The relationship between negative symptoms, social cognition, and social functioning in patients with first episode psychosis
Introduction
Social functioning, defined as the ability to work, study, and live independently, as well as to establish interpersonal relationships and adequate leisure activities (Zarate and Land, 2000), is severely affected in psychotic disorders (Heering and van Haren, 2016; Kaneko, 2018; Velthorst et al., 2017). For years, many authors have tried to identify the predictors of functioning in patients with first episode of psychosis (FEP). Among them, we can highlight the role of neurocognition, lower premorbid functioning, longer duration of untreated psychosis (DUP), younger age at onset, substance use problems, or lower educational attainment (Austin et al., 2013; Bratlien et al., 2013; Chang et al., 2018; Devoe et al., 2018; Gerritsen et al., 2020; Hall et al., 2019a; Mellor-Marsá et al., 2017; Robertson et al., 2014; Santesteban-Echarri et al., 2017; White et al., 2009). Apart from these well studied factors, the role of the severity of the psychopathology, especially negative symptoms (Austin et al., 2013; Bratlien et al., 2013; Devoe et al., 2018; Díaz-Caneja et al., 2015; Gerritsen et al., 2020; Mellor-Marsá et al., 2017; Robertson et al., 2014; White et al., 2009), as well as social cognition (Dziwota et al., 2018; González-Ortega et al., 2020; Green et al., 2012; Horan et al., 2012; Jansen et al., 2020) seem to play an important role in social functioning.
Negative symptoms have been defined as a deficit in the ability to perform the normal functions of living, as shown in apathy, blunted affect, emotional withdrawal, poor rapport, and lack of spontaneity (American Psychological Association, 2022). In recent years, negative symptoms have been conceptualized in two categories (Marder and Galderisi, 2017), deficits related to emotional expressiveness (blunted affect and alogia) and those related to a decrease in the interaction with the environment (i.e., experiential deficits: avolition, anhedonia, and asociality)(Blanchard and Cohen, 2006; Kirkpatrick et al., 2006; Millan et al., 2014). The proposition that negative symptoms are composed of more than a single dimension could have important implications (Jang et al., 2016), as they would be associated to different clinical presentation (Strauss et al., 2013), underlying mechanisms (Millan et al., 2014), and functional outcomes. In this sense, previous studies have shown that experiential deficits would have a greater association with global (Glenthøj et al., 2016) and social functioning (Pelletier-Baldelli and Holt, 2020; Robertson et al., 2014; Strassnig et al., 2015; Wilson and Koenig, 2014).
Social cognition can be defined as the mental operations that underlie social interactions (Green et al., 2008, 2019). Research to date has identified four fundamental components of social cognition (Couture, 2006): Theory of Mind (ToM) (Lindgren et al., 2018; Premack and Woodruff, 1978), social perception, attributional style, and emotional processing (Mayer et al., 1999; Mondragón-Maya et al., 2017). Measures of social cognition are increasingly being applied to the study of psychopathology, including schizophrenia and other psychotic disorders (Hellemann et al., 2017), with previous works reporting deficits in social cognition in all stages of the psychotic illness (Healey et al., 2016; Lecardeur et al., 2013; Sen et al., 2020), including the clinical high-risk state (van Donkersgoed et al., 2015), and their association with functional outcomes (González-Ortega et al., 2020). Thus, social cognition could be a factor of key importance both in the prognosis and the global recovery of patients who suffer first episode psychosis (Mancuso et al., 2011; Wiersma et al., 2000).
At present, the relationship between these three essential domains in psychotic disorders (social functioning, social cognition, and negative symptoms) is not clear, and while some authors suggest that social cognition would directly impact functioning (Glenthøj et al., 2016; González-Ortega et al., 2020), others defend that the effect of social cognition deficits in functioning may be mediated by the negative symptoms (Eack and Keshavan, 2020; Lincoln et al., 2011), being the negative symptoms the real world consequences of deficits in social cognition (Pelletier-Baldelli and Holt, 2020).
In recent years, network analysis has gained popularity, constituting a powerful methodological approach for investigating the complex patterns of interaction that could occur between different variables, after controlling the effect of the rest of the variables that make up the network (Epskamp et al., 2018b). Moreover, in contrast to other techniques, it neither requires an a priori assumption regarding the association among the variables nor the selection of predictors, mediators, and outcome measures (Galderisi et al., 2018a, Galderisi et al., 2018b). Previous works have used this technique to study the relationship between cognition, functioning, and/or clinical symptoms in psychotic spectrum disorders (Chang et al., 2020; Galderisi et al., 2018b; Hajdúk et al., 2021; Hasson-Ohayon et al., 2018; Moura et al., 2021). However, previous studies either have not included measures of social cognition (Chang et al., 2020), have not taken into account the different dimensions of negative symptoms (Galderisi et al., 2018b; Hajdúk et al., 2021), or have measured global but not social functioning (Hasson-Ohayon et al., 2018; Moura et al., 2021). Expanding knowledge regarding how these areas are related could be essential for improving our understanding of the underpinnings of social dysfunction in early psychosis and designing early intervention programs (Arango et al., 2017).
In this study, we sought to assess the interrelation between social cognition (specifically emotional processing), social functioning, and the expressiveness and experiential factors of negative symptoms in first-episode psychosis. With all that in mind, we formulated the following hypothesis: there will be an indirect relationship between the emotional processing component of social cognition and social functioning that will be influenced by negative symptomatology.
Section snippets
Sample
Our sample consisted of 196 patients with FEP evaluated between February 2013 to May 2019. All of them were participants in the AGES-CM observational study (www.agescm.es), which is carried out in hospital and outpatient facilities of 7 public hospitals in the Madrid region. The inclusion criteria were: a) age between 17 and 40 years; and b) positive psychotic symptoms of less than 24 months of evolution in the context of a first episode psychosis according to DSM-IV (coded diagnoses F20-29, or
Results
The sample consisted of 196 patients, with a mean age of 25.08 (±5.67) years (range 23). Most of the patients were men (n = 127; 64.8%), single (n = 172; 88.7%), and had secondary education (n = 116; 59.5%). Regarding the most common diagnoses, 56 patients were diagnosed with unspecified psychosis (28.6%), 48 with schizophrenia (24.5%), and 38 with schizophreniform disorder (19.4%) (see Table 1).
Fig. 1 shows the estimated network, including the emotional processing component of social
Discussion
Previous literature has shown that functioning is associated with negative symptoms and social cognition both in schizophrenia and first episode psychosis (González-Ortega et al., 2020; Kaneko, 2018). Although the relationship between these three variables is widely recognized, as far as we know, no previous study has examined the interrelationships between them in FEP patients, considering the expressiveness and experiential factors of negative symptoms. This distinction could have important
Funding
This work has the support of the Community of Madrid (R&D Activities in Biomedicine S2017/BMD-3740 [AGES-CM 2-CM]) and Structural Funds of the European Union. Ana Izquierdo's work is funded by the ISCIII predoctoral program PFIS [FI17/00138] and co-funding by the European Union (ERDF/FSE). Covadonga M. Díaz-Caneja has received grant support from Instituto de Salud Carlos III, Spanish Ministry of Science and Innovation [PI17/00481, PI20/00721, JR19/00024]. Roberto Rodriguez-Jimenez has received
Declaration of competing interest
Roberto Rodriguez-Jimenez has been a consultant for, spoken in activities of, or received grants from: Instituto de Salud Carlos III, Fondo de Investigación Sanitaria (FIS), Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid Regional Government (S2010/BMD-2422 AGES; S2017/BMD-3740), JanssenCilag, Lundbeck, Otsuka, Pfizer, Ferrer, Juste, Takeda, Exeltis, Angelini, and Casen-Recordati. Angela Ibáñez has received research support from or served as speaker or advisor for
Acknowledgements
The authors of this study would like to thank all the people who have collaborated in our training. We would also like to thank all the people of the AGES-CM team who have participated in the data collection as well as all the patients who have participated in this study.
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These authors have contributed equally to this article.