Dr. Salman Kareem will present on social cognition in schizophrenia. Social cognition involves mental processes underlying social interactions and includes perceiving others' intentions. It has several domains impaired in schizophrenia including emotion perception, theory of mind, and attributional style. Social cognition is distinct from neurocognition and negative symptoms, and impacts daily functioning. While treatments show some potential, current medications have not reliably improved social cognition.

1. Presenter – Dr Salman Kareem
Final Year Resident
Department of Psychiatry
ACME , Pariyaram

2.  Defining social cognition in schizophrenia
 What domains of social cognition
 Neurobiology of social cognition
 What is social cognition’s relationship with positive
symptoms (eg, paranoia), negative symptoms, and
disorganization?
 What is the functional significance of social cognition?
Does it behave as a mediator?
 Social cognition and the course of schizophrenia: does
itpredate the illness or occur early in the illness? Are the
impairments trait like?
 Treatment interventions

3.  The Measurement and Treatment Research to Improve
Cognition in Schizophrenia (MATRICS) project
 understanding the nature and extent of cognitive
dysfunction in schizophrenia
 facilitate the development of treatments that will
hopefully improve this debilitating aspect of
schizophrenia (Barch, 2005).

4.  seven cognitive domains
 speed of processing,
 working memory,
 attention/vigilance,
 verbal learning and memory,
 visual learning and memory,
 reasoning and problem solving,
 social cognition
 (Green and Nuechterlein, 2004).

6.  Social cognition is defined as
“the mental operations underlying social
interactions, which include the human ability to perceive
the intentions and dispositions of others” (Brothers,
1990, p. 28).
 how people think about themselves and others in the
social world.

7.  primary domains (constructs) of social cognition:
 emotion perception,
 Theory of Mind (ToM), and
 Attributional style
 social perception, social knowledge (social schema)

8. Neuro Biology
 network of neural structures is critically involved in
processing social stimuli (Adolphs, 2001; Brothers, 1990;
Phillips et al., 2003).
 These models focus on regions of the occipital and
temporal cortices such as the Fusiform Gyrus (FG) and
Superior Temporal Sulcus (STS) which underlie face
processing (Haxby, Hoffmann and Gobbini, 2000; Winston,
Henson, Fine-Goulden, and Dolan, 2004)
 amygdala which plays a critical role in detecting threat,
recognizing emotions, and making complex social
judgments (Adolphs et al., 1994; Adolphs et al.,
 1998; Amaral et al., 2003; Winston et al., 2002)

9. Emotional processing
 Identifying emotions
 Facilitating emotions
 Understanding emotions
 Managing emotions
 Affect perception – a domain of emotion processing
that is frequently measured in schizophrenia research.

10. emotion perception
 In regard to emotion perception (eg, identifying
emotion displayed in various facial expressions or tone
of voice), the following conclusions can be drawn
 First, individuals with schizophrenia display deficits
compared with nonclinical control participants.
 Second, these deficits are more severe relative to
individuals with other psychiatric disorders such as
depressive disorder (unless psychotic features are
present).
• Edwards et al, Hellewell and Whittaker,Kohler and Brennan, and Mandal
et al

11.  Third, the greatest deficits are evident in the
perception of negative emotions (compared with
positive emotions).
 Fourth, the deficit in emotion perception is stable over
time, although evidence suggests that individuals in
remission may outperform individuals in an acute
phase of the disorder.

12.  Fifth, individuals with schizophrenia perform worse
trying to ‘‘read between the lines’’ (ie, identifying what
a given individual is thinking or feeling) but are less
impaired on more concrete social judgments (ie,
identifying what a person is wearing or doing).
 Sixth, many individuals with schizophrenia display
restricted visual scanning and spend less time
examining salient facial features during emotion
perception tasks.

13.  Finally, impairments in emotion perception are
present early in the course of illness.

14. Theory of Mind
 “ToM is defined as the ability to attribute mental states
(including beliefs, intentions, desires, and goals) to the
self and others.”
 includes understanding false beliefs, hints, intentions,
deception, metaphor, irony, and faux pas.

15.  Over 30 studies have been conducted on ToM in
schizophrenia, leading to the following conclusions .
 In general, individuals with schizophrenia exhibit
deficits in ToM relative to non ill and psychiatric
controls.
 The bulk of research supports the conclusion that this
impairment in schizophrenia is a trait deficit.
- Brune and Harrington et al

16.  First-degree relatives of individuals with schizophrenia
who also score high on schizotypy have impaired ToM,
lending support for ToM as a potential endophenotype
for schizophrenia.
 ToM deficits are present in both IP and OP samples,
are not accounted for by deficits in general cognitive
functioning, and are not uniquely associated with any
specific symptom type (eg, paranoia).
 The etiology of ToM deficits in schizophrenia remains
unclear, in part because the genesis of normal ToM is
still vague.

17. Attributional bias
 Attributional style refers to explanations people
generate regarding the causes of positive and negative
events in their lives.
 individuals with -paranoia or persecutory delusions.
 Such individuals tend to blame others rather than
situations for negative events, an attributional style
known as a personalizing bias.’
 persons with Scz tends to focus on hostile
attributional biases or the tendency to attribute hostile
intentions to others actions

18.  Individuals with persecutory delusions may of course
have other social cognitive biases such as the tendency
to ‘‘jump to conclusions’’ and to demonstrate a
‘‘confirmation bias’’ (that is, seeking confirmatory
evidence for a belief rather than disconfirmatory
evidence).

19.  2 factors prevent individuals with persecutory
delusions from correcting their bias in the face of
disconfirming situational information:
 a strong need for closure (ie, an intolerance of
ambiguity) and
 impairments in ToM.
 Associationship seen between need for closure and
persecutory delusions and between deficits in ToM
and personalizing attributions

20.  Individuals with persecutory delusions may of course
have other social cognitive biases such as the tendency
to ‘‘jump to conclusions’’ and to demonstrate a
‘‘confirmation bias’’ (ie, seeking confirmatory evidence
for a belief rather than disconfirmatory evidence).

21.  Social perception
 Definition: The ability to understand and appraise social
roles, rules, and context.
 Involves using verbal and nonverbal cues in order to
make inferences about a social situation
 May be central to functioning in a social context, ie,
facilitating interactions with people in social settings
or establishing relationships
 Can involve making critical appraisals, such as
judgments of trustworthiness in other people

22.  Social knowledge
 Definition: Refers to representational templates of social
situations or awareness of the roles, rules, expectations
and goals that govern social situations.
 Can be declarative, comprising facts and abstract
concepts (eg, social scripts) or procedural (eg, rules,
skills, and strategies) processes.

23.  Relationships among social cognitive constructs and
negative symptoms are less clear.
 negative symptoms that involve reduced emotional
experience (ie, anhedonia) or expression (ie, affective
flattening) might be more associated with the
development or maintenance of social cognition
deficits.

24.  Social cognitive deficits appear to be key determinants
of daily functioning in schizophrenia, including
instrumental actions, interpersonal functioning, and
vocational achievement.

25.  social cognition involves the interface of emotional and
cognitive processing, whereas neurocognitive processing is
relatively affect-neutral
 In contrast, negative symptoms could spring from a similar
affective processing dysfunction as social cognitive
impairments..
 failed empathy or mental simulation of others’ cognitive-affect
states (a putatively social cognitive phenomenon)
may underlie ToM deficits and also foster the extinction of
social reinforcement, leading to increased negative
symptoms.
 .

26.  Empirically, studies using statistical modeling
techniques and matched task designs have concluded
that social cognition is best understood as related to,
but distinct from, neurocognition and negative
symptoms.
 This distinction is also observed at the neural level
because activation circuitry for social cognition vis-à-vis
neurocognition and negative symptoms are
relatively independent

27. Functional Outcome
 Impairments in daily functioning of schizophrenic patients
are related to both social and non-social cognitive domains
(Couture et al., 2006, 2011).
 However, when social and non-social skills are analyzed
together, they are better predictors of functional outcome
(Couture et al., 2011).
 This means that social and non-social domains have an
independent influence on the everyday performance of
these patients.
 Further, several studies show that social cognition has a
mediator effect between neuro-cognition and functional
outcome (Couture et al., 2006; Bae et al., 2010;Schmidt et
al., 2011b).

28.  Social and non-social cognition are associated with functional
outcome when they are studied separately, but when they are
analyzed together, non-social cognition reduces or loses its
association with functional outcome. That is, it is possible that
the impact of non-social cognitive impairment in daily
functioning occurs through social cognitive impairments.
 Hence, it has been proposed that social cognition is a more
proximal factor in the causal mechanism leading to real world
performance.
 For example, to develop interpersonal relationships, alterations
in theory of mind have stronger influence than memory
alterations. However, memory impairment can influence theory
of mind performance which in turn influences the ability to
develop interpersonal relationships.

29. Mediator/Trait
 life history stable trait that precedes, and even predicts, the
illness onset.
 Using a videotape recording of a cohort of children having lunch,
a study showed that alterations of social behavior were the most
significant predictors of those children who developed
schizophrenia in adulthood, even more so than neuro-motor
deficits (Schiffman et al., 2004).
 Moreover, individuals at ultra-high or family risk for psychosis
present social cognition alterations, especially in theory of mind
(Chung et al., 2008;Anselmetti et al., 2009; Eack et al.,
2010; Gibson et al., 2010; Kim et al., 2011a).
 These alterations can predict the psychotic conversion (Chung et
al., 2008; Anselmetti et al., 2009; Eack et al., 2010;Gibson et al.,
2010; Kim et al., 2011a

30.  Consistent results were obtained in a study comparing
social skills in prodromal, first episode, and chronic
patients, as well as in a longitudinal one of first
episode patients (Green et al., 2012; Horan et al., 2012).
Together, these studies show that social alterations are
a stable trait across the illness.

31. Treatment Implications
 Recent studies shows that it has a relationship with
functional outcomes (eg, social skills, community
functioning).
 This, in turn, has inspired researchers to examine
whether social cognition can be improved because
social cognition may be an important target for
pharmacological and psychosocial treatments.

32.  Interestingly, there has been little support for atypical
medications improving social cognition in
schizophrenia because the one large adequately
powered study found that neither quetiapine nor
risperidone resulted in improved emotion perception
among 289 individuals with schizophrenia.

33.  antipsychotic drugs of either class demonstrate little
reliable effect upon social cognition. There is a
modicum of support for the use of oxytocin as an
adjunct to antipsychotic drugs (Katarzyna Kucharska-Pietura • Ann
Mortimer , CNS Drugs (2013) 27:335–343)

34.  Thus, there has been growing interest in psychosocial
treatments as a means of improving social cognition.
 Psychosocial treatment programs use a variety of
techniques to ameliorate social cognitive deficits, from
‘‘targeted’’ interventions that focus on a specific skill
(eg, asking clients to imitate others’ facial expressions
to improve emotion perception) to those that target
integrative social cognitive abilities via viewing
videotapes and role-playing.
 .

35.  While there is growing evidence that social cognition
can be improved, future research needs to determine
whether improvements in social cognition generalize
to other social cognitive domains as well as as to
behaviors

36. The Take Home Points
 Social cognition consists of multiple domains,
including affect perception expression, theory of
mind, attributional styles, and social knowledge.
 Social cognition is not just a subset of neurocognition,
it is a truly separable domain.
 Deficits in social cognition may explain the most or all
of the relationship between neurocognition and social
outcomes.
 Treating social cognitive deficits has the potential to
improve social outcomes, but these treatments are still
early in their development stages.

37. We mortals cannot read other people’s minds
directly. But we make good guesses from
what they say, what we read between the
lines, what they show in their faces and eyes,
and what best explains their behavior.
It is our species’ most remarkable talent.
Steven
Pinker
Social Cognition