Clinical Neuropsychiatry (2015) 12, 3, 64-72
IMPROVEMENT IN COGNITIVE AND AFFECTIVE THEORY OF MIND WITH OBSERVATION AND
IMITATION TREATMENT IN SUBJECTS WITH SCHIZOPHRENIA
Maria C. Pino, Mario Pettinelli, Daniela Clementi, Carlo Gianfelice, Monica Mazza
Abstract
Objective: the main objective of this study is to consider Theory of Mind (ToM), i.e. the ability to perceive other
people in terms of thinking, believing and emotions, as a target for effective rehabilitative intervention, using Emotion
and ToM Imitation Training (ETIT), aimed at improving social cognition and social functioning in schizophrenia.
ToM impairment is a key feature of schizophrenia. According to recent literature, ToM is a multidimensional process
requiring at least two components: cognitive and affective. Cognitive ToM seems to be a prerequisite for affective ToM,
which requires intact empathic ability.
Method: seven patients with schizophrenia completed ETIT treatment and were compared to 7 patients who
participated in Problem Solving Training (PST). The participants were assessed at pre and post treatment regarding
measures of cognitive (Advanced Theory of Mind Task and Social Situation Test) and affective (Emotion Attribution
Task and Eyes Task) ToM and also empathy (Empathy Quotient).
Results: our results showed that when compared to the control group, ETIT participants improved in three social
cognition components evaluated (cognitive and affective ToM and empathy). Improvement in cognitive and affective
ToM was found within the ETIT group pre and post treatment.
Conclusions: Action observation and imitation could be important goals for future “low cost” rehabilitation
treatment in several disorders in which the deficit of social cognition is considered as “core” to the disease. This
represents a new perspective in the rehabilitation field.
Key words: empathy, schizophrenia, social cognition, theory of mind, training
Declaration of interest: none
Maria C. Pino1, Mario Pettinelli2 , Daniela Clementi2 , Carlo Gianfelice2 , Monica Mazza1
1. Department of Life, Health and Environmental Sciences, University of L’Aquila
2. Mental Health Department ‘Area Vasta 2 ’, Fabriano, Italy
Corresponding author
Maria Chiara Pino, PhD student
Department of Life, Health and Environmental Sciences,
University of L’Aquila
Via Vetoio, Località Coppito, 67100 L’Aquila
E-mail address: [email protected]
Tel: +39 0862 433401
Introduction
The ability to attribute mental state to oneself and
others is part of a complex construct called Social
Cognition (Dziobek et al. 2006). Social Cognition is
crucial for successful social interaction because this
ability allows people to understand the intentions and
mental states of other people and use the right and
suitable behaviour for social situations. Subjects with
schizophrenia show deficits, in inferring the mental
state of other people (Mazza et al. 2010). Definitions
of social cognition range from basic competences
such as theory of mind disorder (Brune 2005), to more
complex descriptions such as “the ability to construct
representations of the relations between oneself and
other people and to use those representations flexibly
to guide social behaviour” (Adolphs 2001, Mazza et
al. 2010, p. 676). Social cognition broadly includes the
cognitive processes used to decode and encode the social
world. As such, a more complete description of this
64
concept must include the ability to process information
about all people, including oneself, and about norms
and procedures of the social world. Recently, a
number of studies have shown social cognition to be a
predictor of social functioning (Brune 2005, Lehmann
et al. 2014). However, social cognition difficulties
often make it hard for subjects with schizophrenia to
be successful members of society and often present
serious challenges to parents and other professional
figures. The basic component of social cognition is a
Theory of Mind (ToM) mechanism, which includes
the processes used to perceive other people in terms of
thinking, believing, pretending or perceiving emotions
(Mazza et al. 2010). These components allow the
individual to conceptualise other people’s mental states
(e.g., their beliefs, knowledge and intentions). Premack
and Woodruff (1978) termed ToM as the activity of
explaining and predicting much of other people’s
behaviours (Mazza et al. 2010). Other researchers have
also included within the definition of ToM the ability
Submitted February 2015, accepted June 2015
© 2015 Giovanni Fioriti Editore s.r.l.
Improvement in cognitive and affective theory of mind
to undestand feelings (Shamay-Tsoory et al. 2005).
It is likely that ToM is a multidimensional process,
requiring the integration of at least two components
(Sebastian et al. 2012, Mazza et al. 2014). The
Shamay-Tsoory model (2010) distinguishes cognitive
from affective subprocesses of ToM (Sebastian et al.
2012). Cognitive ToM or mentalizing ability refers
to the capacity to make inferences about the beliefs
and intentions of other people, while affective ToM
refers to the ability to infer what a person is feeling.
According to the Shamay-Tsoory model (2010),
cognitive ToM is a prerequisite for affective ToM and
the latter requires intact empathy processing, which is
defined as experiencing the affective or sensory state
similar to that shown by another individual (Fan et al.
2011). Empathy in the narrow sense, or “true empathy”,
refers to other-directed, vicarious affective responses,
and requires a clear distinction between oneself and
other people. In addition, empathy depends on emotion
regulation, cognitive control and non-social cognitive
functioning (Decety and Jackson 2004, Lehmann et al.
2014). It seems only a few studies have investigated
alterations of the affective components of social
cognition (affective ToM and empathy) in schizophrenia
(Montag et al. 2007, Sparks et al. 2010, Lehmann et al.
2014). Most of the research focuses on mentalizing and
cognitive aspects of social cognition in schizophrenia
(Konstantakopoulos et al. 2014, Lehmann et al. 2014);
whereas the affective conditions of empathy (such as
impairment in the cognitive component of ToM, but
could have intact immediate experience of emotion and
emotional reactions in response to emotional stimuli;
and (2) that the ETIT could improve the cognitive ToM
deficit and strengthen the affective abilities of ToM and
empathy.
Methods
Participants
Fourteen schizophrenic subjects (7 female, 7
males) were recruited from the Day Centre of the
Department of Mental Health of Fabriano (Ancona)
Italy, and participated in this study. Diagnoses of these
patients were made by a trained interviewer, using DSMIV-R Structured Clinical Interview (APA, 2000). The
participants’ socio-demographic details are reported in
table 1.
At the time of testing, patients were taking newgeneration antipsychotics whose mean chlorpromazineequivalent dose (Kessler and Waletzky 1981) was
654.83 mg (SD 513.2). In addition, six patients were
taking valproato (1083 mg; SD 341), three were taking
antidepressants (sertraline: 83 mg; SD 57.7), two were
taking antiparkinsoniani (biperidene) and 10 were
taking benzodiazepines (diazepam: 11.8 mg; SD 5.7)
during the period of treatment. Participants’ intelligence
Table 1. Socio-demographic details of participants
Age
Gender
Years of Education
Mounts of illness
Raven Total
ETIT GROUP
Mean (s.d.)
45 (16.91)
4 M; 3 F
9.83 (3.32)
17 (9.63)
28.33 (2.65)
PST GROUP
Mean (s.d.)
42.25 (8.20)
3 M; 4 F
10 (2.33)
14.50 (11.77)
25.25 (4.68)
affective ToM) have not been examined as frequently
(Brune 2005). The traditional rehabilitative approach
in treating social cognition disorders is mainly based
on techniques aimed at a variety of psychosocial
methodologies, including cognitive remediation and
social skills training, which have been shown to partially
improve social cognition (Mazza et al. 2010; Hogarty et
al. 2004, Roncone et al. 2002). As reported by Combs
et al. (2007) only a few studies address the problem of
social cognition components rehabilitation treatments in
schizophrenia using metacognitive techniques (Combs
et al. 2007, Gambini et al. 2004, Hasson-Ohayon et al.
2009, Mazza et al. 2010). Our previous study (Mazza
et al. 2010) created the only rehabilitation treatment
that was based on social cognition sub-components.
This treatment was called Emotion and ToM Imitation
Training (ETIT).
Our purpose of this study was to compare ETIT
efficacy to another frequently used intervention in
schizophrenia known as Problem Solving Skill Training
(PST). In the current study, we examined the functional
impact of ETIT compared to PTS on social cognition
sub-components, compared to the ability to empathise
and ToM. We specifically tested the hypothesis that
associations between social cognition and functional
outcome would be mediated by the capacity to infer
the mental and emotional state of other people and the
ability to empathise with them. The hypotheses are:
(1) that patients with schizophrenia would show an
Clinical Neuropsychiatry (2015) 12, 3
T
(df=2,12)
.405
P
.693
-.111
.437
1.439
.913
.670
.176
levels, were examined with Raven progressive matrices
(PM38) (Raven 1938). All participants gave their
informed consent. Patients were followed for three
months, with interview, at baseline (T0) and 12 weeks
(T1). Data were collected through clinical interview,
psychological evaluation and rating scales of social
functioning. Subjects were divided into two groups,
composed of seven people, respectively.
Study design
Randomisation was independently conducted at
the Day Centre of the Department of Mental Health
of Fabriano. A random-number table was used to
generate lots that were drawn in sealed envelopes, each
assigning the respective patient to the ETIT or PST
group. Patients were assessed before and after treatment
on key outcome variables including clinical symptoms,
neurocognitive function and social functioning.
Clinical scales
Brief Psychiatric Rating Scale-24 (BPRS) Italian
version (Italian version; Roncone et al. 1999) was used.
Each symptom on the 24-item scale was rated on
levels ranging from 1 to7 (1=absence of symptoms; 7=
65
Maria C. Pino et al.
very severe symptoms). The key score was obtained by
adding the scores of all of the items of the scale. Five
symptom clusters were found after performing a factor
analysis on the BPRS scores on a larger sample of 225
psychiatric patients. The Disorganised cluster, included
items 12 (Bizarre behaviour), 13 (Self-neglect), 14
(Disorientation), and 15 (Conceptual disorganisation).
The Negative affect cluster included items 16 (Blunted
affect), 17 (Emotional withdrawal) and 18 (Motor
retardation). The Positive symptoms cluster included
items 9 (Suspiciousness), 10 (Hallucinations) and
11 (Unusual content of thoughts). The Mania cluster
included items 7 (Mood elevation); 8 (Grandiosity),
21 (Excitement) and 23 (Motion Hyperactivity). The
Depression cluster included items 3 (Depression),
4 (Suicidality), and 5 (Guilty). The last cluster, the
Anxiety cluster included items 1 (Somatic concern),
and 2 (Anxiety). Symptoms were assessed based on the
month previous to the evaluation.
Social functioning
The Personal and Social Performance scale (PSP)
was interviewer-administered to the member of the
rehabilitation team in charge of each patient. These
key workers provided information based on their
knowledge of the patient’s behaviour. PSP was derived
from the social functioning component of the DSM-IV
social and occupational functioning assessment scale
(SOFAS) (Morosini 2000). PSP was designed to be
administered only by trained clinical staff (e.g., nurses,
aides, rehabilitation workers), and allows the clinician
to assign a total score on the basis of the information
gathered by an interview. Patient functioning is assessed
in four main areas: socially useful activities (SOA);
personal and social relationships (PSR); self-care (SC);
and disturbing and aggressive behaviours (DAA).
Difficulty in each area is rated on a single item using a
six-point scale: Absent, Mild, Manifest but not marked,
Marked, Severe, very severe, where lower ratings
indicate better functioning. A global item is then rated
by the interviewer, summarizing the data coming from
the four areas and assigning a score ranging from 1 to
100 in ten-point intervals, where lower scores indicate
poorer functioning (Morosini 2000).
The basic score ranges and the corresponding levels of
functioning described by the developers are: 1–30 (Poor
functioning, requiring intensive support or supervision);
31–70 (Manifest disabilities of various degrees); 71–90
(Mild difficulties); and 91–100 (More than adequate
functioning). The inter-rater reliability for the global
score, measured by the intra-class correlation coefficient
(ICC), was 0.98 and the weighted Kappa was 0.94.
Social Cognition Measures
Cognitive ToM
Advanced Theory of Mind Task: This task is an
Italian adaptation of a cognitive task used by Blair
and Cipolotti (2000) and proposed in the literature by
Happé (1994). The task consists of a short version of
13 comic stories, each accompanied by two questions;
the comprehension question “Was it true, what X said?,”
and the justification question “Why did X say that?”.
The 13 story-types included Lie, White Lie, Joke,
Pretend, Misunderstanding, Double Bluff, and Contrary
Emotion. Each subject obtaines a score ranging from 0
to 1 for each question. The maximum score is 13.
66
Social situation task: this addresse an aspect of social
cognition: the ability to process the appropriateness of
behavior in different social contexts (Blair and Cipolotti
2000).This task investigates the capacity to judge the
appropriateness of behaviour that may induce anger
in observers. Twenty-five short stories which describe
social situations incorporating behaviour were read by
the subject. At various points in every story, the subject
must assign a value about how appropriate the behaviour
was, giving a score from A to D. A grades meant that he
judged the situation as normative. B to D grades meant
that he judged the situation as a norm violation and
indexed the extent of the violation (B grades being mild
and D being serious). Blair and Cipollotti (2000) report
that previous piloting on a large, independent sample of
healthy controls had resulted in the identification of a
set of consistently identified normative situations and
violations. Two scores were obtained for this task: one
referring to the number of normative situations and the
other one to the number of correctly identified violations.
The third refers to the extent to which the patient judged
the violations to be socially inappropriate. For each
situation, the participant obtained a score between 0 and
3, matching their response of A to D (A= 0, B=1; C=2
and D = 3).
Affective ToM
The Eyes Task is a revised version of the “Reading
the Mind in the Eyes Test” (Baron-Cohen et al. 2001a).
In brief, participants are given 36 photographs depicting
the ocular area in an equal number of different actors
and actresses. At each corner of every photo, four
complex mental state descriptors, e.g. dispirited, bored,
are printed, only one of which (the target word) correctly
identifies the depicted person’s mental state, while the
others are included as foils. The test is scored by totaling
the number of items (photographs) correctly identified
by the participant; therefore, the maximum total score
is 36. In the Italian version the internal consistency
(Cronbach’s alpha) was .605. Test-retest reliability for
the Eyes test, as measured by intraclass correlation
coefficient, was .833 (95% confidence interval=.745 to
.902). The study of Vellante and collaborators (2013)
confirms the validity of the Eyes test. Both internal
consistency and test-retest stability were good for the
Italian version of the Eyes test.
In the Emotion Attribution Task (Blair and Cipolotti
2000). This task assessed ability to represent the emotions
of others. In this task, the participant was presented with
58 short stories describing an emotional situation and
was required to provide an emotion describing how
the main character might feel in that situation. The
sentences were designed to elicit attributions of positive
and negative emotions. The task was scored according
to the number of correct attributions. As well validation
studies are lacking for this test (Mazza et al. 2007).
Empathy
Empathy Quotient (EQ). (Baron-Cohen and
Wheelwright 2004; Baron-Cohen et al. 2001b): this is
self- administered questionnaire made to 40 questions
which evaluated empathy and 20 control items. It is
designed to examine empathy competences. Participants
were asked to indicate whether they strongly agree,
slightly agree, slightly disagree or strongly disagree with
a statement. Each of the items listed scores 1 point if the
respondent records the empathic behaviour mildly or 2
points if the respondent records the behaviour strongly.
Clinical Neuropsychiatry (2015) 12, 3
Improvement in cognitive and affective theory of mind
Intervention conditions
Emotion and ToM Imitation Training (Mazza et al.
2010). ETIT is a group-based intervention that aims to
improve social cognition processes such as empathy
and theory of mind in individuals with schizophreniaspectrum disorders.
Seven subjects, randomly selected, were considered
eligible for the ETIT rehabilitation program, consisting
of a two-days-per-week treatment over a 12-week
period, with each session lasting approximately 50
minutes and composed of four phases.
Phase 1: participants observed the eye direction in
photos of normal people (session 1) and then complete
a computerised task (session 2). In the first session,
subjects observed sketches in which a little figure and
human face directs his/her eyes towards an object. By
observing the direction of the eyes, patients formulate a
judgement on the congruity of what is represented. With
this observation, participants could interpret someone’s
intention. During session 2, subjects performed a
computerised eyes-orienting attention task. In this task,
we used two centrally placed cues that enabled subjects
to predict when a subsequent target would occur. Each
cue consisted of an arrow or a gaze with three different
orientations (front, right and left). The appearance of a
cue as an arrow or gaze anticipated the appearance of
the target by 600 ms.
Phase 2: the participants observed faces in specific
paintings and then imitated facial emotional expression
using a mirror. The primary goal of Phase 2 (sessions
3 and 4) was to learn and associate an emotion to a
facial expression by imitating the expression of each
emotion. Subjects had to observe 50 sketches and
guess the emotion of the character. Later, the operator
mimicked three facial expressions with emotional
meaning and subjects, looking in the mirror, replicated
the expression that matched the emotion described in
the sketch. Facial expressions play a crucial role in
human communication (Darwin 1872, Ekaman 1993).
The expression on a person’s face provides a variety of
information about the person, the situation, and feedback
about how to respond appropriately. Expressions of
anger convey a signal to modify behaviour, whereas
expressions of happiness can reward and maintain
current behaviour. In other words, facial expressions
help to regulate one’s reactions to others. We assessed
whether practice in imitating expressions would
improve the ability to self-generate expressions, in the
absence of the modelled expression (Schwartz et al.
2006). The intervention also included two further steps,
which are not based on the observation of processes as
required by the intervention, but allow patients to work
on ToM tasks. Also in the following two phases (3 and
4 phases) the task is implicitly based on an imitative
strategy. Imitation is a difficult and complex issue,
but it is necessary when the subject makes inferences
about others’ mental states or creates a representation
of others’ intentions, thus becoming one of the main
sources of learning. Introspection shows that imitation
also plays a significant role in adult learning. In fact, this
mechanism is prevalent in much of everyday decisionmaking activity, in particular when the environment is
complex or largely unknown (Apesteguia et al. 2004).
Phase 3: participants inferred a character’s mental
state in a social situation shown in a sequence of
sketches. Emotions can be caused by specific situations
(for instance, falling down causes crying, or being given
a present causes happiness), but they can also be caused
by mental states, such as desires and beliefs (Harris et al.
1989), Phase 3’s primary goal (sessions 5 and 6) was to
Clinical Neuropsychiatry (2015) 12, 3
understand emotional causation through the knowledge
of a subject’s desires and beliefs. Subjects were invited
to observe 20 sketches representing a typical social
situation, only having to guess what the character’s
feelings were like and what they would feel in the same
situation. The subjects were asked both to interpret the
social and emotional context of the figure represented
and their emotional expression, and to predict what the
represented characters would do in that context.
Phase 4: participants attributed intentions through
the observation of other people’s actions. The primary
goal of Phase 4 (sessions 7 and 8) was the attribution
of intentions through the observation of other people’s
actions in a sequence of comic strips (Sarfati et al.
1997). The stories were designed to depict simple
first order intentional behaviour, and involved human
agents whose situations or behaviours in the correctanswer picture required inferring their intentions. A
special effort was made to avoid emotional situations,
expressions, or social interaction between figures;
behaviour underpinned by beliefs; and higher order
mental states. The patient’s task was to consider the
character’s mental state by having to decide whether the
examiner had ended the story correctly. The observer
could “read” the intention of the acting individual.
This intention-reading interpretation predicts that,
in addition to the mirror neurons that fire during
the execution and observation of the same motor act
(“classical mirror neurons”), there should be neurons
that are visually triggered by a given motor act but are
discharged during the execution of a different motor act
(Arbib 2007). The treatment sessions were conducted
in groups with a psychologist, a psychiatrist and two
rehabilitation therapists. These staff members had the
role of demonstrating and simulating the scenes and of
clarifying the task the subjects had to perform. After 30
minutes of training work during each session, there was
a pause of 5 minutes, to help participants relax, and to
give them encouragement (based on the level of their
participation within the group and their right answers
during treatment) for taking part in the work group. At
the end of each session, the participants were invited to
carry out further “in vivo” practices as homework.
Problem Solving Training (PST). Another group
composed of seven subjects performed the PST
program (Barbieri et al. 2006, Falloon and Talbot
1982, Veltro et al. 2011). A structured method to
resolve problems, such as PST, allows patients with
schizophrenia to develop solutions to everyday issues.
It works by assigning them a role of responsibility and
the experience of active problem management. PST
includes perceptive and attentive task, along with skills
in specific social situations. In addition, PST does not
require participants to give predetermined solutions, but
aims to teach thought strategies that allow the choice of
a solution based on careful evaluation of their actions
and those of others. PST is divided into four stages of
increasing complexity, identification and definition of
practical problems to solve interpersonal problems, and
finally intrapersonal management of crisis situations
and suffering. The program was composed of four
phases:
Phase 1: patients clarified their current personal life
goals and the problems they must overcome to achieve
those goals. They were instructed about the six-step
structured problem solving method and used this to
deal with practical problems related to one or more of
their goals, such as shopping, nutrition, exercise, use
of transport, budgeting and scheduling daily activities.
Phase 2: patients dealt with interpersonal problems
such as making friends, expressing positive feelings,
67
Maria C. Pino et al.
giving and receiving criticisms, etc.
Phase 3: problems of residual psychotic and nonpsychotic symptoms were addressed in this part of
the course. In addition to the six-step problem solving
structure, patients learned to perform a problem
analysis that helps to formulate the precise nature of
the problem.
Phase 4: in the final phase, issues of coping with
distressing feelings associated with major life crises
were addressed, including major stressful life events,
persisting intolerable stressors, and recurrent major
episodes of illness. These could include coping with
a full range of emotions, fear, sadness, jealousy,
anger, frustration, disappointment and their associated
behaviours, such as aggression, self-harm, withdrawal,
and substance use. Techniques used included
brainstorming, role-play, cognitive restructuring,
homework, information and social reinforcement. The
task group provided modelling, immediate feedback
and opportunities for application of skills in the “here
and now”. In addition, work focused on issues related
to the concrete life of the participants. The usual steps
of PST are to define problems in specific terms, to
think creatively to try to find an alternative solution, to
bring the positive or negative side to every situation, to
choose the best solution, to break the chosen solution
into a series of achievable steps and to evaluate the
effectiveness of the choice. The main targets of this
method are to help individual patients achieve the
objectives that they consider most important to their
life. The program had the same structure as the ETIT
program. It consisted of a two-days-per-week treatment
over a 12-week period, with each session lasting
approximately 50 minutes and composed of four phases.
In the same way as the ETIT treatment, sessions were
conducted in groups with a psychologist, a psychiatrist
and two rehabilitation therapists. These staff members
had the role of demonstrating and simulating the scenes
and of clarifying the task subjects had to perform. After
30 minutes of training work during each session, there
was a pause of 5 minutes, to help participants relax, and
to give them encouragement (based on the level of their
participation within the group and their right answers
during treatment) for taking part in the work group. At
the end of each session, participants were invited to
carry out further “in vivo” practices as homework.
Results
We ran t-tests to examine baseline (T0) differences
between ETIT and PST groups on clinical and
demographic variables. We found no differences
between the two groups in the distribution of age,
educational level, length of illness, chlorpromazine
equivalent dosage levels, and IQ level (see table 1). In
addition, there were no differences on social cognition
measures, symptoms and the personal and social
performance scale at baseline (see table 2). Thus, the
two groups were quite comparable before the start of
the treatment. There were no drop-outs from either
treatment group and every participant completed the
Table 2. Clinical and Social Cognition details between both groups pre-treatment (TO)
ETIT GROUP
Mean (s.d.)
PST GROUP
Mean (s.d.)
Clinical measures
BPRS Cluster
Positive
10.17 (3.43)
6.63 (4.27)
Negative
4.17 (2.71)
3.50 (3.33)
Psychotic
22 (4.05)
16.88 (8.13)
Disintegration
Depression
4 (2.60)
4.75 (2.25)
Mania
5.63 (1.92)
7 (4.09)
PSP total score
37.33 (12.54)
42.38 (8.86)
SOA
3.25 (0.71)
3.33 (0.8)
SC
1.75(1.28)
1.83 (1.32)
PSR
1.88 (1.19)
1.83 (0.55)
DAA
0.88 (0.83)
1.33 (1.75)
Cognitive ToM
Advanced Theory of
8.33 (1.96)
8.88 (1.45)
Mind Task
Social situation task:
Normative
12 (2.09)
11.25 (2.25)
Violations
20 (3.09)
19.75 (3.01)
Gravity
40.17 (11.82)
43.25 (13.30)
Affective ToM
Eyes Task
22.83 (6.17)
20.25 (5.70)
Emotion Attribution
38.50 (6.15)
38.88 (7.47)
Task
Empathy
Empathy Quotient
51.67 (9.91)
38.63 (12.07)
T
df=2,12
P
-1.66
.789
.122
.440
-1.41
.184
.577
-.841
.884
-.204
-.119
-1.89
- .651
.575
.417
.394
.841
.908
.089
.525
-.594
.434
.634
.152
-.449
.538
.882
.661
.810
.564
-.100
.922
2.152
0.06
PSP: Personal and social performance scale; SOA: socially useful activities; SC: self-care; PSR: personal and social
relationships; DAA: disturbing and aggressive behaviours
68
Clinical Neuropsychiatry (2015) 12, 3
Improvement in cognitive and affective theory of mind
Table 3. Clinical and Social Cognition details between both groups post-treatment (T1)
Clinical measures
BPRS Cluster
Positive
Negative
Psychotic
Disintegration
Depression
Mania
PSP total score
SOA
SC
PSR
DAA
Cognitive ToM
Advanced Theory of
Mind Task
Social situation task:
Normative
Violations
Gravity
Affective ToM
Eyes Task
Emotion Attribution
Task
Empathy
Empathy Quotient
ETIT GROUP
Mean (s.d.)
PST GROUP
Mean (s.d.)
T
df=2,12
P
8 (3.57)
1 (1.09)
6.13 (5.11)
3.50 (3.70)
.100
-.765
.922
.459
16.33 (2.33)
13 (8.55)
1.588
.184
2.5 (1.64)
5.63 (1.92)
54.17 (11.01)
3.13 (8.35)
1.13 (1.26)
2.50 (.99)
0.75 (.71)
2.5 (2.26)
5.33 (2.58)
54.75 (10.72)
3 (8.94)
0.83 (0.75)
3.50 (.75)
0.50 (.84)
0
-.162
.884
.299
.547
.086
.591
.575
.874
.394
.792
.595
.933
.556
12.33 (.81)
8.63 (2.32)
3.705
.003
13.50 (1.87)
20.50 (3.45)
42.33 (11.55)
12.63 (2.44)
20.13 (3.44)
44 (12.81)
.728
.202
-.251
.480
.844
.806
29.83 (6.17)
22.25 (4.65)
3.437
.005
49.33 (3.20)
42.88 (5.02)
-.100
.018
55 (7.37)
37.38 (8.10)
4.179
0.001
PSP: Personal and social performance scale; SOA: socially useful activities; SC: self-care; PSR: personal and social
relationships; DAA: disturbing and aggressive behaviours
pre- and post-test assessments.
We ran t-tests to examine post-treatment (T1)
differences between ETIT and PST groups on social
cognition measures. Differences between the two
groups were found in the advanced Theory of Mind
Task (Cognitive ToM; t1,12=3.705; p=.003); in the eyes
task, in the emotion attribution task (Affective ToM;
respectively, t1,12=3.437; p=.005 and t1,12=2.742; p=.018)
and in the Empathy Quotient (Empathy; t1,12=4.179;
p=.001; see table 3). Other significant differences were
not found.
In addition, pre and post treatment analyses within
the two groups were conducted. In the ETIT group,
significant differences pre and post treatment were
found in the Positive (t1,12=2.892; p=.032) and Psychotic
Disintegration (t1,12=2.841; p=.036) clusters, of BPRS.
Moreover, significant differences in the advanced
Theory of Mind task (Cognitive ToM; t1,12=18.462;
p=.008) and in the Emotion attribution task (Affective
ToM; t1,12=19.049; p=.007) were also found. Both groups
showed improvement in the PSP total score (ETIT
groups: t1,12=9; p=.0001; PST group t1,12=5.1; p=.004)
and on the personal and social relationships subscale
(ETIT groups: t1,12=5; p=.004; PST group t1,12=11.13;
p=.0001). Other significant differences were not found
in the two groups between pre and post treatment (see
table 4).
Clinical Neuropsychiatry (2015) 12, 3
Discussion
The present study provides evidence of the
effectiveness of social cognition as a rehabilitation
strategy based on observation and imitation in
schizophrenia. Moreover, it points out that such simple
interventions could improve the ability of patients with
schizophrenia to make inferences about other people’s
emotions and mental states and strengthen their
empathic ability.
The ultimate aim of this study was to adopt a
rehabilitative approach, taking into account the
components and development of social cognition, in
order to train patients to enhance the basic abilities of
social cognition that schizophrenics are lacking in.
Specifically, in our research, we evaluated the
improvement of social ability after ETIT and PST
treatment, using a variety of assessment instruments
and splitting the evaluation into three components:
cognitive ToM, affective ToM and Empathy. Our results
show an improvement in the ETIT group compared to
the PST group, in three components, namely in the
Advanced Theory of Mind Task (cognitive ToM); the
Eyes and the Emotion Attribution tasks (affective ToM);
and Empathic Quotients (Empathy). The comparison
between pre and post treatment data, within the ETIT
group, showed a specific improvement in the Advanced
69
Maria C. Pino et al.
Table 4. Clinical, Social Cognition and personal and social performance measures in both groups pre and post
treatment
PRE
ETIT
Clinical measures
BPRS Cluster
Positive
10.17 (3.43)
Negative
4.17 (2.71)
Psychotic
22 (4.05)
Disintegration
Depression
4 (2.60)
PTS total score
37.33 (12.54)
SOA
3.25 (0.71)
SC
1.75 (1.28)
PSR
1.88 (0.54)
DAA
0.88 (0.83)
Cognitive ToM
Advanced Theory of
8.33 (1.96)
Mind Task
Social situation task:
Normative
12 (2.09)
Violations
20 (3.09)
Gravity
40.17 (11.82)
Affective ToM
Eyes Task
22.83 (6.17)
Emotion Attribution
38.50 (6.15)
Task
Empathy
Empathy Quotient
51.67 (9.91)
POST
8 (3.57)*
1 (1.09)
PST
PRE
POST
6.63 (4.27)
3.50 (3.33)
6.13 (5.11)
3.50 (3.70)
16.33 (2.33)*
16.88 (8.13)
13 (8.55)
2.5 (1.64)
54.17 (11.01)**
3.13 (0.82)
1.13 (1.32)
2.50 (1.19)*
0.75 (1.75)
4.75 (2.25)
42.38 (8.86)
3.33 (0.81)
1.83 (1.32)
1.83 (0.75)
1.33 (1.75)
2.5 (2.26)
54.75 (10.72)*
3 (.89)
0.83 (0.72)
3.50 (1.54)**
0.50 (0.83)
12.33 (.81)*
8.88 (1.45)
8.63 (2.32)
13.50 (1.87)
20.50 (3.45)
42.33 (12.81)
11.25 (2.25)
19.75 (3.01)
43.25 (13.30)
12.63 (2.44)
20.13 (3.44)
44 (12.81)
29.83 (3.12)
20.25 (5.70)
22.25 (4.65)
49.33 (3.20)*
38.88 (7.47)
42.88 (5.02)
55 (7.37)
38.63 (12.07)
37.38 (8.10)
*p < .01; **p < .001
PSP: Personal and social performance scale; SOA: socially useful activities; SC: self-care; PSR: personal and social
relationships; DAA: disturbing and aggressive behaviours
Theory of Mind Task and the Emotion Attribution
Task, which measure cognitive and affective ToM
respectively. On the whole, our results suggest that
ToM competences can be modified by imitation.
In fact, when we look at someone’s face and try to
identify a particular emotional state, the emotion of that
other person is spotted and then, through a simulation
including embodied identification that produces the
same position is shared by the observer (Leslie et al.
2004). To date, there have been very few studies about
imitation in schizophrenia (Thakkar et al. 2014). Based
on the ideomotor model, a growing body of research
suggests that the mirror neuron system activates when
an action is observed, imitated, and empathically
understood (Rizzolatti 2005, Kim 2013). When
observing other people’s performance, the human brain
simulates the performance of the observed action. This
simulation pro­cess could reinforce sophisticated mental
functions such as obser­vational learning (Rizzolatti and
Arbib 1998). The mirror neurons system in humans
plays a role in understanding not only other people’s
actions but also their emotions. Many neuroscience
studies have shown that this system, involving visceralmotor centers, allows people to recognize each other’s
emotions, in the same way that visual-motor centers
allow people to recognize each other’s actions (Gallese
et al. 2004, Kim 2013). Neuroimaging studies (Decety
and Jackson 2004) have shown that when looking at
70
a photo of situations which are likely to cause pain
there were significant bilateral changes in activity in
several regions, notably the anterior cingulate, the
anterior insula, the cerebellum, and to a lesser extent
the thalamus, which are known to play a significant
part in the processing of pain. The results suggest a
direct link between perceiving emotion in another
individual and experiencing it for oneself. For this
reason, it is important to develop a social cognition
training that relies more on observation and imitation
than conventional psychotherapeutic approaches, in
particular those based on social cognition competences.
This study confirms the results of our previous research
(Mazza et al. 2010) and shows that subjects who
receive ETIT improve in three components of social
cognition (cognitive and affective ToM and empathy).
To make sense of this data, we can say, that patients in
the ETIT group became more able to understand other
people’s actions, intentions, emotions and seemed to
be more empathic compared to those in the PTS group.
Regarding clinical results, the ETIT group showed
an improvement between pre and post treatment in
positive and psychotic disintegration clusters. These
results demonstrate that an improvement of social
cognition abilities causes an enhancement of some
clinical symptoms. In addition, both treatments (ETIT
and PST) caused an improvement in social and personal
functioning. In particular, the two groups improvemed
Clinical Neuropsychiatry (2015) 12, 3
Improvement in cognitive and affective theory of mind
on the personal and social relationships subscale.
Unfortunately, the small sample group is an
important limitation to our study. Another important
limitation of this study relates to the rehabilitation
intervention: the method should be manualized to make
it more controlled and rigorous; but at present there are
few studies that have used this treatment. Furthermore,
in any future research on this topic a follow-up period
should be allowed for see if the results are long lasting.
Our rehabilitative approach could be use for not
only for patients with schizophrenia, but also for several
psychiatric conditions implying an impairment in social
and empathic abilities, such as autism spectrum disorder
(Mazza et al. 2014) or post-traumatic stress disorder
(Mazza et al. 2013).
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