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http://cdp.sagepub.com/ Science Current Directions in Psychological http://cdp.sagepub.com/content/19/4/243 The online version of this article can be found at: DOI: 10.1177/0963721410377600 2010 19: 243 Current Directions in Psychological Science Michael F. Green and William P. Horan Social Cognition in Schizophrenia Published by: http://www.sagepublications.com On behalf of: Association for Psychological Science can be found at: Current Directions in Psychological Science Additional services and information for http://cdp.sagepub.com/cgi/alerts Email Alerts: http://cdp.sagepub.com/subscriptions Subscriptions: http://www.sagepub.com/journalsReprints.nav Reprints: http://www.sagepub.com/journalsPermissions.nav Permissions: What is This? - Aug 11, 2010 Version of Record >> at NATIONAL CHUNG HSING UNIV on March 27, 2014 cdp.sagepub.com Downloaded from at NATIONAL CHUNG HSING UNIV on March 27, 2014 cdp.sagepub.com Downloaded from

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Page 1: Social Cognition in Schizophrenia

http://cdp.sagepub.com/Science

Current Directions in Psychological

http://cdp.sagepub.com/content/19/4/243The online version of this article can be found at:

 DOI: 10.1177/0963721410377600

2010 19: 243Current Directions in Psychological ScienceMichael F. Green and William P. HoranSocial Cognition in Schizophrenia

  

Published by:

http://www.sagepublications.com

On behalf of: 

  Association for Psychological Science

can be found at:Current Directions in Psychological ScienceAdditional services and information for    

  http://cdp.sagepub.com/cgi/alertsEmail Alerts:

 

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What is This? 

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Page 2: Social Cognition in Schizophrenia

Social Cognition in Schizophrenia

Michael F. Green and William P. HoranVA Desert Pacific Mental Illness Research, Education, and Clinical Center, and UCLA Semel Institute for

Neuroscience and Human Behavior

AbstractSocial cognition has become a rapidly growing area of schizophrenia research. Individuals with schizophrenia show substantial andpersistent impairments in a range of social cognitive domains, including emotion processing, social perception, attributional bias,and theory of mind. The social cognitive impairment in schizophrenia is associated with, but separable from, impairments in(nonsocial) neurocognition such as attention, memory, and problem solving. Social cognition is a key determinant of functionaldisability of schizophrenia; it acts as a mediator between neurocognition and functional outcome, and it contributes uniqueinformation about functional outcome beyond that provided by neurocognition. Efforts to develop interventions to improvesocial cognitive impairments through new pharmacological and training approaches are under way.

Keywordsschizophrenia, social cognition, neurocognition

Despite advances in antipsychotic medications, schizophrenia

remains one of the most disabling illnesses for adults all over

the world. Recently, the treatment of schizophrenia has shifted

fundamentally from a focus on reducing symptoms to a focus

on recovery and improving aspects of functioning. Recovery-

oriented treatments require identifying the determinants of

functioning in schizophrenia, and these include the disorder’s

characteristic cognitive impairments. Although (nonsocial)

neurocognition (e.g., attention, memory, speed of processing,

problem solving) has been a long-standing focus in schizophre-

nia research, social cognition has emerged more recently as a

high-priority topic for exploration. Social cognition generally

refers to the mental operations that underlie social interactions,

including perceiving, interpreting, and generating responses to

the intentions, dispositions, and behaviors of others (Fiske &

Taylor, 1991; Kunda, 1999). Social cognition includes the

ways in which we decipher an emotion on another person’s

face and how we draw inferences about another’s intentions.

Research on social cognition in schizophrenia has expanded

exponentially over the past 5 to 10 years and now clearly indi-

cates that this disorder is characterized by substantial, wide-

ranging social cognitive impairments.

Social cognition research in schizophrenia has addressed

several different goals, including (a) to understand social cog-

nition’s role in functional outcome in schizophrenia; (b) to bet-

ter understand the development of particular clinical symptoms

of schizophrenia such as paranoia; (c) to examine the trait ver-

sus state aspects of social cognitive impairment, for example,

examining social cognitive performance over phases of the

illness or in samples at risk for schizophrenia; (d) to apply

methods from social neuroscience to identify aberrant neural

substrates in schizophrenia that are potentially specific for pro-

cessing of social information; and (e) to evaluate both psycho-

pharmacological and psychosocial interventions for social

cognitive impairment. In this article, we briefly describe the

primary domains of social cognition that have been examined

in schizophrenia and then summarize findings on the first and

last of these goals—namely, the relationship between social

cognition and functional outcome and approaches to interven-

tion for social cognition.

Social Cognitive Domains

Domains in the schizophrenia literature

Social cognitive research in schizophrenia has tended to fall

into four main areas: emotion processing, social perception,

attributional bias, and theory of mind (Green, Olivier, Crawley,

Penn, & Silverstein, 2005; Green et al., 2008; Penn, Addington,

& Pinkham, 2006). These domains capture the way the field is

Corresponding Author:

Michael F. Green, UCLA Semel Institute, 300 Medical Plaza, Rm 2263, Los

Angeles, CA 90095–6968

E-mail: [email protected]

Current Directions in PsychologicalScience19(4) 243-248ª The Author(s) 2010Reprints and permission:sagepub.com/journalsPermissions.navDOI: 10.1177/0963721410377600http://cdps.sagepub.com

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Page 3: Social Cognition in Schizophrenia

covered in the literature and are not generally considered to be

fully separable subprocesses: The boundaries between these

areas are blurry, and there is overlap. In addition, some of the

areas (e.g., emotion processing) are themselves routinely

divided into subprocesses in studies with healthy subjects.

Nonetheless, this listing of domains captures the current state

of the schizophrenia research literature and maps reasonably

well onto other models of social cognition that are based on

neuroimaging findings in healthy samples (Ochsner, 2008).

Emotion processing

Emotion processing refers broadly to perceiving and using

emotions adaptively. One influential model of emotional

processing defines emotional intelligence as a set of four com-

ponents: identifying emotions, facilitating emotions, under-

standing emotions, and managing emotions (Mayer, Salovey,

Caruso, & Sitarenios, 2001). This model includes affect per-

ception, a domain of emotion processing that is frequently mea-

sured in schizophrenia research. Measures of emotion

processing vary broadly and include ratings of emotions that

are displayed in faces or voices or ratings of how individuals

manage, regulate, or facilitate emotion based on their responses

to brief written or videotaped vignettes of people interacting.

Social perception

Tests of social perception assess an individual’s ability to

identify social roles, societal rules, and social context. In social

perception tasks, participants must process nonverbal, voice

intonation, and/or verbal cues to make inferences about com-

plex or ambiguous social situations. Individuals may be asked

to identify interpersonal features in a situation such as inti-

macy, status, and mood state. Social perception can include

‘‘relationship perception,’’ which refers to perception of the

nature of relationships between people as opposed to percep-

tion of individuals acting alone.

Attributional bias

Attributions are causal statements that either include or imply

the word ‘‘because.’’ Attribution bias or style reflects how peo-

ple typically infer the causes of particular positive and negative

events. Attributions can be measured by questionnaires or rated

from transcripts of interactions. In research involving both psy-

chiatric and nonpsychiatric samples, key distinctions between

external personal attributions (i.e., causes attributed to other

people), external situational attributions (i.e., causes attributed

to situational factors), and internal attributions (i.e., causes

attributed to oneself) are typically made.

Theory of mind

Theory of mind (also called mental-state attribution or menta-

lizing) refers to the ability to infer the intentions, dispositions,

and beliefs of others. Much of the initial interest in this area

focused on studies of children and how theory of mind is

acquired in normal and abnormal development. Hence, many

measures in this area were initially developed for use with chil-

dren and then had to be adapted for use with adults. Theory of

mind has been extended to schizophrenia partly due to similar-

ity between aspects of social dysfunction in autism and those in

some patients with schizophrenia. Commonly used tasks in this

area involve responding to questions about brief social vign-

ettes or arranging cartoon panels into a sensible order to

demonstrate one’s understanding of perspective taking, nonlit-

eral language such as sarcasm, or deception.

Magnitude of the impairment

The magnitude of the differences between patients and controls

on social cognitive tasks is substantial. A recent review of 86

studies using various emotion-perception tasks reported an

overall large difference between groups: an effect size of .91

(Kohler, Walker, Martin, Healey, & Moberg, in press). Simi-

larly, a review of theory of mind examined more than 30 stud-

ies and reported large differences, with effect sizes ranging

from .90 to 1.25 (Bora, Yucel, & Pantelis, 2009). Although

research has been conducted primarily with chronically ill

patients, several studies have reported social cognitive impair-

ments in unmedicated or recent-onset patients. Further, the dif-

ferences are relatively stable across acutely symptomatic and

remitted states and across phases of the illness. Hence the

social cognitive impairments in schizophrenia are likely core

features of the illness and not simply a result of medication

side effects or clinical episodes.

Distinctiveness of neurocognition andsocial cognition

If the overlap between neurocognition and social cognition in

schizophrenia were very large, it would raise questions about

the value of considering the two domains separately. The dis-

tinction between these two areas depends mainly on the types

of stimuli (e.g., people or faces vs. objects) and the types of

judgments being made (e.g., attributing mental states to other

people vs. basic tests of attention, speed of processing, or mem-

ory). Neurocognitive and social cognitive tasks often share

cognitive processes, such as working memory and perception,

and therefore are clearly associated. However, several studies

using specialized statistical methods (e.g., confirmatory factor

analyses) have shown that models fit better when the two

domains are separated than they do when they are combined

(Sergi et al., 2007). The general conclusion from these studies

is that social cognition is associated with neurocognition but

not redundant with it. This question about the distinctiveness

of neurocognition and social cognition is not specific to schizo-

phrenia research but also applies to social cognitive and social

neuroscience research in healthy samples. The conclusion that

there is partial overlap in schizophrenia is fully consistent with

studies from nonclinical social neuroscience that reveal par-

tially overlapping and partially distinctive patterns of neural

244 Green, Horan

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Page 4: Social Cognition in Schizophrenia

activation between nonsocial and social cognitive tasks (Van

Overwalle, 2009).

Social Cognition and Functioningin Schizophrenia

A key motivation to study social cognition in schizophrenia is

to explain heterogeneity of functional outcome. Level of social

cognitive impairment appears to be a key determinant of daily

functioning in people with schizophrenia—including function-

ing in instrumental activities, interpersonal functioning, and

vocational achievement. Disturbances in social cognition may

be germane to problems in forming and maintaining interperso-

nal relationships and addressing interpersonal difficulties in

work settings. For example, misperceptions during social inter-

actions could adversely impact how people with schizophrenia

interpret the behavior of others, which may result in interper-

sonal conflicts and/or social withdrawal. In support of this

expectation, a growing literature demonstrates consistent pat-

terns of association between social cognition and various aspects

of community functioning (Couture, Penn, & Roberts, 2006)

Social cognition as a mediator

Beyond these replicated correlations, there is increasing

support from statistical modeling approaches that social cogni-

tive processes act as key mediators between neurocognition

and functional outcome (Addington, Saeedi, & Addington,

2006; Brekke, Kay, Kee, & Green, 2005; Sergi, Rassovsky,

Nuechterlein, & Green, 2006). Findings from at least eight

independent data sets show that social cognition has significant

relationships to both neurocognition and to community func-

tioning. Consistent with mediation, the direct relationships

between basic cognition and outcome are reduced or eliminated

when social cognition is added to a model. This pattern of

findings sheds light on the mechanisms through which neuro-

cognition relates to outcome; at least part of that relationship

(and sometimes all of it) is due to a pathway that runs through

social cognition (see Fig. 1). The mediating role of social cog-

nition suggests that it is a reasonable target for intervention. If

neurocognition and social cognition are both determinants of

functioning, better functional outcomes may be achieved if

intervention is directed at both components. Further, the the-

oretical proximity of social cognition to community outcome

(see Fig. 1) suggests that improvement in this domain may

generalize better to daily functioning than may the somewhat

more distal neurocognition.

Incremental validity from social cognition

Although neurocognition is a determinant of outcome in schi-

zophrenia, most of the individual differences in community

functioning among patients remain unexplained. Hence, other

determinants will help explain individual differences in func-

tioning above and beyond what is explained by neurocognition

(that is, other factors may show incremental validity, because

they would provide additional statistical explanation). The

observation that social cognition acts as a mediator in models

of neurocognition and functional outcome implicates a

mechanism by which neurocognition influences outcome,

and it appears from several data sets that social cognition con-

tributes incremental validity for functional outcome beyond

that provided by neurocognition (e.g., Brekke et al., 2005;

Poole, Tobias, & Vinogradov, 2000; Vauth, Rusch, Wirtz,

& Corrigan, 2004). Thus, having both types of cognition in

models provides a more complete accounting of the variabil-

ity in daily functioning experienced by patients. Even so,

social and nonsocial measures of cognition still do not fully

explain individual differences in functioning in schizophre-

nia, and other likely determinants and mediators of outcome

are being explored as well. For example, Figure 1 has a box

for negative symptoms of schizophrenia, which include

reduced emotional expression (i.e., blunted affect) and

reduced ability to enjoy things (i.e., anhedonia).

These two trends in the literature (i.e., social cognition as a

mediator and explaining additional variability in outcome) are

consistent with the findings mentioned previously—that social

cognition is not fully redundant with neurocognition. Because

social cognition can itself be parsed into separable domains

(emotion processing, theory of mind, etc.), it is possible that

future studies will find that each domain provides a separate

pathway for mediation leading to daily functioning. In addition,

it is possible that some social cognitive domains will explain

outcome better than others or will be related to specific

domains of outcome (e.g., work versus social functioning).

These questions are mainly unexplored. Also unexplored is

whether this approach to understanding determinants of real-

world outcome in schizophrenia applies to other clinical popu-

lations. A few studies with bipolar disorder patients suggest

that these relationships may also characterize other major psy-

chiatric disorders.

Interventions for Social Cognition inSchizophrenia

The documented associations between social cognition and

outcome in schizophrenia have generated considerable interest

in the possibility of enhancing social cognitive abilities as a

means to ultimately improve real-world functioning. As men-

tioned earlier, social cognition appears to be more proximal

in the chain of causal factors that lead to poor functional out-

come than is neurocognition and, hence, could be a better target

for intervention. The modifiability of social cognitive impair-

ments has been studied with two distinct approaches: pharma-

cological interventions and psychosocial interventions. In

terms of pharmacological interventions, a handful of studies

have examined whether treatment with antipsychotic medica-

tions (typically 4–6 weeks) improves performance on social

cognitive (usually facial emotion perception) tasks. Results

have been mixed, and the larger studies have failed to show

effects. However, novel compounds that may target specific

neural systems involved in social cognition are an active area

Social Cognition in Schizophrenia 245

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Page 5: Social Cognition in Schizophrenia

of interest. Recent initiatives by the National Institute of Men-

tal Health (NIMH), such as Measurement and Treatment

Research to Improve Cognition in Schizophrenia (MATRICS)

and Cognitive Neuroscience Treatment Research to Improve

Cognition in Schizophrenia (CNTRICS), are specifically

designed to stimulate development of cognition-enhancing

drugs (Carter & Barch, 2007; Marder & Fenton, 2004). Social

cognition is a domain in the MATRICS Consensus Cognitive

Battery and is also a focus for CNTRICS. A large number of

trials of novel compounds for neurocognition and social cogni-

tion are currently under way.

Aside from psychopharmacology approaches, psychosocial

treatment approaches also indicate that social cognitive impair-

ments in schizophrenia are amenable to intervention (Horan,

Kern, Penn, & Green, 2008). The modifiability of social cogni-

tive impairment is supported by two general types of studies.

First, several broad treatment studies have embedded social

cognitive training exercises within multicomponent treatment

packages aimed at improving multiple treatment targets. These

studies range from short term to 2 years of weekly treatment

and are often grounded in basic cognitive remediation, with

additional training components designed to help training

benefits generalize to different aspects of functioning and/or

psychopathology. Several broad treatment studies have

demonstrated improvements on social cognition measures,

often facial affect perception, with benefits of longer

treatments found to persist up to 12 months following the con-

clusion of treatment.

The second psychosocial approach, targeted treatment

studies, specifically uses social cognitive enhancement tech-

niques without other intervention components. These studies

have predominantly been conducted with inpatient samples,

have spanned 12 to 24 sessions, and have been typically admi-

nistered in small-group formats. Interventions have targeted

either a single component (commonly facial affect perception)

or multiple components, with some addressing all four of the

social cognitive domains described earlier. A variety of novel

treatment techniques have been developed; they include com-

puterized facial emotion perception exercises, imitation of

emotional expressions, role-play exercises, analysis and dis-

cussion of videos of social interactions, identifying and modi-

fying social attributions, and exercises to distinguish facts from

guesses about others’ emotions and intentions. The feasibility

and efficacy of targeted approaches have been demonstrated

by at least six different research groups internationally, with

improvements most consistently found for facial affect percep-

tion. Recent studies have provided initial evidence that targeted

treatments are efficacious in outpatients and that treatment ben-

efits can persist up to 6 months beyond the conclusion of treat-

ment (Horan et al., 2009; Roberts & Penn, 2009).

While encouraging, the existing targeted treatment studies

are limited in a few ways. First, there has been a focus on affect

Social

• Occupational

• Independent Living

• Rehabilitation Success

Mediating Variables

Neurocognition

Functional Outcome Domains

Interventions

Remediation

Psychopharmacology Social Cognition

Negative Symptoms

Basic cognition: - perceptual processes- memory- speed of processing- attention / vigilance- reasoning & problem solving

Social cognition:- emotional processing- social perception- attributional bias- theory of mind

Fig. 1. Connections among neurocognition, social cognition, and functioning in schizophrenia. Specific examples are listed for each of thesethree areas. Social cognition appears to be a mediator between neurocognition and outcome; other variables, such as negative symptoms, mayalso act as mediators. Psychosocial training and psychopharmacological interventions for neurocognition and social cognition are actively beingsought and evaluated.

246 Green, Horan

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Page 6: Social Cognition in Schizophrenia

perception more than on other important social cognitive

domains. Second, not enough studies have been fully con-

trolled (i.e., blinded assessments and randomized assignment

to treatment groups). Third, few studies have convincingly

demonstrated that the interventions generalize to improve-

ments in real-world functioning.

Conclusions

Research on social cognition in schizophrenia has progressed

rapidly over the past decade and has provided key insights into

why many people with this disorder experience difficulties in

daily functioning and in interacting with others. Nonetheless,

fundamental questions remain unanswered, including the opti-

mal parsing of social cognitive domains, the relationships

between social cognition and negative symptoms, the degree

of social cognitive impairment over the course of illness, and

whether impairments are relevant particularly to schizophrenia

as opposed to other psychiatric disorders. Also unaddressed are

measurement issues, such as how to develop tests that have

good psychometric properties when used with patients and that

are appropriate for repeated assessments in clinical trials.

In models of functional outcome in schizophrenia, social

cognitive domains are highly informative as mediators and

they uniquely contribute to explaining individual differences

in functional outcome. New information on the types and

nature of social cognitive impairments in schizophrenia has

stimulated the development of novel psychosocial and pharma-

cological treatments. This emerging work in social cognitive

interventions represents a promising new approach that goes

beyond the traditional focus on symptom management to

include a focus on achieving more complete and satisfying

social functioning.

Recommended Reading

Green, M.F., Penn, D.L., Bentall, R., Carpenter, W.T., Gaebel, W.,

Gur, R.C., et al. (2008). (See References). A summary of the dis-

cussion and conclusions at a consensus meeting at NIMH on social

cognition in schizophrenia.

Horan, W.P., Kern, R.S., Penn, D.L., & Green, M.F. (2008). (See

References). A review of the literature on training approaches to

improve social cognition in schizophrenia.

Sergi, M.J., Rassovsky, Y., Nuechterlein, K.H., & Green, M.F. (2006).

(See References). A study demonstrating that social cognition

appears to act as a mediator between neurocognition and functional

outcome in schizophrenia, using a statistical modeling approach.

Declaration of Conflicting Interests

The authors declared that they had no conflicts of interest with respect

to their authorship or the publication of this article.

Funding

This work was partly supported by grants MH43292 (MFG) and a

NARSAD Young Investigator Award (WPH).

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