Impenetrable faces: Social cognition and schizophrenia

What are the men in the picture feeling? It might seem like an easy question to you, but current research shows that people with schizophrenia might struggle with the answer. It is schizophrenia awareness week, so let’s seize this opportunity and talk about schizophrenia and the research on social cognitive impairments associated with this condition.

What you should know about schizophrenia?

What is it? Schizophrenia is a brain disorder that makes it difficult to tell the difference between what is real and what is not.

How common is it? It affects roughly 1% of global population. Most people are first diagnosed when they are 15-35 years old, and  a majority of them will have chronic or recurrent symptoms for the rest of their life.

What is the cause? The exact cause is not yet known. Whether a person develops the condition likely depends on a combination of genetic and environmental factors. You are 10 times more likely to develop schizophrenia if one of your parents has it, and 2 times more likely, if your mother experienced either floods or famine during pregnancy or if you smoked pot as a teenager.

What are the symptoms?

Contrary to the portrayal in the media, people with schizophrenia are not inherently violent nor do they have a split personality. According to the DSM-V, which is something of a bible for diagnosing mental disorders, at least two of the following symptoms must be present:

Hallucinations. This is probably the best-known symptom of schizophrenia. When hallucinating, people hear or see things that are not really there. Hearing voices is the most common sign, but hallucinations might also affect other senses. This audio might give you a good idea how the auditory hallucinations might sound like but be warned that it might be a rather stressful experience.

Delusions. Delusions are false fixed beliefs that one retains even when they are at odds with reality. Approximately 80% of people with schizophrenia have some kind of delusion. The video below showcases the two most common types—delusions of grandeur, i.e. beliefs that one is an important figure (in this case Prime Minister’s brother), and delusions of persecution, in which one thinks that others spy on him or want to harm him.

Disorganized thoughts and speech. Schizophrenia also interferes with thinking. This might manifest as jumping from topic to topic when speaking (e.g. My cat is 11 years old. 11 is my favourite number. I also like ice-cream) or inventing new words (I like hafing). In severe cases, speech might become an incomprehensible mixture of seemingly random words and phrases that do not make any sense: Herds of marshmallows haf while cat.

Disorganized behaviour. Disorganized behaviour is any behaviour that is not appropriate in the context (e.g. laughing when hearing about tragic events, or stripping on the street). An extreme case of this is catatonia. Catatonic patients are unresponsive and might stay frozen in a single position for hours.

Negative symptoms. Negative symptoms describe decrease in emotional responses, social withdrawal and loss of pleasure or motivation that are also accompany schizophrenia. Unlike positive symptoms (i.e. hallucinations and delusions) that are most prominent during early stages of the disorder and then tend to decrease, the severity of negative symptoms increases over time.

Social cognition – key to understanding others

Social cognition refers to the range of abilities needed to interpret feelings, intentions and actions of others. In the last decade, it has become clear that social cognition is impaired in people with schizophrenia and also in their healthy relatives, albeit to a lesser extent.

Recognition of social cues has been shown to be consistently impaired in schizophrenia. Social cues, such as intonation or facial expressions, are hints that convey person’s feelings or intentions. As highly social animals, we need very little to read other people. In fact, even if we only see the eyes, we can correctly infer their intentions in roughly 70% of cases. If you do not believe me, try this New York Times test and see for yourself.

Schizophrenia makes it difficult to understand social cues. While individuals with this condition can easily establish somebody’s age or gender, they have a hard time identifying their emotions. This might lead them to falsely believe that others are disgusted or angry with them, which in turn might lead to social withdrawal. Emotion or social cue recognition is usually tested by tasks such as the New York Times test above, where participants see a series of faces, and have to choose words that best describe the portrayed emotions. Similar tests can be applied via audio recordings, or a combination of both. In all such tasks, patients with schizophrenia score lower when compared to healthy volunteers. Moreover, brain regions that are associated with interpreting emotional cues, such as the amygdala or medial prefrontal cortex, are less active during these tasks.

Theory of mind describes the ability to put yourself in somebody else’s shoes and infer what they might think or feel given the situation they are in. For instance, if a person speaking on a phone looks at you and holds her index finger up, you will likely assume that she wants you to wait until she finishes the call. However, individuals with schizophrenia might have trouble understanding such situations and get confused.

There are many different tests used to study different aspects of theory of mind. E.g. Intention-inferencing tasks test whether you can assign motivation to characters in short stories or cartoons. Hinting tasks measure the ability to pick up hints, and false beliefs tasks check whether you can distinguish between what you know and what another person knows or believes. In the box below, you can see some examples.

Performance of individuals with schizophrenia is also impaired in these tasks. This is underpinned by reduced activation in the brain regions associated with the theory of mind, such as the medial prefrontal cortex and temporal parietal junction.


Social cognition predicts therapy success

The deep interest in social cognitive function in schizophrenia is motivated by the fact that the degree of social cognitive impairment is the best and most consistent predictor of therapy success. That is, people with better social cognition, regardless of severity of their other symptoms, are more likely to live independently, have a job, deal well with interpersonal problems and be better integrated into their social community. Therefore, there is a wealth of recent studies examining what interventions are suitable for improving social cognition.

Schizophrenia has traditionally been treated by a combination of talk therapies and antipsychotic medication, which is generally very effective against hallucinations and delusions. In 2009, a large study with more than 800 participants investigated whether long-term use of antipsychotics also improves recognition of emotions and social cues. Unfortunately, they found no difference between medicated and non-medicated patients. Together with other smaller studies, this suggests that current antipsychotics are not effective against the impairments in social cognition.

On the other hand, talk therapies seem very promising so far. A recent review concluded that psychosocial programs that include social cognition training (both as their main activity or as a part of more broadly targeted interventions) led to long-term improvement in perception of social cues and theory of mind, along with reduction of negative symptoms and increase in social functioning. In general, the most effective approaches seem to be those where people repeatedly and frequently train to associate facial expressions with intentions or emotions (e.g. raised eyebrows mean surprised). On the downside, current programs are time consuming and require several months to be effective.

Finally, the growing evidence of social cognitive impairments in schizophrenia have prompted pharmaceutical companies to start developing new kinds of medication that focus specifically on improving social cognition. While this process will have its fair share of obstacles, I am positive that in the next few years we will see more rapid and effective treatment for schizophrenia that will make a difference for those who have this condition. And that is great news, don’t you think?

Key References

Green, M. F., Horan, W. P., & Lee, J. (2015). Social cognition in schizophrenia. Nature Reviews Neuroscience, 16(10), 620-3. doi:10.1038/nrn4005

Kurtz, M. M., Gagen, E., Rocha, N. B., Machado, S., & Penn, D. L. (2016). Comprehensive treatments for social cognitive deficits in schizophrenia: A critical review and effect-size analysis of controlled studies. Clinical psychology review, 43, 80-89. doi:10.1016/j.cpr.2015.09.003

Kucharska-Pietura, K., & Mortimer, A. (2013). Can antipsychotics improve social cognition in patients with schizophrenia? CNS drugs, 27(5), 335-343. doi:10.1007/s40263-013-0047-0

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