Self-reported empathy deficits are uniquely associated with poor functioning in schizophrenia☆
Introduction
Deficits in community functioning are hallmarks of schizophrenia and include diminished capacity for competitive employment, independent living, and social interaction (Bellack et al., 2007). Recovery-oriented treatment programs emphasize interventions to improve the underlying causes of these disturbances in the hope that overall functional outcomes will also improve (Glynn et al., 2006, Harvey and Bellack, 2009). Substantial evidence indicates that neurocognitive deficits contribute to poor functional outcomes (Green, 1996), which led to efforts to find new drug and non-drug treatments for neurocognitive deficits (Gold, 2004, Barch and Smith, 2008). More recently, social cognition has become differentiated from other domains of cognition (Green et al., 2008), and there is increasing interest in determining whether social cognitive deficits may have influences on functioning that are distinct from the influences of other cognitive deficits.
Social cognition is a multifaceted construct that encompasses a set of processes involved in understanding and responding to the social cues, motives, and actions of others (Green et al., 2005). Research in schizophrenia has thus far focused on only a subset of these processes. For example, individuals with schizophrenia show deficits in facial emotion perception (Kohler et al., 2010) and the understanding that others have unique mental states (i.e., theory of mind) (Brune and Brune-Cohrs, 2006, Bora et al., 2009). Such deficits have been associated with poor community functioning, and these associations are stronger than those found between other cognitive deficits and poor functioning (Fett et al., 2011). Furthermore, they contribute to the prediction of functioning over and above other cognitive deficits (e.g. Roncone et al., 2002, Pinkham and Penn, 2006, Pan et al., 2009, Brune et al., 2011). These findings demonstrate social cognition's “added value” in explaining functioning and suggest that efforts should be made to develop interventions that target social cognitive deficits (Fett et al., 2011).
Empathy is another element of social cognition and it can be distinguished from emotional perception and theory of mind. Empathy refers to the ability to share and understand the unique emotions and experiences of other people (Shamay-Tsoory, 2011), and while empathy is a central concept in social cognitive neuroscience (Eslinger, 1998, Lieberman, 2007), it has received relatively little attention in schizophrenia research. Although several definitions and models of empathy have been proposed (Batson, 2009), most researchers agree that there are both emotional and cognitive processes involved in empathy that are supported by distinct neural substrates (Decety and Jackson, 2004, Shamay-Tsoory, 2011).
As described by Shamay-Tsoory (2011), emotional empathy refers to sharing emotional reactions to the observed experiences of others. In contrast, cognitive empathy refers to engaging in reasoning about, and adapting to, another person's emotional point of view, while maintaining a clear self-other distinction. Some prominent models posit that these two components of empathy interact with memory and executive regulatory processes to promote empathic responding, and that recalling past experiences is critical for generating appropriate empathic responses (Bechara, 2002, Decety and Jackson, 2004, Lieberman, 2007). As such, impaired self-reported empathy in schizophrenia has been previously correlated with measures of executive function (Shamay-Tsoory et al., 2007). Thus, engaging in emotional and cognitive empathy, and the integrity of the relationships between these empathic components and other neurocognitive processes, are critical for adaptive interpersonal and community functioning.
Available evidence, although sparse, suggests that individuals with schizophrenia show impairments in both emotional and cognitive empathy as compared to healthy controls (Langdon et al., 2006, Lee, 2007, Shamay-Tsoory et al., 2007, Achim et al., 2011). However, no prior studies have examined whether empathic disturbances relate to functional outcome in schizophrenia. In addition, little is known about the relationships between empathic impairments and deficits in other cognitive domains or psychopathology. In two studies, the capacities for emotional and cognitive empathy were associated with attention and executive functioning (Shamay-Tsoory et al., 2007, Derntl et al., 2009). In some (Haker and Rossler, 2009, Sparks et al., 2010), but not all (Montag et al., 2007, Fujiwara et al., 2008, Achim et al., 2011) studies, self-reported empathic deficits have been associated with negative symptoms, though not with reality distortion (e.g., hallucinations, delusions) or disorganization (Haker and Rossler, 2009, Achim et al., 2011). Given the paucity of research on these relationships, additional examination is needed.
The primary goal of the current study was to examine whether impairments in self-reported empathy were uniquely associated with poor functional outcomes in schizophrenia. Individuals with schizophrenia and healthy controls were assessed using an established self-report measure of emotional and cognitive empathy, as well as an extensive battery of neuropsychological tests, clinical ratings of psychopathology, and measures of functioning, including a performance-based measure of functional capacity and ratings of community functioning. Based on prior research and theoretical models, we hypothesized: (1) the schizophrenia group would show impaired emotional and cognitive empathy compared to controls; (2) within the schizophrenia group, deficits in empathy, neurocognition, and psychopathology (particularly negative and disorganized symptoms) would correlate with poor functioning; (3) within the schizophrenia group, deficits in empathy would correlate with neurocognition (particularly executive functioning and episodic memory) and negative symptoms. Finally, we hypothesized that lower levels of empathy would explain variation in functioning in individuals with schizophrenia even after accounting for any variance associated with deficits in neurocognition and psychopathology.
Section snippets
Participants
Participants were recruited through the Northwestern University Schizophrenia Research Group (NU-SRG) and included 46 individuals with a DSM-IV research diagnosis of schizophrenia and 37 control subjects. Individuals with schizophrenia were recruited from local advertisements and outpatient mental health service providers located in the Chicago metropolitan area, while controls were recruited from surrounding communities. All participants were interviewed using the Structured Clinical Interview
Participant characteristics
Demographic characteristics for the schizophrenia and control groups are presented in Table 1. The groups did not significantly differ in terms of gender, parental socioeconomic status, or race. A trend level age difference was present, and thus, we examined age as a covariate in the primary analyses below. However, including age as a covariate did not change the pattern of results and age is therefore not considered further. Individuals with schizophrenia were chronically ill with a mean
Discussion
To our knowledge, this is the first study to examine whether impairments in self-reported empathy are associated with poor functional outcomes in schizophrenia. We hypothesized that (1) individuals with schizophrenia would have impaired emotional and cognitive empathy compared to controls; (2) their deficits in empathy, neurocognition, and psychopathology would correlate with poor functioning; (3) their deficits in empathy would correlate with neurocognition and negative symptoms; and (4) that
Role of funding source
Funding for this study was provided the Department of Psychiatry and Behavioral Sciences at Northwestern University Feinberg School of Medicine.
Contributors
All authors have made significant scientific contributions to this manuscript. Dr. Smith contributed to the conceptualization of the study, conducted the statistical analyses, and wrote the first draft of the manuscript. Dr. Horan contributed to the conceptualization of the study and assisted with statistical analyses and manuscript editing. Ms. Karpouzian and Ms. Abram contributed to the conceptualization of the study, and assisted with the literature review and manuscript editing. Drs.
Conflicts of interest
There are no conflicts of interest between the authors and the reported research.
Acknowledgments
The authors wish to acknowledge research staff at the Northwestern University Schizophrenia Research Group for study coordination and data collection.
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Sources of Support: Support for the preparation of this paper was provided by the Department of Psychiatry and Behavioral Sciences at Northwestern University Feinberg School of Medicine and the Northwestern University Schizophrenia Research Group.