The Functional Significance of Social Cognition in Schizophrenia: A Review

Transcription

1 Schizophrenia Bulletin vol. 32 no. S1 pp. S44 S63, 2006 oi: /schbul/sbl029 Avance Access publication on August 17, 2006 The Functional Significance of Social Cognition in Schizophrenia: A Review Shannon M. Couture, Davi L. Penn 1, an Davi L. Roberts Department of Psychology, University of North Carolina at Chapel Hill, CB #3270, Davie Hall, Chapel Hill, NC Deficits in a wie array of functional outcome areas (eg, social functioning, social skills, inepenent living skills, etc) are marke in schizophrenia. Consequently, much recent research has attempte to ientify factors that may contribute to functional outcome; social cognition is one such omain. The purpose of this article is to review research examining the relationship between social cognition an functional outcome. Comprehensive searches of PsycINFO an MEDLINE/PUBMED were conucte to ientify relevant publishe manuscripts to inclue in the current review. It is conclue that the relationship between social cognition an functional outcome epens on the specific omains of each construct examine; however, it can generally be conclue that there are clear an consistent relationships between aspects of functional outcome an social cognition. These finings are iscusse in light of treatment implications for schizophrenia. Key wors: social functioning/emotion perception/ social perception/theory of min Deficits in social functioning, incluing communicating with others, maintaining employment, an functioning in the community, are observe in many isorers but are a efining feature of schizophrenia. 1 Inee, social functioning eficits are evient premorbily in those who later evelop schizophrenia 2,3 an are often present in first-egree relatives of iniviuals with schizophrenia. 4 Impaire social functioning also impacts the quality of life 5 an preicts outcome in schizophrenia, incluing relapse, poor illness course, an unemployment. 6 8 Thus, social ysfunction is a hallmark characteristic of schizophrenia that has important implications for the evelopment, course, an outcome of this illness. One of the challenges to research in this area is inconsistent efinitions of social functioning. This term has 1 To whom corresponence shoul be aresse; tel: , fax: , penn@ .unc.eu. been use to apply to self- or other report of interpersonal behaviors, behavior in community settings (eg, skill ratings while shopping), skills of inepenent living (eg, self-care skills, grooming, financial skills, etc), ratings of social skill in laboratory settings (eg, role-play tests), an ratings of social problem-solving skills. Accoringly, some researchers have taken to escribing this conglomeration of omains as functional outcome, a broaer term use to encapsulate all these iverse areas. 9,10 This review also uses this term, recognizing that it inclues strictly social behaviors as well as behaviors that are less purely social, such as engaging in activities in the community an caring for oneself. Given the critical role of functional outcome in schizophrenia, there has been growing interest in factors that may unerlie it. If the nature of these factors can be elineate, interventions may be evise to ameliorate them, which, in turn, may have a concomitant impact on long-term outcome. Neurocognition is one such factor. Whereas most previous research supports a significant relationship between at least one aspect of neurocognition an functional outcome, the amount of variance accounte for is typically rather moest. 5,9,11 In fact, although Green et al 11 reporte that 20% to 60% of the variance in functional outcome coul be explaine by composite measures of neurocognition, the variance accounte for in most of the stuies was only in the 20% to 40% range; stuies reporting variance estimates of greater than 40% were the exception, rather than the rule. Thus, anywhere from 60% to 80% of the variance in functional outcome is unaccounte for by traitional neurocognitive measures, spurring researchers to continue searching for other contributing factors. 11 More recently, social cognition has been ientifie as a likely contributor to functional outcome. Brothers 12(p28) efine social cognition as the mental operations unerlying social interactions, which inclue the human ability an capacity to perceive the intentions an ispositions of others. Similarly, Aolphs 13(p231) ientifie social cognition as the ability to construct representations of the relation between oneself an others an to use those representations flexibly to guie social behavior. Thus, the theory implies a close association between social cognition an functional outcome because the ability to quickly process social stimuli is essential for social interactions, an problems in this area can impact peer, Downloae from at University of North Carolina at Chapel Hill on July 31, 2014 Ó The Author Publishe by Oxfor University Press on behalf of the Marylan Psychiatric Research Center. All rights reserve. For permissions, please journals.permissions@oxforjournals.org. S44

2 S. M. Couture et al. romantic, an family relationships as well as work/school behavior. In aition, social cognition may impact the functional outcome of inepenent living skills because accurately assessing social cues from the environment (such as someone responing to boy oor by increasing boily istance or making a facial expression of isgust), an having the social opportunities necessary to learn skills such as home an financial care, may be a necessary prerequisite for making improvements in aily living skills. There is general consensus that neurocognition an social cognition are relate, but ifferent constructs. 5 For example, research examining the neural unerpinnings of neurocognitive an social cognitive abilities suggest semi-inepenent systems for processing nonsocial an social stimuli. In aition, there appears to be only a moest association between neurocognition an social cognition Thus, social cognition may contribute to functional outcome in a way that is not reunant with neurocognition. The purpose of this article is to review the extant research on the relationship between social cognition an functional outcome, with an eye towar implications for social cognition as a potential treatment target for schizophrenia. Before a meaningful escription of the reviewe stuies can occur, efinitions of the relevant constructs an a conceptual moel are neee. Definitions Social cognition is a broa construct encompassing many abilities. The ones ientifie an stuie most frequently in the schizophrenia literature are emotion perception (EP), social perception (SP), theory of min (ToM), an attributional style (AS). 27 EP (also calle 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, prosoy), or some combination of these (ie, vieo clips). SP refers to a person s ability to ascertain social cues from behavior provie in a social context, which inclues, but is not limite to, emotion cues. 27 SP is also closely tie to social knowlege, which refers to a person s comprehension of social rules an conventions (eg, as store in social schemas); thus, these 2 abilities will be groupe together. ToM involves both the ability to unerstan that others have mental states ifferent from one s own an the capability to make correct inferences about the content of those mental states (eg, others intentions or beliefs). ToM is typically operationalize as participants ability to unerstan false beliefs (firstor secon-orer ToM) or the ability to unerstan verbal hints. AS refers to an iniviual s characteristic tenencies in explaining the causes of events in their lives. Research inicates that iniviuals with persecutory elusions an/or paranoia ten to blame others, rather S45 than situations, for negative outcomes, an AS known as a personalizing bias. 28 The personalizing bias can be unerstoo within a social information processing framework. Specifically, it has been emonstrate that when forming impressions of others, nonclinical controls automatically make ispositional jugments an only subsequently correct for situational factors. 29 For example, if you meet someone an they are not frienly, you might infer that they are a rue person. However, if you subsequently learn that the person ha just receive ba news (eg, someone in their family ha ie), you woul correct that impression in light of the contextual information. Thus, iniviuals with persecutory elusions o not engage in the secon stage of moifying initial impressions. This may be ue to a number of factors, incluing the possibility that iniviuals with persecutory beliefs have a strong nee for closure (ie, a esire to get a specific answer on a topic or issue, rather than ealing with ambiguity), 30,31 impaire cognitive flexibility, which prevents iniviuals with elusions from entertaining other causal hypotheses, 32,33 an problems with ToM, which has shown an association with personalizing biases in both nonclinical an clinical samples A Conceptual Moel of Social Cognition an Functional Outcome Figure 1 presents our conceptual moel of social cognition, as well as its propose link with functional outcome. The moel inclues an example of a particular social situation (the reaction of a client with schizophrenia to a coworker who has rushe past him without saying hello) in orer to explicate how this moel woul operate. First, the client may misperceive the emotional expression on the coworker s face to be anger, rather than upset or stresse, an atten to the social cues of rushing past, without observing aitional 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, le the client to conclue that the coworker is angry at me, a bias that is not correcte because the client has ifficulty putting himself in the coworker s position (ie, eficits in ToM). In other wors, the client is unable to grasp the emotional an social context of the coworker s behavior. This results in the client feeling angry an resentful towar the coworker, which causes him to act in an unfrienly manner towar the coworker in the future (ie, inappropriate social behavior), who in turn avois the client. This culminates in an increase in the client s general iscomfort at work, thus affecting life satisfaction, an creating a vicious cycle whereby the client will anticipate negative Downloae from at University of North Carolina at Chapel Hill on July 31, 2014

3 Social Cognition an Functional Outcome Fig. 1. Conceptual Framework for Unerstaning the Interplay Between Social Cognition an Social Functioning. interactions in the future but oes not seek information that may contraict these expectations. 37 Thus, his relationships at work will become straine, via ifficulties 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 ue to being unable to carry out his work activities (ie, as a result of being istracte by his anger towar coworkers). Therefore, accoring to this moel, impairments (or biases) in social cognition can impact a variety of inices of functional outcome. Search Strategy A comprehensive search of the PsycINFO an MED- LINE/PUBMED atabases was conucte. Within the omain of social cognition, the following search terms were use: (1) SP, (2) emotion/affect perception, (3) emotion/affect recognition, (4) attributions/as, (5) ToM, (6) mentalizing/mentalising, (7) social cognition, (8) prosoy, (9) social knowlege, (10) min reaing, (11) social cue, an (12) social jugment. Within the omain of functional outcome, the following terms were use: (1) functional outcome, (2) inepenent living skills/skills of aily 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 ajustment/ysfunction, an (10) employment. Search terms for schizophrenia inclue the following: (1) psychosis, (2) schizophrenia, an (3) schizoaffective isorer. The results from these searches were evaluate for relevance; that is, only stuies incluing at least one statistical technique (ie, correlation, regression, structural equation moeling, t tests, etc) for evaluating the relationship between an aspect of social cognition an functional outcome were inclue in this review. The majority of stuies inclue assessment at only one time point, although 2 stuies 38,39 inclue assessment of abilities 1 year after baseline as well. Domains Comprising the Review For purpose of clarity, we escribe below the most commonly use measures within each omain of social cognition an functional outcome that are the focus of this review. Following this, we summarize the finings on the relationship between social cognition an functional outcome in the text, an in tables 1 4, we provie information on each stuy s measures, results, an effect sizes. Effect sizes were obtaine via examination of all provie correlation coefficients in the reviewe stuies. In instances when a correlation coefficient was not available, the percentage of variance accounte for or a t statistic was converte to a correlation. Ranges for effect sizes are as follows: #.1 (minimal to small),.1.3 (small to > moerate),.3.5 (moerate to large),.5 an above (large), which is in concert with commonly use conventions in the fiel. 40 In aition, power estimates for each stuy were calculate for a moerate effect size (r =.3) to etermine if the reviewe stuies were unerpowere (ie, power less than.80). Due to the fact that social cognition is a multifacete construct, we have groupe stuies in terms of the most common social cognitive omains in the fiel 27,41 (ie, SP, EP, ToM, an AS). Four measures of SP were common across stuies: the Social Cue Recognition Test (SCRT, inclue in 3 of the 12 SP stuies), 42,43 the Schema Downloae from at University of North Carolina at Chapel Hill on July 31, 2014 S46

4 S. M. Couture et al. Table 1. Social Perception (SP) an Functional Outcome (FO) in Schizophrenia (S) Stuy Participants SC Measures FO Measures Major Finings Appelo et al 59 Aington et al 65 Corrigan an Toomey 66 Kim et al S inpatients MA = 30 Male: 71.8% Yrs E: 10 Yrs Ill: 7 Clor eq:? 50 FE inpatients MA = 25 Male: 60% Yrs E: 66% complete 12th grae Yrs ill: <3 mo treatment Clor eq: 307/380 (1st/2n assess) 53 S outpatients MA = 35 Male: 71.6% Yrs E: 71% complete 12th grae Yrs Ill:? > 3y Clor eq: 715/665 (1st/2n assess) 26 S or SA inpatients MA = 34 Male: 6.9% Yrs E: 12.2 Yrs Ill: ;14.3 Clor eq: S outpatients MA = 38 Male: 64% Yrs E: 12 Yrs Ill: 14.5 Clor eq: 290 Picture Arrangement from WAIS-R SCRT, SFRT SCRT Biological motion task Social behavior in milieu: Staff ratings on general behavior subscale from rehabilitation evaluation SSIT Community functioning: QLS Social problem solving: AIPSS Social problem solving: AIPSS Community function: Zigler Social Competence Scale SP preicte 34% of the variance in social behavior in milieu (P <.0001) SP i not preict social skills (i not inclue statistics) Effect size for social behavior is large (r =.58); unable to etect for social skill Power for effect size of r =.3 is In both groups, scores on SCRT an SFRT associate with QLS at baseline an 1 y later (r =.25 to.39, P <.01) an with AIPSS at both time points (r =.33 to.51, P <.011) SP composite preicte 7.8% (P <.05) an 15.2% (P<.0001) of the variance in QLS at baseline an 1 y, respectively SP composite preicte 19.4% (P <.0001) an 24% (P <.0001) of the variance in AIPSS at baseline an 1 y In a series of regressions using composite SP an composite cognition, foun evience to support SP as a meiator for QLS, an particularly for AIPSS Most effect sizes appear to be small to moerate (not all correlations were provie) Power for effect size of r =.3 is SCRT correlate with sening skills at Bonferroni level (r =.73, P <.001) After partialling out effects of verbal memory an learning, the effects remaine but were slightly reuce Effect sizes were all large Power for effect size of r =.3 is Biological motion perception was associate with community functioning scores in full sample (r =.71, P <.0001) This is equivalent to a large effect Power for effect size of r =.3 is Downloae from at University of North Carolina at Chapel Hill on July 31, 2014 S47

5 Social Cognition an Functional Outcome Table 1. Continue Stuy Participants SC Measures FO Measures Major Finings Penn et al 60 Revheim an Mealia 64 Sergi et al 10 Toomey et al S or SA resients of acute care MA = 35 Male: 82.8% Yrs E: 11.3 Yrs Ill:? Clor eq: S or SA inpatients 75 S or SA outpatients MA = 37 Male: 62.3% Yrs E: 11.1 Yrs Ill: ~14 Clor eq:? 75 S Outpatients MA = 47 Male: 92% Yrs E: 13.0 Yrs Ill: 21.2 Clor eq:? 29 S inpatients MA = 34 Male: 68.9% Yrs E: 12.5 Yrs Ill: 14.3 Clor eq: SCST-R, GPT, SMT WAIS-R Comprehension Half-PONS PONS Social behavior in milieu NOSIE: staff ratings for social competence, social interest, neatness Community status (inpatient or outpatient) Community functioning: RFS inepenent living, social functioning, an work functioning subscales (use as latent variable) Social problem solving: AIPSS Social competence associate with SCST-R scales (r =.34, ÿ.35,.42, P s <.05) but not SMT or GPT Social Interest associate with SCST-R scales (r = ÿ.38, ÿ.43, ÿ.47, ÿ.50, P s <.05) but not SMT or GPT Neatness associate with SMT (r =.37, P <.05) an SCST-R (r =.47, P <.05) but not GPT Many correlations were not provie; those given are all moerate to large range effects Power for effect size of r =.3 is Significant ifference in SP base on community status (t = ÿ2.50, P <.01), an it was a significant preictor in logistic regression (r =.12) This is equivalent to a small to moerate range effect (r =.19) Power for effect size of r =.3 is SP significantly correlate with work functioning (r =.36, P <.01) an inepenent living (r =.33, P <.05) but not social functioning (r =.11) SEM reveale SP was preicte by early visual processing (b =.57, P <.05) an SP preicte RFS (b =.44, P <.05); the significant inirect effect of early visual processing on RFS but nonsignificant irect effect suggests meiation Early visual processing an SP together accounte for 18% of the variance in RFS 33.3% of the effect sizes were small to moerate range, an 66.7% were moerate to large range Power for effect size of r =.3 is Controlling for WRAT-R, correlations between AIPSS an PONS was significant the role play (content r =.52, P <.01, performance r =.50, P <.01, overall r =.51, P <.01) All of the effect sizes were large Power for effect size of r =.3 is Downloae from at University of North Carolina at Chapel Hill on July 31, 2014 S48

6 S. M. Couture et al. Table 1. Continue Stuy Participants SC Measures FO Measures Major Finings Vauth et al S inpatients MA = 28 Male: 64.7% Yrs E:? Yrs Ill: 6.6 Clor eq:? SFRT, SCST-R Component Sequencing Task-Revise (SCST-R, 4 of 12 stuies), 44 the Profile of Nonverbal Sensitivity (PONS, 2 of 12 stuies), 45 an the Situational Features Recognition Test (SFRT, 2 of 12 stuies). 42,43 Two of these measures require jugments about short vieotape vignettes (eg, SCRT an PONS) an are clearly SP in nature, whereas the SCST-R an SFRT assess social knowlege. Aitional, less commonly use measures of SP are presente in tables 1 an 4. Within the omain of EP, the most consistently use measure was the Facial Emotion Ientification Task (FEIT, tables 2 an 4; 6 of 10 stuies). 46 In the FEIT, participants choose from among 6 emotion wors (happy, angry, afrai, sa, surprise, an ashame) to escribe the facial expression epicte in black-an-white photographs. Other stuies use similar measures, incluing the Pictures of Facial Affect (3 of 10 stuies) 47 an the Facial Emotion Discrimination Test (3 of 10 stuies). 46 In aition, EP was also measure via other moalities, such as measures of vocal affect perception (2 of 10 stuies, Vocal Emotion Ientification Test), 46 an vieo tasks incluing both vocal an facial affect cues (Bell-Lysaker Emotion Recognition Test), 48 an the Vieotape Affect Perception Test, 49 inclue in 3 of 10 stuies). Social behavior on milieu: Social Skills an Personal Presentation subscales from WPP The only consistently utilize ToM measure was the Hinting Task (tables 3 an 4; 2 of 4 stuies), 50 which requires participants to listen to a story presente verbally an ascertain what one character intens when she/he provies a verbal hint to another character. Other stuies use some form of ToM story (either verbally, with cartoons, or both), which require participants to ascertain characters false beliefs. Finally, AS was typically assesse with a questionnaire that escribe various situations (eg, your frien forgot to pick you up from work), following which, participants are aske to evise an explanation for why this event occurre. These explanations are often coe by the participant him/herself (eg, whether the outcome was ue to themselves or others) or by research assistants (eg, for how much the responses involves an internal or external attribution an/or a hostile response). 51,52 As functional outcome is also a multifacete construct that has been measure in iverse ways, we have ivie most measures of functional outcome into 4 main areas as follows: social behavior in the milieu, community functioning, social skills, an social problem solving. Social behavior in the milieu is comprise of staff-rate assessments of the participants behavior in a variety of treatment settings. Examples of measures inclue in this SFRT correlate with social skills (r =.28, P <.01) an personal presentation (r =.31, P <.001) SCST-R correlate with social skills (r =.23, P <.01) an personal presentation (r =.28, P <.01) SEM analyses reveale 25% of the variance in WPP was accounte for by SP an neurocognition latent variables; SP alone accounte for 10% of the variance 75% of the effect sizes were small to moerate range, an 25% were moerate to large range Power for effect size of r =.3 is Note: SC = Social Cognition; SA = Schizoaffective; FE = First Episoe; MA = Mean Age; Yrs E = Years of Eucation; Yrs Ill = Number of Years Ill; Clor eq = Chlorpromazine equivalent (mg/); AIPSS = Assessment of Interpersonal Problem Solving Skills 57 ; GPT = Gilbert-Pelham Task 107 ;QLS= Quality of Life Scale 56 ;NOSIE= Nurse s Observation Scale for Inpatient Evaluation 53 ; PONS = Profile of Nonverbal Sensitivity 45 ; Rehabilitation Evaluation 108 ; RFS = Role Functioning Scale 55 ; SEM = Structural Equation Moeling; SCRT = Social Cue Recognition Test 42,43 ; SCST-R = Schema Component Sequencing Task-Revise 44 ; SSIT = Simulate Social Interaction Test 109 ; SMT = Situation Matching Task (T. Ferman, unpublishe ata, 1993); SFRT = Situational Features Recognition Test 42,43 ; WAIS-R = Wechsler Ault Intelligence Scales-Revise 110 ; WPP = Work Personality Profile 111 ; Zigler Social Competence Scale. 112 Downloae from at University of North Carolina at Chapel Hill on July 31, 2014 S49

7 Social Cognition an Functional Outcome Table 2. Emotion Perception (EP) an Functional Outcome (FO) in Schizophrenia (S) Stuy Participants SC Measures FO Measures Major Finings Brekke et al 38 Cohen et al S or SA outpatients MA = 38 Male: 69% Yrs E: 11.9 Yrs Ill: 13.9 Clor eq:? 28 S Inpatients MA = 33 Male: 85.7% Yrs E: 11.9 Yrs Ill: 12.9 Clor eq:? FEIT, VEIT, an Vieotape Affect Perception Test; create a composite of these 3 measures FEIT Community functioning RFS: total score, work, social functioning, an inepenent living subscales; combine in composite for global functioning Social skills: role-play test Social behavior in milieu: 5 social behavior questions from SAS-II Global functioning was significantly relate to EP at baseline (r =.35, P <.01) an 12 mo (r =.30, P <.01). Results hel in path moel an neurocognition ha a significant inirect effect through EP on global functioning at baseline an 12 mo Work functioning was significantly relate to EP at baseline (r =.22, P <.01) an 12 mo (r =.27, P <.01). Results hel in path analysis an EP was a meiator between neurocognition an work functioning at baseline an 12 mo Social functioning was significantly relate to EP at baseline (r =.25, P <.01) an 12 mo (r =.18, P <.05). Results hel in path moel an EP meiate the relationship between neurocognition an social functioning Inepenent living was significantly relate to EP at baseline (r =.31, P <.01) an 12 mo (r =.26, P <.01). Results hel in path moel an EP was again a meiator 62.5% of effects were small to moerate range, an 37.5% were moerate to large range Power for effect size of r =.3 is SAS-II correlate with FEIT (r =.38, P <.05), but role play was not correlate with FEIT (r =.24) In regression with cognitive composite, FEIT accounte for nonsignificant proportions of the variance: 1% in role-play test (cognition 24%, P <.01) an 8% in SAS-II (cognition 13%, NS) There was a small to moerate range effect for social skills an a moerate to large range effect for social behavior in the milieu Power for effect size of r =.3 is Downloae from at University of North Carolina at Chapel Hill on July 31, 2014 S50

8 S. M. Couture et al. Table 2. Continue Stuy Participants SC Measures FO Measures Major Finings Hooker an Park 71 Kee et al S inpatients MA = 39 Male: 75% Yrs E: 12.7 Yrs Ill: 18.8 Clor eq: S or SA outpatients MA = 38 Male: 77.8% Yrs E: 12.1 Yrs Ill: 13.6 Clor eq:? Biehl Facial Affect Recognition, Nowicki an Duke Vocal Affect Recognition Measure at baseline an 12 mo: FEIT, VEIT, an Vieotape Affect Perception Test; create a composite of these 3 measures Social behavior in milieu: SDI with 8 subscales Note only 14 participants complete this measure Measure at baseline an 12 mo SCOS: Social Contacts an Useful Employment RFS: work prouctivity, inepenent living, relationships with family an spouse, relationships with friens Community function Split measures into 2 factors: work functioning/ inepenent living an social functioning/ family relationships No significant relationship between SDI total an EP measures in omnibus test Facial EP significantly correlate with communication/social ysfunction (r = ÿ.59, P <.05), occupation ysfunction (r = ÿ.56, P <.05), an with Public self (social behavior) at tren level (r = ÿ.46, P <.10) but not inepenent living, family or other relationships, or community/recreational functioning Vocal EP correlate with occupation ysfunction (r = ÿ.58, P <.05) but not communication/social functioning (r = ÿ.1), public self (r = ÿ.1), inepenent living, family or other relationships, or community/ recreation functioning Significant effects are moerate to large; nonsignificant correlations were not provie Power for effect size r =.3 is At baseline, EP composite correlate with work functioning/inepenent living (r =.36, P <.01) but not social functioning/ family relationships (r =.009) At 12 mo (concurrent), EP relate to work functioning/inepenent living (r =.29, P <.05) but not social functioning/ family relationships (r =.05) Baseline EP correlate with work functioning/ inepenent living at 12 mo (r =.41, P <.001) but not social functioning/ family relationships (r =.04) 50% of effect sizes were minimal to small range, 16.7% were small to moerate range, an 33.3% were moerate to large range Power for effect size of r =.3 is Downloae from at University of North Carolina at Chapel Hill on July 31, 2014 S51

9 Social Cognition an Functional Outcome Table 2. Continue Stuy Participants SC Measures FO Measures Major Finings Mueser et al 72 Poole et al S or SA inpatients MA = 45 Male: 47% Yrs E: 11 Yrs Ill: ~23 Clor eq: S or SA outpatients MA = 41 Male: 77.5% Yrs E: 13 Yrs Ill:? Clor eq: 300 FEIT, FEDT Composite of Ekman an Friesen s Pictures of Facial Affect an Vocal Affect Recognition from Floria Affect Battery Social skill: ratings of social skill from conversation probes Social behavior in milieu SBS: social mixing, inappropriate behavior, altere activity level, personal appearance subscales Community function QLS: interpersonal relations, vocation, community participation subscales an total score For social skills, FEIT relate to nonverbal paralinguistic skills (eg, meshing, fluency, etc; r =.37, P <.05) but not verbal content (r = ÿ.04) or overall social skill (r =.30). The FEDT was not relate to any of these skills (nonverbal r =.20, verbal content r =.06, overall r =.14) For SBS, FEIT relate to social mixing (r = ÿ.45, P <.01) an personal appearance (r = ÿ.61, P <.001) but not inappropriate behavior (r = ÿ.02) or altere activity (r = ÿ.11) For SBS, FEDT relate to social mixing (r = ÿ.35, P <.05), activity level (r = ÿ.34, P <.05), an personal appearance (r = ÿ.38, P <.05) but not inappropriate behavior (r = ÿ.16) For social skills, 33.3% of effect sizes were minimal to small range, 33.3% were small to moerate range, an 33.3% were moerate to large range For social behavior in the milieu, 12.5% of effect sizes were minimal to small range, 25% were small to moerate range, 50% were moerate to large range, an 12.5% were large Power for effect size of r =.3 is EP correlate with QLS total (r =.36, P <.05), interpersonal relations (r =.35, P <.05), an community participation (r =.39, P <.01) but not vocation (r =.03) After partialling out cognition, EP correlate with househol relations (r =.35, P <.05) an social activity (r =.34, P <.05) on the QLS 25% of the effects were minimal to small range, an 75% were moerate to large range Power for effect size of r =.3 is Downloae from at University of North Carolina at Chapel Hill on July 31, 2014 Note: SC = Social Cognition; NC = Neurocognition; SA = Schizoaffective; MA = Mean Age; NS = Not Significant; Yrs E = Years of Eucation; Yrs Ill = Number of Years Ill; Clor eq = Chlorpromazine equivalent (mg/); Biehl Facial Affect Recognition 113 ; FEIT = Facial Emotion Ientification Task 46 ; FEDT = Facial Emotion Discrimination Task 46 ; Nowicki an Duke Vocal Affect Recognition 114 ; QLS = Quality of Life Scale 56 ; Pictures of Facial Affect 47 ; RFS = Role Functioning Scale 55 ; SAS-II = Social Ajustment Scale-II 115 ; SBS = Social Behavior Scale 54 ; SCOS = Strauss an Carpenter Outcome Scale 116 ; SDI = Social Dysfunction Inex 117 ; VEIT = Vocal Emotion Ientification Task 46 ; Vieotape Affect Perception Task. 49 S52

10 S. M. Couture et al. Table 3. Theory of Min (ToM) or Attributional Style (AS) an Functional Outcome (FO) in Schizophrenia (S) Stuy Participants SC Measures FO Measures Major Finings Pollice et al 76 Schenkel et al S or SA outpatients MA = 33 Male: 77.3% Yrs E: 11.6 Yrs Ill: 10.6 Clor eq: S or SA inpatients MA = 41 Male: 60% Yrs E: 12.1 Yrs Ill:? Clor eq:? First-orer ToM from Sally an Anne an Cigarettes tasks; secon-orer ToM from Ice Cream Van an Burglar tasks; also combine measures for global ToM score Hinting Task Community function Disability Assessment Scheule: Self-care, social contact, work activity, global rating of community functioning mae by interviewer Premorbi social functioning coe from charts Global community functioning correlate with combine ToM (r =.43, P <.01) an secon-orer ToM (r =.30, P <.05) but not first-orer ToM (r =.276); effects remaine or were strengthene after partialling out IQ; secon-orer ToM explaine 15% of the variance in global community functioning in stepwise regression Poor self-care an combine ToM significantly correlate after partialling out IQ (r = ÿ.367, P <.05) but not before (r = ÿ.002); not relate to seconorer (r = ÿ.216) or first-orer ToM (r = ÿ.017) ToM not relate to poor social contact (first orer, r = ÿ.078; secon orer, r = ÿ.148; combine, r = ÿ.201) ToM not associate with work ability (first orer, r = ÿ.026; secon orer, r = ÿ.085; combine, r = ÿ.020) 41.7% of effects were minimal to large range, 33.3% were small to moerate range, an 25% were moerate to large range Power for effect size of r =.3 is Group ifferences on ToM between poor an goo premorbi social functioning groups (t(40) = 3.86, P <.0001) This is equivalent to a large effect size (r =.52) Power for effect size of r =.3 is Downloae from at University of North Carolina at Chapel Hill on July 31, 2014 S53

11 Social Cognition an Functional Outcome Table 3. Continue Stuy Participants SC Measures FO Measures Major Finings Lysaker et al 51 Walheter et al S or SA outpatients MA = 46 Male: 97.5% Yrs E: 12.5 Yrs Ill: ~21.4 Clor eq:? 29 S or SA inpatients MA = 33 Male: 86% Yrs E: 10.6 Yrs Ill:? Clor eq: ASQ AIAQ IPSAQ Community function QLS: interpersonal function, community participation Social behavior in milieu: Moifie Overt Aggression Scale Making a greater number of stable attributions preicte 8% of the variance in interpersonal function, 16% in community participation When cognitive variables were covarie, the relationships with the ASQ were the same except for community participation (NS) Effect sizes were small to moerate range an moerate to large range, respectively Power for effect size of r =.3 is Frequency of violence correlate with AIAQ hostility bias in acciental situations (r =.407, P <.05) but not in intentional (r = ÿ.010) or ambiguous (r =.053) situations Severity of violence was not significantly correlate with any AIAQ hostility bias (acciental r =.368, intentional r =.129, ambiguous r =.106) The IPSAQ personalizing bias was correlate with severity (r =.325, P <.05) but not history (r =.269) of violence AIAQ hostility bias for ambiguous situations an the IPSAQ personalizing bias together preicte 4% of the variance in severity of violence 25% of effect sizes were minimal to small range, 37.5% were small to moerate range, an 37.5% were moerate to large range Power for effect size of r =.3 is Downloae from at University of North Carolina at Chapel Hill on July 31, 2014 Note: SC = Social Cognition; NC = Neurocognition; SA = Schizoaffective; MA = Mean Age; NS = Not Significant; Yrs E = Years of Eucation; Yrs Ill = Number of Years Ill; Clor eq = Chlorpromazine equivalent (mg/); AIAQ = Ambiguous Intentions Attributions Questionnaire (Combs et al, in preparation); ASQ = Attributional Style Questionnaire 118 ; Burglar Task 119 ; Cigarettes Task 120 ; Disability Assessment Scheule (WHO) 121 ; Hinting Task 50 ; Ice Cream Van Task 122 ; IPSAQ = Internal, Personal, an Situational Attributions Questionnaire 123 ; Moifie Overt Aggression Scale 124 ; Sally an Anne Task 125 ; QLS = Quality of Life Scale. 56 S54

12 S. M. Couture et al. Table 4. Multiple Measures of Social Cognition (SC) an Functional Outcome (FO) Stuy Participants SC Measures FO Measures Major Finings Brune 73 Ihnen et al S inpatients or ay clinic attenees MA = 38 Male: 78.2% Yrs E:? Yrs Ill: 12.3 Clor eq:? 26 S outpatients MA = 33 Male: 57.6% Yrs E: 12.1 Yrs Ill:? Clor eq: 698 EP: 36 photos from Ekman an Friesen Pictures of Facial Affect ToM: 6 Cartoon picture stories (sequencing an time scores erive), ToM questionnaire; also combine these two for ToM total score EP: FEIT, FEDT SP: SCRT Social behavior on milieu SBS: total, BSM (mil to severe behavior problems), BSS (severe behavior problems only) Social skills: Conversation probe role play rate for: Overall social skill, clarity, fluency, affect, gaze, involvement, an asks questions BSM correlate with ToM questionnaire (r = ÿ.421, P <.05) but not ToM sequencing (r = ÿ.261), ToM time (r = ÿ.073), ToM total (r = ÿ.366) BSS correlate with ToM total (r = ÿ.444, P <.05) an ToM questionnaire (r = ÿ.524, P <.05) but not ToM sequencing (r = ÿ.308) or ToM time (r = ÿ.165); BSS no longer correlate with ToM total when IQ controlle for (r = ÿ.27, P =.22) No correlation between EP an BSM (r = ÿ.086), BSS (r = ÿ.082) or SBS total (r = ÿ.005) No correlations between ToM an SBS total (sequencing, r = ÿ.188; time, r =.081; questionnaire, r = ÿ.264; total, r = ÿ.245) ToM questionnaire ae 15% of the variance in BSS after uration of illness an IQ For EP, all effect sizes were minimal to small range For ToM, 16.7% of effect sizes were minimal to small range, 41.7% were small to moerate range, 33.3% were moerate to large range, an 8.3% were large Power for effect size of r =.3 is FEIT correlate with overall social skills (r =.44, P <.05), speech clarity (r =.50, P <.01), an involvement (r =.34, P <.05) but not fluency (r =.08), affect (r =.32), gaze (r = ÿ.29) or asks questions (r =.09) FEDT not correlate with any skills (overall r =.17, speech clarity r =.29, fluency r =.12, affect r =.07, involvement r =.18, ask questions r =.08) except gaze (r = ÿ.39, P <.05) SCRT not relate to any skills (overall r =.14, fluency r =.27, affect r =.09, gaze r = ÿ.17, involvement r =.23, asks questions r = ÿ.04), except clarity (r =.38, P <.05) After multiple test correction, only clarity an FEIT were significantly correlate Downloae from at University of North Carolina at Chapel Hill on July 31, 2014 S55

13 Social Cognition an Functional Outcome Table 4. Continue Stuy Participants SC Measures FO Measures Major Finings Penn et al 62 Pinkham an Penn S or SA inpatients MA = 34 Male: 66.7% Yrs E:? Yrs Ill:? Clor eq: S or SA outpatients MA = 33 Male: 57% Yrs E: 14.3 Yrs Ill: 10.4 Clor eq: EP: Pictures of Facial Affect SP: Sequencing task EP: FEIT, FEDT, BLERT SP: SCST (time, accuracy) ToM: Hinting Task, ToM vignettes Social behavior on milieu NOSIE: staff ratings for social interest, neatness, social competence Social skills conversation probe role play using overall rating of social skill Backwar multiple regression foun FEIT was a significant preictor of overall social skill (b =.37), greater speech clarity (25% of the variance); FEDT was a significant preictor of gaze (b = ÿ.41) For EP, 28.5% of effect sizes were minimal to small range, 35.7% were small to moerate range, 28.5% were moerate to large range, an 7.2% were large For SP, 28.5% of effect sizes were minimal to small range, 57.1% were small to moerate range, an 14.3% were moerate to large range Power for effect size of r =.3 is EP associate with neatness at Bonferroni level (r =.54, P <.01), but social competence (r =.37, P <.05) an social interest (r =.34, P <.05) i not meet correction criteria SP not relate to social competence (r = ÿ.31 an.12), social interest (r = ÿ.19 an.07) or neatness (r = ÿ.26 an.24) For EP, 66.7% of effect sizes are moerate to large range, 33.3% are large For SP, 16.7% of effect sizes are minimal to small range, 66.7% are small to moerate range, an 16.7% are moerate to large range Power for effect size of r =.3 is Of the EP measures, BLERT (r =.38, P <.01) an FEIT (r =.32, P <.05) were significantly relate to social skill but the FEDT was not (r =.224) Of the SP measures, both time (r = ÿ.497, P <.01) an accuracy (r =.406, P <.01) on the SCST were significantly correlate with social skill Of the ToM measures, both Hinting (r =.387, P <.05) an ToM vignettes (r =.456, P <.05) were significantly associate with social skill Aition of all social cognition measures preicting social skill (except FEDT) to a regression containing cognition ae 26% variance Downloae from at University of North Carolina at Chapel Hill on July 31, 2014 S56

14 S. M. Couture et al. Table 4. Continue Stuy Participants SC Measures FO Measures Major Finings omain are the Nurse s Observation Scale for Inpatient Evaluation 53 an the Social Behavior Scale. 54 Community functioning encompasses a wie variety of behaviors an activities relate to inepenent living skills, such as social or work functioning. Examples of measures use to assess this construct are the Role Functioning Scale 55 an the Quality of Life Scale, 56 with most measures being rate by the interviewer. The area of social skill was conceptualize as those stuies that use role-play tasks in which specific interactional skills were rate (eg, eye contact, voice volume, meshing, etc). Finally, social problem solving was efine as the ability of participants to generate solutions to everyay social problems. The most commonly use measure in this area is the Assessment of Interpersonal Problem Solving Skills, 57 although one stuy use the problem solving subscale of the Inepenent Living Scales. 58 It shoul be note that when measures were ientifie by the authors as assessing social skill or social problem solving, they were only inclue in the review if irect observation of social skill or social problem solving behavior occurre, so as to ifferentiate it from more cognitively base skills. In the following section, we summarize the relationship between each social cognitive omain an the 4 inices of functional outcome. The Relationship of Social Cognition to Functional Outcome SP There is general support for a significant association between SP an social behavior on the milieu (tables 1 an 4). Specifically, 3 stuies reporte significant relationships between SP an social behavior in treatment In regression, only significant preictor was SCST time, which accounte for 7% of the variance in social skill For EP, 66.7% effect sizes were moerate to large range, an 33.3% were small to moerate range For SP an ToM, all effect sizes were moerate to large range Power for effect size of r =.3 was Note: NC = Neurocognition; S = Schizophrenia; SA = Schizoaffective; MA = Mean Age; ToM = Theory of Min; Yrs E = Years of Eucation; Yrs Ill = Number of Years Ill; Clor eq = Clorpromazine equivalent ose (mg/); BLERT = Bell-Lysaker Emotion Recognition Test (D. Bell, P. Lysasker, G. Bryson, unpublishe ata) FEIT = Facial Emotion Ientification Task 46 ; FEDT = Facial Emotion Discrimination Task 46 ; Hinting Task an ToM vignettes 50 ; NOSIE = Nurse s Observation Scale for Inpatient Evaluation 53 ; Pictures of Facial Affect 47 ; SBS = Social Behavior Scale 54 ; SCRT = Social Cue Recognition Test 42, 43 ; SCST-R = Schema Component Sequencing Task-Revise. 44 settings, although 1 i not. 62 The null finings for Penn et al 62 may have been ue to the fact that the measure of SP, a social sequencing task (similar to the SCST an Picture Arrangement task), was evelope for this stuy an i not have well-establishe psychometric properties. SP has also shown a consistent relationship with community functioning 10,62,63 across a variety of tasks an inices of functioning an preicte community status (ie, inpatient or outpatient). 64 Likewise, a robust relationship has been foun between SP an social problem solving, although these finings were mostly observe within inpatient samples. In contrast, the link between SP an social skill has not been firmly establishe because one stuy supports an association, 68 whereas two o not. 59,69 Although the only notable ifference between these stuies is the higher eucational level of participants in Pinkham et al 68 stuy that foun positive results, it is unclear if this is contributing to the iscrepant finings. The stuies reviewe above generally use correlational analyses to examine the relationship between SP an functional outcome. A number of recent stuies have extene this line of research to investigate whether SP meiates the relationship between neurocognition an functional outcome. Specifically, Sergi et al 10 an Vauth et al 61 use path analysis an Structural Equation Moeling, respectively, to show that SP oes serve as a meiator between neurocognition an outcome, finings that have been replicate in a recent stuy that use multiple regression. 65 In summary, SP has generally emonstrate significant relationships with most measures functional outcome, as evience by 10 of the 12 stuies fining evience for significant associations (see tables 1 an 4), although the Downloae from at University of North Carolina at Chapel Hill on July 31, 2014 S57

15 Social Cognition an Functional Outcome specific link with social skill remains equivocal. Effect sizes for these stuies range the gamut, from null finings to large effects. Thus, SP may be more relevant for some social behaviors more than others. EP There appears to be a relationship between EP an social behavior in the milieu (tables 2 an 4), 44,70 72 although there are exceptions. 62 The stuy which i not support a relationship is methoologically similar to the others; thus, the reason for this iscrepancy is unclear. However, it is important to note that most stuies foun evience for moerate to large effect sizes for the relationship between EP an social behavior in the milieu, with the exception of Brune. 73 Consistent with the foregoing, the majority of stuies show a significant association between EP an social skill, 68,69,72 although there are exceptions. 70 Again, the reason for these iscrepant finings are unclear, although Cohen et al 70 stuy ha a substantially larger percentage of males than the other stuies. EP also has a fairly consistent relationship with community functioning because 2 stuies clearly support an association 38,74 an a thir foun 3 of 6 correlations of EP an community functioning to be statistically significant. 39 No stuy has yet examine the relationship between EP an social problem solving. Finally, there is preliminary evience that EP may meiate the relationship between neurocognition an functional outcome. 38 In summary, EP is consistently associate with community functioning, an there is goo support for a relationship with social behavior in the milieu an social skill as well. Finally, the relationship of EP to social problem solving is unknown. ToM To ate, few stuies have examine the relationship between ToM an functional outcome. 75 Brune 73 examine the relationship between ToM an social behavior in the milieu an foun that 3 of the 11 correlations between these omains were statistically significant. However, it shoul also be note that of the nonsignificant correlations, only 2 woul be interprete as a null effect (ie, r <.1). Pinkham an Penn 68 foun that performance on the Hinting task was associate with overall social skill among outpatients with schizophrenia. In the only stuy examining the relationship between ToM an community functioning, 5 of the 11 correlations conucte between a combine inex of ToM or secon-orer ToM an community functioning were significant; none were significant if only first-orer ToM performance was examine. 76 Aitionally, ToM was relate to premorbi social functioning as coe (poor or goo) from chart recors. 77 Finally, no stuy to ate has examine the relationship between ToM an social problem solving. Thus, given the relative paucity of stuies in this area, it is ifficult to raw firm conclusions about the relationship between ToM an any one omain of functional outcome. However, there is some preliminary evience that ToM is relate to social skill, community functioning, an social behavior in the milieu, although these results clearly require replication. It shoul be note that all these stuies foun at least some significant results (incluing Brune 73 ), but few of them presente reliability estimates on their ToM measures. This is a critical methoological issue, given the low reliability reporte for ToM vignettes (.31) of Pinkham an Penn 68, which is a commonly use measure in this area. AS Only 2 stuies have examine AS an functional outcome. Lysaker an colleagues 51 foun that the number of stable attributions mae was relate to community functioning. Walheter et al 52 foun that having a hostile attributional bias preicte a small, yet significant amount of variance in aggression on an inpatient unit (ie, social behavior in the milieu), even after accounting for previous violence history. Clearly, however, more research is require before confient conclusions can be rawn about the relationship of AS to functional outcome. Conclusions an Future Directions The purpose of this review was to examine the relationship between social cognition (SP, EP, ToM, an AS) an functional outcome (social behavior in the milieu, community functioning, social skill, an social problem solving). Base on this review, we have rawn the following conclusions: First, there is a fairly consistent relationship between SP an various omains of functional outcome, particularly social problem solving, social behavior in the milieu, an community functioning. There is promising, but still inconsistent, evience for a relationship between SP an social skill. Finally, there is growing evience that SP may serve as a meiator between neurocognition an functional outcome. Secon, EP appears to have a fairly consistent, yet moest, relationship with community functioning, social skill, an social behavior in the milieu, while no stuy has examine its relationship with social problem solving. Finally, one stuy suggests that EP may meiate the relationship between neurocognition an functional outcome. Thir, the omains of ToM an AS have receive far less attention in terms of their functional significance. Current work is suggestive of a significant association between ToM an social skills an possibly with community functioning an social behavior in the milieu, but clearly more research is neee to raw firm conclusions. Only 2 stuies have examine the relationship between S58 Downloae from at University of North Carolina at Chapel Hill on July 31, 2014