Theory of Mind intervention for outpatients with schizophrenia

A machine-learning approach to investigating the complexity of theory of mind in individuals with schizophrenia

Individuals with schizophrenia have difficulty attributing mental states to themselves and to others - Theory of Mind (ToM). ToM is a complex, multifaceted theoretical construct comprising first and second order, first and third person, egocentric and allocentric perspective, and cognitive and affective ToM. Most studies addressing ToM deficit in people with schizophrenia consider it an "all-or-nothing" ability and use a classical statistical methodology to test a null hypothesis. With the present study, we investigated ToM in individuals with schizophrenia, considering its complex nature and degrees of impairment. To do this, we used a machine-learning approach to detect patterns in heterogeneous and multivariate data. Our findings highlight the complex nature of ToM deficit in individuals with schizophrenia and reveal the relationship between various different aspects of ToM.

The relation of depressive symptoms to theory of mind in adults

BACKGROUND

Theory of mind (ToM) is the ability to understand thoughts and feelings of others. Significant heterogeneity exists for the strength of the association between depression and ToM performance.

METHODS

To clarify these relations, two studies of depressed and nondepressed adults investigate cross-sectional associations of four latent depression factors (i.e., somatic symptoms, depressed affect, positive affect, and interpersonal problems) to two aspects of ToM (reasoning vs. decoding). Study 1 investigated associations between depression factors and reasoning ToM (N = 258), and Study 2 investigated associations between depression factors and decoding ToM (N = 219).

RESULTS

In Study 1, the interpersonal problems factor was negatively related to reasoning ToM, though in Study 2, no consistent associations emerged between depression and decoding ToM. Study 2 also replicated a novel approach to assessing valence with the Reading the Mind in the Eyes Test.

LIMITATIONS

This investigation was primarily limited by cross-sectional designs, self-report, and online delivery of measures.

CONCLUSIONS

Findings emphasize the heterogeneity of ToM as a construct and identify targets for clinical intervention, with specific focus on bolstering reasoning ToM skills.

A cultural training for the improvement of cognitive and affective Theory of Mind in people with Multiple Sclerosis: a pilot randomized controlled study

Theory of Mind (ToM), the ability to understand and attribute mental states to ourselves and others, could be impaired in Multiple Sclerosis (MS), a neurodegenerative disease affecting young adults. Considering that ToM is strictly connected to Quality of Life (QoL) in MS and that could enhance the social support network -which is particularly important for this population-, we aimed to design and implement a novel ToM rehabilitation training. To make the training as much ecological as possible, we have devised a protocol enhancing ToM through stimuli depicting real-world conditions (video-clips taken from cinema movies, literary fictions, and audio voices). We test training's effect on both cognitive and affective components of ToM in a sample of 13 subjects, randomly assigned to the ToM training Group and to the Control Group. The following ToM tasks were administered: the Reading the Mind in the Eyes (RMET), the Strange Stories task, the Faux Pas Task and the False Belief First- and Second - Order Task (FB II and III order). We also administered a psycho-behavioral assessment through the Toronto Alexithymia Scale (TAS-20). Results show that our novel ToM training is useful in enhancing ToM abilities measured by the following tasks: the RMET (affective task, p = 0.015) and the FB II-order task (FB, cognitive task, p = 0.032). Our ToM training had also a significant effect on the total score of the TAS-20 Scale (p = 0.018) and on its "Difficulty Describing Feelings subscale" (p = 0.018), indicating a reduction of the alexithymia traits. Future works with larger samples could investigate the ToM training effectiveness in a more representative MS populations.

Calling on clinicians to get social and emotional

OBJECTIVE

Disorders of social cognition, such as difficulties with emotion perception, alexithymia, Theory of Mind (ToM), empathy and disorders of emotion regulation, are prevalent and pervasive problems across many neurological, neurodevelopmental and neuropsychiatric conditions. Clinicians are familiar with how these difficulties present but assessment and treatment has lagged behind other traditional cognitive domains, such as memory, language and executive functioning.

METHOD

In this paper, we review the prevalence and degree of impairment associated with disorders of social cognition and emotion regulation across a range of clinical conditions, with particular emphasis on their relationship to cognitive deficits and also real-world functioning. We reported effects sizes from published meta-analyses for a range of clinical disorders and also review test usage and available tests.

RESULTS

In general, many clinical conditions are associated with impairments in social cognition and emotion regulation. Effect sizes range from small to very large and are comparable to effect sizes for impairments in nonsocial cognition. Socio-emotional impairments are also associated with social and adaptive functioning. In reviewing prior research, it is apparent that the standardized assessment of social cognition, in particular, is not routine in clinical practice. This is despite the fact that there are a range of tools available and accruing evidence for the efficacy of interventions for social cognitive impairments.

CONCLUSION

We are using this information to urge and call for clinicians to factor social cognition into their clinical assessments and treatment planning, as to provide rigorous, holistic and comprehensive person-centred care.

Use of Technologies in the Therapy of Social Cognition Deficits in Neurological and Mental Diseases: A Systematic Review

Objective: This article systematically reviews the effects of technology-based (TB) treatments on impaired social cognition (SC) in neurological and mental disorders. Methods: Strictly adhering to the PRISMA guidelines, a systematic search was carried out in PsycINFO, PubMed, and Web of Science (last search: April 22, 2021) to identify studies that, implementing a control group design, evaluated TB treatments targeting deficits in emotion recognition, Theory of Mind (ToM) and social behavior in adult patients with nondevelopmental and nonprogressive neurological or mental disorders. Risk of bias was assessed using the PEDro Scale, certainty assessment followed the GRADE approach. Results: Sixteen studies involving 857 patients, all focusing on psychotic disorders, were retrieved. The most pronounced effects were observed concerning emotion recognition with all studies revealing overall improvements. Regarding ToM and social behavior, results were mixed. However, the number of studies including outcome measures for these domains, is significantly lower compared to the domain of emotion recognition, limiting the validity of the results. Risk of bias and certainty assessment revealed further limitations of evidence. Conclusion: TB treatment achieves positive effects especially with regard to emotion recognition impairments, at least for patients with schizophrenia. Future research should expand the evaluation of TB training of other SC domains, ought to be carried out in more diverse patient populations, rely on different devices, and include follow-up measurements.

Cognitive reserve profiles are associated with outcome in schizophrenia

Cognitive reserve (CR), the brain's ability to cope with brain pathology to minimize symptoms, could explain the heterogeneity of outcomes in neuropsychiatric disorders, however it is still rarely investigated in schizophrenia. Indeed, this study aims to classify CR in this disorder and evaluate its impact on neurocognitive and socio-cognitive performance and daily functioning. A group of 106 patients diagnosed with schizophrenia was enrolled and assessed in these aereas: neurocognition, Theory of Mind (ToM) and daily functioning. A composite CR score was determined through an integration of the intelligence quotient and education and leisure activities. CR profiles were classified with a two-step cluster analysis and differences among clusters were determined with an analysis of variance (ANOVA). The cluster analysis was identified with three CR profiles characterized, respectively, by high, medium and low CR. ANOVA analysis showed significant differences on neurocognition, ToM and daily functioning between the clusters: people with higher CR reached significantly superior scores. This study suggests that greater general cognitive resources could act as a buffer against the effect of brain pathology, allowing patients to have a better cognitive performance, social outcome and quality of life.

Virtual reality-based theory of mind intervention in schizophrenia: Preliminary efficacy results

BACKGROUND

In recent years, a growing body of literature has supported the core nature and functional significance of Theory of Mind (ToM) deficit in schizophrenia. These findings have made ToM impairment a promising treatment target. However, despite the encouraging results, its complexity makes it difficult to develop new interventions and even to understand the exact nature and scope of the deficit. Yet, further investigation has suggested that using modern technology and multilevel assessment may help solve the problem.

METHODS

Virtual Reality-based Theory of Mind Intervention (VR-ToMIS) is a recently developed structured method using the combination of cognitive and behavioral therapeutic techniques and the advantages of Virtual Reality (VR) technology. A controlled study with a three-month follow-up was conducted with 42 patients (suffering from schizophrenia or schizo-affective disorder) randomly assigned to either an experimental (VR-ToMIS) or control group (passive-VR). Repeated two-way factorial analysis of covariance was used to evaluate the effects of VR-ToMIS on symptoms, neuro- and social cognition, pragmatic skills, and quality of life when the effect of IQ was controlled.

RESULTS

Patients participating in VR-ToMIS showed significant improvements in all types of ToM tasks (except for hyper-ToM task, based on the results of Cartoon test, Faux pas test and and Baron-Cohen Minds in the Eyes Test) compared to the control group with moderate to large effect sizes. In the case of negative and cognitive symptoms, significant between-group differences were also supported. Improvement was moderated by IQ in the case of higher-order ToM, manner, and relevance implicatures. Results were proved to be sustainable three months after the treatment.

CONCLUSION

Although the presented results are considered preliminary, they support the potential of the integration of modern technology and traditional methods for future interventions.

Regrouping scalets: Psychometric properties of the theory of mind picture stories task in a schizophrenic sample

Theory of mind is one of the most intensively studied phenomena in the development of schizophrenic symptoms and impairments in social adjustment. Complex theory of mind processing requires both visual and verbal aspects of the social-perceptual and social-cognitive components of mind reading. Reliable assessment methods are considered essential for the proper conduct of research. The current study aims at investigating the psychometric properties of the Theory of Mind Picture Stories Task (ToM PST). Forty-seven patients with schizophrenia were enrolled in the study from three sites. Data from ToM PST were used for computing the consistency, reliability, and internal and construct validity of the test.Our preliminary findings showed less appropriate consistency. Therefore, we attempted to carry out structural changes on the task while preserving its scales and subscales, which measure crucial factors of ToM. The newly structured task has four scales. They show proper consistency (Sequencing: Cronbach's α = 0.70, Theory of a Single Person's Mind: α = 0.74, Switching Between Minds: α = 0.70, Comprehension of Misleading Behaviour: α = 0.67, Total: α = 0.80) with appropriate internal and construct validity, a moderate test-retest reliability over a four-month-course, and a proper inter-rater reliability.

Theory of Mind and Suicidality: A Meta-Analysis

OBJECTIVE

Disturbances in interpersonal functioning are prevalent in individuals with suicidality. Foundational for interpersonal functioning is theory of mind (ToM), a social-cognitive ability that allows individuals to understand the thoughts and feelings of others. Recent work has begun to investigate ToM performance in individuals with suicidality, though no review has quantitatively aggregated findings from these varied studies. The current study investigated the relations between ToM and suicidality with meta-analysis.

METHOD

We identified and meta-analyzed 15 studies that presented data for 2,895 participants (617 of whom had reported at least one suicide attempt).

RESULTS

Results indicated a significant, negative relation between ToM and suicidality with a medium overall effect size (g = -.475). Moderator analyses revealed that this effect was consistent across age, sex, ToM content, and suicidal outcome.

CONCLUSION

Deficits in ToM associated with suicidality hold promise for risk-identification, treatment, and prevention work.HighlightsTheory of mind (ToM) abilities are critical for effective interpersonal functioning.Meta-analytics results indicate that ToM deficits are associated with suicidality.Identifying such suicidality-related ToM deficits may inform risk-identification, treatment, and prevention work.

Efficacy of metacognitive training on symptom severity, neurocognition and social cognition in patients with schizophrenia: A single-blind randomized controlled trial

Over the past decades, a number of complementary treatments for schizophrenia have emerged. One of these is metacognitive training (MCT), which combines the principles of cognitive-behavioral therapies, cognitive remediation, and psychoeducation into a hybrid approach placing emphasis on increasing metacognitive awareness. The aim of our study was to investigate the efficacy of MCT on symptom severity, and neurocognitive and social cognitive functioning in schizophrenia; also, attention was paid to the assessment of subjective acceptability. Forty-six patients diagnosed with schizophrenia were included in our single-blind randomized controlled trial, who were assigned to the intervention or control group. The intervention group was provided standard MCT, while the control group received treatment as usual. We assessed symptom severity and cognitive functions before and after the training, as well as after a 6-month follow-up period. Compared to the control group, the intervention group showed improvement in overall symptom severity, and positive and disorganized symptoms. Training participans showed further improvement at the follow-up assessment. Regarding neurocognitive functions, improvement in visuospatial functions was observed between pre- and post-intervention assessments compared to the control group. Patients showed excellent adherence, and evaluated the training as useful and interesting. In line with the results of previous studies, our results demonstrate the efficacy of MCT on symptom severity in schizophrenia. Improvements in cognitive functions that are closely related to the onset and prevalence of symptoms of schizophrenia were also found.

Theory of mind and stereotypic behavior promote daily functioning in patients with schizophrenia

OBJECTIVES

Functional disruption is a main feature of schizophrenia and still represents a major treatment challenge. A more in-depth identification of functional predictors is crucial for the creation of individualized rehabilitation treatments, which can translate into better functional outcomes. In this study, we aimed at pinpointing specific domains that affect different functional profiles, using a data-driven approach.

METHODS

We included a comprehensive evaluation of functional predictors, namely demographic, cognitive, sociocognitive and clinical variables, with a focus on constituent subdomains of autistic symptoms that have been associated with functioning in the recent literature.

RESULTS

In 123 schizophrenia patients, a two-step cluster analysis identified two groups of patients with different functional profiles (low vs high functioning). A backward stepwise logistic regression analysis showed that the odds of being a member of the high functioning group are significantly higher for individuals with (1) more years of education, (2) better Theory of Mind abilities, (3) higher levels of stereotypies/narrowed interests, (4) lower difficulties in social interaction, (5) lower communication difficulties and with (6) being male.

CONCLUSION

Findings raise the intriguing possibility that stereotypic behaviors may have a beneficial effect on functioning in schizophrenia. While the underlying mechanism is currently unknown, we hypothesize that patients may benefit from contexts in which more predictive relationships between environmental entities can systematically be established. This study underscores the potential utility of routinely assessing autistic symptomatology in schizophrenia, which can be instrumental in identifying novel therapeutic targets that can be utilized to improve daily functioning.

Theory of mind performance in depression: A meta-analysis

BACKGROUND

Theory of mind (ToM) is a social-cognitive skill that involves the ability to understand the thoughts and feelings of others. Evidence is mixed regarding the extent of ToM ability in individuals with depression.

METHODS

We conducted a meta-analysis of 43 studies to investigate the strength of the association between ToM and depression.

RESULTS

Results indicated significant, small- to moderate impairment in ToM with a medium overall effect size (g = -0.398) in individuals with depression. Moderator analyses compared effect sizes across groups for the following variables: ToM content, process, and sample type. Additionally, meta-regression analyses tested age and gender as continuous moderators.

LIMITATIONS

The cross-sectional nature of included studies limits this meta-analysis from clarifying temporal or bidirectional relations.

CONCLUSIONS

We discuss findings in the context of the extant developmental, cognitive, social, and clinical literatures. We also suggest several possible explanations for these findings and offer implications for intervention.

Psychosocial functioning in the balance between autism and psychosis: evidence from three populations

Functional impairment is a core feature of both autism and schizophrenia spectrum disorders. While diagnostically independent, they can co-occur in the same individual at both the trait and diagnostic levels. The effect of such co-occurrence is hypothesized to worsen functional impairment. The diametric model, however, suggests that the disorders are etiologically and phenotypically diametrical, representing the extreme of a unidimensional continuum of cognition and behavior. A central prediction of this model is that functional impairment would be attenuated in individuals with mixed symptom expressions or genetic liability to both disorders. We tested this hypothesis in two clinical populations and one healthy population. In individuals with chronic schizophrenia and in individuals with first episode psychosis we evaluated the combined effect of autistic traits and positive psychotic symptoms on psychosocial functioning. In healthy carriers of alleles of copy number variants (CNVs) that confer risk for both autism and schizophrenia, we also evaluated whether variation in psychosocial functioning depended on the combined risk conferred by each CNV. Relative to individuals with biased symptom/CNV risk profiles, results show that functional impairments are attenuated in individuals with relatively equal levels of positive symptoms and autistic traits-and specifically stereotypic behaviors-, and in carriers of CNVs with relatively equal risks for either disorder. However, the pattern of effects along the "balance axis" varied across the groups, with this attenuation being generally less pronounced in individuals with high-high symptom/risk profile in the schizophrenia and CNV groups, and relatively similar for low-low and high-high individuals in the first episode psychosis group. Lower levels of functional impairments in individuals with "balanced" symptom profile or genetic risks would suggest compensation across mechanisms associated with autism and schizophrenia. CNVs that confer equal risks for both disorders may provide an entry point for investigations into such compensatory mechanisms. The co-assessment of autism and schizophrenia may contribute to personalized prognosis and stratification strategies.

A Systematic Review of the Current Measures of Theory of Mind in Adults with Schizophrenia

Adults with schizophrenia usually have impairments in theory of mind (ToM), which subsequently cause them problems in social interaction. Therefore, it is important for healthcare providers to assess their ToM using adequate measures. This systematic review evaluated current ToM measures (or ToM tasks) for adults with schizophrenia and summarized their specific characteristics, including the concept and construct, administration, and psychometric properties. From a review of 117 articles, 13 types of ToM tasks were identified, and the findings from these articles were qualitatively synthesized. The results showed that ToM tasks are diverse in their presentation modalities, answer modes, strategies of controlling cognitive confounders, and scoring. Most tasks employ cognitive and affective dimensions and target a specific, single ToM concept. The present systematic review found that psychometric evidence supporting the ToM tasks, such as internal consistency, test–retest reliability, unidimensionality, and convergent, criterion, and ecological validities, is insufficient. Based on the results, we propose several principles for selecting appropriate ToM tasks in practice, e.g., selecting a task with multiple ToM concepts, or an exclusive ToM construct containing the cognitive and affective dimensions. Moreover, future studies are needed to provide more psychometric evidence on each type of ToM task applied in people with schizophrenia.

The Effects of Narrative and Movie Therapy on the Theory of Mind and Social Functioning of Patients with Schizophrenia

Introduction

The objective of this study was to investigate the effects of narrative therapy (NT) in which the patients tell their own life story in a group environment, and the movie therapy (MT), which is an interaction-based, emotion-themed, culturally compatible video screening activity, on chronic schizophrenia patients' theory of mind abilities, psychopathology, and social functioning.

Method

Thirty patients with schizophrenia were included in this study. At the beginning of the study, 2 patients dropped out as they started to work in a job. Participants were randomly assigned into two groups: one group received NT, and the other had MT. Dokuz Eylül Theory of Mind Index (DEToMI), Reading the Mind in the Eyes Test (RMET), Social Functioning Assessment Scale (SFAS), the Positive and Negative Symptoms Scale (PANSS), and Montreal Cognitive Assessment Scale (MoCA) were applied to the patients before and after the study. Pre- and post-test results within the group were compared via Wilcoxon test. Mann-Whitney U and mixed-design ANOVA were used for group comparisons regarding treatment efficiency.

Results

In the NT group, PANSS negative and general psychopathology, DEToMI, SFAS, and MoCA scores significantly increased. In the MT group, PANSS negative, DEToMI, SFAS, MoCA, and RMET scores significantly enhanced. Regarding the comparisons for before and after the treatment, it was found that mean RMET scores and DEToMI faux pas sub-scale scores were higher in the MT group comparing to the NT group.

Conclusion

This study suggests that NT and MT could be beneficial on different domains of the theory of mind, and may lead to a decrease in psychopathology, and increase in neurocognition and social functioning. MT might be a more effective treatment in the field of perceptual theory of mind.

The functional significance of cognitive empathy and theory of mind in early and chronic schizophrenia

Theoretical models suggest that it is the interplay between social cognitive processes that result in adaptive social functioning in schizophrenia. This study explored the relative contributions of, and interplay between, cognitive empathy, affective theory of mind (ToM), neurocognition, and severity of clinical symptoms, in predicting the social functioning of individuals with schizophrenia. Clinical participants (early schizophrenia n = 26, chronic schizophrenia n = 32) were administered an ecologically valid measure of ToM (viz., the Virtual Assessment of Mentalising Ability or VAMA) and the Empathy Quotient (EQ) as part of a larger neuropsychological and social functioning assessment battery. Results indicated that individuals with early schizophrenia reported significantly better cognitive empathy than individuals with chronic schizophrenia. ToM was found to have added value in predicting both community functioning and functional capacity that was beyond that accounted for by cognitive empathy, clinical symptoms, and neurocognition for both clinical groups. Further, our results indicated that the capacity to demonstrate empathic understanding of another's situation (i.e., cognitive empathy) mediates the relationship between ToM and social functioning. Together, our findings highlight the intricate and compounding nature of social cognition constructs, and their effect on social functioning for individuals with schizophrenia.

The Recovery Process for Individuals With Schizophrenia in the Context of Evidence-Based Psychotherapy and Rehabilitation

Abstract. This systematic review aimed to evaluate the efficacy of Cognitive Behavioral Therapy (CBT), META Cognitive Therapy (MCT), Metacognitive Training (MCTR), Metacognitive Reflection and Insight Therapy (MERIT), of various rehabilitation programs and of recovery programs in schizophrenia. Medline/Pubmed was searched for studies published in English from January 2010 to August 2018, which were screened against inclusion criteria by two reviewers. The methodological quality of the included studies was evaluated by two independent raters, which are the Effective Public Health Practice Project (EPHPP) quality assessment tool for quantitative studies and the fidelity criteria. The study included 41 RCTs and 12 case studies with n = 3,059 persons with schizophrenia. Cognitive Behavioral Therapy (CBT) proved to be superior in terms of the improvement of primary and secondary outcomes. MCT decreased positive symptoms and improved metacognitive capacity and insight. MCTR reduced positive symptoms and socially disruptive behavior. MERIT improved metacognitive capacity and insight. Rehabilitation programs were efficacious in the improvement of cognition, symptoms, and functional outcome. The recovery programs enhanced illness-management knowledge, attitudes toward medication and insights related to negative symptoms. It is recommended to combine the above evidence based psychotherapeutic interventions. Limitations of this systematic review are discussed toward the end of the essay. Some important factors have to be considered in the future have been mentioned.

The BAT: A videotaped battery to assess theory of mind in schizophrenia

The ability of attributing mental states to oneself and to the others (theory of mind, ToM) is impaired in schizophrenia. ToM is not a monolithic function, it includes different capacities: some implies the decoding of affective states, others the reasoning about mental states. We have developed the BAT, a Battery to Assess Theory of mind abilities in adult psychotic subjects in an ecological audiovisual format. The performance on the BAT and three other test of social cognition was compared in a sample of schizophrenic patients with a control group. The samples were matched in terms of age and premorbid IQ. The BAT was sensitive to detect the ToM impairments in schizophrenia, showed good internal consistency and concurrent validity. The area under the ROC curves established a cutoff point that would correctly classify controls and patients in a 96.6% of cases. The factorial analysis isolated two factors: empathy and reasoning, with a good adjustment. Our results showed that the BAT could be a valid, ecological and usable tool to assess ToM in psychotic patients, with good psychometric properties, that would allow obtaining a more complete profile of their impairment.

Functional Impairments and Theory of Mind Deficits in Schizophrenia: A Meta-analysis of the Associations

Schizophrenia is associated with major functioning difficulties. Theory of mind (ToM), the ability to infer the mental states of others, is an important determinant of functioning. However, the contribution of ToM to each specific domain of functioning remains to be better understood. The objectives of this meta-analysis were to document and compare the magnitude of the associations between ToM and (1) different domains of functioning (social functioning, productive activities, and instrumental activities of daily living), each assessed separately for functional performance and functional outcome and (2) different aspects of functioning (functional performance and functional outcome) in schizophrenia. Fifty-nine studies (N = 4369) published between 1980 and May 2019 targeting patients with schizophrenia or schizoaffective disorder aged between 18 and 65 years old were included. Studies were retrieved from seven databases. Correlations were extracted from the articles, transformed into effect sizes Zr and combined as weighted and unweighted means. The strength of the associations between the domains and aspects of functioning were compared using focused tests. A moderate association was observed between ToM and all domains of functioning, with a stronger association between ToM and productive activities compared with social functioning (only for functional outcome [χ2(2) = 6.43, P = 0.040]). Regarding the different aspects of functioning, a stronger association was observed between ToM and functional performance, compared with functional outcome, for overall functioning (χ2(1) = 13.77, P < 0.001) and social functioning (χ2(1) = 18.21, P < 0.001). The results highlight a stronger association of ToM with productive activities and with functional performance, which should be considered in future studies to improve functional recovery in schizophrenia.

The Relationship Between Different Aspects of Theory of Mind and Symptom Clusters in Psychotic Disorders: Deconstructing Theory of Mind Into Cognitive, Affective, and Hyper Theory of Mind

Background: Several meta-analyses highlight pronounced problems in general Theory of Mind (ToM), the ability to infer other persons' mental states, in patients with psychosis in comparison to non-clinical controls. In addition, first studies suggest associations between Hyper-ToM, an exaggerated inference of mental states to others, and delusions. Research on different ToM subtypes (Cognitive ToM, Affective ToM, and Hyper-ToM) and symptom clusters of psychosis (positive, negative, and disorganized symptoms) have gathered conflicting findings. Thus, the present study examined group differences between patients with psychosis and non-clinical controls concerning Cognitive ToM/Affective ToM and Hyper-ToM. Further, the association between ToM subtypes and symptom clusters (positive, negative, and disorganized symptoms) were examined. Methods: Patients with psychotic disorders (n = 64, 1/3 with present delusions indicated by a minimum score of four in the PANSS P1 item) and non-clinical controls (n = 21) were examined with assessments of Cognitive ToM and Affective ToM abilities and Hyper-ToM errors using the Frith-Happé animations. Psychopathology was assessed using the Positive and Negative Syndrome Scale. Results: Patients with psychosis presented more pronounced problems in Cognitive and Affective ToM in comparison to non-clinical controls, whereas there were no group differences with regard to Hyper-ToM errors. Furthermore, deficits in Cognitive ToM were associated with general delusions, whereas problems in Affective ToM were associated with negative and disorganized symptoms. In addition, there was no association between Hyper-ToM errors and any symptoms when controlling for years of education. Conclusions: Our findings suggest that deficits in ToM subtypes might not be directly related to delusions and positive symptoms and are in line with more recently developed cognitive models of delusions. In addition, our results support the well-established finding of associations between ToM alterations and negative or disorganized symptoms. Our results shed light on the role of different dimensions of ToM in specific symptoms of psychosis.

Online Social Cognition Training in Schizophrenia: A Double-Blind, Randomized, Controlled Multi-Site Clinical Trial

Social cognition (SC), the mental operations underlying social functioning, are impaired in schizophrenia. Their direct link to functional outcome and illness status have made them an important therapeutic target. However, no effective treatment for these deficits is currently applied as a standard of care. To address this need, we have developed SocialVille-an online, plasticity-based training program that targets SC deficits in schizophrenia. Here we report the outcomes of a double-blind, controlled, randomized, multi-site clinical trial of SocialVille. Outpatients with schizophrenia were randomized to complete 40 sessions of either SocialVille (N = 55 completers) or active control (computer games; N = 53 completers) from home. The a priori co-primary outcome measures were a social cognitive composite and a functional capacity outcome (UCSD Performance-based Skills Assessment [UPSA-2]). Secondary outcomes included a virtual functional capacity measure (VRFCAT), social functioning, quality of life, and motivation. Linear mixed models revealed a group × time interaction favoring the treatment group for the social cognitive composite (b = 2.81; P < .001) but not for the UPSA-2 measure. Analysis of secondary outcome measures showed significant group × time effects favoring the treatment group on SC and social functioning, on the virtual functional capacity measure and a motivation subscale, although these latter findings were nonsignificant with FDR correction. These results provide support for the efficacy of a remote, plasticity-based social cognitive training program in improving SC and social functioning in schizophrenia. Such treatments may serve as a cost-effective adjunct to existing psychosocial treatments. Trial Registration: NCT02246426.

Transforming treatments for schizophrenia: Virtual reality, brain stimulation and social cognition

Schizophrenia is characterised by delusions, hallucinations, anhedonia and apathy; while impairments in social cognition are often less recognised. Poor social cognition can lead to difficulties in obtaining and maintaining employment, academic progression, interpersonal relationships, and community functioning. Current interventions are highly intensive, require significant resources and have only modest effects on functional outcomes. Virtual reality (VR) and non-invasive brain stimulation (NIBS) may have a role in addressing these limitations. VR allows treatments that are potentially more accessible, less delivery intensive, and have higher ecological validity. While NIBS is able to directly modulate activity in social brain areas in order to promote neuroplasticity, strengthen neural connections and enhance brain function related to social cognitive behaviours. Therefore, the combination of VR and NIBS may allow for more efficient and transferrable interventions than those currently available. This review will explore the potential role of these technologies in the treatment of social cognitive impairment.

A meta-analysis of the associations between theory of mind and neurocognition in schizophrenia

Theory of mind (ToM) refers to the ability to infer the mental states of others. ToM is impaired in schizophrenia and these deficits seem to hinder functional recovery. ToM is thus an important, but complex treatment target, supported by several processes. A large number of studies report significant associations between ToM and neurocognition (e.g. memory, attention), but the neurocognitive domains that are most closely linked to ToM remain to be identified. A meta-analysis was conducted to estimate the magnitude of the associations between ToM and neurocognition in people with schizophrenia. Correlations were extracted from the relevant literature, transformed into effect sizes Zr and pooled as weighted means. Focused-tests were employed to test for differences between neurocognitive domains and for differences linked to the characteristics of ToM tasks. Ninety-one studies (N = 5462) were included. Moderate associations emerged between ToM and each neurocognitive domain (Zrs 0.27-0.43), with no significant difference between domains (χ2(8) = 11.89, p = 0.156). Within the domain of executive functions, abstraction showed a stronger association with ToM (χ2(4) = 18.93, p = 0.001). Several ToM tasks characteristics (e.g. modality of stimuli, type of mental state), were significantly related to the magnitude of the associations between ToM and executive functions, visuospatial/problem solving, attention and episodic memory. These results suggest that ToM is linked to a wide range of neurocognitive abilities in schizophrenia, and that ToM tasks are a significant moderator of these associations. The assessment and treatment of ToM should consider the neurocognitive profile of each patient to understand his difficulties and to tailor interventions.

The association of autistic traits with Theory of Mind and its training efficacy in patients with schizophrenia

Literature has recently identified a discrete subgroup of patients affected by schizophrenia that also present autistic traits (ATs), showing a peculiar cognitive, clinical and functional profile. Theory of Mind (ToM) represents a core, impaired feature in both schizophrenia and Autism Spectrum Disorder (ASD), ToM in patients with schizophrenia and ATs has yet to be investigated. Thus, this study aims, on the one hand, to assess differences among patients with and without ATs on clinical, cognitive and ToM abilities as well as in daily functioning; on the other hand, to compare the efficacy on mentalizing abilities of a specific ToM training in these two groups.

Ninety-six patients with schizophrenia were enrolled and underwent a broad cognitive, social-cognitive and functional assessment before and after the ToM training.

ANOVAs revealed that patients with schizophrenia and ATs are more impaired in cognition, ToM, in premorbid and daily functioning as well as in clinical features, as compared to patients without ATs. This latter group also showed a general improvement in mentalizing abilities after ToM training, while patients with schizophrenia and ATs did not, with a significant time × group interaction on ToM abilities.

These data shed new light on the relation among schizophrenia and ATs, highlighting that patients with these traits are highly impaired in ToM abilities. Thus, ATs seem to limit the effectiveness of ToM training, having implications in clinical and rehabilitative practice.

Observation and Imitation of Social Emotions Are Essential for Improving Cognitive and Affective Theory of Mind in Schizophrenia: A Meta-analysis

People with schizophrenia often demonstrate deficits in theory of mind (ToM), which may be addressed via social cognition training that includes observation and imitation of social emotions. We examined the effect of observation and imitation on ToM and whether computerized cognitive training (CCT) can improve ToM. Among 14 controlled trials, 264 of 494 people with schizophrenia received treatment. Observation and imitation of social emotions improved cognitive (g = 0.53; 95% confidence interval [CI], 0.29-0.76) and affective ToM (g = 0.54; 95% CI, 0.34-0.73), versus treatment as usual or cognitive rehabilitation alone. CCT did not significantly enhance affective ToM (p = 0.42); however, cognitive ToM improvements without CCT (g = 1.20; 95% CI, 0.78-1.61) were superior to those with CCT (g = 0.33; 95% CI, 0.02-0.64; p < 0.01). Observation and imitation of social emotions are essential for improving ToM in schizophrenia, but CCT may not improve ToM.

Interventions for the treatment of theory of mind deficits in schizophrenia: Systematic literature review

Theory of Mind (ToM) plays a central role in regulating social interactions and its impairment is consistently reported in schizophrenia. Regarding schizophrenia, ToM is usually discussed as a sub-domain of social cognition. Since social cognitive deficits have drawn the attention of researchers, a variety of novel treatment techniques and approaches targeting social cognitive deficits have been developed. Encouraging results have repeatedly been reported on the modifiability of social cognitive impairment through these techniques. However, emotional perception seems to be over-represented in these approaches at the expense of other areas, such as ToM. This article presents a systematic review on the social cognitive interventions of the last 10 years, which focused on the remediation of ToM or used techniques primarily focusing on one or more social cognitive domains other than ToM, but with hypothetical effects on it. The aim of our systematic review was to compare these intervention techniques in order to see how effective they are in the remediation of ToM, and to find the best techniques to ameliorate ToM deficits in schizophrenia. According to our findings targeted ToM intervention produced more improvement in ToM tasks, while data regarding non-ToM interventions showed contradictory results with limited effects on ToM.

Cognitive Reserve Profiles in Chronic Schizophrenia: Effects on Theory of Mind Performance and Improvement after Training

OBJECTIVES

Cognitive reserve (CR), defined as individual differences in the ability to cope with brain damage, seem to be associated to the several psychopathological features in psychiatric patients, such as the functional outcome. This study aims to identify different profiles of CR by combining intelligence quotient (IQ) and premorbid functioning, two measures independently associated to CR in previous works, as well as to explore CR effect on both Theory of Mind (ToM) baseline performance and improvement after socio-cognitive trainings.

METHODS

Sixty patients with chronic schizophrenia underwent a socio-cognitive rehabilitation. All patients were assessed for psychopathology, neurocognition, and ToM at baseline and post-treatment. CR profiles were explored with K-means cluster analysis, while differences between clusters in both baseline assessments and post-treatment ToM improvement, were analyzed by means of analysis of variance and repeated measures analysis of covariance.

RESULTS

The analysis revealed three CR profiles, respectively, characterized by low early premorbid functioning and mild intellectual impairment, average/high early premorbid functioning trend with moderate intellectual impairment and good early premorbid functioning associated to IQ within normal limits. Analyses showed a significant effect of CR on both baseline ToM performance and treatment outcome: patients with higher CR reached significantly better ToM scores.

CONCLUSIONS

These results underline the clinical relevance of defining CR profiles of patients to customize trainings: subjects with a lower CR may benefit from more intensive programs. A deeper knowledge about CR may considerably increase our understanding of individual differences and thus potentiate treatment outcome. (JINS, 2018, 24, 563-571).

Social cognitive interventions for people with schizophrenia: A systematic review

Social cognition is the mental process which underpins social interactions. Increasingly, it has been recognized to be impaired in people with schizophrenia, resulting in functional problems. Correspondingly, the past ten years have seen huge developments in the study of interventions to ameliorate social cognitive deficits among people with schizophrenia. In the present review, we systematically reviewed published studies on social cognitive interventions from 2005 to 2015. Of the 61 studies included in this review, 20 were on broad-based social cognitive interventions, which incorporated neurocognitive training, specialized learning technique or virtual reality social skills training. On the other hand, 31 studies on targeted interventions either focused on specific social cognitive domains, or a range of domains. Improvements in emotion processing and theory of mind were often reported, while social perception and attributional style were less frequently measured. Both broad-based and targeted interventions achieved gains in social functioning, albeit inconsistently. Lastly, nine studies on the use of oxytocin and one study on transcranial direct current stimulation reported positive preliminary results in higher-order cognition and facial affect recognition respectively. This review revealed that a wide range of social cognitive interventions is currently available and most have shown some promise in improving social cognition outcomes. However, there is a need to use a common battery of measurements for better comparisons across interventions. Future research should examine combination therapies and the sustainability of gains beyond the intervention period.

Randomized Clinical Trial with e-MotionalTraining® 1.0 for Social Cognition Rehabilitation in Schizophrenia

BACKGROUND

Schizophrenia patients present deficits in social cognition (SC), emotion and social perception, theory of mind (ToM), and attributional style. This study tested the efficacy, in real clinical conditions, of a online self-training program in SC, e-Motional Training^®, in comparison with treatment as usual.

METHOD

A randomized single-blinded multicenter clinical trial was conducted with 60 schizophrenia stable outpatients. All patients (control and intervention) were treated with drug therapy, case management, and individual and group psychotherapy (not focused on SC). Intervention group was treated with e-Motional Training^®, an online program devised for SC rehabilitation.

STATISTICAL ANALYSIS

A descriptive analysis and parametric/non-parametric tests were used to compare both groups at baseline. Analysis of covariance was used to compared post-pre changes in SC between the two interventions. If the group effect was significant, follow-up univariate test (t-test for dependent samples) was carried out in each group to verify whether the effect was due to improvement in the intervention group or deterioration in the control group. We considered statistically significant differences with P < 0.05.

RESULTS

Significant improvements were obtained in the intervention group in emotion recognition and most ToM variables in comparison with the control group.

DISCUSSION

e-Motional Training^® seems to be a promising online training tool for SC deficits in schizophrenia, covering the lack of similar intervention instruments in our community.

Achieving recovery in patients with schizophrenia through psychosocial interventions: A retrospective study

AIM

Recovery, or functional remission, represents the ultimate treatment goal in schizophrenia. Despite its importance, a standardized definition of remission is still lacking, thus reported rates significantly vary across studies. Moreover, the effects of rehabilitative interventions on recovery have not been thoroughly investigated. This study aimed to evaluate recovery in a sample of patients with chronic schizophrenia engaged in rehabilitation programs and to explore contributing factors, with a focus on sociocognitive rehabilitative interventions.

METHODS

Data from 104 patients with schizophrenia treated either with a standard rehabilitation program, including cognitive remediation (n = 46), or the latter plus a specific sociocognitive intervention (n = 58), and assessed for psychopathology, cognition, social cognition, and Quality of Life Scale, were retrospectively analyzed for this study.

RESULTS

Recovery, evaluated with the Quality of Life Scale, was achieved by 56.76% of patients in our sample. While no effects were observed for clinical, cognitive, or sociocognitive variables, participation in the sociocognitive rehabilitative interventions was positively associated with recovery.

CONCLUSION

Our results indicate that high rates of recovery can be achieved in patients treated with psychosocial interventions and suggest that rehabilitative programs targeting social cognition may further facilitate the process of recovery. If confirmed, these results may have relevant implications for daily clinical practice and service provision, allowing clinicians to develop and optimize specific rehabilitation programs in order to promote recovery.

The Importance of Social Cognition in Improving Functional Outcomes in Schizophrenia

Social cognition has become recognized as an important driver of functional outcomes and overall recovery in patients with schizophrenia, mediating the relationship between neurocognition and social functioning. Since antipsychotic therapy targeting remission of clinical symptoms has been shown to have a limited impact on social cognition, there has been an increasing drive to develop therapeutic strategies to specifically improve social cognition in schizophrenia. We sought to review current evidence relating to social cognition in schizophrenia and its clinical implications, including interventions designed to target the core domains of social cognition (emotion processing, theory of mind, attributional bias, and social perception) as a means of improving functional outcomes and thereby increasing the likelihood of recovery. Relevant articles were identified by conducting a literature search in PubMed using the search terms "schizophrenia" AND "cognition" AND "social functioning," limited to Title/Abstract, over a time period of the past 10 years. Current evidence demonstrates that schizophrenia is associated with impairments in all four core domains of social cognition, during the pre-first-episode, first-episode, early, and chronic phases of the disease, and that such impairments are important determinants of functional outcome. Interventions targeting the four core domains of social cognition comprise psychosocial approaches (social cognition training programs) and pharmacological therapies. Social cognition training programs targeting multiple and specific core domains of social cognition have shown promise in improving social cognition skills, which, in some cases, has translated into improvements in functional outcomes. Use of some psychosocial interventions has additionally resulted in improvements in clinical symptoms and/or quality of life. Pharmacological therapies, including oxytocin and certain antipsychotics, have yielded more mixed results, due in part to the confounding impact of factors including variation in receptor genetics, bioavailability, pharmacokinetics, and drug-drug interactions, and inconsistencies between study designs and medication dosages. Additional research is required to advance our understanding of the role of social cognition in schizophrenia, and to further establish the utility of targeted interventions in this setting.

Targeting anxiety to improve quality of life in patients with schizophrenia

BACKGROUND

Several studies suggested that anxiety can significantly affect the outcome of schizophrenia. Despite this evidence, non-pharmacological interventions targeting anxiety are still heterogenous. This study aims to test the efficacy of a novel training specifically designed to target anxiety in patients with schizophrenia. Innovatively, this training, beyond psychoeducation and problem solving, also targets Theory of Mind, as it provides coping strategies.

METHOD

Twenty-seven outpatients with schizophrenia received a novel rehabilitative training targeting anxiety (Anxiety Management Group [AMG]) combined with a Computer-Assisted Cognitive Remediation (CACR), and twenty received CACR plus a control intervention (Control Newspaper discussion Group [CNG]). All patients were assessed at baseline and after treatment for quality of life, neurocognition and anxiety.

RESULTS

After training, patients treated with AMG+CACR showed significantly greater improvements on anxiety. A significant increase in quality of life was observed only for AMG+CACR group. Moreover, the participants' appraisal showed a significant difference between treatment groups with higher ratings among patients who received the AMG+CACR.

CONCLUSIONS

This study thus suggests feasibility and efficacy of the proposed intervention, that could be implemented in rehabilitative programs for patients with schizophrenia with potential benefits also on disease course and outcome.

Social cognition interventions for people with schizophrenia: a systematic review focussing on methodological quality and intervention modality

BACKGROUND

People with a diagnosis of schizophrenia have significant social and functional difficulties. Social cognition was found to influences these outcomes and in recent years interventions targeting this domain were developed. This paper reviews the existing literature on social cognition interventions for people with a diagnosis of schizophrenia focussing on: i) comparing focussed (i.e. targeting only one social cognitive domain) and global interventions and ii) studies methodological quality.

METHOD

Systematic search was conducted on PubMed and PsycInfo. Studies were included if they were randomised control trials, participants had a diagnosis of schizophrenia or schizoaffective disorder, and the intervention targeted at least one out of four social cognition domains (i.e. theory of mind, affect recognition, social perception and attribution bias). All papers were assessed for methodological quality. Information on the intervention, control condition, study methodology and the main findings from each study were extracted and critically summarised.

RESULTS

Data from 32 studies fulfilled the inclusion criteria, considering a total of 1440 participants. Taking part in social cognition interventions produced significant improvements in theory of mind and affect recognition compared to both passive and active control conditions. Results were less clear for social perception and attributional bias. Focussed and global interventions had similar results on outcomes. Overall study methodological quality was modest. There was very limited evidence showing that social cognitive intervention result in functional outcome improvement.

CONCLUSIONS

The evidence considered suggests that social cognition interventions may be a valuable approach for people with a diagnosis of schizophrenia. However, evidence quality is limited by measure heterogeneity, modest study methodology and short follow-up periods. The findings point to a number of recommendations for future research, including measurement standardisation, appropriately powered studies and investigation of the impact of social cognition improvements on functioning problems.

Understanding Social Situations (USS): A proof-of-concept social-cognitive intervention targeting theory of mind and attributional bias in individuals with psychosis

OBJECTIVES

In this proof-of-concept trial, we examined the feasibility and preliminary efficacy of Understanding Social Situations (USS), a new social-cognitive intervention that targets higher level social-cognitive skills using methods common to neurocognitive remediation, including drill and practice and hierarchically structured training, which may compensate for the negative effects of cognitive impairment on learning.

METHOD

Thirty-eight individuals with schizophrenia spectrum disorders completed the same baseline assessment of cognitive and social-cognitive functioning twice over a 1-month period to minimize later practice effects, then received 7-10 sessions of USS training, and then completed the same assessment again at posttreatment.

RESULTS

USS training was well tolerated and received high treatment satisfaction ratings. Large improvements on the USS Skills Test, which contained items similar to but not identical to training stimuli, suggest that we were effective in teaching specific training content. Content gains generalized to improvements on some of the social-cognitive tasks, including select measures of attributional bias and theory of mind. Importantly, baseline neurocognition did not impact the amount of learning during USS (as indexed by the USS Skills Test) or the amount of improvement on social-cognitive measures.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

USS shows promise as a treatment for higher level social-cognitive skills. Given the lack of relationship between baseline cognition and treatment effects, it may be particularly appropriate for individuals with lower range cognitive function. (PsycINFO Database Record

Social Cognitive Interventions in Neuropsychiatric Patients: A Meta-Analysis

Social cognitive deficits are common in neuropsychiatric disorders. Given the proximity of social cognition (SC) to everyday functioning, many intervention studies (including targeted, comprehensive, and broad-based approaches) have focussed on SC. The aim of this paper was to quantitatively meta-analyse the efficacy of SC interventions in adult neuropsychiatric patients. Databases Pubmed, PsycINFO, Web of Knowledge, and Embase were searched for controlled SC intervention studies published between 01-01-2003 and 01-01-2016. Forty-one studies, comprising 1,508 patients with schizophrenia, autism spectrum disorders, or acquired brain injury were included. Outcome measures evaluated emotion perception (EP), social perception (SP), Theory of Mind (ToM), and social functioning (SF). The meta-analyses showed that interventions were effective in improving SC (Cohen'sd=.71). Interventions targeting one specific SC function were found to be most effective (d=.89), followed by broad-based interventions, targeting non-SC domains in addition to SC (d=.65), and comprehensive interventions, that target multiple SC processes (d=.61). Targeted interventions were especially effective in improving EP and ToM. Comprehensive interventions were able to ameliorate EP, ToM, and SF. Broad-based interventions were especially effective in improving SF, but also showed effects on EP and ToM.

Combined social cognitive and neurocognitive rehabilitation strategies in schizophrenia: neuropsychological and psychopathological influences on Theory of Mind improvement

BACKGROUND

Neurocognitive and social cognitive impairments represent important treatment targets in schizophrenia, as they are significant predictors of functional outcome. Different rehabilitative interventions have recently been developed, addressing both cognitive and psychosocial domains. Although promising, results are still heterogeneous and predictors of treatment outcome are not yet identified. In this study we evaluated the efficacy of two newly developed social cognitive interventions, respectively based on the use of videotaped material and comic strips, combined with domain-specific Cognitive Remediation Therapy (CRT). We also analysed possible predictors of training outcome, including basal neurocognitive performance, the degree of cognitive improvement after CRT and psychopathological variables.

METHOD

Seventy-five patients with schizophrenia treated with CRT, were randomly assigned to: social cognitive training (SCT) group, Theory of Mind Intervention (ToMI) group, and active control group (ACG).

RESULTS

ANOVAs showed that SCT and ToMI groups improved significantly in ToM measures, whereas the ACG did not. We reported no influences of neuropsychological measures and improvement after CRT on changes in ToM. Both paranoid and non-paranoid subjects improved significantly after ToMI and SCT, without differences between groups, despite the better performance in basal ToM found among paranoid patients. In the ACG only non-paranoid patients showed an improvement in non-verbal ToM.

CONCLUSION

Results showed that both ToMI and SCT are effective in improving ToM in schizophrenia with no influence of neuropsychological domains. Our data also suggest that paranoid symptoms may discriminate between different types of ToM difficulties in schizophrenia.

Social cognition

Social cognition is a major problem underlying deficiencies in interpersonal relationships in several psychiatric populations. And yet there is currently no gold standard for pharmacological treatment of psychiatric illness that directly targets these social cognitive areas. This chapter serves to illustrate some of the most innovative attempts at pharmacological modulation of social cognition in psychiatric illnesses including schizophrenia, borderline personality disorder, autism spectrum disorders, antisocial personality disorder and psychopathy, social anxiety disorder, and posttraumatic stress disorder. Pharmacological modulation includes studies administering oxytocin, ecstasy (MDMA), modafinil, methylphenidate, and D-cycloserine. Furthermore, some background on social cognition research in healthy individuals, which could be helpful in developing future treatments, is provided as well as the potential for each drug as a long-term treatment option.