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Bora E, Eyuboglu MS, Cesim E, Demir M, Yalincetin B, Ermis C, Özbek Uzman S, Sut E, Demirlek C, Verim B, Baykara B, İnal N, Akdede BB. Social cognition and neurocognition in first-episode bipolar disorder and psychosis: The effect of negative and attenuated positive symptoms. J Affect Disord 2024; 351:356-363. [PMID: 38290586 DOI: 10.1016/j.jad.2024.01.237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/13/2024] [Accepted: 01/26/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Schizophrenia and bipolar disorder are associated with neurocognitive and social-cognitive impairments. To date very few studies investigated social cognition in first-episode bipolar disorder (FEBD). Our main aim was to investigate the differences in social cognition and neurocognition between FEBD and first-episode psychosis (FEP). Another aim was to investigate neurocognitive correlates of negative symptoms and attenuated psychotic symptoms in FEBD. METHODS This study included 55 FEBD, 64 FEP and 43 healthy controls. A comprehensive neuropsychological battery assessing social cognition, processing speed, verbal and visual memory, working memory, sustained attention, and executive functions was administered to all participants. RESULTS Both FEBD and FEP were associated with widespread deficits in all neurocognitive domains and social cognition. Both FEP (d = -1.19) and FEBP (d = -0.88) were also impaired in social cognition. In FEP, effect sizes (Cohen's d) of neurocognitive deficits ranged from -0.71 to -1.56. FEBD was also associated with relatively milder but similar neurocognitive deficits (d = -0.61 to-1.17). FEBD group performed significantly better than FEP group in verbal and visual memory, processing speed, and executive function domains (d = -0.40 to-0.52). Negative symptoms and social functioning were associated with neuropsychological impairment in both groups. The severity of attenuated psychotic symptoms was associated with poorer verbal memory in FEBD (r = -0.39, p < 0.01). LIMITATIONS The cross-sectional nature of the current study is the main limitation. CONCLUSIONS Neurocognitive and social-cognitive deficits are evident in both FEBD and FEP. In FEBD, more severe memory deficits might be markers of clinical overlap and shared neurobiological vulnerability with psychotic disorders.
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Affiliation(s)
- E Bora
- Department of Psychiatry, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey; Department of Neurosciences, Health Sciences Institute, Dokuz Eylul University, Izmir, Turkey; Melbourne Neuropsychiatry Centre, Department of Psychiatry, University of Melbourne and Melbourne Health, Carlton South, Victoria 3053, Australia.
| | - M S Eyuboglu
- Department of Neurosciences, Health Sciences Institute, Dokuz Eylul University, Izmir, Turkey
| | - E Cesim
- Department of Neurosciences, Health Sciences Institute, Dokuz Eylul University, Izmir, Turkey
| | - M Demir
- Department of Neurosciences, Health Sciences Institute, Dokuz Eylul University, Izmir, Turkey
| | - B Yalincetin
- Department of Neurosciences, Health Sciences Institute, Dokuz Eylul University, Izmir, Turkey
| | - C Ermis
- Queen Silvia Children's Hospital, Department Child and Adolescent Psychiatry, Gothenburg, Sweden
| | - S Özbek Uzman
- Department of Psychiatry, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - E Sut
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - C Demirlek
- Department of Neurosciences, Health Sciences Institute, Dokuz Eylul University, Izmir, Turkey; Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, MA, USA
| | - B Verim
- Department of Neurosciences, Health Sciences Institute, Dokuz Eylul University, Izmir, Turkey
| | - B Baykara
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - N İnal
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - B B Akdede
- Department of Psychiatry, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey; Department of Neurosciences, Health Sciences Institute, Dokuz Eylul University, Izmir, Turkey
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Abella M, Vila-Badia R, Serra-Arumí C, Vallejo-Rius G, Colomer-Salvans A, Rolduà-Ros J, Del Cacho-Ortega N, Butjosa A, Muñoz-Samons D, Cuevas-Esteban J, Profep G, Usall J. The relevance of processing speed in the functioning of people with first-episode psychosis. J Psychiatr Res 2023; 160:171-176. [PMID: 36804112 DOI: 10.1016/j.jpsychires.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/11/2023]
Abstract
Deficits in functioning affect people with first-episode psychosis. Deficits in cognitive performance are common in such individuals and appear to be related to functioning. The present study examined the relationship between the domains of cognitive performance and personal and social functioning, as well as evaluating which cognitive domains are the most closely related to personal and social functioning and whether they explain variations once other clinical and sociodemographic aspects are accounted for. Ninety-four people with first-episode psychosis participated in the study; they were assessed with the MATRICS battery. Symptoms were evaluated with the Emsley factors of the positive and negative syndrome scale. Cannabis use, duration of untreated psychosis, suicide risk, perceived stress, antipsychotic doses, and premorbid intelligence quotient was accounted for. Processing speed, attention/vigilance, working memory, visual learning, reasoning and problem solving correlated to personal and social functioning. Processing speed emerged as the strongest predictor of social and personal functioning and underscores the importance of targeting this domain in treatment. Moreover, suicide risk and excited symptoms were also significant variables in functioning. Early intervention, focusing on improvement of processing speed, may be crucial to the improvement of functioning in first-episode psychosis. The relationship of this cognitive domain with functioning in first-episode psychosis should be studied further.
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Affiliation(s)
- Manuel Abella
- Etiopatogènia i Tractament Dels Trastorns Mentals Greus (MERITT), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; Parc Sanitari Sant Joan de Déu, CIBERSAM, Doctor Antoni Pujadas, Sant Boi de Llobregat, Spain; Universitat de Barcelona, Facultat de Medicina i Ciències de La Salut Barcelona, Barcelona, Spain.
| | - Regina Vila-Badia
- Etiopatogènia i Tractament Dels Trastorns Mentals Greus (MERITT), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; Parc Sanitari Sant Joan de Déu, CIBERSAM, Doctor Antoni Pujadas, Sant Boi de Llobregat, Spain; Universitat de Barcelona, Facultat de Medicina i Ciències de La Salut Barcelona, Barcelona, Spain
| | - Clara Serra-Arumí
- Etiopatogènia i Tractament Dels Trastorns Mentals Greus (MERITT), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; Parc Sanitari Sant Joan de Déu, CIBERSAM, Doctor Antoni Pujadas, Sant Boi de Llobregat, Spain; Universitat de Barcelona, Facultat de Medicina i Ciències de La Salut Barcelona, Barcelona, Spain
| | - Georgina Vallejo-Rius
- Etiopatogènia i Tractament Dels Trastorns Mentals Greus (MERITT), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; Parc Sanitari Sant Joan de Déu, CIBERSAM, Doctor Antoni Pujadas, Sant Boi de Llobregat, Spain
| | - Alícia Colomer-Salvans
- Etiopatogènia i Tractament Dels Trastorns Mentals Greus (MERITT), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; Parc Sanitari Sant Joan de Déu, CIBERSAM, Doctor Antoni Pujadas, Sant Boi de Llobregat, Spain; Universitat de Barcelona, Facultat de Medicina i Ciències de La Salut Barcelona, Barcelona, Spain
| | - Júlia Rolduà-Ros
- Etiopatogènia i Tractament Dels Trastorns Mentals Greus (MERITT), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; Parc Sanitari Sant Joan de Déu, CIBERSAM, Doctor Antoni Pujadas, Sant Boi de Llobregat, Spain
| | - Nuria Del Cacho-Ortega
- Etiopatogènia i Tractament Dels Trastorns Mentals Greus (MERITT), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; Parc Sanitari Sant Joan de Déu, CIBERSAM, Doctor Antoni Pujadas, Sant Boi de Llobregat, Spain
| | - Anna Butjosa
- Etiopatogènia i Tractament Dels Trastorns Mentals Greus (MERITT), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; Parc Sanitari Sant Joan de Déu, CIBERSAM, Doctor Antoni Pujadas, Sant Boi de Llobregat, Spain
| | - Daniel Muñoz-Samons
- Etiopatogènia i Tractament Dels Trastorns Mentals Greus (MERITT), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; Hospital Infanto-juvenil Sant Joan de Déu, Institut de Recerca Sant Joan de Déu, CIBERSAM, Esplugues de Llobregat, Spain
| | - Jorge Cuevas-Esteban
- Hospital Universitari Germans Trias i Pujol, CIBERSAM, Badalona, Spain; Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Grup Profep
- Etiopatogènia i Tractament Dels Trastorns Mentals Greus (MERITT), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; Parc Sanitari Sant Joan de Déu, CIBERSAM, Doctor Antoni Pujadas, Sant Boi de Llobregat, Spain
| | - Judith Usall
- Etiopatogènia i Tractament Dels Trastorns Mentals Greus (MERITT), Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain; Parc Sanitari Sant Joan de Déu, CIBERSAM, Doctor Antoni Pujadas, Sant Boi de Llobregat, Spain
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Social interaction, psychotic disorders and inflammation: A triangle of interest. Prog Neuropsychopharmacol Biol Psychiatry 2023; 122:110697. [PMID: 36521587 DOI: 10.1016/j.pnpbp.2022.110697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022]
Abstract
Social interaction difficulties are a hallmark of psychotic disorders, which in some cases can be definitely traced back to autoimmunological causes. Interestingly, systemic and intrathecal inflammation have been shown to significantly influence social processing by increasing sensitivity to threatening social stimuli, which bears some resemblance to psychosis. In this article, we review evidence for the involvement of systemic and intrathecal inflammatory processes in psychotic disorders and how this might help to explain some of the social impairments associated with this group of disorders. Vice versa, we also discuss evidence for the immunomodulatory function of social interactions and their potential role for therapeutic interventions in psychotic disorders.
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Montaner-Ferrer MJ, Gadea M, Sanjuán J. Cognition and social functioning in first episode psychosis: A systematic review of longitudinal studies. Front Psychiatry 2023; 14:1055012. [PMID: 36950257 PMCID: PMC10025326 DOI: 10.3389/fpsyt.2023.1055012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/03/2023] [Indexed: 03/08/2023] Open
Abstract
Introduction This systematic review aimed to answer whether we can predict subsequent social functioning in first episode psychosis (FEP) by means of an initial cognitive examination. In order to do this, we gathered longitudinal studies which evaluated neurocognition and/or social cognition regarding their impact on long-term social functioning of FEP patients. Methods The MOOSE method was employed and 28 studies covering data from a total of 2572 patients with longitudinal trajectories from 2 months to 5 years were reviewed. Results In general, cognitive deficits impacted on the social functioning of the FEP patients across the time. The neurocognitive domains which most closely predicted social functioning were processing speed, sustained attention and working memory. An overall cognitive dysfunction, low IQ and the academic trajectory were also found predictive. Regarding social cognition, the findings were not unanimous. Discussion In addition of the impact of each variable, several of the articles found a complex relationship between social cognition, neurocognition, social functioning and negative symptoms, pointing social cognition as a modulator of neurocognition but being modulated as well by negative symptoms. The principal clinical implication of this review is that the initial assessment of FEP patients and their rehabilitation must take cognition into account.
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Affiliation(s)
| | - Marien Gadea
- Department of Psychobiology, Faculty of Psychology, Universitat de València, Valencia, Spain
- CIBERSAM-Mental Health, Madrid, Spain
- *Correspondence: Marien Gadea,
| | - Julio Sanjuán
- CIBERSAM-Mental Health, Madrid, Spain
- Department of Psychiatry, Faculty of Medicine, Universitat de València, Valencia, Spain
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García-Fernández L, Romero-Ferreiro V, Sánchez-Pastor L, Dompablo M, Martínez-Gras I, Espejo-Saavedra JM, Rentero D, Aparicio AI, Alvarez-Mon MA, Lahera G, Lee J, Santos JL, Rodriguez-Jimenez R. Impact of Negative Symptoms on Functioning and Quality of Life in First Psychotic Episodes of Schizophrenia. J Clin Med 2022; 11:jcm11040983. [PMID: 35207256 PMCID: PMC8879613 DOI: 10.3390/jcm11040983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/08/2022] [Accepted: 02/11/2022] [Indexed: 11/16/2022] Open
Abstract
Negative symptoms are not considered a unitary construct encompassing two different domains, diminished expression, and avolition-apathy. The aim of this study was to explore the relationships between each domain and psychosocial functioning and quality of life in people with a first psychotic episode of schizophrenia. In total, 61 outpatients were assessed with the Clinical Assessment Interview for Negative Symptoms (CAINS), The Functioning Assesment Short Test (FAST) and The Quality of Life Scale (QLS). The mean global score for CAINS was 21.5 (SD: 15.6), with a CAINS Avolition-Apathy (MAP) score of 17.0 (SD: 11.8), and CAINS Diminished Expression (EXP) score of 4.5 (SD: 5.0). The mean FAST score was 31.9 (SD: 18.9), and 41.1 (SD: 17.9) for QLS. Linear regression analysis revealed a significant (F(4,53) = 15.65, p < 0.001) relationship between MAP and EXP CAINS’ score and FAST score. CAINS-MAP was more predictive of FAST scores (β = 0.44, p = 0.001) than CAINS-EXP (β = 0.37, p = 0.007). Linear regression analysis for QLS revealed a significant model (F(4,56) = 29.29, p < 0.001). The standardized regression weight for the CAINS-MAP was around three times greater (β = −0.63, p < 0.001) than for CAINS-EXP (β = −0.24, p = 0.024). The two different domains are associated differently with functionality and quality of life.
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Affiliation(s)
- Lorena García-Fernández
- Clinical Medicine Department, Universidad Miguel Hernández, 03550 Alicante, Spain;
- Psychiatry Department, Hospital Universitario de San Juan, 03550 Alicante, Spain
- Biomedical Research Networking Centre in Mental Health (CIBERSAM), 28029 Madrid, Spain; (V.R.-F.); (M.D.); (D.R.); (A.I.A.); (G.L.); (J.L.S.)
| | - Verónica Romero-Ferreiro
- Biomedical Research Networking Centre in Mental Health (CIBERSAM), 28029 Madrid, Spain; (V.R.-F.); (M.D.); (D.R.); (A.I.A.); (G.L.); (J.L.S.)
- Quality and Academic Compliance Unit, Universidad Europea de Madrid, 28670 Madrid, Spain
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas 12), 28041 Madrid, Spain; (L.S.-P.); (I.M.-G.); (J.M.E.-S.)
| | - Luis Sánchez-Pastor
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas 12), 28041 Madrid, Spain; (L.S.-P.); (I.M.-G.); (J.M.E.-S.)
| | - Mónica Dompablo
- Biomedical Research Networking Centre in Mental Health (CIBERSAM), 28029 Madrid, Spain; (V.R.-F.); (M.D.); (D.R.); (A.I.A.); (G.L.); (J.L.S.)
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas 12), 28041 Madrid, Spain; (L.S.-P.); (I.M.-G.); (J.M.E.-S.)
- Cardenal Cisneros, Centro de Enseñanza Superior Adscrito a la Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Isabel Martínez-Gras
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas 12), 28041 Madrid, Spain; (L.S.-P.); (I.M.-G.); (J.M.E.-S.)
- RETIC (Network of Addictive Conditions), Institute of Health Carlos III, 28029 Madrid, Spain
| | - Juan Manuel Espejo-Saavedra
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas 12), 28041 Madrid, Spain; (L.S.-P.); (I.M.-G.); (J.M.E.-S.)
- Legal Medicine, Psychiatry and Pathology Department, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - David Rentero
- Biomedical Research Networking Centre in Mental Health (CIBERSAM), 28029 Madrid, Spain; (V.R.-F.); (M.D.); (D.R.); (A.I.A.); (G.L.); (J.L.S.)
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas 12), 28041 Madrid, Spain; (L.S.-P.); (I.M.-G.); (J.M.E.-S.)
| | - Ana Isabel Aparicio
- Biomedical Research Networking Centre in Mental Health (CIBERSAM), 28029 Madrid, Spain; (V.R.-F.); (M.D.); (D.R.); (A.I.A.); (G.L.); (J.L.S.)
- Psychiatry Department, Hospital Virgen de la Luz, 16002 Cuenca, Spain
- Neurobiological Research Group, Institute of Technology, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
| | - Miguel Angel Alvarez-Mon
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain;
- Department of Psychiatry and Mental Health, Hospital Universitario Infanta Leonor, 28031 Madrid, Spain
| | - Guillermo Lahera
- Biomedical Research Networking Centre in Mental Health (CIBERSAM), 28029 Madrid, Spain; (V.R.-F.); (M.D.); (D.R.); (A.I.A.); (G.L.); (J.L.S.)
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain;
| | - Jimmy Lee
- Research Division, Institute of Mental Health, Singapore 539747, Singapore;
- North Region & Department of Psychosis, Institute of Mental Health, Singapore 539747, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 639798, Singapore
| | - Jose Luis Santos
- Biomedical Research Networking Centre in Mental Health (CIBERSAM), 28029 Madrid, Spain; (V.R.-F.); (M.D.); (D.R.); (A.I.A.); (G.L.); (J.L.S.)
- Psychiatry Department, Hospital Virgen de la Luz, 16002 Cuenca, Spain
- Neurobiological Research Group, Institute of Technology, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
| | - Roberto Rodriguez-Jimenez
- Biomedical Research Networking Centre in Mental Health (CIBERSAM), 28029 Madrid, Spain; (V.R.-F.); (M.D.); (D.R.); (A.I.A.); (G.L.); (J.L.S.)
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (Imas 12), 28041 Madrid, Spain; (L.S.-P.); (I.M.-G.); (J.M.E.-S.)
- Legal Medicine, Psychiatry and Pathology Department, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Correspondence: ; Tel.: +34-91-390-85-36
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Lysaker PH, Hasson-Ohayon I, Wiesepape C, Huling K, Musselman A, Lysaker JT. Social Dysfunction in Psychosis Is More Than a Matter of Misperception: Advances From the Study of Metacognition. Front Psychol 2021; 12:723952. [PMID: 34721183 PMCID: PMC8552011 DOI: 10.3389/fpsyg.2021.723952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/15/2021] [Indexed: 11/13/2022] Open
Abstract
Many with psychosis experience substantial difficulties forming and maintaining social bonds leading to persistent social alienation and a lack of a sense of membership in a larger community. While it is clear that social impairments in psychosis cannot be fully explained by symptoms or other traditional features of psychosis, the antecedents of disturbances in social function remain poorly understood. One recent model has proposed that deficits in social cognition may be a root cause of social dysfunction. In this model social relationships become untenable among persons diagnosed with psychosis when deficits in social cognition result in inaccurate ideas of what others feel, think or desire. While there is evidence to support the influence of social cognition upon social function, there are substantial limitations to this point of view. Many with psychosis have social impairments but not significant deficits in social cognition. First person and clinical accounts of the phenomenology of psychosis also do not suggest that persons with psychosis commonly experience making mistakes when trying to understand others. They report instead that intersubjectivity, or the formation of an intimate shared understanding of thoughts and emotions with others, has become extraordinarily difficult. In this paper we explore how research in metacognition in psychosis can transcend these limitations and address some of the ways in which intersubjectivity and more broadly social function is compromised in psychosis. Specifically, research will be reviewed on the relationship between social cognitive abilities and social function in psychosis, including measurement strategies and limits to its explanatory power, in particular with regard to challenges to intersubjectivity. Next, we present research on the integrated model of metacognition in psychosis and its relation to social function. We then discuss how this model might go beyond social cognitive models of social dysfunction in psychosis by describing how compromises in intersubjectivity occur as metacognitive deficits leave persons without an integrated sense of others' purposes, relative positions in the world, possibilities and personal complexities. We suggest that while social cognitive deficits may leave persons with inaccurate ideas about others, metacognitive deficits leave persons ill equipped to make broader sense of the situations in which people interact and this is what leaves them without a holistic sense of the other and what makes it difficult to know others, share experiences, and sustain relationships. The potential of developing clinical interventions focused on metacognition for promoting social recovery will finally be explored.
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Affiliation(s)
- Paul H. Lysaker
- Department of Psychiatry, Richard L. Roudebush VA Medical Center, Indianapolis, IN, United States
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
| | | | - Courtney Wiesepape
- Department of Psychology, Indiana State University, Terre Haute, IN, United States
| | - Kelsey Huling
- School of Psychological Sciences, University of Indianapolis, Indianapolis, IN, United States
| | - Aubrie Musselman
- Department of Psychology, Indiana State University, Terre Haute, IN, United States
| | - John T. Lysaker
- Department of Philosophy, Emory University, Atlanta, GA, United States
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