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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
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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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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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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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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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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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