Social cognition and metacognition contribute to

SCHRES-07950; No of Pages 3 Schizophrenia Research xxx (2018) xxx–xxx

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Letter to the editor Social cognition and metacognition contribute to accuracy for self-evaluation of real-world functioning in patients with schizophrenia

Keywords: Social cognition Cognitive insight Metacognition Real-world functioning Daily-living skills

Dear Editors, Enhancement of social function is an important goal in the treatment of schizophrenia. To designate appropriate measures of real-world functioning, the Validation of Everyday Real-World Outcomes initiative recommended the Specific Levels of Functioning-Scale (SLOF). The SLOF has been developed as an interview-based assessment tool; the scores by clinicians are based on information from both patients and caregivers (Leifker et al., 2009). The SLOF covers interpersonal functioning, everyday activities, and vocational functioning (Schneider and Struening, 1983). Factors affecting SLOF scores evaluated objectively (by clinicians or caregivers) or subjectively (by patients) have been investigated. Durand et al. (2015) observed that scores on the SLOF rated by clinicians were correlated with performance on the UCSD Performance-based Skills Assessment-Brief (UPSA-B), representing daily-living skills, while scores reported by patients were associated with depression (Durand et al., 2015). Specifically, Ermel et al. (2017) examined the discrepancy between caregiver- and patient-evaluated SLOF scores, and found its relationship with depressive emotion and work function (Ermel et al., 2017). However, little is known about other clinical factors affecting the judgment of his/her own real-world functioning. Specifically, we considered social cognition and metacognition may influence evaluation of social function. In fact, social cognition has been shown to mediate neurocognition and social function (Schmidt et al., 2011), while metacognition has been associated with real-world functioning (Sumiyoshi et al., 2016). In this study, we sought to determine if social cognition and metacognition contribute to the difference between SLOF scores provided by patients and those by caregivers/clinicians. We hypothesized that social cognition, as measured by the Social Cognition Screening Questionnaire (SCSQ) (Roberts et al., 2011) and meta-cognition, as evaluated by the Beck Cognitive Insight-Scale (BCIS) (Beck et al., 2004) would explain the discrepancy between self-reporting and objectively-rated scores on the SLOF.

A total of 58 outpatients receiving antipsychotic drugs and 53 caregivers were enrolled from 10 institutes (Table 1). The ethics committees of the participating institutions approved this study, and written informed consent was obtained. Results of analysis of other issues using this dataset have been reported (Sumiyoshi et al., 2016)We Multiple regression analysis (stepwise method) was conducted. Independent variables were scores on the UPSA-B, SCSQ (excluding Hostility subscale scores), BCIS (composite index), and Positive and Negative Syndrome Scale (five factors model). The SCSQ consists of five domains, i.e. verbal memory, schematic inference, theory of mind, metacognition, and hostility bias. Short fiction stories were read by testers, and participants are requested to answer questions relevant to these domains. Hostility was excluded because the direction of its score is opposite to those of other subscale scores, as has been reported (Kanie et al., 2014). A higher SCSQ score represents better skills. The BCIS consists of the Self-Reflectiveness and Self-Certainty subscales, as reported by patients. These subscales, as well as the composite index, i.e. subtraction of the Self-Certainty subscale scores from the SelfReflectiveness subscale scores, are generally used, with higher indices representing better conditions. The differences in SLOF scores (caregiver-reported SLOF scores minus patient-reported scores, and clinician-reported SLOF scores minus patient-reported scores) were used as dependent variables. A positive or negative difference indicates a higher or lower estimation by the patient of his/her real-world functioning, compared to the actual one. SLOF scores rated by caregivers were missing for five patients. Therefore, data from these subjects were excluded from multiple regression analyses using caregiver-reported SLOF scores. The difference in SLOF scores between caregivers and patients was predicted by BCIS scores (B = 0.968, SE = 0.426, beta = 0.303, t = 2.272, p = 0.027, R2 = 0.092), while that between clinicians and patients was predicted by SCSQ scores (B = 1.036, SE = 0.274, beta = 0.451, t = 3.778, p = 0.030, R2 = 0.203). On the other hand, the difference in SLOF scores between caregivers and clinicians was not associated with any of the variables studied. The contribution of BCIS scores to the difference between SLOF scores by caregivers and those by patients indicates that the failure of patients to appropriately estimate their functional status may partly be explained by deficits of cognitive insight. In fact, SLOF scores evaluated by caregivers have been suggested to provide appropriate information on social function (Moritz and Woodward, 2007). Further research on interventions targeting metacognition is warranted to assess its ability to improve self-estimation of real-world functioning in schizophrenia. The discrepancy between SLOF scores evaluated by clinicians and those by patients was predicted by SCSQ scores. Domains of socialcognition estimated by the SCSQ include the ability to understand what others are thinking, i.e., theory of mind (Kanie et al., 2014). Data from this study suggest some domains of social cognition, e.g. theory of mind, may help objectively evaluate one's own social function.

https://doi.org/10.1016/j.schres.2018.06.071 0920-9964/© 2018 Published by Elsevier B.V.

Please cite this article as: Nishida, K., et al., Social cognition and metacognition contribute to accuracy for self-evaluation of real-world functioning in patients with schizophrenia, Schizophr. Res. (2018), https://doi.org/10.1016/j.schres.2018.06.071

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Letter to the editor

Table 1 Demographic data and clinical scores.

M/F Patient's age, yr Duration of illness, month PANSS PANSS (positive syndrome) PANSS (negative syndrome) Estimated IQ Medication (CPZ equiv. mg/day) SLOF (caregiver) SLOF (patient) SLOF (rater) SLOF (caregiver-patient) SLOF (rater-patient) BCIS SCSQ

Mean (SD)

Range

31/27 35.9 (9.6) 148.3 (111.4) 61.1 (20.1) 13.2 (5.5) 16.6 (7.1) 100.2 (11.8) 546.8 (407.7) 91.1 (18.2) 91.6 (12.9) 90.7 (15.7) −0.1 (17.7) −0.8 (10.5) 8.5 (5.4) 31.9 (4.6)

20 to 58 4 to 396 33 to 115 7 to 29 7 to 36 69.3 to 119.8 5 to 1730 44 to 119 52 to 113 42 to 117 −43 to 48 −36 to 23 −2 to 24 19 to 39

PANSS, Positive and Negative Syndrome Scale. CPZ: chlorpromazine. SLOF, Social Functioning Scale. SCSQ, Social Cognition Screening Questionnaire. BCIS, Beck Cognitive Insight Scale.

In conclusion, differences in the evaluation of social function among patients, caregivers, and clinicians may be explained by social cognition and metacognition of patients. These observations provide a clue to accurate evaluation of real-world functioning in patients with schizophrenia. Contributors Authors Sumiyoshi and Nakagome designed and organized the collaborative team of institutions. Author Nishida conducted the analyses, and prepared the first draft. Authors Koshikawa, Toyomaki and Sumiyoshi provided opinions for statistical analyses and interpretations of data. Authors Nishida, Niimura, Toyomaki, Morimoto, Tani, Inada, Ninomiya, Hori, Manabe, Katsuki, Kubo, Koshikawa, Shirahama, Kohno, Ueno, and Sumiyoshi assisted with data collection. Authors Inada, Kinoshita, Kusumi, Iwanami, Kishimoto, Terao, and Nakagome provided resources to assist with study completion. All authors contributed to and have approved the final manuscript. Conflict of interest statement Keiichiro Nishida, Hidehito Niimura, Masayuki Tani, Hikaru Hori, Akira Iwanami, Kazuyuki Nakagome and Tomiki Sumiyoshi have received speaker's role and honoraria for advisory board from Dainippon Sumitomo Pharmaceutical (DSP) and Otsuka Pharmaceutical (OP). Yosuke Koshikawa have received speaker's role from OP and honoraria for advisory board from DSP. Asuka Katsuki has received honoraria for advisory board from DSP. Takeshi Terao has received honoraria for speaker's role from OP and DSP. Ken Inada and Toshihiko Kinoshita have received speaker's role and honoraria for advisory board, consultations from Astellas Pharmaceutical (AP), DSP and OP. Ichiro Kusumi has received honoraria for advisory board, consultations, and/or speaker's role, and research/ grant support from DSP, OP and AP. All other authors declare that they have no conflicts of interest. Acknowledgement The authors thank to Ms. Ueda, Dr. Nakamura, Ms. Kobayashi, Dr. Hagiya, Ms. Shimmitsu, Ms. Ashida, Ms. Azuma, Mr. Shirahama, and Mr. Kono. Part of this work was supported by Japan Society for the Promotion of Science KAKENHI Grant Number No. 17K10321, Intramural Research Grant (29-1, 30-1, 30-8) for Neurological and Psychiatric Disorders of NCNP, AMED under Grant Number 18dk0307081 and the Center of Innovation (COI) Program from Japan Science and Technology Agency, JST.

References Beck, A.T., Baruch, E., Balter, J.M., Steer, R.A., Warman, D.M., 2004. A new instrument for measuring insight: the Beck Cognitive Insight Scale. Schizophr Res. 68 (2-3), 319–329. Durand, D., Strassnig, M., Sabbag, S., Gould, F., Twamley, E.W., Patterson, T.L., Harvey, P.D., 2015. Factors influencing self-assessment of cognition and functioning in schizophrenia: implications for treatment studies. Eur. Neuropsychopharmacol. 25 (2), 185–191. Ermel, J., Carter, C.S., Gold, J.M., MacDonald, A.W., Ragland, J.D., Silverstein, S.M., Strauss, M.E., Barch, D.M., 2017. Self versus informant reports on the specific levels of functioning scale: relationships to depression and cognition in schizophrenia and schizoaffective disorder. Schizophr. Res. Cogn. 9, 1–7. Kanie, A., Hagiya, K., Ashida, S., Pu, S., Kaneko, K., Mogami, T., Oshima, S., Motoya, M., Niwa, S.-i., Inagaki, A., Ikebuchi, E., Kikuchi, A., Yamasaki, S., Iwata, K., Roberts, D.L., Nakagome, K., 2014. New instrument for measuring multiple domains of social cognition: construct validity of the Social Cognition Screening Questionnaire (Japanese version). Psychiatry Clin. Neurosci. 68 (9–10), 701–711.

Leifker, F.R., Patterson, T.L., Heaton, R.K., Harvey, P.D., 2009. Validating measures of realworld outcome: the results of the VALERO expert survey and RAND panel. Schizophr. Bull. 334–343. Moritz, S., Woodward, T.S., 2007. Metacognitive training in schizophrenia: from basic research to knowledge translation and intervention. Curr. Opin. Psychiatry 20 (6), 619–625. Roberts, D.L., Fiszdon, J., Tek, C., 2011. Initial validity of the Social Cognition Screening Questionnaire (SCSQ). Schizophr. Bull. 37 (Suppl. 1), 280. Schneider, L.C., Struening, E.L., 1983. SLOF: a behavioral rating scale for assessing the mentally ill. Soc. Work Res. Abstr. 19 (3), 9–21. Schmidt, S.J., Mueller, D.R., Roder, V., 2011. Social cognition as a mediator variable between neurocognition and functional outcome in schizophrenia: empirical review and new results by structural equation modeling. Schizophr. Bull. 37 (suppl_2), S41–S54. Sumiyoshi, T., Nishida, K., Niimura, H., Toyomaki, A., Morimoto, T., Tani, M., Inada, K., Ninomiya, T., Hori, H., Manabe, J., 2016. Cognitive insight and functional outcome in schizophrenia; a multi-center collaborative study with the specific level of functioning scale–Japanese version. Schizophr. Res. Cogn. 6, 9–14.

Keiichiro Nishida Department of Neuropsychiatry, Kansai Medical University, Osaka, Japan Corresponding author at: Department of Neuropsychiatry, Kansai Medical University, 10-15 Fumizono-cho, Moriguchi-city, Osaka 5708506, Japan. E-mail address: [email protected] Atsuhito Toyomaki Department of Neuropsychiatry, Graduate School of Medicine, Hokkaido University, Sapporo, Japan Yosuke Koshikawa Department of Neuropsychiatry, Kansai Medical University, Osaka, Japan Hidehito Niimura Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan Tsubasa Morimoto Department of Psychiatry, Nara Medical University School of Medicine, Nara, Japan Masayuki Tani Department of psychiatry, Showa University School of Medicine, Tokyo, Japan Ken Inada Department of Psychiatry, Tokyo Women's Medical University, School of Medicine, Tokyo, Japan Taiga Ninomiya Department of Neuropsychiatry, Oita University Faculty of Medicine, Oita, Japan Hikaru Hori Department of Psychiatry, School of Medicine, University of Occupational and Environmental Health, Kita-Kyushu, Japan Jun Manabe Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan Asuka Katsuki Takamitsu Kubo Department of Psychiatry, School of Medicine, University of Occupational and Environmental Health, Kita-Kyushu, Japan Masanao Shirahama Kentaro Kohno Department of Neuropsychiatry, Oita University Faculty of Medicine, Oita, Japan


Letter to the editor

Toshihiko Kinoshita Department of Neuropsychiatry, Kansai Medical University, Osaka, Japan Ichiro Kusumi Department of Neuropsychiatry, Graduate School of Medicine, Hokkaido University, Sapporo, Japan Akira Iwanami Department of psychiatry, Showa University School of Medicine, Tokyo, Japan Takefumi Ueno Department of Psychiatry, Hizen Psychiatric Center, Saga, Japan Toshifumi Kishimoto Department of Psychiatry, Nara Medical University School of Medicine, Nara, Japan

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Takeshi Terao Department of Neuropsychiatry, Oita University Faculty of Medicine, Oita, Japan Kazuyuki Nakagome National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan Tomiki Sumiyoshi Department of Preventive Intervention for Psychiatric Disorders, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan 20 September 2017 Available online xxxx
