Schizophrenia requires perpetual treatment even after the disappearance of symptoms.

Programs for the treatment of social cognition in schizophrenia

Over the last few years, there have been many programs aimed at the treatment of deficits in social cognition that usually occur in the case of schizophrenia and which, in turn, have been scientifically validated. In this first article related to this topic, some of them will be discussed.

Training of affect recognition

According to Durá et al (2008), Training of affect recognition (TAR) (Frommann et al, 2003; Wölwer et al, 2005) is a standardized and computerized training for facial expression recognition.

The program comprises 3 blocks with 4 sessions per block, with a duration per session of approximately 45 minutes and a total of 12 sessions. Work is done in pairs of patients with the guidance of the psychotherapist. The tasks presented are of increasing difficulty:

• In the first block patients learn to identify and discriminate, as well as to verbalize the main facial signs of the 6 basic emotions. The question they are asked is “what affect does this person express?”.
• In the second block, an attempt is made to integrate this detailed view of affect into an increasingly global processing mode, starting from first impressions, non-verbal processing and processing of facial expressions with low intensity. The task to be performed is “Classify the pictures according to the intensity of facial affect”.
• The third block comprises, on the one hand, the processing of non-prototypical and ambiguous expressions of affect, which often occur in everyday life and, on the other hand, the integration of facial expressions in the social, behavioral and situational context. An example of a task asked here is to answer the question “which of these people just received flowers and is thinking: how pretty they are?”.

Throughout the program a set of substitution strategies (repetition, errorless learning, instant feedback) and compensatory strategies (feature abstraction, verbalization, self-instructions) are used. The primary compensatory strategy is verbalization of facial expression in terms of elementary gestures.

In a recent study Vaskinn et al (2019), find that affect recognition training provides evidence about beneficial effects that are generalizable and last over time, but also highlight the need for additional treatment to work on social cognition in schizophrenia to achieve benefits on psychosocial functioning.

Emotion Management Training

According to Ruiz et al (2006) Emotion Management Training (EMT; Hodel et al, 1998) is a program that assesses deficits in the perception of emotions, as well as the consequences of these on social adjustment and psychopathology.

It is administered in small groups in three steps:

• In the first step, deficits in emotion perception are addressed by step-by-step assessment of self- and others’ expression.
• In the second step, poor social adjustment is addressed by recall of currently used coping strategies.
• Finally, in the third step, both social adjustment and low stress tolerance are improved by the person’s acquisition of effective coping strategies.

Participants are trained to achieve the program objectives through the use of behavioral interventions such as role-playing or live exercises.

Integrated psychological therapy

In addition to a first module called Cognitive Differentiation, there are also four other modules aimed at addressing the treatment of social cognition in schizophrenia and the improvement of interpersonal competencies.

These modules consist of the following:

• Social Perception: It aims at improving the patient’s perceptual and interpretative ability in social situations and will be explained in depth later on.
• Verbal Communication: Its main objective is to stimulate exchange and social communication among group members.
• Social Skills: This is a module aimed at improving the interpersonal performance of the subjects. Its work methodology does not differ from the traditional intervention procedures already designed in this area.
• Interpersonal Problem Solving: It deals in an open and flexible way with problematic situations provided by the participants. Work is done on the discussion and analysis of such situations, incorporating the possibility of using role-play to shape the appropriate response to the situation.

The social perception module

According to Ruiz et al (2006), of the five modules, the second, called Social Perception, is the most closely related to social cognition, since it is one of its components. It uses 40 slides representing different social situations. They vary in terms of the degree of cognitive complexity and emotional charge of the content. At the beginning, the less complex slides are worked on, which usually present an emotionally neutral content, and as the therapy progresses, more complex and emotionally charged slides are worked on.

The module is divided into three phases:

• In the first phase, called collecting information from the slide, participants are asked to describe the elements present in the projected image. Some of the tasks consist of: focusing, dealing with relevant contents of the image, drawing attention to what was forgotten and summarizing.
• In the second phase called interpretation and discussion of the slide, participants offer an explanation of the contents of the slide. Each opinion must be justified with reference to the visual information collected in the first stage. This is followed by a discussion on which interpretation seems to them to be the most appropriate or the most probable. The tasks, therefore, consist of: interpreting, justifying the interpretation and group discussion.
• Finally, in the third phase called assigning a title, each participant indicates a short title that summarizes the most important aspects of the situation described in the image, and then a new discussion is held on which title seems most appropriate.

References to the treatment of social cognition in schizophrenia

Brenner, H.D., Hodel, B., Roder, V. y Corrigan, P. (1992). Treatment of cognitive dysfunctions and behavioural deficits in schizophrenia. Schizophrenia Bulletin, 18 (1), 21-26.

Brenner, H.D., Roder, V., Kienzle, N., Reed, D. y Liberman, R.P. (1994). Integrated Psychological Therapy for Schizophrenia Patients. Toronto: Hogrefe y Huber Publishers.

Durá, I. F., Ruiz, J. C. R., Ferrer, S. G., Boada, M. J. S., y Vivo, C. D. (2008). Esquizofrenia: déficit en cognición social y programas de intervención [Schizophrenia: deficits in social cognition and intervention programs]. Informació Psicológica, (93), 53-64.

Frommann, N., Streit, M., y Wölwer, W. (2003) Remediation of facial affect recognition impairments in patients with schizophrenia: a new training program. Psychiatry Research, 117, 281-284.

Hodel, B., Brenner, H.D., Merlo, M.C. y Teuber, J.F. (1998). Emotional management therapy in early psychoses. Brithish Journal of Psychiatry, 172 (Supl. 33),128-133.

Roder, V., Brenner, H.D., Hodel, B. y Kienzle, N. (1996). Terapia integrada de la esquizofrenia [Integrated therapy of schizophrenia]. Barcelona: Ariel.

Ruiz, J. C., García, S., y Fuentes, I. (2006). La relevancia de la cognición social en la esquizofrenia [The relevance of social cognition in schizophrenia.]. Apuntes de Psicología, 24(1-3), 137-155

Vaskinn, A., Løvgren, A., Egeland, M. K., Feyer, F. K., Østefjells, T., Andreassen, O. A., … y Sundet, K. (2019). A randomized controlled trial of training of affect recognition (TAR) in schizophrenia shows lasting effects for theory of mind. European archives of psychiatry and clinical neuroscience, 1-10.

Wölwer, W., Frommann, N., Halfmann, S., Piaszek, A., Streit, M. y Gaebel, W. (2005) Remediation of impairments in facial affect recognition in schizophrenia: Efficacy and specificity of a new training program. Schizophrenia Research, 80, 295-303.