The complex construct of social cognition in schizophrenia

Social cognition - predictive of function

Prof Armida Mucci, University of Campania “Luigi Vanvitelli”, Italy, defined social cognition as the mental operations that underlie social interactions, including perceiving, interpreting and generating responses to the intentions and behaviors of others. Social cognition is a complex construct. In all phases of schizophrenia, as well as in at-risk individuals, deficits in all domains of social cognition are observed. This has immediate relevance - we live in communities, and interactions with other people are essential in everyday life.

Interactions with other people are essential in everyday life

Prof Mucci explained that social cognition is predictive of function in patients with schizophrenia - particularly the domains of theory of mind, and recognizing the intentions of others. The complex relationship between social cognition, neurocognitive functioning and functional outcome is still unclear.

The Italian Network for Research on Psychoses looked into factors that impact the outcome of patients with schizophrenia, as well as their unaffected first-degree relatives. Prof Mucci and colleagues investigated the effects of neurocognition, social cognition and functional capacity on two types of functioning: vocational and interpersonal functioning. They used structural equation modeling to describe these effects. Social cognition was assessed using facial emotion recognition tests, emotional intelligence and theory of mind. Neurocognition was investigated using the MATRICS Consensus Cognitive Battery (MCCB). MCCB assesses 7 domains of cognition: speed of processing, attention, working memory, verbal and visual learning, problem solving, and social cognition.

Their study included 922 patients at 26 centers. It was found that both subjects with schizophrenia and their relatives had cognitive impairment, as well as social cognition impairment.  In both groups, social cognition had a direct impact on outcome. It was independent of negative symptoms. Neurocognition was a predictor of social cognition and functional capacity, both of which had an impact on outcome.

Social cognition had a direct impact on outcome

Prof Mucci concluded that better understanding of the relationship between neurocognitive dysfunction and social cognition deficits may inform targeted treatment approaches.

Disorganization - losing direction

Prof Paola Rocca, University of Turin, Italy, described the relationship between disorganization and social cognition. Patients with disorganized schizophrenia struggle to use contextual information to choose an appropriate response for a particular situation. Patients lose the ability to be directed toward a particular goal. Disorganization has been linked to cognition (both neurocognition and social cognition), which is linked to social functioning.

Prof Rocca presented a 3-way model that describes the pathway from conceptual disorganization to interpersonal functioning in patients with schizophrenia. She proposed that conceptual disorganization may be a suitable treatment target.

Mentalizing deficits

Prof Gabriele Sachs, Medical University of Vienna, Austria, explained the difficulty that patients with schizophrenia have in recognizing emotions. They struggle with the perception, identification and discrimination of facial emotions. Patients also experience mentalizing deficits - which is the ability to think about states of mind in the self and others, such as thoughts, feelings and intentions. Hypoactivation of the core mentalizing network, which includes the medial prefrontal cortex and the bilateral temporoparietal junction, have been reported in patients with schizophrenia.

They struggle with the perception, identification and discrimination of facial emotions

These mentalizing deficits have been linked with key aspects of schizophrenia, including core psychotic symptoms, poorer insight into illness, and greater social dysfunction.

Prof Sachs discussed the application of Training of Affect Recognition (TAR) and Mentalization-Based Training (MBT) in a first episode and early psychosis program. TAR focusses on emotion recognition, emotion perception and social interaction, while MBT addresses perspective taking and social interactions. Mentalization-based treatment can impact social networks in the brain, and may be a promising approach in the treatment of schizophrenia.

Two dimensional

Prof Andrea Aleman, UMCG, The Netherlands, described two dimensions of the negative symptoms in schizophrenia - expressive deficits and amotivation. A two-factor model may better account for the heterogeneity in negative symptoms.

Two dimensions of the negative symptoms in schizophrenia - expressive deficits and amotivation

Prof Aleman and colleagues used functional MRI (fMRI) to look into the neural correlates of these two negative symptom dimensions. During fMRI, patients with schizophrenia (N=38) and healthy controls (N=20) were given the ‘Wall of Faces’ task. Each person was presented with an array of faces with different emotional expressions - angry or happy. This task measures emotional ambiguity in a social context. It is a social-emotional appraisal. It was found that the severity of expressive deficits was negatively correlated with activation in prefrontal, precentral, parietal, thalamic and temporal brain areas.

Prof Aleman suggested that negative symptoms could be deconstructed into more homogeneous components, allowing for investigation of the underlying neurocognitive mechanisms.