Part I : Literature Review
2.5 Associations between patients’ social functioning and their clinical, cognitive and nonverbal
Many studies have tried to identify associations between patients’ performance on social cognitive tests, symptoms and social functioning. One of the challenges in this area is the inconsistency in methods used to measure social functioning. All of these measures come under the umbrella term of ‘functional outcome’ (Couture, Penn, & Roberts, 2006; Green, 1996; Green, Kern, Braff, & Mintz, 2000) and fall into two main categories (1) Community outcome measures: Self, or other, rated assessments of patients’ global functional attainment in key areas of life such as occupational or educational attainment,
relationships with peers and family and level of social support (e.g. The objective social outcomes index (SIX) (Priebe, Watzke, Hansson, & Burns, 2008). (2) Social-skill assessments: Lab-based measures aimed at detecting specific social skills of receiving, processing and sending social cues. In such tests, a problem-solving task assesses patients’ receiving and processing skills. Patients watch short videos of social interactions, are asked to identify problems within these interactions and plan a course of action to deal with those problems. Patients then act out their solutions in a role-play task with a confederate. Patients’ ability to produce nonverbal cues (sending skills) is assessed separately during a role-play task. Patients’ behavioural features such as speech clarity and fluency, appropriateness of tone, facial expression of affect, posture, gesture, and eye gaze are rated by an independent observer. An example of this type of measure is the assessment of Interpersonal Problem Solving Skills (AIPSS) (Donahoe, Carter, Bloem, Hirsch, & et. al., 1990). Other forms of the social skills test use only the role-play task, assessing only sending skills as an indicator of functional outcome (e.g. conversation probe (CP)).
The method used to assess functional outcome must be kept in mind when identifying an association between patients’ social cognitive performance and their social functioning. The receiving and processing skills assessed in social skills measures displays some similarity with assessments of social perception, e.g. the SCRT. In both measures, patients are asked to watch a short clip of an interaction and then answer questions based on what they have just watched. The ability to perceive and process social information is being assessed in both tasks, using similar methodology. Shared method variance may play a role in artificially inflating an association between these two measures (Ihnen, Penn, Corrigan, & Martin, 1998). The final part of the social skills measures assesses patients’ ability to send social information during a, sometimes scripted, role-play task with one other individual. Although this is not a natural interaction and should not be treated as such, it demonstrates patients’ repertoire of verbal and nonverbal behaviour, which are the tools they will be using in their encounters with others. Community functioning measures reflect patients’ global functioning in real world terms and can be used as an indicator of how well they are functioning in society. With this in mind, the findings of such studies revealed that patients’ performance on measures of affect perception have been associated with poorer occupational functioning, social
functioning, interpersonal relationships and community participation (Brekke, Nakagami, Kee, & Green, 2005; Kee, Horan, Mintz, & Green, 2004; Poole, Tobias, & Vinogradov, 2000). Impaired affect recognition was also predictive of impaired social functioning using role-play tasks (Ihnen, Penn, Corrigan, & Martin, 1998; Pinkham & Penn, 2006)
Poor performance on assessments of social perception was predictive of impaired social behaviour in the milieu for inpatients (Appelo et al., 1992; Ihnen, Penn, Corrigan, & Martin, 1998), community functioning (Kim, Doop, Blake, & Park, 2005; Sergi & Green, 2003; Vauth, Rusch, Wirtz, & Corrigan, 2004) and quality of life for out-patients (Addington, Saeedi, & Addington, 2006). Lab-based measures of functional outcome were also associated with social cue perception (Addington, Saeedi, & Addington, 2006; Corrigan & Toomey, 1995; Toomey, Wallace, Corrigan, Schuldberg, & Green, 1997). However, using the role-play task as a measure of functional outcome (i.e. measure of sending skill) saw a weak or absent association (Ihnen, Penn, Corrigan, & Martin, 1998).
Impaired performance on assessments of theory of mind were associated with reduced premorbid social functioning (Schenkel, Spaulding, & Silverstein, 2005) and reduced community functioning (Bora, Eryavuz, Kayahan, Sungu, & Veznedaroglu, 2006; Brune, 2005; Roncone et al., 2002). Few studies have investigated the association between nonverbal behaviour and social functioning, however, reduced pro-social facial expressions have been found to be associated with reduced social functioning, occupational functioning and poor prognosis (Troisi, Pompili, Binello, & Sterpone, 2007).
2.5.1 Association between patients’ symptoms and social cognition
Research suggests that poorer performance on assessments of affect and social perception was seen in patients with more negative symptoms (Mueser, Bellack, Douglas, & Wade, 1991; Schneider, Gurb, Gurb, & Shtasel, 1995; Strauss, Jetha, Ross, Duke, & Allen, 2010) and those in the acute phase of the disorder (Mueser et al., 1996; Revheim & Medalia, 2004). However, patients with more paranoid symptoms perform better than those without paranoid symptoms (Lewis & Garver; Nelson, Combs, Penn, &
Basso, 2007; Toomey, Schuldberg, Corrigan, & Green, 2002). Negative, positive symptoms and disorganised symptoms also showed an association with poor performance on theory of mind tasks (Frith & Corcoran, 1996; Pickup & Frith, 2001; Sprong, Schothorst, Vos, Hox, & van Engeland, 2007). However, there is mixed evidence for remitted patients, with some studies reporting no impairment in these patients (Frith & Corcoran, 1996) and others reporting significant impairment (Herold, Tényi, Lénárd, & Trixler, 2002).
2.5.2 Association between patients’ symptoms and their nonverbal behaviour
The findings regarding associations between nonverbal behaviour and symptoms have been contradicotry, with some studies reporting no association with patients’ symptoms (Gaebel & Wolwer, 2004; Troisi, Spalletta, & Pasini, 1998), and others reporting an association between reduced nonverbal beahviour and greater negative symptoms (Brüne et al., 2008). Patients with symptoms of thought disorder have also showed more grooming behaviour during social interaction (Fairbanks, McGuire, & Harris, 1982).