The predictive value of measures of social cognition for community functioning in schizophrenia: Implications for neuropsychological assessment

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1 Journl of the Interntionl Neuropsychologicl Society (2009), 15, Copyright 2009 INS. Published by Cmbridge University Press. Printed in the USA. doi: /s The predictive vlue of mesures of socil cognition for community functioning in schizophreni: Implictions for neuropsychologicl ssessment G.H.M. PIJNENBORG,1, 2, 3 F.K. WITHAAR,1, 4 J.J. EVANS,5 R.J. VAN DEN BOSCH,3, 4 M.E. TIMMERMAN,2 nd W.H. BROUWER2, 5, 6 1Deprtment of Psychotic Disorders, GGZ Drenthe, Assen, The Netherlnds 2Deprtment of Psychology, University of Groningen, Groningen, The Netherlnds 3 School for Behviorl nd Cognitive Neurosciences (BCN), University Medicl Centre, Groningen, The Netherlnds 4Deprtment of Psychitry, University Medicl Center Groningen, Groningen, The Netherlnds 5Section of Psychologicl Medicine, University of Glsgow, Acdemic Centre, Grtnvel Royl Hospitl, Glsgow, United Kingdom 6Deprtment of Neurology, University of Groningen, Groningen, The Netherlnds (Received June 9, 2008 ; Finl Revision November 28, 2008 ; Accepted December 1, 2008 ) Abstrct The objective of this study ws to exmine the unique contribution of socil cognition to the prediction of community functioning nd to explore the relevnce of socil cognition for clinicl prctice. Forty-six schizophreni ptients nd 53 helthy controls were ssessed with tests of socil cognition [emotion perception nd Theory of Mind (ToM)], generl cognition, nd, within the ptient smple, psychitric symptoms. Community functioning ws rted by nurses or fmily members. Socil cognition ws better predictor of community functioning thn generl cognition or psychitric symptoms. When the contributions of emotion perception nd ToM were exmined seprtely, only ToM contributed significntly to the prediction of community functioning. Independent living skills were poor in ptients with impired socil cognition. In controls, socil cognition ws not relted to community functioning. ToM ws the best predictor of community functioning in schizophreni. However, to fully understnd ptient s strengths nd weknesses, ssessment of socil cognition should lwys be combined with ssessment of generl cognition nd psychitric symptoms. ( JINS, 2009, 15, ). Keywords : Psychotic disorder, Socil djustment, Neuropsychologicl tests, Adult, Emotion, Socil behvior INTRODUCTION Schizophreni is severe psychitric illness tht ffects socil behvior in dily life situtions. Commonly ffected domins re self-cre, work, nd socil reltionships. These domins re usully summrized by the term community functioning (Couture et l., 2006 ). Community functioning is mong the most meningful outcome mesures of schizophreni, s it is closely connected to ptients perception of qulity of life (Dickerson et l., 1998 ). The ssocition between psychitric symptoms nd community functioning hs been studied extensively. Typiclly, smll to moderte negtive ssocitions re found between negtive symp toms nd community functioning (e.g., Milev et l., 2005 ). Another Correspondence nd reprint requests to: Mrieke Pijnenborg, Deprtment of Psychotic Disorders, GGZ Drenthe, Dennenweg 9, 9404 LA Assen, The Netherlnds. E-mil: series of studies hve demonstrted tht cognitive impirments hmper severl res of socil functioning, including community functioning (for review, see Green 1996 ), but the vrince ccounted for by cognition is usully smll (Holthusen, 2003 ; vn Beilen, 2004 ), even in combintion with mesures of psychitric symptomtology (Milev et l., 2005 ). Thus, besides generl cognition nd psychitric symptoms, other fctors must ccount for the vrince in community functioning in schizophreni. Fctor nlytic studies (Nuechterlein et l., 2005 ) revel seven cognitive domins tht re relibly impired in schizophreni (speed of processing, ttention/vigilnce, working memory, verbl lerning, visul lerning, resoning nd problem solving, nd verbl comprehension). Recently, socil cognition hs been dded to this list. It hs been suggested tht socil cognition is ssocited with community functioning in schizophreni (for review, see Couture et l., 2006 ). Socil cognition is defined s mentl opertions 239

2 240 underlying socil interctions, which include the humn bility nd cpcity to perceive the intentions nd dispositions of others (Brothers, 1990 ). Two importnt spects of socil cognition re emotion perception nd Theory of Mind (ToM). Emotion perception is the bility to infer emotion from fcil expressions, vocl inflections, or combintion of both (Couture et l., 2006 ). ToM is defined s the bility to infer mentl sttes nd to understnd tht they cn be used to predict others behvior (Premck & Woodruff, 1978 ). Impirments in emotion perception nd ToM re found in mny schizophreni ptients (for review, see Brüne, 2005 nd Edwrds et l., 2002 ). Positive reltionships between emotion perception nd community functioning (Brekke et l., 2005 ; e.g., Kee et l., 2003 ), nd ToM nd community functioning (Pollice, et l., 2002 ; Zhu et l., 2007 ) hve been demonstrted severl times. ToM hs lso been ssocited with functioning in tretment milieu (Brüne, 2005b; Brüne et l ) nd roleplying (Pinkhm & Penn, 2006 ). Severl issues remin uncler from previous studies. First, to the best of our knowledge, no study hs included tests of both emotion perception nd ToM to predict community functioning. Therefore, the unique contribution of these functions together over nd bove the effect of generl cognition nd psychitric symptoms is unknown. Furthermore, it is not yet cler whether performnce in specific domins of community functioning is prticulrly poor in schizophreni ptients with impired socil cognition. Finlly, none of the previous studies exmined the reltionship between socil cognition nd community functioning in the control group. Therefore, it is uncler whether the processes tht re ssocited with poor community functioning in schizophreni re different from those in helthy controls. In clinicl prctice, these issues re especilly relevnt since clinicins re fced with the tremendous impct of schizophreni on community functioning nd other spects of socil functioning. To dte, insufficient clinicl indices re vilble to predict socil outcome. The min objective of the present study ws to exmine the predictive vlidity of mesures of socil cognition for community functioning. First, we hypothesized tht socil cognition (emotion perception nd ToM) would hve predictive vlue for community functioning in schizophreni tht goes beyond tht of psychitric symptoms nd generl cognition. Second, we hypothesized tht both emotion perception nd ToM ech would mke unique nd significnt contribution to the prediction of community functioning. Furthermore, we re interested in the vlue of tests of socil cognition for clinicl purposes. We exmined whether impired socil cognition ccording to norm scores bsed on controls tsk performnce is ssocited with poorer performnce in specific domins of community functioning. We hypothesized tht ptients with impired socil cognition would demonstrte significntly poorer performnce on ech domin of community functioning thn those who score within the norml rnge. G.H.M. Pijnenborg et l. Finlly, we re interested in whether cognitive functions tht underlie community functioning in schizophreni re different from cognitive functions ssocited with community functioning in control smple. Our third hypothesis is tht socil cognition would lso be relted to community functioning in helthy controls. MATERIALS AND METHODS Prticipnts Forty-six people (34 men nd 12 women) with dignosis of schizophreni ccording to Dignostic nd Sttisticl Mnul, 4th Edition (DSM IV) criteri (Americn Psychitric Assocition, 1994 ) were included. Dignoses were determined by using chrt informtion to check whether DSM IV criteri for schizophreni were met nd were confirmed by independent on-site psychitrists. Exclusion criteri were the existence of comorbid neurologicl pthology nd intelligence quotient (IQ) score <70 (which is considered the upper border of mentl retrdtion). Ptients men ge ws 27.4 ( SD = 7.7) yers. A scle (Verhge, 1983 ) rnging from 1 = primry school (6 yers of forml eduction) to 7 = university (16 yers of forml eduction) ws used to clssify the level of eduction; the men level of eduction ws 4.8 ( SD = 0.9). In this smple, the men number of psychotic episodes ws 2.1 (rnge 1 10, SD = 2.0), the men durtion of illness ws 7 ( SD = 8.5) yers, nd the men ge of onset ws 24.2 ( SD = 5.1) yers. Four ptients did not use ntipsychotic mediction t the time of ssessment, being firstepisode ptients not yet prescribed mediction. One ptient used clssic ntipsychotic mediction (hloperidol) nd 41 ptients used typicl ntipsychotic mediction (ripiprzol, n = 5; clozpine, n = 8; olnzpine, n = 12; quetipine, n = 1; nd risperidone, n = 15). Fifteen ptients were living independently, of whom nine received outptient cre nd six prticipted in rehbilittion progrm (Withr & Arends, 2002 ). Twenty-seven ptients lived temporrily in houses provided by the institution to fcilitte prticiption in rehbilittion progrm. One ptient lived in sheltered home. The remining 3 ptients were inptients. A group of 53 helthy controls (24 men nd 29 women) ws lso included. Exclusion criteri were history of psychitric disorders, comorbid neurologicl pthology, nd IQ <70. Ptients men ge ws 31.1 (rnge 18 53, SD 10.2) yers, nd men eduction level ws 6 ( SD = 0.6). Mterils Community functioning Community functioning ws ssessed with the Socil Functioning Scle (SFS; Birchwood, 1990 ). The scle is mesure of community functioning of individuls with schizophreni nd hs good psychometric properties; it hs proven to be relible nd vlid (SFS; Birchwood, 1990 ). The community functioning scle consists of seven subscles: socil enggement/withdrwl

3 Socil cognition nd community functioning in schizophreni 241 (time spent lone, initition of converstions, nd socil voidnce), interpersonl behvior (number of friends, whether the ptient hs prtner, nd qulity of communiction), independence competence (bility to perform skills necessry for independent living), independence performnce (performnce of skills necessry for independent living), recretion (enggement in rnge of common hobbies, interests etc.), prosocil behviour (enggement in rnge of common socil ctivities), nd employment (enggement in structured employment or structured progrm of dily ctivity). Community functioning ws rted by persons who were close to the ptients, s the SFS ssesses objective nd fctul informtion bout person s dily life (e.g., how often someone wshes the dishes). In ddition to the stndrd SFS subscles, number of other vribles were extrcted from this mesure. We constructed vrible clled work performnce, consisting of five-point scle rnging from hving job consistent with level of eduction or student to never hd job. This ws done becuse the SFS subscle employment lso includes informtion on subjective rtings of the subject being cpble of working, while we were interested in ctul job performnce only. Furthermore, we scored the number of friends nd whether ptients hd prtner. Higher scores on the SFS men better community functioning. Socil cognition Emotion perception mesures. Prosody tsk. To ssess the perception of uditory ffect, the prosody tsk (Pijnenborg et l., 2007 ) ws dministered. The prosody tsk consists of 16 udiotped sentences with neutrl content (e.g., The old cr drives through the streets of the cpitl nd The big plne flies over the trees of the rin forest ) nd eight ptterned syllble structures ( b b b b b b ). Sentences re pronounced with five different emotions (nger, fer, sdness, hppiness, nd surprise) nd in neutrl wy. Prticipnts were sked to identify the emotion; nswer ctegories were presented in multiple-choice formt. A totl score ws clculted by counting ll correct nswers. FEEST. The Fcil Expression of Emotions: Stimuli nd Test (Young et. l., 2002 ) requires prticipnts to identify emotions in pictures of fces. The test includes 60 pictures of six bsic emotions (nger, fer, sdness, hppiness, disgust, nd surprise) from the Ekmn nd Friesen ( 1976) series. Prticipnts were sked to identify the emotion: nswer ctegories were presented in multiple-choice formt. A totl score ws clculted by counting ll correct nswers. ToM mesure. Fux ps tsk, short version (Stone et l., 1998 ). Prticipnts were presented with 10 short stories, red loud by the experimenter. Five of these stories contined fux ps. A fux ps implies n embrrssing or wkwrd sitution tht occurs when someone sys something he or she should not hve sid, without relizing tht he or she should not sy it. After hering ech story, prticipnts were sked whether someone in the story sid something he should not hve sid (detection of fux ps) nd how the other person in the story my feel (empthy). The first question ssesses cognitive process/knowledge of socil rules, while the second question concerns empthic bilities. This tsk requires the representtion of two mentl sttes: tht of the person who mde the fux ps nd tht of the person who is hurt or embrrssed by it. The recognition of fux ps requires the bility to detect flse beliefs: one needs to relize tht the person who mkes the fux ps misses informtion to infer the mentl stte of the other chrcter in the story. The number of correctly detected fux ps nd the number of correctly nswered empthy questions (the totl score cross the five genuine fux ps stories) re counted, nd totl score is clculted for ech. Generl cognition A bttery of neuropsychologicl tests ws used to ssess overll intellectul bility, psychomotor speed, nd memory. All these res hve shown to be relted to community functioning in previous studies. To estimte generl intellectul bilities, we used the short version of the Groninger Intelligentietest (GIT; Luteijn & Brelds, 2004 ), n intelligence test tht is widely used in the Dutch lnguge re. The GIT hs good psychometric properties. The short GIT consists of five subtests: sptil bilities, rithmetic, verbl knowledge, verbl logicl resoning, nd word fluency I nd II. The totl IQ score ws used s the independent vrible. The 15 Words Test (Sn & Deelmn, 1986 ), Dutch modifiction of the Rey Auditory Verbl Lerning Test with good psychometric properties, ws used to ssess verbl memory. The totl number of words reproduced over five trils ws used s the independent vrible. Perceptul-motor speed nd speed of informtion processing were ssessed with the Tril Mking A, wheres the Tril Mking B ws used to ssess perceptul-motor speed, speed of informtion processing, nd mentl flexibility (Reitn, 1979 ). The independent vribles were the time needed on ech tsks. Psychopthology The Positive nd Negtive Symptom Scle (; Ky et l ) ws used to mesure psychopthology. Symptom clusters were bsed upon the model of Lindenmyer et l. ( 1994), which encompsses five psychitric symptom subscles: positive symptoms, negtive symptoms, disorgniztion, depression, nd excitement. Procedure All ptients were ssessed during their tretment t the Deprtment of Psychotic disorders of GGZ Drenthe in Assen, the Netherlnds. All ptients in the study gve their written informed consent for the use of their ssessment dt for reserch purposes. The conduct of the work reported in the

4 242 rticle is in line with the APA Ethicl Stndrds, nd the dt included in this rticle were obtined in complince with regultions of our institution. Ptients community functioning ws rted by nurse or in the cse of the outptients, spouse, close friend, or fmily member. Controls were recruited by dvertising in locl newspper. Their community functioning ws rted by close friend or fmily member. RESULTS Between-Group Differences The comprbility of the ptient nd control groups ws ssessed for ech demogrphic vrible. Ptients nd controls differed on relevnt demogrphic vribles (see Prticipnts ). The men ge in the control smple ws slightly higher thn tht of the ptients [ t = 2.04, p =.04; 95% confidence intervl (CI) [0.1, 7.4]], wheres the ptient group contined reltively more mles ( χ 2 = 8.3, p =.005; 95% CI [0.16, 0.52]). Therefore, ge nd gender were included s covrites in the between-group nlyses for the dependent mesures. To this end, univrite nlyses of covrince were performed for the mesures of cognition nd community functioning. After controlling for the effect of group differences in ge nd gender, sttisticlly significnt min effects for group (ptients vs. controls) were found on ech of the dependent mesures (with ptients performing worse thn controls; see Tble 1 ). Within-Group Correltions Person s correltion coefficients between community functioning, socil cognition, generl cognition, nd psychitric symptoms for ptients nd controls re shown in Tble 2. For ll ptients, ll mesures of socil cognition were significntly ssocited with community functioning. Moreover, community functioning ws lso significntly ssocited with G.H.M. Pijnenborg et l. ll mesures of generl cognition, except Tril Mking A, nd with the negtive symptom score. Significnt correltions existed between most of the independent vribles. On the contrry, in helthy controls, none of the mesures of socil cognition or generl cognition were ssocited with community functioning in helthy controls. Intercorreltions between mesures of socil cognition nd generl cognition were lso lower thn in the ptient smple. Given the smller vrince in test performnce in helthy controls, the low correltions between cognition nd community functioning for controls could be due to restriction of rnge effect. To exmine the ltter, we estimted for the control group correltions with correction for restriction of rnge between ll mesures of socil cognition, generl cognition, nd community functioning. If the difference in correltions between ptients nd controls could entirely be ttributed to restriction of rnge effect in the ltter, then restriction of rnge-corrected correltions of the controls re expected to be bout equl to the observed correltions of the ptients. In our smple, ech of the corrected correltions in the control group still ppered to be lower thn the observed correltions in the ptient group. This difference reched significnce for the correltions between detection of fux ps, FEEST, Tril Mking B, nd community functioning. Thus, for those mesures, observed correltions of the ptients were significntly lrger thn corrected correltions of the controls. This suggests tht the bsence of significnt correltions between community functioning nd (socil) cognitive mesures of controls is not just reflection of smller vrince in test performnce in controls. Regression Anlyses Given the bsence of significnt correltions in controls, we did not perform ny further nlyses on the predictive vlue of socil cognition nd generl cognition in this smple. For the ptient smple, we clculted Z scores for ech of the independent vribles nd clculted composite Z scores by Tble 1. Difference in test performnce between ptients nd controls Test Ptients, M (SD ) (n = 46) Controls, M (SD ) (n = 56) Min effect for group SFS totl (mximum score = 197) (21.5) (16.2) F (1,95) = FEEST (mximum score = 60) 46.2 (7.2) 50.2 (4.1) F (1,95) = 9.5 b FP empthy (mximum score = 5) 3.7 (1.4) 4.6 (0.8) F (1,95)1 = 9.7 b FP detected (mximum score = 5) 4.3 (1.2) 4.8 (0.4) F (1,95) = 7.2 b Prosody (mximum score = 24) 14.7 (3.0) 16.7 (2.1) F (1,95) = 15.2 GIT 90.2 (14.1) (13.5) F (1,95) = Words test (mximum score = 75) 41.9 (10.9) 52.1 (9.1) F (1,95) = 19.5 Tril A 32.1 (13.3) 28.4 (8.7) F (1,95) = 6.5 b Tril B 71.9 (37.7) 59.8 (29.9) F (1,95) = 6.8 b Note. SFS, totl score on the SFS (Birchwood et l., 1990 ); FP empthy, correct nswers on the empthy questionnire of the fux ps test (Stone et l., 1998 ); FP detected, number of correctly detected fux ps on the fux ps test (Stone et l., 1998 ); FEEST, correct nswers on the FEEST (Young et l., 2002 ); GIT, IQ bsed on the GIT (Luteijn nd Brelds, 2004 ); 15 WT, totl number of words encoded on the 15 Words Test (Sn nd Deelmn, 1986 ); tril A, time needed on the Tril Mking A (Reitn, 1979 ); tril B, time needed on the Tril Mking B. Difference is significnt t the.001 (one-tiled). bdifference is significnt t the.05 level (one-tiled).

5 Socil cognition nd community functioning in schizophreni 243 Tble 2. Person s correltions of community functioning, socil cognition, neuropsychologicl ssessment, nd psychopthology in the schizophreni ptient smple (correltions in the control smple re in itlics) SFS FP empthy FP detected FEEST Pros GIT 15 WT Tril A Tril B positive negtive disorgniztion excitement depression SFS b FP empthy b FP detected b b FEEST b Pros 1.36 b.29 b.13.29b b GIT b WT 1.35b b.35 b Tril A Tril B b positive negtive disorgniztion 1.16 excitement depression 1 Note. SFS, totl score on the SFS (Birchwood et l., 1990 ); FP empthy, correct nswers on the empthy questionnire of the fux ps test (Stone et l., 1998 ); FP detected, number of correctly detected fux ps on the fux ps test (Stone et l., 1998 ); FEEST, correct nswers on the FEEST (Young et l., 2002 ); Pros, number of correct nswers on the prosody tsk (Pijnenborg et l., 2007 ) GIT, IQ bsed on the GIT (Luteijn nd Brelds, 2004 ); 15 WT, totl number of words encoded on the 15 Words Test (Sn nd Deelmn, 1986 ); tril A, time needed on the Tril Mking A (Reitn, 1979 ); tril B, time needed on the Tril Mking B (Reitn, 1979 ); positive, score on the positive subscle of the ; negtive, score on the negtive subscle of the ; disorgniztion, score on the disorgniztion subscle of the ; excitement, score on the excitement subscle of the ; depression, score on the depression subscle of the (Lindenmyer et l., 1994 ). Correltion is significnt t the.001 (one-tiled). bcorreltion is significnt t the.05 level (one-tiled). summing mesures of ToM, emotion perception, generl cognition, nd psychitric symptoms. Subsequently, ToM nd emotion perception were entered simultneously into regression eqution, with community functioning s the dependent vrible. The overll reltionship of the model ws significnt, F (2,43) = 10.4, p <.01. This model explined 33% of the vrince in community functioning. ToM ws the strongest nd only significnt predictor of community functioning ( B = 5.0, p <.05, 95% CI [1.2, 8.8]). The regression weight for emotion perception ws 3.0 [not significnt (ns), 95% CI [ 0.8, 6.9]]. When generl cognition nd psychitric symptoms were entered into the model, the overll reltionship remined significnt, F (2,43) = 6.2, p <.01. This model explined 38% of the vrince in community functioning; however, the prediction of community functioning ws not significntly better thn tht on the bsis of ToM nd emotion perception only ( F chnge = 1.7, ns). Furthermore, none of the B vlue in this model ppered to be significnt (ToM: B = 3.7, ns, 95% CI [ 0.6, 8.1]; emotion perception: B = 1.6, ns, 95% CI [ 2.5, 5.9]; generl cognition: B = 2.0, ns, 95% CI [ 0.7, 4.7]; psychitric symptoms: B = 1.4, ns, 95% CI [ 4.8, 2.0]). This is due to the reltively high correltions between the independent vribles. To ssess the strength of the unique reltionship of ech of the independent vribles with community functioning, the semiprtil correltions between ech of the independent vribles nd community functioning were inspected. ToM hd the highest semiprtil correltion with community functioning ( r =.21), nd semiprtil correltions with emotion perception, generl cognition, nd psychitric symptoms were lower ( r s =.10,.19, nd.10, respectively). Finlly, we exmined the contribution of fux ps detection nd empthy seprtely. When these vribles were entered into regression eqution together with emotion perception, none of them contributed significntly to the prediction of community functioning (fux ps detection: B = 5.9, ns, 95% CI [ 1.0, 12.9]; fux ps empthy: B = 4.3, ns, 95% CI [ 2.1, 10.7]; emotion perception: B = 2.9, ns, 95% CI [ 1.0, 6.9]). This cn be explined by the reltively lrge correltions between the independent vribles.

6 244 Impired Versus Unimpired Ptients For clinicl purpose, we were interested in whether impired socil cognition ccording to norm scores bsed on current clinicl stndrds would differentite between ptients on different spects of community functioning. To identify fctors of community functioning, we performed principl component nlysis with vrimx rottion on the seven SFS subscles to estblish whether seprble fctors in community functioning could be distinguished. This resulted in three fctors with eigenvlues greter thn 1. These fctors together ccounted for 70% of the vrince in community functioning (see Tble 3 for fctor lodings). The strongest lodings on the first fctor were withdrwl, interpersonl behviour, recretion, nd prosocil behviour; on the second fctor were independence performnce, independence competence, nd recretion; nd on the third fctor ws employment. We lbeled these three fctors socil ctivities, independent living, nd work performnce, respectively. Subsequently, we clculted decile scores from the helthy control smple for ech of the mesures of socil cognition. Ptients who scored within the first decile (impired performnce ccording to clinicl stndrds) on more thn one of the four mesures of socil cognition were considered to hve n impirment in socil cognition. Bsed on this rting, the ptient smple ws divided into two groups: impired ( n = 22) nd unimpired ( n = 24) (see Tble 4 for demogrphic nd cognitive vribles of both subgroups). Ptients in the impired subgroup were reltively younger nd experienced less psychotic episodes. As ws to be expected given the significnt correltions between generl cognition, symptoms, nd socil cognition in our study, ptients with poor socil cognition lso performed significntly poorer on the GIT nd 15 Words Test nd scored higher on the disorgniztion subscle of the. Tble 5 provides summry of group comprisons on relevnt outcome mesures. Unimpired ptients scored significntly higher thn impired ptients on SFS totl, SFS fctors independent living, nd number of friends. Unimpired ptients lso scored better on socil ctivities nd work/work performnce, but this difference did not rech significnce. Although unimpired ptients scored better thn impired ptients, they still performed significntly worse thn helthy controls on ll mesures. DISCUSSION G.H.M. Pijnenborg et l. Socil cognition ws s better predictor of community functioning in schizophreni thn either generl cognition or negtive symptoms together. Furthermore, the vrince tht ws explined by symptoms nd generl cognition overlpped lmost entirely with the vrince explined by socil cognition. This mens tht generl cognition nd psychitric symptoms mde no unique contribution to the prediction of community functioning when socil cognition ws included s predictor. By contrst, with regrd to our second hypothesis tht emotion perception nd ToM would both mke n independent significnt contribution to prediction of community functioning, we found tht emotion perception did not mke significnt independent contribution to vrince in community functioning once ToM hs been ccounted for. Thus, ToM emerged s the best predictor of community functioning in schizophreni. The mount of vrince in outcome tht is explined by socil cognition in our study is somewht smller thn tht in studies where wrd functioning (Brüne, 2005b) or roleplying (Pinkhm & Penn, 2006 ) ws used s n outcome mesure. This my be becuse behviorl demnds in complex dily life situtions re lrger thn those in more structured wrds or role-ply situtions. Therefore, specific fctors such s personlity nd motivtion my hve been more importnt in our study. Nevertheless, the effect size observed ws very lrge, t lest in Cohen s ( 1988) terms, suggesting tht robust reltionship exists between performnce on mesures of socil cognition (prticulrly ToM) nd everydy functioning in the community. For clinicl purposes, it is relevnt to exmine whether ptients with impired socil cognition ccording to norm scores bsed on controls performnce indeed show poorer community functioning. Therefore, our third hypothesis ws tht ptients with impired socil cognition would show poorer community functioning thn unimpired ptients. Overll, ptients with impired socil cognition showed significntly poorer community functioning. Ptients with impirments in socil cognition were older nd hd experienced more psychotic episodes. Moreover, they performed more poorly on tests of intelligence nd memory nd hd more symptoms of disorgniztion. When different components of community functioning were exmined seprtely, the difference between impired nd unimpired ptients ws significnt for independent living skills. The independent living scle ssesses the bility to perform skills necessry for independent living Tble 3. Fctor lodings for principl components nlysis of SFS subscles(lodings >.4 re indicted in boldfce) Fctor 1 (socil ctivities) Fctor 2 (independent living) Fctor 3 (work) SFS withdrwl SFS interpersonl behvior SFS independence/performnce SFS independence/competence SFS recretion SFS prosocil behvior SFS employment

7 Socil cognition nd community functioning in schizophreni 245 Tble 4. Difference between impired nd unimpired ptients in demogrphicl vribles, generl cognition, nd symptoms Ptients impired ( n = 22) Ptients unimpired ( n = 24) 95% CI of the difference of impired versus unimpired ptients Age M = 29.95, SD = 9.3 M = 25.0, SD = 5.1 [0.6, 9.4] Gender (chi-squre) Proportion men = 0.8 Proportion men = 0.7 [ 0.9, 0.4] Episodes M = 2.8, SD = 2.6 M = 1.6, SD = 0.9 [0.1, 2.5] GIT IQ M = 81.0, SD = 7.3 M = 98.0, SD = 13.8 [ 24.1, 10.8] 15 WT M = 37.8, SD = 10.7 M = 45.6, SD = 10.1 [ 13.9, 1.6] Tril Mking A M = 35.1, SD = 15.3 M = 30.3, SD = 10.9 [ 3.0, 12.7] Tril Mking B M = 83.05, SD = 9.1 M = 61.5, SD = 6.1 [ 0.3, 43.2] positive M = 8.2, SD = 3.5 M = 7.2, SD = 3.0 [ 0.9, 3.0] negtive M = 15.3, SD = 5.2 M = 12.8, SD = 3.8 [ 0.3, 5.1] disorgniztion M = 9.0, SD = 3.0 M = 6.8, SD = 1.8 [.7, 3.6] excitement M = 6.5, SD = 1.9 M = 6.4, SD = 2.0 [ 1.0, 1.3] depression M = 10.2, SD = 3.1 M = 10.6, SD = 3.5 [ 3.4, 1.6] Note. Dt re men (M ), stndrd devition ( SD ), nd 95% CI of differences between impired nd unimpired ptients. Significnt t the.05 level (one-tiled). bsignificnt t the.001 level (one-tiled). such s wshing, grooming, clening, cooking, shopping, nd budgeting. An ssocition with socil cognition nd independent living bilities is consistent with erlier studies: emotion perception is relted to personl ppernce nd hygiene (Mueser et l., 1996 ), netness on inptient wrd (Penn et l., 1996 ), pproprite clothing nd ppernce (Poole et l., 2000 ), nd self-cre skills (Kee et l., 2003 ). Kee et l. ( 2003) rgue tht the skills needed for independent living require the sme informtion-processing skills nd tsk-oriented requirements s emotion perception. Alterntively, we propose tht impired ptients my not process the socil context effectively. Therefore, they will not experience feedbck from nonverbl socil cues. For exmple, in the cse of ToM impirments, motivtion for household tsks my be lcking if someone is not ble to infer the mentl sttes of his roommtes (e.g., their being nnoyed by his dirty room). Contrry to our expecttions, the difference between impired nd unimpired ptients did not rech significnce with regrd to work, number of friends, hving prtner, nd socil ctivities. The fct tht substntil number of ptients were Tble 5. SFS totl nd subscles, number of friends, number of people with prtner, nd work performnce Test Ptients impired ( n = 22) Ptients unimpired ( n = 24) Controls ( n = 53) 95% CI of the difference of impired versus unimpired ptients 95% CI of the difference unimpired ptients versus controls SFS totl M = 103 (64 156, SD = 22.9) SFS fctor 1 (socil M = 44.0 (22 78, ctivities) SD = 15.1) SFS fctor 2 M = 53.1 (30 73, (independent SD = 11.0) living) SFS fctor 3 M = 5.5 (1 7, (work) SD = 2.2) Number of friends M =.7 (0 4, SD = 1.2) Work performncec M = 3.68 (1 5, M = 118 (91 159; SD = 17.8) M = 50.3 (27 86; SD = 16.0) M = 62.0 (46 74; SD = 7.9) M = 156 ( ; SD = 16.2) M = 75.2 (44 102; SD = 13.3) M = 72.1 (6 78; SD = 4.8) [ 27, 2.9] [ 46.5, 30.12] [ 2.9, 15.6] [ 32.0, 18.1 ] [3.2, 14.5] [ 13.1, 7.3] M = 6.0 (1 9; SD = 2.3) M = 9.1 (2 10; SD = 1.9) [ 0.79, 1.88 ] [ 21.1, 8.1] M = 1.5 (0 4; M = 6 (1 20; [ 5.0, 0.05]b [ 6.1, 3.5] SD = 1.4) SD = 4.2) M = 3.79 (2 5; M = 1.6 (1 4; [ 0.32,.60] [1.6, 2.8] SD = 1.1) SD = 1.3) SD = 1.2) Prtner n = 3 n = 2 n = 26 [ 0.01,.24] [ 0.56, 0.20] p =.14 p =.08 p =.49 Note. men (M ), stndrd devition ( SD ), rnge (R), nd 95% CI of differences between impired nd unimpired ptients, nd unimpired ptients nd controls Significnt t the.001 level (one-tiled). bsignificnt t the.05 level (one-tiled). c 1 = job consistent with level of eduction or student, 2 = job below expecttions bsed on level of eduction, 3 = hd job consistent with level of eduction, currently no job, 4 = hd job below expecttions bsed on level of eduction, currently no job, 5 = never hd job.

8 246 prticipting in rehbilittion progrm my hve plyed role here. In this regrd, Brekke et l. ( 2007) investigted whether intensity of rehbilittion progrm modertes the reltionship between socil cognition nd outcome. The uthors found tht so cil cognition ws predictive of tretment success nd tht the influence of socil cognition on rehbilittive chnge incresed t trend level s the dys of tretment decresed. Results suggest tht n intensive tretment compenstes for the effects of impired socil cognition on rehbilittive chnge. Our findings my be interpreted in the sme vein: for exmple, by prcticing job skills in sheltered jobs with job coching, the ssocition between socil cognition nd work performnce my decrese s prctice compenstes for socil cognition impirments. In ddition, some ptients my not hve hd job nor were they looking for one becuse they were ttending dily trining sessions nd did not hve enough time to work. Also, prticipting in rehbilittion progrm my enhnce the number of socil ctivities, regrdless of ptient s cognitive cpcities. Stronger ssocitions between socil cognition nd work/socil ctivities re to be expected in smples of ptients who receive less intensive tretment. It should be noted tht even ptients with unimpired socil cognition showed much poorer community functioning thn controls. This illustrtes clerly tht fctors other thn socil cognition lso severely hmper community functioning in schizophreni. As to our finl hypothesis, we did not find the expected ssocition between socil nd generl cognition nd outcome in helthy controls. It ppered tht this finding is not simply cused by methodologicl issues, such s ceiling effect or restriction of rnge effect. Severl possible explntions rise here. It my be tht helthy controls will hve enough spre cognitive bilities to compenste in cse of impired socil cognition. This phenomenon hs lso been demonstrted in utism (Klin, 2000 ). A second possibility is tht socil cognition is only ssocited with community functioning when bilities re below certin criticl limit. If socil cognition is bove this level, n individul hs the necessry cognitive prerequisites for dptive community functioning nd performnce will depend upon other fctors. Finlly, specific perceptul bises in socil cognition in schizophreni, for exmple, the tendency to perceive more negtive ffect in neutrl fces (Kohler et l., 2003 ) my ccount for the ssocition between socil cognition nd community functioning. These ides wrrnt more elbortion in future studies. The present study hs number of limittions. First, we did not control for the effect of ntipsychotic mediction. We expect this did not seriously ffect our results s Sergi et l. ( 2007) recently showed no effect of ntipsychotic mediction on socil cognition in schizophreni. Second, there is gender imblnce between ptients nd controls, with men being overrepresented in the ptient smple. Third, the number of tests of generl cognition ws limited, which my hve bised the results in fvor of the predictive vlidity of ToM. Finlly, since our study concerns cross-sectionl dt, cuslity is questionble. Bsed on our results, we provide number of recommendtions for clinicl prctice. First, for reserch purposes, G.H.M. Pijnenborg et l. stndrd test bttery to ssess cognition in schizophreni hs recently been proposed (Nuechterlein et l., 2008). This bttery covers cognitive domins tht re often impired in schizophreni (Nuechterlein et l., 2004). With regrd to socil cognition, the committee hs recommend two tests of the MSCEIT bttery (Myer et l., 2002 ). These tests ssess emotion perception nd mngement. Our findings demonstrte tht ToM predicts community functioning even better thn emotion perception. Thus, when clinicins im to predict outcome in dily life in schizophreni for individul ptients, we dvise them ssess ToM bilities in their test bttery. Second, t group level, socil cognition is better predictor of community functioning thn generl cognition nd psychitric symptoms combined. One potentil impliction of this is tht tests of socil cognition could replce tests of generl cognition nd psychitric symptoms for the purpose of individul ssessment. However, this would be in pproprite. Neuropsychologicl ssessment involves creful observtion nd collection of dt tht is tken into ccount to mke n individulized prediction of outcome, nd the reltionship between test performnce nd functioning in dily life is potentilly much stronger in individul cses thn t group level. Third, clinicins should ber in mind tht n ssocition between socil cognition nd community functioning ws only found in ptients nd not in controls. Bsed on this finding, we discussed fctors tht my medite the reltionship between socil cognition nd community functioning, such s compenstion by generl cognition nd illness-relted perceptul bises in socil cognition. To identify these fctors in individul ptients, the necessity of crefully documented observtions of individul test performnce is stressed. ACKNOWLEDGEMENTS This project received finncil support from the Foundtion de Open Ankh, Foundtion Dienstbetoon Gezondheidszorg, PO Box 142, 3769 ZJ, Soesterberg nd ZONMW, PO Box , 2509 AE, Den Hg. The uthors grtefully cknowledge Jikkelies Spoelmn for her help in collecting the dt. The uthors hve no finncil or other reltionships tht could be interpreted s conflict of interest ffecting this rticle. REFERENCES Americn Psychitric Assocition. (1994 ). Dignostic nd Sttisticl Mnul of Mentl Disorders (4th ed. ). Wshington, DC : Americn Psychitric Assocition. Birchwood, M., Smith, J., Cochrne, R., Wetton, S., & Copestke, S. (1990 ). The Socil Functioning Scle: The development nd vlidtion of new scle of socil djustment for use in fmily intervention progrmmes with schizophrenic ptients. 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9 Socil cognition nd community functioning in schizophreni 247 Brothers, L. (1990 ). The socil brin: A project for integrting primte behviour nd neurophysiology in new domin. Concepts in Neuroscience, 1, 28. Brüne, M., Abdel-Hmid, M., Lehmkmper, C., & Sonttg, C. ( 2007 ). Mentl stte ttribution, neurocognitive functioning, nd psychopthology: Wht predicts poor socil competence in schizophreni best? Schizophreni Reserch, 92, Brüne, M. (2005b ). Emotion recognition, theory of mind, nd socil behvior in schizophreni. Psychitry Reserch B, 133, Brüne, M. (2005 ). Theory of mind in schizophreni: A review of the literture. Schizophreni Bulletin, 31, Cohen, J. (1988 ). Sttisticl power nlysis for the behviourl sciences (2nd ed. ). Phildelphi, PA : Lwrence Erlbum Assocites. Couture, S.M., Penn, D.L., & Roberts, D.L. (2006 ). The functionl significnce of socil cognition in schizophreni: A review. Schizophreni Bulletin, 32 (Suppl), S44 S63. Dickerson, F.B., Ringel, N.B., & Prente, F. (1998 ). Subjective qulity of life in out-ptients with schizophreni: Clinicl nd utiliztion correltes. Act Psychitric Scndinvi, 98 (2 ), Edwrds, J., Jckson, H.J., & Pttison, P.E. (2002 ). Emotion recognition vi fcil expression nd ffective prosody in schizophreni. Clinicl Psychology Review, 22 (6 ), Ekmn, P. & Friesen, W.V. (1976 ). Pictures of fcil ffect series. Plo Alto, CA : Consulting Psychologists Press. Green, M.F. (1996 ). Wht re the functionl consequences of neurocognitive deficits in schizophreni? Americn Journl of Psychitry, 153, Holthusen, E.A.E. (2003 ). Does cognition predict outcome nd course of illness in schizophreni? Schizophreni Reserch, 53, Ky, S.R., Fishbein, A., & Opler, L.A. (1987 ). The Positive nd Negtive Syndrome Scle () for schizophreni. Schizophreni Bulletin, 13, Kee, K.S., Green, M.F., Mintz, J., & Brekke, J.S. (2003 ). Is emotion processing predictor of outcome in schizophreni? Schizophreni Bulletin, 29, Klin, A. (2000 ). 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Predictive vlue of neurocognition nd negtive symptoms on functionl outcome in schizophreni: A longitudinl first episode study with 7 yers follow-up. Americn Journl of Psychitry, 162, Mueser, K.T., Doonn, R., Penn, D.L., Blnchrd, J.J., Bellck, A.S., Nishith, P., & Deleon, J. (1996 ). Emotion recognition nd socil competence in chronic schizophreni. Journl of Abnorml Psychology, 105, Nuechterlein, K.H., Brch, D.M., Gold, J.M., Goldberg, T.E., Green, M.F., & Heton, R.K. (2004 ). Identifiction of seprble cognitive fctors in schizophreni. Schizophreni Reserch, 72 (1 ), Nuechterlein, K.H., Green, M.F., Kern, R.S., Bde, L.E., Brch, D.M., Cohen, J.D., Essock, S., Fenton, W.S., Frese III, F.J., Gold, J.M., Goldberg, T., Heton, R.K., Keefe, R.S.E., Kremer, H., Mesholm-Gtely, R., Seidmn, L.J., Stover, E., Weinberger, D.R., Young, A.S., Zlcmn, S.M.D., & Mrder, S.R. ( 2008 ). The MATRICS Consensus Cognitive Bttery, Prt1: Test selection, relibility, nd vlidity. Americn Journl of Psychitry, 165 ( 2 ), Nuechterlein, K.H., Robbins, T.W., & Eint, H. (2005 ). Distinguishing seprble domins of cognition in humn nd niml studies: Wht seprtions re optiml for trgeting interventions? A summry of recommendtions from brek out group 2 t the mesurement nd tretment reserch to improve cognition in schizophreni new pproches conference. Schizophreni Bulletin, 31 (4 ), Penn, D.L., Spulding, W., Reed, D., & Sullivn, M. (1996 ). The reltionship of socil cognition to wrd behvior in chronic schizophreni. Schizophreni Reserch, 20, Pijnenborg, G.H.M., Withr, F.K., vn den Bosch, R.J., & Brouwer, W.H. (2007 ). Impired perception of negtive emotionl prosody. The Clinicl Neuropsychologist, 52 (2 ), Pinkhm, A.E. & Penn, D.L. (2006 ). Neurocognitive nd socil cognitive predictors of interpersonl skill in schizophreni. Psychitry Reserch, 143 (2 3 ), Pollice, R., Roncone, R., Flloon, I.H.R., Mzz, M., de Risio, A., & Necozione, S. (2002 ). Is theory of mind in schizophreni more strongly ssocited with clinicl nd socil functioning thn with neurocognitive deficits. Psychopthology, 35, Poole, J.H., Tobis, F.C., & Vinogrdov, S. (2000 ). The functionl significnce of ffect recognition errors in schizophreni. Journl of the Interntionl Neuropsychologicl Society, 6, Premck, D. & Woodruff, G. (1978 ). Does the chimpnzee hve theory of mind? Behviorl Brin Science, 4, Reitn, R.M. (1979 ). Mnul of dministrtion of neuropsychologicl test btteries for dults nd children. Tucson, AZ : Neuropsychologicl Lbortory. Sn, R.J. & Deelmn, B.G. (1986 ). De 15-WoordenTests A (Mnul). Groningen, The Netherlnds : University of Groningen, Deprtment of Neuropsychology (Internl Publiction). Sergi, M.J., Green, M.F., Widmrk, C., Reist, C., Erhrt, S., Brff, D.L., Kee, K.S., Mrder, S.R., & Mintz, J. ( 2007 ). Socil cognition nd neurocognition: Effects of risperidone, olnzpine, nd hloperidol. Americn Journl of Psychitry, 164, Stone, V.E., Bron-Cohen, S., Clder, A.W., & Kene, J. (1998 ). Impirments in socil cognition following orbitofrontl or mygdl dmge. Society for Neuroscience Abstrcts, 24, vn Beilen, M. (2004 ). Mesuring executive functioning in schizophreni (Thesis disserttion ). Groningen, The Netherlnds : University of Groningen. Verhge, F. (1983 ). Het coderen vn het opleidingsniveu voor reserchdoeleinden (English trnsltion: Eductionl clssifiction system for reserch purposes: revised version). Groningen, The Netherlnds : University Medicl Center, Stte University Groningen (Internl Publiction). Withr, F.K. & Arends, J. (2002 ). Cognitive rehbilittion in schizophreni. In W.H. Brouwer, E. Vn Zomeren, I. Berg, A. Boum, & E. Hn (Eds.), Cognitive rehbilittion: A clinicl pproch, Amsterdm, The Netherlnds : Boom. Young, A.W., Perrett, D., Clder, A., Sprengelmeyer, R., & Ekmn, P. (2002 ). The fcil expressions of emotion: Stimuli nd test, mnul. Bury St., Edmunds, UK : Thmes Vlley Test Compny.

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