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Published in final edited form as: Schizophr Res. 2025 Jan 31;276:167–174. doi: 10.1016/j.schres.2025.01.015

Social stress in schizophrenia: Unique contributions to social cognition and social functioning

Kathryn C Kemp a,*, Ivy F Tso a,b, Stephan F Taylor b, Aubrey M Moe a
PMCID: PMC12159669  NIHMSID: NIHMS2082651  PMID: 39892250

Abstract

Schizophrenia-spectrum disorders have been associated with heightened stress sensitivity, which can worsen prognosis, functioning, and quality of life. However, more research is needed to determine whether different types of stress impact specific functional domains. This study used the Psychological Stress Index (PSI)—a self-report instrument designed and validated to measure perceived stress in psychosis—to delineate the unique contribution of social versus non-social stress to social functioning and social cognition. Fifty-nine participants with schizophrenia/schizoaffective disorder and fifty non-clinical controls completed the PSI and a battery of social functioning and social cognition measures. Elevated social stress statistically predicted worse performance on an emotion recognition task and worse interviewer-rated social functioning, over-and-above non-social stress. Higher social stress also statistically predicted worse interviewer-rated social functioning over-and-above performance on emotion recognition and theory-of-mind tasks. These results provide promising evidence that examining social stress separately from non-social stress provides unique information about social difficulties in schizophrenia-spectrum psychopathology. Examining social stress and other specific forms of stress may improve understanding of stress sensitivity in this population and better inform treatments aimed at improving functioning.

Keywords: Psychotic disorders, Stress sensitivity, Social stress, Social functioning

1. Introduction

1.1. Schizophrenia and stress sensitivity

Schizophrenia-spectrum disorders are debilitating conditions that involve cognitive, affective, social, and occupational impairments (Schaefer et al., 2013; Handest et al., 2023; Kring and Elis, 2013). Thus, identifying the mechanisms that lead to development or worsening of these disorders in order to promote functional recovery is at the forefront of mental health research. For example, following diathesis-stress models of psychosis (e.g., Nuechterlein and Dawson, 1984; Myin-Germeys and van Os, 2007; Beards et al., 2013; Mizrahi, 2016), a great deal of research has indicated that psychosis is associated with increased vulnerability and reactivity to stress, and that stress predicts the severity of psychotic symptoms and episodes (see review by Muddle et al., 2022). Furthermore, similar patterns have been observed in individuals at clinical high risk for psychosis (van der Steen et al., 2017) and in sub-clinical schizotypy (Kemp et al., 2024) – thus suggesting stress sensitivity may be a key clinical feature across stages of illness. Although there is conflicting evidence on whether people with schizophrenia actually experience more stressful life events (Horan et al., 2005; Mote and Fulford, 2020) than unaffected individuals, evidence indicates that risk for schizophrenia-spectrum psychopathology increases as one experiences more stressful life events (Shevlin et al., 2008; Miller et al., 2001). Furthermore, people at varying points along the schizophrenia spectrum tend to experience elevated negative affect and elevated perceptions of uncontrollability in response to everyday stress (Jones and Fernyhough, 2007; Kemp et al., 2023; Myin-Germeys et al., 2000; Horan et al., 2005). Thus, people with schizophrenia-spectrum psychopathology may be at increased risk for symptom exacerbation due to difficulty managing negative affect in response to daily-life stressors.

1.2. Social stress in schizophrenia

Beyond the general experience of elevated negative affect in response to stress, much research has emphasized the role of social stressors in the etiology of schizophrenia-spectrum disorders. Social stress research has typically focused on broadly examining a variety of environmental stressors (Almuqrin et al., 2023). For example, some environmental stressors associated with schizophrenia-spectrum psychopathology include urbanicity (van Os et al., 2003; van Os et al., 2004), immigration status (Cantor-Graae and Selten, 2005), employment and educational difficulties (Malla et al., 1990; Lange et al., 2017), racial/ethnic discrimination (Veling et al., 2007), and other forms of discrimination (Janssen et al., 2003). The stressors associated with these broad social experiences play a far-reaching effect that is typically best addressed at a systemic level.

In essence, much of the social stress literature has emphasized the impact of broader social system levels (e.g., neighborhood, social status); however, social stress may also be conceptualized and understood at the individual or dyadic level, such as direct interactional experiences occurring at the microsystem level (Bronfenbrenner, 1979). In other words, stressors that occur directly from interpersonal interactions (or lack thereof) may represent a specific type of social stress that is prevalent and important to examine separately in schizophrenia-spectrum psychopathology (Moe et al., 2018). For example, people with schizophrenia-spectrum disorders often experience stressors directly from interacting or withdrawing from others (e.g., Blanchard et al., 1996), such as social anxiety, social isolation, and criticism from family, as well as social cognitive difficulties (e.g., Lukoff et al., 1984; Green et al., 2015). These difficulties often are associated with diminished social functioning, which can include elevated interpersonal conflict, difficulty resolving interpersonal conflicts, and diminished tendency to seek out, develop, and maintain a variety of satisfying interpersonal relationships and activities. As a result, individuals with schizophrenia-spectrum psychopathology with social functioning difficulties often experience fewer relationships, increased psychotic, depressive, and anxiety symptoms (see review by Degnan et al., 2018), as well as diminished general functioning and quality of life (Vázquez Morejón et al., 2018; Caron et al., 2005). Considering evidence that people with schizophrenia-spectrum disorders exhibit interpersonal difficulties that impact quality of life, examining social stress at this level of analysis appears important for implementing interventions that typically occur at the individual level. Furthermore, social stress experienced at the individual level is readily addressable via targeted intervention. For consistency in discussing the present study, we now use the term “social stress” to refer specifically to stress that is experienced by an index person and is directly related to interpersonal interaction.

1.3. Stress measurement

Stress appears relevant to understanding functioning in schizophrenia-spectrum psychopathology, and different types of stressors may play a role in the heterogeneous etiology and expression of these disorders, as well as the difficulties in social functioning outlined above. Due to the evident stress sensitivity in schizophrenia-spectrum psychopathology, Tso et al. (2012) developed the Psychological Stress Index (PSI) to examine self-reported psychological stress in psychosis. The PSI was designed by adapting items from the Perceived Stress Scale (PSS; Cohen et al., 1983) and including new items that examine vulnerability to experiencing negative affect in response to everyday stressors, such as social interactions and expectations, daily obligations, and unfamiliar situations. The PSI has good psychometric properties (Tso et al., 2012), including internal consistency (α) and test-retest reliability (ρ) in people with schizophrenia (α = 0.88; ρ = 0.77) and non-clinical controls (α = 0.89; ρ = 0.82). Furthermore, Tso et al. provided support for the construct validity of the PSI; the PSI exhibited moderate to high correlations with measures of stress and negative affect, and statistically predicted current and prospective social adjustment and number of hospitalizations in a 12-month period.

Reliable measurement of stress sensitivity may be essential to the identification and development of interventions to target stress sensitivity among vulnerable individuals. Although concerns have been raised regarding the validity of questionnaire measures among people with schizophrenia-spectrum disorders, promising evidence suggests these individuals can accurately self-report their emotional experiences (Kring et al., 2003; Hempel et al., 2007). However, “stress” has often been treated as an omnibus, catch-all construct in its measurement. It may be important to examine whether particular types of stress (e.g., social stress) give rise to particular functional difficulties (e.g., social impairment) among people with schizophrenia. For example, one might examine whether experiencing elevated negative affect specifically in response to being in social settings has a more direct impact on one’s ability to attend to, understand, and execute social behaviors compared to stress from managing daily responsibilities.

Although the PSI was originally developed as a single measure of stress, it may provide an ideal measure for delineating the effect of different types of stress on social functioning. That is, the PSI includes items that appear to assess social stress (e.g., self-reported stress due to interpersonal relationships and expectations) versus non-social, or generalized, stress (e.g., self-reported stress due to novel or unfamiliar situations). Thus, the PSI permits examination of whether social stress specifically impacts social functioning over-and-above non-social stress, which may be important to fine-tuning individualized treatments. For example, Tso et al. (2012) found that higher self-reported stress was associated with worse social adjustment in people with schizophrenia, yet the possibility that items emphasizing social stress contribute most strongly to these difficulties remains untested. Furthermore, given that social cognition is robustly associated with social functioning (Couture et al., 2006; Pinkham and Penn, 2006; Fett et al., 2011), the PSI provides the opportunity to determine if social stress explains more variance in social functioning over-and-above social cognition. Thus, we can examine the differential contributions of aptitude for social tasks (e.g., emotion recognition, theory of mind) versus perceptions of social events (i.e., social stress) to explaining unique variance in social functioning. This information could similarly inform individualized treatments, such as clinical decision-making around whether prioritizing one’s negative perceptions of social interactions or one’s social cognitive abilities may most effectively improve social functioning.

1.4. Goals and hypotheses

The goal of the present study was to clarify the role of social stress in social functioning and social cognition. Specifically, our first aim was to examine the unique contribution of social stress in the statistical prediction of both social cognition and social functioning measures, over-and-above non-social stress. Second, we aimed to examine the unique contribution of social stress on social functioning, over-and-above abilities in various social cognitive domains. Although this examination is largely exploratory, we hypothesized that: 1) higher perceived social stress would be associated with poorer social functioning and social cognition, 2) social stress would account for unique variance in social functioning and social cognition over-and-above non-social stress, and 3) social stress would account for unique variance in social functioning over-and-above social cognitive abilities.

2. Method

2.1. Participants

Participants (n = 109) were recruited from community advertisements and referrals from local mental health providers or researchers. The total sample was comprised of 50 non-clinical controls and 59 participants with schizophrenia or schizoaffective disorder; the sample size was determined based on the specific aims of the neuroimaging study from which our data were drawn (Blain et al., 2023). Given that we conceptualize stress to be a continuous variable, examining both non-clinical controls and participants with schizophrenia or schizoaffective disorder increased the likelihood of examining across a wide range of stress reports. Demographics for the sample are provided in Table 1. Participants were excluded from the study if they were not between the ages of 18 to 55, had significant medical or neurological illness, had uncorrected visual impairment, or had evidence of substance abuse in the past month or dependence in the past six months. For non-clinical controls, additional exclusion criteria included the following: past or current mental diagnosis, history of psychotic or bipolar disorder among first-degree relatives; and current Beck Depression Inventory (BDI-II; Beck et al., 1996) rating >8. Non-clinical controls were matched to participants in the schizophrenia-spectrum group based on age, sex, and parental education. Diagnoses for participants with schizophrenia or schizoaffective disorder were established using the Structured Clinical Interview for DSM-IV Axis 1 Disorders (First and Gibbon, 2004). This project was approved by the University of Michigan Medical School IRB. Each participant provided written informed consent.

Table 1.

Demographics by group.

Demographics Total sample Schizophrenia/schizoaffective disorder Non-clinical controls
M SD M SD M SD
Age 33.66 10.20 33.27 10.06 34.12 10.44
Demographics Total sample Schizophrenia/schizoaffective disorder Non-clinical controls
n % n % n %
Female 53 48.6 28 47.5 25 50.0
Male 56 51.4 31 52.5 25 50.0
Asian 8 7.3 1 2.7 7 14.0
Black 32 29.4 21 35.6 11 22.0
White 60 55.0 31 52.5 29 58.0
Native American 1 0.9 0 0 1 2.0
Multiracial 5 4.6 4 6.8 1 2.0
Other 3 2.8 2 3.4 1 2.0
Hispanic 8 7.3 4 6.8 4 8.0
Non-Hispanic 101 92.7 55 93.2 46 92.0
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Note. Percentages listed by group represent the proportion of the group (i.e., control or schizophrenia/schizoaffective disorder group), not the total sample.

2.2. Measures and procedures

Participants completed measures as part of a larger neuroimaging study (Blain et al., 2023), though the present study only examines self-report and interview-based measures and tasks examining social functioning and social cognition.

The Psychological Stress Index (PSI) is an 18-item scale that assesses self-reported stress in response to “interpersonal interactions, social expectations, and novel situations” (Tso et al., 2012, p. 40). Participants rate these items on a scale of 0 = never to 4 = very often over the prior month. Although the PSI was developed to provide a single assessment of general stress levels, for the purposes of the present study we divided the PSI into a seven-item “Social Stress” index and 11-item “Non-Social Stress” index based on visual examination of the PSI items. Items involving any interpersonal elements, including interactions or others’ expectations, were classified as an indicator of social stress. We opted for this face validity approach to item selection due to the limited sample size. See Supplementary Text 1 for an overview of the items comprising these two indices.

We included several measures to examine social cognition and social functioning. First, participants completed the Social Skills Performance Assessment (SSPA; Patterson et al., 2001a), which is a role-play assessment that examines a variety of social skills. Participants completed two SSPA role plays that were rated by a trained research assistant and averaged into one overall score on this measure. Rater reliability was established when a research assistant independently rated and reached 80% agreement with a senior investigator’s ratings for a subset of role-plays. Participants completed the UCSD Performance-Based Skills Assessment (UPSA; Patterson et al., 2001b), although given our focus on interpersonal social functioning in the present study we only examined the communication skills subscale. Participants additionally completed the Reading the Mind in the Eyes Test (RMET) to examine theory of mind or mental state attribution (Baron-Cohen et al., 2001), and emotion recognition was assessed using the Penn Emotion Recognition Test (ER-40; Kohler et al., 2003). Lastly, interviewers rated participants on the Global Functioning Scale (Cornblatt et al., 2007) to provide an estimate of role and social functioning; however, consistent with the goals of the present study we only examine the Global Functioning: Social (GF: Social) scale to capture participants’ interpersonal functioning specifically.

2.3. Statistical analyses

Cronbach’s alpha (Cronbach, 1951) was computed for PSI Social and Non-Social indices separately to examine internal consistency reliability in the total sample. Bivariate correlations were calculated among all measures using Pearson’s r correlations to provide a baseline assessment of their associations, although these zero-order correlations did not indicate the unique contribution of social stress over-and-above other relevant predictors. To examine whether social stress explained more variance on social functioning and abilities, we used hierarchical regression analyses. In all regression analyses, participant group status (non-clinical control = 0, schizophrenia/schizoaffective disorder =1) was entered at step 1 to account for the impact of group status on the dependent variables (i.e., scores on social functioning and social cognition measures). Thus, any additional variance explained by social stress would not simply be attributed to group differences. We first examined whether social stress explained more variance in social functioning and social cognition over-and-above non-social stress. Therefore, PSI Non-Social was entered at step 2 to examine the unique variance explained above-and-beyond group status. Lastly, PSI Social was entered at step 3 to examine the unique variance accounted for by this index over-and-above group status and PSI Non-Social.

We next examined whether social stress explained more variance in social functioning over-and-above individual social cognition indicators (specifically, emotion recognition and theory of mind). We conducted separate hierarchical regression analyses in which the social cognition measure (ER-40 or RMET) was entered at Step 2 to examine the unique variance explained over-and-above group status. PSI Social was again entered at step 3 to examine the unique variance accounted for by this index over-and-above the ER-40 and RMET, respectively. The goal of this study was not to interpret a single result from multiple tests, but rather to evaluate the holistic patterns of all results based on a specific set of hypotheses; thus, no corrections for multiple comparisons were included.

3. Results

3.1. Descriptive statistics

Descriptive statistics for all measures are provided in Table 2. Participants scored almost across the full range on the PSI Social (1–28) and PSI Non-Social (3–44) indices, and both indices exhibited good internal consistency as measured with Cronbach’s alpha (PSI Social: α = 0.80; PSI Non-Social: α = 0.86). Bivariate correlations among all measures in the total sample are provided in Table 3. Higher scores on the PSI Social and PSI Non-Social indices generally were associated with diminished performance on indicators of social functioning, with PSI Social exhibiting the most robust associations.

Table 2.

Descriptive statistics.

Total sample Schizophrenia/schizoaffective disorder Non-clinical controls
Measure n Mean S.D. n Mean S.D. n Mean S.D. t p
PSI Total 94 31.25 13.22 47 39.47 12.52 47 22.68 7.3 −7.94 <0.001***
PSI Social 94 11.09 5.98 47 14.85 5.51 47 7.19 3.53 −8.03 <0.001***
PSI Non-Social 94 20.16 7.82 47 24.62 7.79 47 15.49 4.53 −6.94 <0.001***
SSPA Average 82 4.55 0.36 40 4.33 0.38 42 4.77 0.16 6.79 <0.001***
UPSA-Comm 95 39.35 6.25 47 37.59 5.46 48 41.32 6.37 3.07 0.003**
RMET 90 0.73 0.12 44 0.69 0.12 46 0.78 0.1 4.04 <0.001***
ER-40 94 32.84 4.62 47 31.34 5.72 47 34.32 2.5 3.27 0.002**
GF-Social 109 21.55 5.52 59 18.12 3.75 50 26.04 2.63 12.55 <0.001***
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Note. S.D. = standard deviation; PSI = Psychological Stress Index; SSPA = Social Skills Performance Assessment (average score); UPSA-Comm = UCSD Performance-Based Skills Assessment (Communication subscale); RMET = Reading the Mind in the Eyes; ER-40 = Penn Emotion Recognition Task; GF = Global Functioning Scale.

**

p < .01.

***

p < .001.

Table 3.

Bivariate correlations of stress and social functioning measures.

PSI-Non-social SSPA −Average UPSA −Comm RMET ER-40 GF −Social
PSI −Social 0.83*** −0.49*** −0.27** −0.38*** −0.33** −0.66***
PSI −Non-social −0.41*** −0.18 −0.36*** −0.20 −0.55***
SSPA −Average 0.26* 0.23* 0.28* 0.59***
UPSA −Comm 0.29** 0.15 0.37***
RMET 0.46*** 0.30**
ER-40 0.27**
GF −Social
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Note. PSI = Psychological Stress Index; SSPA = Social Skills Performance Assessment (average score); UPSA-Comm = UCSD Performance-Based Skills Assessment (Communication subscale); RMET = Reading the Mind in the Eyes; ER-40 = Penn Emotion Recognition Task; GF = Global Functioning Scale.

*

p < .05.

**

p < .01.

***

p < .001.

3.2. Contribution of social stress to social functioning over-and-above non-social stress

Hierarchical regression analyses were performed to test the unique statistical prediction of social cognition and social functioning by the PSI Social and PSI Non-Social indices (Table 4). Of note, non-social stress did not explain significant amounts of variance in any of the social cognitive or social functioning measures after accounting for participant group. However, after accounting for group and non-social stress, social stress significantly explained additional amounts of variance in emotion recognition (Δr2 = 5.04 %) and interviewer-rated social functioning abilities (Δr2 = 3.29 %). Social stress did not explain significant amounts of variance in performance on role-plays, a functional communication task, or mental state attribution task above what could be accounted for by group.

Table 4.

Comparison of regression using PSI social stress and non-social stress as predictors of social cognition and social functioning.

Outcome n Predictor Variable Statistics Model Statistics
β t p r 2 Δr 2 ΔF p
SSPA 82 Step 1
 Group −0.61 −6.79 <0.001*** 0.37 0.37 46.12 <0.001***
Step 2
 Group −0.55 −5.09 <0.001***
 PSI Non-Social −0.10 −0.96 0.340 0.37 0.01 0.92 0.340
Full Model
 Group −0.49 −4.43 <0.001***
 PSI Non-Social 0.10 0.61 0.542
 PSI Social −.28 −1.59 0.116 0.39 0.02 2.53 0.116
UPSA-Comm 90 Step 1
 Group −0.28 −2.74 0.007** 0.08 0.08 7.53 0.007**
Step 2
 Group −0.26 −2.09 0.039*
 PSI Non-Social −0.02 −0.18 0.85 0.08 0.00 0.03 0.854
Step 3
 Group −0.19 −1.47 0.144
 PSI Non-Social 0.23 1.16 0.249
 PSI Social −0.34 −1.67 0.098 0.11 0.03 2.79 0.098
RMET 87 Step 1
 Group −0.40 −4.07 <0.001*** 0.16 0.16 16.57 <0.001***
Step 2
 Group −0.29 −2.41 0.018*
 PSI Non-Social −0.19 −1.57 0.120 0.19 0.02 2.47 0.120
Step 3
 Group −0.27 −2.11 0.038*
 PSI Non-Social −0.10 −0.53 0.599
 PSI Social −0.12 −0.61 0.542 0.19 0.00 0.38 0.542
ER-40 90 Step 1
 Group −0.34 −3.43 <0.001*** 0.12 0.12 11.78 <0.001***
Step 2
 Group −0.34 −2.75 0.007**
 PSI Non-Social 0.00 0.01 0.991 0.12 0.00 0.00 0.991
Step 3
 Group −0.25 −1.94 0.056
 PSI Non-Social 0.33 1.76 0.081
 PSI Social −0.45 −2.30 0.024* 0.17 0.05 5.27 0.024*
GF-Social 94 Step 1
 Group −0.78 −11.84 <0.001*** 0.60 0.60 140.27 <0.001***
Step 2
 Group −0.69 −8.65 <0.001***
 PSI Non-Social −0.15 −1.82 0.072 0.61 0.01 3.31 0.072
Step 3
 Group −0.61 −7.45 <0.001***
 PSI Non-Social 0.09 0.83 0.410
 PSI Social −0.35 −2.91 0.005** 0.64 0.03 8.49 0.005**
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Note. PSI = Psychological Stress Index; SSPA = Social Skills Performance Assessment (average score); UPSA-Comm = UCSD Performance-Based Skills Assessment (Communication subscale); RMET = Reading the Mind in the Eyes; ER-40 = Penn Emotion Recognition Task; GF = Global Functioning Scale.

*

p < .05.

**

p < .01.

***

p < .001.

3.3. Contribution of social stress to social functioning over-and-above social cognition

We similarly performed hierarchical regression analyses to test social stress’s unique statistical prediction of interviewer-rated social functioning, over-and-above social cognition (specifically, emotion recognition and theory of mind; Tables 5 and 6). Although better performance on the ER-40 and RMET were associated with better self-reported social functioning at the bivariate level, neither social cognitive task explained significant amounts of variance after accounting for group. Self-reported social stress explained significant amounts of variance (Δr2 = 4.80 %) in social functioning over-and-above performance on the ER-40. Social stress also explained significant variance (Δr2 = 4.73 %) in social functioning over-and-above performance on the RMET task.

Table 5.

Linear regressions examining social functioning prediction by PSI social stress after controlling for ER-40.

Outcome n Predictor Variable statistics Model statistics
β t p r 2 Δr 2 ΔF p
GF-Social 87 Step 1
 Group −0.79 −11.89 <0.001*** 0.62 0.62 141.46 <0.001***
Step 2
 Group −0.78 −10.96 <0.001***
 ER-40 0.03 0.42 0.676 0.62 0.00 0.18 0.676
Step 3
 Group −0.61 −7.35 <0.001***
 ER-40 −0.01 −0.12 0.907
 PSI Social −0.29 −3.51 <0.001*** 0.67 0.05 12.34 <0.001***
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Note. PSI = Psychological Stress Index; ER-40 = Penn Emotion Recognition Task; GF = Global Functioning Scale.

***

p < .001.

Table 6.

Linear regressions examining social functioning prediction by PSI social stress after controlling for Reading the Mind in the Eyes.

Outcome n Predictor Variable statistics Model statistics
β t p r 2 Δr 2 ΔF p
GF-Social 90 Step 1
 Group −0.78 −11.53 <0.001*** 0.61 0.61 132.92 <0.001***
Step 2
 Group −0.78 −10.44 <0.001***
 RMET 0.01 0.10 0.919 0.61 0.00 0.01 0.919
Step 3
 Group −0.62 −7.30 <0.001***
 RMET −0.03 −0.48 0.635
 PSI Social −0.28 −3.39 0.001** 0.66 0.05 11.48 0.001**
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Note. PSI = Psychological Stress Index; RMET = Reading the Mind in the Eyes; GF = Global Functioning Scale.

**

p < .01.

***

p < .001.

4. Discussion

4.1. Stress dimensions and statistical prediction of social cognition and social functioning

Stress has often been examined as an omnibus construct, yet distinct types of stress may be relevant for different types of functioning. The present study aimed to parse social stress from non-social (generalized) stress in statistically predicting social cognition and functioning. To our knowledge, this is the first study to examine whether self-reported social stress explains unique variance in interview−and performance-based measures of social functioning. Higher self-reported social stress uniquely contributed to poorer emotion recognition and interviewer-rated social functioning above-and-beyond non-social stress; however, it did not uniquely explain variance in performance on role-plays, a functional communication task, or a theory of mind task. Notably, the GF-Social scale appears to provide a more comprehensive, interviewer-rated assessment of one’s perceived social functioning over time, which may provide an ecologically valid indicator of one’s social functioning and align more closely with ratings on a self-report measure of stress. That is, the GF-Social scale provides a gold-standard measure of one’s actual social world, as it is associated with other measures of social engagement (Cornblatt et al., 2007) and is rated based on one’s breadth and depth of a variety of interpersonal relationships and interactions; thus, self-reported social stress is likely reflective of the perceptions of one’s real-world social context outside of the laboratory environment. In contrast, self-reported social stress may not correspond with performance on individual role-plays (as in the SSPA) given their time-limited nature and focus on a discrete, pre-specified social goal.

Our findings that higher self-reported social stress uniquely contributed to diminished emotion recognition may suggest that this stress dimension impacts automatic processing of social information, but not higher-order functions. For example, theory of mind typically requires more complex processing in order to make inferences about the mental state of another individual, whereas simply identifying an emotion based on another person’s facial expression occurs more automatically. It may be that social stress specifically impacts less complex social decision-making, which may be regulated by more deliberate processing. However, the theory of mind task (RMET) implemented here may require more complex processing due to knowledge retrieval rather than mental state attribution. That is, researchers have questioned this task’s use of more advanced vocabulary, which may contaminate the intended measurement of theory of mind and correspond with its weaker psychometric properties (Pinkham et al., 2018). To clarify if complex social decision-making is impacted by social stress, research may benefit from using additional theory of mind measures that are relatively unaffected by other forms of complex or deliberate processing. Another consideration is that higher-order social functions are impacted in schizophrenia-spectrum psychopathology, yet social stress specifically might not contribute over-and-above other confounds not examined in the present study (e.g., cognitive deficits).

The correspondence between social stress and specific social functioning outcomes is particularly notable given that, after accounting for group status, non-social stress did not explain significant amounts of variance in any indicator of social functioning, even before accounting for social stress. This finding is consistent with Tso et al., 2012 development of the brief version of the PSI (PSI-9), in which they noted that only three of the nine items found to have the best predictive validity for functional outcomes from the original PSI were non-social items. The present study offers preliminary support that measuring stress as a multidimensional construct (perhaps comprised of more than two dimensions) may provide some clarity about corresponding functional outcomes (i.e., social stress explaining social functioning). Future studies would benefit from examining whether different types of stress exhibit differential impacts on other functional outcomes (e.g., cognitive functioning, emotion regulation). Similarly, these studies could determine the extent to which specific types of stress do not impact dissimilar areas of functioning (e.g., social stress explaining cognitive functioning). Such an examination would provide conceptual clarity of an over-arching “stress” construct, which could inform individualized treatments among people with schizophrenia.

4.2. Differentiating social stress from social cognition

Furthermore, distinguishing between the contributions of social stress and social cognition on social functioning is important given that social cognitive difficulties have often been associated with diminished social functioning (Couture et al., 2006). However, in the present study, emotion recognition abilities and theory of mind did not significantly contribute to interviewer-rated social functioning after accounting for group status. Social stress still remained a significant predictor of interviewer-rated social functioning over-and-above these indicators of social cognition. Social stress appears to offer unique information about social functioning beyond social cognitive abilities as assessed within the context of specific laboratory tasks. These findings are promising because a questionnaire measure of social stress may be easily implemented in measurement-based care to identify a mechanism for targeting social functioning. Perhaps targeting one’s negative perceptions of social interactions, rather than improving one’s social cognitive abilities, would provide better social functioning outcomes for people with schizophrenia-spectrum psychopathology.

4.3. Limitations and future directions

The present study examined social stress, social cognition, and social functioning in a combined sample of both people with schizophrenia and non-clinical controls in order to preserve predictive power and provide a range of scores on the measures. However, the use of non-clinical controls with minimal psychopathology (e.g., minimal BDI-II scores) likely constrained scores on self-reported stress in this group compared to a general sample (and certainly compared to the schizophrenia group). As shown in the hierarchical regression analyses, group identification accounted for the majority of the variance. It would be important to continue these analyses in a larger sample of people with schizophrenia to clarify more specifically the impact of social stress on social cognition and functioning in this population. However, the results thus far provide promising evidence that social stress may play a distinct role in social functioning. Furthermore, although nearly half of the PSI items are social in nature, the PSI was originally developed to be a unidimensional measure that captures a broad range of self-reported stress. Dividing the PSI into two subscales that assess social and non-social stress was exploratory, however, employing larger samples may be similarly useful to derive an empirically driven factor structure of the PSI, whether additional dimensions of stress can be identified, and whether all items consistently measure stress.

4.4. Conclusions

This is the first study to examine the differential statistical prediction of types of stress with social cognition and social functioning. Preliminary findings suggest that social stress may have unique implications for one’s ability to engage effectively with others. However, future research with larger samples is needed at this time. Identifying the relevance of different types of stress in schizophrenia-spectrum psychopathology may be essential to understanding stress sensitivity in this population and improving functional outcomes over-and-above management of general stress.

Supplementary Material

1

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.schres.2025.01.015.

Acknowledgements

We have no acknowledgements.

Funding sources

This work was supported by the National Institute of Mental Health (NIMH) (grant numbers 5K23MH108823, R01MH122491, R01MH135117 [to IFT], and K23MH131967 [to AMM]).

Footnotes

Declaration of competing interest

None.

CRediT authorship contribution statement

Kathryn C. Kemp: Writing – review & editing, Writing – original draft, Investigation, Formal analysis, Conceptualization. Ivy F. Tso: Writing – review & editing, Supervision, Resources, Project administration, Methodology, Investigation, Funding acquisition, Data curation, Conceptualization. Stephan F. Taylor: Writing – review & editing, Supervision. Aubrey M. Moe: Writing – review & editing, Supervision, Methodology, Investigation, Conceptualization.

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Supplementary Materials

1
NIHMS2082651-supplement-1.pdf (348KB, pdf)

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