1. Introduction
Social cognition (SC) is a mental assembles which includes all operations encountered in the process of perceiving, understanding & production of appropriate reactions while confronting with others. The amounts of elements included in social cognition domain are varied but in general it ranges from 3 to 5 areas. These include: social awareness, theory of mind, attributive style, and emotion processing. Social awareness means making inferences about social situations in a specific social circumstances & applying this knowledge, comprehension in producing suitable response; while theory of mind (ToM) is related to the talents of understanding, comprehension of other’s thoughts, opinions, intuitions & to differentiate between it and one’s own; attributive style (AS), which is concerned with how people tend to attribute and explain causes of situations that they are encounter in their life either caused by the misconduct of others or by themselves and lastly emotion processing which concerned with recognizing of different emotions, expressions and management process [1] [2].
Social cognition skills have been recognized as a vital component in the rehabilitation process for schizophrenic persons, its strong contributors in social function among individual suffering from schizophrenia [3] [4]. The purpose of this review is to appraise various researches about social cognition and its correlates in addition to evaluating various cognitive interventions targeted toward improving social cognition function among patients group and to find the greatest methods to eliminate social cognitive deficits in schizophrenia.
1.1. Search Strategy (Figure 1)
Guidelines for preferred reporting items for systematic review were utilized. The following databases were searched: Pub Med, science direct, internet, and Midline from the period from the year 2000 to October 2018. The search terms used were “Social cognition”, emotional management program, schizophrenia.
A total of 85 articles were identified and those who meet inclusion criteria including 27 articles.
1.2. Inclusion Criteria
We set out the following inclusion criteria:
1) Target group had a diagnosis of schizophrenia.
2) Systematic review was conducted up to May 2018.
3) Focused on empirical study or systematic review.
4) Focused on evidence based intervention program.
5) Focused on recommendation of authenticate source.
1.3. Exclusion Criteria
1) Not a peer-reviewed original research article, e.g. commentary, editorial, letter, report, guidelines or conference or meeting proceedings.
2) Not published in English.
2. Results
Twenty seven articles have been recognized to meet inclusion criteria were categorized into two parts:
・ PART I: -DESCRIPTIVE STUDIES (Table 1)
Twelve descriptive studies were drawn to provide data about natures of social cognition deficit, organic origin for social cognition insufficiency in schizophrenic persons and relation between social cognition and social function among schizophrenic patients.
Zhua LX et al. (2013) compare between nearly one hundred schizophrenic patients & one hundred healthy subjects regarding eye movement while recognizing of different emotions and expression. They found that patients with schizophrenia have limited ability in emotion recognition process especially for negative faces. They attribute this to the presence of -ve symptoms which may influence patient ability in visual scrutinize stricture [5].
Regarding organic origin for social cognition insufficiency in schizophrenic persons; Akara SA et al. (2015) monitor recorded EEG (Electroencephalogram) data to examine neural network in the left fronto-temporal area during emotional processing task [6]. They record EEG in 2 circumstances. First one while latent period and second one during hearing stimulation using white noise. Results indicating the presence of abnormality in the left fronto-temporal area.
While Razafimandimby A et al. (2016) uses Magnetic Resonance Imagine to examine the neural activity under two different conditions. First condition is to
examine neural base while producing emotional sentences. Second condition is to examine neural base while producing grammatical composition [7]. Results shows irregularity observed in cortex praefrontalis while producing passionate sentences. This indicates an organic origin for social cognition insufficiency in schizophrenic persons. In general, many studies revealed abnormality in neural activity in schizophrenia using theory of mind tasks.
From another aspect Vogel B et al. (2016) investigates the ability of the patients to associate between both verbal & nonverbal cues [8]. Different video shows were offered to twenty one patients versus 21 control subject. Results indicate that patients be inclined to stand their choice fewer on expressions cues and depend more on verbal statement than matched group.
There was much focus from research on emotional processing as one of essential elements of social cognition. Tabak, N. T et al. (2015) examined emotional intelligence (EI) trait in manic and schizophrenic patients versus corresponding control group. The purpose of study was to examine emotional intelligence trait & its relation to clinical and social factors among studied groups [9]. Results reveal that both clinical groups show considerable poorer perceived emotional intelligence trait than corresponding group, but did not change from each other. Higher total emotional intelligence traits associated with elevated levels of self-governing living in both groups. The result proposed that emotional intelligence disturbance affecting community functioning in both groups.
Moreover, Zou MY (2018) administrate deposit of checklists cover different aspect of emotional processing including emotional expression and regulation, experiential pleasure plus assessing anhedonia, depressive symptoms & negative symptoms. Subject of study included one hundred forty six in-patients with schizophrenia versus seventy three corresponding group. Results show three-groups. Group 1 differentiate by a shortage in experiential enjoyment and emotional regulation, group 2 differentiate by a universal shortage in experiential enjoyment, emotional regulation and emotion expression, and group 3 differentiate by a shortage in emotion expression [10]. literature study was done by Fiszdon, J. M., & Reddy, L. F. (2012) which target social cognitive interventions in schizophrenia, finding indicate that there was a variety of interference have be initiated to target ToM, affect recognition, social perception, affect recognition but there is no attempt have particularly embattled ascription bias, emotional intelligence or social knowledge [1].
Edit Vass et al. (2018) compare intervention method to observe to what extent useful they are in the remediation of ToM, and to find the best techniques to ameliorate ToM deficits in schizophrenia. Findings indicating that best interference was that directed ToM, produce more advance in ToM tasks [11].
Vita et al. (2018) provide more information about various drugs enhancing neuroplasticity for schizophrenia alongside with intervention targeted social cognitive deficit. Second Generation Antipsychotics (SGAs) stated to be partially improving cognitive dysfunction, due to their relatively high attraction for serotonin 5HT2A receptors. Dysfunction of Geaba led to cognitive insufficiencies. The properties of Geaba produce improvement on cognition of a group of amino acids that act as glutamate agonists by tie to the glycyl site on The N-methyl-D-aspartate receptor receptors.
It was discovered that the administration of muscarinic antagonists potentiated the cognitive impairments, and the α7 nicotinic acetylcholine receptors have been shown to play an important role in cognition with potential therapeutic effect in schizophrenia. A number of studies regarding drugs targeting neuroinflammation and oxidative stress to advance cognitive deficits appeared [12].
Furthermore, a lot of researchers attempt to address relation between elements of social cognition and social function among patients. For example, Lehmann A et al. (2014) investigate empathy, inner experience of emotion, emotional contagion among 55 with paranoid schizophrenia versus fifty five control subject using Interpersonal Reactivity Index, Experience of Emotions and Emotional Contagion tools. Finding indicate that patients have considerably more negative emotional contagion, devastating feelings, deficiency in feelings, and imagination capacity than control group [13].
Whereas, Ahmeda OH (2018) investigate the relation between aggression traits & cognitive impairment taken into consideration how negative emotions affect cognitive deficit. They found that cognitive insufficiency raise the liability of reckless violence in schizophrenia by means of incompetent control of negative emotional condition [14].
Ferrara et al. (2012) investigated literature for the association between emotional processing insufficiency and hallucinations mainly auditory verbal (AVH). The relation between hallucination and emotional prosody understanding has stayed inspected among schizophrenicpatients. Results of researches are contrary a number of inquiries did not discover a relation involving emotional process deficits & hallucinations. While others indicate presence of relation. Author concluded that auditory hallucinations & emotional process in schizophrenia appear to be foundation on corresponding neural networks, in which the training seems to occupy an essential role. Remarkably, targeting the training has been shown to decrease the intensity of hallucination [15].
・ PART II: INTERVENTION STUDIES (Table 2)
Fifteen intervention studies were drawn in this review. It was found that most of provided intervention was targeting emotions & affect recognition training. For example, Sachs, G et al. (2012) investigates the impact of an affect recognition computer-based training on recognizing of different emotions & on patients’ life feature & quality. Training sessions on recognizing emotions was employed. An assessment was done before & after intervention regarding recognizing of different emotions, patients’ life quality and clinical condition. Results show considerable progress especially in recognize gloomy expressions and, in addition, in the excellence of life area societal joining [16].
Moreover, Drusch K et al. (2014) examined the effect of emotions recognition teaching on emotions recognition by calculating numbers of right response & eye look behavior (amount & period of fixation into salient or non-salient facial regions) was assessed using 2 × 2-design 16 patients & sixteen corresponding group carry out a facial affect recognition task .Results showed that at beginning patients demonstrate fewer facial affect recognition than matched group but after training session they was be better [17]. The same findings have been replicated by Bechi et al. (2012) and Prova et al. (2014) [3].
Tsotsia S et al. (2017) randomly assigned thirty nine patients from outpatient’s clinic in three groups intervention. First group involve training on facial affect recognition, Second group involve training on attention-training, third group involve treatment as usual. Noticing that twenty four healthy subject harmonized for oldness and schooling, were distributed to one of the two interventions. Study found improved in affect recognition training group following the intervention targeting Facial Affect Recognition (FAR) this progress was marked more in terror recognition [18].
Others researches focus on Emotion management skills. For example Won, M et al. (2012) implement Emotion management training program for I hour per week for sum of 2 months. The statistics were gathered from twenty two patients in intervention group & thirty subjects in corresponding group [4].
Patients undergoing training session demonstrate a considerable distinction in interpersonal relationship, emotional expression, emotional behavior and social behavior scores than those in the corresponding group. Thus this program indicates its efficiency with schizophrenic patients, and it serving as an evidence-based nursing practice.
Wang Y et al. (2013) examined the clinical utility of Social Cognition and Interaction Training (SCIT) in patients with schizophrenia, treatment was done for twenty weeks. Patients received the SCIT interference & usual treatment-. Attributional Style Questionnaire, Emotion Identification Task, Social Performance Scale, Chinese versions of the Personal and (PSP), Face (FEIT), Eyes task, and (ASQ) were given before & after intervention. Results showed a considerable
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Table 2. Summary of intervention studies.
progress in the areas of mind theory, attribution style, emotion perception, and social functioning compared to corresponding group [19].
While Peters MJ (2013) examined the effect of emotional training by using different video scenarios where by subjects given 5 different emotions including 2 negative, 1 neutral, one positive, and one delusional theme [20]. Following watching video, subject rating their confidence, naming emotions to create their judgment along with ratings, examine remembrance correctness and meta-memory insufficiency in more interacting context. Almost all patients confidently valenced video, patients recognized less right items contrast to corresponding subject, and did not vary with regard to the amount of false memories for related items.
Campo VM (2016) examined schizophrenia patients whereby 21 patients were involved in experimental group and nine in the corresponding group. Corresponding group was given typical treatment leisure & occupational therapy. The experimental group established usual treatment in addition to twelve session (60 minutes per week) as well as education element on emotional awareness and a short lively cartoon for mind theory and attribution style training, plus computerized metacognitive feedback. Endpoints: EP (Ekman 60 Faces Test), ToM (Hinting Task, Faux Pas, Happé), AS (Ambiguous Intentions Hostility Questionnaire). Following the interference, statistically considerable data were obtained for the EP, ToM and AS variables. Group reflect on the intervention plus treatment-as-usual. All patients were fill the Chinese forms of the Personal and Social Performance Scale (PSP), Face Emotion Identification Task (FEIT), Eyes task, and Attributional Style Questionnaire (ASQ) at baseline of the social cognitive intervention treatment period and at follow-up, 6 months after completion of the 20-week treatment period [2].
Tso F I et al. (2010) investigated the input of emotional skill, social cognition & neurocognition in functional outcome of schizophrenia. Thirty nine patients from outpatient’s clinic accidentally allocated to three groups intervention. First group involve training on facial affect recognition, second group involve training on attention-training, third group involve treatment as usual. Noticing that twenty four healthy subject harmonized for oldness and schooling, were allocated to one of the two interventions. Descriptive correlation patients and corresponding group show signs of good quality inner dependability on all self-report measures, except for negative affect severity. Patients describe evenly intense but fewer frequent positive emotions, more intense and frequent negative emotions, and additional anhedonia Study found improved in affect recognition training group following the intervention targeting FAR this progress was marked more in terror recognition. Furthermore, neurocognition and social cognition, emotional experience made exclusive influences to social outcome inschizophrenia [21].
Regarding attribution style, most of studies found no effect of social cognitive interventions on attribution style [22] [23] [24] [25] [26]. However, Wangs et al. 2013 found that patients in social cognitive intervention group showed a considerable enhancement in the areas of emotion perception, theory of mind, attributional style, and social functioning compared to control group. The same was reported previously by Horan et al. (2011) [23].
3. Discussion & Conclusion
In conclusion inquiry today has recognized that some social cognitive fields are responsive to planned teaching, and a great deal of work is still needed to be done, improving their effects on more complex social cognitive areas, to examine its effects as well as their extending to significant societal performance and also in enhancing neuroplasticity.
This review indicates the efficacy of social intervention that targets cognitive aspect and functional abilities of schizophrenic patients; and that effect perception is flexible and can be managed. Medications can properly modify neurochemical discrepancies that trigger neuroplasticity alterations in the brain, whereas cognitive training may induce the creation of more adaptive neural circuits. Emotion processing is significant mediators of social performance aptitudes in schizophrenia; variables such as social cognition deficit which limit patient ability in integrative capacity for verbal and non-verbal cues should be considered during management plan. This means that higher levels of social cognition are associated with better functioning in schizophrenia and that social cognition might have a specific impact in neurocognition; the same was indicated by many studies [26] [27] [28].
Clinical Implications
While social cognition intervention that target cognitive aspect and functional abilities of schizophrenic patients should be generally considered during management to create more adaptive neural circuits this can includes medications that can properly modify neurochemical discrepancies and trigger neuroplasticity alterations in the brain, emotion processing training, considering limited patient ability in integrative capacity for verbal and non-verbal cues.
Limitation of This Review
These review only emphases somewhat on predictive social cognitive factors that may be involved in outcome and recovery. The lack of uniform methods among long-term outcome studies limits generalizations regarding the difference between current outcomes and outcomes proceeding to the initiation of current management.
Further Research
Further researches is needed to assess effect and durability of applying social cognitive intervention on neuroplasticity taken into consideration patients subjective experience upon this intervention, symptoms severity and period of follow up.