EPS: a scale for the assessment of social perception in schizophrenia.
Juan Carlos Ruiz, Sonia García, Inma Fuentes
and Marisa García-Merita
Faculty of Psychology. University of Valencia (Spain)
VII International Symposium on Schizophrenia
Bern, March, 17-18, 2005
The cognitive processes involved in how schizophrenic patients think about
themselves, other people, social situations, and interactions, contribute to
symptomatology, psychosocial impairment, and rehabilitation. This processes
have been grouped under the term ‘Social Cognition’ (Penn et al., 1997), and it
has been proposed that it’s a mediator variable between neurocognition and
functional outcome (Vauth et al., 2004).
Social cognition is linked to the information-processing mechanisms (attention,
working memory and executive functioning) involved in the encoding and
processing of social information, and to the social skills that determine functional
outcome.
Research is now beginning to investigate the relations among this tree factors
(neurocognition – social cognition – functional outcome).
Social cognition has been considered one of the mayor cognitive impairments in
schizophrenia (Kern et al., 2004; Nuechterlein et al., 2004). Because of its
relevance some rehabilitation approaches pay attention to the improvement of
social cognitive processing skills, as the IPT (Integrated Psychological Therapy)
(Roder et al., 1996), and some instruments have been developed to asses social
cognition (see table 1). While some of those instruments focus the attention either
in basic perception skills (e.g. identification of facial affect) or in highly complex
situations (e.g. recognition of relevant components in social situations), there
aren’t instruments targeted in the evaluation of the processing of social
information in intermediate situations.
Table 1.: Social cognition assessment instruments
Social Cue Recognition Test (Corrigan & Green. 1993)
Situational Feature Recognition Test (SFRT-2)(Corrigan
et al., 1996)
Social Perception Test( Bellack et al., 1992).
Videotape Affect Perception Test (Bellack et al., 1996)
Pictures of facial affect (Ekman, 1976).
Face Emotion Identification (Kerr & Neale, 1993)
Face Emotion Discrimination (Kerr & Neale, 1993)
The aim of this study was to develop a specific assessment instrument (Social
Perception Scale –SPS-) to evaluate performance on the social perception skills
trained in the social perception programme of the IPT. It has been developed
considering the three parts of the Social Perception Program.
SOCIAL PERCEPTION SCALE (SPS)
Instructions for Administering and Scoring
MATERIAL:
FOUR PHOTOGRAPHS (slides 2, 5, 6, 7 from the IPT)
RESPONSE SHEET
SCORE SHEET
Administering the Scale
The purpose of the scale is to evaluate the improvement in the social perception
abilities trained in the “social perception program” of the IPT. To administer this
scale, it is essential for therapists to know this program.
Procedure: Four photographs are showed to the subject and three questions
have to be answered in relation to each one:
First question (Identification of Stimuli).
In the first question, the stimuli that the subjects identify in the photo are collected
by asking the following question:
What elements / details / things can you see in this picture?
The subjects have two minutes to respond and the words are written on the
response sheet. At a later time, the number of stimuli listed on the score sheet
that the subjects have mentioned is counted. Some of the words they come up
with may be synonyms or be very similar to the stimuli listed on the score sheet.
In order to determine the final score, all the identified elements are added up,
including any synonyms or equivalent words used.
Second question (Interpretation of the Photograph).
The interpretation that the subject makes on the photograph is asked through the
following question:
Could you tell me what is happening in this picture?
To score this item, it is necessary to determine whether or not their responses
make reference to three key aspects: where or in which context the action takes
place; who performs the action; what they are doing or what their interaction is.
The responses are given 0 to 3 points according to the following criteria:
0: When the response does not make reference to any of these aspects.
1: When the response makes reference to one of these aspects.
2: When the response makes reference to two of these aspects.
3: When the response makes reference to all three aspects.
Third question (Title of the Photograph).
Subjects are asked to tell the therapist in a few words what they consider most
relevant in the photo with the following question:
What title would you give to this photo?
To score this question, it is necessary to determine whether or not their responses
make reference to three key aspects: where or in which context the action takes
place; who performs the action; what they are doing or what their interaction is.
The responses are given 0 to 3 points according to the criteria used to score the
second question.
SOCIAL PERCEPTION SCALE (SPS)
Identification Information.
Name and Surname:
Age:
Date:
You are going to see four photographs. For each of them, you will be asked a few
questions which will be the same for all four photos. It is essential that you limit
your answers to what appears in the photo and not make any assumptions.
.
Answer Sheet. Photo N°1
Score Sheet. Photo N°1
Question 1.
What things can you see in the photo:
Number of identified stimuli:
Man
Clothes 1 person
Plants / garden
.
Answer Sheet. Photo N°2
Score Sheet. Photo N°2
Question 1.
What things can you see in the photo: (Allotted
Number of identified stimuli:
time: 2 minutes)
_______________________________
_______________________________
_______________________________
Question 2.
What is happening in the photo?
_______________________________
Women
Shops / stores
Vehicles
Men
Clothes 1 person
Trees
Shopping bags
Clothes 2/3 people
Buildings
Handbags
Posture / gestures
Street Lamps
Pushchair boy / girl
Street
Signs
Description of trees
buildings
Interpretation score:
Canopies (Awnings)
Elements of
.
Answer Sheet. Photo N°3
Question 1.
Score Sheet. Photo N°3
Number of identified stimuli:
.
Answer Sheet. Photo N°4
Score Sheet. Photo N°4
Question 1.
What things can you see in the photo:
Number of identified stimuli:
(Allotted time: 2 minutes)
_______________________________
_______________________________
_______________________________
Question 2.
What is happening in the photo?
_______________________________
_______________________________
5 young people
Parts of body
Top glass on door
Main girl
Clothes
Light switch on tiles
Main boy
Hair
Door knob
Door
Door spring
Tiles on wall
Background lights
Young man´s reflection on door
Lights on faces
Young woman’s reflection on tiles
Interpretation score:
Title score:
Question 3.
What title would you give to the photo?
_______________________________
SUMMARY OF SCORES
STIMULI
Photo
nº1
21
Photo nº 2 Photo nº Photo nº 4
3
18
12
16
Encoded stimuli
Identified Stimuli
INTERPRETATION Photo nº Photo nº 2 Photo nº Photo nº 4
1
3
MV
3
3
3
3
I
TITLE
Photo nº Photo nº 2 Photo nº Photo nº 4
1
2
MV
3
3
3
3
T
RESULTS
Stimuli
Interpretation
Direct Score
Percentage of
maximum value
MV: Maximum Value. I: Interpretation Score. T: Title Score.
TOTAL
67
TOTAL
12
TOTAL
12
Title
We developed an experimental study to assess the effectiveness of the
social perception scale to discriminate between schizophrenic patients trained on
the social perception programme of the IPT, and patients not trained in this
programme.
Method:
Procedure: Eighteen schizophrenic outpatients randomly divided in two
groups were enrolled in the study. Patients in the therapy group follow the social
perception rehabilitation program of IPT. Patients in the control group received
therapy as usual. Clinical assessment (BPRS), neuropsychology assessment
(TASS), social functioning assessment (DAS-II), and patient’s performance on
social perception (SPS), was carried out before the intervention (T1), after the
intervention (T2) and at the end of a six months follow-up period (T3). Data were
analyzed using nonparametric statistical procedures.
Participants: Eighteen outpatients were recruited from the Centre of Mental
Health of Aldaia (Valencia). The following selection criteria were applied:
diagnosis of schizophrenia according to CIE-10, no organic damage or abuse of
alcohol or drugs and either a score of 4 or more in the vocabulary test of the
WAIS-III or an IQ of 65 or more in the TONI-2 test. All the patients were receiving
pharmacological treatment either typical (haloperidol, fluphenazine) or atypical
antipsychotic (clozapine, risperidone). Twenty-three subjects met the inclusion
criteria and were randomly assigned to the therapy and control groups, though
five patients dropped out because of finding jobs or an attendance to the sessions
of 50% or less. Because of these dropouts, the final number of subjects in the
therapy group was 10 and 8 in the control group. Subjects in the therapy group (8
males and 2 females) had an average age of 40.40 (7.49), an average IQ of 75.20
(14.63), an average number of years of education of 7 (3.13), and average illness
duration of 21.30 (6.96) years. Subjects in the control group (4 males and 4
females) had an average age of 37.75 (8.21), an average IQ of 73.13 (11.28), an
average number of years of education of 7.75 (2.19), and average illness duration
of 15.38 (6.23) years. Patients in the therapy group followed the “social
perception” module of IPT and patients in the control group received therapy as
usual.
Results:
Results show that the intervention was effective. Both groups differed in their
social perception capacity after treatment. Patients in the therapy group improve
their ability to identify stimuli, to interpret and to resume the information in a
picture (see tables 2 and 3), although there were no changes in psychopathology
and social role-functioning.
Table 2: Comparison results between the two groups in the three assessment
sessions in the SPS (social perception scale) by Mann-Whitney U-test. And effect
sizes in the therapy group. (T1: Before intervention; T2: After intervention; T3:
Follow-up).
Effect sizes
T1
T2
T3
T1-T2
T1-T3
Identified stimuli
CONTROL
33,96 36,94 41,21
THERAPY
35,52 50,30 55,47 1,39
2,02
Z
0,267 2,403 1,915
p
0,789 0,016 0,055
Adequate
CONTROL
63,54 61,46 59,38
interpretations
THERAPY
57,50 80,83 80,00 1,94
2,04
Z
1,090 2,228 2,560
p
0,276 0,026 0,010
Title
CONTROL
53,13 45,83 53,12
THERAPY
44,17 85,00 75,00 3,05
2,61
Z
1,961 3,548 2,878
p
0,055 0,000 0,004
Table 3: Results in the two groups in the three assessment sessions in the SPS
(social perception scale). (C: control group; T: therapy group).
SPS results
Performance (%)
100
80
Before intervention
After intervention
Follow-up
60
40
20
0
C
T
identified
stimuli
C
T
adecuate
interpretations
SPS items
C
T
title
DISCUSSION.
Due to the lack of a specific instrument to measure social perception, we
developed a scale (SPS) focused on the measurement of the specifically targeted
abilities trained with the social perception program of IPT. The SPS does not
measure social functioning or social skills, its goal is to measure the cognitive
variables/abilities that are basic in social perception.
Results show that the social perception of the patients who participated in the
program has improved. Patients that have received training in social perception
learn to gather more information from an image, to make more adequate
interpretations and to summarize, with a title, the most important information of
the image. This improvement in the capacity of gathering and interpreting social
situations is maintained during the follow-up phase.
We have found that the SPS is sensitive to the differences produced after the
treatment between the therapy and control group. The fact that so few questions
produced any significant difference at all between the two groups is promising in a
psychometric sense. Therefore, we are developing an instrument which can help
the therapists in their decision process.
REFERENCES
Batlle, S. & Tomás, J. (1999). Evaluación de la Atención en la Infancia y la
Adolescencia: Diseño de un Test de Atención Selectiva y Sostenida.
Estudio piloto. Revista Española de PsiquiatríaInfanto-Juvenil, 3, 142148.
Bellack et al., (completar nombres)1992
Bellack, Blanchard & Mueser, 1996
Brown, L., Sherbenou, R.J. & Johnsen, S.K. (2001). Toni-2, test de
inteligencia no verbal: apreciación de la habilidad cognitiva sin
influencia del lenguaje. Madrid: TEA Ediciones, S.A.
Corrigan & Green. 1993
Corrigan, P.W., Silverman, R., Stephenson, J., Nugent-Hirschbeck, J &
Buican, B. (1996). Situational familiarity and feature recognition in
schizophrenia Schizophrenia Bulletin, 22, 153-162.
Ekman, 1976
Kern, R.S., Green, M.F., Nuechterlein, K.H. & Deng, B.H ( 2004). NIMHMATRICS survey on assessment of neurocognition in schizophrenia.
Schizophrenia Research, 72, 11-19.
Kerr, S.L & Neale, J.M (1993). Emotion Perception in Schizophrenia: Specific
Deficit or Further Evidence of Gerneralized Poor Performance. Journal
of Abnormal Psychology, 102,312-318.
Lukoff, D., Nuechterlein, K.H. & Ventura, J. (1986). Manual for Expanded
Brief Psychiatric RatingScale (BPRS). Schizophrenia Bulletin, 12, 594602.
Montero, I., Bonet, A., Puche, E. & Gómez Beneyto, M. (1988). Adaptación
española del DAS-II (Disability Assesment Shedule). Psiquis, 175, 17-22.
Nuechterlein, K.H., Barch, D.M., Gold, J.M., Goldberg, T.E., Green, M.F. &
Heaton, R.K. (2004). Identification of separable cognitive factors in
schizophrenia. Schizophrenia Research, 72, 29-39.
Organización Mundial de la Salud (1992). CIE-10. Trastornos Mentales y del
Comportamiento. Madrid: Meditor.
Penn, D.L., Corrigan, P.W., Bentall, R.P., Racenstein, J.M. & Newman, L.
(1997). Social Cognition in Schizophrenia. Psychological Bulletin, 121,
1, 114-132.
Roder, V., Brenner, H.D., Hodel, B. & Kienzle, N. (1996). Terapia Integrada de
la Esquizofrenia. Barcelona: Ariel.
Vauth, R., Rüsch, N., Wirtz, M. & Corrigan, P.W. (2004). Does social
cognition influence the relation between neurocognitive deficits and
vocational functioning in schizophrenia?. Psychiatry Research, 128, 116.
Wechsler, D. (1999). Escala de Inteligencia de Wechsler para Adultos-III.
WAIS-III. Madrid: TEA Ediciones, S.A.