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Veterans with psychotic disorders often experience employment difficulties. Job tenure is highly variable with shorter tenure frequently tied to interpersonal difficulties in the workplace. The present study sought to address this problem by examining the efficacy of social cognition skills training (SCST) and social problem solving skills training (SPSST) interventions, implemented sequentially, and added to usual VA employment services (augmented vocational rehabilitation [VR]).Participants were 91 Veterans with schizophrenia and other psychotic disorders who were recently enrolled in one of three types of VA employment services (incentive therapy, transitional work, supported employment), and randomized 1:1 to augmented VR versus control VR. Training for the augmented VR group included 12 weeks of SCST plus 6 weeks of work-related SPSST; training for the control VR group included a control intervention (symptom management training) matched in instructional format and length of training to the SCST and SPSST interventions. All participants received baseline and posttraining measures of social cognition. For those who got jobs, the primary work outcome measures were social skills work behavior and job tenure.Results showed a significant group x time interaction favoring the augmented VR group on measures of social cognition and social skills work behavior, but there were no significant differences in job tenure.The findings for workplace social skills support a promising new direction for enhancing work outcomes in this population; the null effect on job tenure may have been due to high job retention rates across the three types of employment service programs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The US Food and Drug Agency (FDA) requires clinical trials targeting cognitive impairment associated with schizophrenia (CIAS) to demonstrate the functional relevance of cognitive improvements by employing a functional co-primary measure. Although quantitative evidence supports the suitability of the Virtual Reality Functional Capacity Assessment Tool (VRFCAT) for this purpose, FDA guidelines for qualification of clinical outcome assessments require evidence of content validity, defined as qualitative evidence that key stakeholders view the measure as relevant and important. To collect this important qualitative data, semi-structured interviews were conducted with outpatients with schizophrenia (n = 24), caregivers (n = 12), and professional peer support specialists (n = 12) to elicit their views about the definition and importance of functional independence, the importance of the functional domains assessed by the VRFCAT (meal planning, using transportation, handling money, shopping), and the relevance of the VRFCAT tasks to these domains. Qualitative thematic analyses revealed consistent themes across groups in defining functional independence, including: performing instrumental self-care, financial, and social tasks; making decisions autonomously; and not depending on others to carry out daily activities. There were, however, notable differences in their views about regarding the importance of and barriers to functional independence. All groups viewed the VRFCAT as assessing skill domains that are central to independent functioning and, with some minor differences, the VRFCAT tasks were viewed as relevant and meaningful examples of the domains. These qualitative results provide converging evidence that key stakeholders view the VRFCAT as a content valid measure.

ObjectivesSocial and nonsocial cognition are defined as distinct yet related constructs. However, the relative independence of individual variables—and whether specific tasks directly depend on performance in other tasks—is still unclear. The current study aimed to answer this question by using a Bayesian network approach to explore directional dependencies among social and nonsocial cognitive domains.Study DesignThe study sample comprised 173 participants with schizophrenia (71.7% male; 28.3% female). Participants completed 5 social cognitive tasks and the MATRICS Consensus Cognitive Battery. We estimated Bayesian networks using directed acyclic graph structures to examine directional dependencies among the variables.Study ResultsAfter accounting for negative symptoms and demographic variables, including age and sex, all nonsocial cognitive variables depended on processing speed. More specifically, attention, verbal memory, and reasoning and problem solving solely depended on processing speed, while a causal chain emerged between processing speed and visual memory (processing speed → attention → working memory → visual memory). Social processing variables within social cognition, including emotion in biological motion and empathic accuracy, depended on facial affect identification.ConclusionsThese results suggest that processing speed and facial affect identification are fundamental domains of nonsocial and social cognition, respectively. We outline how these findings could potentially help guide specific interventions that aim to improve social and nonsocial cognition in people with schizophrenia.

Cognitive impairment associated with schizophrenia (CIAS) is widely regarded as a critically important treatment target for schizophrenia. Despite major efforts and a number of promising findings, we do not yet have an approved drug for CIAS. Similarly, promising cognitive remediation approaches are limited in their ability to help patients achieve real-world functional gains on a wide scale. This article provides an update and critical evaluation of recent treatment development activities for CIAS. First, we provide update on pharmacological approaches, which include a glutamatergic drug that is currently in Phase III trials for CIAS, and discuss factors that may have impacted past efforts to identify efficacious drugs. Second, we review positive findings, limitations, and current trends involving cognitive remediation approaches. Third, we consider newer transdiagnostic approaches aimed at looking beyond, or identifying more homogenous subgroups within, the diagnostic category schizophrenia to advance treatment development. Despite its many challenges, treatment development for CIAS remains a major public health issue and research continues to push forward on several encouraging fronts.

Several studies of reward processing in schizophrenia have shown reduced sensitivity to positive, but not negative, outcomes although inconsistencies have been reported. In addition, few studies have investigated whether patients show a relative deficit to social versus nonsocial rewards, whether deficits occur across the spectrum of psychosis, or whether deficits relate to negative symptoms and functioning. This study examined probabilistic implicit learning via two visually distinctive slot machines for social and nonsocial rewards in 101 outpatients with diverse psychotic disorders and 48 community controls. The task consisted of two trial types: positive (optimal to choose a positive vs. neutral machine) and negative (optimal to choose a neutral vs. negative machine), with two reward conditions: social (faces) and nonsocial (money) reward conditions. A significant group X trial type interaction indicated that controls performed better on positive than negative trials, whereas patients showed the opposite pattern of better performance on negative than positive trials. In addition, both groups performed better for social than nonsocial stimuli, despite lower overall task performance in patients. Within patients, worse performance on negative trials showed significant, small-to-moderate correlations with motivation and pleasure-related negative symptoms and social functioning. The current findings suggest reward processing disturbances, particularly decreased sensitivity to positive outcomes, extend beyond schizophrenia to a broader spectrum of psychotic disorders and relate to important clinical outcomes.

The placebo response is a highly complex psychosocial-biological phenomenon that has challenged drug development for decades, particularly in neurological and psychiatric disease. While decades of research have aimed to understand clinical trial factors that contribute to the placebo response, a comprehensive solution to manage the placebo response in drug development has yet to emerge. Advanced data analytic techniques, such as artificial intelligence (AI), might be needed to take the next leap forward in mitigating the negative consequences of high placebo-response rates. The objective of this review was to explore the use of techniques such as AI and the sub-discipline of machine learning (ML) to address placebo response in practical ways that can positively impact drug development. This examination focused on the critical factors that should be considered in applying AI and ML to the placebo response issue, examples of how these techniques can be used, and the regulatory considerations for integrating these approaches into clinical trials.

Social cognition has become a major focus in psychosis research aimed at explaining heterogeneity in functional outcome and developing interventions oriented to functional recovery. However, there is still no consensus on the structure of social cognition in psychosis, and research in this area has been plagued by lack of replication. Our first goal was to replicate the factor structure of social cognition using nearly identical tasks in independent samples. Our second goal was to externally validate the factors as they relate to nonsocial cognition and various symptoms in the prediction of functioning using machine learning. Confirmatory factor analyses validated a three-factor model for social cognition in psychosis (low-level, high-level, attributional bias factor). A least absolute shrinkage and selection operator regression and cross-validation provided evidence for external validity of data-driven linear models including the social-cognitive factors, nonsocial cognition, and symptoms. We addressed the replicability problems that have impeded research in this area, and our results will guide future psychosis studies.

Background Cognition and functional capacity predict functional outcomes in mental illness. Traditional approaches conceptualize cognition as comprised of domains, but many studies support a unifactorial structure. Some functional capacity measures may share a single-factor structure with cognition. In this study, we examined the factor structure of two measures of functional capacity, a conventional assessment and a newer computerized assessment, testing for a shared factor structure with cognition. Methods Patients with schizophrenia and healthy controls were examined with the MATRICS Consensus Cognitive Battery (MCCB), the UCSD Performance Based Skills Assessment (UPSA), and the Virtual Reality Functional Capacity Assessment Tool (VRFCAT). Models of the factor structures of the MCCB, UPSA, and VRFCAT were calculated, as were correlations between MCCB scores and individual VRFCAT objectives. Results The MCCB, VRFCAT, and UPSA all had unifactorial structures. The best fitting model of the correlations between MCCB and UPSA was a shared single factor, while the best fit for the relationship between MCCB and VRFCAT had two factors. Correlations between the MCCB domain and composite scores and the VRFCAT objectives suggested global rather than specific patterns of correlation. Discussion The relationship between cognitive performance and functional capacity was found to vary across functional capacity assessments. The UPSA and MCCB were not differentiated into separate factors, suggesting that the UPSA may overlap with neurocognitive performance. However, the VRFCAT appears to measure functional abilities that are separable from, yet correlated with, neurocognitive performance. It may provide a more distinctive assessment of the functional capacity construct.

BackgroundLittle is known about the determinants of community integration (i.e. recovery) for individuals with a history of homelessness, yet such information is essential to develop targeted interventions.MethodsWe recruited homeless Veterans with a history of psychotic disorders and evaluated four domains of correlates of community integration: perception, non-social cognition, social cognition, and motivation. Baseline assessments occurred after participants were engaged in supported housing services but before they received housing, and again after 12 months. Ninety-five homeless Veterans with a history of psychosis were assessed at baseline and 53 returned after 12 months. We examined both cross-sectional and longitudinal relationships with 12-month community integration.ResultsThe strongest longitudinal association was between a baseline motivational measure and social integration at 12 months. We also observed cross-sectional associations at baseline between motivational measures and community integration, including social, work, and independent living. Cross-lagged panel analyses did not suggest causal associations for the motivational measures. Correlations with perception and non-social cognition were weak. One social cognition measure showed a significant longitudinal correlation with independent living at 12 months that was significant for cross-lagged analysis, consistent with a causal relationship and potential treatment target.ConclusionsThe relatively selective associations for motivational measures differ from what is typically seen in psychosis, in which all domains are associated with community integration. These findings are presented along with a partner paper (Study 2) to compare findings from this study to an independent sample without a history of psychotic disorders to evaluate the consistency in findings regarding community integration across projects.

Social cognition has become a topic of widespread interest in experimental and treatment research in schizophrenia over the past 15 years. This explosion of interest largely reflects the robust evidence that social cognition is among the strongest known correlates of poor community functioning throughout the course of schizophrenia. While progress has been impressive, we consider several fundamental questions about the scope, structure, and optimal measurement of social cognition that remain unanswered and point to the need for continued method development. We also consider more recently emerging questions about individual differences, ecological and cross-cultural validity, and intervention approaches, as well as broader technological changes that impact how we understand and use social cognition at a societal level. Continued efforts to creatively grapple with the complexities and challenges the field now faces hold great promise for helping us understand and more effectively treat a major source of functional disability in schizophrenia.

Event-related potential (ERP) studies of motivated attention in schizophrenia typically show intact sensitivity to affective vs. non-affective images depicting diverse types of content. However, it is not known whether this ERP pattern: 1) extends to images that solely depict social content, (2) applies across a broad sample with diverse psychotic disorders, and (3) relates to self-reported trait social anhedonia. We examined late positive potential (LPP) amplitudes to images involving people that were normatively pleasant (affiliative), unpleasant (threatening), or neutral in 97 stable outpatients with various psychotic disorders and 38 healthy controls. Both groups showed enhanced LPP to pleasant and unpleasant vs. neutral images to a similar degree, despite lower overall LPP in patients. Within the patients, there were no significant LPP differences among subgroups (schizophrenia vs. other psychotic disorders; affective vs. non-affective psychosis) for the valence effect (pleasant/unpleasant vs. neutral). Higher social anhedonia showed a small, significant relation to lower LPP to pleasant images across all groups. These findings suggest intact motivated attention to social images extends across psychotic disorder subgroups. Dimensional transdiagnostic analyses revealed a modest association between self-reported trait social anhedonia and an LPP index of neural sensitivity to pleasant affiliative images.

Studies demonstrate that dynamic assessment (i.e., learning potential) improves the prediction of response to rehabilitation over static measures in individuals with schizophrenia. Learning potential is most commonly assessed using neuropsychological tests under a test-train-test paradigm to examine change in performance. Novel learning potential approaches using social cognitive tasks may have added value, particularly for the prediction of social functioning, but this area is unexplored. The present study is the first to investigate whether patients with schizophrenia demonstrate social cognitive learning potential across phase of illness. This study included 43 participants at clinical high risk (CHR), 63 first-episode, and 36 chronic schizophrenia patients. Assessment of learning potential involved test-train-test versions of the Wisconsin Card Sorting Test (non-social cognitive learning potential) and the Facial Emotion Identification Test (social cognitive learning potential). Non-social and social cognition pre-training scores (static scores) uniquely predicted concurrent community functioning in patients with schizophrenia, but not in CHR participants. Learning potential showed no incremental explanation of variance beyond static scores. First-episode patients showed larger non-social cognitive learning potential than CHR participants and were similar to chronic patients; chronic patients and CHR participants were similar. Group differences across phase of illness were not observed for social cognitive learning potential. Subsequent research could explore whether non-social and social cognitive learning potential relate differentially to non-social versus social types of training and rehabilitation.

Efforts to develop psychosocial interventions that specifically target social cognition in schizophrenia spectrum disorders began nearly two decades ago. The field has matured considerably since then and has engendered a great deal of optimism about this treatment approach. Indeed, the efficacy of social cognitive interventions, especially those that address multiple domains of social cognition, has received substantial support. This article critically evaluates the current evidence for social cognitive interventions, identifies limitations and open questions, and suggests priorities and directions for further research. Limitations of available studies include a frequent lack of methodological rigor, suboptimal selection of endpoints, and sparse evidence for generalization to functional improvements. We highlight several emerging psychosocial and non-psychosocial approaches that may enhance the efficacy of social cognitive interventions and promote generalization to improvements in real world functioning. We conclude that cautious optimism is warranted as the field moves forward into the next wave of social cognitive treatment studies.

Social cognitive impairment is a core feature of schizophrenia and plays a critical role in poor community functioning in the disorder. However, our understanding of the relationship between key biological variables and social cognitive impairment in schizophrenia is limited. This study examined the effect of sex on the levels of social cognitive impairment and the relationship between social cognitive impairment and social functioning in schizophrenia. Two hundred forty-eight patients with schizophrenia (61 female) and 87 healthy controls (31 female) completed five objective measures and one subjective measure of social cognition. The objective measures included the Facial Affect Identification, Emotion in Biological Motion, Self-Referential Memory, MSCEIT Branch 4, and Empathic Accuracy tasks. The subjective measure was the Interpersonal Reactivity Index (IRI), which includes four subscales. Patients completed measures of social and non-social functional capacity and community functioning. For objective social cognitive tasks, we found a significant sex difference only on one measure, the MSCEIT Branch 4, which in both patient and control groups, females performed better than males. Regarding the IRI, females endorsed higher empathy-related items on one subscale. The moderating role of sex was found only for the association between objective social cognition and non-social functional capacity. The relationship was stronger in male patients than female patients. In this study, we found minimal evidence of a sex effect on social cognition in schizophrenia across subjective and objective measures. Sex does not appear to moderate the association between social cognition and functioning in schizophrenia.

BackgroundIn an initial study (Study 1), we found that motivation predicted community integration (i.e. functional recovery) 12 months after receiving housing in formerly homeless Veterans with a psychotic disorder. The current study examined whether the same pattern would be found in a broader, more clinically diverse, homeless Veteran sample without psychosis.MethodsWe examined four categories of variables as potential predictors of community integration in non-psychotic Veterans: perception, non-social cognition, social cognition, and motivation at baseline (after participants were engaged in a permanent supported housing program but before receiving housing) and a 12-month follow-up. A total of 82 Veterans had a baseline assessment and 41 returned for testing after 12 months.ResultsThe strongest longitudinal association was between an interview-based measure of motivation (the motivation and pleasure subscale from the Clinical Assessment Interview for Negative Symptoms) at baseline and measures of social integration at 12 months. In addition, cross-lagged panel analyses were consistent with a causal influence of general psychiatric symptoms at baseline driving social integration at 12 months, and reduced expressiveness at baseline driving independent living at 12 months, but there were no significant causal associations with measures of motivation.ConclusionsThe findings from this study complement and reinforce those in Veterans with psychosis. Across these two studies, our findings suggest that motivational factors are associated at baseline and at 12 months and are particularly important for understanding and improving community integration in recently-housed Veterans across psychiatric diagnoses.

Homelessness is a major public health problem, and serious mental illness (SMI) is highly prevalent in the homeless population. Although supported housing services-which provide permanent housing in the community along with case management-improve housing outcomes, community integration typically remains poor, and little is known about the underlying determinants of poor community integration postresidential placement. The general SMI literature has indicated that motivational and cognitive ability factors are key determinants of successful community integration, which provides a foundation for examining this issue. This study evaluated whether interview- and performance-based assessments of motivation, nonsocial and social-cognitive ability, and psychiatric symptoms were associated with community integration indices in 2 samples of homeless veterans either with (N = 96) or without (N = 80) a psychotic disorder who had recently been admitted to a supported housing program but who had not yet attained housing. Motivation indices, including experiential negative symptoms and defeatist performance attitudes, stood out as the most robust correlates (rs = -.30 to -.69) of community integration across both samples, particularly for social role participation. Demographics, general psychiatric symptoms, and nonsocial cognition showed generally weak relations with community integration, though social cognition showed a few relations. The consistent findings across samples point to the importance of motivational factors for understanding the determinants of poor community integration in this complex population. Further, interventions that target motivational challenges may have widespread usefulness for enhancing community integration outcomes beyond obtaining housing. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Black Americans are overrepresented in Veteran and non-Veteran homeless populations. Community integration remains a problem for many Veterans after they obtain housing, and Black Veterans may encounter additional difficulties due to systemic racism. However, no prior study has specifically examined whether there are racial differences in community integration; similarly, no study has considered racial differences in psychosocial correlates of community integration in homeless Veterans. Knowledge of these factors could inform the development of culturally congruent rehabilitative interventions for Black Veterans. Semi-structured clinical interviews were administered to Black (N=99) and White (N=49) homeless Veterans to examine relations among psychiatric symptoms, motivation, and community integration domains (e.g., social integration, work productivity, and independent living). There were no significant racial differences in independent living or work productivity. Black Veterans had better social integration with family compared to White Veterans. In addition, psychiatric symptoms were more strongly correlated with social integration for Black than White Veterans. The association between motivation and work productivity was also stronger for Black Veterans. Recovery-oriented interventions could harness family connections and better target psychiatric symptoms to improve community integration for Black Veterans. Work productivity may improve from interventions aimed at enhancing motivation for Black Veterans.

Background Human beings find social stimuli rewarding, which is thought to facilitate efficient social functioning. Although reward processing has been extensively studied in schizophrenia, a few studies have examined neural processes specifically involved in social reward processing. This study examined neural sensitivity to social and nonsocial rewards in schizophrenia. Methods Twenty-seven patients with schizophrenia and 25 community controls completed a One-Armed Bandit Task, an implicit reinforcement learning task, in the scanner. There were 2 conditions with an identical trial structure, one with social rewards and the other with nonsocial rewards. The data were analyzed using a region of interest (ROI) approach, focusing on the ventral striatum, ventromedial prefrontal cortex, and anterior cingulate cortex. Results Across all 3 ROIs, patients showed reduced activation for social rewards compared to controls. However, the 2 groups showed comparable levels of activation for nonsocial rewards. Within the patient group, levels of neural activation in these ROIs during the social reward condition were associated with better performance. Conclusions This study found reduced neural sensitivity in patients with schizophrenia in key reward-processing regions for social but not for nonsocial rewards. These findings suggest a relatively specific social reward-processing deficit in schizophrenia during an implicit reinforcement learning task.

Effort-based decision-making paradigms are increasingly utilized to gain insight into the nature of motivation deficits. Research has shown associations between effort-based decision making and experiential negative symptoms; however, the associations are not consistent. The current study had two primary goals. First, we aimed to replicate previous findings of a deficit in effort-based decision making among individuals with schizophrenia on a test of cognitive effort. Second, in a large sample combined from the current and a previous study, we sought to examine the association between negative symptoms and effort by including the related construct of defeatist beliefs. The results replicated previous findings of impaired cognitive effort-based decision making in schizophrenia. Defeatist beliefs significantly moderated the association between negative symptoms and effort-based decision making such that there was a strong association between high negative symptoms and deficits in effort-based decision making, but only among participants with high levels of defeatist beliefs. Thus, our findings suggest the relationship between negative symptoms and effort performance may be understood by taking into account the role of defeatist beliefs, and finding that might explain discrepancies in previous studies.

Although a number of studies examined recollection and familiarity memory in schizophrenia, most of studies have focused on nonsocial episodic memory. Little is known about how schizophrenia patients remember social information in everyday life and whether social episodic memory changes over the course of illness. This study aims to examine episodic memory for dynamic social interaction with multimodal social stimuli in schizophrenia across phase of illness. Within each phase of illness, probands and demographically matched controls participated: 51 probands at clinical high risk (CHR) for psychosis and 36 controls, 80 first-episode schizophrenia patients and 49 controls, and 50 chronic schizophrenia patients and 39 controls. The participants completed the Social Remember-Know Paradigm that assessed overall social episodic memory, social recollection and familiarity memory, and social context memory, in addition to social cognitive measures and measures on community functioning. Probands showed impairment for recollection but not in familiarity memory and this pattern was similar across phase of illness. In contrast, impaired social context memory was observed in the first-episode and chronic schizophrenia samples, but not in CHR samples. Social context memory was associated with community functioning only in the chronic sample. These findings suggest that an impaired recollection could be a vulnerability marker for schizophrenia whereas impaired social context memory could be a disease-related marker. Further, a pattern of impaired recollection with intact familiarity memory for social stimuli suggests that schizophrenia patients may have a different pattern of impaired episodic memory for social vs nonsocial stimuli.

Attachment has recently been proposed as a key developmental construct in psychosis, in particular with respect to interpersonal functioning and social cognition. The current study examined the latent structure of the self-report Psychosis Attachment Measure (PAM) and its relationship to lower-level perceptual and higher-order inferential social cognitive processes. The PAM was administered to 138 psychiatrically stable outpatients with schizophrenia alongside a battery of symptom, social cognitive, and functional measures. PAM responses were analyzed using latent variable measurement models, which did not yield evidence of the coherent two-dimensional structure predicted by previous literature. A unidimensional subscale comprising 6 of the 16 original PAM items possessed the strongest psychometric properties. This subscale was generally uncorrelated with social cognitive measures and showed weak correlations with some symptoms measures and with community functioning. These results suggest that either the PAM may not measure attachment in psychosis or it may measure only attachment anxiety but demonstrate little construct validity in this population. These results tell a cautionary tale regarding making theoretical inferences on the basis of measures without coherent latent structure. Attachment measures with stronger psychometric properties will help clarify putative relationships between attachment and social cognitive processes in psychosis.

The United States Department of Housing and Urban Development (HUD)-Veteran Administration Supportive Housing (VASH) program uses project- and tenant-based vouchers to provide permanent supportive housing for homeless Veterans. We compared Veteran characteristics, health service utilization, and neighborhood characteristics between HUD-VASH participants with project-based (n=114) vs. tenant-based (n=978) vouchers. We found that project-based voucher holders were older and more ill than tenant-based voucher holders. Project-based vouchers were also associated with higher-quality neighborhoods and higher rates of health service utilization than tenant-based vouchers. With the limited availability of project-based vouchers, juxtaposed with the increased service use and better neighborhood quality with this voucher type, our findings suggest a need to think strategically about how best to allocate housing vouchers to meet homeless Veteran's needs.

Disturbances in motivation are prominent in the clinical presentation of people with schizophrenia and might reflect a disturbance in reward processing. Recent advances in affective neuroscience have subdivided reward processing into distinct components, but there are two limitations of the prior work in schizophrenia. First, studies typically focus on only one component rather than on the unfolding of reward processing across multiple stages. Second, studies have not considered the impact of certainty effects, which represent an important contextual factor that impacts processing. We examined whether individuals with schizophrenia show the typical certainty effects across three phases of reward processing: cue evaluation, feedback anticipation, and feedback receipt. Electroencephalography from 74 healthy controls and 92 people with schizophrenia was recorded during a cued gambling task under conditions in which cues indicated forthcoming reward outcomes that were certain or uncertain. Controls demonstrated the expected certainty effects across each stage. Initial cue evaluation (cue P300) was intact in the schizophrenia group, but people with schizophrenia showed diminished certainty effects during feedback anticipation (stimulus-preceding negativity [SPN]) and receipt (feedback reward positivity [fRewP] and feedback P300). During feedback receipt, event-related potentials in people with schizophrenia were similar to controls for the uncertain context but larger than controls for the certain context. Essentially, people with schizophrenia appeared to process certain feedback as though it were uncertain. These findings show, for the first time, that the fundamental distinction between certain and uncertain contexts is altered in schizophrenia at a neural level. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Schizophrenia is associated with amotivation and reduced goal-directed behavior, which have been linked to poor functional outcomes. Motivational deficits in schizophrenia are often measured using effort-based decision-making (EBDM) paradigms, revealing consistent alterations in effort expenditure relative to controls. Although these results have generally been interpreted in terms of decreased motivation, the ability to use trial-by-trial changes in reward magnitude or probability of receipt to guide effort allocation may also be affected by cognitive deficits. To date, it remains unclear whether altered performance in EBDM primarily reflects deficits in motivation, cognitive functioning, or both. We applied a newly developed computational modeling approach to the analysis of EBDM data from two previously collected samples comprising 153 patients and 105 controls to determine the extent to which individuals did or did not use available information about reward and probability to guide effort allocation. Half of the participants with schizophrenia failed to incorporate information about reward and probability when making effort-expenditure decisions. The subset of patients who exhibited difficulties using reward and probability information were characterized by greater impairments across measures of cognitive functioning. Interestingly, even within the subset of patients who successfully used reward and probability information to guide effort expenditure, higher levels of negative symptoms related to motivation and avolition were associated with greater effort aversion during the task. Taken together, these data suggest that prior reports of aberrant EBDM in schizophrenia patients are related to both cognitive function and individual differences in negative symptoms. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Cognitive impairment in schizophrenia involves a broad array of nonsocial and social cognitive domains. It is a core feature of the illness, and one with substantial implications for treatment and prognosis. Our understanding of the causes, consequences and interventions for cognitive impairment in schizophrenia has grown substantially in recent years. Here we review a range of topics, including: a) the types of nonsocial cognitive, social cognitive, and perceptual deficits in schizophrenia; b) how deficits in schizophrenia are similar or different from those in other disorders; c) cognitive impairments in the prodromal period and over the lifespan in schizophrenia; d) neuroimaging of the neural substrates of nonsocial and social cognition, and e) relationships of nonsocial and social cognition to functional outcome. The paper also reviews the considerable efforts that have been directed to improve cognitive impairments in schizophrenia through novel psychopharmacology, cognitive remediation, social cognitive training, and alternative approaches. In the final section, we consider areas that are emerging and have the potential to provide future insights, including the interface of motivation and cognition, the influence of childhood adversity, metacognition, the role of neuroinflammation, computational modelling, the application of remote digital technology, and novel methods to evaluate brain network organization. The study of cognitive impairment has provided a way to approach, examine and comprehend a wide range of features of schizophrenia, and it may ultimately affect how we define and diagnose this complex disorder.

Social cognitive skills training interventions for psychotic disorders have shown improvement in social cognitive performance tasks, but little was known about brain-based biomarkers linked to treatment effects. In this pilot study, we examined whether social cognitive skills training could modulate extrinsic and intrinsic functional connectivity in psychosis using functional magnetic resonance imaging (fMRI). Twenty-six chronic outpatients with psychotic disorders were recruited from either a Social Cognitive Skills Training (SCST) or an activity- and time-matched control intervention. At baseline and the end of intervention (12 weeks), participants completed two social cognitive tasks: a Facial Affect Matching task and a Mental State Attribution Task, as well as resting-state fMRI (rs-fMRI). Extrinsic functional connectivity was assessed using psychophysiological interaction (PPI) with amygdala and temporo-parietal junction as a seed region for the Facial Affect Matching Task and the Mental State Attribution task, respectively. Intrinsic functional connectivity was assessed with independent component analysis on rs-fMRI, with a focus on the default mode network (DMN). During the Facial Affect Matching task, we observed stronger PPI connectivity in the SCST group after intervention (compared to baseline), but no treatment-related change in the Control group. Neither group showed treatment-related changes in PPI connectivity during the Mental State Attribution task. During rs-fMRI, we found treatment-related changes in the DMN in the SCST group, but not in Control group. This study found that social cognitive skills training modulated both extrinsic and intrinsic functional connectivity in individuals with psychotic disorders after a 12-week intervention. These findings suggest treatment-related changes in functional connectivity as a potential brain-based biomarker of social cognitive skills training.

Although social cognitive impairments are evident in patients with schizophrenia across many cultures, psychosocial interventions are less used in Eastern countries. Despite a growing emphasis on community care in mental health services in Eastern countries, the synergistic effects of social cognitive intervention strategies on routine community mental health services are not well documented. This study aimed to adapt a group-based social cognitive skills training (SCST) program for use in a Korean context and evaluate its feasibility and preliminary effects among community-dwelling individuals with schizophrenia. Forty-seven patients were assigned to either the SCST + treatment as usual (TAU) group (n = 21) or the TAU only group (n = 24). Participants completed tasks to assess social cognition, social functioning, neurocognition, and psychiatric symptoms before and after treatment. Over a period of approximately 12 weeks, drop-out rates were comparably low in both groups, and the attendance rates for the SCST program were high (85.7 %, mean sessions attended = 20.56/24 sessions). The SCST + TAU group demonstrated significant improvements in facial affect recognition, social functioning, and psychiatric symptoms compared to the TAU only group. A non-significant trend in theory of mind was observed, along with no improvements in social perception and neurocognition. The adapted version of the SCST program is feasible for implementation and demonstrates promise for enhancing social cognition and functioning in Korean outpatients with schizophrenia.

Although individuals with schizophrenia show impaired feedback-driven learning on probabilistic reversal learning (PRL) tasks, the specific factors that contribute to these deficits remain unknown. Recent work has suggested several potential causes including neurocognitive impairments, clinical symptoms, and specific types of feedback-related errors. To examine this issue, we administered a PRL task to 126 stable schizophrenia outpatients and 72 matched controls, and patients were retested 4 weeks later. The task involved an initial probabilistic discrimination learning phase and subsequent reversal phases in which subjects had to adjust their responses to sudden shifts in the reinforcement contingencies. Patients showed poorer performance than controls for both the initial discrimination and reversal learning phases of the task, and performance overall showed good test-retest reliability among patients. A subgroup analysis of patients (n = 64) and controls (n = 49) with good initial discrimination learning revealed no between-group differences in reversal learning, indicating that the patients who were able to achieve all of the initial probabilistic discriminations were not impaired in reversal learning. Regarding potential contributors to impaired discrimination learning, several factors were associated with poor PRL, including higher levels of neurocognitive impairment, poor learning from both positive and negative feedback, and higher levels of indiscriminate response shifting. The results suggest that poor PRL performance in schizophrenia can be the product of multiple mechanisms.

Background Although individuals with, or at risk for, psychotic disorders often show difficulties with performance monitoring and feedback processing, findings from studies using event-related potentials (ERPs) to index these processes are not consistent. This meta-analytic review focused on studies of two different indexes of performance monitoring, the early error-related negativity (ERN; n = 25) and the later error positivity (Pe; n = 17), and one index of feedback processing, the feedback negativity (FN; n = 6). Methods We evaluated whether individuals (1) with psychotic disorders, or (2) at heightened risk for these disorders differ from healthy controls in available studies of the ERN, Pe, and FN. Results There was a significant, large ERN reduction in those with psychosis (g = −0.96) compared to controls, and a significant, moderate ERN reduction in those at-risk (g = −0.48). In contrast, there were uniformly non-significant, small between-group differences for Pe and FN (gs ≤ |0.16|). Conclusions The results reveal a differential pattern of impairment in psychosis. Early performance monitoring (ERN) impairments are substantial among those with psychotic disorders in general and may be a useful vulnerability indicator for these disorders. However, later performance monitoring (Pe) and basic feedback processing (FN) appear to be relatively spared in psychosis.

Impairments in social cognition are key determinants of poor functioning in psychosis and an important new target for treatment development. Initial studies support the feasibility and efficacy of training interventions for social cognition, but have been small and have had substantial methodological limitations. This report describes the largest rigorously controlled study of a social cognitive treatment to date. We evaluated the efficacy of a refined version of the 24-session Social Cognitive Skills Training (SCST) program, and whether adding in vivo training sessions in community settings would enhance generalization to functional improvements. One hundred thirty-nine outpatients with psychotic disorders were randomly assigned to one of 3 time- and format-matched conditions: (1) SCST plus in vivo community-based training, (2) SCST plus clinic-based training, or (3) Illness management control condition. SCST targeted the domains of emotion processing, social perception, attributional bias, empathy, and mentalizing. Assessments of social cognition, nonsocial cognition, symptoms, and functioning were completed at baseline, mid-treatment, posttreatment, and 3-month follow-up. On the primary social cognitive outcome measures, there was significant, durable SCST-related improvement in facial emotion identification. There was also a significant SCST benefit for emotional intelligence and an in vivo training effect for empathy, though these improvements were not durable. Further, there were no overall or in vivo-related changes in functioning. This study bolsters and extends support for the efficacy of SCST in a relatively large and rigorously controlled trial, although our effort to enhance generalization to functional improvements through in vivo community-based training was not successful.

Individuals with schizophrenia exhibit impaired social cognition, which manifests as difficulties in identifying emotions, feeing connected to others, inferring people's thoughts and reacting emotionally to others. These social cognitive impairments interfere with social connections and are strong determinants of the degree of impaired daily functioning in such individuals. Here, we review recent findings from the fields of social cognition and social neuroscience and identify the social processes that are impaired in schizophrenia. We also consider empathy as an example of a complex social cognitive function that integrates several social processes and is impaired in schizophrenia. This information may guide interventions to improve social cognition in patients with this disorder.

Impairments in willingness to exert effort contribute to the motivational deficits characteristic of the negative symptoms of schizophrenia. The current study evaluated the psychometric properties of 5 new or adapted paradigms to determine their suitability for use in clinical trials of schizophrenia. This study included 94 clinically stable participants with schizophrenia and 40 healthy controls. The effort-based decision-making battery was administered twice to the schizophrenia group (baseline, 4-week retest) and once to the control group. The 5 paradigms included 1 that assesses cognitive effort, 1 perceptual effort, and 3 that assess physical effort. Each paradigm was evaluated on (1) patient vs healthy control group differences, (2) test-retest reliability, (3) utility as a repeated measure (ie, practice effects), and (4) tolerability. The 5 paradigms showed varying psychometric strengths and weaknesses. The Effort Expenditure for Rewards Task showed the best reliability and utility as a repeated measure, while the Grip Effort Task had significant patient-control group differences, and superior tolerability and administration duration. The other paradigms showed weaker psychometric characteristics in their current forms. These findings highlight challenges in adapting effort and motivation paradigms for use in clinical trials.

Because negative symptoms, including motivational deficits, are a critical unmet need in schizophrenia, there are many ongoing efforts to develop new pharmacological and psychosocial interventions for these impairments. A common challenge of these studies involves how to evaluate and select optimal endpoints. Currently, all studies of negative symptoms in schizophrenia depend on ratings from clinician-conducted interviews. Effort-based decision-making tasks may provide a more objective, and perhaps more sensitive, endpoint for trials of motivational negative symptoms. These tasks assess how much effort a person is willing to exert for a given level of reward. This area has been well-studied with animal models of effort and motivation, and effort-based decision-making tasks have been adapted for use in humans. Very recently, several studies have examined physical and cognitive types of effort-based decision-making tasks in cross-sectional studies of schizophrenia, providing evidence for effort-related impairment in this illness. This article covers the theoretical background on effort-based decision-making tasks to provide a context for the subsequent articles in this theme section. In addition, we review the existing literature of studies using these tasks in schizophrenia, consider some practical challenges in adapting them for use in clinical trials in schizophrenia, and discuss interpretive challenges that are central to these types of tasks.

Social disability is a defining characteristic of schizophrenia and a substantial public health problem. It has several components that are difficult to disentangle. One component, social disconnection, occurs extensively in the general community among nonhelp-seeking individuals. Social disconnection is an objective, long-standing lack of social/family relationships and minimal participation in social activities. It is associated with negative health effects, including early mortality, and is distinct from subjective loneliness. These 2 topics, social disability in schizophrenia and social disconnection in the general community, have generated entirely distinct research literatures that differ in their respective knowledge gaps and emphases. Specifically, the consequences of social disability in schizophrenia are unknown but its determinants (ie, nonsocial cognition, social cognition, and social motivation) have been well-examined. Conversely, the health consequences of social disconnection in the general community are well-established, but the determinants are largely unknown. Social disconnection is a condition that presents substantial public health concerns, exists within and outside of current psychiatric diagnostic boundaries, and may be related to the schizophrenia spectrum. A comparison of these 2 literatures is mutually informative and it generates intriguing research questions that can be critically evaluated.

Delay discounting (DD) is a future-oriented decision-making process that refers to whether one is willing to forego a smaller, sooner reward for the sake of a larger, later reward. It can be assessed using hypothetical tasks, which involve choices between hypothetical rewards of varying amounts over delay periods of days to years, or experiential tasks, which involve receiving actual rewards in real time over delay periods of seconds to minutes. Initial studies in schizophrenia have only used hypothetical tasks and have been mixed in finding either elevated or normal levels of DD. One hundred thirty-one outpatients with schizophrenia and 70 healthy controls completed hypothetical and experiential DD tasks involving monetary rewards, and the schizophrenia group was retested after 4 weeks. Although both groups showed qualitatively similar hyperbolic discounting functions on both tasks, they showed a quantitative DD difference. The schizophrenia showed higher DD than controls on the experiential task but normal DD on the hypothetical task. This pattern was not attributable to a range of potential confounds, including smoking status, substance use disorder status, or neurocognition. It was also not attributable to differences in the test-retest reliability, which was good for both tasks. The schizophrenia group's robust pattern of altered experiential but normal hypothetical task performance points to key factors that may contribute to impaired DD in this disorder. These may include increased valuation of small (but not large) monetary rewards, or a hypersensitivity to costs associated with waiting inactively for those rewards. (PsycINFO Database Record

Individuals with schizophrenia often show substantial deficits in social cognitive abilities, which are strongly associated with social functioning. To advance our understanding of the genetic variation that is associated with social cognitive deficits in schizophrenia, we genotyped 74 schizophrenia outpatients who completed social cognitive performance measures assessing mentalizing, social perception, and emotional intelligence, as well as clinical symptoms. We assessed seven single nucleotide polymorphisms (SNPs) of the oxytocin receptor (OXTR) previously found to show replicable associations with socio-emotional processes. For one of the seven SNPs, rs2268493, the ‘T’ allele was significantly associated with poorer performance on a composite social cognition index, as well as specific tests of mentalizing and social perception. None of the SNPs were associated with clinical symptoms. Though the sample size is small, these findings provide initial support for the involvement of genetic variants of the OXTR in social cognitive impairments in schizophrenia.

Schizophrenia is associated with motivational deficits that interfere with a wide range of goal directed activities. Despite their clinical importance, our current understanding of these motivational impairments is limited. Furthermore, different types of motivational problems are commonly seen among individuals within the broad diagnosis of schizophrenia. The goal of the current study was to examine whether clinically meaningful subgroups could be identified based on approach and avoidance motivational tendencies. We measured these tendencies in 151 individuals with schizophrenia. Although prior studies demonstrate elevated BIS sensitivity in schizophrenia at the overall group level, none have explored various combinations of BIS/BAS sensitivities within this disorder. Cluster analyses yielded five subgroups with different combinations of low, moderate, or high BIS and BAS. The subgroups had interpretable differences in clinically rated negative symptoms and self-reported anhedonia/socio-emotional attitudes, which were not detectable with the more commonly used linear BIS/BAS scores. Two of the subgroups had significantly elevated negative symptoms but different approach/avoidance profiles: one was characterized by markedly low BIS, low BAS and an overall lack of social approach motivation; the other had markedly high BIS but moderate BAS and elevated social avoidance motivation. The two subgroups with relatively good clinical functioning showed patterns of BAS greater than BIS. Our findings indicate that there are distinct motivational pathways that can lead to asociality in schizophrenia and highlight the value of considering profiles based on combined patterns of BIS and BAS in schizophrenia.

The DSM-5 changes to the diagnostic criteria for schizophrenia reflect modest incremental changes. The two most substantial changes, the elimination of subtypes and de-emphasis of Schneiderian First-Rank Symptoms, are a significant departure from long-standing approaches to conceptualizing and defining schizophrenia, but are unlikely to have an appreciable impact on caseness or clinical management. Several minor modifications to the diagnosis are generally useful additions that will likely enhance diagnostic precision. The two most controversial changes that were considered, the addition of dimensional ratings and attenuated psychosis syndrome, were ultimately placed in the third section of DSM-5 for further research and consideration. In sum, the changes demonstrate increased precision of diagnosis, with minimal changes in caseness.

The past decade has witnessed a resurgence of interest in the development of novel pharmacological agents to treat the negative symptoms of schizophrenia. This review provides an overview of pharmacological approaches that have been evaluated as potential treatments and describes the emergence of several promising new approaches. First, we briefly describe recent methodological developments, including consensus-based clinical trial guidelines for patient selection criteria, symptom assessment, and trial duration. Next, we overview mono- and adjunctive-therapies that have been evaluated, including first- and second-generation antipsychotics, antidepressants, psychostimulants, molecules targeting cholinergic and glutamatergic systems, and hormones. We highlight the most promising pharmacological agents on the horizon, including glycine transporter-1 inhibitors, α7-nicotinic receptor positive allosteric modulators, and oxytocin, as well as non-pharmacological electromagnetic stimulation approaches. Further investigations, using optimal clinical trial design, hold considerable promise for discovering effective treatments for these functionally disabling symptoms in the near future.