Content of this journal is licensed under a Abstract
Background:
Social cognition can be defined as the ability to perceive and interpret others’ thoughts, intentions, and behaviors. It is known that there are deficiencies in social cognitive skills in schizophrenia. This study aims to evaluate the social cognitive skills of schizophrenia spectrum disorder patients from the very early stages using theory of mind and emotion identification/discrimination tests and to examine the changes in these skills during schizophrenia.
Methods:
Seventy-nine patients who met the schizophrenia criteria according to Diagnostic and Statistical Manual of Mental Disorders-5 , except for duration, and were diagnosed with schizophrenia were divided into 3 groups according to the duration of illness: less than 6 months (n = 18), 6-24 months (n = 35), and more than 24 months (n = 26). The participants were administered the Positive and Negative Syndrome Scale (PANSS), the Global Assessment of Functioning Scale (GAF), the Reading the Mind in the Eyes Test (RMET), and the Facial Identification and Discrimination Tests (FEIT and FEDT), and the test scores were compared between the 3 groups.
Results:
There was no significant difference between the groups regarding PANSS, GAF and RMET, FEIT, and FEDT scores (P > .05). There was also no significant relationship between the illness duration and RMET, FEIT, and FEDT scores (P > .05).
Conclusion:
There was no significant relationship between disease duration and social cognitive skills in schizophrenia spectrum disorder patients. This finding suggests that social cognitive deficits may be a trait marker of schizophrenia.
Main Points
In patients with schizophrenia spectrum disorder, Reading the Mind in the Eyes Test scores indicating theory of mind are similar in patients with different disease durations.
In patients with schizophrenia spectrum disorder, emotion identification and emotion discrimination skills are similar in patients with different disease durations.
In patients with schizophrenia, performance on the Reading the Mind in the Eyes Test and emotion discrimination test is negatively correlated with negative symptoms.
In women with schizophrenia, RMET, FEIT, and FEDT scores are higher than those in men with schizophrenia.
In patients with schizophrenia, RMET scores are higher in those with higher education.
Introduction
Social cognition refers to the psychological processes related to perceiving, coding, storing, retrieving, and organizing information about oneself and other people. These processes include perceiving social cues, sharing experiences, understanding other people’s thoughts and feelings, and managing emotional reactions to others.1 In other words, it is the ability to use the information obtained about other people and oneself for conscious decision-making or attitudes.2 Social cognitive abilities can be divided into 4 categories: emotion recognition, theory of mind (ToM), social knowledge and perception, and attribution bias.3 Emotion recognition can be defined as the ability to perceive and express emotions, recognize and perceive the emotions of others, and respond appropriately to the emotional expressions of others. Theory of mind is the ability to comprehend others’ intentions, feelings, and beliefs, and to create a mental representation of these situations.3,4 There are 2 subtypes of theory of mind: social-cognitive ToM and social-perceptual ToM. Social-cognitive ToM is the ability to interpret the mental states underlying people’s behavior; social-perceptual ToM is the ability to interpret the mental states of other people from directly observable information.5-7 Social knowledge is the awareness of the roles, rules, and goals that guide social interactions and characterize social situations. Social perception is the ability to identify social roles, social rules, and social context. Attribution bias refers to the typical inferences people make about the causes of positive/negative situations.3,4
It is known that patients with schizophrenia have social cognitive deficits, manifested by difficulties in identifying emotions, connecting with others, understanding people’s thoughts, and responding emotionally to others. These social cognitive deficits significantly affect the social relationships and daily functioning of schizophrenia patients.1,8-10
More specifically, ToM deficits have been identified in schizophrenia patients at different stages of disease11,12 and have been shown to be strongly associated with functional impairment.13,14 In some studies, ToM deficits have been identified in early stages of the disease and have been observed to remain stable over time.15,16 Schizophrenia patients also have impairments in the recognition and perception of emotions from facial expressions.17,18 However, there are contradictions in the literature on emotion recognition. Some authors reported that emotion recognition skills decreased during the chronic process of schizophrenia,17 some reported that these deficits in schizophrenia patients did not change over time,19,20 and some reported that these abilities improved when symptoms subsided and approached healthy controls.15,21 The common finding of all these studies is that there are deficits in various areas of social cognition in schizophrenia patients from the early stages. However, data regarding the course of social cognitive deficits during the course of the disease are still contradictory.
Determining whether social cognitive deficits are a sequela of the process or trait marker is very important for understanding the nature of schizophrenia and developing appropriate treatment methods. Therefore, this study aimed to evaluate the emotion recognition and ToM skills of schizophrenia patients from the very early stages of the disease and to examine the changes in these skills during the course of schizophrenia. For this reason, it was planned to include patients who do not yet meet the diagnostic criteria in terms of duration but who meet other diagnostic criteria and to include patients in a wide range from the early stages to the chronic stage.
Material and Methods
Procedure and Participants
This is a cross-sectional, observational, and descriptive study. Ethics committee approval was obtained from Ankara Bilkent City Hospital Medical Research Scientific and Ethical Evaluation Committee No. 1 (dated July 3, 2024, decision no. TABED 1-24-153).
A total of 79 patients, aged 18 to 65, with at least a primary school education and meeting the DSM-5 diagnostic criteria for schizophrenia, schizophreniform disorder, or acute and transient psychotic disorder were included in the study. Patients with psychotic depression, psychotic mania, substance-related psychosis, or delusional disorder were excluded. Sociodemographic data and scores from the Positive and Negative Syndrome Scale (PANSS), Global Assessment of Functioning Scale (GAS), Reading the Mind in the Eyes Test (RMET), Facial Emotion Identification Test (FEIT) and Facial Emotion Discrimination Test (FEDT) were recorded. Tests were applied in the following order: PANSS, GAS, FEIT, FEDT, RMET. The GAS was scored based on a psychiatric interview with the patient and caregiver. The PANSS was scored based on the semi-structured interview for PANSS. Information about the tests was given in writing and verbally. The FEIT, FEDT, and RMET were applied by the same person on the computer, without any time limit.
The 79 patients, whose diagnoses were confirmed through hospitalization during active symptom phases, were grouped based on the duration of their illness: 18 patients with <6 months, 35 patients with 6-24 months, and 26 patients with ≥24 months since the onset of illness. Duration of illness was calculated from the onset of symptoms (including the duration of untreated psychosis). The social cognition test results (RMET, FEIT, FEDT) of these 3 groups were compared, and associations between sociodemographic/clinical data and social cognition test scores were analyzed.
Data Collection Form
A structured form was developed by the researchers to record patient identity information, educational background, psychiatric and medical history, substance use history, and clinical assessment scale scores.
Structured Clinical Interview for DSM-5:
A semi-structured interview designed to diagnose psychiatric disorders based on DSM-5 criteria was adapted into Turkish by Elbir et al.22 In this study, it was used for the diagnostic evaluations of the patients.
Reading the Mind in the Eyes Test:
Developed by Baron-Cohen and colleagues in 1999 and validated for Turkish use by Yıldırım et al23 in 2011, the RMET Turkish form Kuder-Richardson reliability coefficient was 0.72 and in this study group, it was calculated 0.76. The RMET assesses social perceptual ToM and emotion recognition abilities. The Turkish version of the test consists of 32 black-and-white images showing only the eye region, and participants select the option that best describes the mental state of the individual in each image. Correct responses are scored as 1, with a maximum possible score of 32. The total number of correct answers reflects the participant’s ToM ability, with higher scores indicating better social cognition.23
Facial Emotion Identification Test and Facial Emotion Discrimination Test:
Developed by Kerr and Neale24 in 1993, these tests assess the ability to perceive emotions, especially in schizophrenia patients. The Turkish validity and reliability study was conducted by Erol et al25 in 2009. In the original psychometric assessment of the FEIT and FEDT, the reliability coefficient alpha was 0.74 for the FEIT and was 0.74 for the FEDT.24 In the psychometric evaluation of these scales in the Turkish patient sample, the test-retest reliability coefficient was found to be 0.90 for the FEIT and 0.70 for the FEDT. In this sample, the reliability coefficient was calculated as 0.674 for the FEIT and 0.741 for the FEDT. The FEIT: This test consists of 19 black-and-white photographs, each depicting 1 of 6 basic emotions. Participants are required to identify the correct emotion from a list of options. Correct responses are scored as 1, with a maximum possible score of 19. The FEDT: This test presents 30 pairs of black-and-white photographs showing facial expressions. Participants must determine whether the emotions in each pair are the same or different. Each correct response earns 1 point, with a maximum possible score of 30.25
Positive and Negative Syndrome Scale:
Developed by Kay et al in 198726 and validated for Turkish use by Kostakoğlu et al27 in 1999, PANSS is the gold standard for measuring symptom severity in schizophrenia. It consists of 3 subscales: the positive symptomatology scale (7 items), the negative symptomatology scale (7 items), and the general psychopathology scale (16 items). Scores for each item range from 1 to 7, with a total minimum score of 30.27 Cronbach alpha reliability coefficients of the Turkish form of PANSS were calculated as PANSS positive 0.75, PANSS negative 0.77, and PANSS general psychopathology 0.71,27 in this study group, they were calculated as PANSS positive 0.58, PANSS negative 0.71, and PANSS general psychopathology 0.62.
Global Assessment of Functioning Scale:
Developed by Endicott et al28 in 1976, the GAS measures psychological, social, and occupational functioning on a scale from 0 to 100. It excludes impairments due to physical or environmental limitations. Higher scores indicate better overall functioning.28
Statistical Analysis
Data analysis was performed using IBM SPSS Statistics (IBM SPSS Corp.; Armonk, NY, USA) for Windows. Normality was assessed using the Kolmogorov-Smirnov test, and skewness and kurtosis values were also examined. Categorical variables were compared using the Chi-Square test, while pairwise comparisons were conducted using the Independent Samples t-test. Categorical variables are given as number (percent) (n(%) ), numerical variables are given as mean ± SD. The ANOVA test was used to compare the means of 3 or more groups. Post-hoc analyses were performed with Bonferroni correction when required. Categorical variables are presented as frequencies and percentages, while continuous variables are presented as mean ± SD. A P-value of <.05 was considered statistically significant.
Results
A total of 79 patients diagnosed with schizophrenia spectrum disorder, aged 18 to 65 years, were included in the study. Among the participants, 65.8% (n = 52) were male, 79.7% (n = 63) were single, and 75.9% (n = 60) had a high school education or less. The duration of illness ranged from 1 to 480 months. Patients were divided into 3 groups based on the time elapsed since disease onset: 22.8% (n = 18) patients with less than 6 months, 44.3% (n = 35) patients with 6 to 24 months, and 32.9% (n = 26) patients with 24 months or more. The sociodemographic characteristics of the participants are summarized in Table 1. The mean age of the group with disease duration >24 months was higher than the other groups (P = .004). Apart from this, the clinical sociodemographic characteristics of the 3 groups were similar. Comparison of sociodemographic and clinical characteristics of the 3 groups are presented in Table 2.
Table 1.
Sociodemographic Clinical Characteristics of the Participants
| n | % | ||
|---|---|---|---|
| Age mean (±SD) | 79 | 31.96 ± 10.1 | |
| Gender | Male | 52 | 65.8 |
| Female | 27 | 34.2 | |
| Education | Primary school | 10 | 12.7 |
| Middle school | 16 | 20.3 | |
| High school | 34 | 43 | |
| Associate degree | 2 | 2.5 | |
| University student | 8 | 10.1 | |
| University degree | 9 | 11.4 | |
| Marital status | Unmarried | 63 | 79.7 |
| Married | 16 | 20.3 | |
| History of alcohol use disorder | No | 75 | 94.9 |
| Yes | 4 | 5.1 | |
| History of substance use | No | 52 | 65.8 |
| Cannabis | 14 | 17.7 | |
| Amphetamine/methamphetamine | 2 | 2.5 | |
| Opioid/cocaine/phencyclidine/ketamine | 0 | 0 | |
| Mixed substance using | 11 | 14 | |
| Smoking | No | 28 | 35.4 |
| Yes | 51 | 64.6 | |
| Medical Comorbidity | No | 65 | 82.3 |
| Yes | 14 | 17.7 |
Categorical variables are given as number (percent) (n(%) ), numerical variables are given as mean +SD.
Table 2.
Comparison of Sociodemographic and Clinical Characteristics of There Groups
| <6 months (n = 18) | 6-24 months (n = 35) | >24 months (n = 26) | P | ||
|---|---|---|---|---|---|
| Age mean (±SD) | 28.7 (±8.9) a | 29.7 (±9.3) a | 37.23 (±10.2) b | .004* | |
| Gender | Male | 13 (72.2%) | 22 (62.9%) | 17 (65.4%) | .792 |
| Female | 5 (17.8%) | 13 (37.1%) | 9 (34.6%) | ||
| Education | Primary school | 5 (27.8%) | 4 (11.4%) | 1 (3.8%) | .409 |
| Middle school | 2 (11.1%) | 8 (22.9%) | 6 (23.1%) | ||
| High school | 6 (33.3%) | 14 (40.0%) | 14 (53.8%) | ||
| Associate degree | 1 (3.8%) | 0 (0%) | 1 (3.8%) | ||
| University student | 2 (11.1%) | 5 (14.3%) | 1 (3.8%) | ||
| University degree | 2 (11.1%) | 4 (11.4%) | 3 (11.5%) | ||
| Marital status | Unmarried | 15 (83.3%) | 26 (74.3%) | 22 (84.6%) | .557 |
| Married | 3 (16.7%) | 9 (25.7%) | 4 (15.4%) | ||
| History of alcohol use disorder | No | 17 (94.4%) | 34 (97.1%) | 24 (92.3%) | .692 |
| Yes | 1 (5.6%) | 1 (2.9%) | 2 (7.7%) | ||
| History of substance use | No | 11 (61.1%) | 23 (65.7%) | 18 (69.2%) | .066 |
| Cannabis | 5 (27.8%) | 5 (14.3%) | 4 (15.4%) | ||
| (Meth)Amphetamine | 0 (0%) | 2 (5.7%) | 0 (0%) | ||
| Mixed substance using | 2 (11.1%) | 5 (14.3%) | 4 (15.4%) | ||
| Smoking | No | 3 (16.7%) | 15 (42.9%) | 10 (38.5%) | .156 |
| Yes | 15 (83.3%) | 20 (57.1%) | 16 (61.5%) | ||
| Medical comorbidity | No | 14 (77.8%) | 29 (82.9%) | 22 (86.6%) | .837 |
| Yes | 4 (22.2%) | 6 (17.1%) | 4 (15.4%) | ||
ANOVA was used to compare mean ages. Other variables were compared using chi-square. *Bonferronni correction was used to calculate significance in subgroup analyses. <6 months vs 6-24 months: P > .05; <6 months vs >24 months: P = .014; 6-24 months vs > 24 months: P > .009.
Bold values indicate variables with statistically significant differences.
When comparing the 3 groups in terms of symptom severity, functionality, and social cognition, no statistically significant differences were observed in mean scores of the PANSS, GAF, RMET, FEIT and FEDT (P > .05) (Table 3). Additionally, Pearson correlation analysis showed no significant relationship between the duration of illness and social cognition test scores (P > .05).
Table 3.
Comparison of Clinical Scale Scores of Three Groups
| mean (±SD) | <6 months (n = 18) | 6-24 months (n = 35) | >24 months (n = 26) | P |
|---|---|---|---|---|
| RMET | 19.4 (±3.7) | 19.7 (±5.6) | 17.8 (±5.3) | .319 |
| FEIT | 12.3 (±3.0) | 10.7 (±2.8) | 10.8 (±3.8) | .213 |
| FEDT | 24.1 (±4.1) | 24.2 (±3.6) | 23.4 (±4.5) | .710 |
| GAS | 22.2 (±4.6) | 19.3 (±7.8) | 21.5 (±8.5) | .315 |
| PANSS scores | ||||
| Positive | 21.5 (±3.9) | 22.1 (±5.4) | 23.5 (±6.8) | .448 |
| Negative | 22.9 (±5.1) | 23.5 (±5.3) | 23.0 (±6.0) | .911 |
| General psycopathology | 36.4 (±4.9) | 38.2 (±7.7) | 36.3 (±6.2) | .472 |
| Total | 80.8 (±10.5) | 83.8 (±12.6) | 82.8 (±15.4) | .744 |
One-way ANOVA was used.
FEDT, Facial Emotion Discrimination Test; FEIT, Facial Emotion Identification Test; GAS, Global Assessment of Functioning Scale; PANSS, Positive and Negative Syndrome Scale; RMET, Reading the Mind in the Eyes Test.
The influence of demographic factors on social cognitive functions was also examined. No significant correlation was found between age and performance on social cognition tests (P > .05). However, when comparing social cognition scores by gender and education level, it was found that female participants scored significantly higher than males on all 3 tests (RMET, FEIT, and FEDT), and participants with higher education levels had significantly higher RMET scores (P < .05). These results are presented in Table 4.
Table 4.
Social Cognition Test Scores According to Demographic Data
| mean (±SD) | n | RMET | FEIT | FEDT | |
|---|---|---|---|---|---|
| Gender | Male | 52 | 18.1 (±5.7) | 10.4 (±3.3) | 22.9 (±4.1) |
| Female | 27 | 20.7 (±3.3) | 12.4 (±2.7) | 25.9 (±2.8) | |
| P | .011 | .009 | <.001 | ||
| Marital status | Unmarried | 63 | 18.8 (±5.1) | 11.1 (±3.5) | 23.7 (±4.2) |
| Married | 16 | 19.8 (±5.5) | 11.0 (±1.7) | 24.8 (±2.9) | |
| P | 0.523 | 0.889 | 0.314 | ||
| Education level | High school and below | 60 | 18.3 (±5.1) | 10.8 (±3.3) | 23.6 (±4.1) |
| Above high school | 19 | 21.3 (±4.6) | 12.2 (±2.7) | 24.8 (±3.6) | |
| P | .027 | .086 | .265 |
FEDT, Facial Emotion Discrimination Test; FEIT, Facial Emotion Identification Test; RMET, Reading the Mind in the Eyes Test.
Bold values indicate variables with statistically significant differences.
To assess the relationship between clinical characteristics and social cognition, Pearson correlation analysis was conducted between PANSS scores, GAF score and the social cognition test scores (RMET, FEIT, and FEDT). A significant negative correlation was found between PANSS negative subscale scores and RMET scores (P < .05), as well as between PANSS total scores and RMET scores (P < .05). Furthermore, a significant negative correlation was observed between PANSS negative subscale scores and FEDT scores (P < .05). These findings are detailed in Table 5.
Table 5.
Relationship Between Age, Clinical Test Scores and Social Cognition Test Scores
| n = 79 | Age | PANSS Positive | PANSS Negative | PANSS Gn Psychopathology | PANSS Total | GAS | |
|---|---|---|---|---|---|---|---|
| RMET | r | −0.147 | −0.172 | −0.395*** | −0.087 | −0.284* | 0.206 |
| P | .197 | .129 | <.001 | .443 | .011 | .069 | |
| FEDT | r | 0.098 | −0.136 | −0.274* | 0.003 | −0.175 | 0.151 |
| P | .389 | .233 | .014 | .980 | .123 | .184 | |
| FEIT | r | −0.131 | −0.115 | −0.103 | 0.001 | −0.092 | 0.082 |
| P | .249 | .314 | .369 | .993 | .422 | .471 |
Pearson correlation analysis was used.
FEDT, Facial Emotion Discrimination Test; FEIT, Facial Emotion Identification Test; PANSS, Positive and Negative Syndrome Scale; RMET, Reading the Mind in the Eyes Test.
*P < .05.
***P < .001.
Bold values indicate variables with statistically significant differences.
Discussion
This study is important because it shows that social cognitive skills do not change with the duration of illness in patients with schizophrenia spectrum disorder and indicates that it can be found as a trait in schizophrenia patients. It is seen that symptom severity does not have a significant confounding effect on social cognitive skills in these 3 groups of patients, whose durations since the onset of the disease are different but whose symptom severity and functionality are similar. Additionally, no significant relationship was found between disease duration and social cognition test scores (theory of mind, emotion recognition, and emotion discrimination tests). In this study, the absence of a significant difference in the impairment in social cognition according to the duration of illness in schizophrenia spectrum disorders is consistent with other studies showing that theory of mind skills do not change in the early period, chronic period, and remission.16 While most authors found no significant relationship between emotion perception ability and disease duration, consistent with the results of this study,29 a few authors reported that emotion perception ability worsened as the disease progressed.30,31 Although the sample includes a wide range of disease duration from the very early period of the disorder to as late as the 480th month of the disorder, the lack of studies following the same samples for many years prevents the clarification of this contradiction in the literature. If the deterioration in social cognitive skills increased during the disease, a negative relationship would be expected between the duration of the disease, age, and social cognition tests; however, in this study, no significant relationship was found between the age of the patients, duration of the disease, and social cognition tests. In this respect, the findings indicate that social cognitive deficits in patients are largely stable from the beginning of the disease.
When other studies are looked at in the literature on this subject, studies examining and monitoring individuals at high risk for psychosis are important sources of information. Individuals who are at clinically high risk for developing psychosis based on subthreshold psychotic symptoms have been referred to as high-risk individuals. High-risk patients present a prodromal picture characterized by changes in behavior and thinking prior to the onset of a psychotic disorder. A review of studies on this subject showed that high-risk individuals had social-cognitive deficits before the onset of the disease.32 In a recent study in North America following individuals at high risk for psychosis, it was observed that social cognitive decline was present in these individuals from the beginning and continued during the 2-year follow-up period.33 In another study, improvement in social cognition was observed within 24 months in those who did not transition to psychosis, while this improvement was not seen in those who transitioned to psychosis.34 In addition, in a study in which family members of schizophrenia patients who were at genetic risk for schizophrenia were evaluated with emotion recognition and theory of mind tests, it was observed that they also experienced social cognitive difficulties.35 This study aligns with research showing that social cognitive impairment exists before the onset of illness and remains unchanged during the illness.13,17,19,20,32-34,36
An important finding of this study is the relationship between social cognition (with theory of mind and emotion discrimination tests) and negative symptoms. The study found a negative correlation between RMET, FEDT, and PANSS negative scores, and it was seen that the increase in social cognitive skills was associated with a decrease in negative symptoms. These findings are consistent with other studies showing that social cognitive skills and negative symptoms are associated, and accordingly, better theory of mind skills predict fewer negative symptoms.16,18 When social cognition is mentioned in schizophrenia, social cognitive abilities are most often understood; such as perceiving social cues, inferring what others are thinking, accuracy in reading instant changes in others, and the ability to regulate emotions. People with schizophrenia are impaired in most, if not all, of these areas. Additionally, there are differences in social motivation and propensity to interact in schizophrenia.37 Although these findings are part of negative symptoms and do not directly express social cognition, they are related to social cognition. Social cognition and social cognitive functions contribute to establishing empathy and healthy communication by correctly understanding the other person’s mind and emotions. In this respect, the lack of social cognitive skills may contribute to the increase in negative symptoms by reducing communication and social interaction. Therefore, it is not surprising that a relationship was found between negative symptoms and social cognitive deficits both in this study and in other studies in the literature.
Differentiating whether social cognitive deficits seen in patients with schizophrenia are developmental deficits or the result of disruption in social functions is important for both diagnostic and therapeutic purposes. The observation of social cognitive deficits in family members of schizophrenia patients35 and in individuals at high risk for psychosis before the onset of the disease32 suggests that these symptoms may have a neurodevelopmental aspect transmitted through a genetic predisposition.38-41 However, it is possible that schizophrenia patients develop additional social cognitive deficits throughout their disease, over many years, in addition to the social cognitive deficits that are present at baseline as a trait. If so, this could only be determined in larger samples and long-term follow-up studies of the same patients.
This study also examined how sociodemographic factors affect social cognitive functions in patients with schizophrenia spectrum disorders. While social cognitive skills are expected to increase during the developmental process, social cognition is expected to decrease with aging.42 In this sample consisting entirely of adults, no significant relationship was found between age and social cognitive functions. The fact that individuals under the age of 18, whose developmental process is ongoing, and patients over the age of 65, who are elderly, were not included in the sample may have caused the lack of a relationship between age and social cognition in the sample. When looking at the relationship between social cognitive skills and gender, studies in the literature are contradictory. While there are studies reporting that social cognitive skills are no different between male and female genders,43 there are also studies showing that women have better social cognitive abilities in both healthy individuals and schizophrenia patients, as in this study, and that this difference may vary from field to field.44,45 The differences in social cognitive skills according to gender may be due to sociocultural characteristics and differences in gender roles, as well as neurofunctional differences in social cognitive characteristics between male and female genders.44,46
The fact that those with higher levels of education in the sample had better social cognitive skills may be related to the fact that those with better social cognition, along with other cognitive functions, were able to receive higher education. On the other hand, this situation may also indicate the positive effect of education on social cognition. Indeed, literature supports this, indicating that psychoeducation on social cognitive functions in patients with schizophrenia increases social cognitive skills.47 The fact that those with higher education in the sample had better social cognition is also consistent with these data. Therefore, although social cognitive deficits seem to be a trait of the disease, in parallel with the findings of the literature and studies, it is important that education is a modifiable factor regarding social cognitive skills and points to the value of psychoeducational interventions and skills training aimed at increasing social cognitive skills.
An important limitation of the cross-sectional study is that patients were evaluated while their symptoms were active and were not re-evaluated in remission. Another limitation is that participants with different disease durations were examined rather than the same patient group being monitored and compared at different times of the disease. In subsequent studies, it would be appropriate to evaluate the social cognitive skills of the same patient group in episodes and remissions and to follow them longitudinally. The aim was to eliminate the confounding effect of other psychotic disorders such as mood disorders, and focus on schizophrenia (and spectrum disorder) patients at different stages of the disease. Therefore, other mental illnesses, including affective psychoses and comorbid mental illnesses, were excluded. But on the other hand, the exclusion of other comorbid mental illnesses is another limitation of this study.
In this study, 2 areas of social cognition were examined, namely social-perceptual ToM and emotion recognition/discrimination. Studies that examine other components of social cognition (social-cognitive ToM, social perception, attribution bias) using more comprehensive batteries that assess social cognition may provide more comprehensive information about the nature and course of social cognitive deficits in schizophrenia. In addition, since the literature consistently reports that there are social cognitive impairments in schizophrenia patients, this study was conducted without a control group; a control group may be included in subsequent studies.
The findings of this study suggest that deficits in social cognition are a marker of the development of schizophrenia rather than a sequela of the schizophrenia process.17 Longitudinal studies of schizophrenia samples and studies examining social cognitive skills in the acute period and remission would be more useful. In addition, when other factors affecting social cognition in schizophrenia patients, such as gender and education level, are considered, although social cognitive deficits in patients seem to be a trait, the importance of psychoeducational and therapeutic interventions aimed at improving social cognition becomes evident.
Funding Statement
The authors declared that this study has received no financial support.
Footnotes
Ethics Committee Approval: This study was approved by the Ankara Bilkent City Hospital Medical Research Scientific and Ethical Evaluation Committee No. 1 (Approval no.: TABED 1-24-153; Date: July 3, 2024).
Informed Consent: Written informed consent was obtained from the patientswho agreed to take part in the study.
Peer-review: Externally peer-reviewed.
Author Contributions: Concept – G.Z.K., Ö.S.Ö.S.; Design – G.Z.K., Ö.S.Ö.S.; Supervision – G.Z.K.; Resources – G.Z.K., Ö.S.Ö.S; Materials – G.Z.K., Ö.S.Ö.S.; Data Collection and/or Processing – G.Z.K., Ö.S.Ö.S, B.Ş., Ö.Ö.E.; Analysis and/or Interpretation – G.Z.K., Ö.S.Ö.S.; Literature Search – G.Z.K., Ö.S.Ö.S.; Writing Manuscript – G.Z.K., Ö.S.Ö.S., B.Ş.; Critical Review – G.Z.K.
Declaration of Interests: Dr. Gülsüm Zuhal Kamış has no conflict of interest in this research but participated as a speaker in the promotional event organized for Ozaprin (olanzapine), a pharmaceutical product of Ali Raif Pharmaceutical Industry IC, on December 22, 2023, and for Serex (quetiapine), a pharmaceutical product of Gensenta Pharmaceutical Industry, on April 29, 2024. The other authors have no conflict of interest to declare.
Data Availability Statement:
Data generated and/or analyzed in the research report can be requested from the corresponding author.
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Data generated and/or analyzed in the research report can be requested from the corresponding author.