Can antipsychotics improve social cognition in patients with schizophrenia?

Social cognitive training among individuals with schizophrenia: Identifying responders to treatment

In this follow-up study of a previous randomized controlled trial of targeted facial affect recognition training among individuals with schizophrenia, reliable change indices (RCIs) were employed to identify responders to treatment. The original study found improved theory of mind at 3-month follow-up. The current study included 15 participants who received the intervention and who completed all three assessment points in the original study. Six of them had RCIs over the cutoff (≥+1.64), indicating that they had a clinically meaningful and statistically reliable improvement in ToM. The responders had significantly higher psychotic symptom level at baseline, but no other group differences between responders and nonresponders were identified. The study found no support for suggested moderators of treatment effect of social cognitive training (sex, education). As no consistently replicated barriers to treatment gains have been identified, we suggest that social cognitive training, where available, should be offered to interested clients.

Lack of social interaction advantage: A domain-general cognitive alteration in schizophrenia

People with schizophrenia (PSZ) showed preserved ability to unconsciously process simple social information (e.g., face and gaze), but not in higher-order cognition (e.g., memory). It is yet unknown how PSZ process social interactions across different cognitive domains. This study systematically investigated the cognitive characteristics of PSZ during social interaction processing from bottom-up perception to top-down memory, and established correlations with schizophrenic symptoms. In two experiments, social interactions were consistently displayed by face-to-face or back-to-back dyads. Experiment 1 enrolled 30 PSZ and 30 healthy control subjects (HCS) with a breaking continuous flash suppression (b-CFS) paradigm. Experiment 2 recruited 36 PSZ and 36 HCS for two memory tasks, wherein participants restored the between-model distance (working memory task) and recalled the socially bound pairs (long-term memory task). Results indicated that HCS showed advantageous processing of socially interactive stimuli against non-interactive stimuli throughout two experiments, including faster access to visual consciousness, closer spatial distance held in working memory and higher recollection accuracy in long-term memory. However, PSZ did not show any of these advantages, with significant interaction effects for all three tasks (task one: p = .018, ηp2 = .092; task two: p = .021, ηp2 = .074; task three: p = .015, ηp2 = .082). Moreover, correlation analyses indicated that PSZ with more severe negative symptoms (r = -.344, p = .040) or higher medication dosages (r = -.334, p = .046) showed fewer advantages in memorizing socially interactive information. Therefore, social interaction is not prioritized in schizophrenia from bottom-up perception to top-down memory, and the magnitude of such a domain-general cognitive alteration is clinically relevant to symptom severity and medication.

International perspective on social cognition in schizophrenia: current stage and the next steps

In the last decades, research from cognitive science, clinical psychology, psychiatry, and social neuroscience has provided mounting evidence that several social cognitive abilities are impaired in people with schizophrenia and contribute to functional difficulties and poor clinical outcomes. Social dysfunction is a hallmark of the illness, and yet, social cognition is seldom assessed in clinical practice or targeted for treatment. In this article, 17 international experts, from three different continents and six countries with expertise in social cognition and social neuroscience in schizophrenia, convened several meetings to provide clinicians with a summary of the most recent international research on social cognition evaluation and treatment in schizophrenia, and to lay out primary recommendations and procedures that can be integrated into their practice. Given that many extant measures used to assess social cognition have been developed in North America or Western Europe, this article is also a call for researchers and clinicians to validate instruments internationally and we provide preliminary guidance for the adaptation and use of social cognitive measures in clinical and research evaluations internationally. This effort will assist promoting scientific rigor, enhanced clinical practice, and will help propel international scientific research and collaboration and patient care.

Social cognition interventions for patients with first-episode psychosis: A scoping review

This scoping review seeks to identify existing evidence of social cognition interventions for patients with first-episode psychosis. This review followed the five steps of Arksey and O'Malley's scoping review framework. Studies published between October 2002 and June 2023 were examined in the following six databases: PsycArticles, PsycINFO, CINAHL, EMBASE, Medline, and Scopus. We also searched grey literature and references of included studies. Studies reporting on social cognition interventions for adults with first-episode psychosis were included. Review findings were synthesised employing the PAGER framework. The PRISMA Extension for Scoping Reviews guideline was followed to prepare and report this manuscript. Twelve articles were included in this review. Most of the social cognition interventions were provided in out-patient clinics. Four studies provided board-based social cognition interventions, while the remaining eight studies introduced interventions to targeted domains of social cognition. All studies reported an improvement in patients' social functioning and social skills after receiving the intervention. Barriers and facilitators for patients with first-episode psychosis in receiving social cognition intervention were also summarised. Future studies could be conducted to explore the long-term effects of social cognition interventions, particularly for in-patient setting and the domain of social perception.

Validation of behavioral measures of social cognition in individuals diagnosed with schizophrenia

Schizophrenia, a complex neuropsychiatric disorder, manifests severe impairments in social cognition, notably in Theory of Mind (ToM), empathy, and emotion recognition, which significantly influence social competence and overall functioning. These aspects are crucial for prognosis in individuals diagnosed with schizophrenia (SZ). This study validates a comics strip paradigm for ToM and empathy assessment, the Montreal Affective Voices (MAV) for measuring emotion recognition, and a Go-NoGo task for inhibition control estimation in individuals diagnosed with SZ, comparing their performance with healthy controls. SZ participants exhibited diminished abilities in the comics strip task, especially in ToM and empathy conditions, alongside challenges in identifying emotions from vocal cues in MAV. They responded slower and tended to be less accurate in the Go-NoGo task. The validated behavioral battery addresses the limitations of previous measures and emerges as a promising tool for future investigations into the neural systems underlying social cognition in schizophrenia. Such insights can lead to the development of long-needed treatment for negative symptoms and social dysfunctions in schizophrenia.

Emotional anticipation for dynamic emotional faces is not modulated by schizotypal traits: A Representational Momentum study

Schizotypy, a personality structure that resembles schizophrenia symptoms, is often associated with abnormal facial emotion perception. Based on the prevailing sense of threat in psychotic experiences, and the immediate perceptual history of seeing others' facial expressions, individuals with high schizotypal traits may exhibit a heightened tendency to anticipate anger. To test this, we used insights from Representational Momentum (RM), a perceptual phenomenon in which the endpoint of a dynamic event is systematically displaced forward, into the immediate future. Angry-to-ambiguous and happy-to-ambiguous avatar faces were presented, each followed by a probe with the same (ambiguous) expression as the endpoint, or one slightly changed to express greater happiness/anger. Participants judged if the probe was "equal" to the endpoint and rated how confident they were. The sample was divided into high (N = 46) and low (N = 49) schizotypal traits using the Schizotypal Personality Questionnaire (SPQ). First, a forward bias was found in happy-to-ambiguous faces, suggesting emotional anticipation solely for dynamic faces changing towards a potential threat (anger). This may reflect an adaptative mechanism, as it is safer to anticipate any hostility from a conspecific than the opposite. Second, contrary to our hypothesis, high schizotypal traits did not heighten RM for happy-to-ambiguous faces, nor did they lead to overconfidence in biased judgements. This may suggest a typical pattern of emotional anticipation in non-clinical schizotypy, but caution is needed due to the use of self-report questionnaires, university students, and a modest sample size. Future studies should also investigate if the same holds for clinical manifestations of schizophrenia.

Combining transcranial magnetic stimulation with training to improve social cognition impairment in schizophrenia: a pilot randomized controlled trial

Schizophrenia is a severe, chronic mental disorder that profoundly impacts patients' everyday lives. The illness's core features include positive and negative symptoms and cognitive impairments. In particular, deficits in the social cognition domain showed a tighter connection to patients' everyday functioning than the other symptoms. Social remediation interventions have been developed, providing heterogeneous results considering the possibility of generalizing the acquired improvements in patients' daily activities. In this pilot randomized controlled trial, we investigated the feasibility of combining fifteen daily cognitive and social training sessions with non-invasive brain stimulation to boost the effectiveness of the two interventions. We delivered intermittent theta burst stimulation (iTBS) over the left dorsolateral prefrontal cortex (DLPFC). Twenty-one patients were randomized into four groups, varying for the assigned stimulation condition (real vs. sham iTBS) and the type of cognitive intervention (training vs. no training). Clinical symptoms and social cognition tests were administered at five time points, i.e., before and after the treatment, and at three follow-ups at one, three, and six months after the treatments' end. Preliminary data show a trend in improving the competence in managing emotion in participants performing the training. Conversely, no differences were found in pre and post-treatment scores for emotion recognition, theory of mind, and attribution of intentions scores. The iTBS intervention did not induce additional effects on individuals' performance. The methodological approach's novelty and limitations of the present study are discussed.

Schizophrenia and cognitive dysfunction

Schizophrenia is a psychiatric disorder with cognitive dysfunction as a core symptom along with positive and negative symptoms. Cognitive dysfunction in schizophrenia can be broadly classified into neurocognitive and social cognitive deficits, with these deficits significantly influencing social functioning. Therapeutic interventions aiming to enhance neurocognition and social cognition have been developed. In this review, we describe the characteristics of cognitive dysfunction in patients with schizophrenia, its relationship to social function, and intervention strategies. J. Med. Invest. 71 : 205-209, August, 2024.

Emotional interference and attentional control in schizophrenia-spectrum disorders: The special case of neutral faces

BACKGROUND AND OBJECTIVES

Schizophrenia-spectrum disorders (SSD) are characterized by impaired emotion processing and attention. SSD patients are more sensitive to the presence of emotional distractors. But despite growing interest on the emotion-attention interplay, emotional interference in SSD is far from fully understood. Moreover, research to date has not established the link between emotional interference and attentional control in SSD. This study thus aimed to investigate the effects of facial expression and attentional control in SSD, by manipulating perceptual load.

METHODS

Twenty-two SSD patients and 22 healthy controls performed a target-letter discrimination task with task-irrelevant angry, happy, and neutral faces. Target-letter was presented among homogenous (low load) or heterogenous (high load) distractor-letters. Accuracy and RT were analysed using (generalized) linear mixed-effect models.

RESULTS

Accuracy was significantly lower in SSD patients than controls, regardless of perceptual load and facial expression. Concerning RT, SSD patients were significantly slower than controls in the presence of neutral faces, but only at high load. No group differences were observed for angry and happy faces.

LIMITATIONS

Heterogeneity of SSD, small sample size, lack of clinical control group, medication.

CONCLUSIONS

One possible explanation is that neutral faces captured exogenous attention to a greater extent in SSD, thus challenging attentional control in perceptually demanding conditions. This may reflect abnormal processing of neutral faces in SSD. If replicated, these findings will help to understand the interplay between exogenous attention, attentional control, and emotion processing in SSD, which may unravel the mechanism underlying socioemotional dysfunction in SSD.

Effects of NMDA-receptor blockade by ketamine on mentalizing and its neural correlates in humans: a randomized control trial

Schizophrenia is associated with various deficits in social cognition that remain relatively unaltered by antipsychotic treatment. While faulty glutamate signaling has been associated with general cognitive deficits as well as negative symptoms of schizophrenia, no direct link between manipulation of glutamate signaling and deficits in mentalizing has been demonstrated thus far. Here, we experimentally investigated whether ketamine, an uncompetitive N-methyl-D-aspartate receptor antagonist known to induce psychotomimetic effects, influences mentalizing and its neural correlates. In a randomized, placebo-controlled between-subjects experiment, we intravenously administered ketamine or placebo to healthy participants performing a video-based social cognition task during functional magnetic resonance imaging. Psychotomimetic effects of ketamine were assessed using the Positive and Negative Syndrome Scale. Compared to placebo, ketamine led to significantly more psychotic symptoms and reduced mentalizing performance (more "no mentalizing" errors). Ketamine also influenced blood oxygen level dependent (BOLD) response during mentalizing compared to placebo. Specifically, ketamine increased BOLD in right posterior superior temporal sulcus (pSTS) and increased connectivity between pSTS and anterior precuneus. These increases may reflect a dysfunctional shift of attention induced by ketamine that leads to mentalizing deficits. Our findings show that a psychotomimetic dose of ketamine impairs mentalizing and influences its neural correlates, a result compatible with the notion that deficient glutamate signaling may contribute to deficits in mentalizing in schizophrenia. The results also support efforts to seek novel psychopharmacological treatments for psychosis and schizophrenia targeting glutamatergic transmission.

Efficacy of technology-based interventions in psychosis: a systematic review and network meta-analysis

BACKGROUND

Technology-based interventions (TBIs) are a useful approach when attempting to provide therapy to more patients with psychosis.

METHODS

Randomized controlled trials of outcomes of TBIs v. face-to-face interventions in psychosis were identified in a systematic search conducted in PubMed/Ovid MEDLINE. Data were extracted independently by two researchers, and standardized mean changes were pooled using a three-level model and network meta-analysis.

RESULTS

Fifty-eight studies were included. TBIs complementing treatment as usual (TAU) were generally superior to face-to-face interventions (g = 0.16, p ≤ 0.0001) and to specific outcomes, namely, neurocognition (g = 0.13, p ≤ 0.0001), functioning (g = 0.25, p = 0.006), and social cognition (g = 0.32, p ≤ 0.05). Based on the network meta-analysis, the effect of two TBIs differed significantly from zero; these were the TBIs cognitive training for the neurocognitive outcome [g = 0.16; 95% confidence interval (CI) 0.09-0.23] and cognitive behavioral therapy for quality of life (g = 1.27; 95% CI 0.46-2.08). The variables educational level, type of medication, frequency of the intervention, and contact during the intervention moderated the effectiveness of TBIs over face-to-face interventions in neurocognition and symptomatology.

CONCLUSIONS

TBIs are effective for the management of neurocognition, symptomatology, functioning, social cognition, and quality of life outcomes in patients with psychosis. The results of the network meta-analysis showed the efficacy of some TBIs for neurocognition, symptomatology, and quality of life. Therefore, TBIs should be considered a complement to TAU in patients with psychosis.

Training volitional control of the theory of mind network with real-time fMRI neurofeedback

Is there a way improve our ability to understand the minds of others? Towards addressing this question, here, we conducted a single-arm, proof-of-concept study to evaluate whether real-time fMRI neurofeedback (rtfMRI-NF) from the temporo-parietal junction (TPJ) leads to volitional control of the neural network subserving theory of mind (ToM; the process by which we attribute and reason about the mental states of others). As additional aims, we evaluated the strategies used to self-regulate the network and whether volitional control of the ToM network was moderated by participant characteristics and associated with improved performance on behavioral measures. Sixteen participants underwent fMRI while completing a task designed to individually-localize the TPJ, and then three separate rtfMRI-NF scans during which they completed multiple runs of a training task while receiving intermittent, activation-based feedback from the TPJ, and one run of a transfer task in which no neurofeedback was provided. Region-of-interest analyses demonstrated volitional control in most regions during the training tasks and during the transfer task, although the effects were smaller in magnitude and not observed in one of the neurofeedback targets for the transfer task. Text analysis demonstrated that volitional control was most strongly associated with thinking about prior social experiences when up-regulating the neural signal. Analysis of behavioral performance and brain-behavior associations largely did not reveal behavior changes except for a positive association between volitional control in RTPJ and changes in performance on one ToM task. Exploratory analysis suggested neurofeedback-related learning occurred, although some degree of volitional control appeared to be conferred with the initial self-regulation strategy provided to participants (i.e., without the neurofeedback signal). Critical study limitations include the lack of a control group and pre-rtfMRI transfer scan, which prevents a more direct assessment of neurofeedback-induced volitional control, and a small sample size, which may have led to an overestimate and/or unreliable estimate of study effects. Nonetheless, together, this study demonstrates the feasibility of training volitional control of a social cognitive brain network, which may have important clinical applications. Given the study's limitations, findings from this study should be replicated with more robust experimental designs.

The effect of reading literary fiction on the theory of mind skills among persons with schizophrenia and normal controls

Introduction

Recent research data suggest that theory of mind (ToM) skills may improve after reading literary fiction. However, beside this short term favorable effect, regular long-term reading of literary fiction may also support ToM development or may improve ToM performance. The presence of impaired ToM abilities is well-documented in schizophrenia; however, the role of reading in these deficits is unknown. In the present study our aim was to assess the effect of prior reading experiences on theory of mind performance in patients with schizophrenia, and in healthy controls.

Materials and methods

ToM assessment was done with the Short Story Task, which is based on the interpretation of a Hemingway short story. After reading the short story, questions were asked in an interview format regarding comprehension, explicit and implicit ToM skills, then comparative analysis of schizophrenia patients was performed (n = 47) and matched to a normal control (n = 48) group concerning deficits of ToM abilities. Participants were also stratified according to their prior reading experiences.

Results

Previous reading experience was associated with better comprehension and explicit ToM performance both in patients with schizophrenia, and in healthy controls. However, the explicit ToM performance of patients with prior reading was still weaker compared to healthy controls with reading experiences. Path model analysis revealed that reading had a direct positive effect on ToM, and an indirect effect through improving comprehension.

Conclusions

Prior reading experience is associated with better ToM performance not just in healthy controls but also in patients living with schizophrenia. Previous reading experience also improves comprehension, which in turn has a favorable impact on ToM. Our results support the idea that literary fiction reading may have a therapeutic potential in the rehabilitation of schizophrenia.

Effectiveness of accelerated intermittent theta burst stimulation for social cognition and negative symptoms among individuals with schizophrenia: A randomized controlled trial

BACKGROUND

Social cognitive and negative symptoms impairment may increase the risk of mental disability in individuals with schizophrenia. However, randomized controlled studies on the effectiveness of accelerated intermittent theta burst stimulation (iTBS) for social cognition and negative symptoms in individuals with schizophrenia are very limited.

METHODS

A total of 125 individuals with schizophrenia were recruited, 66 of whom were randomly divided into an active iTBS group (n=34) and sham iTBS group (n=32) by stratified sampling. Participants received either active iTBS or sham iTBS targeting the left dorsolateral prefrontal cortex (DLPFC) 20 sessions for 4 weeks under navigation. The Facial Emotion Recognition Test (FERT), Hinting Task (HT), and Positive and Negative Syndrome Scale (PANSS) were measured at baseline, 2 weeks, and 4 weeks. The trial protocol was registered with the Chinese Clinical Trial Registry (ChiCTR2100051984).

RESULTS

Sixty patients (90.90%) completed the intervention and the 4-week follow-up, including 29 women (43.94%) and 37 men (56.06%) with a mean (SD) age of 47.53 (10.17) years. The primary outcomes showed FERT scores (week 2; 0.27 [95% CI, 0.09 to 0.45]; P< .01; ES 0.14) (week 4; 0.63 [95% CI, 0.45 to 0.80]; P< .001; ES 0.47) and HT scores (week 2; 1.00 [95% CI, -0.02 to 1.98]; P< .05; ES 0.67) (week 4; 2.13 [95% CI, 1.21 to 3.06]; P< .001; ES 0.27) in the active iTBS group were significantly different from those in the sham iTBS group at 2 and 4 weeks of follow-up. The secondary outcome showed that the negative symptom score (-3.43 [95% CI, -4.85 to -2.01]; P< .001; ES 0.29) of the active iTBS group was significantly different from that of the sham iTBS group at the 4th week of follow-up.

CONCLUSIONS

Accelerated iTBS can effectively ameliorate the social cognition and negative symptoms of individuals with schizophrenia. These results suggest that accelerated iTBS may be a safe and effective neuromodulation technique to improve the overall functional recovery of individuals with schizophrenia, and has a good clinical application prospect.

Emotion Recognition Deficits in Psychiatric Disorders as a Target of Non-invasive Neuromodulation: A Systematic Review

Background. Social cognition deficits are a core feature of psychiatric disorders, such as schizophrenia and mood disorder, and deteriorate the functionality of patients. However, no definite strategy has been established to treat social cognition (eg, emotion recognition) impairments in these illnesses. Here, we provide a systematic review of the literature regarding transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) for the treatment of social cognition deficits in individuals with psychiatric disorders. Methods. A literature search was conducted on English articles identified by PubMed, PsycINFO, and Web of Science databases, according to the guidelines of the PRISMA statement. We defined the inclusion criteria as follows: (1) randomized controlled trials (RCTs), (2) targeting patients with psychiatric disorders (included in F20-F39 of the 10th revision of the International Statistical Classification of Diseases and Related Health Problems [ICD-10]), (3) evaluating the effect of tDCS or rTMS, (4) reporting at least one standardized social cognition test. Results. Five papers (3 articles on tDCS and 2 articles on rTMS) met the inclusion criteria which deal with schizophrenia or depression. The significant effects of tDCS or rTMS targeting the left dorsolateral prefrontal cortex on the emotion recognition domain were reported in patients with schizophrenia or depression. In addition, rTMS on the right inferior parietal lobe was shown to ameliorate social perception impairments of schizophrenia. Conclusions. tDCS and rTMS may enhance some domains of social cognition in patients with psychiatric disorders. Further research is warranted to identify optimal parameters to maximize the cognitive benefits of these neuromodulation methods.

Perceptions of and subjective difficulties with social cognition in schizophrenia from an internet survey: Knowledge, clinical experiences, and awareness of association with social functioning

AIM

Social cognition impacts social functioning in schizophrenia; however, little is known about how patients with schizophrenia themselves perceive social cognition. This study, using an internet survey, aimed to investigate their knowledge of social cognition, clinical experiences related to social cognition, awareness of social cognition's role in one's social life, and the relationships between subjective difficulties with social cognition and social functioning.

METHODS

Data from 232 outpatients with schizophrenia (SZ) and 494 healthy controls (HC) were obtained through an internet survey and were weighted according to the demographics of the national population. A newly developed survey questionnaire on knowledge, experience, and awareness of social cognition was administered. Subjective difficulties were evaluated using the Self-Assessment of Social Cognition Impairments and the Observable Social Cognition Rating Scale.

RESULTS

Less than a quarter of both groups were familiar with the term or concept of social cognition. Less than 5% of both groups had experienced being assessed or treated for social cognition. More than half of both groups were aware of the relationship between social cognition and social functioning. The SZ group had higher levels of subjective difficulties than the HC group across all social cognitive domains. The attributional bias domain of subjective difficulties was negatively associated with social functioning.

CONCLUSION

Patients with schizophrenia had substantial subjective difficulties in social cognition, which they perceived as being related to social functioning. However, their knowledge of social cognition was limited, and the assessment and treatment might not be widespread in regular clinical practice.

Real-time facial emotion recognition deficits across the psychosis spectrum: A B-SNIP Study

Affective and non-affective psychotic disorders are associated with variable levels of impairment in affective processing, but this domain typically has been examined via presentation of static facial images. We compared performance on a dynamic facial expression identification task across six emotions (sad, fear, surprise, disgust, anger, happy) in individuals with psychotic disorders (bipolar with psychotic features [PBD] = 113, schizoaffective [SAD] = 163, schizophrenia [SZ] = 181) and healthy controls (HC; n = 236) derived from the Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP). These same individuals with psychotic disorders were also grouped by B-SNIP-derived Biotype (Biotype 1 [B1] = 115, Biotype 2 [B2] = 132, Biotype 3 [B3] = 158), derived from a cluster analysis applied to a large biomarker panel that did not include the current data. Irrespective of the depicted emotion, groups differed in accuracy of emotion identification (P < 0.0001). The SZ group demonstrated lower accuracy versus HC and PBD groups; the SAD group was less accurate than the HC group (Ps < 0.02). Similar overall group differences were evident in speed of identifying emotional expressions. Controlling for general cognitive ability did not eliminate most group differences on accuracy but eliminated almost all group differences on reaction time for emotion identification. Results from the Biotype groups indicated that B1 and B2 had more severe deficits in emotion recognition than HC and B3, meanwhile B3 did not show significant deficits. In sum, this characterization of facial emotion recognition deficits adds to our emerging understanding of social/emotional deficits across the psychosis spectrum.

Cariprazine's Potential in Improving Social Dysfunction in Patients With Schizophrenia: A Perspective

Social dysfunction is one of the most debilitating aspects of schizophrenia. Treatment of this complex phenomenon, constituted by negative, cognitive, and affective symptoms, has been difficult with the available pharmacological agents, hence it represents an unmet medical need. Cariprazine, a novel, third-generation antipsychotic with a unique mechanism of action has been proven to sufficiently alleviate negative, cognitive, and affective symptoms of schizophrenia. These characteristics make this compound a valid candidate for addressing social dysfunction too. In this perspective, we argue that cariprazine can be viewed as a "socializing drug" that has the ability to improve the patient's functionality and ultimately their quality of life. Data from animal research, clinical trials, an observational study, and patient cases are provided.

Feasibility and Efficacy of Virtual Reality Interventions to Improve Psychosocial Functioning in Psychosis: Systematic Review

BACKGROUND

Functional recovery in psychosis remains a challenge despite current evidence-based treatment approaches. To address this problem, innovative interventions using virtual reality (VR) have recently been developed. VR technologies have enabled the development of realistic environments in which individuals with psychosis can receive psychosocial treatment interventions in more ecological settings than traditional clinics. These interventions may therefore increase the transfer of learned psychosocial skills to real-world environments, thereby promoting long-term functional recovery. However, the overall feasibility and efficacy of such interventions within the psychosis population remain unclear.

OBJECTIVE

This systematic review aims to investigate whether VR-based psychosocial interventions are feasible and enjoyable for individuals with psychosis, synthesize current evidence on the efficacy of VR-based psychosocial interventions for psychosis, and identify the limitations in the current literature to guide future research.

METHODS

This research followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Literature searches were conducted in PubMed and PsycINFO in May 2021. We searched for peer-reviewed English articles that used a psychosocial intervention with a VR component. Participants in the included studies were diagnosed with schizophrenia, schizoaffective disorder, or another psychotic disorder. The included studies were divided into four categories as follows: cognitive remediation interventions, social skills interventions, vocational skills interventions, and auditory verbal hallucinations and paranoia interventions. The risk of bias assessment was performed for each study.

RESULTS

A total of 18 studies were included in this systematic review. Of these 18 studies, 4 (22%) studies used a cognitive remediation intervention, 4 (22%) studies used a social skills intervention, 3 (17%) studies used a vocational skills intervention, and 7 (39%) studies implemented an intervention aimed at improving auditory verbal hallucinations or paranoia. A total of 745 individuals with psychosis were included in the study. All the studies that evaluated feasibility showed that VR-based psychosocial interventions were feasible and enjoyable for individuals with psychosis. The preliminary evidence on efficacy included in this review suggests that VR-based psychosocial interventions can improve cognitive, social, and vocational skills in individuals with psychosis. VR-based interventions may also improve the symptoms of auditory verbal hallucinations and paranoia. The skills that participants learned through these interventions were durable, transferred into real-world environments, and led to improved functional outcomes, such as autonomy, managing housework, and work performance.

CONCLUSIONS

VR-based interventions may represent a novel and efficacious approach for improving psychosocial functioning in psychosis. Therefore, VR-based psychosocial interventions represent a promising adjunctive therapy for the treatment of psychosis, which may be used to improve psychosocial skills, community functioning, and quality of life.

A systematic review of the effects of psychiatric medications on social cognition

INTRODUCTION

Social cognition is an important area of mental functioning relevant to psychiatric disorders and social functioning, that may be affected by psychiatric drug treatments. The aim of this review was to investigate the effects of medications with sedative properties, on social cognition.

METHOD

This systematic review included experimental and neuroimaging studies investigating drug effects on social cognition. Data quality was assessed using a modified Downs and Black checklist (Trac et al. CMAJ 188: E120-E129, 2016). The review used narrative synthesis to analyse the data.

RESULTS

40 papers were identified for inclusion, 11 papers investigating benzodiazepine effects, and 29 investigating antipsychotic effects, on social cognition. Narrative synthesis showed that diazepam impairs healthy volunteer's emotion recognition, with supporting neuroimaging studies showing benzodiazepines attenuate amygdala activity. Studies of antipsychotic effects on social cognition gave variable results. However, many of these studies were in patients already taking medication, and potential practice effects were identified due to short-term follow-ups.

CONCLUSION

Healthy volunteer studies suggest that diazepam reduces emotional processing ability. The effects of benzodiazepines on other aspects of social cognition, as well as the effects of antipsychotics, remain unclear. Interpretations of the papers in this review were limited by variability in measures, small sample sizes, and lack of randomisation. More robust studies are necessary to evaluate the impact of these medications on social cognition.

Immunological investigations of the cerebrospinal fluid in patients with recent onset psychotic disorders: A study protocol

BACKGROUND

Though many previous studies have indicated immunological alterations in psychotic disorders, the role and prevalence of neuroinflammation is still unknown. Studies previously investigating immune related biomarkers in the cerebrospinal fluid (CSF) of these patients are mainly small studies on few markers, and many have not compared patients to healthy controls.

METHODS

We will conduct a large case-control study including at least 100 patients with recent onset psychotic disorders and 100 sex- and age matched healthy controls. The cases will include patients diagnosed with a psychotic disorder according to ICD-10 (F20/F22-29) within a year prior to inclusion. We will collect both CSF, blood and fecal samples, to gain insight into possible immunological alterations. The psychopathology of all participants will thoroughly be evaluated using the SCAN interview, and multiple rating scales covering different symptom groups. All participants will partake in a detailed neurological examination, including the Neurological Evaluation Scale assessing neurological soft signs. Additionally, we will assess cognitive functioning, evaluate quality of life and level of functioning, and collect data on a broad array of possible confounders. Our primary outcomes will include CSF leucocytes, CSF/serum albumin ratio, CSF total protein, IgG index, CSF levels of IL-6 and IL-8, and presence of antineuronal autoantibodies in CSF and blood. For our secondary outcomes, exploratory analyses will be performed on a broader panel of neuroimmunological markers. All participants will be invited for a follow-up visit to assess longitudinal changes. The current study is part of a larger CSF biobank build-up for severe mental disorders (PSYCH-FLAME).

DISCUSSION

This study will represent the largest investigation of CSF in patients with psychotic disorders compared to healthy controls to date. We expect the study to contribute with new, important knowledge on pathophysiological mechanisms, and to help pave the way for future investigations of individualized treatment options.

TRIAL REGISTRATION

The study is approved by The Regional Committee on Health Research Ethics (Capital Region, j.no: H-16030985) and The Danish Data Protection Agency (j.no: RHP-2016-020, I-Suite no.: 04945).

Slower access to visual awareness but otherwise intact implicit perception of emotional faces in schizophrenia-spectrum disorders

Schizophrenia-spectrum disorders are characterized by deficits in social domains. Extant research has reported an impaired ability to perceive emotional faces in schizophrenia. Yet, it is unclear if these deficits occur already in the access to visual awareness. To investigate this question, 23 people with schizophrenia or schizoaffective disorder and 22 healthy controls performed a breaking continuous flash suppression task with fearful, happy, and neutral faces. Response times were analysed with generalized linear mixed models. People with schizophrenia-spectrum disorders were slower than controls in detecting faces, but did not show emotion-specific impairments. Moreover, happy faces were detected faster than neutral and fearful faces, across all participants. Although caution is needed when interpreting the main effect of group, our findings may suggest an elevated threshold for visual awareness in schizophrenia-spectrum disorders, but an intact implicit emotion perception. Our study provides a new insight into the mechanisms underlying emotion perception in schizophrenia-spectrum disorders.

Pharmacological Treatment for Social Cognition: Current Evidence

Cognitive impairment is currently considered a core feature of schizophrenia (SZ) and is gaining attention as a fundamental therapeutic target. Standard treatment for SZ involves the use of antipsychotics that are successfully used to control positive symptoms and disorganized behaviour. However, it is still unclear whether they are effective on social cognition (SC) impairment. Furthermore, different medications are currently being studied to improve SC in patients with SZ. A literature search on this topic was conducted using the PubMed database. All kinds of publications (i.e., reviews, original contributions and case reports) written in English and published in the last 15 years were included. The aim of our literature review is to draw a picture of the current state of the pharmacological treatment of SC impairment in SZ.

Effects of a Short Emotional Management Program on Inpatients with Schizophrenia: A Pilot Study

The prevalence of schizophrenia is gradually increasing worldwide. Many patients with schizophrenia have a diminished ability to empathize and to detect their own emotions or those of others, deteriorating their social functioning and their quality of life. Nonetheless, emotional management training may improve patients' emotion recognition, emotional expression, and negative symptoms. Developing and applying a short but effective program that reflects the current medical environment, in which hospital stays are ever-diminishing, is warranted. This one-group, pretest-posttest, quasi-experimental pilot study aimed to examine the effects of a short emotional management program (EMP-S) on 17 patients with chronic schizophrenia. Participants were patients hospitalized in the National Center for Mental Health in Korea. After the completion of a twice-a-week, eight-session, four-week long EMP-S, participants showed improvements in emotion recognition, emotional expression, and negative symptoms. Our results suggest the applicability and potential effectiveness of the EMP-S, which takes the length of psychiatric hospital stay and the inpatient environment into consideration. To minimize any barriers to social functioning in the post-discharge lives of inpatients with chronic schizophrenia and enhance their social cognition-by improving their emotion recognition, emotional expression, and negative symptoms-we suggest the periodical administration of this EMP-S to these inpatients.

Preserved intention understanding during moral judgments in schizophrenia

INTRODUCTION

Although there is convincing evidence for socio-cognitive impairments in schizophrenia spectrum disorder (SSD), little evidence is found for deficient moral cognition. We investigated whether patients with SSD showed altered moral judgments in a story task where the protagonist either had a neutral or malicious intention towards another person. This paradigm examined whether SSD relates to altered moral cognition in general or specifically to impaired integration of prior information (such as beliefs) in moral judgments.

METHODS

23 patients and 32 healthy controls read vignettes created in a 2 x 2 design. The protagonist in each story either had a neutral or negative intention towards another person which, as a result, either died (negative outcome) or did not die (neutral outcome). Participants rated the moral permissibility of the protagonist's action. Standard null hypothesis significance testing and equivalent Bayes analyses are reported.

RESULTS

Schizophrenia patients did not differ significantly in permissibility ratings from healthy controls. This finding was supported by the Bayes analyses which favoured the null hypothesis. Task performance was not related to symptom severity or medication.

CONCLUSIONS

The current findings do not support the notion that moral judgments are deficient in schizophrenia. Furthermore, the current study shows that patients do not have observable difficulties in integrating the protagonist's belief in the rating of the moral permissibility of the action-outcome.

Paliperidone Compared with Haloperidol on the Theory of Mind Tasks in Schizophrenia: A Pilot Trial

PURPOSE

Theory of mind (ToM) is an important part of social cognitive function and is associated with medial prefrontal cortical (mPFC) activity. This study aimed to evaluate the efficacy of paliperidone in improving ToM task performance in patients with schizophrenia compared with haloperidol.

PATIENTS AND METHODS

This study was a single-center, single-blinded (assessor), parallel-group randomized clinical trial of patients with schizophrenia randomized to paliperidone or haloperidol. ToM was assessed at weeks 0, 8, 12, and 16 using the first-order belief, higher-order belief, faux-pas, and Reading the Mind in the Eyes tests. The primary outcome was the change in the ToM performance scores from baseline to after 16 weeks of treatment.

RESULTS

The participants received paliperidone (n = 29) or haloperidol (n = 31). For the first-order belief task, there were no between-group differences (P > 0.05) but time differences in both groups (P < 0.05). For the higher-order belief task, there were no between-group differences (P > 0.05), but there were time differences in both groups (P < 0.05) and a time×group interaction in the paliperidone group only (P < 0.05). For the faux-pas task, there was a difference between groups at week 16 (P < 0.05), and the improvement in time was significant for the paliperidone group only (P < 0.05). For the Reading the Mind in the Eyes task, there was an improvement over time for the paliperidone group only (P < 0.05). Safety was manageable in both groups.

CONCLUSION

Paliperidone treatment might be more effective than haloperidol in improving ToM task performance in schizophrenia.

TRIAL REGISTRATION

chictr.org.cn_identifier ChiCTR-IPR-15007635.

Efficacy and safety of anti-inflammatory agents in treatment of psychotic disorders - A comprehensive systematic review and meta-analysis

OBJECTIVE

Antipsychotic effects of immunomodulating drugs have been suggested; however, a thorough, comprehensive meta-analysis on the effect and safety of anti-inflammatory add-on treatment on psychotic disorders is lacking.

METHOD

Multiple databases were searched up until February 2020. Only double-blinded, randomized, placebo-controlled clinical trials (RCTs) were included. Primary outcomes were change in total psychopathology and adverse events. Secondary outcomes included, amongst others, positive and negative symptoms, general psychopathology and cognitive domains. We performed random-effects meta-analyses estimating mean differences (MD) and standardized mean differences (SMD) for effect sizes.

RESULTS

Seventy RCTs (N = 4104) were included, investigating either primarily anti-inflammatory drugs, i.e. drugs developed for immunomodulation, such as NSAIDs, minocycline and monoclonal antibodies (k = 15), or drugs with potential anti-inflammatory properties (k = 55), e.g. neurosteroids, N-acetyl cysteine, estrogens, fatty acids, statins, and glitazones. Antipsychotics plus anti-inflammatory treatment, compared to antipsychotics plus placebo, was associated with a PANSS scale MD improvement of -4.57 (95%CI = -5.93 to -3.20) points, corresponding to a SMD effect size of -0.29 (95%CI = -0.40 to -0.19). Trials on schizophrenia (MD = -6.80; 95%CI, -9.08 to -4.52) showed greater improvement (p < 0.01) than trials also including other psychotic disorders. However, primarily anti-inflammatory drugs (MD = 4.00; 95%CI = -7.19 to -0.80) were not superior (p = 0.69) to potential anti-inflammatory drugs (MD = 4.71; 95%CI = -6.26 to -3.17). Furthermore, meta-regression found that smaller studies showed significantly larger effect sizes than the larger studies (p = 0.0085), and only 2 studies had low risk of bias on all domains. Small but significant effects were found on negative symptoms (MD = -1.29), positive symptoms (MD = -0.53), general psychopathology (MD = -1.50) and working memory (SMD = 0.21). No differences were found regarding adverse events, but only 26 studies reported hereon.

CONCLUSIONS

Anti-inflammatory add-on treatment to antipsychotics showed improvement of psychotic disorders; however, no superiority was found in primarily anti-inflammatory drugs, raising the question of the mechanism behind the effect, and treatment effect might be overestimated due to the large number of small studies.

The social neuroscience of psychosis: From neurobiology to neurotherapeutics

Psychotic disorders form the core of severe mental illnesses and contribute to substantial disability and health-care costs worldwide. A growing research framework to understand and treat psychotic symptoms using a transdiagnostic paradigm is the social brain perspective of psychoses. The theme of my oration is to highlight how the growing knowledge of evolutionarily preserved social brain networks can help integrate social contextual, psychological, and neurobiological aspects of the genesis of psychotic symptoms and use that knowledge in a translational manner to identify potential therapeutic avenues that extend beyond conventional treatments. The concepts and empirical study of social cognition, social brain (e.g., mirror neuron system), social behaviors (e.g., symptoms and real-world functioning) are illustrated. These give insights into potential newer therapies with brain stimulation, oxytocin, and yoga.

Reduced Hippocampal Volume and Its Relationship With Verbal Memory and Negative Symptoms in Treatment-Naive First-Episode Adolescent-Onset Schizophrenia

Accumulating neuroimaging evidence has shown remarkable volume reductions in the hippocampi of patients with schizophrenia. However, the relationship among hippocampal morphometry, clinical symptoms, and cognitive impairments in schizophrenia is still unclear. In this study, high-resolution structural magnetic resonance imaging data were acquired in 36 patients with adolescent-onset schizophrenia (AOS, age range: 13-18 years) and 30 age-, gender-, and education-matched typically developing controls (TDCs). Hippocampal volume was assessed automatically through volumetric segmentation and measurement. After adjusting for total intracranial volume, we found reduced hippocampal volume in individuals with AOS compared with TDCs, and the hippocampal volume was positively correlated with verbal memory and negatively correlated with negative symptoms in AOS. In addition, mediation analysis revealed the indirect effect of hippocampal volume on negative symptoms via verbal memory impairment. When the negative symptoms were represented by 2 dimensions of deficits in emotional expression (EXP) and deficits in motivation and pleasure (MAP), the indirect effect was significant for EXP but not for MAP. Our findings provide further evidence of hippocampal volume reduction in AOS and highlight verbal memory impairment as a mediator to influence the relationship between hippocampal morphometry and negative symptoms, especially the EXP dimension of negative symptoms, in individuals with AOS.

Effect of aerobic exercise combined with cognitive remediation on cortical thickness and prediction of social adaptation in patients with schizophrenia

Aerobic exercise is a promising intervention for patients with schizophrenia, but structural neuroplastic effects on brain regions relevant to the pathophysiology of the disease remain unclear. This study aimed to elucidate longitudinal changes in cortical thickness after aerobic exercise intervention in schizophrenia patients and the relationship of these changes to clinical correlates. We investigated 21 schizophrenia patients and 23 healthy controls who performed aerobic exercise and 21 schizophrenia patients who played table soccer. The 12-week exercise intervention was combined with computer-assisted cognitive remediation training from week 6 to week 12. Magnetic resonance imaging (MRI) scans were acquired at baseline and weeks 6, 12, and 24. The thickness of the entorhinal, parahippocampal, and lateral and medial prefrontal cortices was assessed with FreeSurfer 6.0. The schizophrenia aerobic exercise group showed a significant increase of cortical thickness in the right entorhinal cortex at week 6, and we found a significant correlation between the cortical thickness of the right lateral prefrontal cortex at baseline and improvement of social adaptation at week 12. In the schizophrenia table soccer and healthy control groups, we found no significant longitudinal change in cortical thickness through the intervention and follow-up period and no correlation of cortical thickness at baseline with clinical measures. Our results suggest that aerobic exercise in schizophrenia modulates the thickness of the entorhinal cortex, a structure adjacent to the hippocampus. Greater cortical thickness of the right lateral prefrontal cortex appears to predict better clinical response to an aerobic exercise intervention in patients with schizophrenia.

Persons With Schizophrenia Misread Hemingway: A New Approach to Study Theory of Mind in Schizophrenia

INTRODUCTION

Theory of Mind (ToM) is a key component of social cognition. Recently the Short Story Task (SST) was developed as a new measurement of ToM. SST uses a short story of Ernest Hemingway to assess ToM skills. SST proved to be a suitable tool, and sensitive to individual differences among healthy subjects. Our aim was to test SST to evaluate the ToM skills of persons with schizophrenia.

MATERIALS AND METHODS

SST was used to assess ToM skills. After reading the short story "The End of Something" a structured interview was done with 14 questions. Spontaneous mental state reasoning, explicit mental state inference and comprehension of nonmental aspects of the story were evaluated. 47 persons with schizophrenia in remission and 48 healthy controls were assessed and compared.

RESULTS

Persons with schizophrenia performed significantly more poorly in the explicit mental state inference questions. Ceiling effect was not detectable in explicit ToM scores. Patients made less spontaneous mental state references as well, although the occurrence of spontaneous mental state terms was infrequent in both groups. Patients were also less accurate in answering comprehension questions, but the difference was not significant after Bonferroni correction.

DISCUSSION

Our results lined up with the original findings and we found SST to be a sensitive tool to explore the individual differences in ToM performance, not only among healthy subjects, but also among persons with schizophrenia especially in explicit mental state inferences without observing the ceiling effect. We found, however, SST to be less sensitive to measure spontaneous mental state reasoning and also the lack of the use of another ToM test to assess convergent validity of SST for indicating ToM deficits in schizophrenia stands as a limitation of current study.

Neuropeptides and oligopeptidases in schizophrenia

Schizophrenia (SCZ) is a complex psychiatric disorder with severe impact on patient's livelihood. In the last years, the importance of neuropeptides in SCZ and other CNS disorders has been recognized, mainly due to their ability to modulate the signaling of classical monoaminergic neurotransmitters as dopamine. In addition, a class of enzymes coined as oligopeptidases are able to cleave several of these neuropeptides, and their potential implication in SCZ was also demonstrated. Interestingly, these enzymes are able to play roles as modulators of neuropeptidergic systems, and they were also implicated in neurogenesis, neurite outgrowth, neuron migration, and therefore, in neurodevelopment and brain formation. Altered activity of oligopeptidases in SCZ was described only more recently, suggesting their possible utility as biomarkers for mental disorders diagnosis or treatment response. We provide here an updated and comprehensive review on neuropeptides and oligopeptidases involved in mental disorders, aiming to attract the attention of physicians to the potential of targeting this system for improving the therapy and for understanding the neurobiology underlying mental disorders as SCZ.

Cognition and violent behavior in psychotic disorders: A nationwide case-control study

Background

The excess risk of violence in psychotic disorders may partly be explained by impairments in executive functions (EFs) and theory of mind (ToM). However, previous studies have been limited by composite measures of EFs and small samples of inpatients.

Methods

Data were collected for the research project Genetic Risk and Outcome of Psychosis (GROUP). Patients with psychotic disorders (N = 891) were recruited from various care settings in the Netherlands. The following neuropsychological tests were administered (targeted cognitive function in parentheses): (i) Continuous Performance Test-HQ (inhibition); (ii) Response Shifting Task (cognitive flexibility); (iii) Wechsler Adult Intelligence Scale, Third Edition (WAIS-III) Block Design subtest (fluid intelligence); (iv) Neuropsychological Assessment Battery (NAB) Mazes Test (planning); (v) Degraded Facial Affect Recognition Task (affective ToM); and (vi) Hinting Task (cognitive ToM). Lifetime violence was ascertained from medical records and patient interviews. We used analysis of covariance to compare the mean scores of violent and nonviolent patients on each test, adjusting for age and sex.

Results

Violent patients performed significantly worse than nonviolent patients on the WAIS-III Block Design subtest (F [1, 847] = 5.12, p = .024), NAB Mazes Test (F [1, 499] = 5.32, p = .022) and Hinting Task (F [1, 839] = 9.38, p = .002). For the other tests, the between-group differences were nonsignificant. Violent behavior explained no more than 1% of the variance in performance on each test.

Conclusion

Impairments in EFs and ToM are unlikely to provide useful targets for risk assessment and interventions.

Neural and behavioral effects of oxytocin administration during theory of mind in schizophrenia and controls: a randomized control trial

Social cognitive impairments, including theory of mind (ToM), in schizophrenia more strongly predict functional outcomes than psychotic symptoms or nonsocial cognitive deficits. Despite their clinical importance, current medications do not improve these deficits. The current study investigated the hypothesis that oxytocin, a neuropeptide implicated in social behavior, would normalize neural abnormalities in schizophrenia during ToM, and that this normalization would correlate improvement in ToM behavior. In this cross-over, double-blind, and placebo-controlled functional magnetic resonance imaging study, a single dose of 40 IU of oxytocin was administered via nasal spray to male individuals with a schizophrenia spectrum disorder (schizophrenia and schizoaffective disorder, n = 23) and healthy controls (n = 25). Participants completed two ToM tasks in the scanner, the False Belief and Person Description tasks. During both tasks, on placebo day, schizophrenia was associated with reduced accuracy, hypo-activity in the right temporo-parietal junction (rTPJ; extended into the posterior superior temporal sulcus), and hypo-connectivity between the rTPJ and medial prefrontal cortex (mPFC) compared to healthy controls. Oxytocin, relative to placebo, significantly increased accuracy and rTPJ activation for ToM but not control stories in schizophrenia. Furthermore, a significant positive correlation was found between oxytocin induced increases in rTPJ activity and accuracy, indicating that oxytocin improved rTPJ activity in schizophrenia predicted behavioral improvement. Oxytocin also significantly improved connectivity between rTPJ and mPFC in schizophrenia. These findings suggest that rTPJ activity during ToM might be a potential neural target for the treatment of social cognitive deficits in schizophrenia.

Nucleus accumbens activation is linked to salience in social decision making

Aberrant salience may explain hasty decision making and psychotic symptoms in schizophrenia. In healthy individuals, final decisions in probabilistic reasoning tasks are related to Nucleus accumbens (Nacc) activation. However, research investigating the Nacc in social decision making is missing. Our study aimed at investigating the role of the Nacc for social decision making and its link to (aberrant) salience attribution. 47 healthy individuals completed a novel social jumping-to-conclusion (JTC) fMRI-paradigm, showing morphed faces simultaneously expressing fear and happiness. Participants decided on the 'current' emotion after each picture, and on the 'general' emotion of series of faces. Nacc activation was stronger during final decisions than in previous trials without a decision, particularly in fear rather than happiness series. A JTC-bias was associated with higher Nacc activation for last fearful, but not last happy faces. Apparently, mechanisms underlying probabilistic reasoning are also relevant for social decision making. The pattern of Nacc activation suggests salience, not reward, drives the final decision. Based on these findings, we hypothesize that aberrant salience might also explain social-cognitive deficits in schizophrenia.

Adjunctive use of anti-inflammatory drugs for schizophrenia: A meta-analytic investigation of randomized controlled trials

OBJECTIVE

Recent evidence suggests that adjuvant anti-inflammatory agents could improve the symptoms of patients with schizophrenia. However, the effects of the adjuvant anti-inflammatory agents on cognitive function, general functioning and side effects have not yet been systematically investigated. The present meta-analysis aimed to explore the effects of anti-inflammatory agents in patients with schizophrenia comprehensively.

METHOD

We performed a literature search in online databases, including PubMed, EMBASE and the Cochrane Database of Systematic Reviews. Randomized, placebo-controlled double-blind studies that investigated clinical outcomes including psychopathology, neurocognition, general functioning and extrapyramidal side effects were included. The examined anti-inflammatory agents included aspirin, celecoxib, omega-3 fatty acids, estrogen, selective estrogen receptor modulator, pregnenolone, N-acetylcysteine, minocycline, davunetide and erythropoietin.

RESULTS

Sixty-two double-blind randomized clinical trials studying 2914 patients with schizophrenia met the inclusion criteria for quantitative analysis. Significant overall effects were found for anti-inflammatory agents for reducing total, positive and negative symptom scores in the Positive and Negative Syndrome Scale. Cognitive improvements were significant with minocycline and pregnenolone augmentation therapy. General functioning was significantly enhanced by overall anti-inflammatory agents. There were no significant differences in side effects compared with placebo. Baseline total Positive and Negative Syndrome Scale score and illness duration were identified as moderating factors in the effects of anti-inflammatory augmentation on psychiatric symptom improvements.

CONCLUSION

The comparative evaluation of efficacy and safety supported the use of anti-inflammatory adjuvant therapy over the use of antipsychotics alone. However, future studies could focus on patients with homogeneous clinical profile to figure out more detailed effects of anti-inflammatory therapy.

Establishing a standard emotion processing battery for treatment evaluation in adults with autism spectrum disorder: Evidence supporting the Mayer-Salovey-Caruso Emotion Intelligence Test (MSCEIT)

Autism spectrum disorder (ASD) and schizophrenia are neurodevelopmental disorders which show markedly similar deficits in emotion processing, yet treatment evaluation in ASD and treatment comparisons across ASD and schizophrenia are constrained by a lack of empirical work validating a standard emotion processing battery across ASD and schizophrenia. Encouragingly, the Mayer-Salovey-Caruso Emotion Intelligence Test, version 2.0 (MSCEIT (Mayer et al., 2003) spans the range of emotion processing deficits in schizophrenia and ASD. This study therefore aimed to establish MSCEIT's factorial, measurement, and structural invariance in community-residing adults with schizophrenia (N = 103) and ASD (N = 113) using multigroup confirmatory factor analysis. Consistent with prior studies in normative populations, a two-factor structure comprised of emotional experiencing and emotional reasoning was supported in ASD and schizophrenia. Both groups operationalize MSCEIT measures similarly, with all measures except for Facilitation and Management showing comparability across groups. To our knowledge, this study is not only the first to establish the measurement and structural invariance of a standard emotion perception battery in adults with ASD, it is also the first to establish its comparability across ASD and schizophrenia. Ultimately, these findings underscore MSCEIT's utility for standardizing treatment evaluation of social cognitive outcomes across the autism-schizophrenia spectrum.

Cortisol stress response in psychosis from the high-risk to the chronic stage: a systematic review

OBJECTIVES

We review studies of whether cortisol levels following psychosocial stress exposure differ between patients with psychosis and healthy control subjects.

METHODS

Original research published between 1993 and February 2019 was included in the literature search. Studies that used experimentally induced psychosocial stress and reported stress response measures of plasma or saliva cortisol levels in patients at any stage of illness (i.e. high risk, first episode and chronic phase) were included.

RESULTS

A total of 17 studies were included. Although there was evidence of inconsistencies in measures, we observed moderate evidence of an association with stress-induced cortisol blunting response across studies.

CONCLUSIONS

This review highlights recent evidence of blunting of cortisol response following experimentally induced psychosocial stress. While there was some evidence of this blunted response across illness types and stages, the strongest evidence was observed for those with chronic schizophrenia. Due to the low number of studies, in particular in bipolar disorder, much work is still needed to accurately characterise the biological effects of stress in psychosis.

Improvement of Theory of Mind in Schizophrenia: A 15-Year Follow-Up Study

Neurocognitive and social cognitive deficits are a hallmark of schizophrenia. The purpose of the present study was to investigate long-term changes in theory of mind (ToM), executive functions, lexical retrieval, and speed of information processing/attention in schizophrenia. We followed-up 31 outpatients with schizophrenia and 31 healthy control subjects for 15 years. ToM was assessed with the Reading the Mind from the Eyes Test (RMET), whereas neurocognitive functions were measured with the verbal fluency (VF) task (executive functions and lexical retrieval) and with the Digit-Symbol Substitution Test (DSST) (speed of information processing/attention). Clinical symptoms and general functioning were rated with the Positive and Negative Syndrome Scale (PANSS) and with the Global Assessment of Functioning (GAF) scale, respectively. At baseline assessment, patients with schizophrenia exhibited significant and generalized impairments on all measures. At follow-up, relative to the baseline, we observed marked improvements in ToM (RMET), stability in executive functions and lexical retrieval (VF), and a significant decline in psychomotor speed/attention (DSST) in schizophrenia. Clinical symptoms and psychosocial functions did not differ at baseline and at follow-up examinations (mild-to-moderate symptoms on the PANSS and moderate difficulty in social and occupational functions on the GAF). These results indicate that patients with schizophrenia with mild-to-moderate symptoms and functional deficits are characterized by improved ToM during over a decade.

What Do You Have in Mind? Measures to Assess Mental State Reasoning in Neuropsychiatric Populations

Social interaction is closely associated with both functional capacity and well-being. Previous research has not only revealed evidence of social dysfunction in individuals with a wide range of psychiatric and neurological disorders but also generated an abundance of potential measures for assessing social cognition. This review explores the most popular measures used within neuropsychiatric populations to investigate the ability to recognize or reason about the mental states of others. Measures are also critically analyzed in terms of strengths and limitations to aid task selection in future clinical studies. The most frequently applied assessment tools use verbal, visual or audiovisual forms of presentation and assess recognition of mental states from facial features, self-rated empathy, the understanding of other's cognitive mental states such as beliefs and intentions, or the ability to combine knowledge of other's thoughts and emotions in order to understand subtle communications or socially inappropriate behavior. Key weaknesses of previous research include limited investigation of relationships with clinical symptoms, and underutilization of measures of everyday social functioning that offer a useful counterpart to traditional "lab" tasks. Future studies should aim to carefully select measures not only based on the range of skills to be assessed but also taking into account potential difficulties with interpretation and the need to gain insight into the application of social cognitive skills as well as ability per se. Some of the best measures include those with well-matched control trials (e.g., Yoni Task) or those that restrict the influence of verbal deficits (e.g., intentions comic strip task), elicit spontaneous mentalizing (e.g., Animations Task), and possess greater ecological validity (e.g., Movie for the Assessment of Social Cognition). Social cognitive research within psychiatric populations will be further enhanced through the development of more closely matched control tasks, and the exploration of relationships between task performance, medication, strategy use, and broader emotional and motor functions.

Social cognition remediation interventions: A systematic mapping review

Background

Impairments in social cognition have been described in several psychiatric and neurological disorders. Given the importance of the relationship between social cognition and functioning and quality of life in these disorders, there is a growing interest in social cognition remediation interventions. The aim of this study was to carry out a systematic mapping review to describe the state of the art in social cognition training and remediation interventions.

Methods

Publications from 2006 to 2016 on social cognition interventions were reviewed in four databases: Scopus, PsycINFO, PubMed and Embase. From the initial result set of 3229 publications, a final total of 241 publications were selected.

Results

The study revealed an increasing interest in social cognition remediation interventions, especially in the fields of psychiatry and psychology, with a gradual growth in the number of publications. These were frequently published in high impact factor journals and underpinned by robust scientific evidence. Most studies were conducted on schizophrenia, followed by autism spectrum disorders. Theory of mind and emotional processing were the focus of most interventions, whilst a limited number of studies addressed attributional bias and social perception. Targeted interventions in social cognition were the most frequent practice in the selected papers, followed by non-specific treatment interventions and broad-based interventions.

Conclusions

Research in social cognition remediation interventions is growing. Further studies are needed on attributional bias and social perception remediation programs, while the comparative efficacy of different interventions also remains unclear.

Effect of an emotion management programme for patients with schizophrenia: A quasi-experimental design

One of the goals of psychiatric social rehabilitation treatment is to improve patients' emotion recognition, emotional expression, and empathetic abilities. In this study, we used a quasi-experimental, nonrandomized design to examine the effect of an emotion management programme on the emotion recognition (emotion attention and emotion clarity), emotional expression (positive expressivity, negative expressivity, and impulse strength), and quality of life (QoL) of a sample of patients with schizophrenia in South Korea. Over eight sessions, we collected data from 56 patients with schizophrenia registered in community mental rehabilitation facilities. After attending the emotion management programme, the emotion recognition, emotional expression, and QoL scores of the experimental group were found to have significantly increased, whereas those of the control group had significantly decreased. Therefore, our findings show that emotion management programmes can be used as nursing interventions to improve the QoL of people with schizophrenia.

Neural Effects of Cognitive Training in Schizophrenia: A Systematic Review and Activation Likelihood Estimation Meta-analysis

BACKGROUND

Cognitive dysfunction is a core feature of schizophrenia and a strong predictor of functional outcome. There is growing evidence for the effectiveness of behaviorally based cognitive training programs, although the neural basis of these benefits is unclear. To address this, we reviewed all published studies that have used neuroimaging to measure neural changes following cognitive training in schizophrenia to identify brain regions most consistently affected.

METHODS

We searched PubMed for all neuroimaging studies examining cognitive training in schizophrenia published until December 2018. An activation likelihood estimation meta-analysis was conducted on a subset of functional magnetic resonance imaging studies to examine whether any brain regions showed consistent effects across studies.

RESULTS

In total, 31 original neuroimaging studies of cognitive training were retrieved. Of these studies, 16 were functional neuroimaging studies, and 15 of these studies reported increased neural activation following cognitive training, with increased left prefrontal activation being the most frequently observed finding. However, activation likelihood estimation meta-analysis did not reveal any specific brain regions showing consistent effects across studies but rather suggested a broader, more distributed pattern of effects resulting from the interventions tested.

CONCLUSIONS

Although several studies reported increased left prefrontal cortical activation after cognitive training, the lack of statistically significant overlap of brain regions affected by training across studies suggests broad effects of training on brain activation, possibly due to the variety of training programs used.

Yoga: Balancing the excitation-inhibition equilibrium in psychiatric disorders

Social behavioral disturbances are central to most psychiatric disorders. A disequilibrium within the cortical excitatory and inhibitory neurotransmitter systems underlies these deficits. Gamma-aminobutyric acid (GABA) and glutamate are the most abundant excitatory and inhibitory neurotransmitters in the brain that contribute to this equilibrium. Several contemporary therapies used in treating psychiatric disorders, regulate this GABA-glutamate balance. Yoga has been studied as an adjuvant treatment across a broad range of psychiatric disorders and is shown to have short-term therapeutic gains. Emerging evidence from recent clinical in vivo experiments suggests that yoga improves GABA-mediated cortical-inhibitory tone and enhances peripheral oxytocin levels. This is likely to have a more controlled downstream response of the hypothalamo-pituitary-adrenal system by means of reduced cortisol release and hence a blunted sympathetic response to stress. Animal and early fetal developmental studies suggest an inter-dependent role of oxytocin and GABA in regulating social behaviors. In keeping with these observations, we propose an integrated neurobiological model to study the mechanisms of therapeutic benefits with yoga. Apart from providing a neuroscientific basis for applying a traditional system of practice in the clinical setting, this model can be used as a framework for studying yoga mechanisms in future clinical trials.

Social Cognition Deficits as a Target of Early Intervention for Psychoses: A Systematic Review

Backgrounds: Social cognition deficits are a core feature of schizophrenia and deteriorate functionality of patients. However, evidence is sparse for the treatment effect on social cognition impairments in the early stage of psychosis. Here, we provide a systematic review of the literature on social cognitive impairment in early psychosis in relation to its intervention. Methods: A literature search was conducted on English articles identified by Web of Science and PubMed databases, according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Results: Five papers met the inclusion criteria. Results from two studies of cognitive training and one study of modafinil indicate positive results regarding social cognition outcomes in patients with early psychosis. On the other hand, two studies with oxytocin and modafinil did not suggest such effects. Conclusions: Further research is warranted to explore the benefit of early intervention into disturbances of social cognition in psychoses.

Treatment of social cognition in schizophrenia: Current status and future directions

Efforts to develop psychosocial interventions that specifically target social cognition in schizophrenia spectrum disorders began nearly two decades ago. The field has matured considerably since then and has engendered a great deal of optimism about this treatment approach. Indeed, the efficacy of social cognitive interventions, especially those that address multiple domains of social cognition, has received substantial support. This article critically evaluates the current evidence for social cognitive interventions, identifies limitations and open questions, and suggests priorities and directions for further research. Limitations of available studies include a frequent lack of methodological rigor, suboptimal selection of endpoints, and sparse evidence for generalization to functional improvements. We highlight several emerging psychosocial and non-psychosocial approaches that may enhance the efficacy of social cognitive interventions and promote generalization to improvements in real world functioning. We conclude that cautious optimism is warranted as the field moves forward into the next wave of social cognitive treatment studies.

Neurobiology and treatment of social cognition in schizophrenia: Bridging the bed-bench gap

Social cognition refers to the psychological processes involved in the perception, encoding, storage, retrieval, and regulation of information about others and ourselves. This process is essential for survival and reproduction in complex social environments. Recent evidence suggests that impairments in social cognition frequently occur in schizophrenia, mainly contributing to poor functional outcomes, including the inability to engage in meaningful work and maintain satisfying interpersonal relationships. With the ambiguous definition of social cognition, the neurobiology underlying impaired social cognition remains unknown, and the effectiveness of currently available intervention strategies in schizophrenia remain limited. Considering the advances and challenges of translational research for schizophrenia, social cognition has been considered a high-priority domain for treatment development. Here, we describe the current state of the framework, clinical concerns, and intervention approaches for social cognition in schizophrenia. Next, we introduce translatable rodent models associated with schizophrenia that allow the evaluation of different components of social behaviors, providing deeper insights into the neural substrates of social cognition in schizophrenia. Our review presents a valuable perspective that indicates the necessity of building bridges between basic and clinical science researchers for the development of novel therapeutic approaches in impaired social cognition in schizophrenia.