Social cognition in patients with first episode of psychosis in remission.

AIM: The present study aimed to compare the social cognition (SC) deficits in patients with first-episode psychosis (FEP) and healthy controls and evaluate the association of SC deficits with socio-occupational functioning, insight, quality of life, and stigma.
METHODS: This study included 30 patients with FEP in remission phase and 26 healthy controls matched for age, gender, education, and intelligent quotient. SC was assessed on the domains of theory of mind (ToM), social perception, and attributional bias.
RESULTS: Compared to healthy controls, patients with FEP had significantly higher deficits in the domains of second-order ToM (unpaired t = 4.447, P < 0.001) and Faux Pas Composite Index (unpaired t = 2.824, P = 0.007). In the correlation analysis, higher age of patients with FEP was significantly associated with more externalizing bias (Pearson's correlation coefficient = 0.38, P = 0.039) and those with lower level of education had more social cognitive deficits in the domains of Faux Pas Composite Index (Pearson's correlation coefficient = 0.43, P = 0.018), Social Perception Index (Pearson's correlation coefficient = 0.38, P = 0.04), and Nonsocial Perception Index (Pearson's correlation coefficient = 0.5, P = 0.005). Duration of untreated psychosis was associated with higher deficits in the first-order ToM (Pearson's correlation coefficient = -0.38, P = 0.04) and Externalizing Bias Index (Pearson's correlation coefficient = -0.49, P = 0.006). Longer duration of treatment was associated with higher impairment in first-order ToM index (Pearson's correlation coefficient = -0.42, P = 0.02). General psychopathology and total Positive and Negative Syndrome Scale total score correlated significantly with externalizing bias, with a higher level of psychopathology associated with more severe deficits in this domain. There was no correlation of SC with the quality of life, cognitive insight, and stigma (except for occasional correlation of stereotype endorsement and externalizing bias).
CONCLUSION: The present study suggests that compared to healthy controls, patients with FEP have impairment in the domains of second-order ToM and Faux Pas Composite Index. However, social cognitive deficits have only a few correlations with various psychosocial outcomes of FEP. Copyright:

INTRODUCTION

In general, it is understood that schizophrenia is often associated with poor outcome if there is a long duration of untreated psychosis.[123] Due to this, it is often suggested that intervention in psychotic illnesses should be started at the earliest, to minimize the long-term deficits.[45] Due to this, over the last decade or so, the focus of research has shifted to first-episode psychosis (FEP) or the prodromal phase of illness.

Research on patients with FEP suggests that despite treatment, a significant proportion of patients with FEP continue to experience deficits in the form of poor quality of life, disability, cognitive deficits, stigma, etc.[6] Social cognition (SC) has been evaluated as an important construct, which may be playing an important role in mediating these deficits in patients with psychosis.[78910] Hence, there is a need to quantify these deficits in patients with FEP and study the association of SC deficits with other outcome variables.

SC is defined as “the sum of the processes that allow a person to live in the society and manifest mainly through the ability to create effective relationships with others and through interacting with them.”[11] In order to provide an organizing framework, the National Institute of Mental Health, United States, has delimited five dimensions within the construct of SC, i.e., Theory of Mind (ToM), Social Perception, Social Knowledge, Attribution bias, and Emotion Processing. ToM is defined as “ability to infer intentions, dispositions, and beliefs of others.”[12] Emotion Processing is the ability to perceive emotions expressed by others and is considered important in a person's ability to communicate and comprehend nonverbal cues including both facial expression and affective prosody.[13] Social Perception involves the initial stages in the processing of information that culminates in the accurate analysis of the dispositions and intentions of other individuals.[14] Attributional bias can be defined as the “pervasive tendency to explain the cause of social actions in terms of oneself or others or the context of the event.”[15]

Available studies suggest that compared to healthy controls, patients with psychosis, including FEP, have more social cognitive deficits both in the acute and remission phases and over time.[1617181920] Studies which have evaluated emotional processing suggest that the deficits improve with time and the differences between patients and healthy controls decrease with time.[161721] Studies which have assessed ToM and social perception have reported these deficits to be stable.[16171922] Studies which have evaluated the correlates of SC deficits among patients with FEP suggest lack of significant correlation of SC deficits with age[232425] and duration of untreated psychosis.[26] In terms of psychopathology, there is lack of consensus, with some studies reporting the association of SC deficits with various symptoms of psychosis, whereas others suggest a lack of such an association. Studies suggesting an association between SC deficits and psychopathology have shown a link between externalizing bias and psychotic symptoms such as persecutory delusion and suspiciousness, whereas internalizing bias has been shown to be associated with depression.[2527] A higher level of social perception deficits during the remission phase of illness is associated with more severe negative symptoms.[20282930] Deficits in attributional bias and general SC have been shown to be associated with a higher level of anxiety and positive symptoms.[30] Presence of comorbid obsessive-compulsive symptoms in patients with FEP has been shown to have a deleterious effect on SC.[3132] However, it is important to note that some studies suggest a lack of association between SC deficits and psychopathology.[232425]

In terms of outcome, studies in patients of FEP suggest that higher level of SC deficits, especially the social perception in the remission phase of illness, are associated with impaired psychosocial functioning.[282930] However, some of the studies suggest that ToM deficits do not predict social functioning or quality of life in patients with early psychosis.[3334] Data also suggest that lower level of SC deficits at the baseline and 12-month follow-up were associated with better work functioning, independent living, and social functioning at 1-year follow-up.[35] However, social cognitive deficits have shown not to predict the vocational outcome.[9] It is important to note that these associations have been evaluated in one or two studies, and the reported findings are inconsistent. In general, there is a lack of data on the association of SC deficits in patients with FEP with insight and stigma. In this background, the present study aimed to compare the SC deficits in patients with FEP and healthy controls and evaluate the association of SC deficits with socio-occupational functioning, insight, quality of life, and stigma.

METHODS

This study was conducted in the outpatient setting of a tertiary care multispecialty hospital in North India, which caters to a major part of North India. The study was approved by the ethics committee of the institute, and all the participants were recruited after obtaining written informed consent. To be included in the study, the patients were required to be aged 18–55 years; diagnosed with any psychotic disorder which included schizophrenia, schizoaffective disorder, brief psychotic disorder, delusional disorder, schizophreniform disorder, or psychotic disorder (not otherwise specified [NOS]) of <2 years' duration; and those in clinical remission. The duration criterion was operationalized as the time from the first positive symptom to the time of assessment. The diagnosis of psychotic disorder was confirmed by the Mini-International Neuropsychiatric Interview-PLUS version (MINI-PLUS). Clinical remission was defined by using Andreasen et al.'s criteria.[36] Patients having a visual/hearing impairment; who received electroconvulsive therapy in the last 6 months; and having any comorbid psychiatric illness or any major chronic physical illness (e.g. cerebrovascular accident, epilepsy, head injury, demyelinating diseases, diabetes mellitus, hypertension, etc.) were excluded from the study.

A healthy control group, matched for age, gender, and education, was recruited for comparison. Participants in the healthy control group were required to be free from any mental illness (as screened on MINI-Screen)[3738] and without any family history of mental illness as assessed by the Family Interview for Genetic Studies.[39] Patients with FEP and participants of the healthy control group were matched for age, gender, level of education, and intelligence quotient (IQ).

Assessment

Social cognition rating tools in Indian setting – SOCRATIS

SC was assessed by using SOCRATIS, which has been validated in an Indian cultural setting.[40] It assesses three domains of SC – ToM, Attributional styles, and Social Perception. ToM tasks include two each of first-order (based on the Sally–Anne[41] and Smarties tasks[42]) and second-order (based on the ice-cream van[43] and missing cookies[44] tasks) false belief picture stories, two metaphor-irony stories (adapted from Drury et al., 1998[45]), and 10 Faux Pas recognition stories (based on the Faux Pas recognition test).[44] These story-based tasks evaluate the ability, at different complexity levels, to “meta-represent” the mental states of others. Social perception is evaluated by a set of 18 true/false questions which include questions with respect to social (e.g., Ali asked many questions about the movie because he was trying to impress Sunil) and nonsocial cues (e.g., Harish and Lakshmi were looking over a book together) after showing the participants four each of the low- and high-emotion videos depicting a social interaction. This test has been adapted from the social cue recognition test.[46] Attributional bias is assessed using a 32-point questionnaire where the participants are required to make causal attributions for positive and negative social events, adapted from the Internal, Personal, and Situational Attributions Questionnaire.[47] For attributional styles, external and personalizing bias scores were calculated according to Kinderman and Bentall.[47]

Positive and Negative Syndrome Scale for Schizophrenia

The Positive and Negative Syndrome Scale for Schizophrenia (PANSS) was used to evaluate the severity of residual symptoms and to define remission as per the Andresen criteria. This scale has 30 items in three subscales – positive, negative, and general psychopathology, with each item rated on a 7-point scale based on a formal semi-structured clinical interview and other informational sources, pertaining to the previous 1 week. Alpha coefficient varies from 0.73 to 0.83 (P < 0.001) for each of the subscales, indicating high inter-rater reliability and homogeneity among items.[48]

Global Assessment of Functioning scale

It is a clinician-rated, 100-point instrument with a clear description of each 10-point interval.[49] Ratings are generally made for the past week, but longer intervals are required (e.g., highest adjustment during the past year) to evaluate the general level of functioning.

Scale to Assess Unawareness of Mental Disorder

An abbreviated version of the Scale to Assess Unawareness of Mental Disorder (SUMD) was used to evaluate the three most relevant aspects of insight, namely, awareness of mental illness, awareness of the need for treatment, and awareness of the social consequences of mental disorder.[5051] The SUMD utilizes a semi-structured interview to rate discrete and global aspects of insight. It has satisfactory convergent and criterion validities and can be used reliably with minimum training. It has been used widely among patients with schizophrenia.

Beck's Cognitive Insight Scale

The Beck Cognitive Insight Scale (BCIS) is a self-report questionnaire developed to measure cognitive insight in both clinical and nonclinical populations. It consists of 15 items rated on a 4-point scale. It has been shown to have good test–retest reliability in schizophrenia.[5253]

Social Occupational Functioning Scale

It is a 14-item, comprehensive, and easy-to-administer measure of social functioning, with each item scored on a 5-point rating scale, with higher scores indicating a higher level of impairment. The various items are divided into three domains, namely, adaptive living skills, social appropriateness, and interpersonal skills.[54] It has adequate psychometric properties in terms of reliability and validity.

Internalized Stigma of Mental Illness

Internalized Stigma of Mental Illness Scale (ISMIS) is an interview-based instrument to assess self-stigma/internalized stigma, from the perspective of stigmatized individuals. It comprises of 29 questions with 4 answering options (strongly disagree – 1, disagree – 2, agree – 3, and strongly agree – 4), which are divided into five components (alienation, stereotype endorsement, perceived discrimination, social withdrawal, and stigma resistance).[5556] The higher the scores, higher is the level of self-stigma. As a generic scale, it can be used in different health conditions. Hindi version of the scale has been validated in India, and the factor analysis showed a slight variance in the distribution of various items of ISMIS in the Indian setting. In this study, various domains as per the original description and description for the Hindi version of ISMIS were evaluated. Although various researchers have used different cutoffs, the originator of the scale used a cutoff of 2.5 for total and subscales of ISMIS to categorize the presence or absence of stigma. In this study, the scale was used for the patients, and the original cutoffs were used.

WHO Quality-of-Life Brief version scale-WHOQOL-BREF

It is a 26-item version of the WHOQOL-100 assessment. It has five domains namely general health, physical health, psychological health, social relationship, and environment. The WHOQOL-BREF self-assessment was completed, together with sociodemographic and health status questions. Analyses of internal consistency, item-total correlations, discriminant validity, and construct validity through confirmatory factor analysis indicates that the WHOQOL-BREF has good-to-excellent psychometric properties of reliability and performs well in preliminary tests of validity.[57]

Raven's standard progressive matrices

It measures Spearman's general intelligence factor in individuals' aged between 11 and 65 years. It is available in five black and white sets of 12 problems each and can be completed in 20–45 min. The total score provides a measure of individual capacity. The total number of problems solved correctly is the total score obtained by the participant. From the tabulated raw scores, Wechsler Adult Intelligence Scale equivalent IQ is determined by using the table devised for the same.[58]

Statistical analysis

Descriptive analysis was carried out using mean and standard deviation (SD) for continuous variables, and frequency and percentages were calculated for discontinuous variables. Comparisons were done by using a t-test, Mann–Whitney U-test, Chi-square test, and Fisher's exact test. Pearson's product moment correlation and comparison statistics were used to assess the association between SC and other variables. In view of multiple correlations, Bonferroni's correction was used.

RESULTS

The study included 30 patients with FEP and 26 healthy controls. Majority of the patients in the FEP group were diagnosed with schizophrenia (n = 22; 73.3%), with paranoid subtype (n = 20) being the most common. A small proportion of patients were diagnosed with brief psychotic disorder (n = 7) and one patient was diagnosed with psychosis NOS.

The demographic profile of the study groups is shown in Table 1. When patients in the FEP group were compared with healthy controls, significant difference was seen only for the variables of occupation and income, with a higher proportion of participants in the healthy control group being employed and earning more than rupees 979 [Table 1]. When the demographic profile of patients with first-episode schizophrenia was compared separately with healthy controls, comparisons were like FEP group in terms of occupation and income.

Table 1

Sociodemographic profile of the study groups

	Mean (SD) (range)/frequency (%)		Chi-square/t-test (P)
	FEP group (n=30)	Healthy control (n=26)
Age (years)	27.4 (6.9)	30.4 (9.4)	−1.35 (0.185)
Education (years)	11.9 (4.5)	12.5 (3.1)	−0.58 (0.565)
Sex
Male	21 (70)	16 (61.5)	χ2=0.445 (0.505)
Female	9 (30)	10 (38.5)
Marital status
Single	21 (70)	14 (53.8)	χ2=1.551 (0.213)
Married	9 (30)	12 (46.2)
Education
≤12th	14 (46.7)	14 (53.8)	χ2=0.287 (0.592)
>12th	16 (53.3)	12 (46.2)
Occupation
Unemployed	25 (83.3)	6 (23.1)	χ2=20.464 (<0.001)***
Employed	5 (16.7)	20 (76.9)
Income
≤979	25 (83.3)	6 (23.1)	χ2=20.464 (<0.001)***
≥980	5 (16.7)	20 (76.9)
SES
Lower middle and below	12 (40)	7 (26.9)	χ2=1.063 (0.303)
Upper middle and above	18 (60)	19 (73.1)
Religion
Hindu	22 (73.3)	19 (73.1)	χ2=0 (0.983)
Non-Hindu	8 (26.7)	7 (26.9)
Type of family
Nuclear	14 (46.7)	13 (50)	χ2=0.062 (0.803)
Extended/joint	16 (53.3)	13 (50)
Locality
Urban	13 (43.3)	15 (57.7)	χ2=1.149 (0.284)
Rural	17 (56.7)	11 (42.3)

***P<0.001. SD – Standard deviation; SES – Socioeconomic status; FEP – First-episode psychosis

The clinical details of patients with FEP are shown in Table 2. The mean total PANSS score for the study participants was 56.3 (SD – 11.1). The mean negative symptom subscale score was slightly higher than the positive symptom subscale score. General psychopathology subscale score was 29.6 (SD 6.4).

Table 2

Clinical profile of participants in the first-episode psychosis group

Clinical variables	Frequency (%)/mean (SD) (range)
Subtype of schizophrenia
Schizophreniaa	22 (73.3)
Othersb	8 (26.7)
Family history of mental illness
No	24 (80)
Yesc	6 (20)
Antipsychotic used
Risperidone	9 (30)
Olanzapine	18 (60)
Quetiapine	1 (3.3)
Aripiprazole	1 (3.3)
Trifluoperazine	1 (3.3)
Total duration of illness in months before starting medication (duration of untreated psychosis)	5.2 (3.9) (1-12)
Duration of treatment (months)	3.8 (1.2) (3-7)
Duration of current treatment (months)	3.8 (1.2) (3-7)
Duration of current remission (months)	3.3 (0.59) (3-5)
Positive and Negative Syndrome Scale
Positive subscale	13.0 (2.8) (8-18)
Negative subscale	13.8 (3.2) (7-19)
General psychopathology subscale	29.6 (6.4) (19-40)
Total score	56.3 (11.1) (39-74)

aSchizophrenia: Subtypes included paranoid (n=20) and undifferentiated (n=2), bOther diagnoses included brief psychotic disorder (n=7) and psychosis not otherwise specified (n=1), cFamily history of mental illness included psychotic illness (n=3), affective disorder (n=1), anxiety disorder (n=1), mental retardation (n=1). SD – Standard deviation

The mean scores on the various scales are shown in Table 3.

Table 3

Level of functioning, disability, quality of life, and insight

Variables	Mean (SD) (range)
Global Assessment of Functioning scale
Total score	72.6 (7.6) (60-89)
WHO Quality of Life BREF scale
General	6.2 (2) (2-10)
Physical health	22.4 (4.9) (16-31)
Psychological health	18.9 (4.6) (9-27)
Social relationship	9.3 (2.4) (6-14)
Environment	24.9 (7) (13-38)
WHOQOL-BREF total score	79.6 (17.4) (53-109)
Social and Occupational Functioning Scale
Adaptive living skills	2.5 (1.7) (0-6)
Social appropriateness	0.8 (0.7) (0-2)
Interpersonal skills	3.2 (1.3) (0-5)
Total score	6.4 (3) (1-12)
Beck's Cognitive Insight Scale
Self-reflectiveness	21.1 (7.1) (9-34)
Self-certainty	14.5 (5.7) (6-24)
Composite Index	6.7 (5.8) (-3-21)
Scale to Assess Unawareness in Mental Disorder
Awareness of mental illness (past)	3.8 (1.3) (1-5)
Awareness of effect of medications (past)	3.2 (1.1) (1-5)
Awareness of social consequences (past)	3.2 (1.1) (1-5)
Total SUMD score (past)	10.2 (3.2) (3-15)
Awareness of mental illness (current)	1.6 (0.7) (1-3)
Awareness of effect of medications (current)	1.2 (0.5) (1-3)
Awareness of social consequences (current)	1.4 (0.7) (1-3)
Total SUMD score (current)	4.2 (1.3) (3-7)
Internalized Stigma of Mental Illness Scale
Alienation	8.7 (3.4) (4-18)
Stereotype endorsement	12.2 (4.5) (3-24)
Discrimination experience	7.1 (3.5) (0-13)
Social withdrawal	9 (4.5) (2-18)
Stigma resistance	8.5 (2.5) (3-14)
Total score of ISMIS	44.1 (15.85) (13-84)
Total score of ISMIS without stigma resistance	35.6 (13.85) (10-70)

SD – Standard deviation; SUMD – Scale to Assess Unawareness of Mental Disorder; ISMIS – Internalized Stigma of Mental Illness Scale

The mean IQ for the patient group was 90.07 (SD: 7.42) (range: 73–106) and that for the healthy control group was 94.12 (SD: 8.88) (range: 74–110), and the difference between the two groups was statistically nonsignificant.

Comparison of social cognition deficits of patients with first-episode psychosis and healthy controls

Table 4 shows the performance of the study participants on SOCRATIS. When the SC of patients with FEP was compared with that of the healthy control group, significant differences were noted only for second-order ToM and Faux Pas Composite Index. When patients with first-episode schizophrenia were compared with healthy control group, significant differences were seen in the similar domains too. In addition, there was a trend toward significance for the Social Perception Index and Externalizing Bias Index [Table 4].

Table 4

Comparison of social cognition rating tools in Indian setting score for patients with first-episode psychosis group and healthy controls

Variables	Mean (SD) (range)		Comparison of FEP and healthy controls t-test	Schizophrenia group (n=22), mean (SD)	Comparison of schizophrenia and healthy controls t-test
	FEP group (n=30)	Healthy control (n=26)
First-order ToM index	0.98 (0.06) (0.75-1)	0.98 (0.07) (0.75-1)	0.146 (P=0.884)	1 (0.1) (0.75-1)	−0.171 (P=0.865)
Second-order ToM index	0.4 (0.3) (0-1)	0.77 (0.34) (0-1)	−4.447 (P<0.001)***	0.4 (0.3) (0-1)	−4.685 (P<0.001)***
Faux Pas Composite Index	0.57 (0.19) (0.26-0.88)	0.7 (0.15) (0.33-0.92)	−2.824 (P=0.007)**	0.5 (0.2) (0.26-0.85)	−3.957 (P<0.001)***
Social Perception Index	0.73 (0.17) (0.46-1)	0.79 (0.11) (0.54-0.99)	−1.562 (P=0.125)	0.7 (0.2) (0.45-1)	−1.996 (P=0.054)
Nonsocial Perception Index	0.8 (0.16) (0.44-1)	0.84 (0.12) (0.46-0.99)	−1.13 (P=0.263)	0.8 (0.2) (0.44-1)	−1.671 (P=0.101)
Externalizing Bias Index	3.87 (4.26) (−8-13)	5.77 (5.44) (−8-15)	−1.465 (P=0.149)	3.3 (4.4) (−8-13)	U=277.5 (P=0.064)@
Personalizing Bias Index	0.93 (1.56) (0-9)	0.83 (0.7) (0.2-4)	0.317 (P=0.752)	0.6 (0.4) (0-1)	−1.103 (P=0.276)

@Mann-Whitney U value. *p<0.05; **p<0.01; ***p<0.001

Correlation of social cognition with sociodemographic and clinical variables

When the association between SC and demographic variables was evaluated, no significant association was seen for gender, marital status, religion, occupational status, income categories, socioeconomic status, type of family, and locality. Compared to those educated up to 12th standard, those educated beyond 12th standard had higher scores on the Faux Pas Composite Index (t = 2.25; P = 0.032*) and Nonsocial Perception Index (t = 2.14; P = 0.041*).

Education of patients in years correlated positively with the Faux Pas Composite Index, Social Perception Index, and Nonsocial Perception Index. The total duration of untreated illness (duration of untreated psychosis), duration of treatment, and duration of current treatment correlated negatively with first-order ToM Index. The total duration of untreated illness (duration of untreated psychosis) also correlated negatively with externalizing bias. Duration of current treatment correlated negatively with Nonsocial Perception Index. PANSS General Psychopathology subscale and PANSS total score correlated negatively with externalizing bias [Table 5]. When we used Bonferroni's correction (P < 0.002), only significant correlation, which persisted was that between Faux Pas Composite Index and insight in the form of awareness of effects of medications in the past [Table 5].

Table 5

Correlation of social cognition with sociodemographic and clinical variables among patients with first-episode psychosis

	First-order theory of mind index	Second-order theory of mind index	Faux Pas Composite Index	Social Perception Index	Nonsocial Perception Index	Externalizing Bias Index	Personalizing Bias Index
Age (years)	−0.12 (0.516)	0.21 (0.266)	−0.01 (0.943)	0.04 (0.836)	−0.1 (0.593)	−0.38 (0.039)*	−0.14 (0.447)
Education (years)	0.17 (0.365)	0.15 (0.433)	0.43 (0.018)*	0.38 (0.04)*	0.5 (0.005)**	0.08 (0.692)	0.12 (0.542)
Total duration of illness before treatment (duration of untreated psychosis)	−0.38 (0.04)*	0.28 (0.141)	0.13 (0.491)	−0.05 (0.789)	−0.24 (0.195)	−0.49 (0.006)**	−0.29 (0.118)
Duration of current treatment	−0.5 (0.005)**	−0.08 (0.669)	−0.14 (0.467)	−0.22 (0.238)	−0.4 (0.03)*	−0.13 (0.51)	−0.13 (0.504)
Total duration of treatment$	−0.42 (0.02)*	−0.13 (0.505)	−0.09 (0.631)	−0.1 (0.609)	−0.32 (0.086)	−0.29 (0.125)	−0.07 (0.735)
Positive and Negative Symptom Scale
Positive subscale	−0.29 (0.122)	0.21 (0.266)	0.19 (0.321)	0.08 (0.667)	−0.12 (0.522)	−0.25 (0.18)	−0.26 (0.166)
Negative subscale	−0.19 (0.317)	0.08 (0.683)	0.04 (0.84)	−0.04 (0.84)	0.06 (0.747)	−0.27 (0.147)	−0.11 (0.558)
General psychopathology subscale	−0.31 (0.091)	0.15 (0.433)	0.16 (0.407)	0.18 (0.33)	0.16 (0.406)	−0.42 (0.022)*	−0.13 (0.485)
Total score	−0.31 (0.097)	0.16 (0.394)	0.15 (0.43)	0.12 (0.541)	0.08 (0.683)	−0.38 (0.037)*	−0.18 (0.356)
Scale to Assess Unawareness in Mental Disorder
Awareness of mental illness (past)	0.17 (0.372)	−0.35 (0.06)*	−0.39 (0.035)	−0.04 (0.845)	0.02 (0.921)	0.18 (0.35)	−0.03 (0.859)
Awareness of effects of medication (past)	0.3 (0.103)	−0.48 (0.008)**	−0.57 (0.001)***	−0.01 (0.942)	−0.1 (0.604)	0.06 (0.76)	0.06 (0.748)
Awareness of social consequences (past)	0.16 (0.404)	−0.45 (0.012)*	−0.41 (0.026)*	0.16 (0.403)	0.1 (0.609)	0.09 (0.639)	−0.13 (0.487)
Total Score SUMD (past)	0.23 (0.22)	−0.47 (0.009)*	−0.5 (0.005)*	0.04 (0.85)	0.01 (0.964)	0.13 (0.51)	−0.04 (0.834)
Awareness of mental illness (current)	0.03 (0.889)	−0.1 (0.589)	−0.41 (0.024)	−0.07 (0.723)	−0.15 (0.43)	−0.01 (0.963)	−0.13 (0.506)
Awareness of effects of medication (current)	0.11 (0.555)	0.27 (0.15)	−0.03 (0.866)	0.1 (0.594)	0.17 (0.368)	−0.04 (0.847)	−0.08 (0.693)
Awareness of social consequences (current)	−0.03 (0.889)	0.08 (0.665)	−0.21 (0.267)	0.03 (0.873)	−0.09 (0.626)	−0.1 (0.605)	−0.14 (0.477)
Total SUMD score (current)	0.04 (0.829)	0.09 (0.644)	−0.33 (0.074)	0.02 (0.925)	−0.06 (0.745)	−0.07 (0.719)	−0.16 (0.394)
Internalized Stigma of Mental Illness scale
Alienation	0.06 (0.77)	−0.31 (0.098)	−0.1 (0.598)	0.05 (0.786)	0 (0.996)	−0.11 (0.582)	0.02 (0.929)
Stereotype endorsement	−0.05 (0.8)	−0.39 (0.034)*	−0.27 (0.143)	−0.09 (0.647)	0.01 (0.966)	−0.19 (0.323)	0 (0.996)
Discrimination experience	−0.18 (0.334)	−0.18 (0.341)	−0.16 (0.398)	−0.04 (0.835)	0.08 (0.678)	−0.33 (0.078)	−0.04 (0.826)
Social withdrawal	−0.21 (0.266)	−0.24 (0.196)	−0.19 (0.313)	−0.06 (0.738)	0.14 (0.449)	−0.09 (0.644)	−0.03 (0.863)
Stigma resistance	−0.17 (0.379)	−0.16 (0.386)	−0.08 (0.668)	0.09 (0.63)	0.11 (0.548)	−0.13 (0.484)	−0.01 (0.962)
Alienation	0.06 (0.77)	−0.31 (0.098)	−0.1 (0.598)	0.05 (0.786)	0 (0.996)	−0.11 (0.582)	0.02 (0.929)

$Spearman rank correlation coefficient. SUMD – Scale to Assess Unawareness of Mental Disorder. *p<0.05; **p<0.01; ***p<0.001

There was no significant association of SC with BCIS domains and current SUMD scores. Second-order ToM correlated negatively with scores on all the SUMD items (awareness of mental illness, effects of medications, and social consequences) in the past and SUMD total score in the past. Among the various subscales of stigma, only stereotype endorsement had a significant negative correlation with second-order ToM. No significant correlations emerged between SC and global assessment of function, quality of life, and socio-occupational functioning.

DISCUSSION

In recent years, there have been rigorous efforts to identify and treat patients with FEP effectively to minimize the negative impact of illness on the patients, caregivers, and society. SC has been evaluated as one such construct which may be responsible for deficits in patients with psychosis even after clinical remission and is considered to be an endophenotype. Having an understanding of this construct in patients with FEP can help in improving the overall outcome in these patients.

Although many studies have evaluated SC deficits among patients with schizophrenia, literature specific to patients with FEP is limited. Accordingly, the present study attempted to evaluate SC in patients with FEP in remission. Further, an attempt was made to understand the relationship between social cognitive deficits and social outcomes. Only very few studies have evaluated patients with FEP in the asymptomatic phase,[16171819585960] and investigations which have compared the SC deficits of patients with FEP/early psychosis with healthy controls are limited.[1622596061] The definition of FEP/early psychosis has varied between the studies, which further limits the generalizability of the findings.[62] To overcome some of these limitations, in the present study, FEP psychosis was defined by duration criterion of <2 years, and the assessment of SC was done when the patients were in clinical remission. Multiple social outcomes such as stigma, socio-occupational functioning, and global functioning were evaluated so as to understand the association of these outcomes with social cognitive deficits. In addition, the association of social cognitive deficits with insight into the illness was evaluated. It was expected that this design will improve the understanding of how these complex domains are interlinked. The patients with FEP were matched with healthy controls in terms of age, gender, level of education, and IQ, as these variables are known to influence SC.[6364656667] Many of the previous studies have failed to do so or have been silent about the same.[233368697071727374]

Majority of the patients in the FEP group were diagnosed with schizophrenia, with paranoid subtype being the most common. The predominance of patients with schizophrenia in the FEP is similar to studies from other parts of the globe and India.[1819757677] However, compared to studies from other parts of the world, about one-fourth of the patients were diagnosed with brief psychotic disorders in the present study. This prevalence profile of brief psychotic disorders among patients with psychosis is very much similar to the profile of patients with psychosis seen at this center when the proportion of new patients with schizophrenia and acute and transient psychotic disorders is compared.[78] The mean total PANSS score for the study participants was comparable to that of previous studies on patients with schizophrenia, who have been evaluated while in remission,[187980] or which have followed up patients with FEP to remission.[7677]

When the SC of patients with FEP was compared with the healthy control group, significant differences were noted only for second-order ToM and Faux Pas Composite Index. ToM is understood as the ability to infer intentions, dispositions, and beliefs of others.[12] It refers to the ability of a person to represent the mental states and/or to make inferences about other's intentions. It includes understanding false beliefs, hints, intentions, deception, metaphor, irony, and Faux Pas.[81] Impairment of ToM in patients of FEP suggests that psychosocial intervention among patients with FEP must include social skill training, mainly addressing these deficits.

Previous studies from India have compared the SC deficits among patients with schizophrenia, both during the acute phase and remission phase with healthy controls, and these suggest that patients of schizophrenia and significantly higher SC deficits when compared with healthy controls in all the domains.[7982] However, it is important to note that although some of these studies have controlled for demographic factors such as age, gender, and education, these studies have not controlled for IQ, which can influence SC deficits.[6183] In contrast, in the present study, both the study groups were matched not only for the demographic variables but also for the IQ. Hence, this could not have influenced the significant differences between patients with FEP and healthy controls. Previous studies which have compared patients of FEP with healthy controls suggest that patients with FEP perform poorly than healthy controls on tasks of facial emotion recognition and ToM tasks.[1683] However, some of the studies have found no significant difference between healthy controls and remitted patients with FEP.[84] A review of studies on SC deficits among patients with FEP concluded that compared to healthy controls, patients with FEP consistently perform poorly in the tests of emotional processing and ToM.[20] For the other domains of SC, findings are inconclusive, with some reporting significant difference, whereas others refute the presence of a significant difference between patients with FEP and healthy controls.[20] Findings of the present study also support the significant difference between patients with FEP and healthy controls in terms of ToM and Faux Pas Composite Index, but not for other domains.

When patients of FEP with schizophrenia were compared with healthy control group, a significant difference was seen in the SC domains of second-order ToM and Faux Pas Composite Index. In addition, there was a trend toward significance for Social Perception Index and Externalizing Bias Index. Accordingly, it can be said that lack of significant difference between patients of FEP and healthy controls in the present study could not have been influenced by the inclusion of patients with brief psychotic disorder and psychosis (NOS).

Findings of the present study suggest that older patients of FEP have significantly more externalizing bias and those with a lower level of education have more social cognitive deficits in the domain's Faux Pas Composite Index, Social Perception Index, and Nonsocial Perception Index. However, these correlations were weak and when Bonferroni's corrections were used, these correlations can be considered nonsignificant. Previous studies which have commented on the association of SC with demographic variables on patients with FEP have also suggested that a higher level of education is associated with better SC.[85]

In the present study, a longer duration of untreated psychosis was associated with higher deficits in the first-order ToM and Externalizing Bias Index. Further, longer duration of treatment was associated with higher impairment in first-order ToM index. Previous studies have not looked at these associations. Although these correlations can be considered nonsignificant, when Bonferroni's corrections were used, these associations, without the correction, suggest that a longer duration of untreated psychosis is associated with higher social cognitive deficits in the domain of ToM. Hence, efforts to reduce the DUP can reduce the social cognitive deficits.

A review of studies on SC among patients with FEP also suggests that there is no consistent association of social cognitive deficits with psychopathology. Some of the studies have reported lack of association between ToM and psychotic symptoms,[81723242860658687] whereas others suggest an association between ToM and negative symptoms.[1929333488] Studies have reported the association of ToM with positive[1989] and disorganized symptoms.[88] Similarly, for social perception, some of the studies have reported lack of association with any of the symptoms subscales,[2328] whereas others suggest an association of Social Perception Index with negative[2224] and positive symptoms.[22] Available data suggest the association of attributional style with paranoia subscale, but not with other subscales of PANSS.[90] In previous studies, externalizing and personalizing biases have been found to be significantly associated with the severity of delusional thinking and distress using the Peters Delusion Inventory[91] but was not associated with PANSS scores.[92] In the present study, only general psychopathology and total PANSS total score had a significant association with externalizing bias (in the uncorrected analysis), with a higher level of psychopathology associated with more severe deficits in this domain. However, these findings must be considered as preliminary and must be replicated in future.

In the present study, no significant association was noted between SC and cognitive insight as assessed by the BCIS. However, poor insight as assessed by SUMD was associated with higher level of SC deficits in the domains of second-order ToM and Faux Pas Composite Index. When Bonferroni's correction was used only significant correlation which persisted was that between, insight item of “awareness of effect of medication (in the past)” and Faux Pas Composite Index. Only a few studies have evaluated this relationship, and the results of the present study are in line with those of the existing literature.[7982] Accordingly, it can be said that any kind of intervention to improve SC or insight can lead to improvement in both aspects.

In general, no significant correlations emerged between SC and stigma, except for the higher level of externalizing bias, which was associated with higher stigma in the domain of stereotype endorsement, which also disappeared on using Bonferroni's correction. Previous studies involving patients of FEP have not looked at this association. The association of externalizing bias with stereotype endorsement suggests that SC plays a role in the perception of stigma, and efforts to mitigate stigma need to focus on SC deficits in patients with FEP.

There was no significant association of SC with BCIS domains and current SUMD scores. Second-order ToM correlated negatively with scores on all the SUMD items (awareness of mental illness, effects of medications, and social consequences) in the past and SUMD total score in the past. Among the various subscales of stigma, only stereotype endorsement had a significant negative correlation with second-order ToM. No significant correlations emerged between SC and global assessment of function, quality of life, and socio-occupational functioning.

The present study has certain limitations in the form of small sample size, cross-sectional assessment, and inclusion of patients of FEP belonging to heterogeneous diagnostic categories. The present study did not involve the assessment of emotional processing and facial recognition.

The study was limited to the patients attending the treatment services. Hence, the findings cannot be generalized to all the patients with FEP living in the community. Future studies can overcome the limitations of the current study by including a larger number of patients, recruited from the community, inclusion of a homogenous group of patients with FEP, and carrying out a longitudinal assessment of patients.

CONCLUSION

To conclude, the present study suggests that compared to healthy controls, patients with FEP have impairment in the domains of second-order ToM and Faux Pas Composite Index. However, when the sample was limited to patients with first-episode schizophrenia, additionally, there was a trend for impairment in the domain of social perception and externalizing bias. This finding suggests that FEP is not a homogenous group and the deficits in the SC are affected by the diagnostic groups. Hence, in future, researchers need to define the FEP properly and must limit their studies to a single diagnostic group, to have a better understanding of SC in patients with FEP. SC deficits are also associated with insight at the worse level of psychosis. However, SC deficits are not associated with quality of life.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.