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BackgroundThe determinants of quality of life (QoL) in schizophrenia are largely debated, mainly due to methodological discrepancies and divergence about the concepts concerned. As most studies have investigated bi- or tri-variate models, a multivariate model accounting for simultaneous potential mediations is necessary to have a comprehensive view of the determinants of QOL. We sought to estimate the associations between cognitive reserve, cognition, functioning, insight, depression, schizophrenic symptoms, and QoL in schizophrenia and their potential mediation relationships.MethodsWe used structural equation modeling with mediation analyses to test a model based on existing literature in a sample of 776 patients with schizophrenia from the FondaMental Foundation FACE-SZ cohort.ResultsOur model showed a good fit to the data. We found better functioning to be positively associated with a better QoL, whereas better cognition, better insight, higher levels of depression, and schizophrenic symptoms were associated with a lower QoL in our sample. Cognitive reserve is not directly linked to QoL, but indirectly in a negative manner via cognition. We confirm the negative relationship between cognition and subjective QoL which was previously evidenced by other studies; moreover, this relationship seems to be robust as it survived in our multivariate model. It was not explained by insight as some suggested, thus the mechanism at stake remains to be explained.ConclusionThe pathways to subjective QoL in schizophrenia are complex and the determinants largely influence each other. Longitudinal studies are warranted to confirm these cross-sectional findings.

International audience; The determinants of metacognition are still poorly understood in bipolar disorders (BD). We aimed to examine the clinical determinants of metacognition, defined as the agreement between objective and subjective cognition in individuals with BD. The participants consisted of 281 patients with BD who underwent an extensive neuropsychological battery and clinical evaluation. To assess subjective cognition, participants provided a general rating of their estimated cognitive difficulties. Clinical characteristics of BD were also recorded, along with medication. We studied the potential moderation of the association between cognitive complaints and global objective cognitive performance by several clinical variables with ordinal logistic regressions. Depression and impulsivity were associated with greater cognitive complaints. The only variable that moderated the relationship between objective and subjective cognition in the global model was the prescription of antipsychotics. Patients taking antipsychotics had a poorer association between cognitive complaints and objective neuropsychological performance. This result suggests a role for dopamine in the modulation of metacognitive performance, and calls for the systematic control of antipsychotic medication in future studies documenting metacognitive deficits in severe and persistent mental disorders. Depression and impulsivity should be investigated as potential therapeutic targets for individuals with BD and cognitive complaints, before proposing an extensive neuropsychological evaluation.

The interest in social cognition in schizophrenia is justified by the relationship between deficits in these skills and negative functional outcomes. Although assessment batteries have already been described, there is no consensus about which measures are useful in predicting patient functioning or quality of life (QoL). We investigated a set of five measures of recognition of facial emotions, theory of mind (ToM), and empathy in a cohort of 143 patients with schizophrenia or schizoaffective disorder at inclusion and, amongst whom 79 were reassessed 1 year later. The distribution was satisfactory for the TREF (Facial Emotion Recognition Task), V-SIR (Versailles-Situational Intention Reading), and QCAE (Questionnaire of Cognitive and Affective Empathy). Internal consistency was satisfactory for the TREF, V-SIR, V-Comics (Versailles Intention Attribution Task), and QCAE. Sensitivity to change was acceptable for the TREF. The TREF and V-SIR showed a cross-sectional relationship with functioning beyond the clinical symptoms of schizophrenia but not beyond neurocognition. Moreover, the TREF and V-SIR at inclusion could not predict functioning one year later, whereas most neurocognitive and clinical dimensions at inclusion could. Finally, only affective QCAE showed a significant cross-sectional, but not longitudinal, association with QoL. In conclusion, the TREF had satisfactory psychometric properties and showed a cross-sectional, but not longitudinal, association with objective outcome measures, thus appearing to be reliable in clinical practice and research. The V-SIR also showed promising psychometric properties, despite a possible weakness to detect change. However, these measures should be interpreted within the context of the good predictive power of the neurocognitive and clinical status on the outcome.

Resume Le but de cette communication etait de resumer l’etat des connaissances sur les liens entre fonctionnement psychosocial et cognition sociale dans la schizophrenie. La cognition sociale, et en particulier la Theorie de l’Esprit, est perturbee dans la schizophrenie. La litterature retrouve une plus forte association entre fonctionnement psychosocial et les performances en Theorie de l’Esprit qu’entre fonctionnement et mesures de la cognition dite froide (definie comme l’ensemble des processus de traitement de l’information de nature non sociale, par opposition a la cognition sociale). Cette influence serait mediee par les competences sociales. Des etudes longitudinales ont montre que, dans ces associations, la direction de causalite etait unique et partait des troubles de la cognition froide vers les troubles de la cognition sociale, ces derniers entrainant les deficits fonctionnels. Dans une etude utilisant des modeles d’equations structurales, les niveaux de symptomes positifs, de desorganisation et de symptomes negatifs etaient tous les trois fortement lies a une alteration du fonctionnement. L’effet de la desorganisation et les symptomes negatifs sur le fonctionnement etaient en partie medies par la cognition sociale, contrairement aux symptomes positifs. Cette revue de litterature suggere que l’amelioration de la cognition sociale pourrait permettre d’ameliorer le fonctionnement psychosocial dans la schizophrenie.

Objectives: The aim of this study is to design a questionnaire, the Versailles Metacognitive Strategies Evaluation Questionnaire, for assessing the use of metacognitive and help-seeking strategies in three key-domains of impaired daily functioning in schizophrenia. To evaluate its psychometric properties (internal consistency, factor structure, convergent and divergent validity, and stability). Design: Development of a questionnaire and psychometric validation procedure in patients with schizophrenia compared with healthy controls. Stability over one year was assessed in the patient group. Setting: Schizophrenia Centers of Expertise (French FondaMental Network). Subjects: A total of 141 patients with schizophrenia, among whom 77 participated in the second evaluation; 97 healthy subjects. Main measures: The Versailles Metacognitive Strategies Evaluation Questionnaire, Positive and Negative Symptoms Scale, Personal and Social Performance Scale, Evaluation of Cognitive Processes involved in Disability in Schizophrenia Scale, Schizophrenia Quality of Life Questionnaire, and Stages of Recovery Instrument. Results: From the 36-items version, stepwise exploratory factor analysis (oblimin) produced a 25-items scale which had a 3-factors structure (hygiene concern, social relationships, and hygiene help-seeking). Cronbach’s were respectively equal to 0.91, 0.82, and 0.78. One-year stability was good (intra-class correlation coefficient = 0.7). The three factors showed good convergent validity with measures of quality of life (rho = 0.34, P ⩽ 0.001). The first two factors correlated with recovery ( N = 34, rho = 0.53, P ⩽ 0.001). On the contrary, the factors exhibited divergent validity, with no significant correlation, with symptoms and cognitive and psychosocial functioning ( P > 0.05). Factor structure in healthy controls did not match with that of patients, all items but one were found significantly different among groups. Conclusion: The Versailles Metacognitive Strategies Evaluation Questionnaire provides a simple and valid means to assess metacognitive strategies in individuals with schizophrenia.

Objective: The aim of this study is to review published research on treatment of social cognition impairments in patients with traumatic brain injury (TBI).Methods: Following the PRISMA guidelines, a PubMed literature search was conducted, followed by a manual search in recently published papers. Main criteria for selection were that patients had sustained a TBI, and that social cognition was the main target of treatment. A total of 16 papers and three reviews were selected and included in the present review.Results: Five studies (including three randomized controlled trials (RCT)) addressed facial affect recognition, one study specifically addressed emotional prosody, two RCTs used a combination of treatment strategies addressing social perception deficits. Six studies, including two RCTs, addressed social communication skills or theory of mind. Finally, two RCTs reported the effectiveness of a more global approach, addressing multiple domains of social cognition, such as emotion perception, social skills training, and theory of mind.Discussion/conclusion: Although there has been much less research on treatment of social cognition in patients with TBI as compared with psychiatric conditions, the findings reported in the present review are encouraging. Further multicenter large-scale RCTs are needed, with special emphasis on the generalization of treatment effects to social skills in everyday life.

Resume Les dernieres annees ont apporte de nombreuses innovations dans le domaine de la remediation des troubles cognitifs participant a la genese de l’alteration du fonctionnement des patients atteints de schizophrenie. Parmi les programmes ciblant la cognition sociale a disposition des services de soins francophones, ToMRemed peut aujourd’hui beneficier du retour d’experience de la part des equipes (nous comptons 146 soignants formes en France) l’employant regulierement, contribuant a determiner ses principales proprietes et son impact. Utilise en groupes de patients, animes par des soignants, ce traitement cible specifiquement l’attribution d’intentions a autrui et les facultes metacognitives qui lui sont associees. L’harmonisation de la formation a l’usage de ToMRemed a contribue au recueil de donnees cliniques en soins courants de 110 patients pris en charge dans 11 centres en France. Nous rapportons ici les principales modifications cliniques et cognitives constatees indiquant une amelioration des performances mesurees a une echelle cognitive liee a la therapie (Versailles – lecture intentionnelle en situation). Les donnees rapportees sont conformes aux ameliorations attendues et rapportees dans la litterature. De plus, en l’absence de facteur predictif clinique ou sociodemographique de l’amelioration cognitive, nous n’identifions pas de population de patients atteints de schizophrenie et presentant un trouble du fonctionnement social, echappant a l’indication d’un tel entrainement. Les limitations de la presente etude sont cependant a prendre en compte, notamment concernant l’absence de groupe temoin et la presence de biais de selection (les patients inclus sont ceux qui ont beneficie de l’ensemble du module ToMRemed et qui ont ete reevalues ensuite).

It is now largely accepted that patients with schizophrenia have a deficit to attribute mental states to others, such as intentions, needs and motivations but also to perform memory tasks. According to one hypothesis, these impairments may be due to an early visual attention deficit during the encounter of social stimuli. Another hypothesis posits a robust correlation between intention attribution and autobiographical memory that results in impaired recollection of past events making it difficult to infer others’ intentions. In sum, the link between intention attribution and encoding process is yet to be explored in patients with schizophrenia. The objective of the present study is to contribute to this debate by investigating whether schizophrenic patients’ recollection can be boosted by an attentional cueing on relevant information and to determine the influence of two different situational contexts: attribution of intentions or physical causality scripts. By using a supraliminal attentional cue, we made relevant areas of our material more salient across two conditions: attribution of intentions (AI) and physical causality with human characters (PCCH). The results confirmed expected deficit of explicit memory in schizophrenia patients while attentional cueing on relevant areas for intentions attribution or physical causality had no effect on recollection in any group. However, it seems that the recollection performances are highly influenced by the nature of intentions attribution. Also, it is the first time that the material used for the assessment of theory of mind performances has been tested with a recognition test.

International audience; Background: Up to half of the patients with schizophrenia attempt suicide during their lifetime. Better insight is associated with better functioning but also with increased suicidality. The direction of the relationship between insight and suicidality is not clear, hence we aimed to provide new elements using structural equation modeling. Methods: Insight, quality of life (QoL), depression, and suicidality were measured at baseline and at 12 months in individuals with schizophrenia spectrum disorders. The relationships between these variables were investigated by latent difference score models, controlling for chlorpromazine doses, positive and negative symptoms, and general psychopathology. Results: 738 patients were included, and 370 completed the study. Baseline levels of insight predicted changes in suicidality, whereas baseline levels of suicidality did not predict changes in insight, suggesting that better insight underlies suicidality and predicts its worsening. Our results suggest this temporal sequence: better insight → worse QoL → increased depression → increased suicidality, while insight also affects the three variables in parallel. Conclusion: Better insight predicts a worsening of QoL, depression and suicidality. These findings contribute to our global understanding of the longitudinal influence of insight on suicidality. We advocate that insight-targeted interventions should not be proposed without the monitoring of depression and suicide prevention.

Objective: This study aimed to evaluate the validity of the Evaluation of Cognitive Processes involved in Disability in Schizophrenia scale (ECPDS) to discriminate for cognitive impairment in schizophrenia. Design: This multicentre cross-sectional study used a validation design with receiver operating characteristic (ROC) curve analysis. Settings: The study was undertaken in a French network of seven outward referral centres. Subjects: We recruited individuals with clinically stable schizophrenia diagnosed based on the Structured Clinical Interview for assessing Diagnostic and Statistical Manual of Mental Disorders (4th ed., rev.; DSM-IV-R) criteria. Main measures: The index test for cognitive impairment was ECPDS (independent variable), a 13-item scale completed by a relative of the participant. The reference standard was a standardized test battery that evaluated seven cognitive domains. Cognitive impairment was the dependent variable and was defined as an average z-score more than 1 SD below the normative mean in two or more cognitive domains. Results: Overall, 97 patients were included (67 with schizophrenia, 28 with schizoaffective disorder, and 2 with schizophreniform disorder). The mean age was 30.2 (SD 7.7) years, and there were 75 men (77.3%). There were 59 (60.8%) patients with cognitive impairment on the neuropsychological battery, and the mean ECPDS score was 27.3 (SD 7.3). The ROC curve analysis showed that the optimal ECPDS cut-off was 29.5. The area under the curve was 0.77, with 76.3% specificity and 71.1% sensitivity to discriminate against cognitive impairment. Conclusion: The ECPDS is a valid triage tool for detecting cognitive impairment in schizophrenia, before using an extensive neuropsychological battery, and holds promise for use in everyday clinical practice.

International audience; The functional outcome in schizophrenia spectrum disorders is affected by multiple factors such as cognitive performance and clinical symptoms. Psychiatric disability may be another important determinant of functional outcome. The purpose of this study was to test whether schizophrenia symptoms and psychiatric disability mediated the association between cognition and functioning. Between April 2013 and July 2017, we included 108 community-dwelling adults with stable schizophrenia spectrum disorder in a multicenter study. Psychiatric disability was assessed with the Evaluation of Cognitive Processes involved in Disability in Schizophrenia (ECPDS) scale by relatives of patients. ECPDS focused on the broad array of motivational, neurocognitive, sociocognitive, and metacognitive impairments that result in activity restrictions. We used a battery of tests to assess seven cognition domains (processing speed, attention/vigilance, working, verbal and visual memory, reasoning and problem solving, and executive functioning) and cross-sectional structural equation modeling (SEM) for the mediation analyses. We estimated the one-year temporal stability of ECPDS scores in 45 participants. The model provided showed good fit and explained 43.9% of the variance in functioning. The effect of neurocognition on functioning was fully mediated by symptoms (proportion mediated: 36.5%) and psychiatric disability (proportion mediated: 31.3%). The ECPDS score had acceptable one-year temporal stability. The ECPDS scale has satisfactory psychometric properties, and shows significant convergence with neurocognition and functioning, suggesting a role for this tool in the routine evaluation of cognitive remediation needs. Our model validates psychiatric disability as a crucial step from cognitive impairment to restricted participation in life situations.

Although many instruments measure empathy, most of them focus on specific facets (e.g., Spreng et al., 2009) or specific contexts (e.g. Wang et al., 2003) of empathy. For this reason, the Questionnaire of Cognitive and Affective Empathy (QCAE; Reniers et al., 2011) was recently built to grasp the general construct of empathy through its Affective-Cognitive duality, although not providing clear-cut results about the bidimensionality of the scale. In this study, Confirmatory Factor Analyses were conducted on the responses of 418 adults on the French QCAE (backtranslated for this study). A total of 8 models were tested - including the models of the original investigation. The 5-correlated factors model had the best fit, and the pattern of correlations between the factors did not support the Cognitive-Affective distinction. The QCAE is discussed as showing signs of psychometrical robustness, but also as a tool that is more 5-dimensional than bidimensional.

BACKGROUND Schizophrenia is associated with poor theory of mind (ToM), particularly in the attribution of intentions to others. It is also associated with abnormal gaze behaviours and contextual processing. This study investigated to what extent impaired ToM in patients with schizophrenia is related to abnormal processing of social context. METHODS We evaluated ToM using a nonverbal intention attribution task based on comic strips depicting social/nonsocial and contextual/noncontextual events while eye movements were recorded. Eye-tracking was used to assess processing time dedicated to visual cues contained in regions of interest identified in a pilot study. We measured cognitive contextual control on a separate task. RESULTS We tested 29 patients with schizophrenia and 29 controls. Compared with controls, patients were slower in intention attribution but not in physical reasoning. They looked longer than controls at contextual cues displayed in the first 2 context pictures of the comic strips, and this difference was greater for intention attribution than for physical reasoning. We found no group difference in time spent looking at noncontextual cues. Patients' impairment in contextual control did not explain their increased reaction time and gaze duration on contextual cues during intention attribution. LIMITATIONS Difficulty may not have been equivalent between intention attribution and physical reasoning conditions. CONCLUSION Overall, schizophrenia was characterized by a delay in intention attribution related to a slowdown of social context processing that was not explained by worse executive contextual control.

This article discusses the important advances in a recent field of science dealing with the brain processes implicated in understanding social situations and interacting with others. Many behavioral studies on schizophrenia have shown the impairment of these processes and their preferential relation with disorganization and negative syndromes. Brain imaging is a powerful method to identify brain systems participating in these processes in healthy subjects and will be used increasingly to study mental disorders such as schizophrenia. A few preliminary studies have opened this field of research and allowed for the drawing of some limited conclusions. We emphasize the importance of developing an integrated neurocognitive framework to account for the multifaceted nature of social cognition deficits in schizophrenia. Inspired by contemporary models of empathy and social cognition that identify different components such as shared representation, mentalizing, self/other distinction, we show how schizophrenia affects these components at the behavioral and functional levels. We also outline the interest of this model to understand putative abnormalities of contextual integration within the area of mentalization. Finally, we discuss how specialized measures of brain functions during the performance of these precisely defined mental processes might be used as outcome predictors.

Numerous behavioral and electrophysiological studies have provided evidence of abnormal semantic processing in schizophrenia. However, the neural basis of these deficits is poorly understood. We investigated magnetic cortical responses elicited by a word-pair lexical decision task in 20 patients with schizophrenia and 12 healthy control subjects. The task involved presentation of a prime word (200 ms), followed by a blank (250 ms), and then a target stimulus (1200 ms); the subject had to decide whether the target was a real word or not. During this task, bilateral temporal and left prefrontal activations were observed in both groups. However, in contrast to controls, patients with schizophrenia did not show increased activation in the left temporal and anterior cingulate cortices between 200 and 450 ms in response to semantic incongruity. These results suggested that schizophrenia was associated with a functional disturbance in some semantic regions that gave rise to the N400 component. Moreover, a significant modulation in the right temporal cortex was observed in patients, but not in controls. This suggested the existence of alternative processes in patients because both groups showed similar behavioral priming. Finally, we elucidated some functional abnormalities in the semantic network during prime word processing in patients, indicated by prolonged activation compared to healthy controls. Thus, in addition to context integration impairment, abnormal activations during the prime word provided new evidence of context processing deficits in schizophrenia.

International audience; Schizophrenia is associated with abnormal cortical activation during theory of mind (ToM), as demonstrated by several fMRI or PET studies. Electrical and temporal characteristics of these abnormalities, especially in the early stages, remain unexplored. Nineteen medicated schizophrenic patients and 21 healthy controls underwent magnetoencephalography (MEG) recording to measure brain response evoked by nonverbal stimuli requiring mentalizing. Three conditions based on comic-strips were contrasted: attribution of intentions to others (AI), physical causality with human characters (PCCH), and physical causality with objects (PCOB). Minimum norm localization was performed in order to select regions of interest (ROIs) within bilateral temporal and parietal regions that showed significant ToM-related activations in the control group. Time-courses of each ROI were compared across group and condition. Reduced cortical activation within the 200 to 600 ms time-window was observed in the selected regions in patients. Significant group by condition interactions (i.e., reduced modulation in patients) were found in right posterior superior temporal sulcus, right temporoparietal junction, and right inferior parietal lobule during attribution of intentions. As in healthy controls, the presence of characters elicited activation in patients' left posterior temporal regions and temporoparietal junction. No group difference on evoked responses' latencies in AI was found. In conclusion, ToM processes in the early stages are functionally impaired in schizophrenia. MEG provides a promising means to refine our knowledge on schizophrenic social cognitive disorders.

Representation of others' actions and mental states leads to the activation of several brain networks: the mentalizing and the "mirror neuron" systems as well as a "low level" social perception component. However, respective activations of the regions belonging to these networks remain unknown with respect to chronometrical data when static drawing stimuli are presented. To determine anatomical and temporal characteristics of theory of mind processes, magnetic signals were measured in 21 subjects during a validated nonverbal attribution of intentions task. Minimum norm estimation provides chronometric and localization data showing that regions known to be involved in the mentalizing, "mirror neuron" and social perception networks have simultaneous activations between 100 and 700 ms post-stimulus, a period which may be thought as corresponding to early stages of social processes. Among some regions, different profiles as well as modulations regarding experimental conditions suggest functional distinctions between these structures, pleading for a cooperative nature of these networks. While the left temporo-parietal area and superior temporal sulcus seem more specialized in social cues coding, we demonstrate that their right homologues, as well as the right inferior parietal cortex, are preferentially recruited during attribution of intentions stimuli compared to scenarios based on physical causality from 200 to 600 ms.