-life social behavior as stimuli and has high verisimilitude. We examined the Interpersonal Perception Task-15 in 72 persons with schizophrenia and 58 healthy controls. The test discriminated well between groups, but failed to show associations with community functioning in participants with schizophrenia, indicating poor veridicality. This study shows that the 2 approaches to ecological validity can dissociate. Hence, it is important for investigators to conduct psychometric investigations when borrowing measures from social psychology for schizophrenia research.

Social functioning impairments in schizotypy when social cognition and neurocognition are not impaired.

The present study examined the social, cognitive, and emotional functioning of persons with schizotypy. Over 2000 undergraduate students were screened for schizotypy with the Schizotypal Personality Questionnaire - Brief over two consecutive semesters. Ninety-two persons with high schizotypy and 22 persons with low schizotypy completed measures of social functioning (Social Adjustment Scale, Social Functioning Scale, MOS Social Support Survey), working memory (Paced Auditory Serial Addition Test, Digit Span, Letter-Number Sequencing, Corsi Block Tapping Test) and empathy (Interpersonal Reactivity Index, Empathy Quotient). Persons with high schizotypy, when compared to their counterparts with low schizotypy, displayed deficits on many indices of social functioning even though differences in working memory and empathy were not observed. The social functioning deficits of persons with high schizotypy included impairments in friendship relations, family relations, interpersonal engagement, and recreational activities. These findings indicate that persons with high schizotypy experience broad deficits in social functioning even when their cognitive and emotional skills are unaffected.

Social cognition [corrected] and neurocognition: effects of risperidone, olanzapine, and haloperidol.

OBJECTIVE: This study examined the short-term effects of first- and second-generation antipsychotic medications on social cognition and basic cognition. METHOD: One hundred patients with schizophrenia or schizoaffective disorder participated in an 8 week, double-blind study of risperidone, olanzapine, and haloperidol. Participants were administered multiple measures of social cognition, basic cognition, and clinical symptoms at baseline, the end of week 4, and the end of week 8. Seventy-three patients completed the baseline assessment and at least one other assessment. Data were analyzed with mixed-effects analyses of covariance. For data reduction, the social cognitive measures were clustered into a summary score, and the cognitive measures were clustered into two summary scores: general cognitive ability and processing speed. RESULTS: There were no treatment-related differences on any of the three summary scores. Social cognition did not show within-group changes over time either by itself or after control for the cognitive clusters. One cognitive score (general cognitive ability) increased during the study period for all three medication groups. CONCLUSIONS: The present study included a rather thorough assessment of social cognition and did not find any evidence of between-group or within-group effects of antipsychotic medication on social cognition.

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.

Social cognition in schizophrenia: relationships with neurocognition and negative symptoms.

Despite the growing importance of social cognition in schizophrenia, fundamental issues concerning the nature of social cognition in schizophrenia remain unanswered. One issue concerns the strength of the relationships between social cognition and key features of the disorder such as neurocognitive deficits and negative symptoms. The current study employed structural equation modeling to examine three key questions regarding the nature of social cognition in schizophrenia: 1) Are social cognition and neurocognition in schizophrenia better modeled as one or two separate constructs? 2) Are social cognition and negative symptoms in schizophrenia better modeled as one or two separate constructs?, and 3) When social cognition, neurocognition, and negative symptoms are included in a single model, is social cognition more closely related to neurocognition or to negative symptoms? In this cross sectional study, one hundred outpatients with schizophrenia or schizoaffective disorder were administered measures of social cognition, neurocognition, and negative symptoms. A two-factor model that represented social cognition and neurocognition as separate constructs fit the data significantly better than a one-factor model, suggesting that social cognition and neurocognition are distinct, yet highly related, constructs. Likewise, a two-factor model that represented social cognition and negative symptoms as separate constructs fit the data significantly better than a one-factor model, suggesting that social cognition and negative symptoms are distinct constructs. A three-factor model revealed that the relationship between social cognition and neurocognition was stronger than the relationship between social cognition and negative symptoms. The current findings start to provide insights into the structure of social cognition, neurocognition, and negative symptoms in schizophrenia.

Social perception as a mediator of the influence of early visual processing on functional status in schizophrenia.

OBJECTIVE: The potential of social cognition as a mediator of relations between neurocognition and functional status in schizophrenia has been suggested by correlational studies that link neurocognition to social cognition or link social cognition to functional status. The authors used structural equation modeling to test more directly whether one aspect of social cognition (social perception) mediates relations between basic visual perception and functional status in patients with schizophrenia. METHOD: Seventy-five outpatients with schizophrenia were administered measures of early visual processing (computerized visual masking procedures), social perception (Half Profile of Nonverbal Sensitivity), and functional status (Role Functioning Scale). RESULTS: Structural equation modeling supported social perception as a mediator of relations between early visual processing and functional status in schizophrenia. The mediation model indicated that early visual processing is linked to functional status through social perception, thereby supporting a significant indirect relationship. The direct relationship between early visual processing and functional status was significant in a model that did not include social perception but was not significant in the mediation model that included social perception. CONCLUSIONS: Social cognition appears to be a key determinant of functional status in schizophrenia. Using a very basic measure of visual perception, the present study found that social perception mediates the influence of early visual processing on functional status in schizophrenia.

A videotape intervention to enhance the informed consent process for medical and psychiatric treatment research.

OBJECTIVE: This study evaluated a brief educational video designed to enhance the informed consent process for people with serious mental and medical illnesses who are considering participating in treatment research. METHOD: Individuals with schizophrenia who were being recruited for ongoing clinical trials, medical patients without self-reported psychiatric comorbidity, and university undergraduates were randomly assigned to view either a highly structured instructional videotape about the consent process in treatment research or a control videotape that presented only general information about bioethical issues in human research. Knowledge about informed consent was measured before and after viewing. RESULTS: Viewing the experimental videotape resulted in larger gains in knowledge about informed consent. Standardized effect sizes were large in all groups. CONCLUSIONS: The videotape was thus an effective teaching tool across diverse populations, ranging from individuals with severe chronic mental illness to university undergraduates.

Sensorimotor gating, orienting and social perception in schizophrenia.

Basic neurocognition and social cognition appear to influence the social impairments of persons with schizophrenia. This study examined relationships between two very basic automatic processes (i.e., sensorimotor gating and orienting) and social perception in schizophrenic patients. Thirty outpatients with schizophrenia completed psychophysiological measures of sensorimotor gating (prepulse inhibition, PPI), orienting (prepulse facilitation, PPF), and social perception (the Half Profile of Nonverbal Sensitivity, Half PONS). A median split was used to divide patients into poor and good gaters and poor and good orienters. Analyses revealed that patients with good PPI scored significantly higher on the Half PONS than patients with poor PPI. PPI showed a significant correlation (r=-0.54) with Half PONS performance, indicating that schizophrenia patients who were better able to gate out competing stimuli (i.e., less startle) were also better at detecting relevant social cues. Orienting (PPF) and social perception were not related. This study is the first to our knowledge to demonstrate an association between sensorimotor gating and social perception. The findings are consistent with other studies that have demonstrated relationships between basic neurocognition and social cognition. By showing a link between sensorimotor gating and social perception, this study supports social cognition's potential role as a mediator of the relationship between neurocognition and social functioning in schizophrenia.

Learning potential and the prediction of work skill acquisition in schizophrenia.

This study examined whether a measure of learning potential could predict work skill acquisition in schizophrenia beyond the prediction offered by a single administration assessment. Fifty-seven outpatients with schizophrenia or schizoaffective disorder completed a test-train-test version of the Wisconsin Card Sorting Test as a measure of their learning potential. The outpatients were randomly assigned to training by errorless learning or conventional instruction on two work skills (index card filing and toilet tank assembly). Work skills were assessed both immediately and 3 months after training. Generally, patients with high learning potential performed better on the work skill tasks. Learning potential explained an additional 15 percent of variance beyond single administration assessment in participants' accuracy immediately after work skill training and an additional 13 percent of variance in participants' accuracy 3 months after training. These findings indicate that measures of learning potential contribute to the prediction of work skill acquisition, going beyond the predictive power of single administration assessments.

Social perception and early visual processing in schizophrenia.

Persons with schizophrenia experience deficits in social cognition-the cognitive processes involved in how people perceive and interpret information about themselves, others, and social situations. These deficits may be related to the neurocognitive impairments often experienced by persons with schizophrenia. Our primary objective was to examine associations between social perception and early visual processing in schizophrenia. Our secondary objective was to examine whether outpatients with schizophrenia and healthy persons differ in social perception. Forty outpatients with schizophrenia and 30 healthy persons completed a measure of social perception (the Half-Profile of Nonverbal Sensitivity), visual masking procedures, and ratings of positive and negative symptoms. Within patients, performance on visual masking procedures was related to performance on the Half-Profile of Nonverbal Sensitivity. Patients with schizophrenia and the healthy persons differed significantly in their performance on the Half-Profile of Nonverbal Sensitivity, but this difference became nonsignificant when education was a covariate. These findings suggest that social perception in schizophrenia is related to very early aspects of visual processing.

Social cognition in schizophrenia, Part 2: 12-month stability and prediction of functional outcome in first-episode patients.

This study evaluated the longitudinal stability and functional correlates of social cognition during the early course of schizophrenia. Fifty-five first-episode schizophrenia patients completed baseline and 12-month follow-up assessments of 3 key domains of social cognition (emotional processing, theory of mind, and social/relationship perception), as well as clinical ratings of real-world functioning and symptoms. Scores on all 3 social cognitive tests demonstrated good longitudinal stability with test-retest correlations exceeding .70. Higher baseline and 12-month social cognition scores were both robustly associated with significantly better work functioning, independent living, and social functioning at the 12-month follow-up assessment. Furthermore, cross-lagged panel analyses were consistent with a causal model in which baseline social cognition drove later functional outcome in the domain of work, above and beyond the contribution of symptoms. Social cognitive impairments are relatively stable, functionally relevant features of early schizophrenia. These results extend findings from a companion study, which showed stable impairments across patients in prodromal, first-episode, and chronic phases of illness on the same measures. Social cognitive impairments may serve as useful vulnerability indicators and early clinical intervention targets.

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.

Emotional intelligence and social functioning in persons with schizotypy.

The present study is the first to examine emotional intelligence in persons with schizotypy. Over 2100 undergraduates were screened for schizotypy with the Schizotypal Personality Questionnaire-Brief Version. Forty participants identified as persons with high schizotypy and 56 participants identified as persons with low schizotypy completed assessments of emotional intelligence (Mayer-Salovey-Caruso Emotional Intelligence Test), social functioning (Social Adjustment Scale-Self Report), verbal episodic (secondary) memory (California Verbal Learning Test), and executive functioning (Wisconsin Card Sorting Test). Persons high in schizotypy were impaired in overall emotional intelligence and two aspects of emotional intelligence, the ability to perceive emotions and the ability to manage emotions. Persons high in schizotypy were also impaired in three aspects of social functioning: peer relationships, family relationships, and academic functioning. Group differences in verbal episodic (secondary) memory and executive functioning were not observed. For persons with high schizotypy, overall emotional intelligence and two aspects of emotional intelligence, the ability to perceive emotions and the ability to manage emotions, were associated with peer relationship functioning. Overall emotional intelligence was associated with verbal episodic (secondary) memory, but not executive functioning, in persons with high schizotypy. The current findings suggest that emotional intelligence is impaired in persons with schizotypy and that these impairments affect their social functioning.