Neurocognition, Social Cognition, Perceived Social Discomfort, and Vocational Outcomes in Schizophrenia
Social cognition has been suggested to be an important mediating variable in the relationship between neurocognition and functional outcome. The present study tested this model in relation to work rehabilitation outcome and added self-reported social discomfort as a possible mediator. One hundred fifty-one participants with schizophrenia or schizoaffective disorder participated in a 26-week work therapy program. Neurocognition was constructed as a latent construct comprised of selected variables from our intake test battery representing executive functioning, verbal memory, attention and working memory, processing speed, and thought disorder. Social cognition at intake was the other latent construct comprised of variables representing affect recognition, theory of mind, self-reported egocentricity, and ratings of rapport. The 2 latent constructs received support from confirmatory factor analysis. Social discomfort on the job was based on their self-report on a weekly questionnaire. In addition, we constructed a composite rehabilitation outcome that was based on how many hours they worked, how well they worked, and how complex was the job that they were doing. Path analysis showed direct effects of neurocognition on rehabilitation outcome and indirect effects mediated by social cognition and social discomfort. This model proved to be a good fit to the data and far superior to another model where only social cognition was the mediating variable between neurocognition and rehabilitation outcome. Findings suggest that neurocognition affects social cognition and that poorer social cognition leads to social discomfort on the job, which in turn leads to poorer rehabilitation outcomes. Implications for rehabilitation interventions are discussed.
Neurocognition, Social Cognition, Perceived Social Discomfort, and Vocational
Outcomes in Schizophrenia
, Hector W. H. Tsang
, Tamasine C. Greig
and Gary J. Bryson
Department of Psychiatry, School of Medicine, Yale University;
Department of Veterans Affairs, Rehabilitation Research and
Development Service, VACHS 116B, 950 Campbell Avenue, West
Haven, CT 06516;
Department of Rehabilitation Sciences, The
Hong Kong Polytechnic University
Social cognition has been suggested to be an important me-
diating variable in the relationship between neurocognition
and functional outcome. The present study tested this
model in relation to work rehabilitation outcome and added
self-reported social discomfort as a possible mediator. One
hundred ﬁfty-one participants with schizophrenia or schiz-
oaffective disorder participated in a 26-week work therapy
program. Neurocognition was constructed as a latent con-
struct comprised of selected variables from our intake test
battery representing executive functioning, verbal memory,
attention and working memory, processing speed, and
thought disorder. Social cognition at intake was the other
latent construct comprised of variables representing affect
recognition, theory of mind, self-reported egocentricity,
and ratings of rapport. The 2 latent constructs received sup-
port from conﬁrmatory factor analysis. Social discomfort
on the job was based on their self-report on a weekly ques-
tionnaire. In addition, we constructed a composite rehabil-
itation outcome that was based on how many hours they
worked, how well they worked, and how complex was
the job that they were doing. Path analysis showed direct
effects of neurocognition on rehabilitation outcome and in-
direct effects mediated by social cognition and social dis-
comfort. This model proved to be a good ﬁt to the data
and far superior to another model where only social cogni-
tion was the mediating variable between neurocognition
and rehabilitation outcome. Findings suggest that neuro-
cognition affects social cognition and that poorer social
cognition leads to social discomfort on the job, which in
turn leads to poorer rehabilitation outcomes. Implications
for rehabilitation interventions are discussed.
Key words: neurocognition/social cognition and
In 1996, Michael Green’s landmark article
the significant relationship between neurocognition
and community functioning in schizophrenia. Evidence
for this relationship has strengthened since then by exam-
ining specific domains of functioning, including social
and vocational functioning.
that social cognition can be posited as a construct related
to but distinct from neurocognition is not new and can be
dated back to studies in the 80s and 90s.
dent contribution of social cognitive processes to under-
standing function has received further evidence in more
A review in 2006 found support for dis-
tinct associations between social perception, emotion
perception, and theory of mind (or attributional style)
to various measures of social functioning and that these
social cognitive abilities often mediated or made indepen-
dent contributions from neurocognition in explaining
variance in social functioning.
Social cognition has been variously defined but is gen-
erally agreed to represent cognitive capacity for process-
ing social information, such as affect recognition, theory
of mind, and understanding the gist of social conversa-
tions, and social reasoning. There is to date no common
agreement on the assessment of social cognition though
all would agree that it is a multifaceted construct. Despite
complexities in the measurement of social cognition, it
has recently been shown that social cognition represents
a separable cognitive domain in schizophrenia.
ies have shown that people with schizophrenia performed
poorly on tests of social cognition compared with the
Despite uncertainty about what constitutes social cog-
nition, a commonly accepted definition is that social cog-
nition is the mental operations underlying social
interactions, which include processes involved in perceiv-
ing, interpreting, and generating responses to the inten-
tions, dispositions, and behaviors of others.
To whom correspondence should be addressed; tel: 203-932-5711
Ext 2281, fax: 203-937-4883, e-mail: Morris.firstname.lastname@example.org.
Schizophrenia Bulletin vol. 35 no. 4 pp. 738–747, 2009
Advance Access publication on January 31, 2008
Ó The Author 2008. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.
For permissions, please email: email@example.com.
investigators have recently examined the role that social
cognition might play in community functioning.
Using structural equation modeling, recent studies have
found support for the hypothesis that social cognition
mediates the effects of neurocognition on function.
A complex examination of the relationship between
neurocognition, social cognition, and several functional
domains was recently presented by Bowie and Harvey.
Using path analysis, they showed that attention/working
memory and processing speed predicted social compe-
tence. Their social competence measure was based on
the UCSD Performance based Skills Assessment and the
Social Skills Performance Assessment, which is not the
same as social cognition but contains skills that require so-
cial cognition. They found in their path analysis that this
social competenc y endogenous variable mediated the re-
lationship between neurocognition and community ac-
tivities and work skills. Their finding regarding wo rk
skills is of special interest to o ur research group because
of our focus on v ocatio nal rehabilitation for people wit h
severe mental illness. While the article of Bowie and
used a person’s capacity for work based on rat-
ings of employable skills, level of supervision required t o
complete tasks, ability to stay on task, and punctuality,
the authors make a special point that these ratings were
not based upon behavior during employment and
should be distin guished from actual work p erformance
on the job.
Working involves many features that may be related to
social cognition. Work performance inventories used in
rehabilitation programs usually include social skills, co-
operativeness, and personal presentation
elements. Moreover, sustaining employment involves
continuously dealing with new demands in the work en-
vironment from changes in schedule to new personnel,
and adapting to these changes often requires social un-
derstanding. Misattributions and misperceptions in
regard to these changes can lead to abrupt job loss
and briefer periods of employment. Finally, social cogni-
tion may affect an individual’s likelihood of being given
more complex assignments by the supervisor because
complexity usually includes greater interpersonal
demands such as helping a trainee, organizing other
workers, or dealing with the public.
In the present study, we examine the relationship of
neurocognitive and social cognitive functioning to actual
work rehabilitation outcomes. The rehabilitation out-
come variable that we have developed incorporates the
3 most critical features of work performance: how well
they worked, how much they worked, and how complex
was the job that they were doing (detailed in ‘‘Method’’
section). Participants were outpatients with schizophre-
nia or schizoaffective disorder engaged in a 6-month
work therapy (WT) program that provided up to
20 hours per week of paid work activity. By observing
them on the job every other week, we were able to se e
their work performance over time. Thus, we believe
that the o utcome variable in our model has verisimilitude
and adds significance to the predictive value of our tested
In addition to neurocogniti on and social cognition,
we had observed clinically that so cial discomfort on
the job appeared to influence o utcomes, and we rea-
soned that su ch discomfort might b e caused in part
by di fficulty in social information process ing. Therefore,
we asked participants each week to rate their l evel of
social discomfort on the job on 3 questions using Li kert
scales: was being at your job stressful?, was talking to
your coworkers difficult for you?, and was it difficult
to understa nd your coworkers? Thus, a single individual
could give as many as 26 ratings on each of these ques-
tions over the co urse of their 6-month WT program. By
averaging their weekly scores on each question, adding
them together, and generating a z distri bution, we were
able to derive a single variable to capture this potentially
importa nt feature of the person’s work experience. The
present study is the first to offer a measure of social dis-
comfort on the job as a possibl e mediator o f neuro cog-
nitive and social cognitive variable’s effects on vocational
The purpose of this report is to test the relationship
between neurocognition, social cognition, and vocational
performance and to determine whether social discomfort
is an important mediating variable. We hypothesize that
neurocognition will have direct effects upon vocational
performance as has been demonstrated in previous stud-
ies and that it will have indirect effects on vocational per-
formance that are mediated by social cognition. We
further hypothesize that impairments in social cognition
will be related to social discomfort on the job, which
will mediate the effect of social cognition on vocational
One hundred fifty-one participants with schizophrenia
(n = 105, 69.5%) or schizoaffective disorder (n = 46,
30.5%) as determined by PhD psychologists using the
Structured Clinical Interview for Diagnostic and Statisti-
cal Manual of Mental Disorders, Fourth Edition, proce-
participated in intake procedures after
being referred by their clinicians. All provided informed,
written consent. Participants were in treatment at the
VA Connecticut Healthcare System, West Haven, or at
the Connecticut Mental Health Center. The study was
approved by the local institutional review boards at
both institutions. Data were collected from 1998 to
2003 as part of a study that randomized subjects into
WT or WT plus neurocognitive enhancement therapy
(NET þ WT), an experimental program of cognitive
Neurocognition, Social Cognition, Perceived Social Discomfort, and Vocational Outcomes
Participants were not considered suffi-
ciently stable to participate if there had been a change
in psychiatric medications or housing in the last 30
days, if they had an episode of drug abuse within the
past 30 days, or if they had a Global Assessment of Func-
tioning score of 30 or below. Known neurological
disease and developmental disability were also cause
for exclusion. Participants were on average 42.8 (8.9)
years of age, 58% male, 63.8% single and never married,
and 61.2% Caucasian. Their average Wechsler Adult
Intelligence Scale III (WAIS-III) full-scale IQ was 88.5
(13.1), and their education was 13.19 (2.0) years. Average
age of first onset was 22.6 (7.4) years, and their average
age of first hospitalization was 25.8 (7.3) years with an
average total number of hospitalizations of 13.2 (2.0).
Twenty-two percent were receiving a typical antipsy-
chotic only, 68% an atypical antipsychotic only, 8%
were receiving both, and 2% were taking other psychoac-
tive medications but not antipsychotics. Average chlor-
promazine equivalent dosage was 684.7 (493.5).
Neuropsychological Assessment. Our own factor analy-
have consistently found that neuropsy-
chological test performance in schizophrenia typically
yield the following factors: executive functioning, verbal
memory, attention and working memory, processing
speed, and thought disorder. To create a single exogenous
variable to represent the latent construct of neurocogni-
tion, we selected variables from our neurocognitive test
battery that represented each of these factors. We limited
ourselves to one variable to represent each factor in order
to keep the number of parameters within the acceptable
range for a confirmatory factor analysis given our sample
size. Executive function was represented by percent con-
ceptual level on the Wisconsin Card Sorting Test
verbal memory by the Hopkins Verbal
Learning Test Revised
trial 1 total, attention and work-
ing memory by Digit Span scaled score from the WAIS-
processing speed by Digit Symbol Substitution Test
also from the WAIS-III, and thought disorder by
Bizarreness score on the Gorham’s Proverbs Test.
Social Cognition. Unlike neurocognition, there is little
consensus about how social cognition should be mea-
sured in schizophrenia. Although there is conceptual co-
herence to the construct, it remains a matter of conjecture
as to what constitutes social cognitive processes. Our
view is that social cognition is comprised of both elemen-
tal and more complex reasoning processes. Affect recog-
nition and theory of mind are 2 elemental social cognitive
processes that have received scientific development in
terms of measurement methodology and some evidence
of relationship to social functioning. These 2 aspects of
social cognition were represented in our model by the
Bell Lysaker Emotion Recognition Test (BLERT)
score and by the Hinting Task
total score. However,
we also wanted to capture a broader understanding of
social cognition that is reflected in the self-experience
of relatedness and in the ability to establish rapport.
To do so, we employed the Bell Object Relations Inven-
Egocentricity Scale. This self-report in-
strument has been used in a number of studies in
schizophrenia (eg, Bell and Bruscato
, Bell et al
Bell and Zito
), and the Egocentricity Scale is associated
with a more autistic understanding of others. The assess-
ment of capacity for rapport came from the Rapport item
on the Quality of Life Scale (QLS),
which was rated by
our trained interviewers and is defined as how well the
participant was able to engage and sustain connection
during the questioning. Thus, we constructed our latent
construct of social cognition with the deliberate intent of
gaining robustness from convergent methods of assess-
ment: performance (BLERT and Hinting Task), self-
report (BORI Egocentricity), and interview (QLS
Social Discomfort on the Job. Each participant attended
a workers group once per week (described below). At the
beginning of each group, they were asked to respond to
the following questions regarding social discomfort by
circling a number on a scale from 1 (not at all) to 7 (com-
pletely). Was it difficult to understand your coworkers
this week? Was being at your job stressful this week?
Was talking to your coworkers difficult for you this
week? These questions were developed from our observa-
tions of common concerns expressed by previous partic-
ipants that we thought had influenced their work
Rehabilitation Outcome: Work Performance, Complexity,
and Total Hours Worked. We wanted to create a com-
posite score of overall rehabilitation outcome that would
capture the most salient features of good workers: how
well they worked, how much they worked, and how com-
plex the job was. We used the total score from the Work
Behavior Inventory (WBI) to measure work perfor-
mance. It is an observational measure that we have found
and predictive of future work functioning.
WBI evaluations are done on site and include observation
of the worker and brief interviews with the supervisor.
We used the last 3 WBIs (over a 6-week period) as a mea-
sure of the workers’ final work performance. We used
3 rather than the last one because we wanted to increase
the stability of measurement. WBI total ratings had ex-
cellent reliability in this study (intraclass correlation
[ICC] = .91).
Along with the WBI ratings, the complexity of the job
was rated using a complexity scale from 1 to 5, with high-
er scores indicating that the job required multiple tasks,
greater autonomy, and more interpersonal complexity.
M. Bell et al.
Changes in complexity score occurred when a worker was
given new duties. For example, a worker in mail delivery
would generally begin by going with someone else and
helping on the route of deliveries (rated ‘‘1’’). The worker
would then progress to having his own route (rated ‘‘2’’)
and then might be asked to learn several routes and to do
package deliveries and take phone calls in the mailroom
(rated ‘‘3’’). The worker might be entrusted with special
handling deliveries (such as refrigerated specimens),
taught to operate complicated machines that sorted
and stamped mail, and asked to handle the reception
desk for general inquiries (rated ‘‘4’’). Finally, the worker
might be expected to do all the above and also break in
new workers and assign work to others (rated ‘‘5’’).
Changes in complexity ratings for an individual were rel-
atively infrequent and were done by consensus of the re-
search staff after a presentation of the circumstances.
This is a similar procedure used by our university for de-
termining when a staff member’s duties have changed
sufficiently to warrant a possible raise. A job audit is con-
ducted, and a panel makes a determination comparing
the new duties with established standards. Because con-
sensus ratings were used, ICCs were not established for
the complexity score.
To capture the consistency of working, we chose to use
the total hours worked over the 6 months of the program
rather than merely the final 6-week period of the WBI
evaluations. We did so to increase the range and to fairly
capture the difference between someone who worked well
but quit after 13 weeks and someone who worked steadily
the entire 26 weeks. To create a composite score, average
WBI totals, average complexity score, and total hours
were normalized by creating z distributions, and then
the z values were averaged, creating a single score repre-
sentative of overall rehabilitation outcome.
Following informed consent, diagnostic and psychoso-
cial data were collected and the intake neuropsycholog-
ical testing was performed over 2 or 3 sessions. PhD or
Master’s-level psychologists trained specifically in study
methods performed all procedures. For brevity and to
preserve the focus of the current report on predictors
of work performance, we minimize the presentation of
procedures related to the randomized study and do not
present results regarding condition assignments, which
are available elsewhere.
Following intake test-
ing, participants were stratified based on degree of cog-
nitive impairment and randomly assigned to 6 months of
either NET þ WT or WT only.
Work Therapy. WT consisted of (1) payment for work
activity at the rate of $3.40 per hour for up to 15 hours per
week with increasing bonus pay ($3.90–$8.40) for 16–20
hours; (2) job placement at the medical center; (3) indi-
vidual counseling when problems arose; (4) a group of-
fering support, problem solving, goal setting, and
detailed work performance feedback based on the
; (5) a job coach for job-related difficulties and in-
dividual vocational counseling; (6) a certificate of partic-
ipation in the program; and (7) referral to other
vocational services upon completion of the 6-month ac-
tive phase. The most common work sites were in dietetics,
mailroom, grounds, maintenance, patient transport, and
medical administration with duties similar to those of
entry-level employees supervised by regular medical cen-
Neurocognitive Enhancement Therapy. NET consisted
of (1) feedback from the Vocational Cognitive Rating
a rating of work-related cognition, in
the support group; (2) cognitive exercises for up to
5 hours each week for 26 weeks; and (3) a weekly social
information–processing group. In addition to the cogni-
tive exercises, participants in the NET condition were
also able to participate in up to 15 hours of WT (see
above), for a maximum of 20 hours productive activity.
Pay structure and maximum hours of productive activity
were equivalent between the conditions.
VCRS feedback was given on a biweekly schedule (at
the same time as the WBI feedback) and consisted of job
ratings of attention, memory, and executive function.
Patients were also encouraged to develop goals based
on their WBI and VCRS feedback.
Cognitive exercises involved repeated practice on
computer-based exercises for attention, memory, and ex-
ecutive function and a dichotic listening task. Participants
attended up to five 1-hour sessions per week. Cognitive
exercises utilized a modified form of Psychological Soft-
ware Services CogReHab Software,
a multimedia cog-
nitive rehabilitation software designed for use with
individuals with compromised brain function. Details
of the tasks are described in Bell et al
The analyses were performed by SPSS version 14 and
AMOS version 7.0 (SPSS, Inc., Chicago, IL). Descriptive
statistics of all variables involved were first computed.
A correlational matrix between the variables for neuro-
cognition and social cognition was produced. We then
performed a confirmatory factor analysis to assess if
the variables we selected load well on the latent constructs
‘‘neurocognition’’ and ‘‘social cognition.’’ Factor load-
ings were used to specify the association between the in-
dicator variable and the latent construct. By using
principal axis factoring, factor analysis was used to gen-
erate factor scores for subsequent path analysis. Factors
with eigenvalues over 1 were extracted along with vari-
Neurocognition, Social Cognition, Perceived Social Discomfort, and Vocational Outcomes
With support from the confirmatory factor analysis,
we created factor scores for neurocognition and social
cognition that were summated z scores of the relevant
component variables. In addition, we compiled a compos-
ite rehabilitation outcome score based on the number of
hours worked, WBI scores, and the complexity score.
Again, it was a factor score by summation of the con-
verted z scores of the 3 parameters. All the above factor
scores were used for the subsequent analyses.
A correlational matrix showing the relationship be-
tween variables of neurocognition and social cognition
and variables of perceived social discomfort and rehabil-
itation outcome was computed. Path analysis was then
used to test the relationship between neurocognition, so-
cial cognition, and perceived social discomfort at work in
relation to the rehabilitation outcome. In the analysis,
neurocognition was treated as the exogenous variable
while social cognition and perceived social discomfort
in the workplace were treated as the mediating variables.
We hypothesized that neurocognitive function has both
direct and indirect effects on rehabilitation outcomes. We
tested 2 models based on the literature and our hypoth-
esis. In model 1, only social cognition was treated as the
mediating variable between neurocognition and rehabil-
itation outcome based on available literature.
model 2, we test our own model that perceived social dis-
comfort was treated as an additional mediating variable
between social cognition and rehabilitation outcome.
Three different goodness-of-fit statistics were used which
included the model relative chi square (v
parative fit index (CFI),
and the root mean square error
of approximation (RMSEA).
The relative chi square
has the advantage of being less dependent on sample
The CFI compares the final model with an ‘‘inde-
pendence’’ model, which is a null model that assumes all
variables are uncorrelated with dependent variable. It
provides good model fit even with a small sample
RMSEA is also a commonly used fit statistic be-
cause it does not require a null model.
A model that fits
well with the data has a v
/df ratio less than 3,
a CFI of
greater than 0.90, and an RMSEA less than 0.08.
compare the 2 models to be developed by our analysis, we
used the following formula to compute the P value for
comparison of model fit.
P value = chidist
The means and SDs of the variables pertaining to neuro-
cognition, social cognition, and perceived social discom-
fort are presented in table 1. The correlational matrices of
the variables are shown in table 2.
Conﬁrmatory Factor Analysis
Table 3 summarizes the hypothesized model that neuro-
cognition was a 5-factor latent construct that consisted of
thought disorder, verbal memory, attention and working
memory, executive function, and processing speed. The
model shows that the 5-factor structure fit well with
the observed data that was confirmed by the goodness-
of-fit statistics (v
= 5.353, df = 5, P value = .374; CFI =
1.00 (saturated model), 0.992 (default Model); and
RMSEA = 0.022.
Similarly, confirmatory factor analysis shows that the
4-factor solution of social cognition variables—affect rec-
ognition, theory of mind, egocentricity, and rapport—
fitted well with the observed data. This was confirmed
by the goodness-of-fit statistics (v
= 2.459, df = 2,
P value = .292; CFI = 1.00 (saturated model), 0.975 (de-
fault model); and RMSEA = 0.039).
In our path analysis, we treated neurocognition as the ex-
ogenous variable and social cognition as the endogenous
variable for our 2 models.
In model 1, we tested the model suggested by available
literature that neurocognition had a direct effect on
rehabilitation outcome and that it was also mediated by
Table 1. Descriptive Statistics
Variables N Mean SD
Proverbs total 149 3.23 4.02
HVLT 1 151 4.62 1.64
WCST conceptual level 151 81.21 19.43
Digit Span 151 9.32 2.47
Digit Symbol 151 6.32 2.07
Hinting Task total 150 16.02 3.68
BLERT total 151 15.90 4.60
Egocentricity 150 0.40 0.86
Rapport 151 4.06 1.11
Perceived Social Discomfort
Difficult understanding coworkers 143 2.28 1.07
Work stressful 143 2.62 1.26
Difficult talking to coworkers 143 2.23 1.12
Composite Rehabilitation Outcomes
Hours (total number) 148 227.40 164.87
Complexity (average last 3 weeks) 145 2.74 0.69
WBI (average last 3 weeks) 145 117.41 24.52
Note: Proverbs total refers to Bizarreness score on the Gorham’s
Proverbs Test. HVLT 1 refers to trial 1 total of Hopkins Verbal
Learning Test Revised. WCST conceptual level refers to percent
conceptual level on the Wisconsin Card Sorting Test. Digit Span
and Digit Symbol are scores from Wechsler Adult Intelligence
Scale III. Egocentricity refers to the scale of the Bell Object
Relations Inventory. Rapport is extracted from the item from
Quality of Life Scale. WBI, Work Behavior Inventory; BLERT,
Bell Lysaker Emotion Recognition Test.
M. Bell et al.
outcome. Table 4 shows the result of path analysis for this
The model shows that social cognition was the medi-
ator between neurocognition and rehabilitation outcome.
Neurocognition explained 22.3% of variance of social
cognition, which in turned explained 5.5% of variance
of the rehabilitation outcome. However, the model on
the whole did not fit well with the observed data. Statistics
= 6.961, df = 1, P value = .008; CFI = 1.00 (saturated
model), 0.868 (default model); and RMSEA = 0.199)
show that it is not a well-fitted model according to our
Table 5 shows the second model that was conceptual-
ized as the multiple mediator model. First, social cogni-
tion was the mediator between neurocognition and
rehabilitation outcome similar to model 1. Second, per-
ceived social discomfort was conceptualized as another
mediator between social cognition and rehabilitation out-
come. This model shows that neurocognition had a signif-
icant direct effect on rehabilitation outcome. In addition,
Table 2. Corelational Matrices of Study Variables
Neurocognition Social Cognition
Total Egocentricity Rapport
Proverbs total 1.00 0.137 0.275*** 0.229*** 0.092 0.455*** 0.186* 0.038 0.045
HVLT 1 1.00 0.242*** 0.198* 0.272*** 0.253*** 0.141 0.319*** 0.247***
1.00 0.208* 0.253*** 0.260*** 0.184* 0.169* 0.115
Digit Span 1.00 0.231*** 0.234*** 0.045 0.273*** 0.018
Digit Symbol 1.00 0.100 0.170* 0.282*** 0.002
Hinting Task total 1.00 0.169* 0.202* 0.196*
BLERT total 1.00 0.270*** 0.167*
Egocentricity 1.00 0.080
Perceived Social Discomfort Composite Rehabilitation Outcomes
Coworkers Hours Complexity WBI
Proverbs total 0.014 0.073 0.127 0.123 0.220*** 0.199*
HVLT 1 0.247*** 0.218*** 0.262*** 0.106 0.296*** 0.243***
0.086 0.028 0.037 0.077 0.058 0.120
Digit Span 0.101 0.091 0.051 0.207* 0.178* 0.169*
Digit Symbol 0.099 0.074 0.081 0.109 0.108 173*
Hinting Task total 0.190* 0.138 0.181* 0.154 0.349*** 0.355***
BLERT total 0.153 0.076 0.133 0.024 0.123 0.096
Egocentricity 0.115 0.062 0.086 0.013 0.145 0.149
Rapport 0.076 0.092 0.036 0.037 0.056 0.101
Understanding_1ST 1.00 0.637*** 0.796*** 0.037 0.187* 0.150
Stressful_1ST 1.00 0.728*** 0.180* 0.201* 0.175*
Talking_1ST 1.00 0.047 0.191* 0.144
Hours 1.00 0.488 0.637***
Complexity 1.00 0.707***
Note: HVLT, Hopkins Verbal Learning Test trial 1; WCST, Wisconsin Card Sorting Test; BLERT, Bell Lysaker Emotion Recognition
Test; WBI, Work Behavior Inventory.
* P<.05; ***P < .001.
Neurocognition, Social Cognition, Perceived Social Discomfort, and Vocational Outcomes
it exerted a significant indirect effect mediated by social
cognition and perceived social discomfort. Neurocogni-
tion had a significant positive effect on social cognition
explaining 22.5% of its variance. On the other hand, so-
cial cognition had a significant negative relationship with
perceived social discomfort in the workplace with 6.7% of
its variance explained. Perceived social discomfort simi-
larly had a significant negative impact on rehabilitation
outcome. The model explained altogether 18.4% of the
total variance of the rehabilitation outcome. Goodness-
of-fit statistics (v
= 2.128, df = 2, P value = .345; CFI
= 1.00 (saturated model), 0.998 (default model); and
RMSEA = 0.021) shows that the model is well fitted to
the observed data.
To compare the 2 models, we computed the P value
based on the formula presented above. Table 6 shows
that model 2 is better than model 1 in terms of their good-
ness of fit.
Results of the current study reveal the contribution that
social cognition and social discomfort make to voca-
tional rehabilitation outcomes. The model that we tested
was based on previous work showing that social cognition
(measured in ways somewhat different than in this study)
mediated the effects of neurocognition on community
M. Bell et al.
Our first model, which did not include
social discomfort and did not have a direct path for neu-
rocognition, proved to be a poor fit to the data. Our
second model, which included the direct effects of neuro-
cognition on rehabilitation outcome and the mediating
role of both social cognition and social discomfort,
proved to be a good fit to the data and far superior to
the first model. These results may be interpreted to indi-
cate that social cognition is dependent upon neurocogni-
tive processes and that its functional impact may occur
indirectly through its effects on social discomfort. People
with poorer neurocognition are likely to have more prob-
lems with social cognition. Impaired social cognition
makes it more difficult for people to be comfortable in
the workplace, to understand their coworkers, and to
communicate with them. These difficulties have direct
effects upon how well they do their job, how much re-
sponsibility they are given, and how many hours of
work they perform.
In order to test our model, we needed to make many
choices in data reduction and in our selection of varia-
bles. In particular, our choice of variables to represent
the latent construct of social cognition is somewhat orig-
inal. We wanted to avoid shared method variance and
enhance the robustness of the construct by selecting var-
iables that came from performance testing (BLERT and
Hinting Task), self-report (Egocentricity), and observa-
tion (Rapport). These variables had relatively low bivar-
iate correlations with each other, but the confirmatory
factor analysis showed that they all contributed signifi-
cantly to the latent variable that we labeled social cog-
nition. The resulting construct is contributed to by
elemental features of social cognition such as theory of
mind and affect recognition and more holistic aspects
such as perceived relatedness and observed ability to es-
tablish rapport. As a latent construct, it proved to have
an important role in explaining rehabilitation out-
The final model suggests that social cognition and so-
cial discomfort on the job may both be relevant targets
for intervention. There are a few interventions that
have appeared recently in the literature including Social
Cognition and Interaction Training,
and social cognitive enhancement train-
that may be helpful in addressing both elemental
functions such as affect recognition and more holistic
functions such as ‘‘gistful learning.’’
that directly concern social functioning in the workplace
may be useful in addressing social discomfort. These in-
clude ‘‘Work Place Fundamentals,’’ a social skills training
and a work feedback and goal setting group de-
scribed in Bell et al
that includes issues of social skills
and cooperativeness on the job. In addition, cognitive
and behavioral techniques to help clients cope with
and psychoeducation used to help people to
handle work-related stress
are promising approaches.
There are a number of limitations that come from the
post hoc nature of this analysis and the choices that were
necessary in selecting variables and building models. For
example, tests selected for the social cognition construct
did not include a specific assessment of attributional style,
which may have been an important feature to capture.
Table 6. Comparison of Model 1 and Model 2
CFI RMSEA v
Model 1: social cognition as
0.868 0.199 6.961 1 .008
Model 2: multiple mediating
0.988 0.021 2.128 2 .345
Comparisons of model fit
Model 1 vs model 2 .003
Note: Conclusion—Model 2 has a better fit than Model 1.
RMSEA, root mean square error of approximation.
Neurocognition, Social Cognition, Perceived Social Discomfort, and Vocational Outcomes
The data came from a randomized study of cognitive re-
mediation, and the conditions of that trial are not in-
cluded in the model because of limitations in power
that constricted the number of parameters that could
be included. However, the effects of condition should
not have been relevant to neurcognition or social cogni-
tion that were evaluated before entry into condition. Fur-
thermore, although cognitive training proved to have
a favorable effect on vocational outcomes in the 6 months
following the intervention,
those effects were not found
at the conclusion of the intervention, the time period
when our rehabilitation outcome measure was recorded.
Results of this study may not be generalizable to other
types of vocational rehabilitation such as supported em-
ployment or to a younger sample, such as those recover-
ing from their first episode. However, results suggest the
potential significance of social discomfort as a contribu-
tor to vocational outcomes, and future studies in sup-
ported employment or with first-episode patients may
wish to consider examining its effects.
1. Green MF. What are the functional consequences of neurocog-
nitive deficits in schizophrenia? Am J Psychiatry. 1996;153:
2. Couture SM, Penn DL, Roberts DL. The functional signifi-
cance of social cognition in schizophrenia: A review. Schiz-
ophr Bull. 2006;32(suppl):S44–S63.
3. Mindt M, Moss M, Spaulding W. Cognitive measures: what
can they tell us about social competence? Psychiatr Rehabil
4. Zanello A, Perrig L, Huguelet P. Cognitive functions related
to interpersonal problem-solving skills in schizophrenic
patients compared with healthy subjects. Psychiatry Res.
5. Abi-Saab D, Fiszdon J, Bryson G, Bell M. The implications
of memory profiles in schizophrenia on vocational and
neuropsychological functioning. Schizophr Res. 2006;75:
6. Evans JD, Bond GR, Meyer PS, et al. Cognitive and clinical
predictors of success in vocational rehabilitation in schizo-
phrenia. Schizophr Res. 2004;70:331–342.
7. Morrison RL, Bellack AS, Mueser KT. Deficits in facial-
affect recognition and schizophrenia. Schizophr Bull. 1988;
8. Penn DL, Corrigan PW, BentallRP, Racenstein JM, NewmanL.
Social cognition in schizophrenia. Psychol Bull. 1997;121:
9. Brekke JS, Hoe M, Long J, Green MF. How neurocognition
and social cognition influence functional change during com-
munity-based psychosocial rehabilitation for individuals with
schizophrenia. Schizophr Bull. 2007;33:1247–1256.
10. Dickinson D, Bellack AS, Gold JM. Social/communication
skills, cognition and vocational functioning in schizophrenia.
Schizophr Bull. 2007;33:1213–1220.
11. Hogarty GE, Flesher S. Developmental theory for a cognitive
enhancement therapy of schizophrenia. Schizophr Bull.
12. Silverstein SM. Information processing, social cognition, and
psychiatric rehabilitation in schizophrenia. Psychiatry.
13. Allen DN, Strauss GP, Donohue BC, van Kammen DP. Fac-
tor analytic support for social cognition as a separable cogni-
tive domain in schizophrenia. Schizophr Res. 2007;93:325–333.
14. Sergi MJ, Rassovasky Y, Widmark C, et al. Social cognition
in schizophrenia: relationships with neurocognition and neg-
ative symptoms. Schizophr Res. 2007;90:316–324.
15. Bigelow NO, Paradiso S, Adolphs R, et al. Perception of so-
cially relevant stimuli in schizophrenia. Schizophr Res.
16. Sergi MJ, Green MF. Social perception and early visual
processing in schizophrenia. Schizophr Res. 2003;59:233–241.
17. Green MJ, Uhlhaas PJ, Coltheart M. Context processing and
social cognition in schizophrenia. Curr Psychiatry Rev.
18. Toomey R, Wallace CJ, Corrigan PW, Schuldberg D, Green
MF. Social processing correlates of nonverbal social percep-
tion in schizophrenia. Psychiatry. 1997;60:292–300.
19. Wynn JK, Sergi MJ, Dawson ME, Schell AM, Green MF.
Sensorimotor gating, orienting and social perception in
schizophrenia. Schizophr Res. 2005;73:319–325.
20. Sergi MJ, Rasoovasky Y, Nuechterlein KH, Green MF. So-
cial perception as a mediator of the influence of early visual
processing on functional status in schizophrenia. Am J Psy-
21. Bowie CR, Harvey PD. Predicting real world outcomes from
discrete functional and cognitive abilities. Schizophr Bull.
22. Bolton B, Roessler R. Manual for the Work Personality Pro-
file. Fayetteville, Ark: Research and Training Center in Voca-
tional Research; 1986.
23. Bryson G, Bell M, Kaplan E, Greig T. The Work Behavior
Inventory: prediction of future work success of people with
schizophrenia. Psychiatr Rehabil J. 1999;23:113–120.
24. First MB, Spitzer RL, Gibbon M, Williams JB. Structured
Clinical Interview for DSM-IV Axis I Disorders–Patient
Edition (SCID-I/P, Version 2.0). New York, NY: Biometrics
Research Department, New York State Psychiatric Institute;
25. Bell MD, Bryson GJ, Greig TC, Fiszdon JM, Wexler BE.
Neurocognitive enhancement therap y with work therapy:
Productivity outcomes at 6-and 12-month follow-ups.
J Rehabil Res Dev. 2 005;42:829–838.
26. Wexler BE, Bell MD. Cognitive remediation and vocational
rehabilitation for schizophrenia. Schizophr Bull. 2005;31:
27. Harvey PD, Keefe RSE. Cognitive impairment in schizophre-
nia and implications of atypical neuroleptic treatment. CNS
28. Heaton R. Wisconsin Card Sorting Test Manual. Odessa, Fla:
Psychological Resources; 1981.
29. Bell MD, Greig TC, Kaplan E, Bryson G. Wisconsin Card
Sorting Test dimensions in schizophrenia: Factorial, predic-
tive, and divergent validity. J Clin Exp Neuropsychol.
30. Brandt J, Benedict RHB. Hopkins Verbal Learning Test-
Revised. Professional manual. Lutz, Fla: Psychological As-
sessment Resources; 2001.
31. Wechsler D. Wechsler Adult Intelligence Scale-3rd Edition
(WAIS-3). New York, NY: Harcourt Assessment; 1997.
M. Bell et al.
32. Gorham D. The use of the proverbs test for differentiating
schizophrenia from normal. J Consult Psychol. 1950;20:
33. Marengo J, Harrow M, Rogers C. A Manual for Scoring Ab-
stract and Concrete Responses to Verbal Tests. New York,
NY: Microfilm Publications; 1980.
34. Bell M, Bryson G, Lysaker P. Positive and negative affect rec-
ognition in schizophrenia: a comparison with substance abuse
and normal control subjects. Psychiatr Res. 1997;73:73–82.
35. Corcoran R, Mercer G, Frith CD. Schizophrenia, symptom-
atology and social inference: investigating ‘‘theory of mind’’
in people with schizophrenia. Schizophr Res. 1995;17:5–13.
36. Greig TC, Bryson GJ, Bell MD. Theory of Mind performance
in schizophrenia: diagnosis, symptom and neuropsychological
correlates. J Nerv Ment Dis. 2004;192:12–18.
37. Bell MD. The Bell Object Relations Reality Testing Inventory
(BORRTI). Los Angeles, Calif: Western Psychological Serv-
38. Bell MD, Bruscato W. Object relations deficits in schizophre-
nia: a cross-cultural comparison between Brazil and USA.
J Nerv Ment Dis. 2002;190:73–79.
39. Bell M, Bryson G, Greig T, Corcoran C, Wexler BE. Neuro-
cognitive enhancement therapy with work therapy: effects on
neuropsychological test performance. Arch Gen Psychiatry.
40. Bell MD, Zito W. Integrated versus sealed-over recovery in
schizophrenia: BORRTI and executive function. J Nerv
Ment Dis. 2005;193:3–8.
41. Heinrichs DW, Hanlon TE, Carpenter WT. The Quality of
Life Scale: an instrument for rating the schizophrenic deficit
syndrome. Schizophr Bull. 1984;10:388–398.
42. Bryson G, Bell M, Lysaker P. The Work Behavior Inventory:
a scale for the assessment of work behavior for clients with
severe mental illness. Psychiatr Rehabil J. 1997;20:47–55.
43. Bell MD, Fiszdon JM, Greig T, Wexler BW, Bryson G. Neu-
rocognitive enhancement therapy with work therapy in
schizophrenia: a six month follow-up of neuropsychological
performance. J Rehabil Res Dev. 2007;44:761–770.
44. Bracy O. CogReHab Software. Indianapolis, Ind: Psycholog-
ical Software Services; 1995.
45. Fiszdon JM, Whelahan H, Bryson GJ, Wexler BE, Bell MD.
Cognitive training of verbal memory using a dichotic listening
paradigm: impact on symptoms and cognition. Acta Psychiatr
46. Ohaeri JU, Awadalla AW, El-Abas AHM, Jacob A. Confir-
matory factor analytical study of the WHOQOL-Bref: experi-
ence with Sudanese general population and psychiatric
samples. BMC Med Res Methodol. 2007;7:37.
47. Bentler PM. Comparative fit indexes in structural models.
Psychol Bull. 1990;107:238–246.
48. Browne MW, Cudeck R. Alternative ways of assessing model
fit. In: Bollen KA, Long JS, eds. Testing Structural Equation
Models. Newbury Park, Calif: Sage Publications; 1993:136–162.
49. Vauth R, Rusch N, Wirtz M, Corrigan PW. Does social cog-
nition influence the relation between neurocognitive deficits
and vocational functioning in schizophrenia? Psychiatr Res.
50. Carmines EG, McIver JP. Analysing Models With Unobserved
Variables: Analysis of Covariance Structures. Beverly Hills,
Calif: Sage; 1981.
51. Dunn G, Everitt B, Pickles A. Modeling Covariances and La-
tent Variables Using EQS. London, UK: Chapman & Hall;
52. Hu L, Bentler PM. Cutoff criteria for fit indexes in covariance
structure analysis: conventional criteria versus new alterna-
tives. Struct Equation Model. 1999;6:1–55.
53. Kelloway EK. Using Lisrel for Structural Equation Modeling:
A researcher’s Guide. Thousand Oaks, Calif: Sage; 1998.
54. Steiger JH, Shapiro A Browne MW. On the multivariate as-
ymptotic distribution of sequential chi-square statistics, Psy-
55. Combs DR, Adams SD, Penn DL, et al. Social cognition and
interaction training (SCIT) for inpatients with schizophrenia
spectrum disorders: preliminary findings. Schizophr Res.
56. Eack SM, Hoga rty GE, Greenwald DP, Hogarty SS,
Keshavan MS. Cognitive enhancement ther apy improves
emotional intelligence in early course schizophrenia: prelimi-
nary effects. Schizophr Res. 2007;89:308–311.
57. Choi KH, Kwon JH. Social cognitive enhancement training
for schizophrenia: a preliminary randomized controlled trial.
Community Ment Health J. 2006;42:177–187.
58. Wallace CJ, Tauber R, Wilde J. Teaching fundamental work-
place skills to persons with serious mental illness. Psychiatr
59. Bell MD, Lysaker P, Bryson G. A behavioral intervention
to improve work performance in schizophrenia: Work
Behavior Inventory Feedback. J Vocat Rehabil. 2003;18:
60. Norman RMG, Malla AK, McLean TS, et al. An evaluation
of a stress management program for individuals with schizo-
phrenia. Schizophr Res. 2002;58:293–303.
61. Lee H, Tan HK, Ma H, Tsai C, Liu Y. Effectiveness of
a work-related stress management program in patients with
chronic schizophrenia. Am J Occup Ther. 2006;60:435–441.
Neurocognition, Social Cognition, Perceived Social Discomfort, and Vocational Outcomes