Social anxiety is associated with personal distress and disrupted recognition of negative emotions

Past research investigating the relation between social anxiety (SA), empathy and emotion recognition is marked by conceptual and methodological issues. In the present study, we aim to overcome these limitations by examining whether individuals with high (n = 40) vs. low (n = 43) social anxiety differed across these two facets of empathy and whether this could be related to their recognition of emotions. We employed a naturalistic emotion recognition paradigm in which participants watched short videos of individuals (targets) sharing authentic emotional experiences. After each video, we measured self-reported empathic concern and distress, as well as their ability to recognize the emotions expressed by the targets in the videos. Our results show that individuals with high social anxiety recognized the targets' emotions less accurately. Furthermore, high socially anxious individuals reported more personal distress than low socially anxious individuals, whereas no significant difference was found for empathic concern. The findings suggest that reduced recognition of emotions among SA individuals can be better explained by the negative effects of social stress than by a general deficit in empathy.

Suicidal ideation in Chinese adults with schizophrenia: associations with neurocognitive function and empathy

BACKGROUND

Suicidal ideation is common among people diagnosed with schizophrenia spectrum disorders and may be related to neurocognitive, social cognitive, and clinical variables. This study aimed to investigate the relationships between suicidal ideation and both neurocognitive function and empathy.

METHODS

The sample for this cross-sectional study comprised 301 schizophrenic patients aged 18-44 years. All participants were administered the Beck Scale for Suicide Ideation-Chinese Version (BSI-CV), the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), the Interpersonal Reactivity Index (IRI), and the Positive and Negative Syndrome Scale (PANSS). The demographic and clinical data of the patients were also collected.

RESULTS

In total, 82 patients reported suicidal ideation. Compared to patients without suicidal ideation, patients with suicidal ideation showed significant differences in the IRI-Personal Distress subscale, PANSS-General Psychopathology symptom scores, and suicide attempts. Moreover, there were moderating effects of neurocognitive function and empathy on the relationship between suicide attempts and suicidal ideation.

CONCLUSIONS

These results indicate that the personal distress component of empathy, general psychopathology symptoms and suicide attempts are independent risk factors for suicidal ideation in Chinese adults with schizophrenia. Moreover, neurocognitive function may also be related to suicidal ideation through a moderating relationship. In order to reduce suicidal ideation among patients with schizophrenia, early screening of empathy and neurocognitive function is essential.

Empathy, memory, and aging during the COVID-19 pandemic

Recently, there has been increasing attention to the interaction between empathy and memory. During the COVID-19 pandemic, a period when empathy played a key role in people's behaviors, we assessed the relationship between empathy and memory. In this pre-registered report, we used memory accuracy for the number of COVID-19 cases as a measure of recent memory and examined its relationship with trait empathy. Moreover, we investigated whether cognitive vs. affective empathy differently associate with one's memory for the number of COVID-19 cases, given evidence for distinct mechanisms for the two aspects of empathy. Finally, we assessed how age is related to empathy-memory associations. To address these questions, we used the Boston College COVID-19 Dataset, which included surveys assessing dispositional empathy and memory for the number of confirmed COVID-19 cases during the first wave of the pandemic. Empathy was not associated with memory accuracy for the confirmed cases when using an empathy measure that combined both cognitive and affective empathy. However, when using a measure that separately assessed cognitive and affective empathy, only affective empathy, specifically the personal distress subscale, was associated with greater memory accuracy. There was no age-related difference in memory accuracy despite age-related decreases in affective empathy. Results suggest that individuals with greater affective empathy (i.e., greater tendency to feel discomfort by the suffering of others) can have more accurate memory for details of an ongoing empathy-evoking situation. Findings are discussed in the context of motivation and emotional arousal. The current study provides ecological evidence to corroborate the interplay of empathy and memory.

French drivers' behavior: Do psychological resources and vulnerabilities matter?

INTRODUCTION

Driving is a risky activity, and road users' behavior is one of the many factors that participate in increasing the risk of road-traffic crashes. Drivers must constantly adapt their behavior to the environment and control their vehicles, and must also anticipate the behavior of others, which may pose a threat to their own safety. Interactions between road users can therefore be stressful and elicit strong negative emotions. Psychological resources and vulnerabilities may be important in understanding how drivers perceive and respond to these driving interactions. The aim of this study was to investigate the role of empathy, self-compassion, personal distress, and alexithymia in both dangerous and prosocial driving behaviors.

METHOD

Our sample (N = 550) of French drivers was recruited via snowball sampling. The drivers filled in paper-and-pencil questionnaires including the Driver Behavior Questionnaire (DBQ), the French adaptation of the Toronto Empathy Questionnaire (Short-FTEQ), the Interpersonal Reactivity Index (IRI), the Self-Compassion Scale - Short Form (SCS-SF), and the Toronto Alexithymia Scale (TAS-20).

RESULTS

After controlling for gender and age, regression analyses revealed that road traffic violations were positively predicted by alexithymia and negatively predicted by cognitive empathy; errors were positively predicted by alexithymia and personal distress, and prosocial driving was positively predicted by emotional and cognitive empathy. A two-step cluster analysis identified three groups of drivers: unsafe and psychologically vulnerable (n = 176), self-focused and less prosocial (n = 151), and safe and resourceful (n = 223).

CONCLUSIONS

Empathy seems to promote safe driving behaviors. Moreover, cognitive empathy appears to safeguard drivers against deliberate violations, whereas psychological vulnerabilities seem to increase the probability of engaging in dangerous behaviors. Practical Applications: These results could open new research avenues for the prevention of dangerous driving behaviors and the promotion of road safety.

Socio-cognitive training impacts emotional and perceptual self-salience but not self-other distinction

Training to inhibit imitative tendencies has been shown to reduce self-other interferences in both automatic imitation and perspective taking, suggesting that an enhancement of self-other distinction is transferrable from the motor to the cognitive domain. This study examined whether socio-cognitive training specifically enhances self-other distinction, or rather modulates self-salience, that is, the relative attentional priority of information pertaining to the self-perspective over information pertaining to the other person's perspective. Across two experiments, participants trained on one day to either imitate, inhibit imitation, inhibit control stimuli, or they were imitated. On the following day they completed a visuo-tactile affective perspective-taking paradigm measuring both self-other distinction and emotional self-salience, and a shape matching paradigm measuring perceptual self-salience. Results indicate no significant or consistent impact of training on self-other distinction performance, but reveal an increased emotional and perceptual self-salience following training to inhibit imitative tendencies. Together, these findings raise the question whether socio-cognitive training improves performance via enhanced self-other distinction, and invite to consider self-salience as a complementary angle to explain the past, present, and future findings on self-other distinction.

Intrinsic functional network contributions to the relationship between trait empathy and subjective happiness

Subjective happiness (well-being) is a multi-dimensional construct indexing one's evaluations of everyday emotional experiences and life satisfaction, and has been associated with different aspects of trait empathy. Despite previous research identifying the neural substrates of subjective happiness and empathy, the mechanisms mediating the relationship between the two constructs remain largely unclear. Here, we performed a data-driven, multi-voxel pattern analysis of whole-brain intrinsic functional connectivity to reveal the neural mechanisms of subjective happiness and trait empathy in a sample of young females. Behaviorally, we found that subjective happiness was negatively associated with personal distress (i.e., self-referential experience of others' feelings). Consistent with this inverse relationship, subjective happiness was associated with the dorsolateral prefrontal cortex exhibiting decreased functional connectivity with regions important for the representation of unimodal sensorimotor information (e.g., primary sensory cortices) or multi-modal summaries of brain states (e.g., default mode network) and increased functional connectivity with regions important for the attentional modulation of these representations (e.g., frontoparietal, attention networks). Personal distress was associated with the medial prefrontal cortex exhibiting functional connectivity differences with similar networks--but in the opposite direction. Finally, intrinsic functional connectivity within and between these networks fully mediated the relationship between the two behavioral measures. These results identify an important contribution of the macroscale functional organization of the brain to human well-being, by demonstrating that lower levels of personal distress lead to higher subjective happiness through variation in intrinsic functional connectivity along a neural representation vs. modulation gradient.

First-person perspective sharpens the understanding of distressful physical feelings associated with physical disability: A functional magnetic resonance study

We investigated whether observation of hand movements of people with hemiplegia by healthy individuals from the first-person perspective (FPP), compared to that from the third-person perspective (TPP), enables better understanding of disability-associated distress. We measured the neural activity of healthy individuals using functional magnetic resonance imaging while they observed hemiplegic movements from the FPP or TPP. Subjective assessment of the movements was determined with questionnaires. Compared to the TPP, the FPP elicited stronger activation in the inferior parietal lobule (IPL), right temporoparietal junction, and anterior cingulate cortex, which are associated with body representation, mentalization, and empathy, respectively. Enhanced IPL activity correlated positively with personal empathic traits. Observing movements of hemiplegic individuals from the FPP provided precise subjective understanding of the physically distressing aspects of their movements. These findings suggest that observing hemiplegic individuals from the FPP effectively improved observers' understanding of disability-associated distress via body representation, mentalization, and empathy systems.

The closer you feel, the more you care: Positive associations between closeness, pain intensity rating, empathic concern and personal distress to someone in pain

Previous research revealed inconsistent findings regarding affective responses when facing someone in pain (i.e., empathic concern and/or personal distress). In this paper, we suggest that the degree of closeness between the observer and the person in pain may account for these contradictory results, such that greater closeness towards this person leads to higher personal distress. To test this hypothesis, we induced either low or high closeness with a confederate in 69 randomly assigned participants. Following the closeness induction, participants evaluated their affective responses (empathic concern and personal distress) and rated the confederate's pain intensity after watching the confederate undergoing a painful cold pressure task. Results showed that, despite the non-significant effect of closeness induction, closeness across both conditions (low and high) was positively correlated with pain intensity rating, empathic concern and personal distress. This study thus suggests that closeness is associated with higher cognitive and affective responses to a person in pain.

The role of empathy in the mechanism linking parental psychological control to emotional reactivities to COVID-19 pandemic: A pilot study among Chinese emerging adults

The outbreak of coronavirus disease 2019 (COVID-19) and its worldwide spread have brought economic, social and personal stress. To better understand human adjustments to this public health emergency and its underlying mechanism, the relationship between perceived parental psychological control in emerging adults and individual's emotional reactivity to COVID-19 as well as the role of empathy was examined. The study was conducted among 445 emerging adults using questionnaires measuring parental psychological control, empathy, and emotional reactivities in the initial stage of COVID-19. Results revealed that parental psychological control conferred risks for individual's increased negative emotional reactivity to this pandemic. Moreover, our findings shedlight on personal distress as a mechanism through which parental psychological control induces negative emotional reactivities. Although no direct effect between parental psychological control and positive emotional reactivity was found, personal distress and perspective taking mediate the association in an opposite way. Findings have implications for predicting and intervening mental health problems in COVID-19 pandemic and future public health emergency.

The relations of White parents' implicit racial attitudes to their children's differential empathic concern toward White and Black victims

The goal of this study was to investigate the relations between White parents' implicit racial attitudes and their children's racially based bias in empathic concern toward White and Black victims of injustice as well as the moderating role of children's age in this relation. Children aged 5-9 years (N = 190) reported how sorry (i.e., sympathy) and nervous (i.e., personal distress) they felt after watching sympathy-inducing videos in which either a White (non-Hispanic) child or a Black child was teased by peers. Participants' primary caregivers (mostly mothers) completed a computerized Implicit Association Test to assess their implicit racial attitudes. Parents' implicit race bias was associated with their children's reported sympathy toward Black victims and their sympathetic bias (i.e., relative sympathy toward White vs. Black victims); however, results were moderated by children's age. Specifically, parents with higher implicit race bias tended to have children with lower levels of sympathy toward Black victims for younger children and higher levels of sympathetic bias for younger and average-aged children but not for older children. Older children tended to report relatively high levels of sympathy toward Black victims and low levels of sympathetic bias regardless of their parents' implicit attitudes. The importance of parents' implicit attitudes in understanding young children's race-based moral emotional responses and the implications for intervention work are discussed.

An inverted U-shaped relationship between heart rate deceleration and empathic emotions

Previous studies have shown that the high frequency component of heart rate variability is associated with empathic emotions (empathic concern and personal distress) negatively and quadratically-there is an inverted U-shaped relationship between tonic parasympathetic nervous system (PNS) activity and empathy. However, it is unclear whether the inverted U-shape also applies to the relationship between phasic PNS activity and empathic emotions. Therefore, the present study addressed this issue. Participants were asked to empathize with others' negative states (and neutral states as the control condition), followed by evaluating their own emotions. We measured the participants' cardiac activity during this task by electrocardiogram. Results revealed an inverted U-shaped relationship between heart rate deceleration, which reflects phasic PNS activity, and subjective personal distress and empathic concern. These results suggest that moderate levels of phasic PNS activity are more strongly associated with personal distress and empathic concern than low or high levels of PNS activity.

Neural and behavioral markers of observed pain of older adults

To contribute to better understanding of empathy of younger adults for the pain of older adults, this study examined whether brain responses and behavioral ratings of young adult participants to the observed physical pain of older people differed from that to younger people. fMRI was used to measure participants' brain responses to seeing younger and older people receiving a painful compared with non-painful touch, while they rated both the level of perceived pain observed and their own level of personal discomfort from observing the painful touch. The young participants showed greater brain activation when observing younger versus older people receiving painful stimuli, and they rated the needle-touch to the younger people to appear more painful and more personally distressing. Furthermore, those participants reporting a greater level of contact with older adults at work showed less brain activation in the left insula cortex, a typical neural marker for observed pain, when observing painful touch to the older people. These have implications for understanding both the emotional responses and perception of pain of young adults when observing pain in the elderly.

The impact of social-emotional context in chronic cancer pain: patient-caregiver reverberations : Social-emotional context in chronic cancer pain

PURPOSE

Pain is a multifactorial and subjective experience. Psychological and social factors can modulate it. This study analyzed whether and how prolonged cancer pain is related to the social-relational environment's characteristics. Specifically, we investigated whether the caregiver's emotional support, his/her compassion ability or, on the contrary, his/her personal distress, associates with the patient's pain level.

METHODS

The sample consisted of 38 cancer patients suffering from pain and 38 family caregivers. The patients completed the McGill Pain Questionnaire (MPQ), the Balanced Emotional Empathy Scale (BEES) referred to caregiver, and an interview concerning the patient's perception of the caregiver's compassion level. Caregivers completed the distress thermometer (DT), the BEES, and an interview assessment of their compassion level.

RESULTS

Caregiver's distress level correlated with patient's pain intensity (r = .389; p = .028). Exploratory linear regression confirmed this association (R² = .151; F (1, 30) = 5.33; p = .028; β = 0.389). The number of problems reported by caregivers correlated with the patients' pain level (r = .375; p = .020), which was verified in a regression analysis (R² = .140; F (1, 36) = 5.88; p = .020; β = 0.375). In particular, the caregiver's amount of emotional problems was related to patient's pain level (r = .427; p = .007); this result was reaffirmed in a regression (R² = .182; F (1, 36) = 8.03; p = .007; β = 0.427).

CONCLUSIONS

Our results show an association between social suffering, as indicated by the caregiver's emotional distress and the patient's physical pain. The results also highlight high distress levels and emotional problems among caregivers. The work emphasizes the need of a bio-psychosocial approach in managing cancer pain, along with the necessity to find effective interventions to fight emotional distress in family caregivers. The recovery of the caregivers' emotional resources could have beneficial implications on the patients' pain.

The relationship between clinical insight and cognitive and affective empathy in schizophrenia

Background

Schizophrenia is often associated with poor clinical insight (unawareness of mental illness and its symptoms) and deficits in empathy, which are important for social functioning. Cognitive empathy has been linked to clinical insight while affective empathy and its role in insight and pathology have received mixed evidence.

Methods

Instruments assessing symptomatology (Positive and Negative Syndrome Scale; PANSS), clinical insight (Scales to assess awareness of mental disorders; SUMD), and cognitive and affective empathy were administered to 22 participants with first episode and chronic schizophrenia and 21 healthy controls. Self-report, parent-report, and performance based measures were used to assess cognitive and affective empathy (The interpersonal reactivity index; IRI/Reading the Mind in the Eyes Test/Faux Pas) to reduce bias and parse shared variance.

Results

Age of onset, gender, and symptomatology emerged as significant predictors of poor clinical insight. Additionally, the fantasy subscale of the IRI as reported by parents emerged as a positive predictor while the personal distress (parent report) subscale emerged as a negative predictor of awareness into mental illness. There were significant differences on performance-based measures of empathy between the control and schizophrenia groups.

Conclusion

Findings suggest that affective empathy is relatively intact across phases of illness whereas cognitive empathy abilities are compromised and could be targets for psychotherapy intervention.

Distressed yet empathically sensitive: Preschoolers' responses to infant crying

Using a simulated long bout of progressively intense infant crying, this study demonstrated that preschoolers responded with infant-oriented empathic concern and helping actions despite evidence of self-focused distress. Preschoolers' helping actions were predicted by the interaction between empathic concern and cognitive inquiry.

Empathy in schizophrenia: A meta-analysis of the Interpersonal Reactivity Index

Empathy is a complex construct, thought to contain multiple components. One popular measurement paradigm, the Interpersonal Reactivity Index (IRI), has been used extensively to measure empathic tendencies in schizophrenia research across four domains: empathic concern, perspective-taking, personal distress, and fantasy. However, no recent meta-analysis has been conducted for all four factors of this scale. The goal of this meta-analysis was to examine self-reported empathic tendencies for each factor of the IRI in people with schizophrenia as compared to healthy controls. A literature search revealed 32 eligible schizophrenia studies. The Hedges' g standardized difference effect size was calculated for each component using a random effects meta-analytic model. Compared to healthy controls, schizophrenia samples reported significantly reduced tendencies for empathic concern, perspective-taking, and fantasy, but significantly greater tendencies for personal distress. Duration of illness significantly moderated the results for perspective-taking such that those with a longer duration exhibited greater deficits; percent female significantly moderated the results for personal distress such that samples with more females exhibited reduced effect sizes. Future work is needed to examine the impact of heightened personal distress on the empathic tendencies and abilities of those with schizophrenia, including the possible role of emotion regulation.

Personal distress and the influence of bystanders on responding to an emergency

Spontaneous helping behavior during an emergency is influenced by the personality of the onlooker and by social situational factors such as the presence of bystanders. Here, we sought to determine the influences of sympathy, an other-oriented response, and personal distress, a self-oriented response, on the effect of bystanders during an emergency. In four experiments, we investigated whether trait levels of sympathy and personal distress predicted responses to an emergency in the presence of bystanders by using behavioral measures and single-pulse transcranial magnetic stimulation. Sympathy and personal distress were expected to be associated with faster responses to an emergency without bystanders present, but only personal distress would predict slower responses to an emergency with bystanders present. The results of a cued reaction time task showed that people who reported higher levels of personal distress and sympathy responded faster to an emergency without bystanders (Exp. 1). In contrast to our predictions, perspective taking but not personal distress was associated with slower reaction times as the number of bystanders increased during an emergency (Exp. 2). However, the decrease in motor corticospinal excitability, a direct physiological measure of action preparation, with the increase in the number of bystanders was solely predicted by personal distress (Exp. 3). Incorporating cognitive load manipulations during the observation of an emergency suggested that personal distress is linked to an effect of bystanders on reflexive responding to an emergency (Exp. 4). Taken together, these results indicate that the presence of bystanders during an emergency reduces action preparation in people with a disposition to experience personal distress.

Individual differences in action co-representation: not personal distress or subclinical psychotic experiences but sex composition modulates joint action performance

Successful social interaction requires the ability to integrate as well as distinguish own and others’ actions. Normally, the integration and distinction of self and other are a well-balanced process, occurring without much effort or conscious attention. However, not everyone is blessed with the ability to balance self–other distinction and integration, resulting in personal distress in reaction to other people’s emotions or even a loss of self [e.g., in (subclinical) psychosis]. Previous research has demonstrated that the integration and distinction of others’ actions cause interference with one’s own action performance (commonly assessed with a social Simon task). The present study had two goals. First, as previous studies on the social Simon effect employed relatively small samples (N < 50 per test), we aimed for a sample size that allowed us to test the robustness of the action interference effect. Second, we tested to what extent action interference reflects individual differences in traits related to self–other distinction (i.e., personal distress in reaction to other people’s emotions and subclinical psychotic symptoms). Based on a questionnaire study among a large sample (N = 745), we selected a subsample (N = 130) of participants scoring low, average, or high on subclinical psychotic symptoms, or on personal distress. The selected participants performed a social Simon task. Results showed a robust social Simon effect, regardless of individual differences in personal distress or subclinical psychotic symptoms. However, exploratory analyses revealed that the sex composition of interaction pairs modulated social Simon effects. Possible explanations for these findings are discussed.

The relationship between trait empathy and memory formation for social vs. non-social information

Background

To navigate successfully through their complex social environment, humans need both empathic and mnemonic skills. Little is known on how these two types of psychological abilities relate to each other in humans. Although initial clinical findings suggest a positive association, systematic investigations in healthy subject samples have not yet been performed. Differentiating cognitive and affective aspects of empathy, we assumed that cognitive empathy would be positively associated with general memory performance, while affective empathy, due to enhanced other-related emotional reactions, would be related to a relative memory advantage for information of social as compared to non-social relevance.

Methods

We investigated in young healthy participants the relationship between dispositional cognitive and affective empathy, as measured by Davis’ Interpersonal Reactivity Index (Journal of Personality and Social Psychology, 44, 113–126, 1983), and memory formation for stimuli (numbers presented in a lottery choice task) that could be encoded in either a social (other-related) or a non-social (self-related) way within the task.

Results

Cognitive empathy, specifically perspective taking, correlated with overall memory performance (regardless of encoding condition), while affective empathy, specifically empathic personal distress, predicted differential memory for socially vs. non-socially encoded information.

Conclusion

Both cognitive and affective empathy are associated with memory formation, but in different ways, depending on the social nature of the memory content. These results open new and so far widely neglected avenues of psychological research on the relationship between social and cognitive skills.

Empathy, depressive symptoms, and social functioning among individuals with schizophrenia

Empathy deficits have been associated with schizophrenia and depression. We compared whether individuals with schizophrenia with and without co-occurring depressive symptoms differed on self-reported and performance-based measures of empathy and social functioning. We also examined the relationships among depressive symptoms, empathy, clinical symptoms, and social functioning. Twenty-eight individuals with schizophrenia and depressive symptoms, 32 individuals with schizophrenia without depressive symptoms, and 44 control subjects were compared on assessments of depressive symptoms, empathy, global neurocognition, clinical symptoms, and social functioning. Both groups of individuals with schizophrenia scored higher than controls on the Interpersonal Reactivity Index personal distress subscale. Individuals with schizophrenia and co-occurring depressive symptoms scored significantly higher than individuals with schizophrenia without depressive symptoms on the personal distress subscale. Personal distress and depressive symptoms were significantly correlated among individuals with schizophrenia and co-occurring depressive symptoms, while both measures negatively correlated with social functioning. Emotional empathy was related to clinical symptoms in both groups of individuals with schizophrenia. Personal distress partially mediated the relationship between co-occurring depressive symptoms and social functioning. Personal distress may be an important implication for social functioning among individuals with schizophrenia and co-occurring depressive symptoms, and should be examined further as a potential treatment target.

Physiological evidence of a deficit to enhance the empathic response in schizophrenia

Empathy is crucial for maintaining effective social interactions. Research has identified both an early-emotional sharing and a late-cognitive component of empathy. Although considered a functionally vital social cognition process, empathy has scarcely been studied in schizophrenia (SZ). We used event-related potentials (ERPs) to study the temporal dynamics of empathic response in 19 patients with SZ and 18 matched healthy controls (HC) using an empathy for physical pain paradigm. Participants responded to pictures of hands in neutral and painful situations in an active empathic condition and one manipulated by task demands. Additionally, subjective ratings of the stimuli and empathic self-reports were collected. People with SZ had (1) decreased early-emotional ERP responses to pictures of others in pain; (2) decreased modulation by attention of late-cognitive ERP responses; (3) lower ratings of perspective taking and higher ratings of personal distress which were both related to decreased modulation of late-cognitive empathic responses; (4) a significant relationship between high affective overlap between somebody else's pain and their own pain and decreased modulation of late-cognitive empathic responses; (5) a distinct relationship between regulatory deficits in late-cognitive empathy and functioning. Patients had present but reduced early and late empathy-related ERPs. Patients also reported increased personal distress when faced with distress in others. The late ERP responses are thought to be associated with self-regulation and response modulation. The magnitude of these late responses was inversely associated with reported levels of personal distress in both patients and controls. Additionally, regulatory deficits in cognitive empathy were highly related with deficits in functioning. Decreased ability to regulate one's own emotional engagement and response to emotions of others may be an important source of distress and dysfunction in social situations for patients with schizophrenia.