Deficit of theory of mind in individuals at ultra-high-risk for schizophrenia

Mentalizing impairments and hypermentalizing bias in individuals with first-episode schizophrenia-spectrum disorder and at-risk mental state: the differential roles of neurocognition and social anxiety

Mentalizing, or theory of mind (ToM), impairments and self-referential hypermentalizing bias are well-evident in schizophrenia. However, findings compared to individuals with at-risk mental states (ARMS) are inconsistent, and investigations into the relationship between social cognitive impairments and social anxiety in the two populations are scarce. This study aimed to examine and compare these deficits in first-episode schizophrenia-spectrum disorder (FES) and ARMS, and to explore potential specific associations with neurocognition and symptomatology. Forty patients with FES, 40 individuals with ARMS, and 40 healthy controls (HC) completed clinical assessments, a battery of neurocognitive tasks, and three social cognitive tasks. The comic strip and hinting tasks were used to measure non-verbal and verbal mentalizing abilities, and the gaze perception task was employed to assess self-referential hypermentalizing bias. FES and ARMS showed comparable mentalizing impairments and self-referential hypermentalizing bias compared to HC. However, only ambiguous self-referential gaze perception (SRGP) bias remained significantly different between three groups after controlling for covariates. Findings suggested that self-referential hypermentalizing bias could be a specific deficit and may be considered a potential behavioral indicator in early-stage and prodromal psychosis. Moreover, working memory and social anxiety were related to the social cognitive impairments in ARMS, whereas higher-order executive functions and positive symptoms were associated with the impairments in FES. The current study indicates the presence of stage-specific mechanisms of mentalizing impairments and self-referential hypermentalizing bias, providing insights into the importance of personalized interventions to improve specific neurocognitive domains, social cognition, and clinical outcomes for FES and ARMS.

N400 Peculiarities During Intentional Inferences Production in Subjects With Schizotypal Traits

Abstract. A deficit in context processing may underlie theory of mind (ToM) difficulties in schizophrenia, although few studies to date have explored the impact of contextual processing on ToM performances within the same task. We used electroencephalography to investigate the production of intentional inferences from highly versus weakly structured sentences in healthy participants with schizotypal traits. Thirty-four participants were divided into two groups according to their scores on the Schizotypal Personality Questionnaire (SPQ). The participants listened to stories that required a degree of understanding in order to produce an inference about the main character’s intention. Each story was followed by a target word that could either be highly predictable (HP), weakly predictable (WP), or incompatible with the context. The results indicate that the N400 component for WP targets was stronger in the high-SPQ group. This increase correlated with the negative dimension of schizotypy. This may reflect difficulties with generating intentional inferences when the context is insufficiently structured for high schizotypy participants.

Intrinsic cerebellar functional connectivity of social cognition and theory of mind in first-episode psychosis patients

Neuroimaging studies have revealed how intrinsic dysconnectivity among cortical regions of the mentalizing network (MENT) and the mirror neuron system (MNS) could explain the theory of mind (ToM) deficit in schizophrenia patients. However, despite the concurrent involvement of the cerebellum with the cortex in social cognition, the dysfunction in intrinsic interplay between the cerebellar nodes of MENT/MNS and the cortex in schizophrenia patients remains unknown. Thus, we aimed to investigate whether resting-state cerebello-cortical dysconnectivity exists in first-episode psychosis (FEP) patients in relationship with their ToM deficit. A total of 37 FEP patients and 80 healthy controls (HCs) underwent resting-state functional magnetic resonance imaging. Using a priori-defined cerebellar seeds that functionally connect to the MENT (right crus II) and MNS (right crus I), we compared cerebello-cortical functional connectivities (FCs) in FEP patients and HCs. Correlations between cerebello-parietal connectivities and ToM performance were investigated in FEP patients. FEP patients showed hyperconnectivity between the right crus II and anterior cingulate gyrus and between the right crus I and supplementary motor area, bilateral postcentral gyrus, and right central/parietal operculum (CO/PO). Hypoconnectivity was found between the right crus II and left supramarginal gyrus (SMG) in FEP patients. FCs between the right crus II and left SMG and between the right crus I and right CO/PO were significantly correlated with ToM scores in FEP patients. In accordance with the "cognitive dysmetria" hypothesis, our results highlight the importance of cerbello-cortical dysconnectivities in understanding social cognitive deficits in schizophrenia patients.

Empathy and Theory of Mind in Ultra-High Risk for Psychosis: Relations With Schizotypy and Executive Function

OBJECTIVE

While recent studies have found deficits in theory of mind (ToM) skills in individuals at ultra-high risk (UHR) for psychosis, empathic tendencies in these subjects remain unclear. The presence of high schizotypy and compromised executive functions, which are found in UHR individuals, would affect ToM skills and empathic tendencies. We investigated the ToM skills and empathic tendencies of UHR individuals and examined their relationship with schizotypy and executive function.

METHODS

This study included 28 UHR individuals and 28 age- and sex-matched healthy controls. All participants completed a self-reported empathic scale (Interpersonal Reactivity Index) and the Wisconsin Schizotypy Scales. Additionally, the ToM Picture Stories Task and Wisconsin Card Sorting Test were conducted.

RESULTS

UHR individuals showed a trend toward lower self-reported empathic tendencies; however, there were no differences in ToM skills between the two groups. Of the four subscales of the IRI, only empathic concern showed a significant difference between the two groups. Empathic concern was inversely associated with negative schizotypy.

CONCLUSION

Our findings suggest that UHR individuals show relatively preserved cognitive empathy but compromised emotional empathy. Furthermore, in UHR individuals, the empathic concern subscale of the IRI was associated with negative schizotypy, while ToM skills were related to positive schizotypy and executive function.

Predictors of social and role outcomes in first episode psychosis: A prospective 12-month study of social cognition, neurocognition and symptoms

BACKGROUND

Poor functioning is common in psychosis, with predictors of poor outcome including negative symptoms and deficits in neurocognition (NC) and social cognition (SC). The extent to which these variables contribute unique variance in social and role trajectories remains inconclusive. Identifying robust predictors of outcome will inform targeted interventions in early psychosis, where functional trajectories are being set.

METHOD

Prospective 12-month follow-up study investigating the predictive values of NC and SC on social and role functioning in individuals with first-episode psychosis (FEP), within the context of clinical variables. 98 individuals with FEP (mean age = 24; male = 77) were assessed within the first year of diagnosis on functioning (social and role), cognition (SC and NC) and psychosis symptoms.

RESULTS

Negative symptoms were the only significant predictor of 12-month social (χ²  = 9.59, P = .002, OR = 1.12) and role (χ²  = 10.86, P < .001, OR = 1.16) functioning in FEP. In exploratory analyses, negative symptoms mediated the relationship between baseline social knowledge and social functioning (Z = 1.92, P = .05; d = 0.56), and between baseline logical memory and role functioning (Z = 2.40, P = .02; d = 0.80) at 12-month follow-up.

CONCLUSION

Although social and role trajectories in early psychosis appear somewhat distinct, negative symptoms were the best prognostic marker of social and role outcome in FEP, and mediated the relationship between SC and social outcome, and NC and role outcome; these relationships may be important when considering interventions to improve functional outcome in early psychosis.

Relationship between social cognition, general cognition, and risk for suicide in individuals with a psychotic disorder

OBJECTIVE

Cognitive alterations putatively contribute to the risk for suicide in individuals with psychosis. Yet, a comprehensive assessment of social- and general-cognitive abilities in a large sample is lacking.

METHODS

Seven-hundred-fifteen individuals diagnosed with a psychotic disorder performed tasks of facial emotion recognition, Theory of Mind, and general cognitive functioning (sustained attention, set-shifting, IQ-tests and verbal learning) as part of the Genetic-Risk-and-Outcome-of-Psychosis (GROUP) study. Presence of past suicide attempt/s and/or current suicidal ideation was reported by 261 individuals and 454 individuals reported no suicide attempt or ideation. We used general linear models to investigate group differences in task performance. All analysis were controlled for age, sex, education, and psychotic symptom severity.

RESULTS

Individuals with suicide attempt and/or ideation showed better performance on the facial emotion recognition task and lower performance on tasks of sustained attention and verbal learning, compared to individuals without suicide attempt and/or ideation, without a clear effect of attempt or ideation. Theory of Mind performance was also better for individuals with suicide attempt and/or ideation, with largest differences between individuals who reported both attempts and ideation compared to individuals without suicide attempt and/or ideation. No effect of suicide attempt and/or ideation was found on misperception of facial emotions, IQ and set-shifting. Overall, effect sizes were small.

CONCLUSION

Higher sensitivity to social-emotional cues together with weakened attentional control and learning capacity was observed in individuals with psychosis and suicide attempt and/or ideation. This may suggest that insufficient capacity for regulating perceived social stress contributes to suicidal thoughts and behavior.

White Matter Correlates of Theory of Mind in Patients With First-Episode Psychosis

Deficits in theory of mind (ToM) are considered as a distinctive feature of schizophrenia. Functional magnetic resonance imaging (fMRI) studies have suggested that aberrant activity among the regions comprising the mentalizing network is related to observed ToM deficits. However, the white matter structures underlying the ToM functional network in schizophrenia remain unclear. To investigate the relationship between white matter integrity and ToM impairment, 35 patients with first-episode psychosis (FEP) and 29 matched healthy controls (HCs) underwent diffusion tensor imaging (DTI). Using tract-based spatial statistics (TBSS), fractional anisotropy (FA) values of the two regions of interest (ROI)-the cingulum and superior longitudinal fasciculus (SLF)-were acquired, and correlational analysis with ToM task scores was performed. Among the patients with FEP, ToM strange story scores were positively correlated with the FA values of the left cingulum and left SLF. There was no significant correlation between FA and ToM task scores in HCs. These results suggest that the left cingulum and SLF constitute a possible neural basis for ToM deficits in schizophrenia. Our study is the first to demonstrate the white matter connectivity underlying the mentalizing network, as well as its relation to ToM ability in patients with FEP.

Longitudinal investigation of the relationship between omega-3 polyunsaturated fatty acids and neuropsychological functioning in recent-onset psychosis: A randomized clinical trial

Alterations in polyunsaturated fatty acids (PUFAs), including omega-3 and omega-6, have been implicated in the pathophysiology of psychotic disorders, but little is known about their associations with neuropsychological functioning. The present study includes 46 recent-onset psychosis patients who participated in a larger (n = 50) double blind, placebo-controlled randomized clinical trial comparing 16 weeks of treatment with either risperidone + fish oil (FO) (EPA 740 mg and DHA 400 mg daily) or risperidone + placebo and completed neuropsychological assessments at the baseline timepoint. We investigated the relationship between baseline omega-3 (i.e., eicosapentaenoic acid, EPA; docosapentaenoic acid, DPA and docosahexaenoic acid, DHA) and omega-6 (i.e., arachidonic acid, AA) PUFA with baseline MATRICS Consensus Cognitive Battery (MCCB) and Brief Psychiatric Rating Scale (BPRS) scores. Twenty-five patients had neuropsychological data available at 16 weeks following participation in the clinical trial, which included 12 patients assigned to risperidone + FO and 13 patients assigned to risperidone + placebo. At baseline both higher DHA and EPA correlated significantly with better social cognition after controlling for functioning on other neuropsychological domains, total BPRS score, AA level and substance use. Also, at baseline higher AA correlated significantly with hostility/uncooperativeness after controlling for DHA + EPA + DPA, overall neuropsychological functioning and substance use. Patients treated with risperidone + FO demonstrated a significant longitudinal increase in social cognition that was significantly higher at 16 weeks compared to patients treated with risperidone + placebo. DHA also correlated significantly with social cognition at the 16-week timepoint. This study provides novel evidence for a differential role of omega-3 vs. omega-6 PUFA in neuropsychological deficits and symptoms in recent-onset psychosis and its treatment.

Reduced Plasma Dopamine-β-Hydroxylase Activity Is Associated With the Severity of Bipolar Disorder: A Pilot Study

Dopamine-β-hydroxylase (DβH) is an enzyme converting dopamine to norepinephrine, a key neurotransmitter in mood disorders, such as major depressive disorder (MDD) and bipolar disorder (BD). Due to overlapping symptomology of unipolar and bipolar depression, the present study attempted to explorer if the plasma DβH activity could discriminate the depressive episodes of BD from MDD. The aim of this study was to compare the plasma DβH activity among MDD patients (n = 104), BD patients (n = 101), and healthy controls (n = 160). Clinical characteristics and cognitive function were assessed using the Young Mania Rating Scale (YMRS), Hamilton Depression Scale (HAM-D), Hamilton Anxiety Scale (HAM-A), Patient Health Questionnaire-9 (PHQ-9), and Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Our data showed a lower plasma DβH activity in patients with BD, not MDD, than that in controls. For the BD patients, the plasma DβH activities were negatively correlated with HAM-D scores and HAM-A scores. However, there was no significant correlation between plasma DβH activity and severity of depressive symptoms in MDD patients. No significant correlation between DβH activities and cognitive assessments neither in BD nor in MDD patients. The present study provides evidence that BD is associated with decreased circulating DβH activity.

Benefits of social cognitive skills training within routine community mental health services: Evidence from a non-randomized parallel controlled study

Although social cognitive impairments are evident in patients with schizophrenia across many cultures, psychosocial interventions are less used in Eastern countries. Despite a growing emphasis on community care in mental health services in Eastern countries, the synergistic effects of social cognitive intervention strategies on routine community mental health services are not well documented. This study aimed to adapt a group-based social cognitive skills training (SCST) program for use in a Korean context and evaluate its feasibility and preliminary effects among community-dwelling individuals with schizophrenia. Forty-seven patients were assigned to either the SCST + treatment as usual (TAU) group (n = 21) or the TAU only group (n = 24). Participants completed tasks to assess social cognition, social functioning, neurocognition, and psychiatric symptoms before and after treatment. Over a period of approximately 12 weeks, drop-out rates were comparably low in both groups, and the attendance rates for the SCST program were high (85.7 %, mean sessions attended = 20.56/24 sessions). The SCST + TAU group demonstrated significant improvements in facial affect recognition, social functioning, and psychiatric symptoms compared to the TAU only group. A non-significant trend in theory of mind was observed, along with no improvements in social perception and neurocognition. The adapted version of the SCST program is feasible for implementation and demonstrates promise for enhancing social cognition and functioning in Korean outpatients with schizophrenia.

Impaired Performance on the Reading the Mind in the Eyes Test in First-Episode Psychosis and Clinical High Risk for Psychosis

OBJECTIVE

Although previous studies have reported impaired performance in the reading the mind in the eyes test (RMET), which measures complex emotion recognition abilities, in patients with schizophrenia, reports regarding individuals at clinical high risk (CHR) for psychosis have been inconsistent, mainly due to the interacting confounding effects of general cognitive abilities and age. We compared RMET performances across first-episode psychosis (FEP) patients, CHR individuals, and healthy controls (HCs) while controlling for the effects of both general cognitive abilities and age.

METHODS

A total of 25 FEP, 41 CHR, and 44 HC subjects matched for age participated in this study. RMET performance scores were compared across the groups using analysis of variance with sex and intelligence quotient as covariates. Exploratory Pearson's correlation analyses were performed to reveal the potential relationships of RMET scores with clinical symptom severity in the FEP and CHR groups.

RESULTS

RMET performance scores were significantly lower among FEP and CHR participants than among HCs. FEP patients and CHR subjects showed comparable RMET performance scores. RMET scores were negatively correlated with Positive and Negative Syndrome Scale (PANSS) positive symptom subscale scores in the FEP patients. No significant correlation was identified between RMET scores and other clinical scale scores.

CONCLUSION

Impaired RMET performance is present from the risk stage of psychosis, which might be related to positive symptom severity in early psychosis. Longitudinal studies are necessary to confirm the stability of complex emotion recognition impairments and their relationship with social functioning in early psychosis patients.

Can theory of mind be improved? Positive expectations cause better theory of mind performance in a community sample

BACKGROUND AND OBJECTIVES

Theory of Mind (ToM) deficits are present in several mental disorders and closely related to problems in social functioning and lower quality of life. While several trainings are aimed at improving ToM performance, it is unknown whether positive expectations on a persons' ToM performance might cause better ToM achievement.

METHODS

Participants (n = 131) first completed a mock ToM test and were then randomly assigned to either receive standardized positive, negative or no feedback on their ToM performance. Secondly, their expectations on their own ToM performance were assessed. Thirdly, ToM was assessed using the Movie Task for the Assessment of Social Cognition (MASC).

RESULTS

Participants who received positive feedback resulted in positive expectations on their ToM performance and showed enhanced ToM performance, whereas negative feedback did not lead to negative expectations and negative expectations did not affect a change in ToM performance.

LIMITATIONS

In the present exploratory study, the effect of positive expectations on ToM performance was assessed in a community sample. Thus, the study should be replicated in a clinical sample for more in-depth results.

CONCLUSIONS

ToM performance could be enhanced by inducing positive expectations on one's ToM performance, whereas negative feedback had no effect. The present study suggest that interventions that focus on strengthening positive expectations on one's ToM performance could enhance the efficacy of present ToM training methods.

Memory Impairments and Psychosis Prediction: A Scoping Review and Theoretical Overview

Impairments in memory functions are among the most robust correlates of schizophrenia and of poor functional outcomes in individuals with psychotic disorders. Prospective, longitudinal studies are crucial to determining the meaning of these deficits in relation to mechanisms associated with the onset and course of these disorders.The objective of this review is to examine the literature concerning premorbid memory impairments during the prodromal phase of psychosis to address three primary questions 1) are memory impairments present among individuals with a clinical high risk syndrome? 2) are memory deficits in clinical high risk cases predictive of future conversion to psychosis? and 3) what are the underlying neural correlates of memory impairment in clinical high risk individuals and are they also predictive of future conversion?PubMed and Google Scholar databases were systematically searched. The primary inclusion criteria were to select studies that 1) were original research articles published in a peer-reviewed journal in the past 25 years, 2) studied subjects at clinical high risk for psychosis or in the prodromal phase of illness, and 3) included examinations into verbal memory performance in those at clinical high risk for psychosis.64 articles were identified and screened for eligibility. The review included 34 studies investigating verbal memory impairment in clinical high risk individuals compared to controls. The average effect size of verbal learning total recall was .58, indicating a moderate level of impairment in verbal learning among individuals at clinical high risk for psychosis as compared to healthy controls. Of studies that predicted time to conversion, indices of memory, particularly declarative and verbal working memory, were especially predictive of future conversion. Finally, when examining investigations of the neural correlates of memory dysfunction in the clinical high risk state, findings suggest altered activation and functional connectivity among medial temporal lobe regions may underlie differences in memory performance between clinical high risk individuals and healthy controls.Findings to date strongly indicate that memory impairments are present during the premorbid phase of psychosis and that verbal memory impairment in particular is predictive of future conversion to psychosis. Evidence from fMRI studies is fairly consistent in showing greater activation of memory-related regions during retrieval among clinical high risk cases who convert, with less consistent evidence of altered functional connectivity in the encoding phase. These findings support the use of verbal learning and memory measures in the psychosis prediction and prevention field.

Self-reported empathy in adults with autism, early psychosis, and social anxiety disorder

The Empathy Quotient (EQ) self-report questionnaire is used to measure empathy in individuals with clinical conditions that have been associated with social impairments. In this study, older teens and adults with autism spectrum disorder (ASD; N = 60), early psychosis (EP; N = 51) and social anxiety disorder (SAD; N = 71) and neurotypical controls (NT; N = 26) were compared on the cognitive empathy, emotional reactivity and social skills sub-scales of the Empathy Quotient (EQ) measure. All three clinical groups reported lower cognitive empathy than NT controls, and the ASD group reported lower cognitive empathy than EP and SAD groups. The ASD group reported lower emotional reactivity than the SAD group. All three clinical groups reported lower social skills that NT controls. The poor self-rated empathy for the ASD and EP groups generally reflects previous research that found individuals with these conditions perform relatively poorly on certain objective measures of empathy. However, the poor self-rated cognitive empathy and social skills for the SAD group conflicts with previous research that has found that SAD groups perform well on objective measures of empathy. This suggests that both EQ and objective measures should be used to fully assess empathy in clinical groups.

Vulnerability to psychosocial disability in psychosis

Psychosocial disability affects a number of individuals with psychosis and often begins years before the formal onset of disorder. This suggests that for many, their psychosocial disability is enduring, and targeted interventions are therefore needed earlier in their developmental trajectories to ensure that psychosocial disability does not become entrenched. Poor psychosocial functioning also affects individuals with a range of different emerging mental health problems, putting these young people at risk of long-term social marginalisation and economic disadvantage; all of which are known risk factors for the development of psychosis. Identification of the markers of poor psychosocial functioning will help to inform effective treatments. This editorial will discern the early trajectories and markers of poor psychosocial outcome in psychosis, and highlight which individuals are most at risk of having a poor outcome. This editorial will also discuss whether early interventions are currently being targeted appropriately and will propose how intervention and preventative strategies can be implemented, to restore psychosocial trajectories in a way that enables young people to maximise their life chances.

Factors Associated With Psychosocial Functioning and Outcome of Individuals With Recent-Onset Schizophrenia and at Ultra-High Risk for Psychosis

Background: Patients with schizophrenia have impairments in social functioning and are readmitted to healthcare institutions frequently. Individuals at ultra-high risk (UHR) for psychosis already present poor social functioning; among those individuals, the conversion rate from the putative prodromal phase to overt psychosis is 20%-30% within 1-2 years. Here, we analyzed the factor structure of self-related variables and neuro- and socio-cognitive function, and investigated whether these factors were associated with psychosocial function and prognostic outcome in individuals with recent-onset schizophrenia (ROSPR) or at UHR for psychosis. Methods: We evaluated 60 individuals at UHR for psychosis, 47 individuals with ROSPR, and 71 healthy controls using a comprehensive neurocognitive test battery and self-reported attribution scales, self-esteem, resilience, aberrant subjective experiences of schizotypy (physical anhedonia, social anhedonia, magical ideation, and perceptual aberration), and basic symptoms. We assessed psychosocial function with the Quality of Life Scale (QLS). Results: Factor analysis of all subjects revealed a four-factor structure comprising social-cognitive bias, reflective self, neurocognition, and pre-reflective self factors. Multiple regression analysis at baseline revealed that the factor structure predicted QLS. In the UHR group, social-cognitive bias, reflective self, neurocognition, and negative symptoms were significant determinants, explaining 38.0% of total QLS score variance. In the ROSPR group, reflective self and negative symptoms were significant determinants, explaining 54.4% of total QLS score variance. During follow-up, 13 individuals at UHR for psychosis developed psychosis (cumulative prevalence: 31.2% ± 7.6% at 6 years), with neurocognition score at baseline remaining a significant predictor of conversion [χ²(1) = 4.009, p = 0.045; hazard ratio 0.56, 95% confidence interval 0.31-0.99, p = 0.048]. Five patients with schizophrenia were (re)admitted during follow-up (cumulative prevalence: 16.1% ± 7.1% at 6 years); no factor was found to predict (re)admission. Conclusion: Factor analysis revealed an intrinsic four-factor structure of social-cognitive bias, reflective self, neurocognition, and pre-reflective self. The four factors were associated with social functioning at baseline and prodrome-to-psychosis conversion during follow-up, indicating the clinical significance of the four-factor structure. These findings provide a framework for understanding schizophrenia.

Rationale, Methods, Feasibility, and Preliminary Outcomes of a Transdiagnostic Prevention Program for At-Risk College Students

PURPOSE

Early adulthood represents one period of increased risk for the emergence of a serious mental illness. The college campus provides a unique opportunity to assess and monitor individuals in this at-risk age group. However, there are no validated early detection programs that are widely implemented on college campuses. In an effort to address this gap, we designed and tested an early detection and prevention program tailored to college students. A transdiagnostic approach was employed because of evidence for shared risk factors across major mental illnesses.

DESIGN

Single arm, prospective study evaluating outcomes following a 4-week intervention.

METHOD

Three in-person mental health screenings were conducted on the campus of one university. Undergraduate students with at least mildly elevated, self-reported levels of depressive or subclinical psychotic symptoms, who were not receiving treatment for these symptoms, were invited to participate in a 4-session workshop focused on increasing self- and other- awareness and emotion regulation using established mindfulness, self-compassion, and mentalization principles and experiential exercises. Symptoms, resilience-promoting capacities, and aspects of social functioning were assessed pre- and post- intervention.

RESULTS

416 students were screened and a total of 63 students participated in the workshop. 91% attended at least 3 of the 4 sessions. The majority of participants found the workshop interesting and useful and would recommend it to a friend. Significant pre-to-post reductions in symptoms (depression, anxiety, and subclinical psychotic symptoms, ps < 0.004) and improvements in resilience-promoting capacities (self-compassion and self-efficacy, ps < 0.006) and indices of social functioning (social motivation, activity, and a measure of comfort with the physical presence of others, ps < 0.04) were observed. Moreover, the significant increases in resilience-promoting capacities correlated with the reductions in affective symptoms (ps < 0.03).

CONCLUSIONS

These findings suggest that an on-campus mental health screening and early intervention program is feasible, acceptable, and may be associated with improvements in resilience-related capacities and symptom reductions in young adults with non-impairing, subclinical symptoms of psychopathology. Follow-up work will determine whether this program can improve both shorter and longer-term mental health and functional outcomes in this at-risk population.

Autism, early psychosis, and social anxiety disorder: understanding the role of social cognition and its relationship to disability in young adults with disorders characterized by social impairments

Impairments in social cognition are believed contribute to disability, particularly for disorders characterized by difficulties in social interaction. There has been little transdiagnostic investigation of this across social cognition domains in young adults. A total of 199 young adults diagnosed with autism spectrum disorder (ASD; N = 53), early psychosis (EP; N = 51), and social anxiety disorder (SAD; N = 64) were compared against neurotypical controls (NT; N = 31) on a battery of lower and higher-order and self-report social cognition measures. For both ASD and EP, participants showed impaired performance on all lower-order emotion recognition tasks and one higher-order social cognition test. Self-reports of empathy were reduced in all clinical groups and particularly in ASD. For SAD, despite showing no objective social cognition impairment, self-reported empathy was reduced to the same level as EP. Discriminant analysis revealed that self-reported empathy and lower-order emotion recognition tests provide best capacity to differentiate groups. Regressions predicting disability revealed depression as the strongest predictor across all disability measures. Empathy provided additional predictive value for social disability and social interaction anxiety. Overall, results support a similar social-cognitive development profile across ASD and EP. While self-reported empathy differentiated between groups, discrepancy between objective social cognition test performance and self-reported empathy in the SAD group suggests probable threat-related self-monitoring report biases that likely further influence all group outcomes. As depression and empathy were the most important predictors of disability, regardless of diagnostic group, research is required to explore targeted interventions for difficulties in these domains to reduce disability.

Correlates of neurocognitive functions in individuals at ultra-high risk for psychosis - A 6-month follow-up study

Cognitive deficits are evident at the prodromal phase of psychosis. It has been noted that brain-derived neurotrophic factor (BDNF) is correlated with cognition in both preclinical and clinical studies. However, to our knowledge, no study has evaluated blood BDNF levels and their association with cognitive impairment in individuals at ultra-high risk for psychosis (UHR). We included 13 individuals at UHR and 30 healthy controls (HC) matched by sex, age, and educational level. Plasma BDNF levels were measured at baseline and 6 months. Neurocognitive functions (executive functions, speed of processing, verbal learning and memory, working memory) were examined at 6 months. Regression analyses were conducted to examine the relationship between BDNF levels and cognitive performance. BDNF levels were lower in UHR group than in HC group both at baseline and at 6 months (P = 0.001, and P = 0.007, respectively). There were no associations between plasma BDNF levels and all of the cognitive domains in both groups. Our findings showed that peripheral BDNF levels were not related to cognitive deficits in UHR and HC groups while the lower BDNF level in the former persisted up to 6 months. Further research is needed in a large sample.

Aberrant within- and between-network connectivity of the mirror neuron system network and the mentalizing network in first episode psychosis

INTRODUCTION

It has been suggested that the mentalizing network and the mirror neuron system network support important social cognitive processes that are impaired in schizophrenia. However, the integrity and interaction of these two networks have not been sufficiently studied, and their effects on social cognition in schizophrenia remain unclear.

METHODS

Our study included 26 first-episode psychosis (FEP) patients and 26 healthy controls. We utilized resting-state functional connectivity to examine the a priori-defined mirror neuron system network and the mentalizing network and to assess the within- and between-network connectivities of the networks in FEP patients. We also assessed the correlation between resting-state functional connectivity measures and theory of mind performance.

RESULTS

FEP patients showed altered within-network connectivity of the mirror neuron system network, and aberrant between-network connectivity between the mirror neuron system network and the mentalizing network. The within-network connectivity of the mirror neuron system network was noticeably correlated with theory of mind task performance in FEP patients.

CONCLUSION

The integrity and interaction of the mirror neuron system network and the mentalizing network may be altered during the early stages of psychosis. Additionally, this study suggests that alterations in the integrity of the mirror neuron system network are highly related to deficient theory of mind in schizophrenia, and this problem would be present from the early stage of psychosis.

A Developmental Perspective on Social-Cognition Difficulties in Youth at Clinical High Risk for Psychosis

After participating in this activity, learners should be better able to:• Evaluate the evolution of social cognitive abilities as a developmental process• Assess the evidence regarding social cognition difficulties in youth at clinical high risk for psychosisIndividuals at clinical high risk (CHR) for psychosis exhibit a broad range of difficulties, including impaired social cognition, which may represent a target for early identification and intervention. Several studies have examined various domains of social cognition in CHR individuals. Most focus on adolescent and young adult populations, but given the accumulating evidence that impairment exists before the onset of psychotic disorders, it is critically important to begin to look for these risk markers in younger children. The present article reviews 25 studies on CHR that examine any of the following four domains of social cognition: emotion processing, theory of mind, social perception, or attribution bias. Eligible studies were identified through a comprehensive literature search, conducted using electronic databases, including PubMed/MEDLINE and PsycINFO, and combinations of key social-cognition and CHR search terms. Despite some mixed results, the existing literature establishes that CHR individuals display social-cognitive impairment, though it remains unclear as to how and when that impairment develops. Thus, by using the literature on social cognition in typically developing children as a model and reference, and by looking at the evolution of social-cognitive abilities as a developmental process, our review presents a valuable new perspective that indicates the necessity of further investigation in younger, at-risk populations. Implications for treatment and future research are discussed.

The Importance of Social Cognition in Improving Functional Outcomes in Schizophrenia

Social cognition has become recognized as an important driver of functional outcomes and overall recovery in patients with schizophrenia, mediating the relationship between neurocognition and social functioning. Since antipsychotic therapy targeting remission of clinical symptoms has been shown to have a limited impact on social cognition, there has been an increasing drive to develop therapeutic strategies to specifically improve social cognition in schizophrenia. We sought to review current evidence relating to social cognition in schizophrenia and its clinical implications, including interventions designed to target the core domains of social cognition (emotion processing, theory of mind, attributional bias, and social perception) as a means of improving functional outcomes and thereby increasing the likelihood of recovery. Relevant articles were identified by conducting a literature search in PubMed using the search terms "schizophrenia" AND "cognition" AND "social functioning," limited to Title/Abstract, over a time period of the past 10 years. Current evidence demonstrates that schizophrenia is associated with impairments in all four core domains of social cognition, during the pre-first-episode, first-episode, early, and chronic phases of the disease, and that such impairments are important determinants of functional outcome. Interventions targeting the four core domains of social cognition comprise psychosocial approaches (social cognition training programs) and pharmacological therapies. Social cognition training programs targeting multiple and specific core domains of social cognition have shown promise in improving social cognition skills, which, in some cases, has translated into improvements in functional outcomes. Use of some psychosocial interventions has additionally resulted in improvements in clinical symptoms and/or quality of life. Pharmacological therapies, including oxytocin and certain antipsychotics, have yielded more mixed results, due in part to the confounding impact of factors including variation in receptor genetics, bioavailability, pharmacokinetics, and drug-drug interactions, and inconsistencies between study designs and medication dosages. Additional research is required to advance our understanding of the role of social cognition in schizophrenia, and to further establish the utility of targeted interventions in this setting.

The relationship of categorical and phonological verbal fluency to negative schizotypy and social functioning in a non-clinical sample

INTRODUCTION

Research suggests that levels of schizotypy are related to cognitive and social functioning, with negative schizotypy being particularly related to deficits in verbal fluency (VF) and distinct social skills. Considering the possibility that different VF tasks may involve both shared and unique underlying processes, this study sought to examine the separate contributions of categorical and phonological forms of VF to social functioning in those with varying levels of negative schizotypy.

METHODS

Face-to-face interviews were conducted in which 228 college students completed VF tasks, the SPQ-BR, and a social functioning questionnaire.

RESULTS

Both phonological and categorical VF were inversely related to levels of negative schizotypy and inversely related to several social functioning domains. High and low levels of negative schizotypy groups were significantly different on elements of social engagement and interpersonal behaviour. In two instances, phonological VF appeared to moderate the relationships between negative schizotypy and specific elements of social functioning.

CONCLUSIONS

These findings support a general link between verbal processing and social functioning among those with greater negative schizotypy. Possible avenues of future research are discussed.

Cognitive Correlates of Different Mentalizing Abilities in Individuals with High and Low Trait Schizotypy: Findings from an Extreme-Group Design

Mentalizing or Theory of Mind (ToM) deficits in schizophrenia have been studied to great extent, but studies involving samples of trait schizotypy yield ambiguous results. Executive functions like cognitive inhibition, cognitive flexibility, and agency are all prerequisites of mentalizing, and it is assumed that the impairment of these functions contributes to ToM deficits in schizophrenia. Whether these impairments influence the ToM performance of people with high trait schizotypy remains unclear. Although impaired self-agency has repeatedly been identified in people with schizotypy, its role in mentalizing is yet to be investigated. The main aim of this study was to explore whether deficits in cognitive and affective ToM can be found in high trait schizotypy, and to identify in what way these deficits are related to the positive and negative dimensions of schizotypy. The secondary aim was to examine whether these deficits correlate with executive functions. Based on the dimensional view of the schizophrenia spectrum, an extreme-group design was applied to non-clinical volunteers demonstrating high (N = 39) and low (N = 47) trait schizotypy. Affective and cognitive ToM were investigated using the Movie for Assessment of Social Cognition, a sensitive and video-based measurement. Cognitive inhibition was assessed using the Stroop Test, and cognitive flexibility was analyzed using the Trail-Making Test. Agency was measured using a computerized self-agency paradigm. Participants in the high-schizotypy group performed significantly worse in the affective ToM task (d = 0.79), and their overall ToM performance was significantly impaired (d = 0.60). No between-group differences were found with regards to cognitive ToM, executive functions, and self-agency. Cognitive flexibility correlated negatively with positive schizotypy, and contributed to a worse overall and affective ToM. Impaired cognitive inhibition contributed to undermentalizing-type errors. It was found that non-clinical participants with high trait (positive) schizotypy - especially those with slight executive-function deficits - may have difficulties in understanding the emotional state of others and consequently in functioning in social situations.

Do cognitive schema mediate the association between childhood trauma and being at ultra-high risk for psychosis?

Exposure to childhood trauma has been associated with psychotic symptoms, being at ultra-high risk for psychosis (UHR), and psychotic disorders such as schizophrenia. Negative self-beliefs have been shown to partially mediate the relationship between childhood trauma and paranoia and have been shown to be characteristic of patients with psychosis. However, whether the association between childhood trauma and being at high risk of developing psychosis (e.g., UHR) and paranoia symptoms is mediated by altered cognitive schema is unknown and warrants investigation to inform preventive interventions. Data was collected on 30 UHR patients from Outreach and Support in South London about exposure to childhood trauma, cognitive schema, paranoia and cannabis use. Relative to healthy controls (n = 38), UHR patients were significantly more likely to report exposure to various types of childhood trauma (emotional and sexual abuse, and emotional and physical neglect), had more negative schema and less positive schema about themselves and others, and were more likely to use cannabis more than once a month. Emotional neglect was found to be significantly associated with UHR status even after controlling for the effects of previous exposure to cannabis use (b = 0.262, 95% CI: 0.115-0.408), and this association was partially mediated by negative self-schema (b = 0.045, 95% CI: 0.004-0.159). Similarly, emotional neglect was significantly associated with paranoia (b = 1.354, 95% CI: 0.246-2.462), and this association was partially mediated by negative self-schema (b = 0.988, 95% CI: 0.323-1.895). These findings provide preliminary evidence about the cognitive mechanisms that may underlie the association between childhood trauma and later risk for psychosis.

Comparing the ability of cognitive and affective Theory of Mind in adolescent onset schizophrenia

BACKGROUND

Evidence in the literature suggests that there is an impairment of social cognition in schizophrenia. Theory of Mind (ToM) is defined as one's ability to understand others' wishes, beliefs, intentions, and other psychological states and thereby to judge others' behavior, as an essential component of social cognition. However, there have been limited studies on social cognition, especially ToM in adolescent onset schizophrenia (AOS). The current study aims to investigate ToM abilities in adolescent schizophrenia according to various ToM subcomponents (cognitive ToM and affective ToM) and various ToM orders (first order and second order).

METHODS

This study examines ToM in 35 adolescent schizophrenic patients and 35 healthy adolescents using the "Yoni task" and "Faux Pas Recognition test" to assess their affective and cognitive ToM abilities.

RESULTS

In the Yoni task, patients with AOS showed differences in ToM abilities either on a different order or under different conditions. The Faux Pas Recognition task results revealed that AOS patients were not always able to recognize a faux pas or understand complicated emotions under the faux pas scenario. Furthermore, as indicated by the correlation analysis, neither cognitive ToM nor affective ToM was related to the patients' symptoms, disease duration, dose of medication, or intelligence quotient (IQ).

CONCLUSION

Our findings showed AOS impairment in the performance of ToM tasks. It seemed that impairment in second-order-ToM is more serious. Moreover, these deficits are largely independent of symptom clusters, disease duration, dose of medication, and IQ. It can be speculated that ToM dysfunction may be a hallmark of adolescent schizophrenia.

Overview of Human Oxytocin Research

Social dysfunction is a core symptom of many psychiatric disorders and current medications have little or no remedial effects on this. Following on from extensive studies on animal models demonstrating that the neuropeptide oxytocin plays an important role in social recognition and bonding, human-based research has explored its therapeutic potential for social dysfunction in psychiatric disorders. Here we outline the historical background of this human-based research and some of the current methodological challenges it is facing. To date, research has primarily attempted to establish functional effects through measuring altered endogenous concentrations, observing effects of exogenous administration and by investigating the effects of polymorphisms and epigenetic modifications of the oxytocin receptor gene. We summarize some of the key findings on behavioral and neural effects that have been reported in healthy subjects in the context of social cognition which have provided encouragement that oxytocin could represent a promising therapeutic target. At the same time, we have identified a number of key areas where we urgently need further information about optimal dosing strategies and interactions with other peptide and transmitter systems. Finally, we have summarized current translational findings, particularly in the context of therapeutic outcomes of intranasal oxytocin administration in autism and schizophrenia. These clinical findings while somewhat varied in outcome do offer increasing cause for optimism that targeting the oxytocin system may provide a successful therapeutic approach for social dysfunction. However, future research needs to focus on the most effective treatment strategy and which types of individuals are likely to benefit most.

Deficits of cognitive theory of mind and its relationship with functioning in individuals with an at-risk mental state and first-episode psychosis

Disturbance of theory of mind (ToM) and its relationship with functioning in schizophrenia is well documented; however, this is unclear in spectrum disorders like at-risk mental state (ARMS) and first-episode psychosis (FEP). To assess mental state reasoning ability, the total score of the Theory of Mind Picture Stories Task questionnaire was compared among 36 Japanese individuals with ARMS, 40 with FEP, and 25 healthy controls (HC). Pearson's correlations between ToM performance and global and social functioning indices were examined. ToM performance for FEP and ARMS subjects was significantly lower than that for HC, though the significance of the difference between the ARMS and HC disappeared when controlling for premorbid IQ. ToM deficits in ARMS subjects were confirmed only in the comprehension of higher-order false belief. Only among FEP subjects were ToM performance and global functioning significantly correlated, though the significance disappeared when controlling for neurocognitive performance or dose of antipsychotics. No significant correlation between ToM performance and social functioning was observed in the FEP and ARMS groups. The current findings suggest that ToM deficits emerge in ARMS subjects confined within a higher-order domain, and that the relationship between ToM impairment and functional deterioration might be established after psychosis onset.

Attachment, Neurobiology, and Mentalizing along the Psychosis Continuum

In this review article, we outline the evidence linking attachment adversity to psychosis, from the premorbid stages of the disorder to its clinical forms. To better understand the neurobiological mechanisms through which insecure attachment may contribute to psychosis, we identify at least five neurobiological pathways linking attachment to risk for developing psychosis. Besides its well documented influence on the hypothalamic-pituary-adrenal (HPA) axis, insecure attachment may also contribute to neurodevelopmental risk through the dopaminergic and oxytonergic systems, as well as bear influence on neuroinflammation and oxidative stress responses. We further consider the neuroscientific and behavioral studies that underpin mentalization as a suite of processes potentially moderating the risk to transition to psychotic disorders. In particular, mentalization may help the individual compensate for endophenotypical impairments in the integration of sensory and metacognitive information. We propose a model where embodied mentalization would lie at the core of a protective, resilience response mitigating the adverse and potentially pathological influence of the neurodevelopmental cascade of risk for psychosis.

Cognitive functioning in individuals at ultra-high risk for psychosis, first-degree relatives of patients with psychosis and patients with first-episode schizophrenia

OBJECTIVE

The aim of the present study was to investigate and compare cognitive functioning of first-degree relatives of people with schizophrenia who were also at ultra-high risk (UHR) for psychosis with patients with first-episode (FE) schizophrenia, first degree relatives of patients not fulfilling UHR criteria (FDR), and healthy control (HC) subjects.

METHOD

Forty subjects in each group were included, underwent a face-to-face interview and completed a neurocognitive test battery, including the Trail Making Test-A (TMT-A, psychomotor functions), Stroop Color Word Test (attention), Digit Symbol Coding Test (DST, processing speed and working memory) and Hopkins Verbal Leaning Test-Revised (HVLT-R, verbal memory).

RESULTS

Functioning in all the cognitive test domains displayed a gradual decrease from the HC, FDR, UHR to FE groups. After controlling for covariates, there were still significant differences in TMT-A (F(7160)=35.4, P<0.001), DST (F(7160)=38.9, P<0.001), Stroop Color Word Test (F(7160)=35.0, P<0.001), Stroop Word Test (F(7160)=36.2, P<0.001), Stroop Color Test (F(7160)=40.9, P<0.001) and HVLT-R (F(7160)=62.5, P<0.001) between the four groups, indicating that the cognitive functioning in the UHR group was intermediate between the FE and FDR groups, while the FDR group had poorer performance than the HC group, and the FE group had the poorest cognitive functioning across all four examined domains.

CONCLUSION

The results indicate that impairments in processing speed, attention, working memory and verbal memory exist in both UHR and FDR subjects. In order to clarify the associations between cognitive functioning and UHR and schizophrenia, longitudinal studies are warranted.

Association between impaired brain activity and volume at the sub-region of Broca's area in ultra-high risk and first-episode schizophrenia: A multi-modal neuroimaging study

Recent studies have suggested that functional abnormalities in Broca's area, which is important in language production (speech and thoughts before speech), play an important role in the pathophysiology of schizophrenia. While multi-modal approaches have proved useful in revealing the specific pathophysiology of psychosis, the association of functional abnormalities with gray matter volume (GMV) here in subjects with an ultra-high risk (UHR) of schizophrenia, those with first-episode schizophrenia (FES), and healthy controls has yet to be clarified. Therefore, the relationship between cortical activity measured using functional near-infrared spectroscopy (fNIRS) during a verbal fluency task, and GMV in the Broca's area assessed using a manual tracing in magnetic resonance imaging (MRI), which considers individual structural variation, was examined for 57 subjects (23 UHR/18 FES/16 controls). The UHR and FES group showed significantly reduced brain activity compared to control group in the left pars triangularis (PT) (P=.036, .003, respectively). Furthermore in the FES group, the reduced brain activity significantly positively correlated with the volume in the left PT (B=0.29, P=.027), while significant negative association was evident for all subjects (B=-0.18, P=.010). This correlation remained significant after adjusting for antipsychotics dosage, and voxel-wise analysis could not detect any significant correlation between impaired cortical activity and volume. The significant relationship between neural activity and GMV in the left PT may reflect a specific pathophysiology related to the onset of schizophrenia.

Faux pas recognition performance in a help-seeking population at clinical high risk of psychosis

There is a growing body of evidence suggesting that patients with psychosis show impaired theory of mind (ToM). However, much remains to be understood as to whether ToM deficits occur in the premorbid or post-onset period of psychosis. Our primary aim was to examine empirically impairment on ToM tasks in a group of individuals with clinical high risk (CHR) of psychosis. Fifty CHR participants identified through the Structured Interview for Prodromal Syndromes and 52 age-/education-matched controls were assessed with a complete standard neuropsychological battery (the MCCB, MATRICS Consensus Cognitive Battery) and a social cognition assessment (Faux Pas Test, FPT). We then examined the association of baseline FPT performance with conversion to psychosis at 12-month follow-up. Compared with controls, the CHR group showed significantly poorer performances on the FPT and most MCCB domains. Significant positive correlations were found between faux pas detection and the MCCB domains of Attention/Vigilance and Working Memory in CHR participants when controlling for age and years of education. Mean scores on the FPT in 14 converters who were diagnosed with full-blown psychosis within 12 months were significantly lower than they were for non-converters. Impairments in ToM ability are acquired earlier in the prodromal stage of psychosis, along with general cognition (such as memory function) deficits. Declines in ToM ability may overlap with the progress of psychosis (the gradual loss insight), sharing similar neural substrates, and reflected by impairments in basic cognitive function.

Social inference in individuals at clinical high risk for psychosis

AIM

Social cognition impairment is a hallmark of schizophrenia and contains multiple domains. The domain of social inference has been relatively understudied in schizophrenia and its risk states.

METHODS

Social inference was assessed in 60 clinical high-risk (CHR) patients and 28 healthy control subjects, using the video social inference task. We hypothesized a deficit in social inference in CHR participants and examined predictive value for psychosis transition.

RESULTS

Social inference was positively associated with increasing age. Social inference did not differ significantly between CHR patients and controls, or predict transition to psychosis.

CONCLUSIONS

Few studies have examined social inference of individuals at clinical high risk for psychosis, and findings have been inconclusive. Additional studies using a variety of measures of social inference in CHR participants are recommended.

Theory of Mind Impairments in Youth at Clinical High Risk of Psychosis

OBJECTIVE

The normal maturational processes of theory of mind (ToM) capacity are ongoing during adolescence and even early adulthood. However, research has shown that ToM ability also declines among adults suffering from prodromal psychotic experiences. The goal of this study was to investigate the characteristics of ToM performance in youth with clinical high risk (CHR) of psychosis.

METHODS

The Reading Mind in Eyes Task (RMET), including own-race and other-race eyes, was administered to 40 CHR youth; 42 age-, gender-, and education-matched healthy controls (HCs); and 62 adult patients with schizophrenia (SZ). Nine-month follow-up data were collected from 31 CHR subjects, of whom 7 (22.6%) had made the transition to psychosis.

RESULTS

CHR youth showed significant impairment in RMET performance compared to HC youth but performed better than did SZ patients. Moreover, they were significantly slower than were HC youth in responding to the RMET, with a response time similar to that of SZ patients. In particular, they had significantly poorer accuracy in interpreting positive and neutral eye expressions compared to the HC group, but not in interpreting negative eye expressions. Preliminary follow-up data showed a trend toward significance (p = 0.079) for RMET performance between those who transitioned to psychosis and those who did not.

CONCLUSIONS

Our findings illustrate that deficits in ToM capacity, specifically the ability to interpret people's mental state from eye expressions, occur early on in prodromal psychosis in youth. Early interventions for CHR youth focusing on ToM enhancement may halt progress toward psychosis.

Evidence from paranoid schizophrenia for more than one component of theory of mind

We previously reported finding that performance was impaired on four out of five theory of mind (ToM) tests in a group of 21 individuals diagnosed with paranoid schizophrenia (pScz), relative to a non-clinical group of 29 individuals (Scherzer et al., 2012). Only the Reading the Mind in the Eyes Test did not distinguish between groups. A principal components analysis revealed that the results on the ToM battery could be explained by one general ToM factor with the possibility of a latent second factor. As well, the tests were not equally sensitive to the pathology. There was also overmentalization in some ToM tests and under-mentalisation in others. These results led us to postulate that there is more than one component to ToM. We hypothesized that correlations between the different EF measures and ToM tests would differ sufficiently within and between groups to support this hypothesis. We considered the relationship between the performance on eight EF tests and five ToM tests in the same diagnosed and non-clinical individuals as in the first study. The ToM tests shared few EF correlates and each had its own best EF predictor. These findings support the hypothesis of multiple ToM components.

Social Cognition in Individuals at Ultra-High Risk for Psychosis: A Meta-Analysis

Objective

Treatment in the ultra-high risk stage for a psychotic episode is critical to the course of symptoms. Markers for the development of psychosis have been studied, to optimize the detection of people at risk of psychosis. One possible marker for the transition to psychosis is social cognition. To estimate effect sizes for social cognition based on a quantitative integration of the published evidence, we conducted a meta-analysis of social cognitive performance in people at ultra high risk (UHR).

Methods

A literature search (1970-July 2015) was performed in PubMed, PsychINFO, Medline, Embase, and ISI Web of Science, using the search terms ‘social cognition’, ‘theory of mind’, ‘emotion recognition’, ‘attributional style’, ‘social knowledge’, ‘social perception’, ‘empathy’, ‘at risk mental state’, ‘clinical high risk’, ‘psychosis prodrome’, and ‘ultra high risk’. The pooled effect size (Cohen’s D) and the effect sizes for each domain of social cognition were calculated. A random effects model with 95% confidence intervals was used.

Results

Seventeen studies were included in the analysis. The overall significant effect was of medium magnitude (d = 0.52, 95% Cl = 0.38–0.65). No moderator effects were found for age, gender and sample size. Sub-analyses demonstrated that individuals in the UHR phase show significant moderate deficits in affect recognition and affect discrimination in faces as well as in voices and in verbal Theory of Mind (TOM). Due to an insufficient amount of studies, we did not calculate an effect size for attributional bias and social perception/ knowledge. A majority of studies did not find a correlation between social cognition deficits and transition to psychosis, which may suggest that social cognition in general is not a useful marker for the development of psychosis. However some studies suggest the possible predictive value of verbal TOM and the recognition of specific emotions in faces for the transition into psychosis. More research is needed on these subjects.

Conclusion

The published literature indicates consistent general impairments in social cognition in people in the UHR phase, but only very specific impairments seem to predict transition to psychosis.

Cognition in at-risk mental states for psychosis

RATIONALE

The devastating nature of schizophrenia and treatment limitations have triggered a search for early detection methods to enable interventions to be implemented as soon as the first signs and symptoms appear. In this effort, several studies have investigated the cognitive functions in individuals regarded as being in at-risk mental states (ARMS) for psychosis.

OBJECTIVE

Our aim was to make a systematic review of the literature regarding basic and social cognition in individuals in ARMS following the guidelines of the PRISMA statement.

RESULTS

In general, the results of the 49 articles included in the review show that individuals in ARMS have pervasive cognitive deficits that seem to be greater in individuals who later convert to psychosis.

CONCLUSIONS

Cognitive impairment can be detected in individuals considered to be in ARMS according to current classifications and may serve as a risk marker for psychotic conversion; however, the lack of standardized criteria to define ARMS and of homogeneous cognitive assessment methods hamper the generalization of findings from different studies.

Figural fluency and immediate visual memory in patients with at-risk mental state for psychosis: empirical study

AIM

Although a number of cognitive functions have been assessed in the ultra-high risk (UHR) population, only one study has reported on figural fluency. Visual memory was measured by different tests providing inconsistent results. The aim of the present study was to compare figural fluency and visual immediate memory performance in UHR patients and normal subjects.

METHODS

The UHR sample consisted of 55 help-seeking individuals meeting CAARMS criteria. The control group consisted of 65 subjects. They were matched as a group by age, gender and education level. Figural fluency (RFFT) and immediate visual memory (BVRT) were assessed within 2 weeks after inclusion in the study in the UHR patient group.

RESULTS

Significant differences were obtained in RFFT and BVRT results. In BVRT, UHR patients scored lower in number of correct designs (P < 0.001) and higher in number of errors (P < 0.0001), especially omissions (P < 0.001) and distortions (P < 0.0001). UHR subjects accurately recalled fewer designs, omitted and distorted more test figures. In RFFT, they scored lower in production of novel designs (P < 0.0001) and higher in the error ratio index (P < 0.008). They produced fewer novel designs and made more preservative errors.

CONCLUSIONS

The current study concerns non-verbal cognitive functions in UHR samples. Our results suggest that figural fluency and visual immediate memory are impaired in help-seeking UHR individuals as compared with matched controls.

Theory of Mind, Emotion Recognition and Social Perception in Individuals at Clinical High Risk for Psychosis: findings from the NAPLS-2 cohort

Social cognition, the mental operations that underlie social interactions, is a major construct to investigate in schizophrenia. Impairments in social cognition are present before the onset of psychosis, and even in unaffected first-degree relatives, suggesting that social cognition may be a trait marker of the illness.

In a large cohort of individuals at clinical high risk for psychosis (CHR) and healthy controls, three domains of social cognition (theory of mind, facial emotion recognition and social perception) were assessed to clarify which domains are impaired in this population.

Six-hundred and seventy-five CHR individuals and 264 controls, who were part of the multi-site North American Prodromal Longitudinal Study, completed The Awareness of Social Inference Test, the Penn Emotion Recognition task, the Penn Emotion Differentiation task, and the Relationship Across Domains, measures of theory of mind, facial emotion recognition, and social perception, respectively.

Social cognition was not related to positive and negative symptom severity, but was associated with age and IQ. CHR individuals demonstrated poorer performance on all measures of social cognition. However, after controlling for age and IQ, the group differences remained significant for measures of theory of mind and social perception, but not for facial emotion recognition.

Theory of mind and social perception are impaired in individuals at CHR for psychosis. Age and IQ seem to play an important role in the arising of deficits in facial affect recognition. Future studies should examine the stability of social cognition deficits over time and their role, if any, in the development of psychosis.

Social cognitive functioning in prodromal psychosis: A meta-analysis

BACKGROUND

There is substantial evidence regarding a social cognitive deficit in schizophrenia, and it has been suggested to be a trait-marker of this disorder. However, a domain-by-domain analysis of social cognitive deficits in individuals at clinical high risk (CHR) for psychosis has not been performed.

METHOD

Electronic databases were searched for studies regarding social cognitive performance in individuals at CHR. The included social cognitive domains, which were classified based on the Social Cognition Psychometric Evaluation (SCOPE) initiative of the National Institute of Mental Health (NIMH), were as follows: theory of mind (ToM), social perception (SP), attributional bias (AB), and emotion processing (EP).

RESULTS

Twenty studies that included 1229 individuals at CHR and 825 healthy controls met the inclusion criteria. The overall effect size for social cognition was medium (g=-0.477). The largest effect size was identified for AB (g=-0.708). A medium effect size was identified for EP (g=-0.446) and ToM (g=-0.425), and small effects were identified for SP (g=-0.383).

CONCLUSION

This is the first quantitative domain-by-domain social cognitive meta-analysis regarding CHR individuals. The present study indicated that individuals at CHR exhibited significant impairments in all domains of social cognition compared with healthy controls, with the largest effect size identified for AB. The identification of social cognitive domains that reflect an increased risk for impending psychosis and of predictors of the conversion to psychosis via a longitudinal follow-up study is required.

An investigation of attributional style, theory of mind and executive functioning in acute paranoia and remission

This study assessed associations between attributional style and ToM measures in patients with paranoid symptoms and non-clinical controls, as well associations between these aspects of social cognition and executive skills. Using a longitudinal design, we further assessed performance on measures following the remission of paranoid symptoms. Patients and controls completed the Internal Personal and Situational Attributions Questionnaire (IPSAQ), ToM tasks, the Stroop, the modified Wisconsin Card Sorting Test (WCST) and a measure of premorbid IQ at time one. Following the remission of paranoid symptoms, the patient group repeated the assessment process. Patients had a higher personalising bias for negative events and impairments in second order false belief and executive skills compared to control participants. Personalising bias for negative events was associated with poorer IQ, a tendency to make perseverative errors, a poorer performance on the second order false belief task and more severe symptoms. Personalising bias for negative events, performance on the second order false belief task or the tendency to make perseverative errors did not significantly change following symptom remission. The findings increase understanding of the mechanisms that potentially underpin the development and maintenance of paranoia. Specifically targeting personalising attributions for negative events in remitted patients may be an important goal of psychological therapy.

Theory of Mind and attachment styles in people with psychotic disorders, their siblings, and controls

OBJECTIVE

Impaired Theory of Mind (ToM) and insecure (adult) attachment styles have been found in persons with schizophrenia as well as in their healthy siblings. ToM refers to the ability to infer mental states of self and others including beliefs and emotions. Insecure attachment is proposed to underlie impaired ToM, and comprises avoidant (discomfort with close relationships, high value of autonomy) and anxious (separation anxiety, dependency on others) attachment. Insight into the association between attachment style and ToM is clinically relevant, as it enhances our understanding and clinical approach to social dysfunction in schizophrenia. Therefore, we studied the association between insecure attachment styles and ToM in patients with schizophrenia, their siblings, and healthy controls.

METHODS

A total of 111 patients with a diagnosis in the schizophrenia spectrum, 106 non-affected siblings and 63 controls completed the Psychosis Attachment Measure, the Conflicting Beliefs and Emotions, a subsection of the Wechsler Adult Intelligence Scale, and the Childhood Trauma Questionnaire-Short Form. Severity of symptoms was assessed with the Community Assessment of Psychic Experiences and the Positive and Negative Syndrome Scale.

RESULTS

After controlling for sex, intelligence, history of trauma and symptom severity, avoidant attachment was significantly associated with cognitive as well as with affective ToM, showing U-shaped associations, indicating better ToM performance for patients with lower or higher levels of avoidant attachment compared to medium levels. Anxious attachment in patients was associated with more problems in cognitive ToM.

CONCLUSION

The results from this study support the idea that an anxious attachment style is associated with worse ToM performance in patients. Results also suggested a potential protective role of higher levels of avoidant attachment on ToM. These findings bear clinical relevance, as activation of (insecure) attachment mechanisms may affect interpersonal relations, as well as therapeutic working alliance. Further clarification is needed, especially on associations between ToM and avoidant attachment.

Schizotypy, autobiographical memory, and theory of mind: sex differences

Individuals with schizophrenia exhibit a range of cognitive impairments, including tasks assessing theory of mind (ToM) and autobiographical memory (AM). This study appears to be the first to examine how ToM and AM abilities interact in relation to schizotypy. Forty-seven undergraduate students reporting a wide continuous range of scores on the Schizotypal Personality Questionnaire (SPQ) completed a measure of ToM and a measure assessing various phenomenological qualities of AM. Female participants exhibited a negative correlation between the ToM score and the SPQ total score and a positive correlation between enhanced phenomenological qualities of AM and the SPQ disorganized factor score. No statistically significant relationships were found for male participants. ToM was negatively correlated with AM across the entire sample, which was not moderated by sex or schizotypy. It is possible that distinct underlying mechanisms account for the observed sex differences on ToM and AM performance in schizophrenia-related conditions.

Exploratory analysis of social cognition and neurocognition in individuals at clinical high risk for psychosis

Neurocognition and social cognition are separate but related constructs known to be impaired in schizophrenia. The aim of this study was to extend the current knowledge of the relationship between social cognition and neurocognition in individuals at clinical high risk (CHR) of developing psychosis by examining, in a large sample, the associations between a wide range of neurocognitive tasks and social cognition. Participants included 136 young people at CHR. Specific domains within neurocognition and social cognition were compared using Spearman correlations. Results showed that poor theory of mind correlated with low ratings on a wide range of neurocognitive tasks. Facial affect was more often associated with low ratings on spatial working memory and attention. These results support a link between neurocognition and social cognition even at this early stage of potential psychosis, with indication that poorer performance on social cognition may be associated with deficits in attention and working memory. Understanding these early associations may have implications for early intervention.

The social cognition psychometric evaluation study: results of the expert survey and RAND panel

BACKGROUND

In schizophrenia, social cognition is strongly linked to functional outcome and is increasingly seen as a viable treatment target. The goal of the Social Cognition Psychometric Evaluation (SCOPE) study is to identify and improve the best existing measures of social cognition so they can be suitably applied in large-scale treatment studies. Initial phases of this project sought to (1) develop consensus on critical domains of social cognition and (2) identify the best existing measures of social cognition for use in treatment studies.

METHODS

Experts in social cognition were invited to nominate key domains of social cognition and the best measures of those domains. Nominations for measures were reduced according to set criteria, and all available psychometric information about these measures was summarized and provided to RAND panelists. Panelists rated the quality of each measure on multiple criteria, and diverging ratings were discussed at the in-person meeting to obtain consensus.

RESULTS

Expert surveys identified 4 core domains of social cognition-emotion processing, social perception, theory of mind/mental state attribution, and attributional style/bias. Using RAND panel consensus ratings, the following measures were selected for further evaluation: Ambiguous Intentions Hostility Questionnaire, Bell Lysaker Emotion Recognition Task, Penn Emotion Recognition Test, Relationships Across Domains, Reading the Mind in the Eyes Test, The Awareness of Social Inferences Test, Hinting Task, and Trustworthiness Task.

DISCUSSION

While it was possible to establish consensus, only a limited amount of psychometric information is currently available for the candidate measures, which underscores the need for well-validated and standardized measures in this area.

Subjects at Ultra High Risk for psychosis have 'heterogeneous' intellectual functioning profile: a multiple-case study

In Ultra High Risk (UHR) studies, intellectual functioning is commonly assessed using premorbid IQ tools as a covariate. The aim of this study was to show that the use of the Wechsler Adult Intelligence Scale (WAIS) could yield accurate neuropsychological profiling and that an alternative approach such as a multiple-case study could be a more interesting way to isolate discrete cognitive processes in the early stage of illness. The studied population consisted of 198 adolescents and young adults (16-30 y.o.) referred to our outpatient clinic. After the CAARMS' interview, we defined 3 subgroups: UHR (N=104), First Episode (FE; N=30), and Help-Seekers (HS; N=64) who were neither UHR nor psychotic. Intellectual functioning was assessed by the WAIS-III (9 subtests version) and 'heterogeneous' intellectual profiles were defined based on the existence of a 3-point difference in scoring at subtests constitutive of the same WAIS index. While UHR did not differ from FE or HS on WAIS' scores and sub-scores, the multiple-case study indicated a higher proportion of 'heterogeneous' profiles in the Verbal Comprehension Index in the UHR sample than in FE and HS (p=0.04). The disease progression could heterogeneously impact on specific domains, in patterns depending on the stage of the illness. This approach exploring intra-subject WAIS performances might be more relevant than the use of global scores in detecting the subtle cognitive alteration of emerging psychosis.

Increased intra-individual variability of cognitive processing in subjects at risk mental state and schizophrenia patients

Intra-individual variability (IIV) has received recent attention as an indicator of the stability of cognitive functioning that may outperform mean performance in reflecting putative neurobiological abnormalities. Increased IIV is regarded as a core deficit in schizophrenia patients; however, whether this deficit is present in the prodromal phase before the onset of schizophrenia has not been well established. In the present study, we investigated IIV using the stop-signal paradigm in at-risk mental state (ARMS) individuals and in schizophrenia patients. The study included 27 ARMS subjects, 37 schizophrenia patients, and 38 normal controls. The stop-signal task was administered to assess IIV and response inhibition. IIV was estimated by calculating the standard deviation across sub-blocks for the three groups. We observed increased IIV in ARMS subjects and schizophrenia patients compared with normal controls in both the “stop” and the “go” processes even though the mean response inhibition performances were not impaired in the ARMS group. Schizophrenia patients showed impaired response inhibition that was associated with the severity of negative symptoms. Our findings suggest that the analysis of IIV may identify cognitive and clinical features of ARMS that are not detectable by conventional mean performance analysis. The unstable response patterns associated with ARMS may originate from abnormal processing in neural systems caused by alterations in the integrity of functional brain networks and dopamine neuromodulation.

Theory of mind and social judgments in people at clinical high risk of psychosis

BACKGROUND

Social cognitive deficits are consistently reported in psychotic populations. Few studies have longitudinally investigated social cognition in clinical high-risk (CHR) populations.

AIMS

Longitudinally examine theory of mind (ToM) and social judgments in a CHR sample to investigate the stability of performance over time and potential ability to predict conversion to psychosis.

METHOD

147 CHR individuals and 85 help seeking controls (HSC) were assessed for up to 2years; 28 participants developed psychosis across both groups. Generalized linear mixed models for repeated measures were used to examine change over time for ratings on the three social cognitive indices of ToM, trustworthiness, and approachability. Hierarchical regression was used to test whether social cognitive variables explain more variance in conversion than IQ.

RESULTS

CHR individuals showed a positive bias in approachability judgments over time compared to HSC. Baseline ToM performance significantly (p<.05) predicted later conversion beyond IQ scores. These results were attenuated when controlling for baseline symptom level.

CONCLUSIONS

Although ToM deficits might predate conversion to psychosis, one must consider initial symptoms as well. Social judgments were not associated with conversion to schizophrenia.