Kimmy S. Kee

Social Cognition in Schizophrenia, Part 1: Performance Across Phase of Illness

Social cognitive impairments are consistently reported in schizophrenia and are associated with functional outcome. We currently know very little about whether these impairments are stable over the course of illness. In the current study, 3 different aspects of social cognition were assessed (emotion processing, Theory of Mind [ToM], and social relationship perception) at 3 distinct developmental phases of illness: prodromal, first episode, and chronic. In this cross-sectional study, participants included 50 individuals with the prodromal risk syndrome for psychosis and 34 demographically comparable controls, 81 first-episode schizophrenia patients and 46 demographically comparable controls, and 53 chronic schizophrenia patients and 47 demographically comparable controls. Outcome measures included total and subtest scores on 3 specialized measures of social cognition: (1) emotion processing assessed with the Mayer-Salovey-Caruso Emotional Intelligence Test, (2) ToM assessed with The Awareness of Social Inference Test, and (3) social relationship perception assessed the Relationships Across Domains Test. Social cognitive performance was impaired across all domains of social cognition and in all clinical samples. Group differences in performance were comparable across phase of illness, with no evidence of progression or improvement. Age had no significant effect on performance for either the clinical or the comparison groups. The findings suggest that social cognition in these 3 domains fits a stable pattern that has outcome and treatment implications. An accompanying article prospectively examines the longitudinal stability of social cognition and prediction of functional outcome in the first-episode sample.

Social Cognition in Schizophrenia, Part 2: 12-Month Stability and Prediction of Functional Outcome in First-Episode Patients

This study evaluated the longitudinal stability and functional correlates of social cognition during the early course of schizophrenia. Fifty-five first-episode schizophrenia patients completed baseline and 12-month follow-up assessments of 3 key domains of social cognition (emotional processing, theory of mind, and social/relationship perception), as well as clinical ratings of real-world functioning and symptoms. Scores on all 3 social cognitive tests demonstrated good longitudinal stability with test-retest correlations exceeding .70. Higher baseline and 12-month social cognition scores were both robustly associated with significantly better work functioning, independent living, and social functioning at the 12-month follow-up assessment. Furthermore, cross-lagged panel analyses were consistent with a causal model in which baseline social cognition drove later functional outcome in the domain of work, above and beyond the contribution of symptoms. Social cognitive impairments are relatively stable, functionally relevant features of early schizophrenia. These results extend findings from a companion study, which showed stable impairments across patients in prodromal, first-episode, and chronic phases of illness on the same measures. Social cognitive impairments may serve as useful vulnerability indicators and early clinical intervention targets.

Perception of emotion and neurocognitive functioning in schizophrenia: what's the link?

In schizophrenia, relatively little is known about the association between deficits in emotion perception and basic neurocognitive functioning. The present study examined perception of emotion and a discrete set of neurocognitive functions in 28 treatment-resistant schizophrenic patients. Measures of emotion perception included a facial emotion identification test (still photographs presented on videotape), a voice emotion identification test (audiotape), and an affect perception test (brief interpersonal vignettes presented on videotape). Measures of neurocognitive functioning were selected based on hypothesized relationships to perception of emotion. These measures included: (a) Span of Apprehension task, a measure of early visual processing, visual scanning, and iconic read-out; (b) Degraded-Stimulus Continuous Performance Test, a measure of visual vigilance; and (c) Digit Span Distractibility Test, a measure of immediate or working memory. Among these measures, performance on the Span of Apprehension strongly correlated with performance on all three emotion perception tasks. The associations between perception of emotion and the other two measures were in the same direction, but were significantly smaller than those of the Span of Apprehension. These findings implicate the importance of early perceptual processing (i.e. visual scanning) in the ability of schizophrenic individuals to perceive emotion.

Do the siblings of schizophrenia patients demonstrate affect perception deficits

Affect perception deficits have been extensively documented in schizophrenia and are associated with the social dysfunction that is characteristic of this disorder. The two previous studies examined facial affect perception in genetically at-risk samples and yielded mixed results. The current study was designed to provide a rigorous test of affect perception abilities among schizophrenia patients (n=58), their biological siblings without psychosis (n=51), and nonpsychiatric controls (n=49). Participants completed three measures of affect perception, including facial, vocal, and combined modality. Schizophrenia patients performed significantly worse than controls on two of the three affect perception tests as well as a composite index based on all three tests. The performance of the sibling group fell between the patient and control groups on each of the affect perception tests. However, group differences achieved statistical significance only for the composite index with the siblings performing significantly worse than controls and significantly better than the schizophrenia group. These findings demonstrate that subtle deficits in affect perception are detectable in the unaffected siblings of schizophrenia patients when multiple measures of different types of affect perception abilities are used in combination.

Social Cognition and Neurocognition: Effects of Risperidone, Olanzapine, and Haloperidol

Objective: This study examined the short-term effects of first- and second-generation antipsychotic medications on social cognition and basic cognition. Method: One hundred patients with schizophrenia or schizoaffective disorder participated in an 8 week, double-blind study of risperidone, olanzapine, and haloperidol. Participants were administered multiple measures of social cognition, basic cognition, and clinical symptoms at baseline, the end of week 4, and the end of week 8. Seventy-three patients completed the baseline assessment and at least one other assessment. Data were analyzed with mixed-effects analyses of covariance. For data reduction, the social cognitive measures were clustered into a summary score, and the cognitive measures were clustered into two summary scores: general cognitive ability and processing speed. (The effects on thinking of risperidone and olanzapine can be found at NCT00108368, www.clinicaltrials.gov.) Results: There were no treatment-related differences on any of the three summary scores. Social cognition did not show within-group changes over time either by itself or after control for the cognitive clusters. One cognitive score (general cognitive ability) increased during the study period for all three medication groups. Conclusions: The present study included a rather thorough assessment of social cognition and did not find any evidence of between-group or within-group effects of antipsychotic medication on social cognition.

Theory of mind deficits for processing counterfactual information in persons with chronic schizophrenia

BACKGROUND Interpersonal communication problems are common among persons with schizophrenia and may be linked, in part, to deficits in theory of mind (ToM), the ability to accurately perceive the attitudes, beliefs and intentions of others. Particular difficulties might be expected in the processing of counterfactual information such as sarcasm or lies. METHOD The present study included 50 schizophrenia or schizo-affective out-patients and 44 demographically comparable healthy adults who were administered Part III of The Awareness of Social Inference Test (TASIT; a measure assessing comprehension of sarcasm versus lies) as well as measures of positive and negative symptoms and community functioning. RESULTS TASIT data were analyzed using a 2 (group: patients versus healthy adults) x 2 (condition: sarcasm versus lie) repeated-measures ANOVA. The results show significant effects for group, condition, and the group x condition interaction. Compared to controls, patients performed significantly worse on sarcasm but not lie scenes. Within-group contrasts showed that patients performed significantly worse on sarcasm versus lie scenes; controls performed comparably on both. In patients, performance on TASIT showed a significant correlation with positive, but not negative, symptoms. The group and interaction effects remained significant when rerun with a subset of patients with low-level positive symptoms. The findings for a relationship between TASIT performance and community functioning were essentially negative. CONCLUSIONS The findings replicate a prior demonstration of difficulty in the comprehension of sarcasm using a different test, but are not consistent with previous studies showing global ToM deficits in schizophrenia.

Procedural Learning in Schizophrenia: Evidence from Serial Reaction Time

Although schizophrenic patients, as a group, show deficits on measures of explicit learning, it is unclear whether they also have deficits on measures of implicit learning. The current study assessed procedural learning in a sample of 48 chronic schizophrenic inpatients and 23 normal controls using the serial reaction time test (SRT). In addition, we examined the clinical correlates of procedural learning. The SRT yields indices of total motor learning and two subcomponents: reaction time learning, and sequence learning. Although patients performed comparably to normal controls on total motor learning, they showed significantly less sequence learning (P <.03) than controls. Reaction time learning did not differ between the two groups. None of the symptom or clinical variables was correlated with the indices of learning. Chronic schizophrenic inpatients showed normal levels of procedural learning on the SRT. However, their learning was qualitatively different than that of controls (i.e. patients showed deficits in sequence learning, but not reaction time learning). Reduced sequence learning could reflect dysfunctional cortico-cerebellar circuits.

Social cognition [corrected] and neurocognition: effects of risperidone, olanzapine, and haloperidol.

Objective: This study examined the short-term effects of first- and second-generation antipsychotic medications on social cognition and basic cognition. Method: One hundred patients with schizophrenia or schizoaffective disorder participated in an 8 week, double-blind study of risperidone, olanzapine, and haloperidol. Participants were administered multiple measures of social cognition, basic cognition, and clinical symptoms at baseline, the end of week 4, and the end of week 8. Seventy-three patients completed the baseline assessment and at least one other assessment. Data were analyzed with mixed-effects analyses of covariance. For data reduction, the social cognitive measures were clustered into a summary score, and the cognitive measures were clustered into two summary scores: general cognitive ability and processing speed. (The effects on thinking of risperidone and olanzapine can be found at NCT00108368, www.clinicaltrials.gov.) Results: There were no treatment-related differences on any of the three summary scores. Social cognition did not show within-group changes over time either by itself or after control for the cognitive clusters. One cognitive score (general cognitive ability) increased during the study period for all three medication groups. Conclusions: The present study included a rather thorough assessment of social cognition and did not find any evidence of between-group or within-group effects of antipsychotic medication on social cognition.

An analysis of categorical perception of facial emotion in schizophrenia

BACKGROUND Emotion perception deficits have been extensively documented in schizophrenia and are associated with poor social functioning. Yet fundamental questions about the nature and scope of these impairments remain unanswered from commonly used experimental tasks. An alternative categorical perception paradigm that focuses on distinguishing boundaries between emotions was used to evaluate whether schizophrenia patients demonstrate atypical patterns of categorical perception and a negativity bias in the identification of ambiguous facial expressions. METHOD 47 schizophrenia outpatients and 31 nonpsychiatric controls completed a forced-choice emotion identification task. Stimuli consisted of a series of digitized facial images that were morphed in 10% signal intensity increments along continua between pairs of emotions (happy-sad; fearful-happy; angry-fearful; angry-sad) and presented in a random order. For each emotion continuum, measures of the response slope and the location of the boundary shift point between emotions were calculated for each group. RESULTS The schizophrenia group demonstrated significantly shallower response curves than controls across all emotion continua. Despite these generally less precise demarcations between emotions, patients did not significantly differ from controls in the location of the shift point between emotions on any of the continua. CONCLUSIONS Schizophrenia patients demonstrated impaired categorical perception of facial expressions with generally less sharp categorizations of ambiguous stimuli to one emotion category or another. However, patients did not demonstrate a negativity bias in their processing of ambiguous facial expressions. The emotional continuum paradigm can help to clarify the nature and boundaries of affect perception deficits in schizophrenia.

Cross-ethnic differences in perception of emotion in schizophrenia

BACKGROUND The purpose of this study was to examine cross-ethnic differences in Perception of Emotion (POE) in schizophrenia. POE is an emerging construct in schizophrenia and involves the recognition and accurate identification of emotion in the facial and vocal expression of others. It has been implicated as relevant to instrumental functioning in schizophrenia, as well as a potential core deficit or marker for the disorder. Studies have shown the role of culture in shaping the expression and perception of emotion in non-clinical samples. It was hypothesized that ethnic minorities would have lower POE scores than Caucasians, and that the differences on POE would remain significant after controlling for neurocognition. METHOD Individuals, 131, diagnosed with schizophrenia or schizoaffective disorder participated in the study. There were 59 Euro-American Caucasian, 56 were African-American, and 16 were Latino. Neurocognition was measured as a standardized sum of five neuropsychological measures. Perception of Emotion was measured with facial and voice recognition tasks. RESULTS Both Latinos and African-Americans scored lower on POE than Caucasians. The cross-ethnic differences on POE remained significant after controlling for neurocognition and overall symptom level. Post hoc analyses showed some support for the predictive validity of the POE measure across cultural contexts. CONCLUSIONS These results suggest that POE in schizophrenia is influenced by ethnicity, and that the ethno-cultural mechanisms influencing POE transcend the shared variation of POE and neurocognition. These results have implications for theories of cross-cultural emotion recognition, measurement bias in POE research, and for the place of culture in the study of POE in schizophrenia.