www.elsevier.com/locate/schres

Schizophrenia Research

Specific cognitive deficits and differential domains of social

functioning impairment in schizophrenia

Alex S. Cohen *, Courtney B. Forbes, Monica C. Mann, Jack J. Blanchard

University of Maryland, College Park, College Park, MD 20742, United States

Received 11 April 2005; received in revised form 30 August 2005; accepted 6 September 2005

Available online 2 November 2005

Abstract

There is considerable inconsistency in findings regarding the relationship between specific cognitive deficits and social

impairment in patients with schizophrenia. This inconsistency may relate to variability across studies in how social functioning

is measured and preliminary evidence suggests that different indices of social functioning (e.g., laboratory test, community

assessment) may have different cognitive correlates. The present study examined this issue by evaluating the relationships

between cognitive deficits (including social cognitive deficits), role-play test performance, and community social functioning in

28 inpatients with schizophrenia. We expected the two measures of social functioning to have only modest convergence with

each other. Moreover, informed by the literature on cognitive functioning in schizophrenia, we identified specific cognitive

processes that were hypothesized to be associated with role-play performance (delayed verbal memory and attentional

vigilance) and social functioning in the community (delayed verbal memory and executive functioning). As expected, the

two measures of social functioning were modestly correlated with each other. Community social functioning was associated

with a relatively constrained pattern of cognitive deficits and received a significant contribution (Dr2=0.24) from specific

cognitive processes beyond that of general cognitive functioning and symptom severity. In contrast to our hypotheses, role-play

test performance was associated with a wide range of cognitive impairments and received little contribution from the specific

cognitive processes beyond the effects of general cognitive functioning. Community social functioning, but not role-play test

performance, was significantly associated with social cognition. These findings highlight the importance of conceptualizing

social functioning as a multidimensional construct for schizophrenia research.

D 2005 Elsevier B.V. All rights reserved.

Keywords: Schizophrenia; Social; Cognition; Functioning; Community; Symptom

0920-9964/$ - see front matter D 2005 Elsevier B.V. All rights reserved.

doi:10.1016/j.schres.2005.09.007

* Corresponding author. Tel.: +1 301 405 7184; fax: +1 301 405

0367.

E-mail address: acohen@psyc.umd.edu (A.S. Cohen).

1. Introduction

There is considerable evidence to suggest that

cognitive deficits are related to poor social functioning

in patients with schizophrenia. Efforts to identify

specific cognitive deficits that underlie these social

81 (2006) 227–238

A.S. Cohen et al. / Schizophrenia Research 81 (2006) 227–238228

impairments are vital for the development of standar-

dized cognitive assessment batteries (e g., see Green et

al., 2004) and for the advancement of effective cogni-

tive remediation interventions. As yet however, the

identification of specific cognitive correlates that reli-

ably predict social functioning has been hampered due

to inconsistent findings across studies. For example,

the Wisconsin Card Sorting Task, a measure of execu-

tive functioning, has been associated with impaired

social functioning in some (e.g., Penades et al., 2003;

Penn et al., 1996), but not most (e.g., Addington and

Addington, 1999; Addington et al., 1998; Dickerson et

al., 1996; Fujii and Wylie, 2003; Simon et al., 2003;

van Beilen et al., 2003; Woonings et al., 2003) studies.

When attempting to resolve this inconsistency, it is

important to note that there is considerable variability

across studies in how social functioning is measured.

Thus, the aforementioned inconsistency of findings

could reflect, at least in part, the use of different

measures of functioning across studies. The present

study examined whether different social functioning

domains would show divergent cognitive correlates in

patients with schizophrenia.

Recent findings have raised questions about the

utility of conceptualizing social functioning within

the context of a single, isomorphic construct. First,

studies that have examined the convergence between

laboratory and community based measures of social

functioning have generally found only modest levels of

inter-correlation (e.g., Mueser et al., 1990; Penn et al.,

1995; Addington and Addington, 1999 but see also

Bellack et al., 1990). Conceptually speaking, there

are differences between these two measures in that

laboratory-based measures typically assess social com-

petence or social skill ability (Bellack et al., 1990),

whereas community functioning-based instruments

measure the degree to which an individual actually

engages in social activities. Second, preliminary find-

ings from a recent review of 39 published studies

provide tentative evidence that different types of cog-

nitive deficits are associated with different domains of

functioning (Green et al., 2000). Across studies, defi-

cits in delayed verbal memory and attentional vigilance

have tended to be associated with role-play test impair-

ment, whereas deficits in executive functioning,

delayed verbal memory, and verbal fluency have

tended to be associated with impairment on instruments

that measured community social functioning. It is

important to note that the results of Green et al.

(2000) were based on a frequency count of the numbers

of replicated findings, and thus, should be interpreted

cautiously because the numbers of null and

bparadoxicalQ findings were not reported. Nonetheless,these findings support the notion that a meaningful

understanding of the cognitive underpinnings of social

dysfunction requires separate consideration for differ-

ent domains of social functioning.

As yet, the hypothesis that specific cognitive

factors are differentially related to different domains

of social functioning has received limited examina-

tion because few studies have included simultaneous

and multidimensional assessments of functioning

when examining cognitive dysfunction in schizo-

phrenia. Milev et al. (2005) found evidence for

cognitive specificity in relation to different domains

of functional outcome, however, the measures used

in these studies each assessed different aspects of

community functioning, and a laboratory-based mea-

sure was not included. Only two studies that have

simultaneously used both laboratory and community-

based social functioning assessments (Addington and

Addington, 1999; Addington et al., 1998) in exam-

ining correlates of cognitive deficits in schizophrenia

could be identified. Generally speaking, results from

these studies provide support for the notion that

laboratory and community-based social functioning

have different cognitive correlates, although there

was mixed support for the specific cognitive sub-

strates reported in Green et al. (2000). In both

Addington and Addington (1999) and Addington et

al. (1998), the magnitudes of correlations between

role-play test and cognitive impairments tended to be

in the small-to-moderate effect size range, whereas

the magnitudes of correlations between community

social functioning and cognitive impairment tended

to be small and nonsignificant.

When looking at cognitive functioning in patients,

one encounters the additional problem of contrasting

traditional bnonsocialQ measures of cognition with

social-based measures of cognition (Penn et al.,

1997). Social cognition, defined as the mental opera-

tions underlying the ability and capacity to perceive

the intentions and dispositions of others (Brothers,

1990), is relevant to the present discussion because it

has been associated with poorer nonsocial cognitive

functioning (e.g., Bryson et al., 1997; Kee et al., 1998,

A.S. Cohen et al. / Schizophrenia Research 81 (2006) 227–238 229

but see Lancaster et al., 2003) and poorer social func-

tioning across multiple domains in schizophrenia

patients, including role-play performance (Bellack et

al., 1992; Ihnen et al., 1998, but see Mueser et al.,

1996), social functioning in an inpatient setting (Penn

et al., 1996), and community social functioning (Hoo-

ker and Park, 2002; Poole et al., 2000). Recent theor-

ists (e.g., Green and Nuechterlein, 1999; Penn et al.,

1997) have proposed that social cognition reflects a

higher order cognitive function that is dependent on

more basic nonsocial cognitive processes, thus ser-

ving as a mediator between basic cognitive processes

and social functioning. However, the relationships

between these variables are presently unclear because

only a few studies have statistically examined the

independent contributions of social vs. nonsocial cog-

nition to functional outcome (e.g., Kee et al., 2003;

Vauth et al., 2004). Thus far, findings suggest that

social cognition deficits uniquely account for a lim-

ited, but significant amount of variance in community

functioning. It has yet to be determined whether social

cognition is related to role-play test performance

beyond that of nonsocial cognition.

Finally, when attempting to understand the relation-

ship between cognitive and social functioning in

patients, it is important to consider the impact of

symptom severity. Negative symptoms in particular,

have been associated with impairments in both cogni-

tive and social functioning (Earnst and Kring, 1997),

although cognitive deficits have contributed to social

functioning impairment beyond the effects of negative

symptoms (Addington and Addington, 1999; Velligan

et al., 1997). The relationships between other symp-

toms and social and cognitive functioning have been

less substantive (Green, 1996), although a few studies

have reported significant associations between disor-

ganization symptom severity and impairment in non-

social (Kerns and Berenbaum, 2002) and social

cognition (Kee et al., 2003) and community social

functioning (Smith et al., 2002) abilities. However,

the differential contribution that symptoms and cogni-

tive impairments make to social functioning across

multiple domains has not been assessed.

The primary purpose of the present study was to

examine the extent to which laboratory and commu-

nity-based social functioning measures differ in their

cognitive and symptom correlates. Given prior

research on the topic, we expected the two measures

of social functioning to have only modest levels of

correlation with each other, and to show different

cognitive correlates. Using the findings of Green et

al. (2000) to inform our hypotheses, we predicted that

deficits on tests of delayed verbal memory and atten-

tional vigilance would be associated with poorer role-

play test performance beyond the effects of other

cognitive tests, and that impairment on tests of delayed

verbal memory and executive functioning would be

associated with poorer community social functioning

beyond the effects of other cognitive tests. We

hypothesized that social cognition scores would

uniquely contribute to the variance of both types of

social functioning above and beyond that of nonsocial

cognition scores. Finally, we examined the relationship

between symptoms and social functioning with the

expectation that cognitive deficits would uniquely

contribute to social functioning score variance beyond

the contribution made by symptoms.

2. Method

2.1. Participants

This study was part of a larger investigation into

affective disturbances in schizophrenia (see Blanchard

et al., 2001). Patients were recruited from an inpatient

hospital, and were in a state of clinical stability when

they enrolled in the current study. Patients met criteria

for Diagnostic and Statistical Manual of Mental Dis-

orders-fourth edition (DSM-IV; American Psychiatric

Association, 1994) schizophrenia based on informa-

tion obtained from a structured clinical interview

(Structured Clinical Interview for DSM-IV; Spitzer

et al., 1990) that was administered by trained mas-

ters-level doctoral students. Patients with evidence of

a history of neurological disorder or serious head

trauma were excluded from the original study. Inter-

rater agreement for diagnosis, based on a review of 14

videotaped interviews, was acceptable (Kappa values

range from 0.85 to 1.00). The methodology and par-

ticipant characteristics are more fully described in

Blanchard et al. (2001).

Not all data were available for each case due to

several factors, such as the inclusion of the role-play

tests late in the study and missing cognitive test data

for some patients. For the present study, cases were

A.S. Cohen et al. / Schizophrenia Research 81 (2006) 227–238230

excluded if there was missing data for any of the

cognitive or social functioning measures. Twenty-

eight of the 55 schizophrenia patient cases were

selected for analysis. There were no significant differ-

ences between those patients that were included and

those that were excluded (n =27) from the present

study in age, education, ethnicity, sex, symptom

severity or intellectual functioning variable scores

(all p values N0.05).

The final sample was composed of 24 males and

four females with an average (meanF standard devia-

tion=mFSD) age of mFSD=33.36F1.26 years

and education of mFSD=12.21F2.42 years. Twelve

of the patients were Caucasian, four were African-

American, 11 were Hispanic and one was Asian-

American/Pacific Islander. Each of these patients

was being prescribed antipsychotic medication.

2.2. Measures

2.2.1. Social functioning

Social functioning was assessed using two different

measures. The first, a Role-Play Test (Bellack et al.,

1994), was used as a measure of laboratory-based

social skill. The version of the role-play test that was

used in this study included two practice, two conver-

sational (e.g., initiating conversation with a new

neighbor) and two assertiveness (e.g., speaking to a

landlord about a ceiling leak that has not been fixed)

role-play situations. The role-plays were enacted with

one of five confederates whose responses were stan-

dardized. Role-play test were videotaped and rated by

one of two raters who independently coded patients’

performance on each of the conversation and asser-

tiveness scenes for a variety of skills, including con-

versational fluency, conversational clarity, number of

social norm violations, positive and negative valance,

and level of arousal (for a review of each of the

measures, see Bellack et al., 1994). For the present

study, the overall skill rating, which is a likert-type

scale from 1 (very poor overall skill) to 5 (very good

overall skill) was used. The overall skill ratings from

the conversational and assertiveness conditions were

highly correlated (r[28]=0.71, p N0.00), suggesting

there was considerable convergence in what they

were measuring. For data reduction purposes, the

four individual overall skill ratings (two from the

conversation scenes and two from the assertiveness

scenes) were averaged together yielding one overall

skill rating. Intra-class Correlation Coefficient (ICC)

for the average overall skill ratings from the role-play

test, computed from independent ratings by both raters

for 24% of the original cases (13 of 55), was adequate

(ICC=0.87).

The second measure of social functioning, a mea-

sure of community functioning, was the Social Adjust-

ment Scale-second edition (SAS-II; Schooler and

Weissman, 1979). The SAS-II is an instrument meant

to assess a wide range of social functioning in the

preceding month. For the present study, we were

most interested in those items that directly tapped

into social behavior as opposed to satisfaction or com-

fort with social relationships. Following the methods

of Blanchard et al. (1998), scores from the five ques-

tions that were related to social behavior were

summed, including frequency of leisure, social, peer

and romantic contacts and degree of activity in social

contacts. The SAS-II has shown adequate reliability

and convergent validity in prior studies with patients

(Blanchard et al., 1998; Glazer et al., 1980; Mueser

et al., 1990). SAS-II scores ranged from 5 to 25, and

were reverse-coded so that higher scores on this mea-

sure would reflect better functioning. This allowed

consistency across measures so that higher scores for

each of the social functioning and cognitive tests

reflected better performance.

2.2.2. Cognitive measures

A battery of cognitive tests was used to assess

patients’ cognitive functioning. The cognitive domains

and their corresponding tests are listed in Table 1.

These tests included: the Vocabulary test from

the Wechsler Adult Intelligence Scales-Revised

(WAIS-R; Wechsler, 1981) as a measure of verbal

ability, the Block Design test from the WAIS-R

(Wechsler, 1981) as a measure of visual-spatial con-

struction ability, Logical Memory I and II from the

Wechsler Memory Scales-Revised (WMS-R; Wechs-

ler, 1987) as measures of immediate and delayed ver-

bal memory respectively, Visual Reproduction I and II

from the WMS-R (Wechsler, 1987) as measures of

immediate and delayed non-verbal memory respec-

tively, the categories completed score from the Wis-

consin Card Sorting Task (Heaton et al., 1993) as a

measure of executive functioning and cognitive flex-

ibility, and the d’ from the Degraded Stimuli-Contin-

1 The Facial Emotion Discrimination Test (FEDT) was also admi-

nistered but was not included in the present study. This decision was

made to reduce the overall number of analyses. Moreover, facial

emotion recognition ability is more often assessed using the FEIT

rather than the FEDT (Edwards et al., 2002), and it was not clear

what the FEDT test would contribute to our understanding of social

functioning deficits beyond the contribution made by the FEIT test.

Table 1

Means and standard deviations (mFSD) for symptom factor scores

and the social and cognitive functioning measures (N =28)

Domain Measure mFSD

Social functioning

Role-play test Role-play test 2.38F0.69

Community social

functioning

Social Adjustment

Scale II

17.04F5.55

Symptom factors

Thought disturbance BPRS 10.74F4.78

Anergia BPRS 6.86F2.70

Disorganization BPRS 6.46F3.07

Cognitive

Social cognition Facial Emotion

Identification Test

11.11F3.56

IQ Estimated WAIS-R IQ 88.86F1.74

Vocabulary WAIS-R, vocabulary 30.82F13.07

Visual-spatial

construction

WAIS-R, block design 23.36F9.17

Immediate verbal

memory

WMS-R, logical

memory 1

13.57F6.68

Delayed verbal

memory

WMS-R, logical

memory 2

9.86F5.25

Immediate nonverbal

memory

WMS-R, visual

reproduction 1

31.57F7.08

Delayed nonverbal

memory

WMS-R, visual

reproduction 2

23.50F11.16

Visual perception:

facial recognition

Benton’s facial

recognition test

21.54F2.27

Auditory perception speech sounds

perception

24.18F3.55

Executive functioning WCST, categories

completed

3.18F2.00

Attentional vigilance DSCPT, dV 1.88F1.07

BPRS=Brief Psychiatric Rating Scale, WAIS-R=Wechsler Adult

Intelligence Scales-revised, WMS=Wechsler Memory Scales-

Revised, WCST=Wisconsin Card Sorting Task, DSCPT=Degraded

Stimuli Continuous Performance Task.

A.S. Cohen et al. / Schizophrenia Research 81 (2006) 227–238 231

uous Performance Test (DSCPT; Nuechterlein, 1992)

as a measure of attentional vigilance. Auditory and

visual perception ability was measured using the

Speech Sounds Perception test (Boll, 1981) and the

Facial Recognition test (Benton et al., 1978), respec-

tively. For the present project, we were most interested

in evaluating the extent to which social functioning

performance was associated with specific cognitive

abilities beyond that of general cognitive ability. As

in other studies of cognitive functioning (e.g., Jung

et al., 2000; Hobart et al., 1999), we accomplished

this by computing composite scores of the individual

z-transformed test scores. The specific composite

scores that were used in this study are described in

Section 3.1. Social cognition was measured using the

Facial Emotion Identification Test (FEIT; Kerr and

Neale, 1993)1. During the administration of the

FEIT, patients are presented with 19 black and white

still photographs of individuals’ faces and then asked

to identify the primary emotion that is being shown

from a list of six different emotions. Total correct

scores for the identification test were used in the

present study. The FEIT has demonstrated reliability

and validity in its use with patients with schizophrenia

(Kerr and Neale, 1993).

2.2.3. Symptom severity

The 18-item Brief Psychiatric Rating Scale (BPRS;

Overall and Gorham, 1962) was used to evaluate

patients’ symptoms. Ratings were made by masters-

level psychology doctoral students and reflected

patients’ level of symptomatology 1 week prior to the

assessment. Symptom severity scores were computed

based on BPRS factors identified by Mueser et al.

(1997). These included the bthought disturbanceQ(including the grandiosity, suspiciousness, hallucina-

tory behavior, and unusual thought content items),

banergiaQ (including the emotional withdrawal, motor

retardation, uncooperativeness, and blunted affect

items), and bdisorganizationQ (including the conceptualdisorganization, tension and mannerisms and posturing

items) factors. The baffectQ factor was excluded from

the present study because we were most interested in

the relationship between schizophrenia symptoms and

cognition, and because affective symptoms have been

largely excluded from prior studies on this topic. ICC

values, calculated between the interviewers and the

original study’s principal investigator (J. Blanchard)

based on a review of 29% of the original videotaped

interviews (16 of 55), were acceptable (see Blanchard

et al., 2001). It is noteworthy that deficit syndrome

ratings were collected for this study but were not

Table 2

Bivariate correlations and zero-order correlation matrices between symptom factor scores, social functioning and cognitive measures (N =28)

Social functioning measures Symptom factor scores Cognitive constructs

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Social functioning measures

1. Role-play test 1.00 – – – – – – – – – – – – – – –

2. Community social functioning 0.32 1.00 – – – – – – – – – – – – – –

Symptom factor scores

3. Thought disturbance �0.03 0.09 1.00 – – – – – – – – – – – – –

4. Anergia �0.18 �0.28 �0.26 1.00 – – – – – – – – – – – –

5. Disorganization �0.45* �0.39* 0.35 0.16 1.00 – – – – – – – – – – –

Cognitive constructs

6. Social cognition 0.24 0.38* �0.12 �0.18 �0.35 1.00 – – – – – – – – – –

7. IQ 0.32 0.13 �0.09 �0.33 �0.11 0.15 1.00 – – – – – – – – –

8. Vocabulary 0.25 0.10 0.02 �0.28 �0.08 0.37 0.76** 1.00 – – – – – – – –

9. Visual-spatial

construction

0.30 0.13 0.19 �0.25 �0.07 0.31 0.81** 0.41* 1.00 – – – – – – –

10. Immediate verbal memory 0.38* 0.40* 0.07 �0.11 �0.16 0.15 0.61** 0.54** 0.50* 1.00 – – – – – –

11. Delayed verbal memory 0.40* 0.59** �0.07 �0.17 �0.34 0.28 0.30 0.25 0.29 0.75** 1.00 – – – – –

12. Immediate nonverbal memory 0.38* 0.01 0.03 �0.05 0.06 0.23 0.59** 0.34 0.70** 0.49* 0.22 1.00 – – – –

13. Delayed nonverbal memory 0.30 0.07 �0.18 �0.01 �0.07 0.27 0.64** 0.43* 0.64* 0.44* 0.27 0.80** 1.00 – – –

14. Visual perception 0.23 0.26 �0.02 �0.36 �0.02 0.16 0.28 0.32 0.15 0.44* 0.25 0.39* 0.31 1.00 – –

15. Auditory perception 0.22 0.31 0.11 0.11 �0.16 0.24 0.17 0.31 0.04 0.40* 0.34 0.20 0.16 0.28 1.00 –

16. Executive functioning 0.41* 0.24 �0.13 �0.15 �0.38* 0.34 0.48* 0.29 0.48* 0.56** 0.51* 0.59** 0.57** 0.26 0.44* 1.00

17. Attentional vigilance 0.39* 0.30 �0.01 �0.13 �0.17 0.08 0.36 0.35 0.37 0.42* 0.40* 0.48* 0.29 0.37 0.05 0.25

*p b0.05, **p b0.01.

A.S.Cohen

etal./Schizo

phren

iaResea

rch81(2006)227–238

232

A.S. Cohen et al. / Schizophrenia Research 81 (2006) 227–238 233

used in the present study. This is because the results of

many of the cognitive and social functioning

comparisons between deficit and non-deficit patients

are presented elsewhere (Horan and Blanchard, 2003),

and because we were primarily interested in examining

symptoms dimensionally so that we could employ

correlational and regression analyses.

2.2.4. Analyses

The analyses were conducted in four steps. First, we

wanted to understand the relationships between each of

the demographic variables, and symptom factor, cog-

nitive and social functioning scores. Bivariate correla-

tions were computed between each of these variables.

Informed by our literature search, we predicted that the

magnitude of association between the two measures of

social functioning would be modest. We also hypothe-

sized that, of the cognitive variables, only the atten-

tional vigilance, verbal memory and social cognition

test scores would be significantly correlated with role-

play test performance, and that only the executive

functions, verbal memory and social cognition mea-

sures would be significantly associated with commu-

nity social functioning scores. Second, in order to

determine the extent to which social functioning

impairment reflected deficits in the specific cognitive

processes outlined in Green et al. (2000), hierarchical

regressions were computed. Our expectation for these

analyses was that the scores of the specific cognitive

processes would contribute to the variance of social

functioning scores above and beyond that of the more

general cognitive composite scores. Third, we hypothe-

sized that social cognition ability would contribute to

the variance in social functioning scores above and

beyond that of nonsocial cognitive functioning scores

using hierarchical regressions. Finally, using hierarch-

ical regressions, we examined whether cognitive func-

tioning contributed to either social functioning domain

above and beyond the effects of symptoms.

3. Results

Means and standard deviations were computed for the

symptom factor scores and the cognitive and social function-

ing measures. These results are presented in Table 1. The

sample, on average, showed mild levels of thought distur-

bance, anergia and disorganization symptoms. Impairment on

the community social functioning measure was comparable

to that evidenced in a prior study of outpatients with schizo-

phrenia (Blanchard et al., 1998). The skew value for each of

these variables was less than 1.5 suggesting that parametric

statistics were appropriate for statistical computation.

In order to determine whether differences in gender and

ethnicity were associated with differences in cognitive and

social functioning scores, group comparisons were con-

ducted. T-tests revealed that men had significantly better

vocabulary (t[26]=2.12, p b0.05) and visual spatial con-

struction (t[26]=2.09, p b0.05) performance than females,

but that there were no significant differences between males

and females on any of the other social or cognitive function-

ing variables. It is important to point out that this analysis

was underpowered because there were only four females in

the present sample. None of the social and cognitive func-

tioning variable values were significantly different between

the Caucasian vs. non-Caucasians, suggesting that there

were no demonstrable differences between the ethnic groups

on any of these variables.

Zero-order correlations between the symptom factor,

social functioning and cognitive scores were computed

and presented in Table. 2. Some findings from this table

warrant mention here because they bear relevance to the

present hypotheses. First, the role-play test and community

social functioning were modestly, but not significantly cor-

related (r[28]=0.32, ns). Although the magnitude of corre-

lation was at the moderate size level (Cohen, 1987), the two

measures shared only 9% common variance. Second, neither

the thought disturbance nor the anergia factor scores were

significantly related to any of the cognitive or social func-

tioning scores. The disorganization factor scores were sig-

nificantly and inversely related to both the role-play and

community social functioning measures, and executive

functioning impairment, but not any of the other cognitive

measured scores.

3.1. Bivariate correlations between the social functioning

and cognitive measures

Correlations computed between the role-play and com-

munity social functioning and the cognitive scores are pre-

sented in Table 2. As hypothesized, role-play test scores

were significantly and inversely associated with the delayed

verbal memory and attentional vigilance scores. Role-play

test scores were also significantly associated with immediate

non-verbal and verbal memory and executive function

scores. It is noteworthy that each of the correlations was

of a small to medium effect size. Thus, role-play test impair-

ment was associated with a wider range of cognitive deficits

than anticipated. In contrast, community social functioning

impairments were significantly associated with deficits in

Table 3

Hierarchical regression analyses examining the contribution of spe-

cific vs. general cognitive functioning scores to role-play test and

community social functioning ability (N =28)

b r2 Dr2 DF

Dependent variable=Role-play test

Model A

Step 1) Delayed verbal memory 0.29 0.23 – 7.57*

Attentional vigilance 0.28

Step 2) All other cognitive abilities 0.25 0.27 0.04 1.36

Model B

Step 1) All other cognitive abilities 0.44 0.20 – 6.38*

Step 2) Delayed verbal memory 0.20 0.27 0.07 2.32

Attentional vigilance 0.19

Dependent variable=Community social functioning

Model A

Step 1) Delayed verbal memory 0.63 0.36 – 6.90*

Executive functioning �0.08

Step 2) All other cognitive abilities 0.03 0.36 0.01 0.02

Model B

Step 1) All other cognitive abilities 0.29 0.09 – 2.41

Step 2) Delayed verbal memory 0.62 0.36 0.27 5.06*

Executive functioning �0.09

*p b0.05.

A.S. Cohen et al. / Schizophrenia Research 81 (2006) 227–238234

both immediate and delayed verbal memory but none of the

other nonsocial cognitive domains.

The correlations between the social functioning and the

social cognition scores are also presented in Table 2. As

hypothesized, the community social functioning and social

cognition measure scores were significantly associated with

each other. However, the role-play test and social cognition

measure scores were not significantly related with each other.

3.2. The differential cognitive correlates of social

functioning

Two sets of hierarchical regressions were computed to

determine whether the scores of the specific cognitive pro-

cesses outlined in Green et al. (2000) contributed to the

variance in social functioning scores above and beyond the

contribution made by other cognitive scores. The first set of

regressions was set up so that role-play test performance was

the dependent measure and cognitive scores were entered in

two blocks. One of the blocks was comprised of the delayed

verbal memory2 and attention scores. The other block con-

sisted of a general cognitive ability score that was computed

by summing all of the other z-transformed nonsocial cogni-

tive scores. The coefficient alpha for the composite score

was adequate (a =0.88). For each set of regressions, two

independent hierarchical regressions were computed, one

with the specific cognitive score in the first step and the

general score in the second step, and the other regression

with the order of entry reversed. These results are presented

in Table 3. In the first model (Model A), when entered on

the first step, delayed verbal memory and attention vigilance

scores combined to explain 23% of the variance in role-play

test performance. When subsequently entered at the second

step, the other cognitive variables made little incremental

contribution. In the second model (Model B) with general

cognitive ability entered first, general ability accounted for a

2 Although the immediate and delayed verbal memory scores

were highly correlated with each other, the decision was made to

exclude immediate verbal memory from the block of interest for two

reasons. First, a relationship has not been established between

immediate verbal memory and role-play test or community social

functioning (Green et al., 2000). Moreover, post-hoc analyses

revealed that immediate verbal memory scores did not significantly

contribute unique variance to either social functioning score above

and beyond that of delayed verbal memory scores. Conversely,

delayed verbal memory scores contributed significantly to commu-

nity social functioning (DF =7.56, p b .05, Dr2=0.20) but not to

role-play test scores beyond the contribution made by immediate

verbal memory scores. These findings support Green et al.’s (2000)

distinction between immediate and delayed verbal memory as used

in the present study.

significant proportion of variance (20%). However, verbal

memory and attention scores entered in the second step did

not account for a significant change in variance. This pattern

of results indicates that delayed verbal memory and attention

showed little specificity to role-play test performance

beyond that accounted for by general cognitive ability.

The second set of regressions was set up so that the

community social functioning was the dependent measure

and cognitive scores were again entered as two blocks. The

first block included those specific cognitive tasks outlined in

Green et al. (2000): delayed verbal memory and executive

functioning. The second step of the regression analysis

involved a general cognitive score based on the sum of all

the other z-transformed nonsocial cognitive variables. The

coefficient alpha for the composite score was adequate

(a =0.87). These results are also presented in Table 3.

Delayed verbal memory and executive functions, entered

in the first step (Model A), explained approximately 36%

of the variance in scores while general cognitive functions,

entered on the second step, contributed little above and

beyond this. In the second model (Model B), general cogni-

tive functioning was entered first and this step was not

significant. However, when the two specific cognitive vari-

ables were entered in the second step, they continued to

account for a significant increment in variance explained

(approximately 27%). Examination of the beta weights

revealed that the relative contribution made by executive

Table 4

Hierarchical regression analyses examining the contribution of spe-

cific vs. general cognitive functioning scores to role-play test and

community social functioning ability, controlling for symptom

severity scores (N =28)

b r2 Dr2 DF

Dependent variable=Role-play test

Step 1) Disorganization symptom factor �0.40 0.19 – 1.77

Anergia symptom factor �0.14

Thought disturbance symptom factor 0.07

Step 2) All other cognitive abilities 0.48 0.41 0.22 8.10**

Step 3) Delayed verbal memory �0.06 0.47 0.07 1.23

Attentional Vigilance 0.30

Dependent variable=Community social functioning

Step 1) Disorganization symptom factor �0.50 0.27 – 2.89

Anergia symptom factor �0.12

Thought disturbance symptom factor 0.23

Step 2) All other cognitive abilities 0.16 0.30 0.02 0.72

Step 3) Delayed verbal memory 0.62 0.54 0.24 5.25*

Executive functioning �0.15

A.S. Cohen et al. / Schizophrenia Research 81 (2006) 227–238 235

functions was not significant, suggesting that the bulk of the

contribution were made by delayed verbal memory scores. In

sum, these results suggest that relatively specific cognitive

impairments predicted community social functioning, but not

role-play test performance.

3.3. The contribution of social cognition to social

functioning

Hierarchical regressions were then used to examine the

relative contributions of social and nonsocial cognition

scores to social functioning. Two separate regressions

were set up with role-play performance and community

functioning as the dependent variables. In each regression

analysis, two cognitive variables were entered: a z-score-

transformed composite of all of the nonsocial cognition

scores and the social cognition measure. The coefficient

alpha for the nonsocial composite score was adequate

(a =0.86). In each regression model (predicting role-play

and community functioning), the general cognitive compo-

site score was entered first, followed by the social cognition

score. Due to space limitations and the lack of significant

findings in these analyses, these results are presented in text.

For the role-play test, nonsocial cognition, entered in the

first step, accounted for a significant proportion of the var-

iance (Dr2[1, 26]=0.24, p b0.01). However, social cognition

did not account for a significant increment in explained

variance on the second step (Dr2[1, 25]=0.01, ns).

For the community social functioning measure, general

cognitive functioning accounted for a modest but nonsigni-

ficant amount of variance (Dr2[1, 26]=0.13, ns). Entered on

the next step, social cognition failed to account for a sig-

nificant increment in explained variance of community func-

tioning (Dr2[1,25]=0.08, ns). In sum, these results suggest

that social cognition explained a modest but nonsignificant

amount of unique variance in community social functioning

scores, and explained little variance beyond nonsocial cogni-

tion ability to role-play test performance.

3.4. Controlling for symptom severity

We sought to examine whether the unique contributions

that the specific nonsocial cognitive factors made to social

functioning would be maintained beyond the effects of symp-

tom severity. In order to examine this issue, the regressions

from Section 3.2 were recomputed with the thought distur-

bance, anergia and disorganization factor scores entered in

the first block. These results are presented in Table 4. When

the role-play test measure was entered as the dependent

measure, the symptom factor scores, entered in the first

step, accounted for 19% of the variance in role-play test

scores. This contribution was not statistically significant.

The general cognitive factor, entered in the second step,

explained approximately 22% of the variance ( p b0.05)

beyond symptom factor scores. The unique contribution of

the delayed verbal memory and attentional vigilance scores,

entered in the third step, was nonsignificant. Thus, general

cognitive functioning remained a significant predictor of

role-play performance even after controlling for symptoms.

When the community social functioning measure was

entered as the dependent measure, approximately 27% of the

variance was accounted for by symptom factor scores ( p of

F change=0.06), entered in the first step. The general

cognitive factor, entered in the second step, explained

approximately 2% of the variance beyond the symptom

severity, and the contribution of the delayed verbal memory

and executive functioning scores, entered in the third step,

remained significant (Dr2=0.24). As before, this contribu-

tion was primarily accounted for by delayed verbal memory

scores. In sum, specific cognitive deficits were associated

with community social functioning deficits beyond the

effects of symptoms and general cognitive functioning.

4. Discussion

Although cognitive dysfunction has been linked to

functional outcome in schizophrenia, the identification

of specific cognitive deficits that contribute to func-

tional impairments has been complicated by inconsis-

tent findings across studies. Preliminary evidence

A.S. Cohen et al. / Schizophrenia Research 81 (2006) 227–238236

(e.g., Green et al., 2000; Addington et al., 1998;

Addington and Addington, 1999) has suggested that

this inconsistency might be due, in part, to different

domains of social functioning being associated with

different types of cognitive processes. Findings

from the present study support this notion. First, the

role-play test and community social functioning mea-

sures were nonsignificantly, but modestly correlated

with each other suggesting that there was unique

variance in each measure. Second, there were appreci-

able differences in the cognitive correlates between

these two social functioning measures. Role-play

test performance tended to have a diverse set of

cognitive correlates, whereas the community social

functioning measure was significantly correlated

with immediate and delayed verbal memory solely.

Third, specific cognitive deficits showed little unique

contribution to role-play test performance, whereas

delayed verbal memory and executive functioning

uniquely contributed over a quarter of the variance

in community social functioning scores beyond

general cognitive ability. These findings were main-

tained even when thought disturbance, anergia and

disorganization symptom severity was controlled for.

Finally, social cognition made a modest (but not

statistically significant) contribution to the variance

of community social functioning scores beyond that

of nonsocial cognition, while the unique contribution

made to the variance in role-play test performance

was negligible. With respect to future research, studies

that focus on the relationship between cognitive

deficits and social functioning could provide a fuller

understanding of social abilities by including multi-

dimensional assessments.

In support of findings from Green et al. (2000),

secondary verbal memory, and to a lesser extent,

executive functions uniquely accounted for over a

quarter of the variance in community social function-

ing scores beyond other cognitive abilities and symp-

toms. Although this finding should be interpreted

cautiously because it is inconsistent with the findings

of some studies (e.g., Addington and Addington,

1999), the notion that secondary verbal memory and

executive functions are highly related to impaired

community social functioning is promising for the

generation of future hypotheses. On the other hand,

role-play test performance was associated with a more

generalized cognitive deficit. This is consistent with

other studies, in that role-play test performance has

shown a diverse and variable set of cognitive associ-

ates (e.g., Addington and Addington, 1999).

Interpretation of the present findings is constrained

by the reality that domains of social functioning mea-

sured in this study (role-play and community func-

tioning) can be further parsed into subdomains that

may also have differential correlates with cognitions.

For example, our measure of community functioning

could be further broken down into community social

functioning in familial, peer-group and professional

settings. Moreover, aspects of bnon-socialQ commu-

nity functioning such as occupational achievement

were not assessed and may well have different rela-

tionships with cognition (e.g., Milev et al., 2005).

Some limitations of the present project warrant

mention. First, although the cognitive battery was

relatively broad in scope, not all domains of cognitive

functioning were represented. For example, the pre-

sent study lacked a measure of verbal fluency. Green

et al. (2000) reported that at least four studies had

found a significant relationship between verbal flu-

ency deficits and impairments in community social

functioning. Second, the measure of social cognition

was limited in that it was based solely on facial

emotion identification ability. Examples of social

cognition measures used in other studies include

theory of mind, vocal affect perception and measures

of bsocial intelligenceQ (Penn et al., 1997). Third,

although each of the patients in the present study

was medicated, we were unable to examine the

effects of differential dosage and type of medication

on social functioning or cognitive performance

because medication status was clinically determined.

Fourth, the sample was predominantly male. Previous

research has suggested that males and females differ

in the cognitive correlates of their social functioning

impairments (Mueser et al., 1995) and we were

unable to effectively address this issue. Fifth, the

small sample size, while comparable to many other

neuropsychological studies of social functioning

(e.g., Addington et al., 1998), may have reduced

power and precluded finding significance in the rela-

tionships between the community social functioning

and cognitive measures. Finally, the current study

involved inpatients and the social functioning mea-

sure covered an epoch prior to hospitalization, so the

degree to which the findings generalize to stabilized

A.S. Cohen et al. / Schizophrenia Research 81 (2006) 227–238 237

outpatients is unclear. Further, the study examined

social functioning cross-sectionally, and it is possible

that measures of longitudinal social functioning may

have yielded different findings (see Milev et al.,

2005).

4.1. Summary

Given recent efforts to develop effective cognitive

and social rehabilitation treatments for patients with

schizophrenia, identifying which, if any, specific cog-

nitive deficits underlie social functional impairments

is important. The present findings suggest that impair-

ment in different domains of social functioning reflect

different cognitive liabilities. Thus, it seems a reason-

able conclusion that more consistent and specific

cognitive correlates of functional outcome could

potentially be identified by focusing on more refined

domains of functioning.

Acknowledgements

This research was supported by National Institute

of Mental Health grant MH51240 to Dr. Blanchard.

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