The Functional Significance of Social Cognition in Schizophrenia: A Review

Definitions

Social cognition is a broad construct encompassing many abilities. The ones identified and studied most frequently in the schizophrenia literature are emotion perception (EP), social perception (SP), theory of mind (ToM), and attributional style (AS).²⁷ EP (also called emotion recognition, affect recognition, or affect perception) is the ability to infer emotional information (ie, what a person is feeling) from facial expressions, vocal inflections (ie, prosody), or some combination of these (ie, video clips). SP refers to a person's ability to ascertain social cues from behavior provided in a social context, which includes, but is not limited to, emotion cues.²⁷ SP is also closely tied to social knowledge, which refers to a person's comprehension of social rules and conventions (eg, as stored in social schemas); thus, these 2 abilities will be grouped together. ToM involves both the ability to understand that others have mental states different from one's own and the capability to make correct inferences about the content of those mental states (eg, others' intentions or beliefs). ToM is typically operationalized as participants' ability to understand false beliefs (first- or second-order ToM) or the ability to understand verbal hints. AS refers to an individual's characteristic tendencies in explaining the causes of events in their lives. Research indicates that individuals with persecutory delusions and/or paranoia tend to blame others, rather than situations, for negative outcomes, an AS known as a personalizing bias.²⁸

The personalizing bias can be understood within a social information–processing framework. Specifically, it has been demonstrated that when forming impressions of others, nonclinical controls automatically make dispositional judgments and only subsequently “correct” for situational factors.²⁹ For example, if you meet someone and they are not friendly, you might infer that they are a rude person. However, if you subsequently learn that the person had just received bad news (eg, someone in their family had died), you would correct that impression in light of the contextual information. Thus, individuals with persecutory delusions do not engage in the second stage of modifying initial impressions. This may be due to a number of factors, including the possibility that individuals with persecutory beliefs have a strong need “for closure” (ie, a desire to get a specific answer on a topic or issue, rather than dealing with ambiguity),^30,31 impaired cognitive flexibility, which prevents individuals with delusions from entertaining other causal hypotheses,^32,33 and problems with ToM, which has shown an association with personalizing biases in both nonclinical and clinical samples.^34–36

A Conceptual Model of Social Cognition and Functional Outcome

Figure 1 presents our conceptual model of social cognition, as well as its proposed link with functional outcome. The model includes an example of a particular social situation (the reaction of a client with schizophrenia to a coworker who has rushed past him without saying hello) in order to explicate how this model would operate. First, the client may misperceive the emotional expression on the coworker's face to be anger, rather than upset or stressed, and attend to the social cues of rushing past, without observing additional information present in the situation. These misperceptions may then result in the client making a faulty conclusion that the coworker is angry. Subsequently, the next phase of processing involves the client's generation of an explanation of why the coworker is angry. Biases in AS, such as a personalizing bias, led the client to conclude that the coworker is “angry at me,” a bias that is not corrected because the client has difficulty putting himself in the coworker's position (ie, deficits in ToM). In other words, the client is unable to grasp the “emotional and social context” of the coworker's behavior. This results in the client feeling angry and resentful toward the coworker, which causes him to act in an unfriendly manner toward the coworker in the future (ie, inappropriate social behavior), who in turn avoids the client. This culminates in an increase in the client's general discomfort at work, thus affecting life satisfaction, and creating a vicious cycle whereby the client will anticipate negative interactions in the future but does not seek information that may contradict these expectations.³⁷ Thus, his relationships at work will become strained, via difficulties in initiating interactions with others (ie, problems in social skill), via problems in reacting to problems at work (ie, problems in social problem solving), or due to being unable to carry out his work activities (ie, as a result of being distracted by his anger toward coworkers). Therefore, according to this model, impairments (or biases) in social cognition can impact a variety of indices of functional outcome.

Search Strategy

A comprehensive search of the PsycINFO and MEDLINE/PUBMED databases was conducted. Within the domain of social cognition, the following search terms were used: (1) SP, (2) emotion/affect perception, (3) emotion/affect recognition, (4) attributions/AS, (5) ToM, (6) mentalizing/mentalising, (7) social cognition, (8) prosody, (9) social knowledge, (10) mind reading, (11) social cue, and (12) social judgment. Within the domain of functional outcome, the following terms were used: (1) functional outcome, (2) independent living skills/skills of daily living, (3) community/social functioning, (4) work/occupational/vocational functioning, (5) social skill, (6) quality of life, (7) community/social behavior, (8) life satisfaction, (9) social adjustment/dysfunction, and (10) employment. Search terms for schizophrenia included the following: (1) psychosis, (2) schizophrenia, and (3) schizoaffective disorder.

The results from these searches were evaluated for relevance; that is, only studies including at least one statistical technique (ie, correlation, regression, structural equation modeling, t tests, etc) for evaluating the relationship between an aspect of social cognition and functional outcome were included in this review. The majority of studies included assessment at only one time point, although 2 studies^38,39 included assessment of abilities 1 year after baseline as well.

Domains Comprising the Review

For purpose of clarity, we describe below the most commonly used measures within each domain of social cognition and functional outcome that are the focus of this review. Following this, we summarize the findings on the relationship between social cognition and functional outcome in the text, and in tables 1–4, we provide information on each study's measures, results, and effect sizes. Effect sizes were obtained via examination of all provided correlation coefficients in the reviewed studies. In instances when a correlation coefficient was not available, the percentage of variance accounted for or a t statistic was converted to a correlation. Ranges for effect sizes are as follows: ≤.1 (minimal to small), .1–.3 (small to > moderate), .3–.5 (moderate to large), .5 and above (large), which is in concert with commonly used conventions in the field.⁴⁰ In addition, power estimates for each study were calculated for a moderate effect size (r = .3) to determine if the reviewed studies were underpowered (ie, power less than .80).

Due to the fact that social cognition is a multifaceted construct, we have grouped studies in terms of the most common social cognitive domains in the field^27,41 (ie, SP, EP, ToM, and AS). Four measures of SP were common across studies: the Social Cue Recognition Test (SCRT, included in 3 of the 12 SP studies),^42,43 the Schema Component Sequencing Task-Revised (SCST-R, 4 of 12 studies),⁴⁴ the Profile of Nonverbal Sensitivity (PONS, 2 of 12 studies),⁴⁵ and the Situational Features Recognition Test (SFRT, 2 of 12 studies).^42,43 Two of these measures require judgments about short videotaped vignettes (eg, SCRT and PONS) and are clearly SP in nature, whereas the SCST-R and SFRT assess social knowledge. Additional, less commonly used measures of SP are presented in tables 1 and 4.

Within the domain of EP, the most consistently used measure was the Facial Emotion Identification Task (FEIT, tables 2 and 4; 6 of 10 studies).⁴⁶ In the FEIT, participants choose from among 6 emotion words (happy, angry, afraid, sad, surprised, and ashamed) to describe the facial expression depicted in black-and-white photographs. Other studies used similar measures, including the Pictures of Facial Affect (3 of 10 studies)⁴⁷ and the Facial Emotion Discrimination Test (3 of 10 studies).⁴⁶ In addition, EP was also measured via other modalities, such as measures of vocal affect perception (2 of 10 studies, Vocal Emotion Identification Test),⁴⁶ and video tasks including both vocal and facial affect cues (Bell-Lysaker Emotion Recognition Test),⁴⁸ and the Videotape Affect Perception Test,⁴⁹ included in 3 of 10 studies).

The only consistently utilized ToM measure was the Hinting Task (tables 3 and 4; 2 of 4 studies),⁵⁰ which requires participants to listen to a story presented verbally and ascertain what one character intends when she/he provides a verbal hint to another character. Other studies used some form of ToM “story” (either verbally, with cartoons, or both), which required participants to ascertain characters' false beliefs. Finally, AS was typically assessed with a questionnaire that described various situations (eg, your friend forgot to pick you up from work), following which, participants are asked to devise an explanation for why this event occurred. These explanations are often coded by the participant him/herself (eg, whether the outcome was due to themselves or others) or by research assistants (eg, for how much the responses involves an internal or external attribution and/or a hostile response).^51,52

As functional outcome is also a multifaceted construct that has been measured in diverse ways, we have divided most measures of functional outcome into 4 main areas as follows: social behavior in the milieu, community functioning, social skills, and social problem solving. Social behavior in the milieu is comprised of staff-rated assessments of the participants' behavior in a variety of treatment settings. Examples of measures included in this domain are the Nurse's Observation Scale for Inpatient Evaluation⁵³ and the Social Behavior Scale.⁵⁴ Community functioning encompasses a wide variety of behaviors and activities related to independent living skills, such as social or work functioning. Examples of measures used to assess this construct are the Role Functioning Scale⁵⁵ and the Quality of Life Scale,⁵⁶ with most measures being rated by the interviewer. The area of social skill was conceptualized as those studies that used role-play tasks in which specific interactional skills were rated (eg, eye contact, voice volume, meshing, etc). Finally, social problem solving was defined as the ability of participants to generate solutions to everyday social problems. The most commonly used measure in this area is the Assessment of Interpersonal Problem Solving Skills,⁵⁷ although one study used the problem solving subscale of the Independent Living Scales.⁵⁸ It should be noted that when measures were identified by the authors as assessing “social skill” or “social problem solving,” they were only included in the review if direct observation of social skill or social problem solving behavior occurred, so as to differentiate it from more cognitively based skills. In the following section, we summarize the relationship between each social cognitive domain and the 4 indices of functional outcome.

The Relationship of Social Cognition to Functional Outcome

Conclusions and Future Directions

The purpose of this review was to examine the relationship between social cognition (SP, EP, ToM, and AS) and functional outcome (social behavior in the milieu, community functioning, social skill, and social problem solving). Based on this review, we have drawn the following conclusions: First, there is a fairly consistent relationship between SP and various domains of functional outcome, particularly social problem solving, social behavior in the milieu, and community functioning. There is promising, but still inconsistent, evidence for a relationship between SP and social skill. Finally, there is growing evidence that SP may serve as a mediator between neurocognition and functional outcome. Second, EP appears to have a fairly consistent, yet modest, relationship with community functioning, social skill, and social behavior in the milieu, while no study has examined its relationship with social problem solving. Finally, one study suggests that EP may mediate the relationship between neurocognition and functional outcome.

Third, the domains of ToM and AS have received far less attention in terms of their functional significance. Current work is suggestive of a significant association between ToM and social skills and possibly with community functioning and social behavior in the milieu, but clearly more research is needed to draw firm conclusions. Only 2 studies have examined the relationship between attributions and functional outcome. This is likely due to the fact that AS has typically been studied in the context of persecutory delusions, rather than functional outcome. However, findings suggest that attributions might be related to functional outcome, particularly those in which the behaviors match the content of the attributional biases (eg, hostile attributional biases and aggressive behavior).⁵² These conclusions, however, should be met with caution due to the early and still developing nature of the literature. As more data become available on the relationship between social cognition and functional outcome, and some of the methodological problems plaguing this area are addressed in future studies, the findings from the current review may or may not change.

This review raises a number of issues that need to be considered in future research. At the conceptual level, a critical question is which aspects of functional outcome are expected to change to relate to specific domains of social cognition. In the extant literature, many studies focus on the notion that there should be a relationship between social cognition and functional outcome, but these relationships are generically defined, and do not specify which domain of social cognition should relate to which domain of functional outcome. In essence, the field needs to move from exploratory-based studies to hypothesis-based ones. For example, one might expect social cognition to be more strongly related to laboratory-based direct assessments of particular skills, rather than to community functioning. In fact, performance-based assessments might provide the most theoretically relevant link to neurocognition and social cognition in that they assess whether individuals are capable of performing certain behaviors in specific situations.⁷⁸ Of course, these skills are influenced by factors such as the motivation of the individual, but arguably, they provide a closer approximation of an individual's competence in particular areas than other measures of functional outcome. Broader-based domains of functional outcome (eg, recreational and work functioning) are not always strongly related to performance-based assessments,^70,79,80 and in addition, they may be influenced by factors outside the individual's control, such as level of social support, financial means, personal resources (eg, having an automobile), etc.³⁸

A related conceptual issue is how social cognition relates to functional outcome. The majority of studies in this review examined social cognition and functional outcome at a single time point, thus assuming that they covary with one another, but with little consideration for causal relationships. In addition, as noted above, 2 longitudinal studies found evidence that EP was predictive of functional outcome at a later time point.^38,39 These findings provide preliminary support for a causal relationship between social cognition and functional outcome, but clearly more long-term studies are needed.

The review also raises a number of critical methodological issues. First, it is essential for future studies to use well-defined measures of functional outcome and multiple measures of social cognition to help elucidate the relationships between these constructs. Currently, it is difficult to examine specific relationships or employ meta-analytic techniques, given the different measures utilized across studies. Of course, the National Institute of Mental Healths' Measurement and Treatment Research to Improve Cognition in Schizophrenia program (MATRICS)^81,82 is an important step in this direction because well-defined measures of neurocognition have been chosen to comprise this battery (and a number of social functioning tasks are included under secondary outcomes). However, only a single social cognitive measure is included in the MATRICs battery (the Mayer-Salovey-Caruso Emotional Intelligence Test),⁸³ and it does not address the range of social cognitive abilities impaired in schizophrenia. Second, it is important for future studies to clearly operationally define the constructs of interest as well as to utilize measures with sound psychometric properties. For example, we noted that basic psychometric information for ToM measures, such as reliability and validity, are often not presented and, when they are, their coefficients are not satisfactory,⁶⁸ a problem that also has been observed for measures of EP.⁷²

Third, sample characteristics, such as years of education achieved, duration of illness, and medication dosages, were inconsistently reported. Relatedly, over half of the reviewed studies had samples with over 70% of the participants being male. Given that schizophrenia occurs fairly often in females and that females with schizophrenia may have different illness trajectories and perhaps better social functioning, treatment response, and neuropsychological abilities than males,^84–86 it is critical for future work to attempt to recruit women with schizophrenia more heavily.

Fourth, over half of the research in this area included only inpatients. Although improving functioning in treatment settings (ie, social behavior in the milieu) is a valuable treatment goal, increasing current understanding of outpatient community functioning may be more pressing, given the move toward community-based care and that the largest subgroup of individuals with schizophrenia are outpatients.⁸⁷ And finally, most studies were underpowered. Specifically, 65% of studies had power estimates of .50 or less for detecting a moderate effect size, whereas only 17% of studies had adequate power of .80. Thus, extant research in this area may be underestimating significant findings due to the majority of the studies suffering from low statistical power.

Despite these limitations, it is clear that significant relationships exist between the domains of social cognition and functional outcome. Given the preliminary evidence that social cognition does have functional significance in schizophrenia, there has been growing interest in devising interventions aimed at improving functional outcomes via remediation of social cognitive deficits. The rationale for this endeavor is further strengthened by the fact that prominent current interventions, such as symptom-focused cognitive behavior therapy (CBT), show limited generalizability to improvements in social functioning.^88–90

The social cognitive interventions that have been developed to date can be classified as either “targeted” or “broad based.” Targeted interventions focus on a specific social cognitive domain (eg, EP), whereas broad-based interventions combine a variety of psychosocial approaches, including cognitive remediation, social skills training, and social cognitive skill building. Several targeted interventions have been shown to improve EP in schizophrenia.^91–96 Similarly, broad-based interventions have been found to improve some of the cognitive and social cognitive skills that they have targeted.^97–102 These findings are promising but also highlight several key issues that remain unaddressed. First, can we expect the narrow focus of targeted interventions to yield improvements across social cognitive domains or to generalize to social functioning? Second, if targeted interventions are too narrow, are broad-based interventions too burdensome? That is, is it necessary to stack social cognitive training atop intensive cognitive remediation and social skills training or might social cognitive training alone be sufficient to improve social functioning?

In an effort to address these issues, our research group has recently developed a social cognitive intervention that targets the 3 major domains that are impaired in schizophrenia: EP, ToM, and AS. Social Cognition and Interaction Training (SCIT) is an empirically derived, multimodal, 24-week group intervention for individuals with schizophrenia. Preliminary results from SCIT are promising. In our first (uncontrolled) pilot study, we showed that SCIT was associated with improvements in ToM, AS, and symptoms and that social cognitive and symptom improvement was independent of one another.¹⁰³ In a second pilot study, an initial group of participants who received SCIT showed improvement in all 3 social cognitive domains (EP, ToM, and attributions) as well as social functioning (as measured by the Social Functioning Scale¹⁰⁴ and aggression on the ward (as measured by incident reports) and showed a reduced need for closure and better tolerance for ambiguity (D. R. Combs, S. D. Adams, D. L. Penn, D. L. Roberts, J. Tiegreen, P. Stem, unpublished data, 2006) (as measured by the Need for Closure Scale).¹⁰⁵ All effect sizes were in the medium to large range. Although promising, these preliminary, open-trial results require replication in a controlled study before confident conclusions can be drawn.

At the current juncture, it is unclear how successful these social cognitive interventions will be; similar attempts in the cognitive remediation literature have been met with only modest success in improving neurocognitive abilities¹⁰⁶ or in impacting functional outcome.¹⁰⁷ However, it is hoped that over time, these interventions will play a prominent role—alongside medication management, CBT, social skills training, and cognitive remedation—in addressing the perennial riddle of improving functional outcome in schizophrenia.