Social cognition describes the ability to understand the actions and intentions of other people. These include processes such as Theory of Mind, social perception, and emotion processing. Theory of Mind refers to the ability to infer the mental states of other people. Social perception is an awareness of social cues and norms that dictate social interactions. Emotion processing is the ability to perceive emotional cues, including the emotional content of facial expressions or vocal inflections (prosody). Social cognition is crucial for effective communication and relates to social competence and may predict work functioning.

What is the evidence regarding social cognition in bipolar disorder?

High quality evidence finds a small reduction in social cognition ability in people with bipolar disorder compared to people without the disorder. There is also a small reduction in this ability in first-degree relatives of people with bipolar disorder. In patients, there is reduced emotional intelligence, and reduced recognition of surprise, fear and disgust emotions. There were no differences in recognition of anger, happiness or sadness between patients and controls.

Moderate to high quality evidence finds a medium-sized decrease in theory of mind ability in people with bipolar disorder. This effect was largest in verbal tasks, in people with bipolar II disorder, and in acute patients.

High quality evidence finds a medium to large reduction in emotion recognition ability in children with bipolar disorder compared to age-matched controls. Unmedicated children showed longer response times in emotion recognition than medicated children. Caucasian children with bipolar disorder showed longer response time and poorer accuracy in emotion recognition than non-Caucasian children. Moderate quality evidence also finds a large effect of decreased theory of mind ability in children with bipolar disorder.

Moderate to high quality evidence finds a medium-sized increase in social cognition ability in people with bipolar disorder compared to people with schizophrenia. This was found on Theory of Mind and negative facial emotion recognition tasks, and particularly in male patients. There were no differences on positive (happy) facial emotion recognition tasks between bipolar disorder and schizophrenia.

Moderate to low quality evidence finds a weak relationship between decreased emotion processing ability and poorer general functioning, particularly with severe depressive symptoms.

October 2021

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Cognitive impairment is a significant problem for many people with schizophrenia, effecting domains such as executive functioning, attention, memory and social cognition. These deficits interfere considerably with day-to-day function. Cognitive remediation or rehabilitation interventions usually take the form of repetitive exercises with or without computers and sometimes augmented by group sessions, strategy coaching and homework exercises, which serve as training for cognitive processes as well as social skills and communication. Strategy learning focuses on providing alternative strategies to compensate for the observed difficulties with cognition; in contrast, rehearsal learning is aimed at restitution of lost skills. This type of intervention is specifically targeted to particular cognitive domains which are known to be deficient in people with schizophrenia, with the intention of compensating or improving functional outcome.

What is the evidence for cognitive rehabilitation interventions?

Moderate to high quality evidence finds a medium-sized benefit of computerised or non-computerised cognitive remediation over control interventions for improving attention, memory, processing speed, problem solving, cognitive flexibility and social functioning. There was also a small benefit for improving symptoms. Moderate to low quality evidence finds similar effectiveness for short (<15 sessions) and long duration of training (>15 sessions), and that strategy learning is more effective than rehearsal learning.

For computerised cognitive drill and practice training, moderate to high quality evidence finds small to medium-sized improvements in attention and positive symptoms when compared to mixed control conditions. There was also a small improvement in functioning. Moderate quality evidence finds medium-sized improvements in working memory and depressive symptoms, and small improvements in psychomotor speed. There were also small improvements in verbal fluency, verbal and visual learning and memory., and negative and total symptoms.

For observation and imitation of social emotions interventions, moderate to high quality evidence finds a medium-sized benefit of improved theory of mind.

September 2020

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Social cognition describes the ability to understand the actions and intentions of other people. Aspects of social cognition may be altered in people with schizophrenia, including processes such as Theory of Mind, social perception, and emotion processing. Theory of Mind refers to the ability to infer the mental states of other people. Social perception is an awareness of social cues and norms that dictate social interactions. Emotion processing is the ability to perceive emotional cues. Social cognition is crucial for effective communication, and may relate to social competence and predict work functioning.

What is the evidence for social cognition?

Moderate to high quality evidence finds large effects of impaired social perception, emotion perception, and emotion processing, and medium-sized effects of impaired social knowledge, biological motion processing, and empathetic abilities in people with schizophrenia. In general, those with predominately negative symptoms show poorer social cognition than those with predominately positive symptoms. Facial emotion perception can be adversely affected by more severe negative symptoms, and non-emotional recognition may be adversely affected by more severe positive symptoms. High quality evidence shows a very small improvement in facial affect processing with antipsychotic medication, particularly second-generation antipsychotics.

High quality evidence shows a large theory of mind impairment in people with schizophrenia across multiple tasks, and regardless of sex or age. People with disorganised symptoms were particularly impaired on theory of mind tasks. Moderate quality evidence finds patients in an acute phase of the illness performed worse on theory of mind tasks than outpatients or patients soon to be discharged from hospital. Overall, poorer cognition was related to poorer theory of mind.

High quality evidence finds a small to medium-sized theory of mind impairment in relatives of people with schizophrenia, with lower education contributing to lower theory of mind scores. Moderate to high quality evidence also finds medium-sized theory of mind and overall social cognition impairments in people at ultra-high risk of psychosis.

Moderate to high quality evidence finds associations between better theory of mind and emotion processing, and better social functioning, community functioning and insight. There were also associations between poorer facial recognition, emotion processing, emotion perception, social perception, and theory of mind, and poorer performance on cognitive measures and more severe symptoms.

Moderate to high quality evidence finds a medium-sized effect of poorer social cognition in people with schizophrenia than in people with bipolar disorder on theory of mind and negative facial emotion recognition tasks, particularly in males. There were no differences on positive (happy) facial emotion recognition tasks. There were also no differences between people with schizophrenia and people with autism on theory of mind and emotion processing tasks.

March 2022

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