Empathic accuracy and cognition in schizotypal personality disorder
Luis H. Ripolla,b,n, Jamil Zakic,1, Maria Mercedes Perez-Rodrigueza,b,1, Rebekah Snyderd,
Kathryn Sloan Strikeb, Ayelet Boussib, Jennifer A. Bartze, Kevin N. Ochsnerd,
Larry J. Sievera,b, Antonia S. Newa,b
aMount Sinai School of Medicine, Department of Psychiatry, One Gustave L. Levy Place, Box 1230, NY 10029, United States
bJames J. Peters VA Medical Center, Mental Illness Research Education and Clinical Center (MIRECC), 130 West Kingsbridge Rd., Bronx, NY 10468,
cStanford University, Department of Psychology, Stanford, CA 94305, United States
dColumbia University, Department of Psychology, 3009 Broadway, NY 10027, United States
eMcGill University, Department of Psychology, 1205 Dr. Penfield Ave., Montreal, Quebec, Canada H3A 1B1
a r t i c l e i n f o
Received 9 August 2012
Received in revised form
14 May 2013
Accepted 19 May 2013
Schizotypal personality disorder
a b s t r a c t
Interpersonal dysfunction contributes to significant disability in the schizophrenia spectrum. Schizotypal
Personality Disorder (SPD) is a schizophrenia-related personality demonstrating social cognitive
impairment in the absence of frank psychosis. Past research indicates that cognitive dysfunction or
schizotypy may account for social cognitive dysfunction in this population. We tested SPD subjects and
healthy controls on the Empathic Accuracy (EA) paradigm and the Reading of the Mind in the Eyes Test
(RMET), assessing the impact of EA on social support. We also explored whether EA differences could be
explained by intelligence, working memory, trait empathy, or attachment avoidance. SPD subjects did not
differ from controls in RMET, but demonstrated lower EA during negative valence videos, associated with
lower social support. Dynamic, multimodal EA paradigms may be more effective at capturing
interpersonal dysfunction than static image tasks such as RMET. Schizotypal severity, trait empathy,
and cognitive dysfunction did not account for empathic dysfunction in SPD, although attachment
avoidance is related to empathic differences. Empathic dysfunction for negative affect contributes to
decreased social support in the schizophrenia spectrum. Future research may shed further light on
potential links between attachment avoidance, empathic dysfunction, and social support.
& 2013 Elsevier Ireland Ltd. All rights reserved.
Empathy, the capacity to share and understand others' mental
states, is crucial for maintaining social relationships (Eisenberg
and Miller, 1987; Decety, 2011; Zaki and Ochsner, 2012). Thus far,
psychiatric research on affective empathy is often limited to
semantic mental state recognition paradigms that index an indi-
vidual's capacity for recognition of affect in static images, but may
not capture subtle syntactic understanding of mental states in real
time, as in real-world empathic processing (Neisser,1980; Zaki and
Ochsner, 2009; 2012). Schizophrenia is associated with social
cognitive dysfunction (Penn et al., 1997; Pinkham et al., 2003;
Brune, 2005; Irani et al., 2006; Montag et al., 2007; Shamay-Tsoory
et al., 2007; Derntl et al., 2009; Lee et al., 2010; Sparks et al., 2010),
including abnormal neural activity during mental state attribution
(Benedetti et al., 2009; Lee et al., 2010). Misattribution of mental
states in schizophrenia may result from psychosis, cognitive
impairment, or adverse effects of medication, or it may be
independent of these factors. Thus, schizotypal personality dis-
order (SPD), a milder, non-psychotic disorder within the schizo-
phrenia spectrum, provides a unique opportunity for the study of
Empathic processing can concern itself with understanding
affects, thoughts, or intentions of others. Specifically, empathy for
affective mental states consists in several simpler psychological
processes: implicit, automatic sharing of affective experience,
distinction between self and other via perspective-taking and
explicit attribution of others' affect, and deliberation about future
behavior with greater or lesser empathic concern (Leiberg and
Anders, 2006; Zaki and Ochsner, 2012). Careful and accurate
coordination of the first three processes (termed experience-
sharing, perspective-taking, and mental state attribution) contri-
bute to the latter process with greater empathic concern, con-
sidered crucial to prosocial behavior and maintaining important
Contents lists available at ScienceDirect
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0165-1781/$-see front matter & 2013 Elsevier Ireland Ltd. All rights reserved.
nCorresponding author at: Mount Sinai School of Medicine, Department of
Psychiatry, One Gustave L. Levy Place, Box 1230, NY 10029, United States.
Tel.: +1 212 241 5294.
E-mail address: email@example.com (L.H. Ripoll).
1These two authors contributed equally, but in distinct ways, to the present
Psychiatry Research 210 (2013) 232–241
A related construct, theory of mind, is the basic capacity to
understand that others are capable of having intentions, thoughts,
or feelings separate from one's own (Premack and Woodruff,1978;
Dennett, 1978; Baron-Cohen et al., 1985). By definition, Theory of
Mind is related to empathy in that it involves perspective-taking
and explicit mental state attribution for further social cognitive
deliberation. Within various components of empathic processing,
Theory of Mind involves assuming a specific perspective to
distinguish between mental states in self and other. This perspec-
tival aspect of Theory of Mind contrasts with automatic sharing of
affective experience, and each are subserved by distinct neural
networks (Zaki and Ochsner, 2009, 2012). One paradigm that tests
Theory of Mind is the Reading of the Mind in the Eyes Test (Baron-
Cohen et al., 2001), which requires subjects to perform semantic
mental state attributions to recognize complex mental states,
based only upon seeing static images of eye regions of others.
Individuals with high-functioning autism are impaired in the
Reading of the Mind in the Eyes Test (Baron-Cohen et al., 2001).
Impairments in explicit mental state attribution and Theory of
Mind are associated with social dysfunction in schizophrenia
(Roncone et al., 2002; Brune et al., 2007). This impairment may
result from cognitive deficits, psychosis, or antipsychotic medica-
tions. Past research has demonstrated that Theory of Mind deficits
in the schizophrenia spectrum are not explained by intelligence
differences (Doody et al., 1998; Garety and Freeman, 1999;
Mitchley et al., 1998; Pickup and Frith, 2001; Greig et al., 2004)
but contribute to greater disability than psychosis (Doop and Park,
2009; Hooker and Park, 2002; Malaspina and Coleman, 2003;
Perlick et al., 1992). Schizophrenic patients' unaffected relatives
also demonstrate subtle social cognitive deficits, indicating a
familial basis for this dysfunction (Pinkham et al., 2003; Kee
et al., 2004; Brune, 2005; Irani et al., 2006; Bediou et al., 2007;
Penn et al., 2008;de Achaval et al., 2010), independent of cognitive
dysfunction (Alfimova et al., 2009).
Reduced social support predates onset of overt psychosis in
schizophrenic patients (GayerAnderson and Morgan (2013)), and
greater social support reduces impairment from schizophrenia
(Buchanan, 1995). Within the schizophrenia spectrum, greater
social support is associated with positive medical and psychiatric
outcomes, greater quality of life (Salokangas, 1997; Eklund and
Hansson, 2007), greater time between psychotic decompensation
(Hultman et al., 1997), shorter hospitalizations (Ossman and
Mahmoud, 2012), and lesser medication side-effects owing to
increased striatal dopamine transporter availability (Yeh et al.,
2009). Poor social support correlates with longer durations of
untreated psychosis and more severe negative symptoms (Thorup
et al., 2006). Although it remains unclear whether social support
changes clinical outcome or whether more severe psychopathol-
ogy causes both limited support and worse overall outcome, social
support nevertheless remains an important clinical correlate.
SPD is a personality disorder defined by attenuated versions of
schizophrenic symptomatology and subtler impairments in work-
ing memory (Trestman et al., 1995; Gold et al., 1997; Goldman-
Rakic, 1999; Diforio et al., 2000; Farmer et al., 2000; Braff and
Light, 2005; Voglmaier et al., 2005; Matsui et al., 2007). SPD
provides an opportunity for empathy research without confounds
of psychosis or psychiatric medication (Siever and Davis, 2004;
Fossati et al., 2005). In nonclinical samples, schizotypal severity
correlates with social cognitive deficits, independent of cognitive
dysfunction (Poreh et al., 1994; Langdon and Coltheart, 1999;
Pickup, 2006; Brown and Cohen, 2010; Barragan et al., 2011;
Germine and Hooker, 2011). Another non-clinical study correlates
visuospatial cognitive impairment, schizotypy, and empathic abil-
ity (Thakkar and Park, 2010). However, others do not find associa-
tions between psychometric schizotypy and social cognitive
impairment (Jahshan and Sergi, 2007; Versmissen et al., 2008).
More specifically, psychometric schizotypes perform normally on
the Reading of the Mind in the Eyes Test, but show deficits in
another Theory of Mind paradigm that requires greater cognitive
demand than semantic matching of visual stimuli (Gooding and
Pflum, 2011). Research is lacking on social cognition in patients
meeting full clinical criteria for SPD. Moreover, prior studies in SPD
mainly utilized static, affect-recognition paradigms (Mikhailova
et al., 1996; Waldeck and Miller, 2000), rather than studying
multimodal empathic processing of affect in real-time.
The measurement of multimodal empathic processing of affect
in real-time is needed for greater ecologic validity and greater
using static image stimuli may not capture real-life empathic
processing, missing subtler, dynamic and contextual aspects
(Zaki and Ochsner, 2012; Zaki, in press). Deficits in these aspects
of empathy could nevertheless contribute to clinically-relevant
social dysfunction or diminished social support. The Empathic
Accuracy task utilizes video stimuli, requiring perceivers to con-
tinuously evaluate social affective cues produced by targets differ-
ing in emotional expressivity (Zaki et al., 2008, 2009). The stimuli
used in the Empathic Accuracy task are multimodal, requiring
attention to visual, verbal, and nonverbal auditory modalities in
The primary outcome, Empathic Accuracy, is the degree of real-
time correlation between the perceiver's judgment of targets'
affect, and the target's judgments of his/her own affect while
discussing autobiographical experiences (Levenson and Ruef, 1992;
Ickes, 1997; Zaki and Ochsner, 2011; 2012). Judging accuracy by
real-time correlation of perceivers' ratings to targets' own ratings
of themselves contrasts with conventional scoring of other social
cognitive paradigms (via correct answers agreed upon by extrinsic
consensus). The Empathic Accuracy task recruits neural networks
associated with automatic sharing of emotional experience, as well
as brain regions associated with perspective-taking and explicit
mental state attribution (Zaki et al., 2009; Harvey et al., 2012).
Although other social cognitive paradigms isolate specific neuro-
biological processes, they may not capture the capacity for
integration of these processes necessary for real-life empathy as
effectively as the Empathic Accuracy paradigm (Zaki and Ochsner,
2011; 2012; Zaki, in press). Greater Empathic Accuracy is asso-
through adolescence (Gleason et al., 2009; Haugen et al., 2008)
and adulthood (Cohen et al., 2012).
In addition to effects of psychopathology, empathic dysfunction
may be affected by internal working models of earlier relation-
ships and their impact on development. Individuals develop
working models of self and other early in development, influen-
cing the way they understand mental states and how they think,
feel, and behave in relationships (Bowlby, 1969; 1973; 1980),
leading to reliably-measured, overall attachment style. Attach-
ment style consists in relational patterns across relationships,
characterized dimensionally on two orthogonal axes: attachment
anxiety and attachment avoidance. Individuals low in both dimen-
sions tend to experience secure and satisfying relationships.
Attachment anxiety is defined by fears of rejection or abandon-
ment, while attachment avoidance involves discomfort with
closeness or intimacy (Brennan et al., 1998). In order to regulate
affective arousal, attachment style affects the extent to which
others' behavior is ignored, how behavior is understood, and
whether specific actions are later remembered (Collins et al.,
2004). High attachment avoidance is associated with recalling less
details when listening to others describing loss (Fraley et al.,
2000a). In Empathic Accuracy paradigms with non-clinical sub-
jects rating significant others, higher attachment avoidance pre-
dicted lower accuracy during relationship-threatening discussions
(Simpson et al., 2011).
L.H. Ripoll et al. / Psychiatry Research 210 (2013) 232–241
High attachment avoidance is associated with schizotypy in
non-clinical samples (Wilson and Costanzo, 1996; Berry et al.,
2006; 2007; Meins et al., 2008; Tiliopoulos and Goodall, 2009).
Empirical research on attachment style in clinical SPD is lacking.
Schizophrenia has been characterized by ambivalent indifference
toward relationships and intimacy (Bleuler, 1913), suggestive of
attachment avoidance. Attachment avoidance is associated with
greater positive and negative symptoms and poorer interpersonal
functioning in schizophrenic patients (Ponizovsky et al., 2007;
Kyrgic et al., 2012). Although attachment anxiety correlates with
reported distress from hallucinations, high attachment avoidance
correlates with hallucinations whose content is thematically
associated with interpersonal threat (Berry et al., 2012). Attach-
ment anxiety is associated with greater treatment adherence and
depressive symptoms in patients with schizophrenia spectrum
disorders (Kyrgic et al., 2012). Attachment insecurity of either type
is associated with negative interpersonal experiences in psycho-
metric schizotypy (Berry et al., 2007), and earlier illness onset and
longer hospitalizations in schizophrenic patients (Ponizovsky
et al., 2007).
Schizophrenic patients show lower Empathic Accuracy, unrelated
to psychosis severity (Lee et al., 2011), and reduced neural sensitivity
to empathic targets' emotional expressivity (Harvey et al., 2012).
Therefore, we compared healthy subjects to non-psychotic, unmedi-
cated SPD patients, expecting patients to demonstrate lower
Empathic Accuracy. In order to distinguish impairments in Empathic
Accuracy during video stimuli from impairment in semantic proces-
sing of static images, we also included the Reading of the Mind in the
Eyes Test (Baron-Cohen et al., 2001).
Because SPD involves subtler symptoms and neurobiological
dysfunction compared to schizophrenia, we expected no differ-
ences to emerge in Reading of the Mind in the Eyes Test
performance. Because of conflicting evidence about links between
social cognitive impairment on the one hand, and cognitive
impairment or schizotypal severity on the other, we explored
potential correlations in our sample between Empathic Accuracy,
schizotypy, intelligence, and working memory. Given potential
association between schizotypy and attachment avoidance, and
the effect of the latter on Empathic Accuracy in non-clinical
groups, we explored whether attachment avoidance might
account for differences between groups in Empathic Accuracy. In
order to establish the clinical significance of empathic dysfunction,
we also tested for correlations between Empathic Accuracy and
well-validated measures of social support.
Our sample consisted of 19 subjects with SPD and 19 healthy controls (HCs), all
18—60 years of age. Subjects were recruited through advertisement in local
newspapers and internet postings, or via referral from outpatient mental health
clinics at the James J. Peters VA Medical Center.
Patients met full DSM-IV criteria for SPD. HCs had no Axis I or II disorders.
Exclusion criteria included: history of head trauma, neurological disease, organic
mental syndrome, mental retardation, medical illness, substance dependence,
substance use in prior 6 months, use of any psychoactive medications in prior
2 weeks, or positive urine toxicology. SPD subjects were excluded if they met
criteria for psychotic disorder or comorbid bipolar I disorder, active major
depressive disorder, or borderline personality disorder. SPD patients were not
taking medication and denied history of psychiatric hospitalization. All participants
provided written informed consent. The study was approved by the Mount Sinai
School of Medicine Institutional Review Board.
2.2.Structured diagnostic interviews
For each subject, diagnosis was established by doctoral-level psychologists with
expertise in evaluation of Axis II disorders, using Structured Clinical Interview for
DSM-IV Axis I disorders (SCID-I; (First et al., 2001)) and Structured Interview for
DSM-IV Personality Disorders (SIDP-IV; (Pfohl et al., 1997)). Physicians screened
participants for medical and neurological illness via history, physical examination,
and routine blood and urine laboratory testing, just prior to participation.
2.3.Questionnaires assessing social support
Refer to Table 1 for details on measures and references for validity and
reliability. Subjects completed a battery of self-report measures, including the
Interpersonal Support Evaluation List (ISEL, (Cohen and Hoberman, 1983; Cohen
and Wills, 1985)) and Social Network Index (SNI, (Cohen et al., 1997)). These were
used as self-report measures of subjective and objective aspects of social support,
respectively. The ISEL contains subscales measuring an individual's subjective sense
of the perceived availability of tangible, material support (tangible subscale), the
perceived availability of someone to talk with about one's problems (appraisal
subscale), sense of identification and belonging in one's support group (belonging
subscale), and the sense of positive self-esteem when comparing oneself to others
(self-esteem subscale). The SNI involves a subscale that measures overall quantity
of social support, and another that indexes diversity of different types of supportive
2.4.Questionnaires assessing personality factors
The Balanced Emotional Empathy Scale (BEES, (Mehrabian and Epstein, 1972))
was included as a self-report measure of trait empathy. The Schizotypal Personality
Questionnaire (SPQ, (Raine,1991)) provided a measure of the severity of schizotypy.
We scored the SPQ according to three-factor models supported by confirmatory
factor analyses, yielding cognitive—perceptual, interpersonal, and disorganization
factors (Raine et al., 1994; Chen et al., 1997; Reynolds et al., 2000). The Experiences
in Close Relationships Inventory (ECRI, (Brennan et al., 1998; Fraley et al., 2000b)
provided a measure of relational patterns of attachment anxiety and avoidance. The
Childhood Trauma Questionnaire (CTQ, (Bernstein et al., 1994; Bernstein and Fink,
1998)) provided an estimate of severity of childhood trauma. The CTQ was included
due to potential developmental effects of childhood trauma on social cognition and
2.5.Social cognitive tasks
All subjects completed two tasks on laptop computer in research offices. These
were administered with Presentation software (Neurobehavioral Systems). Subjects
were provided instructions before each task. All responses were recorded via
keyboard. Order of tasks was randomized between subjects.
2.5.1. Reading the Mind in the Eyes Task
The Reading of the Mind in the Eyes Test (Baron-Cohen et al., 1997, 2001)
includes 36 self-paced trials, each consisting of an image of an adult cropped to
display only the eyes, alongside four words as answer choices describing possible
internal states that the person in the image could be thinking or feeling. Without
time constraint, subjects chose which word best described the target's mental state,
requiring explicit recognition of complex mental states such as ‘playful,’ ‘worried,’
or ‘suspicious’ (i.e. Theory of Mind). In addition to the total score, we report scores
for positive, negative, and neutral valence Reading of the Mind in the Eyes Test
items, according to the method used by Fertuck et al. (2009) and Harkness et al.
(2005). Although the Reading of the Mind in the Eyes Test is generally considered a
Theory of Mind task, this well-validated subdivision of items into affective
subscores emphasizes the conceptual overlap between Theory of Mind and affect
recognition. Order of images in this task was randomized.
2.5.2.Empathic Accuracy Task
The Empathic Accuracy Task was adapted from (Zaki et al., 2008; 2009).
Subjects viewed a random assortment of 10 of 20 video clips, each lasting for
1—3 min, in which a healthy target is seen discussing an emotional, autobiogra-
phical experience. Half of the viewed videos were of primarily negative valence,
and half positive. Each target was previously filmed and provided continuous
valence ratings for each of his/her videos. Targets previously completed the
Berkeley Expressivity Questionnaire (BEQ; (Gross and John, 1995; Gross, 2000),
assessing the tendency to overtly express emotion. Half of target videos were of
females and half of males.
A central fixation was presented at the start of each video. Then, the target
video played, with a nine-point rating scale presented below (1: very negative;
5: neutral; 9: very positive). Subjects in the present study continuously rated how
positively or negatively the target was feeling during the video, using left or right
arrow keys to adjust the indicated rating number. The selected rating remained
highlighted, so participants could monitor their continuous ratings. Empathic
Accuracy, the primary outcome variable, is the degree of real-time correlation
between subjects' affective ratings and targets' ratings of their own affect in each
video (see Fig. 1). Video order was randomized. As in the specific scoring
L.H. Ripoll et al. / Psychiatry Research 210 (2013) 232–241
Self-report questionnaires administered to subjects, along with brief descriptions of each of these measures and their relevant subscales.
Self-report questionnaireDescription of measure Citation
Interpersonal Support Evaluation List (ISEL)Subjective aspects of social supportCohen and Hoberman (1983) and
Cohen and Wills (1985)
Perceived availability of material support
Appraisal of presence of someone with whom to discuss issues of personal
Perceived availability of group with which one belongs and with which one can
Perceived sense of positive self-esteem relative to others with whom one
favorably compares oneself
Social Network Index (SNI)
Diversity of support
Quantitative aspects of social support
Number of people subject considers supportive
Diversity of types of relationships with supportive persons
Cohen et al. (1997)
Revised Experiences in Close Relationships
Emotional reactions in close or significant relationshipsBrennan et al. (1998) and Fraley et al.
Tendency to experience distress with increasing potential intimacy
Tendency to experience distress with increasing potential aloneness
Balanced Emotional Empathy Scale (BEES) Trait empathy and tendency to automatically share in emotional experiencesMehrabian and Epstein (1972)
Schizotypal Personality Questionnaire (SPQ)
Severity of schizotypal psychopathology
Positive-like symptoms, including referential/magical thinking, perceptual
Negative-like symptoms, including social anxiety, lack of friends, blunted affect
Odd speech, eccentric behavior
Childhood Trauma Questionnaire Childhood trauma (collapsed across different types: physical, sexual, emotional,
Bernstein et al. (1994) and Bernstein
and Fink (1998)
Fig. 1. Schematic of the Empathic Accuracy (EA) procedure and sample timecourses for target and subject ratings. Primary outcomes consisted in the time-series correlation
between ratings produced by targets in videos, and ratings produced by SPD and healthy control subjects.
L.H. Ripoll et al. / Psychiatry Research 210 (2013) 232–241
methodology used for the Reading of the Mind in the Eyes Test (see above), this
paradigm focuses on affect recognition. However, in the Empathic Accuracy Task,
subjects engage in explicit affect recognition in real-time, over the course of a video
of a target engaging in spontaneous, autobiographical speech. The task involves
multi-modal attention to visual, verbal, and other auditory social cues.
After each of the 10 videos, subjects answered questions presented on screen
above a 9-point scale. Questions inquired how accurate subjects believed they
performed (Perceived Accuracy), how likeable the subject considered the target
(Likeability), how similar they believed they were to the target (Self-Similarity),
and the Importance of the target in the preceding video. Questions required
subjects to provide a single-number as overall rating of target Likeability, Self-
Similarity, Importance, and Perceived Accuracy. One SPD subject had technical
difficulties that inadvertently deleted all Empathic Accuracy data.
2.6.1.Wechsler Abbreviated Scale of Intelligence
Subjects completed the Wechsler Abbreviated Scale of Intelligence (WASI;
(Wechsler, 1999)), and Full Scale IQ was extrapolated from two subtests (Vocabu-
lary and Matrix Reasoning).
2.6.2. Dot Test
The Dot Test is a test of visuospatial working memory in which schizophrenic
patients demonstrate impairments (Keefe et al., 1995, 1997). Subjects were shown
each dot trial at a specific position on the paper and then asked to reproduce it at
the same location on a separate paper after no delay, 10 s, or 30 s delay.
Visuospatial working memory is calculated by the mean distance error after 30 s
minus mean distance error at no delay.
2.7. Statistical analysis
Statistical testing was performed with IBM SPSS 19. Primary outcomes were
Empathic Accuracy and Reading of the Mind in the Eyes Test scores. We hypothesized
that SPD subjects would demonstrate lower Empathic Accuracy and no differences in
Reading of the Mind in the Eyes Test, compared to HCs. Self-report scores, Empathic
Accuracy, Reading of the Mind in the Eyes Test scores, Full-Scale IQ, and Dot Test results
were tested for normality across the sample, using Shapiro—Wilk testing. For normally
distributed variables, one-way ANOVA was used to compare SPD and HC groups,
whereas for non-normally distributed variables, Mann—Whitney U testing was used to
compare groups. Spearman's correlations were used to test for correlations, due to non-
normal distribution of relevant variables. Because SPD and HC groups differed in sex
composition (see Table 2), we tested a general linear model for main effects of sex,
diagnosis, and their interaction, on Empathic Accuracy and Reading of the Mind in the
Eyes Test performance.
The only difference between groups in social cognitive measures was in
negative-valence Empathic Accuracy (see below). Subsequent analyses focused on
this, non-normally distributed variable. To understand the clinical significance of
Empathic Accuracy differences between groups, we reported Spearman's correla-
tions between negative-valence Empathic Accuracy on the one hand, and self-
report or cognitive measures on the other. We also tested for main effects of
diagnostic group, sex, and their interaction on negative-valence Empathic Accuracy,
with Full Scale IQ, Dot Test scores, and self-reported trait empathy (BEES scores)
entered as covariates. Mann—Whitney U tested for significant differences between
groups in post-video questions. We also explored correlations between answers to
questions and Empathic Accuracy.
Groups did not differ in terms of age (mean [M]¼38.6, standard
deviation [S.D.]¼10.4; and M¼33.7, S.D.¼9.1 years respectively,
p¼n.s.). A significant difference between groups emerged in terms
of sex (six (32%) HC males and 13 (68%) HC females vs. 13 (68%)
SPD males and six (32%) SPD females, po0.03). We factored sex
into subsequent analyses via general linear model.
SPQ and CTQ results, attachment avoidance, and SNI quantita-
tive support were non-normally distributed in the total sample.
For normally-distributed variables, ANOVA demonstrated differ-
ences between SPD and HC groups, with SPD subjects reporting
lower BEES scores (F¼10.0, d.f.¼1, 36, p¼0.003) and greater
attachment anxiety (F¼6.3, d.f.¼1, 29, po0.02) (see Table 3).
For non-normally distributed self-report measures, expected dif-
ferences emerged between groups in total SPQ (U¼3.0, d.f.¼1, 33,
po0.001), cognitive—perceptual (U¼6.5, d.f.¼1, 33, po0.001),
interpersonal (U¼7.5, d.f.¼1, 33, po0.001), and disorganization
(U¼26.5, d.f.¼1, 33, po0.001) factor scores, all higher in the SPD
group. SPD subjects had lower scores on SNI quantitative support
(U¼65.5, d.f.¼1, 31, po0.03) and the belonging (F¼51.6, d.f.¼1,
29, po0.001), tangible (F¼35.6, d.f.¼1, 29, po0.001), self-esteem
(F¼9.2, d.f.¼1, 29, p¼0.003), and appraisal (F¼26.8, d.f.¼1, 29,
po0.001) subscales of the ISEL, and higher CTQ scores (U¼58.5, d.
f.¼1, 32, p¼0.005) and attachment avoidance (U¼52.0, d.f.¼1, 29,
po0.02) (see Table 4.
3.2. Social Cognition Tasks
3.2.1. Reading of the Mind in the Eyes Test performance
Total Reading of the Mind in the Eyes Test score and positive,
negative, and neutral item scores, were non-normally distributed.
Age and sex composition of healthy control (HC, n¼19) and schizotypal personality disorder (SPD, n¼19) groups, as
well as Axis I and II comorbidity rates for the SPD group. HC subjects did not meet criteria for any Axis I or II
disorders, and no subjects met criteria for active major depressive disorder or substance abuse, or any history of
Age in years (mean7standard deviation)
Axis I Comorbidity
Past major depressive disorder
Post-traumatic stress disorder
Intermittent explosive disorder
Past alcohol abuse
Past cannabis abuse
Past cocaine abuse
13/19 female (68%)
6/19 female (32%)
Axis II Comorbidity
Paranoid personality disorder
Schizoid personality disorder
Narcissistic personality disorder
Antisocial personality disorder
Avoidant personality disorder
Obsessive-compulsive personality disorder
L.H. Ripoll et al. / Psychiatry Research 210 (2013) 232–241
There were no significant differences between groups in total
Reading of the Mind in the Eyes Test score (U¼148.5, d.f.¼1, 37,
p¼n.s.), positive-valence items (U¼161.0, d.f.¼1, 37, p¼n.s.),
neutral-valence items (U¼141.0, d.f.¼1, 37, p¼n.s.).
3.2.2. Empathic Accuracy performance
Empathic Accuracy was non-normally distributed. SPD subjects
demonstrated lower Empathic Accuracy for negative videos, com-
pared with HC subjects (U¼83.0, d.f.¼1, 36, p¼0.007), but there
were no significant differences between groups in positive videos
(U¼164.0, d.f.¼1, 36, p¼n.s.). There were no significant effects of
sex and no significant sex by diagnosis effects on positive- or
negative-valence Empathic Accuracy (see Figs. 2 and 3).
3.2.3. Empathic Accuracy correlations
In the total sample, total BEES scores (rho¼0.4, po0.03), and
(rho¼0.4, po0.03), and belonging (rho¼0.5, po0.01), and SNI
quantitative support scores (rho¼0.5, p¼0.005) were correlated
with negative-valence Empathic Accuracy. There were no signifi-
cant correlations between negative-valence Empathic Accuracy
and SPQ, CTQ, or attachment variables in the total sample. When
examining correlations separately in each diagnostic group, only
the SNI quantitative support and diversity subscales (rho¼0.7,
po0.01 for both) were significantly correlated with negative-
valence Empathic Accuracy in the SPD group, with no significant
correlations with negative-valence Empathic Accuracy in the HC
group (see Table 5.
3.2.4. Post-video questions
Responses to post-video questions were all non-normally
distributed. There were no significant differences between groups
in answers to these questions. We found that in the HC group,
there were significant correlations between subjects' Perceived
Accuracy and Empathic Accuracy (rho¼0.16, n¼181 video trials,
po0.03) and Target Expressivity (BEQ) and Empathic Accuracy
(rho¼0.41, n¼181 video trials, po0.001). In the SPD group, there
was no significant correlation between Empathic Accuracy and
Perceived Accuracy, though there was between target Expressivity
and Empathic Accuracy (rho¼0.18, n¼169, po0.03).
Mean7standard deviation, for each normally distributed self-report measure. Also included are results of ANOVA comparing the healthy control (HC) and schizotypal
personality disorder (SPD) groups. Note significant differences between groups in trait empathy (BEES), attachment anxiety (ECRI), and subjective perception of social
support (ISEL). BEES¼Balanced Emotional Empathy Scale; ECRI¼Experiences in Close Relationships Inventory; ISEL¼Interpersonal Support Evaluation List; SNI¼Social
Self-report measureSPD HC
ECRI attachment anxiety
SNI diversity of support (DIV)
Median (interquartile range), for all non-normally distributed self-report measures. Also presented is Mann—Whitney U testing comparing healthy control (HC) and
schizotypal personality disorder (SPD) groups. Note the expected significant differences between groups in severity of schizotypy and its component factors (SPQ), as well as
significantly increased rates of childhood trauma (CTQ) and attachment avoidance (ECRI), and lower quantity of social support (SNI) in the SPD group. SPQ¼Schizotypal
Personality Questionnaire; CTQ¼Childhood Trauma Questionnaire; ECRI¼Experiences in Close Relationships Inventory; SNI¼Social Network Index.
SPQ cognitive-perceptual factor
SPQ disorganization factor
SPQ interpersonal factor
ECRI attachment avoidance
SNI quantity of support (PPL)
36.5 (13.3); n¼16
14 (5.8); n¼16
6.5 (8.0); n¼16
23.0 (11.0); n¼16
60.5 (31.6); n¼16
81 (48.0); n¼14
5.5 (10.0); n¼14
4.0 (6.3); n¼18
0.8 (2.0); n¼18
0.5 (1.2); n¼18
2.2 (3.6); n¼18
41.4 (9.5); n¼17
38.0 (29.5); n¼16
14.7 (17); n¼18
Fig. 2. Mean Empathic Accuracy (EA) in healthy control (HC) and schizotypal
personality disorder (SPD) groups, separately by overall valence of the video clip
(negative or positive). Note significant differences between groups in negative-
valence clips, but no significant differences in those of positive valence.
L.H. Ripoll et al. / Psychiatry Research 210 (2013) 232–241
Full Scale IQ was non-normally distributed in our sample, but
Dot Test scores were normally-distributed. For the HC group,
median Full Scale IQ (interquartile range)¼110(11), and for the
SPD group, median(interquartile range)¼95(29). For Dot Test
scores, M(S.D.)¼0.76(0.67), and 1.05(1.86) for the HC and SPD
between groups in Full Scale IQ (U¼49.5, d.f.¼1, 25, p¼0.07),
nor in Dot Test results (F¼0.31, d.f.¼1, 27, p¼0.6). There were no
statistically significant correlations between Full Scale IQ, Dot Test
results, and negative valence Empathic Accuracy.
3.4. General linear modeling
We tested a general linear model, with negative-valence
Empathic Accuracy as dependent variable, sex and diagnosis as
fixed factors, and BEES score as covariate, and there remained a
significant difference by diagnosis (F¼4.7, d.f.¼1, 35, po0.04).
Similarly, a general linear model with negative valence Empathic
Accuracy as the dependent variable, sex and diagnosis as fixed
factors, and Full Scale IQ or Dot Test results as covariates, demon-
strated continued, significant diagnosis effects on negative-
valence Empathic Accuracy in each instance (F¼7.6, d.f.¼1, 24,
p¼0.01 for Full Scale IQ; F¼6.2, d.f.¼1, 26, p¼0.02, for Dot Test).
Our study demonstrated that SPD patients have difficulty
understanding others' negative affect, which was associated with
lower indices of social support. SPD subjects did not differ from
controls in Reading of the Mind in the Eyes Test performance,
indicating normal capacity for unimodal, semantic recognition of
affect in a Theory of Mind task. This highlights the importance of
the Empathic Accuracy task in schizophrenia spectrum research, as
a more sensitive, clinically relevant index of empathic processing
compared to conventional paradigms requiring semantic matching
of static images to descriptors. We found no relationship between
general intelligence or working memory deficits and empathic
dysfunction in SPD. We similarly found no significant correlations
between schizotypal severity, self-reported trait empathy (mea-
sured via the BEES), attachment avoidance, attachment anxiety,
childhood trauma, and empathic dysfunction.
The present study's focus on SPD provides an understanding of
empathic processing in the schizophrenia spectrum, without
potential confounds of psychosis or pharmacotherapy. Schizophre-
nic patients show reduced sensitivity to target expressivity (Lee
et al., 2011; Harvey et al., 2012), but, due to milder psychopathol-
ogy, SPD patients appear sensitive to target expressivity in their
empathic judgments. However, SPD subjects are less aware of their
Fig. 3. Mean Empathic Accuracy (EA) in males and females, separately by overall
valence of the video clip (negative or positive). Note there are no significant
differences between sexes in EA for clips of positive or negative valence. Moreover,
there were no significant diagnosis?sex effects on EA for clips of positive or
Spearman correlations between Empathic Accuracy and self-report measures, for the total sample and separately for the healthy control (HC) and schizotypal personality
disorder (SPD) groups. Significant correlations are highlighted in bold. BEES¼Balanced Emotional Empathy Scale; SPQ¼Schizotypal Personality Questionnaire;
CTQ¼Childhood Trauma Questionnaire; ECRI¼Experiences in Close Relationships Inventory; SNI¼Social Network Index.
SPQ cpSPQ ipSPQ do CTQ
ECRI avECRI anISEL apISEL taISEL seISEL beSNI DIVSNI PPL
L.H. Ripoll et al. / Psychiatry Research 210 (2013) 232–241
own empathic dysfunction, indicative of metacognitive dysfunc-
tion. Despite recent interest in metacognitive awareness of social
cognition in healthy controls (Kelly and Metcalfe, 2011), the
significance of this in the schizophrenia spectrum remains
This is the first study to document attachment style in patients
meeting full criteria for SPD. In healthy couples, attachment
avoidance is associated with lower empathic accuracy during
relationship-threatening situations (Simpson et al., 2011). SPD
subjects reported higher levels of attachment anxiety and attach-
ment avoidance, and more severe childhood trauma but these did
not correlate directly with Empathic Accuracy. Sexual trauma is
associated with social cognitive impairment in schizophrenia
(Lysaker et al., 2011), and early maternal separation predicts the
subsequent development of schizotypal symptoms in vulnerable,
angry children (Anglin et al., 2008). Without prospective research
design, we are unable to discern the relationships between child-
hood trauma, attachment anxiety or avoidance, schizotypy, and
Empathic Accuracy. The present study demonstrates that general
cognition, working memory, schizotypal severity, nor attachment
style effectively explain differences in empathic functioning for
negative affect in SPD. Despite a preponderance of negative
results, this suggests that empathic dysfunction in SPD patients
is caused by some other factor, unique to this disorder. The
conceptual overlap between the interpersonal factor of schizotypy
on the one hand, and attachment anxiety and avoidance on the
other, further complicates the present difficulty in characterizing
empathy in the schizophrenia spectrum.
The present study has several other limitations. First, the
sample is small. Groups differed in sex composition, although we
controlled for this difference in data analysis. In non-clinical
research with the present Empathic Accuracy task, there is no
evidence of a sex advantage (Zaki et al., 2008). Others utilizing a
distinct, non-computerized Empathic Accuracy paradigm docu-
ment a seeming female advantage, mediated by greater task
motivation or greater sympathy toward targets (Ickes et al.,
2000; Klein and Hodges, 2001). Another statistical limitation is
that we did not control for multiple comparisons and report
significant tests with alpha o0.05, in an effort to include explora-
tory analyses potentially accounting for Empathic Accuracy differ-
ences. Moreover, correlational analyses do not necessarily prove
causality. Multiple variables were not normally distributed in our
sample, suggesting that some subjects reported extreme values or
a relatively constant distribution across subjects.
The present SPD sample demonstrates psychiatric comorbidity,
although we excluded patients with comorbid borderline person-
ality disorder because recent research in this population suggests a
distinct type of social cognitive impairment in this disorder,
introducing too great a confound. If only SPD patients without
psychiatric comorbidity were included, the sample would be
highly rarified, and findings would not be generalizable. Another
limitation of our sample is that we did not assess whether healthy
controls had a first-degree relative with a schizophrenia spectrum
disorder. Prior research documents subtle social cognitive impair-
ment in unaffected individuals with schizophrenic relatives
(Pinkham et al., 2003; Kee et al., 2004; Brune, 2005; Irani et al.,
2006; Bediou et al., 2007; Penn et al., 2008; de Achaval et al.,
2010). The findings would thus have been strengthened if this had
been an exclusion criterion.
Another limitation concerns generalizability of findings related
to general cognition. In the present sample, SPD subjects did not
differ significantly from controls in visuospatial working memory,
but past research has highlighted working memory deficits in SPD
(Siever and Davis, 2004). The present sample may be characterized
by patients with relatively intact visuospatial working memory
and higher prevalence of childhood trauma. A larger sample is
likely needed to demonstrate significant deficits in working
memory associated with SPD, which are often subtle relative to
those associated with schizophrenia. Nevertheless, variance in
visuospatial working memory, IQ, or childhood trauma did not
correlate or covary with Empathic Accuracy. Other, distinct neu-
ropsychological methods may nevertheless ultimately explain
differences in Empathic Accuracy.
Limitations of the Empathic Accuracy task include that it is
focused primarily on affect (rather than empathic attribution of
thoughts or intentions). Nevertheless, thoughts or intentions are
more difficult to operationalize, as it would require greater
subjective judgment as to the similarity of perceivers' and targets'
attributions. Also, the Empathic Accuracy task uses one Likert scale
for both positive and negative affect. Some evidence suggests that
positive and negative affect do not lie on a continuum, but are
rather separate constructs (Reich et al., 2003; Jacobs et al., 2012).
Nevertheless, requiring subjects to perform separate positive and
negative affect ratings at once while watching each video would
prove too taxing, and performing each rating serially would
unduly skew the second ratings.
Our research suggests that the schizophrenia spectrum is
characterized by empathic dysfunction independent of schizotypal
symptoms, intelligence, trait empathy, or working memory. We
demonstrate empathic dysfunction for negative affect in SPD,
which is associated with lower quantity and diversity of social
support. In order to accurately assess empathic dysfunction in the
schizophrenia spectrum, research paradigms are needed with
greater ecologic validity, involving coordinated implementation
of several neurobiological processes. Future research will examine
the neurobiological underpinnings of differential empathic pro-
cessing in SPD and identify potential genetic and environmental
etiological factors contributing to empathic dysfunction over the
course of development. This will assist in earlier identification of
individuals at-risk and more effective treatments for the inter-
personal disability characteristic of the schizophrenia spectrum.
Comparison of performance in the Empathic Accuracy paradigm
with static, affect-recognition paradigms isolating specific compo-
nents of empathy will also clarify distinct types of social cognitive
dysfunction seen in individuals with schizophrenia spectrum
The present study was funded entirely through a US Dept. of
Veterans' Affairs MIRECC pilot grant, and the authors have no
other significant financial relationships to disclose.
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