Schizophrenia Research 125 (2011) 152–160

Contents lists available at ScienceDirect

Schizophrenia Research
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / s c h r e s

A path model investigation of neurocognition, theory of mind, social

competence, negative symptoms and real-world functioning
in schizophrenia
Shannon M. Couture a,⁎, Eric L. Granholm b,c, Scott C. Fish b
a
University of Maryland College Park, 1123M Biology-Psychology Building, College Park, MD 20742, USA
b
University of California San Diego, USA
c
Veterans Affairs San Diego Health Care System, 3350 La Jolla Village Drive, San Diego, CA 92161, USA

a r t i c l e i n f o a b s t r a c t

Article history: Problems in real-world functioning are pervasive in schizophrenia and much recent effort has
Received 15 June 2010 been devoted to uncovering factors which contribute to poor functioning. The goal of this study
Received in revised form 20 September 2010 was to examine the role of four such factors: social cognition (theory of mind), neurocognition,
Accepted 23 September 2010
negative symptoms, and functional capacity (social competence). 178 individuals with
Available online 20 October 2010
schizophrenia or schizoaffective disorder completed measures of theory of mind, neurocogni-
tion, negative symptoms, social competence, and self-reported functioning. Path models
Keywords:
sought to determine the relationships among these variables. Theory of mind as indexed by the
Schizophrenia
Hinting Task partially mediated the relationship between neurocognition and social
Real-world functioning
Functional capacity
competence, and negative symptoms and social competence demonstrated significant direct
Social cognition paths with self-reported functioning. Study results suggest theory of mind serves as an
Neuropsychological functioning important mediator in addition to previously investigated social cognitive domains of
Negative symptoms 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.
© 2010 Elsevier B.V. All rights reserved.

1. Introduction necessary to achieve this independence, or functional

capacity (Patterson and Mausbach, 2010). In addition,
Deficits in such diverse areas of functioning as communi- neurocognition, social cognition, and negative symptoms
cating with others, obtaining and maintaining employment, are also significantly associated with functioning in prior
and general community functioning have been widely research. The empirical support for each of these constructs is
documented and are apparent throughout the schizophrenia outlined in the following paragraphs.
spectrum (Addington et al., 2003; Walker, 1994; Wiersma Neurocognition, a constellation of cognitive abilities
et al., 2000). Interventions targeting functional impairment including processing speed, working memory, visual and
should be guided by research on the factors that contribute to verbal learning and memory, and executive functioning, has
problems in functioning. Several factors have been theoret- been reliably associated with functional impairment both
ically and empirically linked with functioning. First, function- concurrently and prospectively (e.g., Green et al., 2000).
al attainment, or one's demonstrated ability to live Research has shown that neurocognitive impairment is a
independently in the real-world, is reliant on the skills well-established feature of schizophrenia (reviewed in
Heinrichs and Zakzanis, 1998; Hoff and Kremen, 2002),
⁎ Corresponding author. Tel.: + 1 301 405 7190; fax: + 1 301 314 9566.
with some proposing neurocognitive impairment plays a
E-mail addresses: [email protected] (S.M. Couture), role in most of the disturbances observed in schizophrenia
[email protected] (E.L. Granholm), scott.c.fi[email protected] (S.C. Fish). (Cornblatt et al., 2009). Although neurocognitive impairment

0920-9964/$ – see front matter © 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.schres.2010.09.020
 S.M. Couture et al. / Schizophrenia Research 125 (2011) 152–160 153

may account for 20–60% of the variance in real-world capacity. There may be a discrepancy between which
outcomes (Green et al., 2000), 40–80% of the variance in behaviors are performed in the real-world, versus which
functional outcome is unaccounted for by traditional neuro- behaviors the individual is capable of performing (Harvey
cognitive measures. Clearly other relevant factors contribute et al., 2007). This distinction between performance and
to functional impairment in schizophrenia. capacity has given rise to investigation of several new
In line with this notion, independent research groups have performance-based measures assessing functional capacity.
suggested that attention must focus on identifying factors Social competence is one aspect of functional capacity which
that mediate the relationship between neurocognition and has been reliably measured with role play tasks such as the
functioning behaviors in order to enhance predictive value Maryland Assessment of Social Competence (MASC; Bellack
and identify further treatment targets (Green et al., 2000). et al., 2006). The MASC is able to differentiate between good
Social cognition, “a domain of cognition that involves the and poor work outcomes within schizophrenia, and between
perception, interpretation, and processing of social informa- patients with schizophrenia and healthy controls or those
tion” (Ostrom, 1984, p.176), clearly requires neurocognitive with bipolar disorder (Bellack et al., 2006). Similar to findings
skills (e.g., reasoning, attention, basic perception) and has from real-world functioning measures, the MASC has also
obvious links with social behavior. Thus, it is not surprising demonstrated relationships with neurocognition (Green
social cognition has been proposed as likely candidate for et al., 2008). Other role-play tasks, such as the conversation
mediation. Specifically, it has been demonstrated that social probe (e.g., Penn et al., 1994), have evidenced significant
cognition is distinct from neurocognition (e.g., Sergi et al., relationships with the social cognitive domains of affect
2007), and that it is significantly associated with functional recognition, social perception, and ToM (Pinkham and Penn,
outcome (reviewed in Couture et al., 2006). In addition, 2006). Thus, there is evidence to suggest that the ability to
several studies have investigated the hypothesis that social understand the intentions of others (ToM) is associated with
cognition serves as a mediator between neurocognition and social competence, and ultimately, real-world functioning.
functional outcome. For instance, Addington et al. (2006) Finally, functioning behaviors have also been associated
found that social perception and social knowledge fully with negative symptoms, Clearly, features such as appro-
mediated the relationship between neurocognition and social priate levels of motivation, the ability to experience rewards
problem solving, and partially mediated the relationship with in the environment, and the expression of one's emotional
social functioning in an early psychosis sample. Similarly, a state in an appropriate manner are necessary to navigate life
second study also found support for the role of social challenges effectively. In support of this idea, negative
perception as a mediator between early visual processing symptoms have been significantly associated with func-
and functional outcome (Sergi et al., 2006), and social tional outcome (e.g., Guaiana et al., 2007), neurocognition
perception was also identified as a mediator in the relation- (e.g., Harvey et al., 2006), and ToM (e.g., Corcoran et al.,
ship between neurocogniton and work skills in a third study 1995), which provides evidence of its suitability for
(Vauth et al., 2004). In contrast, Nienow et al. (2006) found inclusion in modern models of real-world functioning. In
evidence that affect recognition performed as a moderator, addition, a recent study (Leifker et al., 2009) found that
rather than a mediator, in the relationship between attention/ negative symptoms served as a mediator between func-
vigilance and social problem solving. Accordingly, it seems tional capacity and real-world functioning behaviors. These
clear that social cognition, as measured by emotion or social findings suggest that if individuals with schizophrenia
perception, appears to play a crucial role in the relationship possess the necessary skills to function well in the
between neurocognition and domains of functional outcome. community, negative symptoms may be predictive of
Theory of Mind (ToM) is another aspect of social cognition whether they actually engage in these behaviors in the
that has not yet been evaluated as a mediator. ToM involves real-world. Deficient skill level (i.e., functional capacity)
the ability to ascertain the mental states of others, and may be impaired prior to illness onset and may thus affect
accordingly is likely to affect functioning behaviors to a great the development of negative symptoms via lack of success-
extent (Bora et al., 2006). Indeed, there is preliminary ful experiences and through the formation of dysfunctional
evidence to support a link between ToM and functional beliefs and low self-efficacy (e.g., Beck et al., 2009). In
outcome (Couture et al., 2006), and several studies have contrast, one recent study found that negative symptoms
found associations between ToM and neurocognition (e.g., are associated with neurocognitive ability and each inde-
Greig et al., 2004). Although ToM and emotion perception are pendently predict functioning behaviors (Bowie et al.,
both under the umbrella of social cognition, ToM and emotion 2006), and another found that social competence mediates
perception are distinct constructs. For example, in individuals the relationship between negative symptoms and interper-
with traumatic brain injury, ToM and emotion perception sonal functioning (Bowie et al., 2008). Thus, these findings
performance could be dissociated (Henry et al., 2006; are in line with conceptualizations of negative symptoms as
McDonald and Flanagan, 2004), and in studies of individuals illness factors which are more closely tied to the neurocog-
with schizophrenia, ToM and emotion recognition have nitive and biological markers of schizophrenia. Taken
demonstrated no, or very little, association with one another together, previous work clearly indicates negative symp-
(Bell et al., 2009; Brune, 2005). Therefore, the present study is toms are important in predicting real-world functioning,
an important extension of previous research by examining although it is unclear whether negative symptoms are best
whether ToM also mediates the relationship between thought of as a proximal cause to functioning behaviors (i.e.,
neurocognitive impairment and functional outcome. reflecting poor drive and motivation to perform the
A third factor found to mediate the relationship between behaviors they are capable of) or a more distal cause
neurocognition and functioning behaviors is functional affecting the ability to correctly ascertain appropriate social
154 S.M. Couture et al. / Schizophrenia Research 125 (2011) 152–160

and functional behaviors (i.e., causing impairment in social Symptom subscale was used for the purposes of this study.
cognition and functional capacity). Based on 10 taped interviews, the inter-rater reliability for
Based on this prior research, path analysis was used to test negative symptoms was good (ICC = .83).
a model of functioning behaviors in schizophrenia that
includes relationships among neurocognition, social cogni-
2.2.2. Theory of Mind (ToM)
tion (as measured by ToM), negative symptoms, functional
A North American version of the Hinting Task (Greig et al.,
capacity, and self-reported functioning in schizophrenia. To
2004) was used to assess theory of mind. This version is
determine whether ToM may be an important focus for
virtually identical to Corcoran et al.'s (1995) Hinting Task, with
treatments that target functioning, it is important to ascertain
the exception that the language is more appropriate for
whether ToM has a unique contribution to predicting
American, as opposed to British, participants. For example,
functional behaviors in the context of other known pre-
the original item reads: “Gordon goes to the supermarket with
dictors. Based on previous research, we hypothesized that
his mum. They arrive at the sweetie aisle. Gordon says, ‘Cor!
ToM (as indexed by the Hinting Task) would mediate the
Those treacle toffees look delicious!’” The revised item reads:
relationships between neurocognition and social competence
“Gordon goes to the supermarket with his mother. They arrive
(as indexed by the MASC) and between neurocognition and
at the cookie aisle. Gordon says, ‘Wow! Those Twinkies look
functional behaviors. In addition, further examined two
delicious!’” The participant is then asked, “What does Gordon
alternative hypotheses regarding negative symptoms gener-
really mean when he says this?” A correct response (e.g., “he
ated from prior research: 1) that negative symptoms and
wants Twinkies”) at this stage receives a score of 2 and the next
neurocognition are correlated and serve as exogenous
vignette is read aloud. If the participant does not answer
predictors relative to the other variables in the model
correctly the examiner gives a prompt (e.g., “Gordon goes on to
(model 1), versus 2) that negative symptoms serve as a
say: ‘I'm hungry Mom’”) and the participant has a second
mediator between functional capacity and self-reported
opportunity to answer the question. A correct response after
functioning (model 2). This is the only study to our
the prompt receives a score of 1, while an incorrect response at
knowledge to include measures of neurocognition, social
this stage receives a score of 0. Therefore, the highest attainable
cognition, negative symptoms, functional capacity, and self-
score is 20 (2 points per 10 items). As part of a study of vocal
reported functioning within the same model.
prosody in our laboratory, test items were pre-recorded and
presented in two standardized formats. Half of the items were
2. Methods and materials
recorded such that affective prosody emphasized the hint,
whereas the remaining items were read with neutral vocal
2.1. Participants
tone. Prosody and neutral items were counterbalanced across
participants. The task was not administered twice. No
This study was approved by the Institutional Review
differences in accuracy emerged across the two presentation
Board of the University of California at San Diego, and all
styles (t181 = −.542, n.s.) and correlations with other study
participants (or their legal guardians) provided written
measures were similar for the two presentation styles; thus,
informed consent after a complete description of the study
the total score was used in the present analyses.
was provided. Participants were recruited from two ongoing
treatment outcome studies and measures included in this
report were obtained at the baseline assessment prior to 2.2.3. Neurocognition
randomization to treatments (N = 178). Participants with Several neurocognitive domains were assessed in the
schizophrenia or schizoaffective disorder over age 18 were current study: (1) Speed of Processing assessed with Trail
recruited from outpatient treatment centers and residential Making Test Part A (TMT; Reitan, 1979; Heaton et al., 1991),
settings in San Diego. Diagnosis was evaluated with the and Brief Assessment of Cognition in Schizophrenia (BACS;
Structured Clinical Interview for DSM-IV (SCID; First et al., Keefe et al., 2004) Symbol Coding; (2) Working Memory was
1995), and supplemented by medical records and consulta- assessed with the Wechsler Adult Intelligence Scale-Third
tion with the treating psychiatrists, when available. Partici- Edition (WAIS-III; Wechsler, 1997a) Letter–Number Se-
pants were excluded from the study if they had a disabling quencing subtest and the Wechsler Memory Scale-Third
medical or psychiatric problem that would interfere with Edition (WMS-III; Wechsler, 1997b) Spatial Span; (3) Verbal
outpatient psychotherapy or had received cognitive-behav- Learning was assessed with the Hopkins Verbal Learning
ioral or social skills training interventions in the past 5 years. Test-Revised (HVLT-R; Benedict et al., 1998) trials 1–3 total
All participants had an IQ above 70 as estimated by the recall); (4) Visual Learning was assessed with the Brief
American National Adult Reading Test (ANART; Grober and Visuospatial Memory Test-Revised (BVMT-R; Benedict et al.,
Sliwinski, 1991). 1996) trials 1–3 total recall; and (5) Executive Functioning
was assessed with the Delis–Kaplan Executive Function
2.2. Measures System (D-KEFS; Delis et al., 2001) Card Sorting subtest
(free sorting, correct number of sorts), 20 Questions subtest
2.2.1. Symptoms (initial abstract, number of questions asked), Word Context
The Positive and Negative Syndrome Scale (PANSS; Kay subtest (consecutively correct); and BACS letter fluency. Each
et al., 1987) was used to assess current levels of schizophre- domain score was calculated as the mean of the variables
nia-related symptoms. Participants answer questions in a listed. First, age-corrected T-scores according to the published
brief (30 min) semi-structured interview, which allows the norms were used for each measure. Then, the Global
examiner to rate their current symptom level. The Negative Neurocognition Composite used in the model was calculated
 S.M. Couture et al. / Schizophrenia Research 125 (2011) 152–160 155

as the mean of the 5 domains. Participants needed scores on symptoms, social competence, and self-reported functioning.
at least 3 of the 5 domains to have a Global score. While it would be preferable to only estimate a portion of the
paths in the model rather than linking each variable to every
2.2.4. Social competence other variable, there is clear empirical evidence to support all
The Maryland Assessment of Social Competence (MASC; paths between model variables (Brekke and Nakagami,
Bellack et al., 2006) was used to assess the functional capacity 2010). For example, when inspecting the top panel of Fig. 1,
domain of social competence. The MASC is a structural neurocognition has consistently demonstrated relationships
behavioral assessment that measures the ability to resolve with negative symptoms, ToM, social competence, and
interpersonal problems through conversation. It is an abbre- functioning. Thus, removal of any of these paths is inconsis-
viated version of an empirically developed social problem tent with prior research. Likewise, negative symptoms have
solving procedure with established reliability and discrimi- been associated with ToM, social competence, and function-
nant validity (Bellack et al., 1994; Sayers et al., 1995). The ing (and so on with the other variables in the model). Because
instrument takes 15–20 min to administer and consists of of this support in prior research, we first examined the
three 3-minute role play scenarios (1 conversation initiation, saturated model that contains paths linking all variables in
2 assertiveness). Participant responses are videotaped for the model (top panel, Fig. 1). It should be noted all models
subsequent coding by blinded raters on dimensions of verbal specified in this study are recursive. That is, all causal arrows
content, nonverbal communication behavior, and an overall specified in the model are unidirectional. The saturated
effectiveness score. Excellent inter-rater reliability was model results in the χ2 statistic and corresponding degrees
achieved (ICC = .86). For the purpose of the current analyses, of freedom to be equal to zero. Post hoc model modifications
the total score was used as has been done in previous studies were subsequently formed by testing nested models by
(Dickinson et al., 2007). eliminating paths suggested by model comparison statistics
and theory, and examining model fit statistics, the statistical
2.2.5. Self-reported functioning significance of each path in the model, and the amount of
Self-reported functioning was assessed with the Indepen- variance accounted for in each of the endogenous variables.
dent Living Skills Survey (ILSS; Wallace et al., 2000). The ILSS This procedure can help ascertain whether a better fitting,
is a 70-item self-report measure that assesses 10 domains of more parsimonious model can be identified.
functioning: (1) Personal Hygiene, (2) Appearance, (3) Care The chi-square (χ2) goodness-of-fit statistic, which is one
of Personal Possessions, (4) Food Preparation, (5) Care of of the most commonly-used statistical tests within this
Personal Health and Safety, (6) Money Management, (7) framework, indicates the degree of consistency between the
Transportation, (8) Leisure, (9) Job Seeking, and, (10) Job pattern of fixed and free parameters and the pattern of
Maintenance. Consistent with prior studies (Granholm et al., variances and covariances in the observed data. It tests the
2005; Mueser et al., 2010), a global composite of the average null hypothesis that the matrix estimated from the model
of the 10 functioning domains was used in the model. The parameters equals the observed data matrix. It should not be
ILSS was designed to have a simple and objective response significant if there is good model fit. The Comparative Fit
scale involving yes or no responses to queries about the Index (CFI) and the Root Mean Squared Error of Approxima-
performance of specific behaviors (e.g., driving, riding the tion (RMSEA) were examined, given that they tend to be the
bus, talking with family or friends, washing clothing) during least biased indices in small samples (Hu and Bentler, 1998).
the past 30 days. The self-report version has demonstrated Both indices use conventional cut-offs (.90 for CFI, and
associations with reports of an informant of a similar .08–.05 for RMSEA) to indicate good model fit. The model
magnitude to investigations of self-other agreement in parameters, which provide information about the relation-
other populations (e.g., Cui et al., 2005; McCrae and Costa, ships among the latent variables, were also interpreted. The
1992). For the total ILSS, internal consistency is .79, stability standardized structural coefficients are the same as stan-
over 6 months is .66, and inter-rater reliability (self-infor- dardized regression weights, which facilitates interpretation.
mant) is .44 (Wallace et al., 2000). The ILSS also has In addition, squared multiple correlations were obtained for
evidenced convergent validity with the Global Assessment each endogenous variable to acquire an estimate of the
Scale and is associated with employment status (Wallace et amount of variance explained by the other variables. Finally,
al., 2000), in addition to being sensitive to the effects of skills the standardized coefficients for indirect effects were exam-
training and other treatments that target functioning (Gran- ined to evaluate meditational effects. Significant effects
holm et al., 2005; Mueser et al., 2010; Wallace et al., 2000). suggest mediation is present, and full mediation is indicated
by the direct path no longer being significant.
2.3. Statistical analyses As reviewed in the Introduction, it is unclear whether
negative symptoms are best conceptualized as a correlate of
Path analysis allows testing of a system of regression neurocognition which influences other variables in the
equations in which variables can serve as both “predictors” model, or a more proximal cause of functioning due to the
and “outcomes,” and multiple “outcomes” can be investigated inherent difficulties with drive and motivation that charac-
in the same analysis. This procedure also allows effects to be terize negative symptoms. To further evaluate these possi-
parsed apart into their components (indirect, direct, and total bilities, an alternative model was tested with negative
effects), which is a significant advantage over multiple symptoms serving as a mediator between social competence
regression. For the current study we used path analysis and self-reported functioning (bottom panel, Fig. 1). A similar
with maximum likelihood estimation to assess the nature of procedure was undertaken as with model 1. The best-fitting
the relationships among neurocognition, ToM, negative models were compared using the Akaike Information
156 S.M. Couture et al. / Schizophrenia Research 125 (2011) 152–160

Fig. 1. Saturated models for model 1 and model 2.

Criterion (AIC) and Consistent AIC (CAIC). The AIC and CAIC
can be used to compare non-hierarchical (non-nested
models). A lower AIC and CAIC indicates better model fit.

Table 1
3. Results
Means and standard deviations for demographics and study measures.

The means and standard deviations for all variables in the Mean Standard Minimum Maximum
path models and participant demographic characteristics are deviation
presented in Table 1. Pearson's correlations revealed all Age 45.9 10.9 18.5 78.3
variables were significantly correlated with one another (see Years of education 12.2 1.8 8 20
Table 2). ILSS composite .7087 .098 .391 .917
Global Neurocognition 34.47 7.03 20.56 51.55
The full model contains all possible paths and is presented
composite
in the top panel of Fig. 1. Model fit statistics cannot be MASC total score 30.0 8.91 9.0 44.0
interpreted in a saturated model, but it is clear upon Hinting task total score 13.2 4.5 1.0 20.0
examining the statistical significance of each path in the PANSS negative symptom 15.7 6.0 7.0 36.0
PANSS positive symptom 19.2 6.4 7.0 35.0
model that there are a number of nonsignificant paths. Paths
PANSS general symptom 33.9 9.9 16.0 62.0
were eliminated in an iterative way to ensure their removal
did not have a negative effect on model fit statistics. The paths Percent Number
between neurocognition and self-reported functioning, neg-
Sex (% male) 63.5 113
ative symptoms and ToM, and ToM and self-reported Race
functioning were successively removed from the model. Caucasian 56.7 101
Removing any of these paths did not result in significantly African-American 15.2 27
Hispanic/Latino 14.0 25
poorer model fit. The final model, excluding these paths, is
Asian 3.9 7
shown in the top panel of Fig. 2. All remaining paths are Bi/multi-racial 5.1 9
statistically significant in the final model. The model has Other 5.1 9
excellent fit statistics (χ 2 (N = 3) = 2.374, p = .498; Note. ILSS = Independent Living Skills Survey; MASC = Maryland
CFI = 1.00; RMSEA b .01). Neurocognition accounted for Assessment of Social Competence; PANSS = Positive and Negative
17.3% of the variance in ToM; and neurocognition, ToM, and Syndrome Scale, N = 178.
 S.M. Couture et al. / Schizophrenia Research 125 (2011) 152–160 157

Table 2 p=.022). Of note, this indicates that social competence partially

Zero-order correlations among path model variables. mediates the relationship between negative symptoms and self-
ToM Neg Sx Social Self-report
reported functioning, and that ToM partially mediates the
Comp functioning relationship between neurocognition and social competence.
Results also suggest that social competence fully mediates the
Neurocognition .516** −.267** .367** .185*
ToM – −.251** .416** .173* relationship of neurocognition or ToM with self-reported
Neg Sx – – −.316** −.214** functioning.
Social Comp – – – .227** Following the procedures outlined previously, the saturated
Note. Neurocognition = Global Neurocognition Composite; ToM = Theory of model depicted in the bottom panel of Fig. 1 was trimmed by
Mind; Neg Sx = Negative Symptoms; Social Comp = Social Competence; successively removing the paths between ToM and negative
Real World Fxn = Real World Functioning; *p b .05; **p b .01. symptoms, ToM and self-reported functioning, and neurocogni-
tion and self-reported functioning. Removal of any additional
paths resulted in significantly poorer model fit, despite the
marginally significant path between negative symptoms and
negative symptoms explained 23.9% of the variance in social self-reported functioning. The final model (bottom panel, Fig. 2)
competence. All variables in the model accounted for only had excellent fit statistics (χ2 (N = 3) = 1.591, p = .662;
7.3% of the variance in self-reported functioning. Removing CFI=1.00; RMSEAb .01). Neurocognition and social competence
any other paths in the model results in significantly poorer explained 12.6% of the variance in negative symptoms, and
model fit and unacceptable fit statistics. neurocognition and ToM explained 20.0% of the variance in social
In addition, all of the indirect effects in the model were competence. Again, all of the indirect effects were significant,
significant, including negative symptoms on self-reported including negative symptoms on self-reported functioning
functioning (standardized coefficient for indirect effect = (standardized coefficient for indirect effect=−.093, pb .01),
−.039, p=.013), neurocognition on social competence (stan- neurocognition on social competence (standardized coefficient
dardized coefficient for indirect effect=.111, p=.011), neuro- for indirect effect = .117, p b .01), neurocognition on self-
cognition on self-reported functioning (standardized coefficient reported functioning (standardized coefficient for indirect
for indirect effect=.055, p=.012), and ToM on self-reported effect=.107, pb .01), and ToM on self-reported functioning
functioning (standardized coefficient for indirect effect=.047, (standardized coefficient for indirect effect=.061, pb .01). In this

Fig. 2. Final path models after post hoc trimming.

158 S.M. Couture et al. / Schizophrenia Research 125 (2011) 152–160

case, social cognition serves as a partial mediator between Remarkably, only a small proportion of the variance in
neurocognition and social competence, negative symptoms and self-reported functioning (7.3%) was accounted for by all
social competence fully mediate the relationship between variables in the model. While this is not entirely discrepant
neurocognition or social cognition and self-reported functioning, from other similar studies using path analysis or structural
and negative symptoms partially mediate the relationship equation modeling (e.g., variance accounted for ranges from
between social competence and self-reported functioning. The 10 to 25%; Brekke et al., 2005; Sergi et al., 2006; Vauth et al.,
AIC for model 1 tested above was 26.37 and the CAIC was 76.55, 2004), it is lower than expected and is substantially less than
whereas the AIC for model 2 was 25.59 and the CAIC was 75.77. estimates of 25–50% of the variance explained by neurocog-
nition alone in other studies (Green et al., 2000). Although
statistically, ToM, as indexed by the Hinting Task, did mediate
4. Discussion the relationship between neurocognition and functioning, it
only accounted for a small amount of variance in self-
The current study aimed to further evaluate the role of reported functioning in the model. The most salient differ-
social cognition as a mediator between neurocognition and ence between the other similar studies and the current one is
functioning in schizophrenia. By using ToM (Hinting Task) as that they used informant and/or interview-based assess-
a measure of social cognition, this study extended the work of ments of real-world functioning, while this study relied on
previous studies that used social or emotional perception to self-report. The ILSS does assess social and leisure activities
assess these relationships. As noted previously, ToM is a (e.g., talking to friends, going to the movies) and thus should
distinct social cognitive ability, and thus it was unclear if it overlap to some degree with the types of behaviors assessed
would operate similarly to social and emotion perception. in the MASC. However, the ILSS does not exclusively focus on
Moreover, negative symptoms and functional capacity interpersonal or social functioning, and thus its relationship
(MASC), both of which have been found to have significant with our measure of functional capacity, social competence,
relationships with the constructs of interest, were also may have been somewhat attenuated. It is possible these
incorporated into the model. Path analyses suggested that methodological differences can explain current findings, and
ToM as indexed by the Hinting Task partially mediated the it is not unusual for studies to vary widely, with some
relationship between neurocognition and a more proximal reporting no relationship between one of the variables of
domain of functioning, social competence, as indexed by the interest and functional outcome (e.g., Bellack et al., 1994), to
MASC. Negative symptoms and social competence were the others supporting strong relationships (e.g., Dickinson and
only variables in the model that demonstrated significant Coursey, 2002). A host of possible explanations for this could
direct paths to self-reported functioning. be entertained, such as differences in sample characteristics
In line with previous studies (Addington et al., 2006; (e.g., illness severity, demographics), or differences in the
Brekke et al., 2005; Meyer and Kurtz, 2009), social cognition measures used across studies.
appears to serve a meditational role between neurocognition A larger proportion (24%) of the variance in functional
and social competence. This study extended previous work by capacity was explained by negative symptoms, neurocogni-
providing evidence that ToM (as indexed by the Hinting Task) tion, and ToM; neurocognition and ToM (as assessed with the
also mediates the neurocognition-functioning relationship in Hinting Task) alone explained 20% of the variance in social
addition to previously investigated domains of emotional or competence (MASC). This is consistent with the notion that
social perception. These findings support current broad- performance of real-world behaviors is multi-determined
based social cognitive interventions that target multiple and a more distal outcome further downstream from
social cognitive domains (e.g., Roberts and Penn, 2009). neurocognition and social cognition then is functional
Neurocognition, ToM, and negative symptoms were all capacity. Performance-based assessments might be more
significant predictors of social competence (MASC) in strongly linked to neurocognition and social cognition
model 1, which is consistent with prior research (e.g., Bora because they assess whether individuals are capable of
et al., 2006; Couture et al., 2006; Green et al., 2000). performing certain behaviors not whether they do perform
Furthermore, the significant relationships often observed them in the real world (McKibbin et al., 2004; Patterson and
between neurocognition and negative symptoms (e.g., Har- Mausbach, 2010). Actual performance of behaviors in the real
vey et al., 2006) and neurocognition and social cognition (e.g., world is not always strongly related to performance-based
Sergi et al., 2007) were replicated. In addition, previous work capacity measures (Cohen et al., 2006; Dickerson et al., 2000);
demonstrating that functional capacity (in this case, the presumably because real world behavior is influenced by
MASC) serves a meditational role between neurocognition factors outside the individual's control, such as level of social
and functioning (e.g., Bowie et al., 2006) was further support, financial means, personal resources (e.g., having an
supported. Thus, this study provides additional verification automobile), etc. (Brekke et al., 2005). Interestingly, the
that negative symptoms, neurocognition, and ToM are all current study tested an alternative model (model 2) with
relevant factors in predicting functioning in people with negative symptoms identified as one of the factors contrib-
schizophrenia, or at the least, the capacity to function well in uting to self-reported functioning beyond the influence of
one's environment. Given that the individual must first functional capacity alone. The results from the path models
possess the skills necessary to function before they will be were not conclusive. Although model 2 fit the data equally
able to pursue real-world functional goals, these findings well and demonstrated a slight advantage when examining
suggest neurocognition, ToM, and negative symptoms are all the AIC and CAIC statistics, there does not appear to be a
relevant factors to target in treatments aiming to improve substantive statistical difference between the two models and
community functioning in individuals with schizophrenia. the direct path of negative symptoms to functioning only
 S.M. Couture et al. / Schizophrenia Research 125 (2011) 152–160 159

approached significance in this model. Theoretically, it seems Role of funding source

This material is based upon work supported in part by the Department of
intuitive that deficits in motivation, persistence and goal-
Veterans Affairs, Veterans Health Administration, Office of Research and
directed behavior (as is captured by negative symptoms) Development, Rehabilitation Research and Development Service, and by the
would be more likely to serve as a mediator between National Institute of Mental Health (RO1MH071410 and P30MH080002) to
functional capacity and real-world functioning. Clearly, Dr. Granholm. The NIMH and the VA had no further role in study design; in
more research is needed to determine the role of negative the collection, analysis and interpretation of data; in the writing of the
report; and in the decision to submit the paper for publication.
symptoms in the context of other known predictors of
functioning behaviors.
Limitations of the current study include the use of a self- Contributors
Dr. Couture carried out the analyses and wrote the initial draft of this
report measure of real-world functioning behaviors, and this may article. Dr. Granholm designed and conducted the study, and provided
have contributed to the relatively lower amount of variance significant editorial feedback on the writing of the manuscript. Mr. Fish
accounted for in functioning. This hypothesis is consistent with conducted and used portions of the study in his dissertation project, and
previous work, which has found varying degrees of relationships provided editorial feedback on the manuscript. All authors have contributed
to have approved the final manuscript.
between functional capacity and real-world functioning depend-
ing on whether the functioning measure used was informant-
based (Twamley et al., 2002) or reliant on self-report (McKibbin Conflict of interest
All authors report no conflict of interest.
et al., 2004). In line with suggestions by other investigators, it
may be best to use multiple measures of functioning behaviors to
capture the complexity of functioning in schizophrenia (Bowie Acknowledgments
None.
et al., 2006). This criticism can also apply to the domains of social
cognition and social competence given that each was also
assessed with only one measure. It should be noted that References
interpretation of study conclusions is limited by the fact that
Addington, J., Young, J., Addington, D., 2003. Social outcome in early
only one measure (i.e., the Hinting Task and the MASC,
psychosis. Psychol. Med. 33, 1119–1124.
respectively) was used to index ToM and functional capacity Addington, J., Saeedi, H., Addington, D., 2006. Influence of social perception
domains. Findings may differ for other ToM tasks or other and social knowledge on cognitive and social functioning in early
measures of functional capacity. psychosis. Br. J. Psychiatry 189 (4), 373–378.
Beck, A.T., Rector, N.A., Stolar, N.M., Grant, P.M., 2009. Schizophrenia:
Within the domain of social cognition, it should be noted Cognitive Theory, Research, and Therapy. Guilford Press, New York.
that the Hinting Task does require participants to use verbal Bell, M., Tsang, H.W.H., Greig, T.C., Bryson, G.J., 2009. Neurocognition, social
and working memory skills to respond correctly to items, and cognition, perceived social discomfort, and vocational outcomes in
schizophrenia. Schizophr. Bull. 35 (4), 738–747.
thus may have increased the magnitude of the relationship Bellack, A., Sayers, M., Mueser, K.T., Bennett, M., 1994. Evaluation of social
between neurocognition and the Hinting Task. Although problem solving in schizophrenia. J. Abnorm. Psychol. 103, 371–378.
neurocognition was indexed as a composite of several Bellack, A., Brown, C., Thomas-Lohrman, S., 2006. Psychometric character-
istics of role-play assessments of social skill in schizophrenia. Behav.
abilities, recent research has suggested a single factor fits Ther. 37, 339–352.
the data best (Dickinson et al., 2006; Keefe et al., 2006), and it Benedict, R.H., Schretlen, D., Groninger, L., Dobraski, M., 1996. Revision of the
was necessary to reduce the number of parameters estimated Brief Visuospatial Memory Test: studies of normal performance,
reliability, and validity. Psychol. Assess. 8, 145–153.
in the model (given that our models already required at least
Benedict, R.H., Schretlen, D., Groninger, L., Brandt, J., 1998. Hopkins Verbal
150 participants). It should also be noted that while path Learning Test-Revised: normative data and analysis of inter-form and
analysis has statistical procedures to detect mediation and test–retest reliability. Clin. Neuropsychol. 12, 43–55.
Bora, E., Eryavuz, A., Kayahan, B., Sungu, G., Veznedaroglu, B., 2006. Social
causal relationships, because the data are cross-sectional in
functioning, theory of mind and neurocognition in outpatients with
nature, conclusions about explaining or causing outcomes schizophrenia; mental state decoding may be a better predictor of social
across time are necessarily speculative. In addition, the functioning than mental state reasoning. Psychiatry Res. 145, 95–103.
participants in the current study were those who volunteered Bowie, C.R., Reichenberg, A., Patterson, T.L., Heaton, R.K., Harvey, P.D., 2006.
Determinants of real-world functional performance in schizophrenia
for a treatment trial. While few exclusionary criteria were subjects: correlations with cognition, functional capacity, and symp-
applied, it can still be argued that these individuals were toms. Am. J. Psychiatry 163, 419–425.
willing to engage in a year long intervention designed to Bowie, C.R., Leung, W.W., Reichenberg, A., McClure, M.M., Patterson, T.L.,
Heaton, R.K., Harvey, P.D., 2008. Predicting schizophrenia patients' real-
improve functioning, and thus may not be representative of world behavior with specific neuropsychological and functional capacity
all individuals with schizophrenia. measures. Biol. Psychiatry 63, 505–511.
The current results suggest that neurocognition and social Brekke, J.S., Nakagami, E., 2010. The relevance of neurocognition and social
cognition for outcome and recovery in schizophrenia. In: Roder, V.,
cognition are viable targets for treatment for individuals who Medalia, A. (Eds.), Neurocognition and Social Cognition in Schizophrenia
perform poorly on measures of functional capacity. It is also Patients: Basic Concepts and Treatment. Karger, Basel, pp. 23–36.
clear that negative symptoms and social competence are Brekke, J.S., Kay, D.D., Kee, K.S., Green, M.F., 2005. Biosocial pathways to
functional outcome in schizophrenia. Schizophr. Res. 80, 213–225.
inter-related. However, results also suggest that improving Brune, M., 2005. Emotion recognition, ‘theory of mind’, and social behavior in
functional capacity will not necessarily result in improved schizophrenia. Psychiatry Res. 33 (2–3), 135–147.
community functioning. Future research may benefit from Cohen, A.S., Forbes, C.B., Mann, M.C., Blanchard, J.J., 2006. Specific cognitive
deficits and differential domains of social functioning impairment in
identifying variables that impede individuals from function-
schizophrenia. Schizophr. Res. 81, 227–238.
ing at their optimal capacity level. That is, those variables Corcoran, R., Mercer, G., Frith, C.D., 1995. Schizophrenia, symptomatology
which affect the relationship between functional capacity and and social inference: investigating “theory of mind” in people with
functioning behaviors. Enhancing understanding of other schizophrenia. Schizophr. Res. 17, 5–13.
Cornblatt, B.A., Green, M.F., Walker, E.F., Mittal, V.A., 2009. Schizophrenia: etiology
factors that hinder functional success is vital for treatments to and neurocognition. In: Blaney, P.H., Millon, T. (Eds.), Oxford Textbook of
translate into more positive outcomes. Psychopathology. Oxford University Press, New York, pp. 298–332.
160 S.M. Couture et al. / Schizophrenia Research 125 (2011) 152–160

Couture, S.M., Penn, D.L., Roberts, D.L., 2006. The functional significance of social Leifker, F.R., Bowie, C.R., Harvey, P.D., 2009. Determinants of everyday
cognition in schizophrenia: a review. Schizophr. Bull. 32 (S1), S44–S63. outcomes in schizophrenia: the influences of cognitive impairment,
Cui, M., Lorenz, F.O., Conger, R.D., Melby, J.N., Bryant, C.M., 2005. Observer, functional capacity, and symptoms. Schizophr. Res. 115, 82–87.
self-, and partner reports of hostile behaviors in romantic relationships. J. McCrae, R.R., Costa, P.T., 1992. Discriminant validity of the NEO-PIR facet
Marriage Fam. 67, 1169–1181. scales. Ed. Psychol. Meas. 52, 229–237.
Delis, D.C., Kaplan, E., Kramer, J.H., 2001. Delis-Kaplan Executive Function McDonald, S., Flanagan, S., 2004. Social perception deficits after traumatic
System (D-KEFS). The Psychological Corporation, San Antonio, Texas. brain injury: interaction between emotion recognition, mentalizing
Dickerson, F., Parente, F., Ringel, N., 2000. The relationship among three ability, and social communication. Neuropsychology 18 (3), 572–579.
measures of social functioning in outpatients with schizophrenia. J. Clin. McKibbin, C.L., Brekke, J.S., Sires, D., Jeste, D.V., Patterson, T.L., 2004. Direct
Psychol. 58 (12), 1509–1519. assessment of functional abilities: relevance to persons with schizo-
Dickinson, D., Coursey, R.D., 2002. Independence and overlap among phrenia. Schizophr. Res. 72, 53–67.
neurocognitive correlates of community functioning in schizophrenia. Meyer, M.B., Kurtz, M.M., 2009. Elementary neurocognitive function, facial
Schizophr. Res. 56, 161–170. affect recognition and social-skills in schizophrenia. Schizophr. Res. 110,
Dickinson, D., Ragland, J.D., Calkins, M.E., Gold, J.M., Gur, R.C., 2006. A 73–179.
comparison of cognitive structure in schizophrenia patients and healthy Mueser, K.T., Pratt, S.I., Bartels, S.J., Swain, K., Forester, B., Cather, C., Feldman,
controls using confirmatory factor analysis. Schizophr. Res. 85, 20–29. J., 2010. Randomized trial of social rehabilitation and integrated health
Dickinson, D., Bellack, A.S., Gold, J.M., 2007. Social/communication skills, care for older people with severe mental illness. J. Consult. Clin. Psychol.
cognition, and vocational functioning in schizophrenia. Schizophr. Bull. 78 (4), 561–573.
33 (5), 1213–1220. Nienow, T.M., Docherty, N.M., Cohen, A.S., Dinzeo, T.J., 2006. Attentional
First, M.B., Spitzer, R.L., Gibbon, M., Williams, J.B.W., 1995. Structured Clinical dysfunction, social perception, and social competence: what is the
Interview for DSM-IV Axis I Disorders-Patient edition (SCID-I/P, Version nature of the relationship? J. Abnorm. Psychol. 115 (3), 408–417.
2.0). Biometrics Research Department, New York State Psychiatric Ostrom, T.M., 1984. The sovereignty of social cognition. In: Wyer, R.S., Srull, T.K.
Institute, New York. (Eds.), Handbook of Social Cognition. : Lawrence Erlbaum Associates, 1.
Granholm, E., McQuaid, J.R., McClure, F.S., Auslander, L.A., Perivoliotis, D., Hillsdale, NJ, pp. 1–37.
Pedrelli, P., et al., 2005. A randomized controlled trial of cognitive Patterson, T.L., Mausbach, B.T., 2010. Measurement of functional capacity: a
behavioral social skills training for middle-aged and older outpatients new approach to understanding functional difficulties and real-world
with chronic schizophrenia. Am. J. Psychiatry 162, 520–529. behavioral adaptation in those with mental illness. Ann. Rev. Clin.
Green, M.F., Kern, R.S., Braff, D.L., Mintz, J., 2000. Neurocognitive deficits and Psychol. 6, 139–154.
functional outcome in schizophrenia: are we measuring the “right stuff”? Penn, D.L., Hope, D.A., Spaulding, W., Kucera, J., 1994. Social anxiety in
Schizophr. Bull. 26 (1), 119–136. schizophrenia. Schizophr. Res. 11, 277–284.
Green, M.F., Neuchterlein, K.H., Kern, R.S., Baade, L.E., Fenton, W.S., Gold, J.M., Pinkham, A.E., Penn, D.L., 2006. Neurocognitive and social cognitive
et al., 2008. Functional co-primary measures for clinical trials in predictors of interpersonal skill in schizophrenia. Psychiatry Res. 143,
schizophrenia: results from the MATRICS psychometric and standardi- 167–178.
zation study. Am. J. Psychiatry 165, 221–228. Reitan, R.M., 1979. Manual for Administration of Neuropsychological Test
Greig, T.C., Bryson, G., Bell, M.D., 2004. Theory of mind performance in Batteries for Adults and Children. Reitan Neuropsychological Laboratory,
schizophrenia: diagnostic, symtpom, and neuropsychological correlates. Tucson, AZ.
J. Nerv. Ment. Dis. 192, 12–18. Roberts, D., Penn, D.L., 2009. Social cognition and interaction training (SCIT)
Grober, E., Sliwinski, M., 1991. Development and validation of a model for for outpatients with schizophrenia: a preliminary study. Psychiatry Res.
estimating premorbid verbal intelligence in the elderly. J. Clin. Exp. 166, 141–147.
Neuropsychol. 13, 933–949. Sayers, M.D., Bellack, A.S., Wade, J.H., Bennett, M.E., 1995. An empirical
Guaiana, G., Tyson, P., Roberts, K., Mortimer, A., 2007. Negative symptoms method for assessing social problem solving in schizophrenia. Behav.
and not cognition predict social functioning among patients with Mod. 19, 267–289.
schizophrenia. Schweiz. Arch. Neurol. Psychiatr. 158, 25–31. Sergi, M.J., Rassovsky, Y., Nuechterlein, K.H., Green, M.F., 2006. Social
Harvey, P.D., Koren, D., Reichenberg, A., Bowie, C.R., 2006. Negative perception as a mediator of the influence of early visual processing on
symptoms and cognitive deficits: what is the nature of their relation- functional status in schizophrenia. Am. J. Psychiatry 163, 448–454.
ship? Schizophr. Bull. 32 (2), 250–258. Sergi, M.J., Rassovsky, Y., Widmark, C., Reist, C., Erhart, S., Braff, D.L., Marder,
Harvey, P.D., Velligan, D.I., Bellack, A.S., 2007. Performance-based measures S.R., Green, M.F., 2007. Social cognition in schizophrenia: relationships
of functional skills: usefulness in clinical treatment studies. Schizophr. with neurocognition and negative symptoms. Schizophr. Res. 90,
Bull. 33 (5), 1138–1148. 316–324.
Heaton, R.K., Grant, I., Matthews, C.G., 1991. Comprehensive Norms for an Twamley, E.W., Doshi, R.R., Nayak, G.V., Palmer, B.W., Golshan, S., Heaton, R.K., et
Expanded Halstead-Reitan Battery: Demographic Corrections, Research al., 2002. Generalized cognitive impairments, ability to perform everyday
Findings, and Clinical Applications. Psychological Assessment Resources, tasks, and level of independence in community living situations of older
Odessa, FL. patients with psychosis. Am. J. Psychiatry 159, 2013–2020.
Heinrichs, R.W., Zakzanis, K.K., 1998. Neurocognitive deficit in schizophre- Vauth, R., Rusch, N., Wirtz, M., Corrigan, P.W., 2004. Does social cognition
nia: a quantitative review of the evidence. Neuropsychology 12 (3), influence the relation between neurocognitive deficits and vocational
426–445. functioning in schizophrenia? Psychiatry Res. 128, 155–165.
Henry, J.D., Phillips, L.H., Crawford, J.R., Ietswaart, M., Summers, F., 2006. Walker, E.F., 1994. Developmentally moderated expressions of the neuro-
Theory of mind following traumatic brain injury: the role of emotion pathology underlying schizophrenia. Schizophr. Bull. 20, 453–480.
recognition and executive dysfunction. Neuropsychologia 44, Wallace, C.J., Liberman, R.P., Tauber, R., Wallace, J., 2000. The independent
1623–1628. Living Skills Survey: a comprehensive measure of the community
Hoff, A.L., Kremen, W.S., 2002. Is there a cognitive phenotype for functioning of severely and persistently mentally ill individuals.
schizophrenia: the nature and course of the disturbance in cognition? Schizophr. Bull. 26 (3), 631–666.
Curr. Opin. Psychiatry 15 (1), 43–48. Wechsler, D., 1997a. Wechsler Adult Intelligence Scale–third edition.
Hu, L., Bentler, P.M., 1998. Fit indices in covariance structure modeling: Psychological Corporation, San Antonio, TX.
sensitivity to underparameterized model misspecification. Psychol. Wechsler, D., 1997b. Wechsler Memory Scale–third edition. Psychological
Meth. 3 (4), 424–453. Corporation, San Antonio, TX.
Kay, S.R., Fiszbein, A., Opler, L.A., 1987. The positive and negative syndrome Wiersma, D., Wanderling, J., Dragomirecka, E., Ganev, K., Harrison, G., An Der
scale (PANSS) for schizophrenia. Schizophr. Bull. 13 (2), 261–276. Heiden, W., et al., 2000. Social disability in schizophrenia: its develop-
Keefe, R.S., Goldberg, T.E., Harvey, P.D., Gold, J.M., Poe, M.P., Coughenour, L., ment and prediction over 15 years in incidence cohorts in six European
2004. The Brief Assessment of Cognition in Schizophrenia: reliability, centres. Psychol. Med. 30 (5), 1155–1167.
sensitivity, and comparison with a standard neurocognitive battery.
Schizophr. Res. 68, 283–297.
Keefe, R.S.E., Bilder, R.M., Harvey, P.D., Davis, S.M., Palmer, B.W., Gold, J.M., et
al., 2006. Baseline neurocognitive deficits in the CATIE schizophrenia
trial. Neuropsychopharmacology 31, 2033–2046.