Social Cognition as a Mediator Variable Between Neurocognition and Functional Outcome in Schizophrenia: Empirical Review and New Results by Structural Equation Modeling

University Hospital of Psychiatry, University of Bern, Bolligenstrasse 111, 3000 Bern 60, Switzerland.
Schizophrenia Bulletin (Impact Factor: 8.45). 09/2011; 37 Suppl 2(2):S41-54. DOI: 10.1093/schbul/sbr079
Source: PubMed


Cognitive impairments are currently regarded as important determinants of functional domains and are promising treatment goals in schizophrenia. Nevertheless, the exact nature of the interdependent relationship between neurocognition and social cognition as well as the relative contribution of each of these factors to adequate functioning remains unclear. The purpose of this article is to systematically review the findings and methodology of studies that have investigated social cognition as a mediator variable between neurocognitive performance and functional outcome in schizophrenia. Moreover, we carried out a study to evaluate this mediation hypothesis by the means of structural equation modeling in a large sample of 148 schizophrenia patients. The review comprised 15 studies. All but one study provided evidence for the mediating role of social cognition both in cross-sectional and in longitudinal designs. Other variables like motivation and social competence additionally mediated the relationship between social cognition and functional outcome. The mean effect size of the indirect effect was 0.20. However, social cognitive domains were differentially effective mediators. On average, 25% of the variance in functional outcome could be explained in the mediation model. The results of our own statistical analysis are in line with these conclusions: Social cognition mediated a significant indirect relationship between neurocognition and functional outcome. These results suggest that research should focus on differential mediation pathways. Future studies should also consider the interaction with other prognostic factors, additional mediators, and moderators in order to increase the predictive power and to target those factors relevant for optimizing therapy effects.

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    • "There is also evidence showing that impairments in social cognition are present before the onset of psychosis (Green et al., 2012a), and in unaffected first degree relatives, suggesting that social cognition may be a trait marker of the illness (Lavoie et al., 2013). Using modeling techniques , some studies have shown that, in patients with schizophrenia, social cognition is related to both neurocognition and functional outcome , suggesting that social cognition plays a mediational role between them (Addington et al., 2010; Green et al., 2012b; Schmidt et al., 2011). "
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    ABSTRACT: 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.
    Schizophrenia Research 12/2015; in press. DOI:10.1016/j.scog.2015.04.004 · 3.92 Impact Factor
    • "Emerging evidence from such studies suggests that these predictors have both direct (independent), as well as, indirect (meditational ) effects on functional outcome through cascading paths. For example, the influence of NC on functional outcome is either direct (Lipkovich et al., 2009; Bell et al., 2009) or indirect, mediated by SC (Schmidt et al., 2012; Hoe et al., 2012), meta-cognition (Lysaker et al., 2010), motivation (Nakagami et al., 2008) and Contents lists available at ScienceDirect journal homepage: "
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    ABSTRACT: Understanding the complex relationship among determinants of real-world functioning in schizophrenia patients in remission is important in planning recovery-oriented interventions. We explored two path-analytical models of functioning in schizophrenia. 170 Schizophrenia patients remitted from positive symptoms underwent fairly comprehensive assessments of cognition - neurocognition (NC) and social cognition (SC), residual symptoms - insight, motivation and other negative symptoms, and socio-occupational functioning. We explored (a) a cascading model, where NC predicted functional outcome through its effects on other determinants and (b) a combined model, incorporating additional direct paths from each of the determinants. The combined model, and not the cascading model demonstrated a good fit. Post-hoc trimming of the combined model by elimination of non-significant paths maintained the goodness-of-fit and was retained as the final model. In addition to the direct paths, this final model demonstrated that (a) NC influenced functioning through SC and insight and (b) SC influenced functioning through motivation and negative symptoms. This suggests that NC and SC may influence functional outcome directly, as well as indirectly, via specific impact on insight, and motivation and negative symptoms respectively. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
    07/2015; 229(1-2). DOI:10.1016/j.psychres.2015.07.022
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    • "Recent meta-analyses have indicated that social cognitive function in patients with schizophrenia was markedly impaired (Savla et al., 2013; Chung et al., 2014). Deficits in social cognition are associated with the functional outcome of schizophrenia and contribute to the functional outcome beyond neurocognition (Schmidt et al., 2011; Mehta et al., 2013a). Social cognitive deficits are relatively stable throughout the disease course (Addington et al., 2006; Horan et al., 2012) given that these deficits are observed during remission (Sprong et al., 2007; Mehta et al., 2013b), as well as in relatives (Lavoie et al., 2013). "
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    ABSTRACT: 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. 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). 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). 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. Copyright © 2015 Elsevier B.V. All rights reserved.
    Schizophrenia Research 03/2015; 164(1-3):28-34. DOI:10.1016/j.schres.2015.02.008 · 3.92 Impact Factor
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