Problems in real-world functioning are pervasive in schizophrenia and much recent effort has been devoted to uncovering factors which contribute to poor functioning. The goal of this study was to examine the role of four such factors: social cognition (theory of mind), neurocognition, negative symptoms, and functional capacity (social competence). 178 individuals with schizophrenia or schizoaffective disorder completed measures of theory of mind, neurocognition, negative symptoms, social competence, and self-reported functioning. Path models sought to determine the relationships among these variables. Theory of mind as indexed by the Hinting Task partially mediated the relationship between neurocognition and social competence, and negative symptoms and social competence demonstrated significant direct paths with self-reported functioning. Study results suggest theory of mind serves as an important mediator in addition to previously investigated social cognitive domains of emotional and social perception. The current study also highlights the need to determine variables which mediate the relationship between functional capacity and real-world functioning.

Theory of mind (ToM) impairment is common in individuals with schizophrenia and is associated with poor social functioning. Poor insight has also been linked to poor outcome in schizophrenia. Social developmental research has shown representations of self (insight) and representations of others (ToM) are related. In schizophrenia, contradictory reports of associations between insight and ToM have emerged, possibly due to a failure to account for neurocognitive impairments and symptoms associated with both mentalization constructs. This study investigated the relationships between ToM (intentions of others on the Hinting task) and clinical and cognitive insight, while accounting for shared variance with neurocognitive impairment and symptom severity in 193 individuals with schizophrenia. Clinical, but not cognitive, insight was associated with ToM. A unique association between Awareness of Mental Illness and Hinting Task performance was found, independent of shared variance with neurocognition and symptoms. Importantly, ToM was found to mediate Awareness of Mental Illness and neurocognition. Results suggested treatments targeting mentalization abilities that contribute to representations of self and others may improve insight deficits associated with poor outcome in schizophrenia.

Cognitive Behavioral Social Skills Training (CBSST) is a 24-session weekly group therapy intervention to improve functioning in people with schizophrenia. In our prior randomized clinical trial comparing treatment as usual (TAU) with TAU plus group CBSST (Granholm et al. 2005), participants with schizophrenia in CBSST showed significantly better functional outcome than participants in TAU. The present study was a secondary analysis of neuropsychological predictors of functional outcome in our prior CBSST trial. We examined (1) whether neuropsychological impairment at baseline moderated functional outcome in CBSST relative to TAU, and (2) whether improvement in neuropsychological abilities mediated improvement in functional outcome in CBSST. Attention, verbal learning/memory, speed of processing, and executive functions were assessed at baseline, end of treatment, and 12-month follow-up. Greater severity of neuropsychological impairment at baseline predicted poorer functional outcome for both treatment groups (nonspecific predictor), but the interaction between severity of neuropsychological impairment and treatment group was not significant (no moderation). Effect sizes for the difference between treatment groups on functional outcome measures at 12-month follow-up were similar for participants with relatively mild (d=.44-.64) and severe (d=.29-.60) neuropsychological impairment. Results also did not support the hypothesis that improvement in neuropsychological abilities mediated improvement in functioning in CBSST. Adding CBSST to standard pharmacologic care, therefore, improved functioning relative to standard care alone, even for participants with severe neuropsychological impairment, and this improvement in functioning was not related to improvement in neuropsychological abilities in CBSST. KeywordsSchizophrenia; cognitive behavior therapy; social skills training; neuropsychological impairment; functioning Please address all correspondence to: Eric Granholm, Ph.D., VA San Diego Healthcare System (116B), 3350 La Jolla Village Drive, San Diego, CA 92161, Phone: (858) 552-8585 x 7768, FAX: (858) 642-6416, Email: egranholm@ucsd.edu. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. NIH Public Access NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author ManuscriptThere is considerable evidence that neuropsychological impairment is associated with poor functioning in people with schizophrenia (Bowen et al. 1994;Green et al. 2000;Kern et al. 1992;Lysaker et al. 1995;McKee et al. 1997;Penn et al. 1995). Neuropsychological impairment is also a strong predictor ...

A differential deficit on the more difficult of 2 cognitive tasks has been found in numerous studies of schizophrenia. Resource limitations, rather than impairments in particular cognitive abilities, can explain these findings. Researchers often match tasks for difficulty level (healthy participant performance) to rule out resource limitations. This assumes processing resource load can be estimated from task difficulty, which is not always the case. A direct measure of resource allocation is needed. In this study, pupillary responses were recorded to index resource allocation (greater dilation indicates greater allocation) during performance of the digit span distractibility task in participants with schizophrenia (n=35) and nonpsychiatric participants (n=35). Nonpsychiatric participants recalled significantly more digits in the distraction, relative to the neutral, condition but also showed significantly greater pupil dilation in the distraction condition. The psychometrically "easier" condition, therefore, had a higher processing load. Participants with schizophrenia showed greater impairment relative to nonpsychiatric participants in the distraction condition. This finding cannot be attributed to a deficit in distractibility, however, because poorer performance was found in the higher-load condition, so resource limitations cannot be ruled out.