Background Social cognition is a core impairment in psychotic disorders and is strongly associated with functional outcomes. Although social cognitive training is effective, challenges remain regarding skill generalization and accessibility. This study aimed to develop culturally adapted French- and English-Canadian versions of RC2S and to assess the feasibility and acceptability of remote delivery. Methods Fourteen individuals with a psychotic disorder were assessed at baseline, offered 24 twice-weekly RC2S sessions with a therapist over 12 weeks, and reassessed post-intervention. Motivation and therapeutic alliance were assessed through intra-session questionnaires. RC2S uses a personalized approach targeting social cognition and combines pen-and-paper exercises with digital relational simulations using avatars to promote skill transfer. Feasibility and acceptability were examined descriptively and paired-samples t-tests assessed exploratory pre–post changes. Results All participants who initiated RC2S met the predefined completion criterion (≥50% of sessions), and all completed at least 75% of planned sessions (mean = 20.9). Acceptability was high for cultural adaptation, ease of use, and remote interaction (all>4.1/5), although ratings were lower for the RC2S interface (mean = 3.75/5). Motivation and therapeutic alliance remained high throughout the intervention (MUSIC>5.1;WAI > 4.3). Therapist support, perceived benefits, and remote accessibility were key facilitators. The largest exploratory pre–post changes occurred in therapist-administered goal attainment and functional impact measures. Findings from independently administered measures were more mixed, although a large change was observed for theory of mind. Conclusions Findings support the feasibility and acceptability of remotely delivered, culturally adapted RC2S. Exploratory outcomes were mixed, requiring confirmation in a randomized trial with independent, blinded outcome assessment.
Adopting a continuum perspective, this study examined figurative language comprehension in individuals with high or low levels of schizotypy within a non-clinical population. We investigated whether difficulties in figurative language processing are specifically driven by the presence of a competing literal interpretation. We hypothesized that higher schizotypy would be associated with fewer figurative responses and more literal and concrete responses for ambiguous idioms only, with no comparable effect for unambiguous idioms. A total of 377 French-speaking adults from the general population completed an idiom comprehension task and the Schizotypal Personality Questionnaire (SPQ). Based on total SPQ scores, 139 participants were included in the group analyses (73 high schizotypy, 66 low schizotypy). The task combined two methodological approaches previously examined separately by including both ambiguous and unambiguous idioms while distinguishing figurative, literal, and concrete response options. Participants with high schizotypy produced significantly fewer figurative responses and significantly more concrete responses than those with low schizotypy, whereas no difference was observed for literal responses. Importantly, these group differences were found regardless of idiom ambiguity, indicating that they were not specifically driven by the presence of a competing literal interpretation. These findings suggest that reduced figurative interpretations in schizotypy cannot be explained solely by competition from a plausible literal interpretation. More importantly, they highlight that distinguishing literal from concrete response options may help clarify previous inconsistencies in figurative language research in schizotypy and schizophrenia.
Objective Executive dysfunction is a hallmark cognitive deficit in schizophrenia, yet phenotypic heterogeneity within the disorder complicates clinical translation. This study aimed to identify discrete executive profiles within a large Korean schizophrenia cohort using the Wisconsin Card Sorting Test (WCST) and to evaluate their clinical and functional correlates. Method We analyzed WCST performance in 276 individuals with schizophrenia and 361 healthy controls. A principal component analysis (PCA)-derived executive composite was validated against chart-reviewed clinical variables in a patient subset (n = 145). K-means cluster analysis was utilized to characterize cognitive heterogeneity, stratifying patients into distinct neurocognitive profiles. Results Patients with schizophrenia exhibited severe, broad executive impairment compared to controls, particularly in total errors (Hedges' g = 2.268), categories achieved (g = 2.122), and conceptual-level responses (g = 1.751). Within the patient group, cluster analysis robustly identified three distinct executive profiles: mild/near-normal (n = 83), intermediate (n = 88), and severe (n = 105). While age was independently associated with the general executive dysfunction composite (β = 0.254, p = 0.004), conceptual disorganization showed a prominent, theoretically consistent trend-level association (β = 0.166,p = 0.065). Exploratory neurodevelopmental burden and mediation pathways did not show robust statistical signals. Conclusions Executive dysfunction in schizophrenia is characterized by reproducible, clinically interpretable sub-profiles rather than a uniform deficit. Stratifying patients into mild, intermediate, and severe executive clusters provides a practical framework for neurocognitive heterogeneity, which may facilitate target selection for individualized cognitive remediation and functional rehabilitation strategies.
We investigated differences in cognitive and social functioning between patients with schizophrenia who met criteria for recovery or remission and healthy controls. This cross-sectional study included 55 patients with schizophrenia who met recovery or remission criteria and 20 healthy controls. Cognitive function was assessed using the Japanese version of the Brief Assessment of Cognition in Schizophrenia (BACS-J), and social function was assessed using the Japanese version of the Social Functioning Scale. Executive function scores did not differ significantly among the three groups; however, the other primary and composite scores of the BACS-J differed significantly among the three groups. In the post hoc analysis, verbal fluency (VF) and attention and processing speed (AP) were higher in the recovery group compared with the remission group (VF: p = 0.043; AP: p = 0.045). All domains of social functioning differed significantly among the three groups. In the post hoc analysis, significant differences between the recovery and remission groups were observed in interpersonal communication (p = 0.002), prosocial activity (p = 0.005), employment/occupation (p < 0.001), and total score (p = 0.005). These results indicate that VF and AP may be important cognitive domains related to clinical recovery in patients with schizophrenia. Furthermore, social functioning domains that require interaction with others may be more important for recovery than daily living skills.
Background:Cognitive symptoms represent a major determinant of long-term disability in chronic schizophrenia and only partially respond to pharmacotherapy. Evidence is growing about the potential effect of cognitive interventions to promote functional recovery. Immersive virtual reality (IVR) offers a simulated, adaptive, and ecologically valid real-world-like scenarios in safe and controlled environments. The present study aimed to evaluate the feasibility, acceptability, and efficacy of IVR-based cognitive rehabilitation in schizophrenia. Methods:We performed a single-blind, randomized, waiting list (WL) controlled trial (Clinicaltrials.gov:NCT07427485). Forty clinically stable outpatients with schizophrenia were allocated (1:1) to IVR or WL. The intervention consisted of 12 weekly IVR-sessions through the CEREBRUM-VR tool. Primary outcome was the change in psychotic symptoms (Positive and Negative Symptoms Scale/PANSS). Secondary outcomes included global functioning (GAF), Digital Symbol Substitution Test (DSST), Animal Naming Test (ANT), Trail-Making Test A (TMT-A). Simple Reaction Choice (SRT) and Choice Reaction Time (CRT) evaluated psychomotor speed. Results:Drop-out rate was 15% per group, attrition rate was 4.9%. Most IVR-assigned participants (77.8%) reported willingness to continue. IVR did not worsen overall or positive psychotic symptoms. A significant IVR between-group improvement emerged for negative symptoms (p < 0.01), psychomotor speed (SRT p = 0.01, CRT p = 0.01), DSST (p = 0.02), and ANT (p = 0.04). GAF and TMT-A changes were nonsignificant. Adverse effects were mostly mild and transient, decreasing over repeated sessions. Conclusion:IVR-based cognitive rehabilitation appears feasible and tolerated in stable outpatients with schizophrenia. Our findings suggest improvement in psychomotor speed and modest improvement in negative symptoms. Larger and longer trials are warranted to confirm clinical relevance.
Background:Cognitive impairment is common in schizophrenia and remains poorly responsive to pharmacological treatment. We examined working-memory change after prefrontal transcranial direct current stimulation (tDCS) across baseline cognitive-severity groups and tested whether baseline severity modified response. Methods:This complete-case secondary analysis included 120 of 173 randomized participants (62 active tDCS, 58 sham) who completed the MATRICS Consensus Cognitive Battery before and after 10 bifrontal tDCS sessions. K-means clustering of seven baseline domain T-scores identified cognitive-severity groups. Treatment effects were assessed using descriptive comparisons and adjusted mixed-effects models. Benjamini-Hochberg correction was applied jointly across 14 domain-by-group hypotheses, with Holm correction as a sensitivity analysis. To address circularity, groups were re-derived without baseline working memory, and moderation was tested using the time × treatment × group interaction. Results:The groups differed mainly in overall cognitive severity rather than profile shape. The active-versus-sham difference in working-memory change was 3.68 T-points (95% CI, 1.57-5.79) in the greater-impairment group and 2.59 T-points (95% CI, 0.90-4.28) in the less-severe-impairment group. Working memory survived joint false-discovery-rate correction in both groups, but Holm correction only in the greater-impairment group. No other domain survived joint correction. After reclustering without baseline working memory, the time × treatment × group interaction was not significant (estimate, 0.93 T-points; 95% CI, -1.71 to 3.56; p = .4915). Conclusions:Prefrontal tDCS showed a working-memory signal across both cognitive-severity groups, but baseline severity did not significantly modify response. The groups should be interpreted as positions along a cognitive-severity continuum rather than distinct profiles or subtypes.
Background:Negative symptoms in schizophrenia are often conceptualized as comprising two domains, i.e., expression and experience, which have been associated with social functioning. However, whether these two negative symptom domains independently or jointly contribute to social functioning in this population remains unclear. Therefore, we investigated this issue by utilizing commonality analysis (CA). Methods:Data were analyzed from 45 outpatients diagnosed with schizophrenia. Negative symptoms were assessed using the Positive and Negative Syndrome Scale, and social functioning was measured with the Specific Levels of Functioning Scale, which includes three subdomains: interpersonal relationships, activities, and work skills. Correlation analyses were conducted to examine the association between the expression and experience domains. Regression analyses were performed to predict the three subdomains of social functioning from the two negative symptom domains. Finally, CA was used to quantify their unique and shared contributions to social functioning. Results:There was a significant positive correlation between expression and experience scores (r = 0.52, p < .01). Regression analyses showed that expression scores were more strongly associated with the activities subdomain, and experience scores with the interpersonal relationships and work skills subdomains. CA revealed that a large proportion (≥ 0.48) of the explained variance in social functioning across subdomains was attributable to shared variance across the expression and experience domains. Conclusions:These findings underscore the importance of assessing both aspects of negative symptoms when planning interventions for patients with schizophrenia. In particular, treatment targets may need to be tailored according to deficits in specific subdomains of social functioning.
Patients with schizophrenia often show impairments in work functioning, yet the precise relationships among positive symptoms, cognition, daily living skills, and work outcome remain to be elucidated. We analyzed data from 396 patients with schizophrenia and 1109 healthy individuals. Work outcome was quantified as the mean weekly working hours. Cognitive decline was defined as the difference between current and premorbid IQ, while social function was evaluated by the Social Functioning Scale. We also conducted group comparisons and correlational analyses among the clinical variables. Using structural equation modeling (SEM), we further examined pathways from positive symptoms through cognitive decline, and determined whether daily living skills account for work outcome. Patients showed impairments in work outcome, cognitive decline, and social function, including daily living skills, as represented by Independence-Performance subscale of the Social Functioning Scale. Consistent with previous studies, cognitive decline and social function were correlated with weekly working hours among patients. SEM revealed several pathways from positive symptoms to working hours via daily living skills with or without a mediational effect of cognitive decline. The findings suggest that work outcome is influenced by multiple clinical symptom domains, including positive symptoms, cognitive decline, and daily living skills. The observed relationships among these features may aid in the development of effective interventions for occupational function in patients with schizophrenia.
Difficulties in figurative language understanding are largely documented as part of a broader pragmatic impairment, especially in psychosis. Among figurative domains, metaphor stands out as a significant predictor of functioning, in addition to exhibiting meaningful associations with psychopathological and cognitive features. Yet, the assessment of metaphor comprehension remains a niche area, also due to the lack of reliable and valid tools. Here, we examined the psychometric properties of a rapid test of metaphor comprehension, the Physical and Mental Metaphors (PMM) task, involving a sample of 143 patients with schizophrenia and 57 controls. Findings provide robust support for the PMM reliability and validity. First, internal consistency was satisfactory, and the factorial structure aligned with theoretical assumptions. Second, the PMM demonstrated good validity, being strongly correlated with the pragmatic profile of patients as measured with a standard tool such as the Assessment of Pragmatic Abilities and Cognitive Substrates (APACS) test, showing also relevant associations with symptomatology, in particular abstract thinking and the broader domains of disorganization and negative symptoms, as well as weakly with Theory of Mind and global cognition. Third, the PMM task proved highly effective both in discriminating between individuals with and without pragmatic deficit, as detected via APACS, and in distinguishing patients from healthy controls. Taken together, these results indicate that the PMM task captures the specific impairment in figurative language and the general pragmatic vulnerability characteristic of schizophrenia, as well as their interface with symptoms. As such, it represents a valuable tool for detecting communicative disorders, characterizing symptoms and complementing the diagnostic process.
Psychosis is conceptualized as existing along a continuum, with schizotypal traits and psychotic-like experiences observed in the general population and schizophrenia at its extreme. Predictive processing has recently been applied to the understanding of psychotic experiences, suggesting that symptoms may arise from disruptions at different levels in the processing hierarchy. We studied facial expression expectations and their impact on social perception in a group of 34 individuals with early-stage psychosis (<5 years from a first psychotic episode) and 34 control individuals. Individuals with psychosis exhibited less stereotypical expectations about facial expressions. Similar results were observed in exploratory analyses considering dimensional schizotypy scores within nonclinical participants. These findings suggest that psychosis may involve the development of less stereotypical, more nuanced, individualized predictions, possibly as a result of an overly prioritization of prediction errors, leading to a world that is hard to predict and may seem uncertain, magical and/or too complex to extract general (possibly stereotyped) rules. These results also support the continuum hypothesis of psychosis by highlighting shared phenomena across early-stage psychosis and schizotypy. These insights into predictive processing and less stereotypical social evaluations offer valuable opportunities for improving early detection and developing targeted interventions for social functioning and mental health in psychosis.
Cognitive impairment, characterized by impaired attention function, is widely recognized as one of the core symptoms of schizophrenia, significantly impacting the quality of life for individuals with this disorder. The objective of this cross-sectional study is to investigate the characteristics of attentional behavior and related brain structure and gene expression of schizophrenia, aiming to provide new trans-scale evidence. A total of 137 participants were enrolled in this study, including 65 patients with schizophrenia and 72 healthy controls. All participants underwent magnetic resonance imaging scans and completed cognitive tests. The results revealed that patients required more time (all p < 0.05) to complete key responses in attention-related tasks compared to the control group. Moreover, significant structural brain alterations were observed in patients with schizophrenia, including enlarged bilateral pallidum, smaller right hippocampus, and reduced cortical thickness in relevant brain regions (all p < 0.05). Further analysis demonstrated a correlation between alertness during Attention Network Test performance and pallidum volume among patients (r = 0.42, p = 4.30 × 10-4), and this correlation was associated with a specific pattern of gene expression in the patients' brain but not observed among controls. Our study reveals that decreased attentional ability in schizophrenia is accompanied by abnormal changes in pallidum along with specific transcriptional profile among patients with schizophrenia; these findings hold clinical significance for precise diagnosis and treatment strategies targeting schizophrenia.
Background:Self-disorders, or anomalous disturbances in the basic sense of self, have been described in psychosis-risk states and may contribute to social cognitive impairment and functioning. This study examined self-disorder severity and associations with social cognition and functioning across individuals at clinical high risk for psychosis (CHR-P), autism spectrum disorder (ASD), and controls. ASD was included due to overlapping difficulties in social cognition/functioning with CHR-P. We hypothesized a graded pattern of self-disorders (CHR-P > ASD > controls) and stronger associations between self-disorders and social cognition in CHR-P. Methods:We included 39 CHR-P, 39 ASD, and 30 controls (mean age ≈24 years; 51% female). Self-disorders were assessed with the Inventory of Psychotic-Like Anomalous Self-Experiences (IPASE). Social cognitive domains included social cognitive bias and theory of mind alongside measures of social functioning. Analyses of covariance and bootstrapped regression models with IPASE as predictor were used, adjusting for age, sex, and IQ. Multiple comparisons were Benjamini-Hochberg corrected. Results:Self-disorders followed a graded distribution (CHR-P > ASD > controls) across all IPASE subscores. Both clinical groups showed elevated social cognitive bias and reduced social functioning compared to controls. Self-disorders were associated with social cognitive bias in ASD (B = 0.392, 95%CI 0.236-0.544, p < 0.001), but not in CHR P. Group differences in associations between self-disorders and social cognition/functioning did not survive correction for multiple comparisons. Conclusion:Self-disorders showed a graded distribution across groups but was only associated with social cognitive deficits in ASD. Findings suggest that shared symptom profiles may reflect divergent experiential processes across groups. Further research is needed to clarify clinical implications and generalizability.
Background: Communicative-pragmatic dysfunction is recognized as a core feature of schizophrenia, as well as a hallmark of Autism Spectrum Disorders (ASD), strongly intertwined with neurocognitive and sociocognitive domains. Autistic symptoms, i.e., autistic-like traits below ASD diagnostic threshold, occur in over 50% of patients with schizophrenia, affecting social cognition and functioning. Strikingly, their specific link with pragmatics remains unexplored. This study tests the relationship between autistic symptoms and pragmatics in schizophrenia, modelling their interplay with executive functions (EF) and Theory of Mind (ToM), in the context of the sprout model of pragmatics. Methods: A sample of 125 individuals with schizophrenia was assessed for autistic symptoms, pragmatics, ToM, and EF. Path analysis examined direct and indirect effects of autistic symptoms on global pragmatics and on pragmatic production and comprehension, with EF and ToM as mediating variables. Results: Autistic symptoms were negatively associated with EF, ToM, and pragmatics. Path analysis revealed that autistic symptoms have a direct effect on global pragmatics, as well as an indirect one, via EF and ToM consecutively. Furthermore, autistic symptoms indirectly affected both pragmatic production, via EF, and comprehension, through EF and ToM sequentially. Conclusions: Results show a strong link between autistic symptoms and pragmatics in schizophrenia, highlighting a cognitive pathway from EF to ToM in supporting pragmatics, in line with the sprout model, with a key role of the former in production and of the latter in comprehension. Clinically, this study highlights that assessing autistic symptoms in routine care may help identify patients at higher risk for pragmatic deficits and guide targeted rehabilitation strategies.
Schizophrenia spectrum disorders (SSD) and Wernicke's aphasia (WA) both disrupt meaningful speech, yet they arise from fundamentally different disturbances in thought and language. SSD is defined by formal thought disorder, in which disorganized thinking is inferred from abnormalities in speech, whereas WA reflects a primary breakdown of language implementation following focal brain damage. We investigated whether quantitative markers of lexical-semantic, syntactic structure, and semantic coherence in spontaneous speech can distinguish SSD, WA, and healthy controls. Using Natural Language Processing techniques, we extracted syntactic, lexical and local semantic similarity features from spontaneous speech transcripts and used them in supervised machine learning models to classify diagnostic groups. In parallel, an instruction-tuned large language model (LLM) was used in a zero-shot setting to assign transcripts to diagnostic categories and to track the severity of language disturbance. Our results showed a distinct linguistic pattern, particularly in syntactic and local semantic organization for WA, indicating a paradigmatic language disorder. By contrast, the same features were less effective in distinguishing SSD from matched controls, in line with the view that SSD reflects a more diffuse disturbance of thought that only partially manifests in surface language. Zero-shot LLM classifications approached the performance of supervised models for WA-related contrasts and were sensitive to graded language disturbance. At the same time, strong task and dataset effects underscored the need for carefully controlled speech elicitation. Together, these findings highlight both the promise and the limitations of automated language analysis for clinical diagnostics and for understanding speech and thought abnormalities.
Introduction:Cognitive flexibility (CF) impairments are a hallmark of schizophrenia (SCZ), bipolar disorder (BD) and neurodevelopmental disorders (NDD). These impairments are associated with functional outcomes and are influenced by neurodevelopmental and neurodegenerative processes. Methods:A retrospective analysis of 135 clinical records (75 SCZ, 29 BD, 31 NDD) was conducted. CF impairments were assessed using the Trail Making Test part B (TMT-B), with impairments defined as scores ≤ -2 standard deviations (SD). Multiple linear regression was used to adjust for confounding factors. Results:Rates of CF impairments were significantly higher in NDD (64.5%) and SCZ (57.3%) groups compared to the BD group (34.5%). No significant difference was observed between NDD and SCZ groups. After adjusting for confounders, the mean education level emerged as the only significant factor influencing CF impairments. Discussion:Our findings suggest that CF impairments are transdiagnostic and influenced by the level of education. This highlights the importance of considering environmental and sociodemographic factors in cognitive outcomes and supports the interplay between neurodevelopmental and neurodegenerative models, where education would appear to mitigate the impact of early neurodevelopmental abnormalities and delaying cognitive decline. Conclusion:CF impairments are shaped by shared vulnerabilities across diagnostic categories, with the level education playing a critical role. Future research should explore longitudinal trajectories and neurobiological mechanisms underlying CF impairments to inform targeted interventions.
Objective Clinical insight and cognitive insight are two different dimensions. The theoretical model of insight growth posits that cognitive insight and social cognition are central for gaining clinical insight in schizophrenia patients, but empirical evidence remains limited. We aimed to examine the mediating role of two social cognitive constructs (theory-of-mind and empathy) in linking cognitive insight and clinical insight, and to clarify their role in bringing confluence of the two insight dimensions in schizophrenia patients. Method Our sample comprised 139 schizophrenia patients. The Schedule for the Assessment of Insight (SAIE) and the Beck Cognitive Insight Scale (BCIS) measured the two dimensions of insight. The Faux Pas Task and the self-report Questionnaire of Cognitive and Affective Empathy (QCAE) were used to measure theory-of-mind and empathy respectively. Correlational analyses and mediation modelling were used to clarify the relationships and mediating roles of social cognition with clinical insight and cognitive insight. Explorative cluster analysis was used to categorize patients into different groups with different insight patterns. Results Theory-of-mind statistically mediated the relationship between clinical insight and cognitive insight. The three groups/clusters with varied insight patterns differed in theory-of-mind, empathy, social functioning, negative and disorganized symptoms. The group with non-confluent insight pattern showed poorer theory-of-mind and empathy than the group with high clinical insight and cognitive insight. Discussion Theory-of-mind links cognitive insight with clinical insight. Schizophrenia patients may have a “non-confluent” insight pattern. Social cognition may bring confluence of insight dimensions. Together, our findings lend support to the insight-growth model of schizophrenia.
Introduction:Insight in psychosis has been associated with psychosis remission, treatment compliance and better functioning, but also with depression, increased suicide risk and worse subjective wellbeing. This insight paradox has not been sufficiently studied. Methods:Participants (N = 443) came from the first-episode psychosis OPTiMiSE trial. Insight was assessed with the clinician-rated Positive and Negative Syndrome Scale for Schizophrenia (PANSS)-G12 item. We investigated the cross-sectional associations of insight with clinical measures at baseline and at 4 weeks and the effect of insight change over the 4-week follow-up on outcomes at that point, whilst adjusting for baseline insight and other potential confounders. Results:At baseline and at week 4 better insight was cross-sectionally associated with higher rates of psychosis remission, lower illness severity and better psychosocial functioning (p < .001). At baseline, but not at week 4, better insight was cross-sectionally linked with more severe depressive symptomatology (p = .001), higher suicidality levels (p = .033) and worse subjective wellbeing (p = .022). Insight improvement was associated with higher rates of psychosis remission (p < .001), lower illness severity (p < .001) and better functioning (p = .014) at 4 weeks. Better baseline insight, but not insight change, was related to more severe depression (p < .001) and worse subjective wellbeing (p = .001) at 4 weeks. Conclusions:Insight was cross-sectionally associated with positive and negative clinical measures at baseline, but the latter was not replicated at 4 weeks. Improvement in insight over 4 weeks was not linked with any adverse outcome, offering reassurance to those making efforts to enhance insight early in treatment.
