Social cognition and quality of life in schizophrenia

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Abstract

Schizophrenia is associated with poor quality of life (QOL). Whereas the effects of neurocognitive deficits and psychopathology on QOL of schizophrenia patients have recently been elucidated, little is known about social cognitive deficits in this regard. This study investigated the influence of social cognition on QOL in schizophrenia. A sample of 1032 patients, 1011 of their siblings, and 552 healthy controls was recruited from the Dutch Genetic Risk and Outcome in Psychosis (GROUP) study. Participants completed a battery of cognitive tests, including social cognitive tests on theory of mind and emotion perception. To assess QOL the World Health Organization QOL Assessment-BREF (WHOQOL-BREF) was used. Schizophrenia symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Social cognitive performance was significantly worse in patients compared to siblings and healthy controls. Patients had the poorest QOL, while QOL in healthy controls was better than in siblings. Theory of mind but not emotion perception or neurocognition was associated with QOL in patients, whereas neurocognition was the only significant predictor of QOL in siblings and healthy controls. There was a significant interaction between theory of mind and symptom severity with respect to QOL. Our study indicates that social cognition is associated with QOL in schizophrenia. Theory of mind rather than emotion perception is associated with QOL, and this association is moderated by schizophrenia symptoms. In particular, patients with relatively unimpaired theory of mind and more severe schizophrenia symptoms have poor QOL and could therefore benefit from therapeutic intervention.

Introduction

Quality of life (QOL) in schizophrenia patients is impaired compared with that in the general population (Ruggeri et al., 2005). Clinical factors, including schizophrenia symptoms and neurocognitive functioning, and socio-demographic variables have been suggested to contribute to the poor life satisfaction of patients with this disorder (Pinikahana et al., 2002, Eack and Newhill, 2007, Fiszdon et al., 2007). However, the associations between neurocognition and QOL are fairly modest and some studies indicate that the association is non-significant when illness severity is taken into account. (Heslegrave et al., 1997, Hofer et al., 2005, Wegener et al., 2005, Matsui et al., 2008). Furthermore, the predictive role of socio-demographic variables appears to be minor (Ruggeri et al., 2005).

QOL and functional outcome in patients with schizophrenia are related (Brekke et al., 2001). The latter scores community functioning, whereas QOL measures subjective life satisfaction (Brekke et al., 2001). Evidence suggests that functional outcome in schizophrenia is more strongly related to social cognition than to neurocognition (McGurk et al., 2007, Pijnenborg et al., 2009, Fett et al., 2011). This raises the possibility that social cognition may be a factor influencing QOL in schizophrenia. To the best of our knowledge, this issue has not been studied so far. Therefore, the aim of the current study was to examine the relation of QOL and social cognition using a large group of schizophrenia patients.

Social cognition is a multidimensional construct (Couture et al., 2006). Theory of mind and emotion perception are important domains of social cognition based on the recent Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) recommendations (Green et al., 2005). Theory of mind is the ability to infer the intentions and beliefs of others, sometimes also referred to as social intelligence (Baron-Cohen et al., 2001). Emotion perception is the ability to infer emotional information from facial expressions (Couture et al., 2006). In this study, we focused on these two core domains of social cognition because they are impaired in schizophrenia and have previously been suggested to play a role in predicting outcome (Couture et al., 2006, Fett et al., 2011). Theory of mind is probably the most important domain in this regard, as it is more strongly associated with community functioning (r = 0.48), compared to other social cognitive domains including emotion perception (r = 0.22) (Fett et al., 2011).

Although neurocognition and social cognition are separable domains (van Hooren et al., 2008), it has been argued that social cognitive impairment in schizophrenia is non-specific and that any association with outcome may be due to confounding by neurocognitive impairment (Kerr and Neale, 1993, Dickinson et al., 2008, Fiszdon and Johannesen, 2010). Estimates of variance in social cognition accounted for by neurocognition range from 34 to 83% (Vauth et al., 2004, Sergi et al., 2007). Importantly, most studies on the association of neurocognition and outcome do not report standardized measures of schizophrenia symptoms, thus neglecting the possibility that schizophrenia symptoms could moderate the relationship between cognition and outcome (Bora et al., 2009, Ventura et al., 2009, Rassovsky et al., 2011). Therefore, we included neurocognition and psychopathology in our analyses. In addition, we investigated the influence of social cognition and neurocognition on QOL of siblings of schizophrenia patients and of healthy controls to compare the effects of these factors on QOL between patients, their relatives and healthy individuals.

We hypothesized that social cognition of schizophrenia patients would predict their QOL. We expected that 1) the nature of the association would be positive, i.e., patients with a relatively unimpaired social cognition have a better QOL, and 2) theory of mind would more strongly predict QOL than emotion perception. To investigate an illness-related association, we explored a possible interaction between schizophrenia symptoms and social cognition in relation to QOL in patients.

Section snippets

Procedure and sample

The data derives from baseline measures of the ongoing longitudinal multicenter study ‘Genetic Risk and Outcome in Psychosis’ (GROUP). The procedure of recruitment, informed consent, approval by the accredited Medical Ethics Review Committee (METC) and population characteristics have been described in a previous report on the GROUP study (N. Korver, P.J. Quee, H.B.M. Boos, C.J.P. Simons, GROUP, unpublished data, 2010). The full GROUP sample consisted of 1120 patients with a non-affective

Results

The current study incorporated a subset of participants from the full GROUP sample. This subsample included 1032 schizophrenia patients, 1011 healthy siblings and 552 healthy controls. A total of 240 patients did not have a corresponding sibling included. The average number of siblings per patient that did have a relative included was 1.3. Sample characteristics are displayed in Table 2. Due to the family structure of the data, the data of patients and siblings was not statistically

Discussion

This study investigated the relationship between social cognition and QOL in schizophrenia taking into account neurocognitive functioning and schizophrenia symptoms. We show that social cognition, rather than neurocognition, is associated with QOL in schizophrenia. Moreover, we found that theory of mind is a more important domain of social cognition than emotion perception in relation to QOL of schizophrenia patients. The inclusion of symptomatology in our analyses revealed an interaction

Role of funding source

The infrastructure for the GROUP study is funded through the Geestkracht program of the Dutch Health Research Council (ZON-MW, grant number 10-000-1002), and matching funds from participating pharmaceutical companies (Lundbeck, AstraZeneca, Eli Lilly, Janssen Cilag) and universities and mental health care organizations (Amsterdam: Academic Psychiatric Center of the Academic Medical Center and the mental health institutions: GGZ Ingeest, Arkin, Dijk en Duin, Rivierduinen, Erasmus Medical Center,

Contributors

AM managed the literature searches. AM and ED undertook the statistical analysis. AM wrote the complete first draft and all authors made meaningful contributions to the writing. All authors contributed to and have approved the final manuscript.

Conflict of interest

There are no conflicts of interest.

Acknowledgments

We are grateful for the generosity of time and effort by the patients and their families, healthy subjects, and all researchers who make this GROUP project possible.

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  • Cited by (0)

    1

    Group Investigators: René S. Kahn (a), Don H. Linszen (b), Jim van Os (c,e), Durk Wiersma (d); Richard Bruggeman (d), Wiepke Cahn(a), Lieuwe de Haan (b), Lydia Krabbendam (c), Inez Myin-Germeys (c)

    (a) Department of Psychiatry, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Utrecht, The Netherlands; (b) Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; (c) South Limburg Mental Health Research and Teaching Network, EURON, Maastricht University Medical Center, Maastricht, The Netherlands; (d) Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; (e) King's College London, King's Health Partners, Department of Psychosis Studies, Institute of Psychiatry, London, United Kingdom.

    Corresponding author at: University Medical Center Utrecht, Department of Psychiatry, Rudolf Magnus Institute of Neuroscience, Universitair Medisch Centrum Utrecht, Locatie AZU, Huispostnummer A 00.241, Postbus 85500. 3508 GA Utrecht, The Netherlands.

    Tel.: + 3 1 88 7557129/ 7558180; fax: + 3 1 88 7555466. E-mail: [email protected].

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