|Year : 2020 | Volume
| Issue : 2 | Page : 102-113
Social cognition: Concept, evaluation, and application in psychiatry
Kartik Singhai, Pooja Patnaik Kuppili, Jitender Aneja
Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
|Date of Submission||12-Aug-2019|
|Date of Acceptance||22-Oct-2019|
|Date of Web Publication||27-Jun-2020|
Dr. Jitender Aneja
Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan - 342 005
Source of Support: None, Conflict of Interest: None
Social cognition (SC) serves an interface between psychology and cognitive neuroscience and its conceptualization has evolved over years. SC broadly refers to a process of encoding and decoding the social information, i.e., how a person thinks about himself/herself and others in his/her social world. The refinement of various constructs of SC as well as the assessment tools has contributed to its better understanding and application in psychiatry. At present, major research groups in this field have agreed on that emotion perception, social perception, theory of mind, and attributional style to be the key domains of SC. A marked growth of evidence for the deficits in SC in various psychiatric disorders has led to the development of a plethora of evaluation tools. Although it has been largely studied in schizophrenia and autism spectrum disorders, lately, an increasing number of researches have been conducted in other psychiatric as well as neurological disorders. Consequent to the evidence of deficits in various domains of SC in psychiatric disorders, a number of targeted interventions have been devised. This article provides an overview of the evolution of concept, definition, and domains of SC, its evaluation, and application in psychiatry.
Keywords: Application, concept, measurement, mental disorders, psychiatry, social cognition
|How to cite this article:|
Singhai K, Kuppili PP, Aneja J. Social cognition: Concept, evaluation, and application in psychiatry. Indian J Soc Psychiatry 2020;36:102-13
|How to cite this URL:|
Singhai K, Kuppili PP, Aneja J. Social cognition: Concept, evaluation, and application in psychiatry. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Oct 1];36:102-13. Available from: http://www.indjsp.org/text.asp?2020/36/2/102/288115
| Introduction|| |
The enigma of human thinking and behavior has since long allured and challenged the field of psychology. Even more enthralling has been the arcane underpinning interlink between thought processes and behavior, particularly in social situations. The sub-branch of social psychology as defined by Gordon Alport is an attempt to understand how the thought, feeling, and behavior of individuals are influenced by the actual, imagined, or implied presence of others. Diving into finer details of social psychology came the concept of social cognition (SC) with its myriad of implications in the field of psychiatry. In this article, an overview of concepts of SC, its assessment, and application in psychiatry is provided.
| Concept of Social Cognition|| |
The impairments in SC observed in various psychiatric illnesses have greatly perturbed patients, families, and mental health professionals alike. Over years of research, it is now established that SC is functionally distinct from traditional neurocognitive domains. Defining and understanding SC has been yet another field of diverse opinions. Beginning from a psychological understanding and progressing to neural mechanisms, there is no shortage of assortments. Indeed, this heterogeneity has been the cause of various obstacles to research in this area and to tackle the same; the National Institute of Mental Health (NIMH), in 2006, held a meeting to resolve the controversies in definition and assessment of SC.
The field of social psychology generally puts SC as the manner in which we interpret, analyze, remember, and use information about the social world., It conceptualizes SC in terms of heuristics, schemas, models of social thought, interplay between affect and cognition, and sources of error. Detailed description of each is beyond the scope of the article and the reader is suggested other references for the same.,
On the other hand, the NIMH group defined SC as the mental operations that underlie social interactions, including perceiving, interpreting, and generating responses to the intentions, dispositions, and behaviors of others.
Neurobiologically, Brothers proposed a neural system of SC that was composed of the orbitofrontal cortex, the superior temporal sulcus, and the amygdala. This signature article has given impetus to various studies, which have majorly confirmed its findings. Pinkham, in his article in 2014, emphasized on particular neural areas, each believed to be responsible for selective aspects of SC, but also interacting with each other to form a collective network. He implied the fusiform gyrus, superior temporal sulcus, amygdala, medial prefrontal cortex, and ventrolateral prefrontal cortex to be the main areas involved in forming a neural network of SC.
Evolution of concept of social cognition
The concept of SC dates back to the 1970s and 80s, when Taylor in 1981 claimed that SC was only about 5 years old. He defined it as “any work that emphasizes how an individual cognizes his or her social world.” In 1982, the journal Social Cognition was established to serve as a new forum for the ever-increasing numbers of research in this emerging field. In 1990, as aforementioned, Brothers gave a new dimension to SC, proposing neural modules for the same which has since sparked a separate arena of research.
In 1991, the psychological aspects of SC got a further boost when Fiske and Taylor, in their 2nd edition on the series in social psychology, compiled the theories, evidences, and practical aspects of SC. They combined new developments in cognitive psychology on attention, memory, and inference, with those emerging from the study of attitudes, affect, and motivation.
Talking specifically about SC in individual mental disorders, although multiple researchers were at work already, Combs et al., in 2007, illustrated its role in schizophrenia. Since then, various research aspects of assessments and interventions of SC in schizophrenia have garnered significant attention worldwide. Other disorders where SC has been implicated with substantial literature available are autism spectrum disorders (ASDs), bipolar affective disorder, substance use disorder, and personality disorders.
At around the turn of the century, the NIMH launched the initiative named Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS), which supports the development of pharmacological agents to improve cognition in schizophrenia, and one of the goals of which was the development of a consensus battery for measuring cognition in schizophrenia and the results were first published in 2004. SC was ultimately included as one of the seven domains represented in the MATRICS Consensus Cognitive Battery for clinical trials in schizophrenia.
The importance of the clinical assessment of cognitive abilities involved in social functioning has been recently recognized in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, which includes SC as one of the six core neurocognitive domains.,
| Evaluation of Social Cognition|| |
SC, in its essence, is a vast field. There is consensus in relation to SC, that it is a multidimensional construct comprising many domains. Research pertinent to the field of psychiatry, SC, and its various measures has mainly focused on schizophrenia and ASD, though the research and its results have then been extrapolated to various other disorders. In 2006, the NIMH held a meeting to discuss various issues related to SC in schizophrenia. Researchers in the meeting suggested five broad measures for the measurement of SC in schizophrenia, namely theory of mind (ToM), social knowledge, social perception, attributional style, and emotional processing. To address the problem of the heterogeneity regarding the number, priority, and value in the various measures, an extensive two-step survey of researchers in the fields of schizophrenia, social psychology, and autism was conducted, namely the Social Cognition Psychometric Evaluation study. This process, published in 2013, derived four main domains for the study of SC in schizophrenia, namely, emotional perception, ToM, social perception, and attributional style. The study also suggested two novel constructs: social metacognition and social reciprocity. However, the four main domains discussed remain the area of focus of research pertaining to SC in schizophrenia in particular and other mental disorders in general.
These four constructs shall remain the main area of discussion in the subsequent sections on assessment of SC and its applications in the field of psychiatry. A brief description of these constructs and the various tools available to asses them is provided in [Table 1] and [Table 2]. The list of tools provided here includes those with a historical importance or those which have some psychometric research on reliability and validity.
| Application Of Social Cognition In Psychiatry|| |
Research on impairment of SC in psychiatry is garnering attention globally. A systematic review of meta-analyses studying SC across 30 psychiatric, neurodevelopmental, and neurological illness stands testimonial to the growing body of evidence. SC has been largely studied in schizophrenia and ASDs among various psychiatric illnesses. SC and interventions targeting SC in psychiatric illnesses are summarized hereunder.
Social cognition in schizophrenia
Green et al. found that social cue perception and emotional regulation are consistently impaired in patients with schizophrenia. In contrast, emotional experience was found to be intact with inconclusive results about sharing of experience. Fett et al. conducted a meta-analysis of 52 studies assessing association between SC, neurocognition, and functional outcomes (community functioning, social behavior in the milieu, social problem-solving, and social skills). Significantly greater association was found between SC and functioning compared to neurocognition. Association of greater effect size was found between the functional outcomes and ToM, social perception, and emotional processing in descending order. Significant correlation was obtained consistently for ToM and community functioning. However, in contrast, a recent study on patients with early stage schizophrenia (assessed within 5 years of onset) from India failed to find any significant association between SC and functioning.
Effect of interventions targeting social cognition in schizophrenia
A meta-analysis of 19 randomized controlled trials assessing the effect of interventions focusing on at least one element of SC reported that significant improvement was noted only in constructs of facial affect recognition (moderate to large effect size) followed by ToM (small effect size). No significant improvement was noted in domains of attributional style and social perception. SC training interventions were significantly associated with better functioning (moderate to large effect size) in community as well as institution. A review of 16 controlled studies assessing comprehensive SC training programs specifically reported significant improvement in constructs of facial affect recognition and ToM (moderate to large effect size) followed by attributional style (small effect size) as well as negative and general symptoms (small to moderate effect size). A systematic review of 32 studies assessing the effect of interventions which focused on at least one domain of SC found that significant improvement was noted in ToM and affect recognition domains. However, no improvement was noted in functional outcomes. A systematic review of 61 studies assessing broad-based as well as targeted SC interventions reported that improvement in domains of emotion processing and ToM consistently with both the types of interventions. Broad-based interventions include cognitive enhancement therapy, integrated psychological therapy, integrated neurocognitive therapy, social skills training, errorless learning, and cognitobehavioral social skills training. The broad-based interventions focus on the domains of perspective taking, appraisal of social context, reading of nonverbal cues, verbal communication, problem-solving, attributional style, emotional processing, assertiveness, and interpersonal relationship skills.
The targeted interventions for each of the constructs of SC are summarized in [Table 3].
Challenges exist in the development of culture-sensitive interventions for improving SC. For example, a recent pilot study demonstrating feasibility of Indian version of the Training of Affect Recognition program for patients of schizophrenia reported issues of culturally appropriate vernacular translation, changing situational cues in social context, and administration of the intervention to subjects who had limited computer literacy.
Social cognition impairment as endophenotype in schizophrenia
There is increasing amount of research on SC as an endophenotype of schizophrenia. SC impairment has been postulated to be a potential trait marker. ToM has been found to be significantly impaired in first-degree relatives of patients with schizophrenia. Domains of SC, such as emotional recognition, ToM, social perception, and attribution bias, have been found to be significantly impaired in patients of schizophrenia in remission compared to healthy controls. The impairment was found to be independent of neurocognitive deficits. Impairment in SC was found to be persistent even during the phase of remission in patients with schizophrenia in two longitudinal studies, which adds credence to the trait marker hypothesis.,
Social cognition in autism spectrum disorders
SC has been extensively studied in ASDs. ToM impairment is believed to be the primary deficit in SC in patients with ASD. The seminal study by Baren Cohen et al. about false belief attribution was key in establishing ToM deficits in ASD. The domains of social cue perception (face), emotional recognition, and ToM have been consistently found to be impaired in patients with ASD compared to general population.,,,, Converging evidence from behavioral, neuroimaging, and electrophysiological studies add to the evidence of impairment of SC in ASD., SC deficits, especially of emotional recognition and ToM, are increasingly being recognized in patients with subthreshold forms of ASD known as broad autism phenotype. A Cochrane review found that interventions targeting ToM had significant improvement in the ToM outcomes, but the evidence was concluded to be of low quality. A systematic review of randomized controlled trials assessing interventions targeting emotional recognition reported significant improvement in emotional recognition domain scores postintervention. However, it was not associated with increase in social skills. Further, need of research to evaluate the utilization of targeting emotional recognition in clinical improvement was emphasized.
Comparison of social cognition deficits between autism spectrum disorders and other psychiatric illness
Several studies have compared domains of SC in ASD with those in other psychiatric illness. Verbal ToM was significantly impaired in high-functioning ASD, compared to attention deficit hyperactivity disorder (ADHD) and typically developing children. Performance as well as applied ToM domains were significantly lower in high-functioning ASD, compared to ADHD and typically developing children. ToM ability was found to be significantly impaired in patients with low- as well as high-functioning autism compared to patients with mental retardation/intellectual disability. A meta-analysis of 37 studies found that the effect sizes for impairment in verbal and visual mentalization were significantly large for patients with schizophrenia as well as ASD. No significant difference was noted between verbal and visual mentalization among patients with ASD. However, a trend toward significance of greater deficits in verbal mentalization compared to visual mentalization was found in patients with schizophrenia.
Social cognition in mood disorders
Akin to other neurocognitive deficits observed in manic episode, significant deficits have been reported for ToM domain in patients with bipolar disorder (BD). Moreover, the deficits in the verbal domain of ToM were found even in the first-degree relatives of patients with BDs in comparison to the healthy controls. As anticipated, compared to schizophrenia, significantly lower deficits in ToM domain of SC had been reported in patients with BD. However, the difference does not remain significant during the manic episode. Further, a meta-analysis of 34 studies assessing ToM deficits in BD reported that the effect size was significantly higher in patients with BD in active episode (d = 1.23) as well as in euthymic state (d = 0.50). Similar findings have been observed during the episodes of depression too. Ladegaard et al. (2014) reported significant deficits in the higher-order SC domains (ToM, Social perception, and metacognition) in patients with first episode of depression in comparison to the healthy controls. In a review of 31 published studies, Weightman et al. noted that interpretation of stimuli of SC was impaired in patients with depression in both active and euthymic states. Moreover, the degree of impairment was found to be inversely related to the severity of depression.
Social cognition in borderline personality disorder
The results for deficits in SC have been conflicting from studies conducted in patients with borderline personality disorder (BPD). Most of the studies have found patients with BPD to be “hypervigilant” and demonstrate “hypermentalization” due to better or similar performance on simpler tasks pertinent to social perception, ToM, and facial affect perception compared to healthy controls.,,,,, However, some studies reported significantly lower scores in complex or advanced tasks assessing domains of ToM and facial affect perception.,, Negativity bias has been noted with better recognition of negative emotions. Furthermore, deficits in emotional recognition were particularly noted for positive and neutral emotions., In contrast, a recent Indian study reported they exhibited hypomentalizing, significantly lesser facial affect perception with no differences in 1st as well as 2nd order ToM and externalizing bias.
Social cognition in alcohol use disorder
There are multiple meta-analyses which assessed emotional recognition and ToM deficits in alcohol use disorder (AUD). One of the meta-analyses reported moderate effect size for deficits in domain of emotional recognition while other found large effect size., Emotional recognition bias was noted in patients with AUD misidentifying facial emotions as angry, fear, and disgust, and a correlation was noted with consumption of alcohol over the last 3 months, but not mood., In addition, ToM deficits of large effect size were reported in two meta-analyses, and it has been shown that patients with AUD perform poorly on third-person ToM tasks compared to first-person ToM tasks.,,
| Social Cognition in Attention Deficit Hyperactivity Disorder|| |
Children with ADHD had significantly greater deficits in emotional recognition and ToM compared to healthy controls. However, children with ASD had significantly higher deficits in emotional recognition and ToM compared to children with ADHD. One interesting point to note is that adults with ADHD did not differ from healthy controls in the tasks on emotion recognition and ToM.
Social cognition in eating disorders
Emotional processing but not ToM was significantly impaired in patients with anorexia nervosa (AN) compared to healthy controls. Children at high risk of developing eating disorder had significantly greater risk for having SC impairment compared to those at low risk for developing eating disorders. It was interesting to note that children of mothers with binging/binging-purging type of eating disorder had significantly greater risk compared to those with mothers having nonbinging eating disorder.
While some studies have found patients with AN having significantly lower scores in ToM tasks, others did not find any difference between patients and healthy controls.,, Obese patients with binge eating disorder (BED) had significantly greater impairment in understanding their own emotions compared to non-BED and under-threshold BED patients. However, no significant difference was noted with regard to understanding of emotions of other persons.
Social cognition in obsessive–compulsive disorder
Patients with obsessive–compulsive disorder were found to have no significant decrease in basic ToM tasks compared to healthy controls., However, they were found to have deficits in advanced ToM or second order tasks.
| Conclusion|| |
The search for literature for SC and psychiatry/mental disorders returned thousands of results. However, a concise article describing the basic concepts of SC, its dimensions, and application in psychiatry was not found. Hence, through this article, we attempted to provide an overview of concept of SC, various methods of its evaluation, and the clinical implication in psychiatric disorders.
The concept of SC has drastically evolved over the last century and the authors have described this construct from varying perspectives. Although certain leading groups of research like the MATRICS initiative of the NIMH have tried to refine the dimensions of SC, still a lot is yet to be understood. However, the domains, namely ToM, emotional perception, and social perception, have remained undoubted components of SC. Further, the existence of differing concepts of SC led to the development of various assessment tools. However, many of these did not withstand the changes in conceptualization of SC or were not amply investigated. The largest body of evidence of deficits in SC has been found in schizophrenia followed by ASDs, and fairly good amount of evidence supports the presence of social cognitive deficits in these disorders. Furthermore, a range of targeted interventions have been developed to address these deficiencies which affect the outcome of illness. Further, the literature is being made available regarding the SC deficits in other psychiatric disorders too. The refinements in neurobiological underpinnings may provide more insight into the role of SC in various psychiatric disorders. However, one may ponder over the clinical implications of evaluation of SC in mental illnesses as some studies did not find any association of improvement in SC with the functional outcome. Nevertheless, the field of SC and its application in psychiatry seems to be promising on the one hand, but the intricacies involved in the conceptualization as well as its evaluation have their limitations too. To exemplify, several earlier studies had methodological limitations such as smaller sample size, broad confidence intervals, lack of blinding, and inadequate description of measures to ensure fidelity of the intervention.,, Many studies have studied only one domain of SC, but on the other hand, assessing and comparing several domains of SC rather than a unimodal approach could be of greater clinical relevance. In addition, the psychometric properties of various measures for SC still remain ill defined. Furthermore, the population norms for SC on the basis of various factors such as culture, gender, ethnicity, and age need to be researched. Furthermore, the standardization and validation of tests for assessing SC in different sociocultural groups is warranted for better understanding of SC. The tests for assessing SC developed in the Western world might not be suitable to the patients from the east which could lead to falsely lesser impairment on measures of SC.
All said and done, the field of SC may appear very intricate to a novice, but it holds on to a vast and promising arena of research. Given the evolving refinement of the concepts of SC, development of various assessment tools, the understanding of the neural systems, and creation of targeted pharmacological as well as nonpharmacological interventions, it is hoped that, in future, it will further benefit persons with mental illnesses.
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Conflicts of interest
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[Table 1], [Table 2], [Table 3]