Self-reported empathy deficits are uniquely associated with poor functioning in schizophrenia

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Abstract

Background

Social cognitive deficits have been proposed to be among the causes of poor functional outcome in schizophrenia. Empathy, or sharing and understanding the unique emotions and experiences of other people, is one of the key elements of social cognition, and prior studies suggest that empathic processes are impaired in schizophrenia. The current study examined whether impairments in self-reported empathy were associated with poor functioning, above and beyond the influences of neurocognitive deficits and psychopathology.

Methods

Individuals with schizophrenia (n = 46) and healthy controls (n = 37) completed the Interpersonal Reactivity Index (IRI), a measure of emotional and cognitive empathy. Participants also completed a neuropsychological test battery, clinical ratings of psychopathology, and functional outcome measures assessing both functional capacity and community functioning. After testing for between-group differences, we assessed the relationships between self-reported empathy and the measures of functioning, neurocognition, and psychopathology. Regression analyses examined whether empathic variables predicted functional outcomes.

Results

Individuals with schizophrenia reported lower IRI scores for perspective-taking and empathic concern, and higher IRI scores for personal distress than controls. Among individuals with schizophrenia, lower perspective-taking, greater disorganized symptoms, and deficits in working memory and episodic memory were correlated with poorer functional capacity and community functioning. Lower scores for perspective-taking explained significant incremental variance in both functional capacity (ΔR2 = .09, p < .05) and community functioning (ΔR2 = .152, p < .01) after accounting for relevant neurocognitive and psychopathological variables.

Conclusions

Impaired perspective-taking, a component of cognitive empathy, is associated with poor functioning even after taking into account the influences of neurocognitive deficits and psychopathology. These findings support further efforts to clarify the underlying causes of empathic disturbances and suggest that treatments for these disturbances may help functional recovery 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.

References (62)

  • A.K. Fett et al.

    The relationship between neurocognition and social cognition with functional outcomes in schizophrenia: a meta-analysis

    Neurosci. Biobehav. Rev.

    (2011)
  • H. Fujiwara et al.

    Female specific anterior cingulate abnormality and its association with empathic disability in schizophrenia

    Prog. Neuropsychopharmacol. Biol. Psychiatry

    (2008)
  • J.M. Gold

    Cognitive deficits as treatment targets in schizophrenia

    Schizophr. Res.

    (2004)
  • P.L. Jackson et al.

    How do we perceive the pain of others? A window into the neural processes involved in empathy

    Neuroimage

    (2005)
  • S.J. Lee et al.

    Multi-level comparison of empathy in schizophrenia: an fMRI study of a cartoon task

    Psychiatry Res.

    (2010)
  • C. Montag et al.

    Self-reported empathic abilities in schizophrenia

    Schizophr. Res.

    (2007)
  • K.H. Nuechterlein et al.

    Identification of separable cognitive factors in schizophrenia

    Schizophr. Res.

    (2004)
  • Y.J. Pan et al.

    Affect recognition as an independent social function determinant in schizophrenia

    Compr. Psychiatry

    (2009)
  • C.A. Pedersen et al.

    Intranasal oxytocin reduces psychotic symptoms and improves theory of mind and social perception in schizophrenia

    Schizophr. Res.

    (2011)
  • A.E. Pinkham et al.

    Neurocognitive and social cognitive predictors of interpersonal skill in schizophrenia

    Psychiatry Res.

    (2006)
  • A. Sparks et al.

    Social cognition, empathy and functional outcome in schizophrenia

    Schizophr. Res.

    (2010)
  • N.C. Andreasen

    The Scale for the Assessment of Negative Symptoms

    (1983)
  • N.C. Andreasen

    The Scale for the Assessment of Positive Symptoms

    (1983)
  • D.M. Barch et al.

    Context-processing deficits in schizotypal personality disorder

    J. Abnorm. Psychol.

    (2004)
  • W. Barratt

    The Barratt Simplified Measure of Social Status (BSMSS): Measuring SES

    (2005)
  • C.D. Batson

    These things called empathy: eight related but distinct phenomena

  • A. Bechara

    The neurology of social cognition

    Brain

    (2002)
  • A.S. Bellack et al.

    Assessment of community functioning in people with schizophrenia and other severe mental illnesses: a white paper based on an NIMH-sponsored workshop

    Schizophr. Bull.

    (2007)
  • A.L. Benton et al.

    Multilingual Aphasia Examination

    (1976)
  • C.S. Carter et al.

    CNTRICS final task selection: social cognitive and affective neuroscience-based measures

    Schizophr. Bull.

    (2009)
  • M.J. Cuesta et al.

    Psychopathological dimensions in schizophrenia

    Schizophr. Bull.

    (1995)
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