by Philip D. Harvey, PhD, and David Penn, PhD
Dr. Harvey is Professor of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia. Dr. Penn is Professor of Psychology, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina.
Psychiatry (Edgemont). 2010;7(2):41–44
Funding: There was no funding for the development and writing of this article.
Financial Disclosures: The authors have no conflicts of interest relevant to the content of this article.
Impairments in different cognitive abilities have been found to be correlated with reduced real-world functioning in people with schizophrenia. A number of other features of the illness, such as depression and negative symptoms, contribute to the overall prediction of these outcomes. Impairment in social cognition is of particular interest as a mediating influence between cognition and social outcomes. Social cognition is a set of cognitive processes applied to the recognition, understanding, accurate processing, and effective use of social cues in real-world situations. In schizophrenia research, social cognition comprises the following domains: emotion perception, theory of mind (ToM), and attributional style. While substantial research has indicated that these abilities are clearly related to social outcomes, research has been slowed by problems in the measurement of these abilities. In this article, I will describe these abilities, discuss how they are currently measured, and how research could improve the current measurement of these abilities to make them more clinically useful.
social cognition, schizophrenia, real-world function
While schizophrenia is noted for its psychotic symptoms and deficit features, cognitive impairments are important aspects of the illness as well. While these cognitive impairments are well known as predictors of different aspects of real-world functional outcomes, social disability in schizophrenia may have a number of additional determinants. One of the domains wherein impairments may contribute to social disability in schizophrenia is social cognition. This is an area that is receiving an increase in attention that parallels the increased interest in cognition in schizophrenia over the past 10 years.
Social cognition refers to an array of abilities that involve cognitive capability applied to social situations. These include emotion perception and recognition, the ability to understand the potential mental states and intentions of others (referred to as Theory of Mind [TOM]), attributional styles, and social knowledge. Deficits in real-world social outcomes are related to impairments in these functions and they add to the contributions of traditionally measured neuropsychological functions for the prediction of impairments in social outcomes.
Cold versus Hot Cognition
The study of cognitive functions has been separated for the last 20 years or more into the study of the processing of emotionally neutral, personally irrelevant (cold) versus affectively laden and/or personally relevant (hot) information. There are a number of implications of this division, but among the most important is the consistent finding that emotionally relevant information processing may require different sets of processing resources and may be differentially affected by manipulations of processing demands compared to “cold” cognitive processes.
The concept of hot versus cold cognition is of particular interest in schizophrenia. Emotional, affective, and arousal disturbances have been described and studied in schizophrenia for a century. It is widely accepted that negative symptoms, such as reduced emotional experience, reductions in expression of emotional/affective states, and reduced interest in participation in emotional interactions, are widely present in people in schizophrenia and likely contribute to reductions in successful social interactions. Thus, hot cognition may be “cooled” in people with schizophrenia, with a resulting reduction in their ability to function in critical social situations.
Social Cognition as a Concept
Social cognition has several different features and their interrelationship has not yet fully been explored. One of the major apparent difficulties in schizophrenia is one of expressing and perceiving emotional displays. For years, emotion perception has been found to be impaired in people with schizophrenia, with this deficit often being measured in terms of the ability to recognize facial affect. It has been shown that impairments in emotion recognition are more common in people with schizophrenia who have other negative symptoms, such as blunted affect.
Another socially relevant cognitive ability is the ability to perceive the motives, intentions, and opinions of other people. This subcomponent of social cognition, referred to as ToM, can be measured with a variety of tests including the “hinting” test (whereby someone drops a hint that has to be interpreted by the patient). This ability is important because many people with schizophrenia manifest unusual patterns of interaction with others, which may be due to misperceptions or confusion about what others want, need, or are trying to communicate.
Alterations in attributional styles, including tendencies to take credit for positive outcomes and disclaim responsibility for adverse outcomes, have long been reported in people with schizophrenia. In fact, although it is part of normal response bias processes to take credit for positive outcomes that occur at random, the tendency to demonstrate extreme variants of this position is commonly associated with paranoia as seen in people with schizophrenia. In fact, even in individuals who are not clinically diagnosable, subclinical paranoid ideation is associated with a style that attributes negative outcomes to external forces (such as other people), often inferring malevolent intent.
Thus, social cognition is a set of socially oriented cognitive abilities that seem to have the potential to exert an influence on real-world social functioning. They have face validity for their association with a variety of features of the illness, from social withdrawal to suspiciousness and paranoia. As noted below, these domains appear to have substantial relevance to real-world social outcomes in people with schizophrenia.
Social cognition and social outcomes. The ability to navigate social interactions appears to require high levels of cognitive ability. Emotional displays are often fleeting and the people with whom interactions occur do not always mean what they say on a literal basis. In addition, there are a large number of implicit social rules and expectations that apply to even simple social interactions. Thus, there are multiple points where social cognitive impairments might lead to reduced quality of social outcomes. In fact, there are multiple recent studies that have found this relationship to be present.[7–10] For instance, it has been shown that impairments in several domains of social cognition, including emotion perception and theory of mind, are correlated with reduced social functioning. It has been found that these impairments are present early on in the illness, including at the time of the first indentified episode, and in some studies of individuals who may be manifesting prodromal symptoms. It may the case that there is an evolution or crystallization of social cognitive impairment at the time of the first episode of illness without further progression, because first episode and more chronic patients have been shown to show somewhat similar social cognitive impairments.
Social cognition and neurocognition. It is known that “cold” cognitive impairments are correlated with the severity of social functioning deficits and with problems in benefitting from social skills training. Social cognitive deficits appear to be somewhat smaller in magnitude, compared to the performance of healthy controls, than deficits in neuropsychological measures. Cognitive impairment effect sizes are often larger than a full standard deviation and the meta-analyses noted above have suggested that social cognitive deficits are half that size. However, several different recent studies have suggested that social cognition may be even more important for social outcomes than neurocognition. Specifically, baseline correlations between social cognitive deficits and real-world social outcomes are approximately twice as large as the correlation between cognitive impairments and these social outcomes. In many studies, the influence of cognitive impairment on social outcomes has largely been eliminated by consideration of the influences of social cognition on social outcomes.[13,14] Thus, these data suggest that understanding impairments in social outcomes in schizophrenia requires careful consideration of more than cognitive impairments as potential determinants. These data would also suggest that treatment of cognitive deficits might not be expected to have a large direct effect on social outcomes.
Treatment of Social Cognitive Deficits
The evidence in support of the functional significance of social cognition in schizophrenia has inspired researchers to examine whether social cognition can be improved, as it may be an important target for pharmacological and psychosocial treatments. Overall, there has been little support for atypical medications improving social cognition in schizophrenia. These negative findings may be due to the fact that some social cognition measures are not sensitive to change or that medications do not target key social cognitive mechanisms.
In contrast, there is growing evidence that psychosocial treatments do improve social cognition. Psychosocial interventions have been conceptualized as either “targeted” or “broad-based” approaches. Targeted approaches typically focus on ameliorating a specific social cognitive deficit, such as emotion perception (e.g., asking a client to imitate the facial expressions of others) and may be done over a single session or a few sessions.
Broad-based approaches tend to be more comprehensive as they address multiple social cognitive areas (e.g., emotion perception, theory of mind), utilize a variety of techniques (e.g., viewing videotapes, role plays, errorless learning), and are typically conducted in a group setting. Overall, there is evidence that both targeted and broad-based approaches can improve social cognition, while the latter has also shown promise in improving social functioning.
As the search for the determinants of real-world disability in schizophrenia becomes more refined, it has become more apparent that the model of “cognitive impairments cause disability” is as simplistic as “schizophrenia is caused by too much dopamine.” We see that real-world outcomes are complex and multiply determined, and, in some cases, the impaired ability that led to functional disability are quite specialized. Social cognition is a prototypical case in point. Social cognitive deficits are separable from neuropsychological deficits and they are themselves multidimensional. They are likely more important for the prediction of social outcomes than neuropsychological deficits and may be treatable themselves. Treating social cognitive deficits seems to have the potential to improve social outcomes in schizophrenia.
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