No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Self-reported social functioning and social cognition in schizophrenia and bipolar disorder: Using ecological momentary assessment to identify the origin of bias
Abstract
Objectives:
People with schizophrenia (SCZ) and bipolar illness (BPI) generate self-reports of their functioning that diverge from objective information. It has been suggested that these participants do not base such reports on daily experiences, relying on other information. We used ecological momentary assessment (EMA) to sample socially relevant daily activities in SCZ and BPI and related them to self-reported and observer-rated social functioning and social cognitive ability.
Methods:
71 people with (BPI) were compared to 102 people with SCZ. Participants were sampled 3 times per day for 30 days with a smartphone-based survey. Each survey asked where they were, with whom they were, what they were doing, and if they were sad. Participants and observers were asked to provide ratings on social functioning and social cognitive abilities at the end of the EMA period.
Results:
There was no association between being home or alone and self-reports of everyday social functioning. In contrast observer ratings were highly correlated with the momentary survey results. Reports of very low levels of sadness were associated with overestimated functioning and participants who were commonly home and alone rated their social functioning as better than participants who were commonly away in the presence of others.
Implications:
Both SCZ and BPI were marked by a disconnect between momentary experiences and self-reports. The largest effect was overestimation of functioning by participants who reported no sadness. Experience appears important, as participants who were routinely home and alone reported better social functioning than participants who spent more time others.
... Psychotic disorders (i.e., schizophrenia and schizoaffective disorder) affect approximately 1.5% of the population and cause the most substantial disability of any psychiatric disorder [1][2][3]. A growing body of literature spanning cognitive science, educational research, and more recently, mental health, links inaccurate judgments of performance, or poor Introspective Accuracy (IA), with diminished real-world functioning in psychotic disorders [4][5][6][7][8]. IA is the discrepancy between objective performance and subjective estimation of performance [5,7]. ...
... IA is the discrepancy between objective performance and subjective estimation of performance [5,7]. IA impairments span psychiatric illnesses, yet aberrant IA appears to be more common and pronounced in psychotic disorders [6,9] and most frequently manifests as overconfidence in abilities [10]. However, there are no interventions that directly target IA. ...
... Previous research indicates that introspective accuracy (IA) is impaired in people with psychotic disorders and is an independent predictor of functional outcomes [4][5][6][7][8]. However, no interventions have been developed and tested to improve IA. ...
Poor introspective accuracy (IA), defined as inaccurate judgments of one’s abilities and performance, is a strong and independent predictor of functional impairment in people with psychotic disorders. However, there are currently no treatments that directly target IA in this population as a primary outcome. We describe a protocol for a clinical trial to test a newly developed blended digital intervention, Improving Thinking through Everyday SelfAssessment Training (iTEST) , aimed at improving IA in people with psychotic disorders to improve functional outcomes. iTEST involves daily training consisting of feedback on IA in mobile cognitive tests, coupled with individual coaching that applies improved IA to participant-identified recovery goals. Following the NIMH experimental therapeutics paradigm, the first step in the evaluation of iTEST is an open trial in 60 individuals with psychotic disorders to assess 1) feasibility and acceptability, and 2) whether the intervention leads to clinically significant improvement in an objective target: IA on trained tasks along with transfer to an untrained task-based measure of IA. After programming of the mobile intervention and the creation of treatment manuals, enrollment for an open trial started in November 2023 and will be completed by April 2025. If effective, iTEST could be integrated with cognitive training and other rehabilitative interventions to boost the impact on functional outcomes. Trial registration: ClinicalTrials.gov NCT05899348.
... One construct that links these domains is Introspective Accuracy (IA), the ability to generate self assessments that are convergent with objective evidence. IA is functionally relevant, as multiple studies, using a variety of methods to operationalize IA, have linked IA challenges with poorer real-world functioning in severe mental illness (Gould et al., 2015, Durand et al., 2021, Pinkham et al., 2018. Since IA impairments share features across domains, including self-assessments of functioning, cognition, and social cognition (Durand et al., 2021;Silberstein and Harvey, 2019) and measurement approaches, it offers promise as a potential target for cognitive training (Reiter et al., 2021). ...
... IA is functionally relevant, as multiple studies, using a variety of methods to operationalize IA, have linked IA challenges with poorer real-world functioning in severe mental illness (Gould et al., 2015, Durand et al., 2021, Pinkham et al., 2018. Since IA impairments share features across domains, including self-assessments of functioning, cognition, and social cognition (Durand et al., 2021;Silberstein and Harvey, 2019) and measurement approaches, it offers promise as a potential target for cognitive training (Reiter et al., 2021). ...
... IA impairments appear greater in psychotic disorders (Tercero et al., 2021;Durand et al., 2021) where global self-assessments of competence are significantly more disconnected from actual performance compared to bipolar disorder. The dominant directional bias is consistent with over estimation of ability and overconfidence (Perez et al., 2020) and overestimation occurs in participants with schizophrenia across the entire range of performance (Jones et al., 2019), suggesting that limited ability is not the only driver. ...
Objective:
Introspective Accuracy (IA) is a metacognitive construct that refers to alignment of self-generated accuracy judgments, confidence, and objective information regarding performance. IA not only refers to accuracy and confidence during tasks, but also predicts functional outcomes. The consistency and magnitude of IA deficits suggest a sustained disconnect between self-assessments and actual performance. The cognitive origins of IA are unclear and are not simply due to poor performance. We tried to capture task and diagnosis-related differences through examining confidence as a timeseries.
Method:
This relatively large sample (N = 171; Bipolar = 71, Schizophrenia = 100) study used item by item confidence judgments for tasks including the Wisconsin Card Sorting Task (WCST) and the Emotion Recognition task (ER-40). Using a seasonal decomposition approach and AutoRegressive, Integrative and Moving Averages (ARIMA) time-series analyses we tested for the presence of randomness and perseveration.
Results:
For the WCST, comparisons across participants with schizophrenia and bipolar disorder found similar trends and residuals, thus excluding perseverative or random responding. However, seasonal components were weaker in participants with schizophrenia, reflecting a reduced impact of feedback on confidence. In contrast, for the ER40, which does not require identification of a sustained construct, seasonal, trend, and residual analyses were highly comparable.
Conclusion:
Seasonal analysis revealed that confidence judgments in participants with schizophrenia on tasks requiring responses to feedback reflected diminished incorporation of external information, not random or preservative responding. These analyses highlight how time series analyses can specify potential faulty processes for future intervention.
... Many functional measures rely on self-reports, which require sufficient insight to observe and report possible impairments. These challenges are also present in self-assessment of cognitive abilities, functional abilities, SC, and social outcomes 60 and are shared across psychiatric conditions. 61 Such insight is frequently lacking during manic states and may be lacking during depressive states. ...
... 58,61,62 Regarding SC, one study found that self-reports of very low levels of sadness were associated with overestimated functioning. 60 Interestingly, experience plays an important part in self-perception, since participants who were commonly home alone rated their social functioning as better than participants who were commonly outside the home and in the company of others. 60 ...
... 60 Interestingly, experience plays an important part in self-perception, since participants who were commonly home alone rated their social functioning as better than participants who were commonly outside the home and in the company of others. 60 ...
Social cognition has gained prominence in psychiatric research, beginning with schizophrenia and more recently in bipolar disorder. Considering the relevance of this domain to interpersonal relationships and functionality, we aimed to explore the fundamental research and clinical issues regarding social cognition and discuss future directions and challenges in the field of bipolar disorder.
... Participants with SCZ who had never worked full-time reported that their work skills were equivalent to, and their ability to perform everyday activities were superior to, participants who were currently employed full time (Gould et al., 2013), despite performing notably more poorly on measures of neurocognition (effect size = 1.0 SD). Durand et al. (2021) reported that participants with schizophrenia generated self-reports of their everyday social functioning that were completely uncorrelated with 30 days (90 assessments) of Ecological Momentary Assessment (EMA) data regarding where they were and who they were with; being home and alone was associated with self-reports of significantly better everyday functioning than participants who were away from home with others. ...
... In this study (Durand et al., 2021;Harvey et al., 2021), we collected daily EMA reports of moods, as well as data regarding whether the participants were home, alone, or both home and alone, as well as end of study self-reports and observer ratings of everyday functional outcomes and cognitive abilities. Participants with bipolar disorder and schizophrenia were examined in the study and our analyses focused on participants with schizophrenia who never reported any sad moods versus those who reported that they were occasionally sad. ...
... In this study, the IB displayed by SCZ patients who reported never being sad over a 30-day period is consistent with the IB previously observed in studies where SCZ patients reported no sadness on a singular assessment (Harvey et al., 2019a;Harvey et al., 2017;Siu et al., 2015). Our findings that some patients with SCZ overestimate their functioning in various domains while displaying no objective differences in performances expand a growing body of evidence (Durand et al., 2021;Gould et al., 2015;Gould et al., 2013) that patients with schizophrenia struggle with impairments in self-assessment of functioning and that one of the markers of this process is the level of selfreported sadness. Excess bias toward socially desirable responding is not the likely cause of these reports of no sadness: never-sad participants endorsed equivalent numbers of surveys compared to the sometimes-sad participants that reported the occurrence of hallucinations and 4 different delusions. ...
Objectives
People with schizophrenia have challenges in their self-assessments of everyday functioning and those who report no sadness also tend to overestimate their everyday functional abilities. While previous studies were cross-sectional, this study related longitudinal assessments of sadness to self-reports of abilities in domains of everyday functioning and cognitive abilities.
Methods
71 people with bipolar illness (BPI) were compared to 102 people with schizophrenia (SCZ). Participants were sampled 3 times per day for 30 days with a smartphone-based Ecological Momentary Assessment (EMA) survey. Each survey asked where they were, with whom they were, what they were doing, and if they were sad. Performance based assessments of executive functioning, social competence, and everyday activities were collected after the EMA period, at which time the participants and observers were asked to provide ratings of three different domains of everyday functioning and neurocognitive ability.
Results
18% of participants with SCZ reported that they were never sad on any one of the 90 EMA surveys. Reports of never being sad were associated with overestimated functioning compared to observers and SCZ participants who reported that they were never sad were more commonly home and alone than both SCZ participants who reported occasional sadness and participants with BPI. These participants reported being significantly happier than all people in the study.
Implications
Reporting that you were never sad was associated with overestimation of everyday functioning and cognitive abilities. Although participants who were never sad did not perform more poorly on objective measures than those were occasionally sad, their self-assessed functioning was significantly elevated. These data suggest that negative symptoms constructs such as reduced emotional experience need to consider reduced ability to subjectively evaluate emotional experience as a feature of negative symptoms.
... Thus, both internally-originating (concept identification, recall of the current concept, evaluation of the match of the sort to the concept) and externally originating (accuracy feedback) information must be integrated to succeed. Excessive reliance on internally generated information and challenges in discriminating information originating internally and externally has been implicated in previous theoretical models of the origin of delusions (Stirling et al., 1998), hallucinations (Keefe et al., 2002), and communication disorders (Harvey, 1985;Batchelder and Riefer, 1990), as well as impairments in self-assessment of cognitive and functional abilities (Durand et al., 2021). Failing to incorporate feedback would seem to render success on the WCST impossible. ...
... In the current report, we note all previously published findings, which overlap minimally with the goals of this sub-study. The overall study structure was such that participants received a baseline diagnostic assessment, answered ecological momentary assessment questions up to 3 times a day for 30 days, and completed an endpoint assessment (Durand et al., 2021). The current data were all collected at that endpoint assessment. ...
... In addition, individuals with bipolar disorder also had to meet stage 3 or higher indicating at least one mood episode recurrence or incomplete remission from a first episode according to the staging model by Frank et al. (2015). For a detailed description of the study protocol please see our previous reports (Durand et al., 2021;Harvey et al., 2021;Jones et al., 2021;Strassnig et al., 2021b). This is an updated data set that includes all data collected to date. ...
... As detailed in our previous reports (Durand et al., 2021;Jones et al., 2021;Strassnig et al., 2021b), a Samsung smartphone with Android OS was used to collect the EMA data. Participants either used their own device or a device was provided to them for use during the 30-day EMA period. ...
Introduction:
Mood states have been reported to manifest a cross-sectional correlation with self-assessment accuracy across functional domains and psychiatric conditions. Ecological momentary assessment (EMA) provides a strategy to examine the momentary course and correlates of mood states. This study tested the association of moods assessed longitudinally with accuracy of immediate self-assessments of cognitive test performance in participants with schizophrenia and bipolar disorder.
Methods:
240 well-diagnosed participants with schizophrenia and bipolar disorder completed a subset of tests from the MATRICS Consensus Cognitive Battery and an immediate self-assessment of cognitive performance. Differences between actual and self-reported performance were used to index the accuracy of self-assessment. Daily smartphone EMA, 3× per day for 30 days, sampled participants´ momentary moods (sad, happy, relaxed, anxious), aggregated into positive affect and negative affect (NA).
Results:
Bipolar participants had better cognitive performance, but both samples had equivalent mis-estimation. Repeated-measures analyses found that NA did not manifest significant variability over time either between or within participants in the two diagnostic groups. Within-group analyses found that higher average NA was associated with greater mis-estimation and poorer cognitive performance in participants with bipolar disorder, but not in those with schizophrenia.
Conclusion:
Negative moods had a significant association with impairments in self-assessment of cognitive performance in participants with bipolar disorder. Our study did not confirm previous cross-sectional findings of more accurate self-assessment associated with greater NA in schizophrenia. These findings suggest that cross-sectional assessments, particularly self-reports, may lead to different results than aggregated data from longitudinal evaluations.
... Second, sadness may increase loneliness by negatively affecting one's interpretation and experience of relationships with others, irrespective of the actual state of those relationships. This phenomenon, which we refer to as the 'extended sadness' hypothesis, nds con rmation in research showing that people experiencing high levels of sadness tend to generate negatively biased ratings of their social functioning compared to ratings generated by observers 53 . Additionally, although sadness is primarily associated with a social context, it can also be triggered by non-social factors, such as loss of good health 54 . ...
This study uses a cross-lagged panel network model with a sample of 4,333 children (Mage = 11.06, SD = 0.73; 50.8% girls at T1) to examine the relationship between loneliness and depressive symptoms over a two-year period. The cross-sectional network shows that loneliness is strongly associated with sadness, perceived parental pressure, and boredom. The longitudinal network suggests: (1) a reciprocal link between loneliness and both sadness and parental pressure; (2) a forward effect of loneliness on anxiety and being busy; (3) the loneliness-reducing effect of prior happiness and loneliness-increasing effect of boredom. This research highlights the complex interplay of emotions in adolescents, emphasizing the need for targeted interventions to address the interrelated emotional and social issues associated with the risk of loneliness and depression.
... The researchers found that introspective accuracy scores were statistically different from 0 for all SLOF scales but that the introspective bias scores were symmetrically distributed around 0, indicating that participants both over-and under-estimated performance. Durand and colleagues [34] collected self-reported and either informant-reported or researcher-rated scores on the SLOF interpersonal functioning subscale. They found that participants with SSDs overestimated their social functioning compared to informants and researchers; they further reported that, when compared to a subgroup with bipolar disorders, individuals with SSDs did not overestimate their functioning more than those with bipolar disorders. ...
Background: An important aspect of recovery in schizophrenia relates to one’s subjective, lived experience. Self-report is a subjective measurement method with yet-uncertain utility in the assessment of functioning among individuals diagnosed with schizophrenia-spectrum disorder. No review to date has comprehensively synthesized existing research to evaluate the degree of correspondence, or lack thereof, between subjective and objective assessments of cognitive and everyday functioning, nor how extant data can inform the use of self-reported information in treatment and research. Methods: A systematic review was completed to provide a broad perspective of the literature on this topic. Relevant manuscripts were identified via a search strategy using key terms in PubMed and PsycINFO and a review of manuscript bibliographies. Twenty-six studies met the inclusion criteria. Results: These studies show minimal to modest associations between subjective assessments of cognition and everyday functioning and objective assessments of these domains, including informant reports and neuropsychological and behavioral measures. Individuals with schizophrenia appear to overestimate their functioning when compared to objective measures. Depression and greater cognitive ability tend to predict greater correspondence between subjective and objective assessments of cognition and everyday functioning. Discussion: This review discusses how we might understand the low correspondence between subjective and objective measures of functioning and provides recommendations for using and eliciting self-reported information in the pursuit of recovery-centered practices.
... BD is a chronic disorder characterized by recurrent manic and depressive episodes. It causes mood swings, increased suicide rates [3,4], self-injuries and other harms [5,6], cognitive impairments [7,8], sleep-wake rhythm disturbances [9], impaired social functioning [10,11], and presenteeism and absenteeism [12]. BD is treated with a combination of therapies, including medications, such as mood stabilizers and atypical antipsychotics, psychotherapy, family education, and social skills training. ...
Treatment of bipolar disorder is prone to prolongation despite various treatments, including medication. The efficacy of exercise treatment (i.e., interventions involving physical exercise and sports intervention) for major depressive disorders has been reported for depressive symptoms, cognitive function, and sleep disturbances. However, its efficacy for bipolar disorder has yet to be established. We designed a randomized, controlled, double-blind clinical trial that includes 100 patients with bipolar disorder aged 20–65 years. This will be a cluster-randomized, two-group trial that will be conducted in ten psychiatric hospitals. The hospitals will be randomly assigned to an exercise intervention + treatment as usual (exercise) group or a placebo exercise intervention (stretching) + treatment as usual (control) group. Patients will be assessed using an extensive battery of clinical tests, physical parameters, sleep status, biological parameters (cytokines, neurotrophic factors), and genetic parameters (DNA and RNA) at baseline after a 6-week intervention period, at 10-week follow-up, and at 6-month follow-up. This innovative study may provide important evidence for the effectiveness of exercise in the treatment of bipolar depression based on clinical, biological, genetic, and physiological markers.
... To capture social behavior and motivation in more ecologically valid contexts, researchers have begun relying on ecological momentary assessment (EMA). [22][23][24][25] EMA involves the collection of surveys in the context of daily life, typically sampling multiple times per day for several days. Surveys in studies examining social functioning usually assess internal experience (eg, how interested a Social Motivation and Psychosis Risk participant is in a social interaction or how much they desire to interact with others) and social behavior (eg, whether they are interacting with another person or not, whom they are interacting with, and the modality of interaction). ...
Background and hypotheses:
Poor social functioning is common among individuals at clinical high-risk (CHR) for psychosis and is associated with greater likelihood of conversion. Unfortunately, processes contributing to social impairment are unclear, making social functioning difficult to improve via treatment. The current study examined whether abnormalities in social functioning result from aberrant temporal interactions between social motivation and behavior.
Study design:
Participants included 105 individuals at CHR and 62 healthy controls (CN) who completed 6 days of ecological momentary assessment. Multilevel models examined time-lagged interactions between social behavior and motivation.
Study results:
CHR and CN did not differ in social motivation; however, CHR were less likely to interact with family and coworkers and more likely to engage in interactions via phone and text/social media. Autocorrelations indicated that social behavior and motivation were generally consistent across time in CHR and CN groups. Time-lagged analyses indicated that both groups had an increase in social motivation across time when they were alone and a decrease in social motivation across time when they were with others. However, the relative decrease when with others and increase when alone were less robust in CHR than CN, particularly for in-person interactions. Social motivation at time t did not differentially impact social partner or modality at time t+1 in the groups.
Conclusions:
Findings suggest that social behavior and motivation have different temporal interactions in CHR and CN. Psychosocial interventions may benefit from targeting the frequency of social behavior with specific partners and modalities to change social motivation.
... In addition, patients with mild or moderate TD may lack insight into their movements and therefore fail to recognize the presence of stigma or burden because of their TD and, therefore, do not report it in an online questionnaire. Indeed, a recent study 19 indicated a divergence between real versus self-reported social function of patients with schizophrenia or BD. Moreover, this survey was conducted during the COVID-19 pandemic, which may have influenced patient experiences. ...
Objective: To assess the physical, psychological, social, and professional impact of tardive dyskinesia (TD) on patients in the United States. Methods: An online survey (April 2020-June 2021) to assess patient burden of TD was developed using targeted literature review and interviews with clinicians, patients, and caregivers. Survey participants (aged ≥ 18 years) with current diagnoses of TD and schizophrenia, bipolar disorder, or major depressive disorder rated the 7-day impact of TD on their physical, psychological, and social functioning via Likert scales (scored from 1 [least impact] to 5 [most impact]). Impact scores were calculated and summarized descriptively overall by self-reported disease severity and underlying disease. Participants also completed the Work Productivity and Activity Impairment Questionnaire and reported the impact of TD on their underlying psychiatric condition. Results: Overall, 269 patients (mean [SD] age = 40.6 years [9.9]; 74.7% employed) responded to the survey. Mean (SD) impact scores of 3.1 (0.9), 3.5 (1.0), and 3.2 (1.1) were reported in the physical, psychological, and social domains, respectively, and scores increased with reported TD symptom severity. Patients with underlying schizophrenia reported the highest burden for all domains. Patients reported 66.2% activity impairment because of TD. Employed patients (n = 193) indicated 29.1% absenteeism, 68.4% presenteeism, and 73.5% overall work impairment. Over one-third of patients reported skipping/reducing (48.4%) or stopping (39.3%) their antipsychotic medication and stopping visits to clinicians treating their underlying condition (35.7%) because of TD. Conclusion: TD imposes a substantial burden on patients' physical, psychological, social, and professional lives and impacts management of their underlying condition.
... The Hinting Task bears its own limitation, including poor testretest reliability in an early psychosis sample (63) and high chances of having ceiling effects in community samples (25,64). There is a need to develop more refined outcome measurements for the SCIT, such as self−/ informant-report or ecological social cognition measures (65,66) to capture social cognitive processes which are typically unfold in daily life (67, 68) that cannot be reflected in traditional scales. This study observed a small effect of reduction in attributional bias and jumping to conclusion tendency among SCIT completers, as compared with those receiving conventional rehabilitation only. ...
Social cognitive impairment is a core limiting factor of functional recovery among persons with first episode psychosis (FEP). Social Cognition and Interaction Training (SCIT) is a group-based, manualized training with demonstrated evidence in improving social cognitive performance among people with schizophrenia. However, there are few studies on the effect of SCIT for people with FEP and for people in non-Western societies. This study evaluated the feasibility, acceptability and initial effectiveness of the locally-adapted SCIT in improving social cognitive functioning in Chinese people with FEP. The SCIT was delivered two sessions per week over a 10-weeks period, each session lasted for 60–90 min. A total of 72 subjects with FEP were recruited from an outpatient clinic and randomized to conventional rehabilitation (“Rehab”) and experimental (“SCIT and Rehab”) groups. Primary outcome measures included four social cognitive domains including emotion perception, theory-of-mind, attributional bias and jumping-to-conclusion, and secondary measures included neurocognition, social competence and quality of life. Participants were assessed at baseline, post-treatment, and 3-months post-treatment. Repeated measures ANCOVAs, with baseline scores as covariates, were used to compare the group differences in various outcomes across time. The results showed that the SCIT was well-accepted, with a satisfactory completion rate and subjective ratings of relevance in the experimental group. Moreover, treatment completers (n = 28) showed evidence of an advantage, over conventional group (n = 31), in reduced attributional bias and jumping-to-conclusions at treatment completion, lending initial support for the SCIT in Chinese people with FEP. Future research should address the limitations of this study, using more refined outcome measurements and higher treatment intensity of the SCIT.
... Such multi-modal integration has been noticed and highlighted in our previous perspective (Schilbach, 2016). However, a synthesis of these approaches in empirical studies on clinical psychiatric cohorts remains to be conducted, despite existing studies on social functioning in PSZ (Schwarz et al., 2020;Durand et al., 2021;Hu et al., 2022). Computational methods in schizophrenia have mostly been generative models based on the Bayesian predictive coding framework-for example, the hierarchical Gaussian filtering approach (Powers et al., 2017;Henco et al., 2020;Charlton et al., 2022;Sheffield et al., 2022), reinforcement learning (Pratt et al., 2021;Geana et al., 2022), and the active inference Markov decision process model that attempts to dissect unobservable mechanistic variables based on actions taken by an agent to promote desired outcomes (Friston et al., 2016). ...
Social functioning impairment is a hallmark of mental illness. As one of the most intractable and severe psychiatric disorders, schizophrenia is characterized by deficits on multiple social cognitive domains. In particular, failures of interpersonal coordination (i.e., actions that occur in spatial and temporal concordance with those of other individuals in a social setting) in schizophrenia are closely linked to significant prognostic indicators, such as symptom remission, quality of life, and employment. Despite the increasing interest in the psychological and neural mechanisms of interpersonal coordination in schizophrenia, important gaps in our understanding remain. Notably, the study of the mechanisms underpinning interpersonal coordination is currently undergoing a methodological shift, moving its focus from single-person tasks to second- and multi-person paradigms, and from model-free to model-based analyses. However, applications of these advanced approaches in schizophrenia has been slow. Here, we provide a concise update on the uses of multi-person paradigms to study interpersonal coordination and mathematical models to dissect its computational mechanisms, at both behavioral and neural levels. We then review prior studies on large-scale neuroimaging studies that explore brain correlates of general social functions and further pointed to the implementation of dissecting interpersonal coordination deficits in schizophrenia. Finally, we highlight key challenges as well as exciting opportunities for integrating research in computational psychiatry with second- and multi-person approaches in investigating interpersonal coordination deficits in schizophrenia.
... Other things equal, being home (versus away), alone (vs with someone, particularly someone of your own choosing), and engaging in relatively more unproductive activities (pacing, smoking, watching TV, resting, sitting alone, doing nothing) would be evidence for greater severity of avolition, particularly if accompanied by the subjective lack of motivation to do anything different. Using EMA to ask the simple question: "Where are you?" is a valuable strategy that has been shown to correlate with clinical ratings of negative symptoms 13,[20][21] . The proportion of surveys answered with "home" as an outcome provides a simple but powerful index of location. ...
In contrast to the validated scales for face-to-face assessment of negative symptoms, no widely accepted tools currently exist for remote monitoring of negative symptoms. Remote assessment of negative symptoms can be broadly divided into three categories: 1) remote administration of an existing negative-symptom scale by a clinician, in real time, using videoconference technology to communicate with the patient; 2) direct inference of negative symptoms through detection and analysis of the patient’s voice, appearance or activity by way of the patient’s smartphone or other device; and 3) ecological momentary assessment (EMA), in which the patient self-reports their condition upon receipt of periodic prompts from a smartphone or other device during their daily routine. These modalities vary in cost, technological complexity, and applicability to the different negative symptom domains. Each modality has unique strengths, weaknesses, and issues with validation. As a result, an optimal solution may be more likely to employ several techniques than to use a single tool.
For remote assessment of negative symptoms to be adopted as primary or secondary endpoints in regulated clinical trials, appropriate psychometric standards will need to be met. Standards for substituting one set of measures for another, as well as what constitutes a “gold” reference standard, will need to be precisely defined and a process for defining them developed. Despite over four decades of progress towards this goal, significant work remains to be done before clinical trials addressing negative symptoms can utilize remotely assessed secondary or primary outcome measures.
... However, participants who reported finding being alone more pleasant had poorer functional outcomes at a 2-year follow-up. We previously found, using EMA in a different sample (Durand et al., 2021), that the subset of people with schizophrenia who were commonly home and alone reported that they had lower levels of sadness and better real-world functioning than people who were more commonly away from home with others. ...
Introduction:
Many people with schizophrenia report low levels of negative affect (NA), which may reflect biases in emotion processing. In the general population there is an inverse correlation between positive affect (PA) and NA. It is possible that this relationship is different among people with schizophrenia. This study aims to understand the relationship between PA and NA among people with schizophrenia, and explore PA and NA variability in relationship to social context.
Method:
105 participants with schizophrenia answered ecological momentary assessment (EMA) surveys seven times/day for seven days. They reported their experiences of mood states on a scale of one to seven: happiness, sadness, relaxation, and anxiety, as well as their social context (alone vs. with someone). Mood variability was calculated using the mean square of successive difference, and multilevel modeling was used to understand the time-course of reported moods within- and between-person.
Results:
45% of surveys reported the absence of NA, though there was an inverse within-subjects correlation between PA and NA. Between-subjects, there was a large inverse correlation between PA and NA. Greater mood variability was associated with a greater number of social interactions.
Discussion:
The results of this study point to both the role of social context in mood variability, and momentary trends in mood experiences, with some individuals reporting no NA, some indicating both PA and NA, and some indicating a more normative affect pattern. Later research should address the possible impact of emotion perception bias and social interactions on moods states in schizophrenia.
... In the last few years, interpersonal tasks, large-scale neuroimaging, and computational models have been used to investigate the mechanisms of social and interpersonal functions in healthy populations; however, a synthesis of these approaches in clinical psychiatric cohorts is lacking despite many studies on social functioning in PSZ (Schwarz et al. 2020;Durand et al. 2021;Hu et al. 2022). Computational methods in schizophrenia have mostly been generative models based on the Bayesian predictive coding framework-for example, the hierarchical Gaussian filtering approach (Powers et al. 2017;Charlton et al. 2022;Sheffield et al. 2022), Markov decision process (ie, reinforcement learning) (Pratt et al. 2021;Geana et al. 2022), and an active inference framework that combines these and other models but describes unobservable mechanistic variables based on actions taken by an agent to promote desired outcomes (Friston et al. 2016). ...
Social functioning impairment is a hallmark of mental illness. As one of the most intractable and severe psychiatric disorders, schizophrenia showed deficits on multiple social cognitive domains. In particular, interpersonal coordination failures in schizophrenia are closely linked to significant prognostic indicators, such as symptom remission and quality of life. Despite the surge of interest in the psychological and neural mechanisms of interpersonal coordination in schizophrenia, important gaps in our understanding remain. Notably, the study of the mechanisms underpinning interpersonal coordination is currently undergoing a methodological shift, moving its focus from single-person tasks to multi-person paradigms, and from model-free analyses to model-based analyses. Notwithstanding, applications of these advanced approaches in schizophrenia have been slow. Here, we provide a concise update on the uses of multi-person paradigms to study interpersonal coordination and mathematical models to dissect its computational mechanisms, at both behavioral and neural levels. We then review prior studies on the interpersonal coordination deficits in schizophrenia and large-scale neuroimaging studies that explore brain correlates of social functions. Finally, we highlight key challenges as well as exciting opportunities for integrating research in computational psychiatry with multi-person approaches in investigating interpersonal coordination deficits in schizophrenia.
... For example, Strassnig et al. (2018) reported that participants with schizophrenia and bipolar disorder who were not living independently reported the same level of disability as those who were paying for their own housing. Durand et al. (2021) noted that self-reports of social functioning were uncorrelated with the actual performance of socially relevant activities over a 30-day, 90-survey ecological momentary assessment (EMA) study of participants with bipolar disorder and schizophrenia, although observers' ratings of social functioning were correlated with these outcomes. ...
Participants with schizophrenia (SCZ) and bipolar disorder (BD) have challenges in self-evaluation of their cognitive and functional abilities, referred to as introspective accuracy (IA). Although psychotic symptoms are commonly found to be uncorrelated with cognitive performance, many models of the development of delusions focus on failures in self-assessment and responses biases during momentary monitoring. We performed a single 4-test cognitive assessment on 240 participants (schizophrenia n = 126; bipolar disorder n = 114) and asked them to make a judgment about their performance immediately after completion of each task. We related performance and these judgments to results of Ecological Momentary Assessments (EMA) of the momentary occurrence of psychotic symptoms (Voices, paranoid ideas, other delusions) collected over up to 90 surveys over a 30 days prior to the single cognitive assessment. We examined test performance and the accuracy of self-assessment at that assessment, looking at diagnostic differences in performance and mis-estimation of performance. Participants with bipolar disorder had better cognitive performance, but there were no differences in mis-estimation. Analyses of the correlation between cognitive performance and self-assessment were all significant and better cognitive performance predicted reduced errors in self-assessment. Examination of the 30-day course of psychotic symptoms and IA could only be performed in participants with schizophrenia, revealing correlations between more common occurrences of all three psychotic symptoms and increased absolute values for IA errors. These data are consistent with theories of cognitive response biases and the formation of delusions.
... Given the reduced life expectancy associated with severe mental illness and the high prevalence of metabolic syndrome, EMA can be used to estimate the amount of time spent sitting versus standing or otherwise engaged in active behaviors. Given that contemporary EMA can collect the occurrence of multiple different activities since the last survey, it is quite easy to see whether only one activity has occurred since the last survey or whether participants are engaging in multiple concurrent activities, including physical activities (88). When paired with the passive digital phenotyping described below, a comprehensive EMA assessment can examine location and social context, refine measurements of activity (exercise vs. agitation), detect sleeping during the daytime and not at night, and assess concurrent subjective emotional responses to these activities. ...
Technology is ubiquitous in society and is now being extensively used in mental health applications. Both assessment and treatment strategies are being developed and deployed at a rapid pace. The authors review the current domains of technology utilization, describe standards for quality evaluation, and forecast future developments. This review examines technology-based assessments of cognition, emotion, functional capacity and everyday functioning, virtual reality approaches to assessment and treatment, ecological momentary assessment, passive measurement strategies including geolocation, movement, and physiological parameters, and technology-based cognitive and functional skills training. There are many technology-based approaches that are evidence based and are supported through the results of systematic reviews and meta-analyses. Other strategies are less well supported by high-quality evidence at present, but there are evaluation standards that are well articulated at this time. There are some clear challenges in selection of applications for specific conditions, but in several areas, including cognitive training, randomized clinical trials are available to support these interventions. Some of these technology-based interventions have been approved by the U.S. Food and Drug administration, which has clear standards for which types of applications, and which claims about them, need to be reviewed by the agency and which are exempt.
... We previously reported that participants who were routinely home and alone reported better social functioning than participants who spent more time with others, as well as notable reductions in sad moods (Jones et al., 2021). Participants with schizophrenia and bipolar disorder displayed a disassociation between the occurrence of momentary activities and their global self-assessments at the end of the EMA period (Durand et al., 2021). Positive schizophrenia symptoms have been associated with the overestimation of various skills (Gohari et al., 2022), particularly reporting high levels of competence in activities that were never performed during the EMA period (e.g., scoring yourself as "superior" at taking public transportation while never leaving home over a 30-day period). ...
Milestone achievements are reduced in people with schizophrenia and are lower in comparison to people with bipolar disorder. However, it is not clear what the implications are for engagement in momentary activities based on milestone achievements. Further, some recent research has suggested that psychotic symptoms are associated with challenges in self-assessment of activities, but there is less information about the correlations of milestone achievements and ongoing psychotic symptoms. We examined momentary activities and symptoms as a function of lifetime milestone achievement in 102 individuals with schizophrenia and 71 with bipolar disorder. Ecological Momentary Assessment (EMA) was used to sample daily activities and concurrent symptoms 3 times per day for 30 days. Each survey asked the participant where they were, who they were with, and what they were doing, as well as sampling the concurrent presence of psychotic symptoms. Not being financially responsible for their residence was associated with engaging in fewer productive activities. Participants who never had a relationship were more commonly home and alone and engaged in fewer social interactions. A lifetime history of employment was correlated with engaging in more productive activities, including at home. More common momentary psychosis was seen in participants who failed to achieve each of the functional milestones. Lifetime milestone achievements were associated with greater frequencies of productive behaviors and with fewer momentary experiences of psychosis, suggesting that psychotic symptoms may have importance for sustaining disability that would be challenging to detect without momentary information.
... Measuring current functioning, moods, and symptoms using smartphone-based ecological momentary assessment (EMA) surveys has the potential to reduce recall bias or the risk that retrospective self-reports of functioning or mood state are reflective of current mood states, not reflecting an accurate aggregation of experiences during the recall period . In specific, for both participants with schizophrenia and bipolar disorder (Durand et al., 2021), EMA-based momentary reports of socially relevant activities were correlated with observer ratings of social functioning, while being completely unrelated to self-reports of functioning. EMA surveys captured the activities that observers rated as reflecting social functioning, bypassing the unawareness of functioning reflected in the self-reported outcomes. ...
Background:
Previous weekly sampling studies found that persistent sad moods are associated with disability in bipolar illness. However, those data were collected retrospectively. We examined the momentary quality of activities (productive, unproductive, and passive recreation) in an ecological momentary assessment (EMA) study and related sadness at each survey to quality of momentary activities and overall everyday functioning.
Methods:
Participants with bipolar illness (N = 91) were sampled three times per day for 30 days. Each survey queried participants as to where they were, with whom, what they were doing, and their mood state. Activities were characterised according to predetermined criteria and related to momentary sadness. Observer ratings of everyday functioning were related to daily reports of sadness and activities.
Results:
Sadness was associated with the quality of activities. Momentary reports of unproductive activities were associated with the most sadness (p < .001), followed by passive recreation, and productive activities. Momentary sadness and momentary unproductive activities correlated with observer ratings of competence in work, everyday activities, and social outcomes (p < .001). Using both predictors led to the best model.
Conclusions:
This study on the course of sad moods in people with bipolar illness to EMA found that momentary sadness correlatesdwith the quality of concurrent activities and that both sadness and the quality of everyday activities predicted observer ratings of everyday functioning. Although we cannot determine the causal direction, these findings support the hypothesis that momentary sadness leads to reductions in productive activities and impairments in everyday functioning.
... The correlation between impaired IA and everyday functioning exceeds the contribution of ability variables (Gould et al., 2015;Silberstein, Pinkham, Penn, & Harvey, 2018). People with psychotic disorders demonstrate poor IA in multiple domains, including cognition, social cognition, functional capacity, and everyday functioning, and across various measurement approaches (Durand et al., 2021;Gould et al., 2015;Harvey & Pinkham, 2015;Tercero et al., 2021). ...
Background
Inaccurate self-assessment of performance is common among people with serious mental illness, and it is associated with poor functional outcomes independent from ability. However, the temporal interdependencies between judgments of performance, confidence in accuracy, and feedback about performance are not well understood.
Methods
We evaluated two tasks: the Wisconsin Card Sorting Test (WCST) and the Penn Emotion recognition task (ER40). These tasks were modified to include item-by-item confidence and accuracy judgments, along with feedback on accuracy. We evaluated these tasks as time series and applied network modeling to understand the temporal relationships between momentary confidence, accuracy judgments, and feedback. The sample constituted participants with schizophrenia (SZ; N = 144), bipolar disorder (BD; N = 140), and healthy controls (HC; N = 39).
Results
Network models for both WCST and ER40 revealed denser and lagged connections between confidence and accuracy judgments in SZ and, to a lesser extent in BD, that were not evidenced in HC. However, associations between feedback regarding accuracy with subsequent accuracy judgments and confidence were weaker in SZ and BD. In each of these comparisons, the BD group was intermediate between HC and SZ. In analyses of the WCST, wherein incorporating feedback is crucial for success, higher confidence predicted worse subsequent performance in SZ but not in HC or BD.
Conclusions
While network models are exploratory, the results suggest some potential mechanisms by which challenges in self-assessment may impede performance, perhaps through hyperfocus on self-generated judgments at the expense of incorporation of feedback.
... Artificial intelligence-based data acquisition and ecological momentary assessments provide real-world data that may provide valuable insights into psychosis (Durand et al., 2021;Parrish et al., 2020). Deep learning applications are likely to be increasingly relevant to unravel the neurobiology, understand the transition, prognosticate and practice personalized precision medicine in schizophrenia (Cortes-Briones et al., 2021). ...
... Les données des experts étaient encore plus significativement liées à la performance des patients (r = 0,54 ; p = 0,001), sur la base des rapports d'auto et d'hétéro-évaluation (Keefe et al., 2006c). Une étude récente a révélé que les participants atteints de schizophrénie ont évalué leur fonctionnement social de manière significativement meilleure que les observateurs, alors qu'il n'y avait aucune différence en moyenne entre leurs auto-évaluations et les évaluations des observateurs (Durand et al., 2021). Cependant, une simple mesure d'auto-évaluation, telle que l'autoévaluation des troubles de la cognition sociale (ACSo), devrait être efficace pour aider et guider le traitement effectué par les cliniciens . ...
Les déficits cognitifs sont perçus comme une caractéristique fondamentale de la schizophrénie. Les fonctions cognitives les plus affectées sont particulièrement la mémoire, l'attention, la motricité, les fonctions exécutives et la cognition sociale. L’évaluation cognitive est l’un des meilleurs indicateurs du pronostic fonctionnel et social des individus. Cette évaluation devient une partie fondamentale dans la pratique clinique et dans la recherche et utilise des batteries qui diffèrent largement dans leurs contenus. En plus, l'évaluation subjective des fonctions cognitives peut donner une vue plus complète du profil cognitif d'un individu, mais elle ne peut pas remplacer les mesures d'évaluation objectives, car l'autoévaluation par les patients de leur fonctionnement neurocognitif peut ne pas être tout à fait exacte. Les plaintes cognitives subjectives sont de plus en plus largement reconnues comme des indicateurs de dysfonctionnement cognitif potentiel, avec des preuves suggérant que de telles plaintes sont un précurseur de troubles cognitifs. Ainsi, il est essentiel de comprendre et d'évaluer la conscience qu’ont les patients de leur état cognitif.Le travail de thèse présenté ici à plusieurs objectifs. Dans un premier temps, nous traitons des généralités concernant la schizophrénie, les fonctions cognitives altérées et leurs évaluations en faisant par ailleurs un état des lieux de leur évaluation au Liban. Dans un deuxième temps, afin de pouvoir évaluer les fonctions cognitives chez des patients schizophrènes institutionnalisés, nous exposons nos travaux de validation d’outils de diagnostic et de dépistage des troubles cognitifs chez les sujets schizophrènes. Dans un dernier temps, nous exposons notre étude des plaintes cognitives subjective chez les patients schizophrènes et les facteurs reliés à celles-ci.Les résultats de ce travail ont abouti à la validation en langue arabe d’une batterie cognitive, le BACS chez des patients schizophrènes. Le BACS arabe est un outil fiable et utile pour mesurer les performances cognitives chez les patients hospitalisés atteints de schizophrénie. De plus, les qualités psychométriques satisfaisantes du MoCA en font un outil de dépistage rapide des fonctions cognitives de ces patients. En outre, nos résultats ont montré que les patients ayant un déficit cognitif objectif pouvaient être conscients de leur déficit cognitif malgré une conscience de la maladie (insight) faible. Les facteurs les plus contributifs de la plainte cognitive subjective étaient la sous-échelle de psychopathologie générale de la PANSS, l’échelle d’autonomie dans les actes de la vie quotidienne (ADL) alors que celles prédictives plus spécifiquement de la plainte dans le domaine de la cognition sociale étaient l’échelle de dépression (Calgary).L’ensemble de nos travaux a démontré des propriétés psychométriques adéquates d’une batterie neurocognitive, le BACS et d’un outil de dépistage, le MOCA en langue Arabe, respectivement dans le diagnostic et le dépistage des déficits cognitifs chez les patients schizophrènes. Nos études pourraient aider les cliniciens à appliquer ces instruments valides dans leur pratique clinique quotidienne et à inclure des stratégies de réadaptation cognitive dans le plan de traitement des patients atteints de schizophrénie ; ce qui fait défaut à l’heure actuelle dans les pays du Moyen Orient. Enfin, nos études ont montré que les patients schizophrènes se plaignent de leur cognition. D'autres études prospectives sont nécessaires pour mieux comprendre les atteintes cognitives chez les patients schizophrènes afin d'aider à y remédier et permettre ainsi un meilleur fonctionnement au quotidien et une vie hors des institutions psychiatriques.
... The assessors' ratings were even more significantly connected with patients' performance (r = 0.54, p.001), based on self and informant reports (Keefe et al., 2006). A recent study found that participants with schizophrenia rated their social functioning significantly better than the observers, while there was no difference on average between their selfreports and the observer ratings (Durand et al., 2021). However, a simple self-assessment measure, such as Self-Assessment of Social Cognition Impairments (ACSo), should be effective in guiding the clinicians' selection of treatment targets . ...
Objective: The primary objective was to evaluate social cognitive complaints in a sample of chronic in-patients with schizophrenia and compare it to healthy controls. The secondary objective was to explore factors related to social cognitive complaints in these patients, such as neurocognition, clinical symptoms, depression, and insight.
Methods: A cross-sectional study conducted between July 2019 and March 2020 at the Psychiatric Hospital of the Cross (HPC)-Lebanon enrolled 120 chronic in-patients diagnosed with schizophrenia and schizoaffective disorders and 60 healthy controls. The Self-Assessment of Social Cognition Impairments (ACSo) scale was used to assess social cognitive complaints.
Results: A significant difference was found between schizophrenia patients and healthy controls in all social cognitive complaints: theory of mind complaint, attributional biases complaint, emotional processes complaint, and social perception and knowledge complaint (p < 0.001 for all). All objective cognitive disorders were significantly associated with social cognitive complaints except for attention and speed of information processing. Higher verbal memory and verbal fluency were significantly associated with lower emotional processes complaint scores. The results of the multivariate analysis showed that a higher cognition (Beta = -0.08, p = 0.001) was significantly associated with a lower total social cognitive complaint, contrary to a higher depression (Beta = 0.38, p = 0.04) was significantly associated with a higher social cognitive complaint, in particular attributional biases complaints.
Conclusion: This study showed that patients with schizophrenia have complaints about their social cognition. It could also demonstrate that subjective social cognitive complaints are correlated with depressive symptoms and objective cognitive deficits among these patients.
There is a broad consensus that the commonly used clinician administered rating scales for assessment of negative symptoms share significant limitations, including: 1) reliance upon accurate self-report and recall from the patient and caregiver; 2) potential for sampling bias and thus being unrepresentative of daily life experiences; 3) subjectivity of the symptom scoring process and limited sensitivity to change. These limitations led a work group from the International Society of CNS Clinical Trials and Methodology (ISCTM) to initiate the development of a multimodal negative symptom instrument. Experts from academia and industry reviewed the current methods of assessing the domains of negative symptoms including diminished (1) Affect; (2) Sociality; (3) Verbal communication; (4) Goal-directed behavior; and (5) Hedonic drives. For each domain they documented the limitations of the current methods and recommended new approaches that could potentially be included in a multimodal instrument. The recommended methods for assessing negative symptoms included ecological momentary assessment (EMA), in which the patient self-reports their condition upon receipt of periodic prompts from a smartphone or other device during their daily routine; and direct inference of negative symptoms through detection and analysis of the patient’s voice, appearance or activity from audio/visual or sensor-based (e.g., GPS, actigraphy) recordings captured by the patient’s smartphone or other device. The process for developing an instrument could resemble the NIMH MATRICS process that was used to develop a battery for measuring cognition in schizophrenia. Although the EMA and other digital measures for negative symptoms are at relatively early stages of development/maturity and development of such an instrument faces substantial challenges, none of them are insurmountable.
People with serious mental illness (SMI) encounter restrictions in the quantity of their community participation. Less is known about the quality of their participation. We aimed to explore the relationship between symptoms of SMI and the daily experience (i.e., loneliness and enjoyment) of community participation. We examined daily community participation among people with SMI using ecological momentary assessment surveys. We built multilevel models to examine the associations between symptoms of SMI and loneliness or enjoyment during community participation. Our analysis included 183 people among four participant groups: bipolar disorder ( n = 44), major depressive disorder ( n = 46), schizophrenia/schizoaffective disorder ( n = 40), and control ( n = 53). People with schizophrenia engaged in more unstructured activities (e.g., socializing) than people among other groups. Symptom association varied across diagnostic groups. To support tailored intervention development, researchers and practitioners should consider the context of participation and the clinical characteristics of the client.
Heterogeneity in the clinical presentation of schizophrenia impairs both proper and preventative care. The digital phenotyping data gathered from an international multi-site cohort study in people with schizophrenia (SZ) offers a novel opportunity to explore clinically meaningful subtypes in the context of clinical, functional, and cognitive data. Using a set of behavioral features derived from smartphone digital phenotyping, clinical assessment of symptoms including PANSS, clinical assessment of cognition with BACS, and clinical assessment of functioning with the social functioning assessments over the target period of twelve months, we found that the international cohort of 74 patients were categorized into three well-defined clusters that suggest clinically actionable targets from differential correlations in each. Namely, the identified clusters seemed to share phenotypic traits with the affective psychosis with more severe symptomatic presentation, a non-affective SZ with functional impairment, and a higher functioning non-affective SZ cluster. Partial correlation analysis further highlighted the emergence of different features per cluster, where anxiety symptoms were most notable for one group, whereas psychotic symptoms were most notable for the other two. Importantly, we showcase an analysis pipeline that transparently addresses challenges of missing data and potential skew so that this research methodology can be applied to future prospective validation studies. This study hopes to build a foundation for future digital phenotyping clustering work by scaling up to new sites, and populations to uncover the nature and extent of heterogeneity in schizophrenia.
Introduction:
The study explored associations between the accuracy of post assessment judgements of cognitive performance with global self-assessments of psychosocial functioning compared to evaluations generated by observers in schizophrenia and bipolar disorder.
Methods:
An abbreviated cognitive assessment based on the MATRICS Consensus Cognitive Battery was administered to 122 individuals with schizophrenia and 113 with bipolar disorder. They provided self-estimates of their performance after each subtest. In addition, self-reports on cognition, social cognition, and everyday functioning were collected and compared to observer ratings.
Results:
Both groups overestimated their cognitive function, but in bipolar disorder, there was 30% shared variance between task performance and self-rated task performance (vs. 5% in schizophrenia). Significant correlations were found between self-reported everyday outcomes and both actual and self-assessed performance. In schizophrenia, immediate judgements were only related to self-rated functioning, not to observer rated functioning. In bipolar disorder, impairments in self-assessment of performance correlated with observer ratings of cognitive ability, which was not observed in schizophrenia.
Conclusions:
While both groups showed correlations between cognitive performance and introspective accuracy, individuals with bipolar disorder showed higher accuracy in assessing their cognitive performance and other outcomes. Notably, impairments in introspective accuracy were associated with observer-rated functioning exclusively in bipolar disorder.
The relationship between mood and productivity has been a topic of interest for researchers and individuals seeking to improve their work output. Numerous studies have shown that mood can have a significant impact on productivity. Positive moods have been found to increase productivity, while negative moods can decrease productivity. Research suggests that positive moods, such as happiness and contentment, can lead to higher levels of productivity by increasing motivation, creativity, and focus. Positive moods have also been linked to higher levels of job satisfaction and better overall performance. On the other hand, negative moods, such as anxiety and stress, can decrease productivity by causing distractions, impairing decision-making ability, and reducing energy levels. Our study seeks to determine the effect of mood on productivity by applying statistical tools on collected data and testing the hypothesis. In our study it is found that employees who experienced positive moods were able to complete tasks faster and with fewer errors than those in a negative mood. Overall, the evidence suggests that mood plays a crucial role in productivity. By recognizing the impact of mood on productivity, individuals can take steps to cultivate positive moods and manage negative ones, leading to better outcomes both in the workplace and in other areas of life.
Amaç: Çalışmamızın amacı Toplum Ruh Sağlığı Merkezi’nde (TRSM) düzenli takibi olan bireylerin uzun dönemde sosyal işlevsellik ve klinik belirtiler açısından karşılaştırılmasıdır. Ek olarak sosyal işlevsellikteki değişimde depresyon, genel psikopatoloji ve negatif belirtilerin etkisi incelenmiştir. Gereç ve Yöntem: TRSM’de 2014 yılından itibaren tedavi ve rehabilitasyon alan 32 şizofreni tanısı olan birey çalışmaya dahil edilmiştir. Veriler iki zaman kesitinde kaydedilmiştir (2014 - 2021). Bireylerin sosyodemografik, Sosyal İşlevsellik Ölçeği (SİÖ), Kısa Psikiyatrik Değerlendirme Ölçeği (KPDÖ), Negatif Belirtileri Değerlendirme Ölçeği (NBDÖ) ve Calgary Şizofrenide Depresyon Ölçeği (CŞDÖ) verileri değerlendirilmiştir. Sonuçlar: Bireylerin 7 yıl sonraki değerlendirmelerinde sosyal işlevselliğin arttığı, negatif ve depresif belirtiler ile genel psikopatolojinin azaldığı saptandı. Yapılan doğrusal regresyon analizi sonucunda, sosyal işlevselliğin alt boyutları üzerinde CŞDÖ ve BPRS değişkenlerinin; kişiler arası işlevsellik üzerinde BPRS değişkeninin, boş zamanlarını değerlendirme, bağımsızlık-yetkinlik ve bağımsızlık-performans boyutları üzerinde CŞDÖ değişkeninin etkili olduğu görüldü. Tartışma: Psikopatoloji ve depresyon şiddetindeki azalmanın iyileşmenin önemli bir boyutu olan sosyal işlevselliği artırdığına yönelik bulgularımız toplumsal katılımın bireylerin yaşam kalitelerindeki etkisi göz önüne alındığında oldukça önemlidir. Depresyon ve hastalık şiddetine yönelik kontrollerin düzenli olarak yapılması ve gerekli psikososyal tedavi uygulamalarının gerçekleştirilmesi sosyal işlevselliği olumlu yönde etkileyecektir.
Background and hypothesis:
Impairments in function (ie, the ability to independently accomplish daily tasks) have been established in psychotic disorders. Identifying factors that contribute to these deficits is essential to developing effective interventions. The current study had several goals: examine potential differential relationships across domains of neurocognition, assess whether reinforcement learning is related to function, identify if predictors of function are transdiagnostic, determine whether depression and positive symptoms contribute to function, and to explore whether the modality of assessment impacts observed relationships.
Study design:
Data from 274 participants were examined with schizophrenia/schizoaffective disorder (SZ; n = 195) and bipolar disorder (BD; n = 79). To reduce dimensionality, a PCA was completed on neurocognitive tasks which resulted in 3 components. These components and clinical interview data were used to investigate predictors of functional domains across measures of function (self- and informant-report SLOF and UPSA).
Results:
Two components, working memory/processing speed/episodic memory (βs = 0.18-0.42), and negative/positive reinforcement learning (β = -0.04), predicted different functional domains. Predictors of function were largely transdiagnostic with two exceptions: reinforcement learning had a positive association with self-reported interpersonal relationships for SZ and a negative association for BD (β = 0.34), and the negative association between positive symptoms and self-reported social acceptability was stronger for BD than for SZ (β = 0.93). Depression robustly predicted self-reported but not informant-reported function, and anhedonia predicted all domains of informant-reported function.
Conclusions:
These findings imply that reinforcement learning may differentially relate to function across disorders, traditional domains of neurocognition can be effective transdiagnostic targets for interventions, and positive symptoms and depression play a critical role in self-perceived functional impairments.
Background
Avolition is associated cross-diagnostically with extensive functional impairment. Participants with schizophrenia and bipolar disorder (BD) engage in fewer productive activities than healthy controls, with more sedentary activities such as sitting. We examined the temporal variability in activities of participants with schizophrenia and bipolar disorder, focusing on persistence of activities and the likelihood of performing more than one activity at a time.
Methods
101 participants with schizophrenia and 76 participants with BD were sampled 3 times per day for 30 days utilizing Ecological Momentary Assessment surveys. Each survey queried current activities along with questions about who they were with and if they were home or away and moods. We separated activities into productive, unproductive, or passive recreational categories.
Results
Participants with schizophrenia and bipolar disorder reported one activity on most surveys, with that activity commonly being passive or unproductive. No participant reported engaging in more than one productive activity. Productive activities were more likely to occur away from home, with 17 % of surveys from home reporting productive activities. All three activities were persistent, but passive and unproductive activities were more likely than productive activities to be persistent at home. Negative mood states predicted unproductive and passive activities in BD participants only.
Discussion
The low numbers of activities, combined with persistence of unproductive and passive activities highlights the impact of avolition. Most persistent activities reflected sedentary behavior. People with schizophrenia or bipolar disorder may benefit from interventions targeting leaving home more often to improve their general levels of functioning and overall health.
Background
The experience sampling method (ESM) is an intensive longitudinal research method.
Participants complete questionnaires at multiple times about their current or very recent state. The design of ESM studies is complex. People with psychosis have been shown to be less adherent to ESM study protocols than the general population. It is not known how to design studies that increase adherence to study protocols. A lack of typology makes it is hard for researchers to decide how to collect data in a way that allows for methodological rigour, quality of reporting, and the ability to synthesise findings. The aims of this systematic review were to characterise the design choices made in ESM studies monitoring the daily lives of people with psychosis, and to synthesise evidence relating the data completeness to different design choices.
Methods
A systematic review was conducted of published literature on studies using ESM with people with psychosis. Studies were included if they used digital technology for data collection and reported the completeness of the data set. The constant comparative method was used to identify design decisions, using inductive identification of design decisions with simultaneous comparison of design decisions observed. Weighted regression was used to identify design decisions that predicted data completeness. The review was pre-registered (PROSPERO CRD42019125545).
Results
Thirty-eight studies were included. A typology of design choices used in ESM studies was developed, which comprised three superordinate categories of design choice: Study context, ESM approach and ESM implementation. Design decisions that predict data completeness include type of ESM protocol used, length of time participants are enrolled in the study, and if there is contact with the research team during data collection.
Conclusions
This review identified a range of design decisions used in studies using ESM in the context of psychosis. Design decisions that influence data completeness were identified. Findings will help the design and reporting of future ESM studies. Results are presented with the focus on psychosis, but the findings can be applied across different mental health populations.
Purpose
Early detection and intervention of mental health problems in youth are topical given that mental disorders often start early in life. Young people with emerging mental disorders however, often present with non-specific, fluctuating symptoms. Recent reports indicate a decline in social functioning (SF) as an early sign of specific emerging mental disorders such as depression or anxiety, making SF a favorable transdiagnostic approach for earlier detection and intervention. Our aim was to investigate the value of SF in relation to transdiagnostic symptoms, and as a predictor of psychopathology over time, while exploring traditional retrospective versus innovative daily diary measurements of SF in youth.
Method
Participants (N = 75) were 16–25 years of age and presented early stage psychiatric symptomatology. Psychiatric symptoms, including anxiety and depression, as well as SF -both in retrospect and in daily life- were assessed at two time points and analyzed cross-sectionally and longitudinally.
Results
A significant and negative association between SF and all psychiatric symptoms was found, and SF was a significant predictor of change in general psychiatric symptoms over time. Results were only significant when SF was measured traditionally retrospective.
Conclusion
This study confirms a distinct relation between SF and transdiagnostic psychiatric symptoms in youth, even in a (sub)clinical population, and points towards SF as a predictor of transdiagnostic psychiatric symptoms. Further research is needed to learn more about the added value of daily life versus retrospective measurements.
Background
Smartphone assessments and sensors offer the ability to easily assess symptoms across environments in a naturalistic and longitudinal manner. However, the value of this new data to make inferences about personal vs population health and the role of environment in moderating symptoms in schizophrenia has not been fully explored in a scalable and reproducible manner.
Methods
Eighty-six adults with a diagnosis of schizophrenia were recruited from the Greater Boston Area between August 2019 and May 2021. Using the open-source mindLAMP app in an observational manner, smartphone surveys and sensors (GPS, accelerometer, screen on/off and call and text logs) were collected for up to six months.
Results
Sixty-three participants were analyzed, who had at least completed one survey in the app. App-based self-reported symptom surveys were highly correlated with scores on gold standard clinical assessments (r = 0.80, p = 10⁻¹¹ for mood and r = 0.78, p = 10⁻¹² for anxiety). For these app-based assessments, inter-individual differences account for a larger proportion of the correlations in longitudinal symptoms as compared to intra-individual differences. Mood, sleep, and psychosis symptoms reported on app surveys were more severe when taken at home as determined by the smartphone's GPS sensor.
Discussion
The intra-individual symptom correlations and the stratification of symptoms by home-time highlight the utility of digital phenotyping methods as a diagnostic tool, as well as the potential for personalized psychiatric treatment building on this data.
Objectives
Schizophrenia participants generate self-reports of their competencies that differ from objective information. They may base their reports on momentary moods or experiences rather than objective data. Theories of delusion formation implicate overconfidence during self-assessment as a cause.
Methods
Ecological momentary assessment (EMA) was used to sample activities and experiences in 101 participants with schizophrenia up to 3 times a day for 30 days. Each survey asked where and with whom they were, what they were doing, and moods and psychotic symptoms they were experiencing. Self-reports and observer ratings of competence in work and everyday activities were collected.
Results
Being home was associated with self-reports of better functioning in activities and work skills (p<.001) and being alone correlated with better self-reported functioning in activities (p<.001). Participants who reported more occurrences of hearing voices, paranoid ideation, and other psychotic symptoms reported their functioning as better (p<.001).
Implications
Schizophrenia was marked by a disconnect between momentary activities and self-assessments. Being home more was associated with better self-reported functioning on tasks that are only performed away from home. Psychotic symptoms were associated with overestimation, consistent with previous theories positing that overconfidence and suspension of plausibility assessment may be associated with psychotic experiences.
The serious mental illness (SMI) phenotype is marked by several different symptom domains and biomedical challenges. The nature of SMI renders in-person assessment challenging, due to problems in event recall, response biases, lack of experience in real-world functional domains, and difficulties identifying informants. Digital strategies offer a promising alternative to in-person assessments and allow for remote delivery of cognitive and social cognitive assessments in addition to continuous momentary assessment of activities, moods, symptoms, expressions, experiences, and psychophysiological variables. Remote assessments of mood, emotion, behavior, cognition, and self-assessment have been successfully collected across various SMI conditions. Both active (paging and triggered observations of facial and vocal expressions) and passive (global positioning, actigraphy) methods have been deployed remotely, similarly to in-person assessments previously conducted in the laboratory. Advanced strategies in data analysis are used to examine this information and to guide the development of newer advances in assessment of phenotypic variation in SMI.
Background
Ecological momentary assessment (EMA) offers a highly valid strategy to assess everyday functioning in people with severe mental illness. Adherence is generally good, but several questions regarding the impact of study length, daily density of sampling, and symptom severity on adherence remain.
Methods
EMA adherence in two separate studies was examined. One sampled participants with schizophrenia (n = 106) and healthy controls (n = 76) 7 times per day for 7 days and the other sampled participants with schizophrenia (n = 104) and participants with bipolar illness (n = 76) 3 times per day for 30 days. Participants were asked where they were, who they were with, what they were doing and how they were feeling in both studies. The impact of rates of very early adherence on eventual adherence was investigated across the samples, and adherence rates were examined for associations with mood state and most common location when answering surveys.
Results
Median levels of adherence were over 80% across the samples, and the 10th percentile for adherence was approximately 45% of surveys answered. Early adherence predicted study-long adherence quite substantially in every sample. Mood states did not correlate with adherence in the patient samples and being home correlated with adherence in only the bipolar sample.
Implications: Adherence was quite high and was not correlated with the length of the study or the density of sampling per study day. There was a tendency for bipolar participants who were more commonly away from home to answer fewer surveys but overall adherence for the bipolar patients was quite high. These data suggest that early nonadherence is a potential predictor of eventual nonadherence and study noncompletion.
Objectives
Disability is common in bipolar disorder (BD) and predicted by persistent sadness. We used ecological momentary assessment (EMA) to examine daily activities in people with BD and schizophrenia. We classified activities as productive, unproductive, or passive recreation, relating them to momentary sadness, location, and social context.
Methods
71 people with BD and 102 people with schizophrenia were sampled 3 times/day for 30 days with an EMA survey. Each survey asked where they were, with whom, what they were doing, and if they were sad.
Results
People with BD were home more than 50% of the time. There were no differences in prevalence of activity types across diagnoses. People with BD were less likely to report only one activity since the prior survey, but the most surveys still reported only one. For both groups, sadness and being home and alone since the last survey was associated with less productive activity and more passive recreation.
Conclusions
Participants with BD and schizophrenia manifested high levels of unproductive and passive activities, predicted by momentary sadness. These activity patterns are consistent with descriptions of avolition and they minimally differentiated people with BD and schizophrenia. Previous reports of negative symptoms in BD may have been identifying these behaviors.
Mobility is an important correlate of physical, cognitive, and mental health in chronic illness, and can be measured passively with mobile phone global positional satellite (GPS) sensors. To date, GPS data have been reported in a few studies of schizophrenia, yet it is unclear whether these data correlate with concurrent momentary reports of location, vary by people with schizophrenia and healthy comparison subjects, or associate with symptom clusters in schizophrenia. A total of 142 participants with schizophrenia (n = 86) or healthy comparison subjects (n = 56) completed 7 days of ecological momentary assessment (EMA) reports of location and behavior, and simultaneous GPS locations were tracked every five minutes. We found that GPS-derived indicators of average distance travelled overall and distance from home, as well as percent of GPS samples at home were highly correlated with EMA reports of location at the day- and week-averaged level. GPS-based mobility indicators were lower in schizophrenia with medium to large effect sizes. Less GPS mobility was related to greater negative symptom severity, particularly diminished motivation, whereas greater GPS mobility was weakly associated with more community functioning. Neurocognition, depression, and positive symptoms were not associated with mobility indicators. Therefore, passive GPS sensing could provide a low-burden proxy measure of important outcomes in schizophrenia, including negative symptoms and possibly of functioning. As such, passive GPS sensing could be used for monitoring and timely interventions for negative symptoms in young persons at high risk for schizophrenia.
Background:
Impairments in social functioning are central to Schizophrenia (SCZ). Patients with SCZ have challenges in the ability to evaluate their functioning. A correlate of self-assessments in SCZ is depression, wherein negligible depression predicts overestimation. Healthy individuals misestimate their functioning, but mild dysthymia predicts accuracy. We examined depression, gender, and schizophrenia as predictors of self-reported everyday functioning.
Methods:
218 people with SCZ and 154 healthy controls self-reported their social functioning. They self-reported their depression with the Beck Depression Inventory (BDI) and their social cognitive ability on the Observable Social Cognition Rating Scale (OSCARS).
Results:
64% of subjects were male. Schizophrenia patients reported more depression, poorer social functioning, and worse social cognition. Linear regression analyses revealed significant correlations between self-reported social functioning and BDI scores, which also predicted self-reported social cognition. There was no significant effect of sex on self-reports of social functioning or social cognition. Finally, when BDI and OSCARS were directly compared to diagnosis and sex for prediction of self-reported social functioning, there was no impact of diagnosis or sex.
Implications:
Self-reported interpersonal functioning is determined by current depression. Both healthy people and people with schizophrenia index their social functioning and their social cognitive by their level of depression.
Impairments in self-assessment in schizophrenia have been shown to have functional and clinical implications. Prior studies have suggested that overconfidence can be associated with poorer cognitive performance in people with schizophrenia, and that reduced awareness of performance may be associated with disability. However, overconfidence is common in healthy individuals as well. This study examines the correlations between performance on a social cognitive test, confidence in performance, effort allocated to the task, and correlates of confidence in patients with schizophrenia and healthy controls (HC). Measures included self-reports of depression, social cognitive ability, and social functioning. A performance-based emotion recognition test assessed social cognitive performance and provided the basis for confidence judgments. Although schizophrenia patients had reduced levels of overall confidence, there was a substantial subset of schizophrenic patients who manifested extreme overconfidence and these people had the poorest performance and reported the least depression. Further, a substantial number of HC over-estimated their performance as well. Patients with schizophrenia, in contrast to HC, did not adjust their effort to match task difficulty. Confidence was minimally related to task performance in patients but was associated with more rapid decisions in HC, across both correct and incorrect responses. Performance on social cognitive measures was minimally related to self-reports of social functioning in both samples. These data suggest global self-assessments are based on multiple factors, with confidence affecting self-assessments in the absence of feedback about performance.
Importance
Biologic systems involved in the regulation of motor activity are intricately linked with other homeostatic systems such as sleep, feeding behavior, energy, and mood. Mobile monitoring technology (eg, actigraphy and ecological momentary assessment devices) allows the assessment of these multiple systems in real time. However, most clinical studies of mental disorders that use mobile devices have not focused on the dynamic associations between these systems.
Objectives
To examine the directional associations among motor activity, energy, mood, and sleep using mobile monitoring in a community-identified sample, and to evaluate whether these within-day associations differ between people with a history of bipolar or other mood disorders and controls without mood disorders.
Design, Setting, and Participants
This study used a nested case-control design of 242 adults, a subsample of a community-based sample of adults. Probands were recruited by mail from the greater Washington, DC, metropolitan area from January 2005 to June 2013. Enrichment of the sample for mood disorders was provided by volunteers or referrals from the National Institutes of Health Clinical Center or by participants in the National Institute of Mental Health Mood and Anxiety Disorders Program. The inclusion criteria were the ability to speak English, availability to participate, and consent to contact at least 2 living first-degree relatives. Data analysis was performed from June 2013 through July 2018.
Main Outcomes and Measures
Motor activity and sleep duration data were obtained from minute-to-minute activity counts from an actigraphy device worn on the nondominant wrist for 2 weeks. Mood and energy levels were assessed by subjective analogue ratings on the ecological momentary assessment (using a personal digital assistant) by participants 4 times per day for 2 weeks.
Results
Of the total 242 participants, 92 (38.1%) were men and 150 (61.9%) were women, with a mean (SD) age of 48 (16.9) years. Among the participants, 54 (22.3%) had bipolar disorder (25 with bipolar I; 29 with bipolar II), 91 (37.6%) had major depressive disorder, and 97 (40.1%) were controls with no history of mood disorders. A unidirectional association was found between motor activity and subjective mood level (β = –0.018, P = .04). Bidirectional associations were observed between motor activity (β = 0.176; P = .03) and subjective energy level (β = 0.027; P = .03) as well as between motor activity (β = –0.027; P = .04) and sleep duration (β = –0.154; P = .04). Greater cross-domain reactivity was observed in bipolar disorder across all outcomes, including motor activity, sleep, mood, and energy.
Conclusions and Relevance
These findings suggest that interventions focused on motor activity and energy may have greater efficacy than current approaches that target depressed mood; both active and passive tracking of multiple regulatory systems are important in designing therapeutic targets.
Introduction:
The global burden of disease (GBD) studies have derived detailed and comparable epidemiological and burden of disease estimates for schizophrenia. We report GBD 2016 estimates of schizophrenia prevalence and burden of disease with disaggregation by age, sex, year, and for all countries.
Method:
We conducted a systematic review to identify studies reporting the prevalence, incidence, remission, and/or excess mortality associated with schizophrenia. Reported estimates which met our inclusion criteria were entered into a Bayesian meta-regression tool used in GBD 2016 to derive prevalence for 20 age groups, 7 super-regions, 21 regions, and 195 countries and territories. Burden of disease estimates were derived for acute and residual states of schizophrenia by multiplying the age-, sex-, year-, and location-specific prevalence by 2 disability weights representative of the disability experienced during these states.
Findings:
The systematic review found a total of 129 individual data sources. The global age-standardized point prevalence of schizophrenia in 2016 was estimated to be 0.28% (95% uncertainty interval [UI]: 0.24-0.31). No sex differences were observed in prevalence. Age-standardized point prevalence rates did not vary widely across countries or regions. Globally, prevalent cases rose from 13.1 (95% UI: 11.6-14.8) million in 1990 to 20.9 (95% UI: 18.5-23.4) million cases in 2016. Schizophrenia contributes 13.4 (95% UI: 9.9-16.7) million years of life lived with disability to burden of disease globally.
Conclusion:
Although schizophrenia is a low prevalence disorder, the burden of disease is substantial. Our modeling suggests that significant population growth and aging has led to a large and increasing disease burden attributable to schizophrenia, particularly for middle income countries.
Depressed mood has a complex relationship with self-evaluation of personal competence in multiple populations. The absence of depression may be associated with overestimation of abilities, while mild depression seems to lead to accurate self-assessment. Significant depression may lead to underestimation of functioning. In this study, we expand on our previous work by directly comparing the association between different levels of depression, everyday functioning, cognitive and functional capacity performance, and self-assessment of everyday functioning in a large (n = 406) sample of outpatients with schizophrenia. Participants with very low self-reported depression overestimated their everyday functioning compared with informant reports. Higher levels of depression were associated with more accurate self-assessment, but no subgroup of patients underestimated their functioning. Depressive symptom severity was associated with poorer informant-rated social functioning, but there were no differences in vocational functioning, everyday activities, cognitive performance, and functional capacity associated with the severity of self-reported depression. There was minimal evidence of impact of depression on most aspects of everyday functioning and objective test performance and a substantial relationship between depression and accuracy of self-assessment.
Despite the increasing attention to social appraisals in suicide risk, the interpersonal correlates of suicidal thoughts and behavior in schizophrenia are not well understood. Ecological momentary assessment could reveal whether dysfunctional social appraisals and behavior are evident in people with schizophrenia with suicidal ideation. A total of 93 outpatients with diagnoses of schizophrenia with (n=18, 19%) and without (N=75; 81%) suicidal ideation participated in one week of intensive daily monitoring via mobile devices, generating real-time reports on the quantity of social interactions and appraisals about them, as well as information concerning concurrent affect and symptoms. The presence of suicidal ideation was not associated with the quantity of social interactions or time spent alone, but it was associated with the anticipation of being alone as well as greater negative and lower positive affect when alone. Despite this aversive experience of being alone, people with suicidal ideation reported negative appraisals about the value of recent and potential social interactions. These findings suggest that suicidal ideation in schizophrenia may not be associated with the quantity of social interactions, but with negative expectations about the quality of social interactions coupled with an aversive experience of being alone. Cognitive therapy interventions that address negative expectations and pleasure about social interactions, especially when alone, may reduce suicidal ideation.
Lack of insight is a well-established phenomenon in schizophrenia, and has been associated with reduced rater-assessed functional performance but increased self-reported well-being in previous studies. The objective of this study was to examine factors that might influence insight (as assessed by the Insight and Treatment Attitudes Questionnaire [ITAQ] or PANSS item G12) and subjective quality-of-life (as assessed by Lehman QoL Interview [LQOLI]), using the large National Institute of Mental Health Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) dataset. Uncooperativeness was assessed by PANSS item G8 (“Uncooperativeness”). In the analysis, we found significant moderating effects for insight on the relationships of subjective life satisfaction assessment to symptom severity (as assessed by CGI-S score), objective everyday functioning (as assessed by rater-administered Heinrichs–Carpenter Quality of Life scale), clinically rated uncooperativeness (as assessed by PANSS G8), and discontinuation of treatment for all causes (all P < 0.05 for statistical interaction between insight and subject QoL). Patients with chronic schizophrenia who reported being "pleased" or "delighted" on LQOLI were found to have significantly lower neurocognitive reasoning performance and poorer insight (ITAQ total score). Our findings underscore the importance of reducing cognitive and insight impairments for both treatment compliance and improved functional outcomes.
Objective:
Self-assessment deficits, often referred to as impaired insight or unawareness of illness, are well established in people with schizophrenia. There are multiple levels of awareness, including awareness of symptoms, functional deficits, cognitive impairments, and the ability to monitor cognitive and functional performance in an ongoing manner. The present study aimed to evaluate the comparative predictive value of each aspect of awareness on the levels of everyday functioning in people with schizophrenia.
Method:
We examined multiple aspects of self-assessment of functioning in 214 people with schizophrenia. We also collected information on everyday functioning rated by high contact clinicians and examined the importance of self-assessment for the prediction of real-world functional outcomes. The relative impact of performance-based measures of cognition, functional capacity, and metacognitive performance on everyday functioning was also examined.
Results:
Misestimation of ability emerged as the strongest predictor of real-world functioning and exceeded the influences of cognitive performance, functional capacity performance, and performance-based assessment of metacognitive monitoring. The relative contribution of the factors other than self-assessment varied according to which domain of everyday functioning was being examined, but, in all cases, accounted for less predictive variance.
Conclusion:
These results underscore the functional impact of misestimating one's current functioning and relative level of ability. These findings are consistent with the use of insight-focused treatments and compensatory strategies designed to increase self-awareness in multiple functional domains. (PsycINFO Database Record
Awareness of illness is a major factor in schizophrenia and extends into unawareness of cognitive and functional deficits. This unawareness of functional limitations has been shown to be influenced by several different predictive factors, including greater impairment and less severe depression. As treatment efforts are aimed at reducing cognitive deficits, discovery of the most efficient assessment strategies for detection of cognitive and functional changes is critical. In this study, we collected systematic assessments from high contact clinicians focusing on their impressions of the cognitive deficits and everyday functioning in a sample of 169 community dwelling patients with schizophrenia. The patients provided self-report on those same rating scales, as well as self-reporting their depression and performing an assessment of cognitive performance and functional skills. There was essentially no correlation between patients' self reports of their cognitive performance and functional skills and either clinician ratings of these skills or the results of the performance-based assessments. In contrast, clinician reports of cognitive impairments and everyday functioning were correlated with objective performance data. Depression on the part of patients was associated with ratings of functioning that were both more impaired and more congruent with clinician impressions, while overall patients reported less impairment than clinicians. These results underscore the limitations of self reported cognitive functioning even with structured rating scales. Concurrently, clinicians provided ratings of cognitive performance that were related to scores on objective tests, even though they were unaware of the results of those assessments.
Given the prominence of cognitive impairments and disability associated with schizophrenia and bipolar disorder, substantial interest has arisen in identifying determinants of the diseases and their features. Genetic variation has been linked to skills that underlie disability (“functional capacity” or FC), highlighting need for understanding of these relationships. We describe the design and methods of a large, multisite, observational study focusing on the genetics of functional disability in schizophrenia and bipolar disorder, presenting initial data on recruitment, and characterization of the sample. Known as Veterans Affairs (VA) Cooperative Studies Program (CSP)#572, this study is recruiting, diagnosing, and assessing U.S. Veterans with either schizophrenia or bipolar I disorder. Assessments include neuropsychological (NP) testing, FC, suicidality, and co-morbid conditions such as posttraumatic stress disorder (PTSD). A sample of “psychiatrically healthy” Veterans from another project serves as a comparison group. An interim total of 8,140 participants (42.1% schizophrenia) have been recruited and assessed as of September 30, 2013, with 9 months of enrollment remaining and with a target sample size of 9,500. Veterans with schizophrenia were more likely to never have married, whereas lifetime PTSD and suicidality were more common in the bipolar veterans. Performance on the FC measures and NP tests was consistent with previous results, with mean t-scores of 35 (−1.5 SD) for schizophrenia and 41 (−0.9 SD) for the bipolar Veterans. This large population is representative of previous studies in terms of patient performance and co-morbidities. Subsequent genomic analyses will examine the genomic correlates of performance-based measures. Published 2014. This article is a U.S. Government work and is in the public domain in the USA.
Objective:
Social cognition is strongly associated with functional outcome in schizophrenia, making it an important target for treatment. Our goal was to examine the average magnitude of differences between schizophrenia patients (SCs) and normal comparison (NCs) patients across multiple domains of social cognition recognized by the recent NIMH consensus statement: theory of mind (ToM), social perception, social knowledge, attributional bias, emotion perception, and emotion processing.
Method:
We conducted a meta-analysis of peer-reviewed studies of social cognition in schizophrenia, published between 1980 and November, 2011.
Results:
112 studies reporting results from 3908 SCs and 3570 NCs met our inclusion criteria. SCs performed worse than NCs across all domains, with large effects for social perception (g = 1.04), ToM (g = 0.96), emotion perception (g = 0.89), and emotion processing (g = 0.88). Regression analyses showed that statistically significant heterogeneity in effects within domains was not explained by age, education, or gender. Greater deficits in social and emotion perception were associated with inpatient status, and greater deficits in emotion processing were associated with longer illness duration.
Conclusions:
Despite the limitations of existing studies, including lack of standardization or psychometric validation of measures, the evidence for deficits across multiple social cognitive domains in schizophrenia is clear. Future research should examine the role of neurobiological and psychosocial factors in models linking various aspects of deficit in schizophrenia, including social cognition, in order to identify targets for intervention.
Retrospective reports are often used as the primary source of information for important diagnostic decisions, treatment, and clinical research. Whether such reports accurately represent individuals' past experiences in the context of a serious mental illness such as schizophrenia is unclear. In the current study, 24 individuals with schizophrenia and 26 nonclinical participants used a mobile device to complete multiple real-time/real-place assessments daily, over 7 consecutive days. At the end of the week, participants were also asked to provide a retrospective report summarizing the same period. Comparison of the data captured by the 2 methods showed that participants from both groups retrospectively overestimated the intensity of negative and positive daily experiences. In the clinical group, overestimations for affect were greater than for psychotic symptoms, which were relatively comparable to their retrospective reports. In both samples, retrospective reports were more closely associated with the week's average than the most intense or most recent ratings captured with a mobile device. Multilevel modeling revealed that much of the variability in weekly assessments was not explained by between-person differences and could not be captured by a single retrospective estimate. Based on the findings of this study, clinicians and researchers should be aware that while retrospective summary reports of the severity of certain symptoms compare relatively well with average momentary ratings, they are limited in their ability to capture variability in one's affective or psychotic experiences over time.
Treatment of cognitive impairment has been proposed as an intervention to reduce disability in people with schizophrenia. The Validation of Everyday Real-World Outcomes (VALERO) study was conducted to evaluate functional rating scales and to identify the rating scale or scales most robustly related to performance-based measures of cognition and everyday living skills.
Adults with schizophrenia (N=198) were tested with the neurocognitive measures from the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) Consensus Cognitive Battery, the UCSD Performance-Based Skills Assessment-Brief Version, and the advanced finances subscale of the Everyday Functioning Battery. They and an informant (a friend, relative, clinician, or case manager) also reported their everyday functioning on six rating scales. Best judgment ratings were generated by an interviewer who administered the rating scales to patients and informants.
Statistical analyses developed an ability latent trait that reflected scores on the three performance-based (i.e., ability) measures, and canonical correlation analysis related interviewer ratings to the latent trait. The overall fit of the model with all six rating scales was good. Individual rating scales that did not improve the fit of the model were systematically deleted, and a final model with two rating scales was fitted to the data. A regression analysis found that the Specific Levels of Functioning Assessment was a superior predictor of the three performance-based ability measures.
Systematic assessments of real-world functioning were related to performance on neurocognitive and functional capacity measures. Of the six rating scales evaluated in this study, the Specific Levels of Functioning Assessment was the best. Use of a single rating scale provides an efficient assessment of real-world functioning that accounts for considerable variance in performance-based scores.
People tend to hold overly favorable views of their abilities in many social and intellectual domains. The authors suggest that this overestimation occurs, in part, because people who are unskilled in these domains suffer a dual burden: Not only do these people reach erroneous conclusions and make unfortunate choices, but their incompetence robs them of the metacognitive ability to realize it. Across 4 studies, the authors found that participants scoring in the bottom quartile on tests of humor, grammar, and logic grossly overestimated their test performance and ability. Although their test scores put them in the 12th percentile, they estimated themselves to be in the 62nd. Several analyses linked this miscalibration to deficits in metacognitive skill, or the capacity to distinguish accuracy from error. Paradoxically, improving the skills of participants, and thus increasing their metacognitive competence, helped them recognize the limitations of their abilities.
The purpose of this column is to provide an overview of social cognition in schizophrenia. The column begins with a short introduction to social cognition. Then, we describe the application of social cognition to the study of schizophrenia, with an emphasis on key domains (i.e., emotion perception, Theory of Mind, and attributional style). We conclude the column by discussing the relationship of social cognition to neurocognition, negative symptoms, and functioning, with an eye toward strategies for improving social cognition in schizophrenia.
Objectives
Disability is common in bipolar disorder (BD) and predicted by persistent sadness. We used ecological momentary assessment (EMA) to examine daily activities in people with BD and schizophrenia. We classified activities as productive, unproductive, or passive recreation, relating them to momentary sadness, location, and social context.
Methods
71 people with BD and 102 people with schizophrenia were sampled 3 times/day for 30 days with an EMA survey. Each survey asked where they were, with whom, what they were doing, and if they were sad.
Results
People with BD were home more than 50% of the time. There were no differences in prevalence of activity types across diagnoses. People with BD were less likely to report only one activity since the prior survey, but the most surveys still reported only one. For both groups, sadness and being home and alone since the last survey was associated with less productive activity and more passive recreation.
Conclusions
Participants with BD and schizophrenia manifested high levels of unproductive and passive activities, predicted by momentary sadness. These activity patterns are consistent with descriptions of avolition and they minimally differentiated people with BD and schizophrenia. Previous reports of negative symptoms in BD may have been identifying these behaviors.
We used ecological momentary assessment (EMA) to track symptoms during a clinical trial. Thirty-six participants with major depressive disorder (MDD) and MADRS scores ≥20 were enrolled in a nonrandomized 6-week open-label trial of commercially available antidepressants. Twice daily, a mobile device prompted participants to self-report the 6 items of the HamD6 sub-scale derived from the Hamilton rating scale for depression (HamD17). Morning EMA reports asked “how do you feel now” whereas evening reports gathered a full-day impression. Clinicians who were blinded to the EMA data rated the MADRS, HamD17 and HamD6 at screen, baseline and weeks 2,4, and 6. Hierarchical linear modeling (HLM) examined the course of the EMA assessments and convergence between EMA scores and clinician ratings. HLM analyses revealed strong correlations between AM and PM EMA derived HamD6 scores and revealed significant improvements over time. EMA improvements were significantly correlated with the clinician rated HamD6 scores at endpoint and predicted clinician rated HamD6 score changes from baseline to endpoint (p< 0.001). There was a large correlation between EMA and clinician derived HamD6 scores at each in-person assessment after baseline. Treatment response defined by EMA matched the clinician rated HamD6 treatment responses in 33 of 36 cases (91.7%). EMA derived symptom scores appear to be efficient and valid measures to track daily symptomatic change in clinical trials and may provide more accurate measures of symptom severity than the episodic “snapshots” that are currently used as clinical outcomes. These findings support further investigation of EMA for assessment in clinical trials.
Background
People with schizophrenia often experience poor health, leading to shortened lifespans. The health of people with schizophrenia may be further exacerbated by increased sedentary behavior, which independently predicts health risk in the general population. However, the prevalence and patterns of objectively measured sedentary behavior in schizophrenia have not been studied extensively on a momentary basis.
Methods
Activity of 100 patients with schizophrenia was compared to that of healthy controls (HC; n = 71) using ecological momentary assessment (EMA). EMA provides real-time, real-world monitoring of behavior. We sampled behavior seven times per day for seven days, quantifying active versus inactive behaviors and four different movement patterns (recumbent, seated, standing, and moving). Due to different employment rates between samples, we focused on surveys completed at home.
Results
Four of the five most commonly reported activities for participants with schizophrenia involved sitting or lying down. When considering activity during the last hour, participants with schizophrenia were more likely to be sitting or pacing and less likely to be standing than HC. If participants with schizophrenia only did one thing in the last hour, it was more likely to involve sitting and less likely to involve standing compared to HC.
Discussion
People with schizophrenia were significantly more likely to be seated and less likely to be standing or active during the past hour than HC, despite high frequencies of seated behaviors in the HC as well. The adverse health consequences of sitting for extended periods may be especially relevant for people with schizophrenia and likely contribute to premature mortality in this population.
Background
Previous research employing global positioning satellite (GPS) data and ecological momentary assessment (EMA) has shown a smaller life-space (distance traveled from home) was associated with poorer community functioning and more severe negative symptoms in people with schizophrenia. Momentary emotional experiences may influence how much time is spent outside of the home. We evaluated the associations between emotional experiences in relation to life-space among people with schizophrenia compared to healthy controls (HCs).
Methods
105 participants with schizophrenia and 76 HCs completed in-lab assessments of symptoms, cognition, and functioning. Participants completed EMA assessments of location and emotions seven times daily for seven days at stratified random intervals. GPS coordinates were collected 24 h a day over the 7-day study period. Analyses were performed at the momentary, day, and full week level using mixed effects models and Spearman correlations.
Results
For HCs, greater happiness was associated with greater concurrent distance traveled away from home as measured by GPS. For participants with schizophrenia, greater anxiety was associated with greater distance traveled away from home and being outside of the home. Less happiness, but not anxiety, was also associated with greater negative symptoms, especially outside the home.
Discussion
These findings suggest diminished positive emotion is associated with the experience of leaving the home in schizophrenia, but also suggest that anxiety may contribute to avoidance of out of home mobility. Interventions targeting both positive emotions and social anxiety may improve social functioning, and life-space may provide a useful outcome for functional rehabilitation interventions in schizophrenia.
It has been reported that people with schizophrenia are frequently overconfident relative to their performance, a trait observed in healthy individuals as well. In schizophrenia, impaired self-assessments have been found to be associated with functional impairments in various domains. Previous studies examining the correlation of overconfidence and task performance within domains (e.g., social cognition) had found overconfidence was associated with particularly poor performance. This study examines how overconfidence on a social cognitive emotion recognition task is correlated with performance on other social cognitive tests, measures of neurocognition, and intelligence. The sample includes 154 healthy controls and 218 outpatient individuals diagnosed with schizophrenia. For the healthy controls, overconfidence was a significant predictor of poorer performance on social cognitive, but not neurocognitive tasks. For the participants with schizophrenia, overconfidence was a predictor of poorer performance on every performance-based task. In addition, overconfidence in healthy controls was more strongly correlated with intelligence than it was in participants with schizophrenia. The data suggest that a bias toward overestimation of performance aligns with poorer performance social cognitive domains, as well as neurocognitive domains in participants with schizophrenia. In healthy individuals, consistent with previous results, lower general intelligence seems to be a substantial predictor of overconfidence. These data suggest that attention to the accuracy of self-assessment is an area for future clinical interventions in people with schizophrenia.
Objective:
Negative symptoms and functional outcome have traditionally been assessed using clinical rating scales, which rely on retrospective self-reports and have several inherent limitations that impact validity. These issues may be addressed with more objective digital phenotyping measures. In the current study, we evaluated the psychometric properties of a novel "passive" digital phenotyping method: geolocation.
Method:
Participants included outpatients with schizophrenia or schizoaffective disorder (SZ: n = 44), outpatients with bipolar disorder (BD: n =19), and demographically matched healthy controls (CN: n = 42) who completed 6 days of "active" digital phenotyping assessments (eg, surveys) while geolocation was recorded.
Results:
Results indicated that SZ patients show less activity than CN and BD, particularly, in their travel from home. Geolocation variables demonstrated convergent validity by small to medium correlations with negative symptoms and functional outcome measured via clinical rating scales, as well as active digital phenotyping behavioral indices of avolition, asociality, and anhedonia. Discriminant validity was supported by low correlations with positive symptoms, depression, and anxiety. Reliability was supported by good internal consistency and moderate stability across days.
Conclusions:
These findings provide preliminary support for the reliability and validity of geolocation as an objective measure of negative symptoms and functional outcome. Geolocation offers enhanced precision and the ability to take a "big data" approach that facilitates sophisticated computational models. Near-continuous recordings and large numbers of samples may make geolocation a novel outcome measure for clinical trials due to enhanced power to detect treatment effects.
Objective:
Anhedonia, traditionally defined as a diminished capacity for pleasure, is a core symptom of schizophrenia (SZ). However, modern empirical evidence indicates that hedonic capacity may be intact in SZ and anhedonia may be better conceptualized as an abnormality in the temporal dynamics of emotion.
Method:
To test this theory, the current study used ecological momentary assessment (EMA) to examine whether abnormalities in one aspect of the temporal dynamics of emotion, sustained reward responsiveness, were associated with anhedonia. Two experiments were conducted in outpatients diagnosed with SZ (n = 28; n = 102) and healthy controls (n = 28; n = 71) who completed EMA reports of emotional experience at multiple time points in the day over the course of several days. Markov chain analyses were applied to the EMA data to evaluate stochastic dynamic changes in emotional states to determine processes underlying failures in sustained reward responsiveness.
Results:
In both studies, Markov models indicated that SZ had deficits in the ability to sustain positive emotion over time, which resulted from failures in augmentation (ie, the ability to maintain or increase the intensity of positive emotion from time t to t+1) and diminution (ie, when emotions at time t+1 are opposite in valence from emotions at time t, resulting in a decrease in the intensity of positive emotion over time). Furthermore, in both studies, augmentation deficits were associated with anhedonia.
Conclusions:
These computational findings clarify how abnormalities in the temporal dynamics of emotion contribute to anhedonia.
Individuals with schizophrenia spectrum disorders (SSD) consistently show deficits in social cognition (SC) which is associated with real world outcomes. Psychosocial treatments have demonstrated reliable improvements in SC abilities, highlighting the need for accurate identification of SC deficits for efficient and individualized treatment planning. To this end, the Observable Social Cognition Rating Scale (OSCARS) is an 8-item scale with both self and informant versions. This study investigated psychometric properties of the OSCARS as both a self and informant-reported scale in a large sample of SSD (n =382) and individuals without a psychiatric diagnosis (n = 289). A two-factor structure (Social Cognitive Bias and Social Cognitive Ability) of the OSCARS demonstrated acceptable model fit with good internal consistency for both self- and informant-report. The OSCARS had adequate convergent, external, and predictive validity. Area Under the Curve (AUC) values suggest the OSCARS has some value in identifying individuals with impaired SC and social competence, although stronger AUC values were demonstrated when identifying individuals with impaired real-world functioning. Overall, psychometric properties indicate the OSCARS may be a useful first-step tool for clinicians to detect functioning deficits in SSD and efficiently identify individuals in need of additional assessment or psychosocial interventions.
Schizophrenia is a major cause of disability worldwide. As new treatments for functioning are tested, the need grows to demonstrate real-world functioning gains. Ecological momentary assessment (EMA) may provide a more ecologically valid measure of functioning. In this study, smartphone-based EMA was used to signal participants with schizophrenia (N = 100) and controls (N = 71) 7 times a day for 7 days to respond to brief questionnaires about social interactions and functioning behaviors. Excellent adherence was found, with both groups completing an average of 85% of surveys and only 3% of participants with schizophrenia excluded for poor adherence. Four-week test-retest reliability was high (r = .83 for total productive behaviors). Relative to controls, participants with schizophrenia reported significantly less total productive activity (d = 1.2), fewer social interactions (d = 0.3), more nonproductive behaviors (d = 1.0; watching TV, resting), and more time at home (d = 0.8). Within the schizophrenia group, participants living independently showed better functioning on EMA relative to participants in supported housing (d = 0.8) and participants engaged in vocational activities showed better functioning than individuals not engaged in vocational activities (d = 0.55). Modest correlations were found between EMA and an in-lab self-report measure of functioning activities performed in the community, but not between EMA and measures of functional capacity or potential. This study demonstrated the feasibility, sensitivity reliability, and validity of EMA methods to assess functioning in schizophrenia. EMA provides a much-needed measure of what individuals with schizophrenia are actually doing in real-world contexts. These results also suggest that there may be important disjunctions between indices of abilities and actual real-world functioning.
Autistic traits are a feature of schizophrenia and has been found to impair social functioning and social cognition. Other influences on social outcomes in schizophrenia include depression and social avoidance. However, challenges in self-assessment of abilities and functioning (i.e., introspective accuracy)and self-assessment bias also contribute to disability. Depression has been studied for its association with introspective accuracy and bias, but autistic traits have not. Participants were 177 patients with schizophrenia who self-reported their everyday functioning and social cognitive ability as well as their depression. All were rated with the PANSS and a separate rater generated all-sources ratings of everyday functioning and social cognitive ability. Correlations between self-reported everyday functioning and social cognitive ability, ratings of everyday functioning and social cognitive ability, and the discrepancies between those ratings were examined for correlations with depression, autistic features and social avoidance. Accuracy was defined by the absolute value of the difference between self-reports and all-sources ratings and bias was defined by the direction of discrepancy (positive vs. negative). There was a statistically significant difference between sources on every measure. Bias was not directional on average, but patients with the lowest levels of depression overestimated their abilities on every measure and those with the highest depression underestimated. Autistic traits were associated with impairments in everyday functioning and underestimation of those impairments, while social avoidance was associated with impaired social functioning and accurate self-assessment. Features of schizophrenia have differential implications for impaired functioning and self-assessment, with autistic features and low levels of depression associated with consistent self-assessment biases.
Introduction: Individuals with schizophrenia present across a spectrum of symptomatology. Disability remains a debilitating reality across varying disease presentations and remains pervasive despite psychiatric medications. Cognition (neuro/social cognition) and negative symptoms have emerged as the strongest predictors of real-world disability, but account for <50% of the variance in outcomes.
Methods: Our attempts to determine what accounts for the remaining 50% of variance has shown that poor introspective accuracy (IA) may be the most potent predictor of functional outcomes 25% of individuals with schizophrenia. We define IA as the adequacy of self-assessments of ability, skills, performance, or decisions. We suggest that IA is a progression of metacognition and can extend beyond cognition to include misestimation of prior and likely future performance in social or other adaptively relevant situations.
Results: Additionally, IA is bidirectional and self-orientated. Emerging research has found that IA of neurocognitive ability better predicts everyday functional deficits than scores on performance-based measures or neurocognitive skills and has found that IA of social cognition accounts unique variance in real-world disability above social cognitive performance.
Discussion: We argue that impaired IA, affecting 25–50% of patients with schizophrenia, in the absence or minimal presence of other impairments might be the most powerful predictor of functional outcomes.
Background:
Impairments in self-assessment are common in people with schizophrenia and impairments in self-assessment of cognitive ability have been found to predict impaired functional outcome. In this study, we examined self-assessment of social cognitive ability and related them to assessments of social cognition provided by informants, to performance on tests of social cognition, and to everyday outcomes. The difference between self-reported social cognition and informant ratings was used to predict everyday functioning.
Methods:
People with schizophrenia (n=135) performed 8 different tests of social cognition. They were asked to rate their social cognitive abilities on the Observable Social Cognition Rating Scale (OSCARs). High contact informants also rated social cognitive ability and everyday outcomes, while unaware of the patients' social cognitive performance and self-assessments. Social competence was measured with a performance-based assessment and clinical ratings of negative symptoms were also performed.
Results:
Patient reports of their social cognitive abilities were uncorrelated with performance on social cognitive tests and with three of the four domains of functional outcomes. Differences between self-reported and informant rated social cognitive ability predicted impaired everyday functioning across all four functional domains. This difference score predicted disability even when the influences of social cognitive performance, social competence, and negative symptoms were considered.
Implications:
Mis-estimation of social cognitive ability was an important predictor of social and nonsocial outcomes in schizophrenia compared to performance on social cognitive tests. These results suggest that consideration of self-assessment is critical when attempting to evaluate the causes of disability and when trying to implement interventions targeting disability reduction.
Background:
Since the Iowa 500 study, residential and occupational status have been frequently used as indicators of everyday achievements in research on schizophrenia and bipolar disorder. The relationships of residential and occupational status with impairment in multiple domains including physical health indicators across these two diagnoses, however, have rarely been studied. We examined these relationships at the 20-year follow-up assessment of a first-admission sample.
Methods:
We included 146 participants with schizophrenia and 87 with bipolar disorder with psychosis who participated in the 20-year follow-up of the Suffolk County Mental Health Project. In addition to interviewer-based ratings of employment and residential independence, we examined self-reported impairment derived from the WHODAS, standard measures of current psychopathology, indicators of obesity, as well as performance-based measures of physical and cognitive functioning.
Results:
Participants with bipolar disorder were more likely to live independently and be gainfully employed; they also performed significantly better on each indicator of impairment apart from balance ability. In both groups, unemployment, but not residential independence, was associated with greater self-reported disability on the WHODAS. Residential independence, gainful employment, and subjective disability were also associated with better physical functioning. Across the two groups, psychiatric symptoms and physical functioning were the major determinants of subjective disability.
Discussion:
People with psychotic bipolar disorder were more likely to be gainfully employed and living independently than participants with schizophrenia but as a group, much less frequently than population standards. Interventions aimed at physical fitness may have the potential to improve both objective functioning and perceived disability.
Social cognition is increasingly recognized as an important treatment target in schizophrenia; however, the dearth of well-validated measures that are suitable for use in clinical trials remains a significant limitation. The Social Cognition Psychometric Evaluation (SCOPE) study addresses this need by systematically evaluating the psychometric properties of promising measures. In this final phase of SCOPE, eight new or modified tasks were evaluated. Stable outpatients with schizophrenia (n = 218) and healthy controls (n = 154) completed the battery at baseline and 2-4 weeks later across three sites. Tasks included the Bell Lysaker Emotion Recognition Task (BLERT), Penn Emotion Recognition Task (ER-40), Reading the Mind in the Eyes Task (Eyes), The Awareness of Social Inferences Test (TASIT), Hinting Task, Mini Profile of Nonverbal Sensitivity (MiniPONS), Social Attribution Task-Multiple Choice (SAT-MC), and Intentionality Bias Task (IBT). BLERT and ER-40 modifications included response time and confidence ratings. The Eyes task was modified to include definitions of terms and TASIT to include response time. Hinting was scored with more stringent criteria. MiniPONS, SAT-MC, and IBT were new to this phase. Tasks were evaluated on (1) test-retest reliability, (2) utility as a repeated measure, (3) relationship to functional outcome, (4) practicality and tolerability, (5) sensitivity to group differences, and (6) internal consistency. Hinting, BLERT, and ER-40 showed the strongest psychometric properties and are recommended for use in clinical trials. Eyes, TASIT, and IBT showed somewhat weaker psychometric properties and require further study. MiniPONS and SAT-MC showed poorer psychometric properties that suggest caution for their use in clinical trials.
The study aimed at investigating the role of the hippocampal subfields in cognitive insight and the clinical and neuropsychological underpinnings of the related two sub-dimensions, Self-Reflectiveness (SR), i.e., openness to external feedback, and Self-Certainty (SC), i.e., unrealistic overconfidence in one’s opinions. In order to do this, 45 patients with a diagnosis of schizophrenia and 45 age- and gender-matched healthy control subjects (HC) were administered the Beck Cognitive Insight Scale (BCIS), along with neuropsychological, clinical and psychopathological assessment, and underwent an MRI investigation. Hippocampal segmentation was carried out. Regression analyses were performed for BCIS indexes, volumetric parameters of hippocampal subfields and clinical and neuropsychological variables. Results highlighted that in the schizophrenia group, higher levels of SC were related to reduced volume of the left presubiculum, and worse episodic memory. No significant relationship emerged for the SR index. There was no significant relationship between any of the BCIS indexes and volumetric data of the hippocampal subfields in the HC group. Our data support the hypothesis that unrealistic self-overconfidence in schizophrenia is related to the hippocampal presubiculum atrophy, which is involved in episodic memory and cognitive control and is supposed to be underpinned by difficulty in integrating new memories and thus in generating new hypotheses about the self.
Patients with severe mental illnesses manifest substantial deficits in self-assessment of the abilities that impact everyday functioning. This study compares patients with schizophrenia to healthy individuals on their social cognitive performance, their assessment of that performance, and the convergence between performance and indicators of effort in solving tasks. Patients with schizophrenia (n=57) and healthy controls (HC; . n=47) completed the Bell-Lysaker Emotion Recognition Test (BLERT), a psychometrically sound assessment of emotion recognition. Participants rated their confidence in the accuracy of their responses after each item. Participants were instructed to respond as rapidly as possible without sacrificing accuracy; the time to complete each item was recorded. Patients with schizophrenia performed less accurately on the BLERT than HC. Both patients and HC were more confident on items that they correctly answered than for items with errors, with patients being less confident overall; there was no significant interaction for confidence between group and accuracy. HC demonstrated a more substantial adjustment of response time to task difficulty by taking considerably longer to solve items that they got wrong, whereas patients showed only a minimal adjustment. These results expand knowledge about both self-assessment of social cognitive performance and the ability to appraise difficulty and adjust effort to social cognitive task demands in patients with schizophrenia.
Measurement of social cognition in treatment trials remains problematic due to poor and limited psychometric data for many tasks. As part of the Social Cognition Psychometric Evaluation (SCOPE) study, the psychometric properties of 8 tasks were assessed. One hundred and seventy-nine stable outpatients with schizophrenia and 104 healthy controls completed the battery at baseline and a 2-4-week retest period at 2 sites. Tasks included the Ambiguous Intentions Hostility Questionnaire (AIHQ), Bell Lysaker Emotion Recognition Task (BLERT), Penn Emotion Recognition Task (ER-40), Relationships Across Domains (RAD), Reading the Mind in the Eyes Task (Eyes), The Awareness of Social Inferences Test (TASIT), Hinting Task, and Trustworthiness Task. Tasks were evaluated on: (i) test-retest reliability, (ii) utility as a repeated measure, (iii) relationship to functional outcome, (iv) practicality and tolerability, (v) sensitivity to group differences, and (vi) internal consistency. The BLERT and Hinting task showed the strongest psychometric properties across all evaluation criteria and are recommended for use in clinical trials. The ER-40, Eyes Task, and TASIT showed somewhat weaker psychometric properties and require further study. The AIHQ, RAD, and Trustworthiness Task showed poorer psychometric properties that suggest caution for their use in clinical trials.
© The Author 2015. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oup.com.
Cognition, negative symptoms, and depression are potential predictors of disability in schizophrenia. We present analyses of pooled data from four separate studies (all n>169; total n=821) that assessed differential aspects of disability and their potential determinants. We hypothesized that negative symptoms would predict social outcomes, but not vocational functioning or everyday activities and that cognition and functional capacity would predict vocational functioning and everyday activities but not social outcomes. The samples were rated by clinician informants for their everyday functioning in domains of social and vocational outcomes, and everyday activities, examined with assessments of cognition and functional capacity, rated clinically with the Positive and Negative Syndrome Scale (PANSS) and self-reporting depression. We computed a model that tested the hypotheses described above and compared it to a model that predicted that negative symptoms, depression, cognition, and functional capacity had equivalent influences on all aspects of everyday functioning. The former, specific relationship model fit the data adequately and we subsequently confirmed a similar fit within all four samples. Analyses of the relative goodness of fit suggested that this specific model fit the data better than the more general, equivalent influence predictor model. We suggest that treatments aimed at cognition may not affect social functioning as much as other aspects of disability, a finding consistent with earlier research on the treatment of cognitive deficits in schizophrenia, while negative symptoms predicted social functioning. These relationships are central features of schizophrenia and treatment efforts should be aimed accordingly.
Copyright © 2015 Elsevier B.V. All rights reserved.
Overconfidence in errors is a well-replicated cognitive bias in psychosis. However, prior studies have sometimes failed to find differences between patients and controls for more difficult tasks. We pursued the hypothesis that overconfidence in errors is exaggerated in participants with a liability to psychosis relative to controls only when they feel competent in the respective topic and/or deem the question easy. Whereas subjective competence likely enhances confidence in those with low psychosis liability as well, we still expected to find more 'residual' caution in the latter group.
We adopted a psychometric high-risk approach to circumvent the confounding influence of treatment. A total of 2321 individuals from the general population were administered a task modeled after the "Who wants to be a millionaire" quiz. Participants were requested to endorse one out of four response options, graded for confidence, and were asked to provide ratings regarding subjective competence for the knowledge domain as well as the subjective difficulty of each item.
In line with our assumption, overconfidence in errors was increased overall in participants scoring high on the Paranoia Checklist core paranoia subscale (2 SD above the mean). This pattern of results was particularly prominent for items for which participants considered themselves competent and which they rated as easy.
Results need to be replicated in a clinical sample.
In support of our hypothesis, subjective competence and task difficulty moderate overconfidence in errors in psychosis. Trainings that teach patients the fallibility of human cognition may help reduce delusional ideation.
Copyright © 2015. Published by Elsevier Ltd.
Introduction:
Individuals with schizophrenia consistently show impairments in social cognition (SC). SC has become a potential treatment target due to its association with functional outcomes. An alternative method of assessment is to administer an observer-based scale incorporating an informant's "first hand" impressions in ratings.
Methods:
The present study used the Observable Social Cognition: A Rating Scale (OSCARS) in 62 outpatients and 50 non-psychiatric controls (NPCs) to assess performance in domains of SC (e.g. emotion perception, theory of mind).
Results:
The OSCARS demonstrated sufficient internal consistency and test-retest reliability. Construct validity was assessed through an exploratory factor analysis. Patient OSCARS indices were not significantly correlated with measures of SC with the exception of aggressive attributional style. Individuals with less impairment in SC reacted more aggressively to ambiguous situations. NPC OSCARS were significantly correlated with measures of theory of mind and attributional style. In a combined sample of patients and controls, six of eight items were significantly correlated with the SC task assessing the same domain, providing modest evidence of convergent validity. In patients, the OSCARS was significantly correlated with measures of functional outcome and neurocognition. Last, the OSCARS was found to be significantly associated with functional outcome after the influence of objective measures of SC was statistically removed.
Conclusions:
The present study provides preliminary evidence that the OSCARS may be useful for clinicians in collecting data about patients' potential real-world SC deficits, in turn increasing the degree to which these impairments may be targeted in treatment.
Psychiatric disorders have traditionally been classified using a static, categorical approach. However, this approach falls short in facilitating understanding of the development, common comorbid diagnoses, prognosis and treatment of these disorders. We propose a 'staging' model of bipolar disorder that integrates genetic and neural information with mood and activity symptoms to describe how the disease progresses over time. From an early, asymptomatic, but 'at-risk' stage to severe, chronic illness, each stage is described with associated neuroimaging findings as well as strategies for mapping genetic risk factors. Integrating more biologic information relating to cardiovascular and endocrine systems, refining methodology for modeling dimensional approaches to disease and developing outcome measures will all be crucial in examining the validity of this model. Ultimately, this approach should aid in developing targeted interventions for each group that will reduce the significant morbidity and mortality associated with bipolar disorder.Molecular Psychiatry advance online publication, 22 July 2014; doi:10.1038/mp.2014.71.
Between 50% and 80% of patients with schizophrenia do not believe they have any illness and self assessment of cognitive impairments and functional abilities is also impaired compared to other information, including informant reports and scores on performance-based ability measures. The present paper explores self-assessment accuracy in reference to real world functioning as measured by milestone achievement such as employment and independent living. Our sample included 195 people with schizophrenia examined with a performance-based assessment of neurocognitive abilities and functional capacity. We compared patient self-assessments across achievement of milestones, using patient performance on cognitive and functional capacity measures as a reference point. Performance on measures of functional capacity and cognition was better in people who had achieved employment and residential milestones. Patients with current employment and independence in residence rated themselves as more capable than those who were currently unemployed or not independent. However, individuals who had never had a job rated themselves at least as capable as those who had been previously employed. These data suggest that lifetime failure to achieve functional milestones is associated with overestimation of abilities. As many patients with schizophrenia never achieve milestones, their self-assessment may be overly optimistic as a result.
Deficits in emotion perception and overconfidence in errors are well-documented in schizophrenia but have not been examined concurrently. The present study aimed to fill this gap. Twenty-three schizophrenia patients and twenty-nine healthy subjects underwent a Continuous Facial Sequence Task (CFST). The CFST comprised two blocks: a female (1st block) and a male protagonist (2nd block) displayed the six basic emotions postulated by Ekman as well as two more complex mental states and a neutral expression. Participants were first asked to identify the affect displayed by the performer and then to judge their response confidence. No group differences emerged regarding overall emotion perception. Follow-up analyses showed that patients were less correct in detecting some negative emotions but performed better for neutral or positive emotions. Regarding confidence, incorrect decisions in patients were associated with higher confidence than in controls (statistical trend level, moderate effect size). Patients displayed significant overconfidence in errors for negative emotions. In addition, patients were more prone to high-confident errors for emotions that were displayed in weak emotional intensity. While the study supports the view that the examination of confidence adds unique information to our understanding of social cognition, several methodological limitations render its findings preliminary.
Dysfunctions in social cognition are implicated in the pathogenesis of schizophrenia and have been extensively replicated over the years. For memory research, the administration of cognitive tasks with metacognitive aspects like confidence ratings has deepened our insight into how impairments contribute to symptoms of the disorder. A total of 76 patients with schizophrenia or schizoaffective disorder and a sample of 30 healthy participants were tested with the Reading the Mind in the Eyes test (Eyes-test). The Eyes-test was complemented with a rating scale requesting response confidence and was administered along with paradigms tapping neuropsychological parameters and cognitive insight. Schizophrenia patients showed impaired abilities on mental state perception. In addition, they committed more high-confidence errors and at the same time made fewer high-confidence correct responses. Impairments were most pronounced in patients with formal thought disorder. The patients displayed a decreased metacognitive awareness for their deficits. The results suggest that adding confidence ratings to the investigation of social cognition promises to advance our understanding of social cognition in schizophrenia. Patients not only show severe impairments in social cognition, but are overconfident in their judgments and lack cognitive insight into their deficits. The results highlight the need for metacognitive therapeutic approaches for the treatment of this population.
The Mini-International Neuropsychiatric Interview (M.I.N.I.) is a short structured diagnostic interview, developed jointly by psychiatrists and clinicians in the United States and Europe, for DSM-IV and ICD-10 psychiatric disorders. With an administration time of approximately 15 minutes, it was designed to meet the need for a short but accurate structured psychiatric interview for multicenter clinical trials and epidemiology studies and to be used as a first step in outcome tracking in nonresearch clinical settings. The authors describe the development of the M.I.N.I. and its family of interviews: the M.I.N.I.-Screen, the M.I.N.I.-Plus, and the M.I.N.I.-Kid. They report on validation of the M.I.N.I. in relation to the Structured Clinical Interview for DSM-III-R, Patient Version, the Composite International Diagnostic Interview, and expert professional opinion, and they comment on potential applications for this interview.
Rating scales for assessing the mentally III usually focus on the role functioning of clients and their psychiatric symptomatology.
This article introduces a rating scale to measure more directly observable behavioral functioning and daily living skills
of clients in mental hospitals and in the community. Results are presented from a series of studies designed to test the instrument's
psychometric properties.
This study was designed to explore the neuropsychological basis of competence to consent to treatment in first-episode schizophrenia by evaluating its differential and joint links with cognitive versus metacognitive performance.
Twenty-one first-episode patients were assessed with the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) and a metacognitive version of the Wisconsin Card Sorting Test (WCST). In addition to the standard administration of the WCST, subjects were also asked to rate their level of confidence in the correctness of each sort (prior to getting the feedback) and to choose whether they wanted each sort to be "counted" toward their overall performance score on the test. Each "ventured" sort received a bonus of 10 cents if correct but an equal penalty if wrong.
Compromised capacity to consent was more strongly related to deficits at the metacognitive level than to cognitive deficits per se. Moreover, prediction of competence to consent significantly improved when adding the new, free-choice metacognitive measures to the conventional WCST measures but not the other way around.
These preliminary results suggest that metacognition plays a fundamental role in capacity to consent, which might be at least equally important for decision-making competence as cognitive deficits per se.
Measuring health and disability: manual for WHO disability assessment schedule WHODAS 2.0. World Health Org
- T B Ustün
Ustün, T.B., et al., 2010. Measuring health and disability: manual for WHO disability assessment schedule WHODAS 2.0. World Health Org, Geneva.
Structured Clinical Interview for DSM-5-Research Version (SCID-5 for DSM-5, Research Version; SCID-5-RV)
- M B First
- J B W Williams
- R S Karg
- R L Spitzer
First, M.B., Williams, J.B.W., Karg, R.S., Spitzer, R.L., 2015. Structured Clinical Interview for
DSM-5-Research Version (SCID-5 for DSM-5, Research Version; SCID-5-RV). Arlington, VA, American Psychiatric Association.