Some reflections on social-cognitive research in schizophrenia
Psychiatry; New York; Winter 2000; David L Penn;
Volume: 63
Issue: 4
Start Page: 339-343
ISSN: 00332747
Subject Terms: Schizophrenia
Studies
Psychology
Cognition & reasoning
Abstract:
Penn comments on the research by Hooker et al (200) regarding
the investigation of counterfactual thinking in outpatients with schizophrenia.
Penn discusses the findings of Hooker et al and offers a brief overview of
social cognition in schizophrenia.
Full Text:
Copyright Guilford Publications, Inc. Winter 2000
In the preceding article, Hooker and colleagues investigated
counterfactual thinking in outpatients with schizophrenia. As hypothesized, the
findings revealed that relative to a nonclinical control sample, persons with
schizophrenia were impaired in multiple measures of counterfactual thinking.
These performance deficits could not be explained by a general performance deficit
(as measured by WAIS-R subtests and a verbal fluency task), and they showed an
association with a measure of general social competence. What is especially
interesting about this article, beside its findings, is that it addresses a
number of issues critical to social cognition research in schizophrenia. Before
discussing these issues, however, a brief overview of social cognition in
schizophrenia will be presented, with an eye toward placing the Hooker et al.
study within its broader scientific context.
APPROACHES TO SOCIAL COGNITION IN SCHIZOPHRENIA
As with many constructs in psychology and psychiatry, the
definition of "social cognition" varies depending on the author or
context. Our working model is based on Brothers' (1990) definition of social
cognition. Brothers states that it refers to the "mental operations
underlying social interactions, which include the human ability and capacity to
perceive the intentions and dispositions of others" (p. 28). This
definition is intentionally broad, as there appear to be numerous
social-cognitive abilities and the underlying structure of social cognition
remains unexamined, especially in schizophrenia. What is also appealing about
this definition is the explicit linking of social cognition to behavior. This
link is especially important in schizophrenia research, where impairments in
social functioning are a hallmark characteristic of the disorder (DSM-IV; APA,
1994). Therefore, exploring social cognition in schizophrenia may provide
insight into the processes that underlie and maintain social dysfunction (Green
and Nuechterlein 1999; Penn, Combs, and Mohamed in press; Silverstein 1997).
In the broad stroke, there have been two major approaches to
studying social cognition in schizophrenia. The first, often associated with
researchers in the United Kingdom, places greater emphasis on the
"biases" that occur during social information processing. As noted in
our previous work (Penn, Corrigan, Bentall, Racenstein, and Newman 1997),
biases refer to a response style that is not necessarily indicative of poor
performance. Rather, a performance bias reflects a response pattern as a
function of condition and context. An example of a performance bias in
schizophrenia is the "self-serving" attributional style associated
with persecutory delusions; taking credit for successful outcomes and denying
responsibility for negative outcomes (reviewed in Bentall, in press). Another
example would be the tendency for persons with schizophrenia to see unrelated
events as connected and meaningful; what is defined clinically as "ideas
of reference" but is measured experimentally as an "illusory
correlation" (Brennan and Helmsley 1984).
The second approach to social cognition involves an emphasis more
on performance deficits rather than biases. Perhaps the best example of this
approach is the voluminous work on facial affect perception. Studies in this
area typically compare the performance of a group with schizophrenia to one or
more control groups on various emotion and general perception tests (i.e., a
differential deficit design) (for reviews, see Edwards, Jackson, and Pattison
1999; Hellewell and Whittaker 1998; Mandal, Pandey, and Prasad 1998; Morrison,
Bellack, and Mueser 1988; Penn et al. 1997). Impairments in one or more tasks,
relative to controls, are thought to reflect a deficit in the construct in
question. Thus, the deficit approach to social cognition implies a polarization
between "normal" and "abnormal," while the bias approach
suggests that social cognitive abilities lie more on a continuum.
These two approaches to social cognition differ in additional
ways. The "bias" approach tends to be more content-oriented and
symptom-focused, for example, investigating memory bias for threatening
information in persons with persecutory delusions (Bentall, in press).
Therefore, a critical question for the researcher who uses this perspective
might be "How does the content of one's symptoms influences social
information processing?" In addition, explanations of etiology are not
limited to biological factors, but may include psychological mechanisms. This
has been especially characteristic of the work on attributional style, which
has investigated the role that self-serving attributions have in protecting the
self-esteem of persons with persecutory delusions (reviewed in Garety and
Freeman 1999).
Conversely, the deficit approach tends to be dominated more by
biologically oriented, reductionistic models, in which the goal is to identify
the neural mechanisms underlying the disorder. Thus, the deficit research may
start with the question of "What is the impact of neuropathology on social
cognition?" rather than "What psychological and/ or behavioral
function do these social-cognitive processes serve?"
Interestingly, these two approaches to social cognition are fairly
compatible with two popular, current approaches to psychosocial treatment in
schizophrenia: Cognitive-Behavioral Therapy (CBT) and cognitive remediation.
The emphasis of CBT on symptoms remission, normalizing rationales, coping
strategies, and self-evaluation appears to be consistent with the bias approach
to social cognition (Garety, Fowler, and Kuipers 2000). Alternatively, cognitive
remediation approaches assume that a performance deficit exists, and that
content-free strategies such as repeated practice, errorless learning, modified
instructions, and reinforcement will strengthen or repair the skill in question
(Kern, Green, and Goldstein 1995; Kern, Wallace, Hellman, Womack, and Green
1996; Medalia, Aluma, Tryon, and Merriam 1998; Penn and Combs in press). These
approaches need not be incompatible, as the ultimate goal is to repair those
cognitive and social-cognitive processes that support social behavior and
adaptive functioning (Spaulding and Poland in press). However, as these
approaches make different assumptions about the underpinnings of social
cognitive difficulties in schizophrenia, the targets of intervention and the
measurement of outcome may differ.
THE SOCIAL-COGNITIVE CONTENT OF THE PRESENT STUDY
The foregoing was intended to provide a context in which to
evaluate the Hooker et al. study. Thus, it appears safe to conclude that, by
linking counterfactual thinking to cognitive impairments (i.e., Wisconsin Card
Sorting Task) and neural functioning (i.e., prefrontal cortex damage), the
Hooker et al. study is most compatible with the deficit model of social
cognition. Of course, this makes sense, given the oft-cited difficulties that
persons with schizophrenia have with frontal tasks (Crider 1997) and the
relationship between measures of cognition and social cognition (Addington and
Addington 1998; Kee, Kern, and Green 1998; Penn, Spaulding, Reed, and Sullivan
1996). It is possible, however, that impairments in counterfactual thinking
result from motivational and/or personal concerns. For example, recalling
negative events, and speculating how they could have turned out differently,
may have been too painful for persons whose lives have not turned out the way
they had hoped. This is not an unreasonable assumption, as personal
perspectives on the experience of schizophrenia often report a sense of loss
(Davidson, Stayner, and Haglund 1998). Furthermore, psychological mechanisms
may underlie insight (Carroll, Fattah, Clyde, Coffey, Owens, and Johnstone
1999) and negative symptoms (Strauss, Rakfeldt, Harding, and Lieberman
1989)-other schizophrenia-related constructs that often assume a
neuropathological basis. Finally, evidence that performance on cognitive and
social-cognitive tasks can be improved with monetary reinforcement (e.g., Kern
et al. 1995; Penn and Combs in press), suggest that performance deficits are
not immutable, and that motivational factors are also important.
Hooker et al. appropriately assessed whether the group with
schizophrenia's deficit in counterfactual thinking can be accounted for by
generalized poor performance, which is a critical issue in social-cognitive
research, since establishing the independence of social cognition from
non-social cognition may have important implications for schizophrenia
assessment and treatment (Green, Kern, Braff, and Mintz 2000). One could argue,
however, that future work that controls for cognitive factors should better
match the cognitive and social-cognitive constructs in question. By better
matching, I don't mean psychometrically, as the authors' note in their article,
but a better conceptual match. For example, the participants could be asked two
types of counterfactual questions that vary in social cognitive content. One
question could pertain to an "interpersonal" event that they wished
had gone differently (e.g., not speaking up for themselves after someone had
insulted or slighted them), while the other could relate to a personal,
"non-interpersonal" event (e.g., just missing a plane by five
minutes). Such tasks require the same skill (i.e., recalling alternative
courses of action) and involve personally relevant events-the only exception
being that task content, in terms of social cognition, is manipulated.
Furthermore, subtyping participants into those with particular symptom clusters
(e.g., persecutory delusions, negative symptoms, etc.) may allow for an
analysis of symptom X content interactions, which is again more consistent with
bias-type approaches.
This issue of conceptually matching tasks also applies to the
relationship between social cognition and social behavior. While the authors
should be commended for including a measure of social functioning in their
study, it is, as they admit, a very global measure of social competence. It is,
arguably, reaching to expect measures of counterfactual thinking to have a
meaningful relationship with important social accomplishments such as
education, martial status, occupation, and employment history without wondering
whether both sets of variables are not actually related to a third, unmeasured,
domain. Thus, a statistical relationship should not be confused with one that
applies in the real world. For example, performance on a leather stitching task
has been shown to associated with social competence among acutely ill
inpatients (Penny, Mueser, and North 1995). It is likely, however, that
training persons with schizophrenia to better "leather-stitch" would
not generalize to better social skill. What it does suggest is that similar
processes may be involved in both activities, although what these processes are
remains unanswered. It should be noted, however, that Hooker et al. are not
unusual in assessing general relationships between social cognitive processes
and broad indices of social functioning. This is clearly an issue that plagues
research examining the functional significance of both cognitive and
social-cognitive processes in schizophrenia, including our own work (reviewed
in Green et al. 2000; Penn et al. in press).
An alternative approach is one that attempts to translate the
social-cognitive processes into specific behaviors. The authors appear to
acknowledge this issue in the limitations section of the Discussion. For
example, Theory of Mind (ToM), the ability to infer the mental states of other
people has been of great recent interest to schizophrenia researchers (reviewed
in Corcoran in press). In the autism literature, efforts have been made to behaviorally
assess ToM-type impairments by evaluating the reaction of children with autism
to staged interpersonal scenarios (Sigman and Ruskin 1999). For example, one
scenario involved an experimenter approaching a table (where a child was
seated) with a tray of refreshments and snacks. However, the table was
completely covered with objects, so the primary dependent variable was whether,
and how quickly, the child spontaneously removed the objects from the table
(Sigman and Ruskin 1999). Similar scenarios were constructed that involved
responses to distress (e.g., the experimenter pretends to bump her/ his knee
and the child's reactions are videotaped). These types of tasks seem to be
better behavioral tests of social-cognitive processes than general, broadly
defined indices of social functioning. Furthermore, they appear to have, at
least superficially, more "face-validity" than standard paper and
pencil tests, which are often used to assess social cognition in schizophrenia
(e.g., attributional style; ToM).
One final point regarding the measurement of social cognition. A
real strength of this study was the utilization of multiple measures of the
same construct, especially the convergence between a paper-and-pencil test and
one based on the participant's own personal experience. This latter approach to
understanding social cognition appears to be especially promising. A level of
analysis based on the individual's perspective has proven fruitful in the areas
of psychosis and violence (Juninger 1996;-Juninger, Parks-Levy, & McQuire
1998), subjective experience and schizophrenia (Davidson et al. 1998), and
self-perception and social skill (Ihnen, Penn, Corrigan, and Martin 1998). It
is also one that is currently being applied to the understanding selfesteem
(Barrowclough, personal communication, July 2000) and attributions (Bentall,
personal communication, July 2000) in schizophrenia. Hopefully, this trend will
help to integrate laboratory-based social cognitive research with that obtained
from the personal perspective of the person with schizophrenia. Unless this
occurs, we are always left with the question of whether the social cognitive
deficits and biases elicited from laboratory tasks actually map onto the
real-world social information processing difficulties of persons with
schizophrenia. If they do not, then such impairments or biases may actually
reflect the influence of alternative variables (e.g., motivation, attention,
lack of personal relevance, etc.). Therefore, a true science of social
cognition in schizophrenia will be one that balances the laboratory with the
real world, internal consistency with external consistency, and the
identification of biases and deficits with their impact on actual social
behavior. In this regard, Hooker et al. have taken a step in that direction.
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[Author note]
David L. Penn,
Ph.D., University of North Carolina-Chapel Hill, Department of Psychology,
Davie Hall, CB #3270, Chapel Hill, NC 275993270. Email: dpenn@email.unc.edu.