Contemporary Perspectives in Schizophrenia Care
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Dr. Green VO: The introduction of antipsychotic medications in the 1950s was a game-changer for schizophrenia in some ways, but not in all ways. These medications were very good at reducing the psychotic symptoms, but they weren’t helpful for community integration. So, this raised the question, like: “If controlling symptoms isn’t helping people go back into the community, to establish connections to friends or family, or go back to work, what is holding these individuals back?” What we’ve learned since then is that it’s very important to pay attention to how we process social information, which is called social cognition. What I mean is how we understand emotion and faces, how we understand what other people are thinking or feeling. One can imagine what it would be like if you didn’t have these social cognitive abilities. You wouldn’t know, in looking at your mom’s face, if she loved you. You wouldn’t know for sure if your boss was angry at you. You’d have trouble interpreting how your friends are excited or not excited to see you. What we’re finding out now is that we understand increasingly the brain basis for this social dysfunction. So, we can refer to the regions of the brain that are active when we’re identifying emotions or when we’re mentalizing and making inferences about other people. Relatively simple social cognitive problems can lead to significant problems in relationships. So, the next question is an obvious one. How do we take our deep understanding of these processes to develop better interventions for social cognitive deficits? There is a history of psychosocial interventions for schizophrenia. They started out kind of simple and behavioral, like training individuals to make eye contact or to nod in a natural and reciprocal way. And that worked well enough for what it was, but it doesn’t take care of the root problem, which is that these individuals, are still having trouble understanding social information. Modern interventions enhance their ability to understand their social world, and thereby act on it in a more successful manner. And that’s where social cognitive remediation and training is going now. The studies so far have shown encouraging efficacy. We’re able to improve endpoints such as emotional intelligence, face-affect perceptions, social perception, and mentalizing. The reason why we’re so enthusiastic is because we know that social cognition is one of the reasons why patients have trouble with community integration and social functioning. So, it’s an effort to get at the heart of the problem. Schizophrenia is still a serious diagnosis, and it’s a long haul for the individuals and their families. But with these types of interventions that are focused on recovery, it brings some hope to this illness.


Social Cognition Rising

Explore the Clinical Insights Behind the Episode

Social Cognition Plays a Critical Role in Functional Recovery

Cognition studies in schizophrenia have historically focused on nonsocial forms of cognition, specifically neurocognition. However, the last 15 to 20 years have seen a shift toward improving social cognition as a means to facilitating greater psychosocial functioning. The data support this development. In a 2011 meta-analysis, social cognition accounted for approximately 16% of patients’ changes in community functioning, while nonsocial cognition (ie, neurocognition) accounted for only 6%.1-3

Michael Foster Green, PhD, Social Cognition Expert

People Thinking About People

At its most basic level, social cognition is people thinking about people. Dr. Michael F. Green, a leading expert on social cognition, defines it in more clinical terms as the psychological processes involved with the perception, encoding, storage, retrieval, and regulation of information about other people and ourselves.1,4

Dr. Green and his lab have led the way in identifying and evaluating the cognitive processes involved in social functioning. In addition to the widely accepted perceptual and nonsocial cognitive domains, there are 4 social cognitive domains that play a key role in a patient’s ability to successfully navigate their social environment.1

Social Cognitive Domains1

In addition to the widely accepted perceptual and nonsocial cognitive domains, Dr. Green has identified 4 key domains of social cognition in schizophrenia.

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Emotion processing

Ability to effectively identify emotions (eg, facial expressions) in others and manage one’s own emotions


Being able to determine whether your boss is angry at you by looking at their face

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Ability to identify social roles, rules, and context from nonverbal cues, including body language, prosody, and social schema knowledge


Figuring out the relationship between two people based on a brief sample of conversation

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Attributional bias/style

Ability to appropriately explain the causes and make sense of social events or interactions


Jumping to the conclusion that you are in danger when you feel fearful

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Ability to represent the mental states of others and make inferences about their intentions and beliefs


Being able to take another person’s perspective during a conversation

I want someone to get better at not just facing another person, but identifying the emotion in the face that they’re looking at, or to make more realistic inferences about what someone might be thinking or feeling.”


Treating the Cause, Not the Symptom

Can a deeper understanding of the social cognitive deficits that characterize schizophrenia lead to psychosocial interventions to better address them? Dr. Green believes that it can. His lab is studying computerized, neuroplasticity-based interventions that target the impaired brain systems underlying social cognition rather than just the impaired social behaviors. And the early results of these potentially highly scalable interventions are encouraging. Studies have demonstrated significant improvements in tests that measure emotional intelligence, social perception, facial affect recognition, and mentalizing—all social cognitive processes that might help individuals regain function and become contributing members of the community.5,6

Recent Guidelines Give Cognitive Status New Importance

With the recent inclusion of cognitive impairment in the ICD-11 diagnostic guidelines for schizophrenia, cognition has risen in importance as a qualifier for identifying and prognosticating the disease. This has sent a clear message to practicing healthcare professionals about the need to understand and identify social and nonsocial cognitive impairments at diagnosis, and how these deficits can impact treatment decisions.1

As the clinical community continues to progress in its understanding of schizophrenia’s impact on social cognition, it’s clear that symptom management is only the beginning of disease management. A focus must also be placed on psychosocial rehabilitation to help improve patient well-being and instill hope for all those who struggle.7

References: 1. Green MF, Horan WP, Lee J. Nonsocial and social cognition in schizophrenia: current evidence and future directions. World Psychiatry. 2019;18(2):146-161. 2. Green MF, Llerena K, Kern RS. The “right stuff” revisited: what have we learned about the determinants of daily functioning in schizophrenia? Schizophr Bull. 2015;41(4):781-785. 3. Fett AK, Viechtbauer W, Dominguez MD, Penn DL, van Os J, Krabbendam L. The relationship between neurocognition and social cognition with functional outcomes in schizophrenia: a meta-analysis. Neurosci Biobehav Rev. 2011;35(3):573-588. 4. Green MF, Olivier B, Crawley JN, Penn DL, Silverstein S. Social cognition in schizophrenia: recommendations from the measurement and treatment research to improve cognition in schizophrenia new approaches conference. Schizophr Bull. 2005;31(4):882-887. 5. Nahum M, Fisher M, Loewy R, et al. A novel, online social cognitive training program for young adults with schizophrenia: a pilot study. Schizophr Res Cogn. 2014;1(1):e11-e19. 6. Nahum M, Lee H, Fisher M, et al. Online social cognition training in schizophrenia: a double-blind, randomized, controlled multi-site clinical trial. Schizophr Bull. Published July 2, 2020. Accessed December 10, 2020. 7. Green M, Harvey PD. Cognition in schizophrenia: past, present, and future. Schizophr Res Cogn. 2014;1(1):e1-e9.

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