Social cognitive skills training in schizophrenia: An initial efficacy study of stabilized outpatients☆
Introduction
Impairments in social functioning are among the most debilitating and treatment refractory aspects of schizophrenia (Bellack et al., 2007). It has become clear that further improvements in social functioning will not occur through gains in psychotic symptom management alone, since psychotic symptoms are typically not closely related to functional adaptation levels in community-dwelling outpatients (Carter, 2006, Heydebrand et al., 2004) and there has been little improvement in community functioning over the past 100 years (Hegarty et al., 1994). Instead, treatments that directly address the key determinants of poor social functioning are required to ameliorate these impairments. There has been good success in identifying basic neurocognitive processes that predict social dysfunction (Green et al., 2000, Green et al., 2004), which has been one rationale for major NIMH initiatives to stimulate the development of new pharmacological treatments for cognitive deficits (Marder and Fenton 2004). However, it is unlikely that interventions targeting only basic neurocognition will be sufficient to achieve optimal functioning since neurocognitive deficits typically account for only 10% to 40% of the variance in outcome (Green et al., 2000, Green et al., 2008, Penn et al., 2006). Thus, there is a critical need to identify and treat other determinants of poor outcome.
Rapidly growing evidence indicates that impairments in the domain of social cognition are important determinants of functional outcome in schizophrenia. Social cognition is a multifaceted construct that refers to the mental operations underlying social interactions, which include processes involved in perceiving, interpreting, and generating responses to the intentions, dispositions, and behaviors of others (Brothers, 1990, Fiske and Taylor, 1991, Kunda, 1999). Schizophrenia patients show substantial deficits in several aspects of social cognition, including emotional processing, social perception, Theory of Mind, and attributional style (Penn et al., 2006). There is a general consensus that social cognition is distinct from, though related to, basic neurocognition and other clinical features of schizophrenia (Green et al., 2005, Penn et al., 1997, Sergi et al., 2007). Furthermore, social cognition shows unique relationships to functional outcome, above and beyond basic cognition (Couture et al., 2006). For example, social cognition has been found to mediate the relationship between basic neurocognition and functional outcome (Addington et al., 2006, Brekke et al., 2005, Sergi et al., 2006, Vauth et al., 2004). Hence, social cognition appears to be more proximal to functional outcome than basic cognition and, for that reason, could be an even better target for intervention.
A few research groups have demonstrated that the social cognitive deficits of schizophrenia are modifiable through brief experimental manipulations or more intensive psychosocial interventions (see Horan et al., 2008). For example, performance on facial affect recognition tests has been enhanced through brief (e.g., an hour or less) intervention probes such as attentional manipulations or monetary reinforcement (Combs et al., 2006, Penn and Combs, 2000, Russell et al., 2006, Silver et al., 2004). In addition, longer-term studies that incorporated social cognitive training exercises into multi-component treatment packages (often including neurocognitive remediation) demonstrate improvements on social cognitive tests (Bell et al., 2001, Hodel et al., 2004, Hogarty et al., 2004, van der Gaag et al., 2002). However, specifically attributing any intervention effects to the social cognitive training in these longer-term treatments is difficult because the procedures were embedded within multi-component rehabilitation programs.
A handful of research groups have begun developing and testing treatment programs that specifically target social cognition. For example, Wolwer and colleagues in Germany developed the Training in Affect Recognition program to remediate facial emotion perception deficits in schizophrenia. This 12-session computer-based training program is administered to pairs of patients at a time. It initially focuses on recognition of specific facial features associated with basic emotions and progresses to more complex facial displays in social contexts. Following an initial uncontrolled feasibility study (Frommann et al., 2003), a randomized trial demonstrated that inpatients who received this intervention demonstrated significant improvements in facial affect perception (and working memory), whereas patients in a time-matched neurocognitive remediation program or treatment as usual did not (Frommann et al., 2003, Wolwer et al., 2005). Since only facial affect perception was assessed, it is unknown whether this resource-intensive intervention leads to improvements in other social cognitive processes.
Penn et al. (2007b) in North Carolina developed Social Cognitive and Interaction Training (SCIT), an 18-session intervention that addresses three social cognitive processes: emotion perception, attributional bias, and Theory of Mind. The intervention is designed for small groups of six to eight patients and includes a variety of interactive training exercises, such as distinguishing facts from guesses, avoiding jumping to conclusions about suspicious beliefs, and gathering information about others' emotions and beliefs. An uncontrolled feasibility study of seven inpatients demonstrated improvements in attributional bias and Theory of Mind (but not emotion perception), as well as clinical symptoms (Penn et al., 2005). A subsequent study using a slightly modified treatment manual demonstrated improvements in social attribution and Theory of Mind, as well as facial emotion perception, in 18 forensic inpatients compared to patients receiving treatment as usual (Combs et al., 2007). Recently, a quasi-experimental study by Roberts and Penn (in press) evaluated an outpatient sample that received either SCIT plus treatment as usual or treatment as usual-only (without random assignment to condition). The SCIT group showed significant treatment benefits on a facial affect perception task, but not on measures of the other two targeted social cognitive processes.
These encouraging findings across studies (also see Roncone et al., 2004) have several limitations, including: 1) most did not include active control groups matched for time in treatment, 2) it is unclear from these studies whether social cognitive improvements merely reflected changes in basic neurocognitive functioning, and 3) with one exception, all used inpatients who often showed concurrent improvements in clinical state that could influence social cognition results. Because schizophrenia inpatients comprise a small fraction of patients, social cognitive interventions will find greater use in stabilized outpatients. Hence, it is critical to evaluate the efficacy of targeted social cognitive interventions in community-dwelling outpatients.
We report here the initial results of a randomized, controlled clinical trial for a new integrative social cognitive intervention for outpatients with psychotic disorders designed to improve four domains, including facial affect perception, social perception, attributional style, and Theory of Mind. As detailed below, this program combines successful elements from two existing programs (Frommann et al., 2003, Penn et al., 2007b) with a variety of novel training exercises and materials. We evaluated whether this new intervention results in specific improvements on social cognitive tests.
Section snippets
Design
In this 6-week clinical trial, 34 study participants were randomly assigned to either Social Cognition or Control (illness self-management and relapse prevention skills) intervention conditions. Three participants completed less than four sessions and did not complete post-treatment assessments, including two participants in the Social Cognition group (one obtained a job that conflicted with the group schedule, one decided he did not want to participate after a single session) and one in the
Results
Descriptive data and results of ANCOVAs for each variable are presented in Table 1. Out of the four social cognitive domains, there was a significant group effect in the predicted direction for facial affect perception. The magnitude of the between-groups effect was large, while the within-group effect was medium to large for the Social Cognition group and small for the Control group. There were no other notable trends toward improvement on the social cognitive tests within the Social Cognition
Discussion
This study provides initial support for the feasibility and efficacy of a new social cognitive skills training program for outpatients with psychotic disorders. Using a randomized controlled trial design, individuals who received the social cognitive intervention demonstrated significant improvements in facial affect perception, one of the four targeted social cognitive domains. These improvements were not attributable to changes in neurocognitive functioning or clinical symptoms. They also
Role of funding source
None.
Contributors
William P. Horan, Robert S. Kern, Karina Shokat-Fadai, Mark J. Sergi, Jonathan K. Wynn, Michael F. Green.
Conflict of interest
There are no conflicts of interest.
Acknowledgments
We thank David L. Penn, David A. Roberts, Wolfgang Wolwer, and Nicole Frommann for providing their treatment manuals and training stimuli and for valuable consultations. Funding for this project was provided to WPH as a pilot grant from the VISN 22 MIRECC with additional support from MH43292 (to MFG).
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