Towards an integrative approach to understanding quality of life in schizophrenia: the role of neurocognition, social cognition, and psychopathology

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Abstract

The term “schizophrenia” refers to a debilitating group of disorders that usually results in a severely impaired quality of life (QoL). Symptomatology appears to have a substantial role in determining QoL, although the relationship between QoL and specific psychotic symptoms is still unclear and has demonstrated mixed results. Due to the intrinsic importance of social functioning in QoL, and the mediating effect of social cognition on social functioning, the aim of this study was to try to investigate QoL in schizophrenia, not only in terms of symptomatology, but also in consideration of potential neurocognitive and social cognitive contributing factors.

Methods

Twenty-eight clinically stable patients with schizophrenia performed a broad range of neurocognitive and social cognitive assessments, and also participated in a semi-structured interview of QoL, assessing four partially independent subdomains of QoL. A stepwise regression model was used to determine the best predictors of QoL, and additionally a mediator analysis was performed to test for the mediating power of social cognition on QoL.

Results

Negative symptoms, intelligence, executive functioning and social cognition all had some power in predicting QoL in schizophrenia. Though most interestingly, mental state reasoning was specifically found to be most strongly related with the Intrapsychic Foundation subdomain of QoL, whereas neurocognition and symptom severity were associated with other subdomains of QoL.

Conclusions

The association between mental state reasoning and the more “internal” aspects of QoL in schizophrenia may reflect a specific role for social cognition in introspective and subjective judgments of one's own QoL, whereas neurocognition and negative symptomatology may be more predictive of the external or extrinsic aspects of QoL. In conclusion, social cognitive skills appear to play a crucial role in the experience of one's own subjective well-being, which could help to explain previous inconsistencies in the literature investigating QoL in schizophrenia.

Introduction

Quality of life (QoL) is defined as “a multidimensional evaluation of an individual's current life circumstances in the context of the culture in which they live and the values they hold” [1]. A wealth of studies have shown that subjective well-being, the prime measure of QoL, is severely compromised in patients with schizophrenia [2]. Put simply, the ultimate goal of remission in psychiatric illness is to improve quality of life.

In the past, symptom severity has been proposed to be the most important illness-related factor determining QoL in schizophrenia [3], however, the evidence for this assumption has received mixed empirical support. Norman et al. [4], for example, reported that patients who reported a greater subjective well-being expressed a lower severity of positive symptoms. However, on the other hand, others found lower negative symptoms to be more associated with better QoL [5], specifically in treatment-resistant patients receiving clozapine [6]. In addition, it has also been argued that women tended to have fewer negative symptoms than men, which could explain the greater potential of the former to attain a better QoL in the social community [7], [8]. Finally, a challenging study using both medicated and unmedicated patients with schizophrenia found no effect of the symptomatology on QoL [9], suggesting that the association between symptomatology and QoL is at best loose.

Recent research points to the fact that subjective well-being is not merely a matter of symptom reduction, but also heavily relies on neurocognitive functioning [10], [11], [12], [13]. In support of this assumption, [14] reported that deficits in visual sustained attention, executive functioning, working memory and motor skills were found to be independent predictors of QoL, as measured by the Quality of Life Enjoyment and Satisfaction Questionnaire [15] and the Quality of Life Scale for Schizophrenia [16]. In their study, neurocognition explained 15% to 35% of the overall variance in QoL when severity of symptoms, medication effects and socio-demographical variables were controlled for. This has been supported by a recent meta-analysis demonstrating small to moderate effect sizes of verbal fluency, working memory, verbal list learning, processing speed, and executive functioning in predicting QoL [17]. In contrast to these findings, Heslegrave et al. [18] found no effect of visual sensory memory, perceptual span and visual processing on QoL. It is therefore plausible to assume that there may be other cognitive factors playing a role in mediating QoL in schizophrenia that have not been previously taken into consideration.

One candidate domain could be “social cognition”, which is defined as “the mental operations underlying social interactions” [19], and which has emerged as a critical mediator between neurocognition and functional outcome, as well as being a substantial predictor of social functioning [20], [21], [22]. Moreover, QoL has been shown to be highly associated with social functioning, thus sharing common ground in the macro social domain [23].

A recent factor analysis has identified three main domains of social cognition that are particularly impaired in schizophrenia (reviewed in [24]): (1) Emotion perception, which comprises of multiple impairments in emotion recognition from facial expression and prosody, emotion discrimination, and emotional awareness; (2) mental state reasoning and decoding, encompassing “theory of mind” (ToM) skills, that is, the ability to represent other people's thoughts and intentions; (3) attributional style, referring to the tendency to whether negative or positive situations are causally attributed to oneself or to others.

To the best of our knowledge, only one study has sought to explore the specific role of social cognition in QoL in schizophrenia [25]. They found that neurocognition and mental state reasoning (ToM), as measured with the Hinting Task, were associated with QoL, whereas emotion perception was not. Importantly, both negative and positive symptomatology served as a mediating factor between ToM skills and QoL. Specifically, patients with preserved ToM skills and relatively high total PANSS scores tended to have a lower QoL, whereas those with preserved ToM and lower symptoms had a better QoL. However their conclusion on the mediating role of negative symptoms is questionable as a substantial number of studies have concluded that social cognitive domains, including ToM skills, are independent from symptom clusters in schizophrenia, specifically from negative symptoms [13].

In sum, there is clearly a paucity of studies that take all possible predictors of QoL in schizophrenia into consideration, namely symptom severity, neurocognition and social cognition. Accordingly, the present study included measures of symptomatology, neurocognition and social cognitive performance comprising mental state reasoning and decoding, emotion perception and attributional style. We hypothesized that symptom severity, neurocognition, and social cognition would make independent contributions to predict QoL in schizophrenia, and that these domains would impact differentially on sub-categories of QoL.

Section snippets

Participants

Participants were 28 adult patients (13 men) with SCID confirmed DSM-IV diagnosis of schizophrenia. All participants were recruited from the Psychosis Unit of Celal Bayar University Psychiatry Department and were clinically stable. Exclusion criteria for all potential participants were having a known neurological disease, current substance abuse, mental retardation or acute psychotic episode in the last 6 months. The mean age was 24.14 ± 10.47 and education level 11.18 ± 3.18. Participants had, on

Results

Table 2 shows the correlations between QoL subdomains and independent predictors. Accordingly, the Interpersonal Relations subdomain of QoL was related with estimated intelligence, executive functioning, the cognitive domain of ToM, reasoning and negative symptoms. Instrumental Role was correlated with estimated intelligence, mental state reasoning and negative symptoms. Intrapsychic Foundation was associated with estimated intelligence, processing speed, verbal learning, mental state reasoning

Discussion

The present study sought to examine the predictive role of symptomatology, neurocognition and social cognition on QoL in schizophrenia. In essence, the results partially support our hypothesis of the independent role of social cognition on QoL. Specifically, mental state decoding was found to be a significant predictor of the Intrapsychic Foundation subdomain of QoL, which encompasses an individual's motivation, sense of purpose, curiosity, aimless inactivity, empathy and emotional interaction.

Acknowledgment

Drs Burak Uykur and Cengiz Cengisiz are gratefully acknowledged for their close collaboration on the data collection.

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