Elsevier

Psychiatry Research

Volume 220, Issue 3, 30 December 2014, Pages 803-810
Psychiatry Research

Cognitive empathy contributes to poor social functioning in schizophrenia: Evidence from a new self-report measure of cognitive and affective empathy

https://doi.org/10.1016/j.psychres.2014.08.054Get rights and content

Highlights

  • The QCAE provides a more contemporary approach for evaluating empathy than the IRI.

  • The QCAE demonstrated generally good reliability and patterns of inter-correlation in schizophrenia subjects.

  • Cognitive empathy accounted for significant variance in social attainment beyond neurocognition and symptoms.

  • Affective empathy may be intact or hyper-responsive among schizophrenia subjects.

  • Assessing affective empathy via self-report still faces challenges.

Abstract

Cognitive empathy impairments have been linked to poor social functioning in schizophrenia. However, prior studies primarily used self-reported empathy measures developed decades ago that are not well-aligned with contemporary models of empathy. We evaluated empathy and its relationship to social functioning in schizophrenia using the recently developed Questionnaire of Cognitive and Affective Empathy (QCAE). Schizophrenia (n=52) and healthy comparison (n=37) subjects completed the QCAE, Interpersonal Reactivity Index (IRI), and measures of neurocognition, symptoms, and social functioning. Between-group differences on the QCAE, and relationships between QCAE and IRI subscales, neurocognition, symptoms, and social functioning were examined. The schizophrenia group reported significantly lower cognitive empathy than comparison subjects, which was driven by low online simulation scores. Cognitive empathy explained significant variance in social functioning after accounting for neurocognition and symptoms. Group differences for affective empathy were variable; the schizophrenia group reported similar proximal responsivity, but elevated emotion contagion relative to comparison subjects. These findings bolster support for the presence and functional significance of impaired cognitive empathy in schizophrenia using a contemporary measure of empathy. Emerging evidence that some aspects of affective empathy may be unimpaired or hyper-responsive in schizophrenia and implications for the assessment and treatment of empathy in schizophrenia are discussed.

Introduction

Empathy, which refers to the ability to understand and share the thoughts and feelings of others, has emerged as an important topic in the field of social neuroscience (Decety and Jackson, 2004). Although empathy has historically been defined in many ways (Batson, 2009), recent social neuroscience research has made considerable progress in identifying key brain-based subcomponents of empathy (Fan et al., 2011) and understanding how empathy is impacted in various forms of psychopathology (Decety and Moriguchi, 2007). There is now general agreement that empathy is a multidimensional construct, which includes distinct cognitive and affective processes (Shamay-Tsoory, 2011).

Social neuroscience defines cognitive empathy as a set of reflective processes that include taking the ‘perspective’ of others, understanding the emotional state of others, distinguishing another׳s feelings from one׳s own, and being able to integrate this information with social knowledge to adaptively guide interpersonal behavior. Social neuroscience defines affective empathy as a set of relatively automatic processes through which perceived social cues trigger an emotional response in oneself that is shared with an observed person (Decety, 2011, Shamay-Tsoory, 2011, Bernhardt and Singer, 2012). The capacity to accurately and adaptively empathize is believed to involve coordinated interaction between these sub-processes (Zaki and Ochsner, 2011). More recent developments suggest that a motor component of empathy contributes to both cognitive and affective processes through imitation and mimicry (Gonzalez-Liencres et al., 2013).

Among the clinical conditions in which empathy has been studied, several investigations have focused on schizophrenia. The vast majority of studies used self-report measures and findings across scales purported to measure cognitive and affective empathy have been mixed. Nearly all studies used the Interpersonal Reactivity Index (IRI) (Davis, 1983), which includes two subscales, perspective-taking and fantasy that are often described as measures of cognitive empathy and two subscales, empathic concern and personal distress that are often described as measures of affective empathy. A recent meta-analysis (Achim et al., 2011) and subsequently published studies (Sparks et al., 2010, Lee et al., 2011, Haker et al., 2012, Smith et al., 2012, Corbera et al., 2013) consistently indicate that schizophrenia subjects report diminished cognitive empathy on the perspective-taking subscale, while findings for the fantasy subscale are mixed. Most studies indicate that schizophrenia subjects report scores that are similar to healthy comparison subjects on the affective empathy subscales; however, several found that patients reported diminished empathic concern and/or elevated personal distress (Shamay-Tsoory et al., 2007, Sparks et al., 2010, Lee et al., 2011, Smith et al., 2012).

Aside from the IRI, a few studies report diminished empathy in schizophrenia using the Empathy Quotient (EQ) (Bora et al., 2008, Lysaker et al., 2013), a self-report measure validated for use with autism spectrum disorders (Baron-Cohen and Wheelwright, 2004). However, the EQ does not appear to distinguish between affective and cognitive empathy. The overall pattern from existing studies indicates that schizophrenia subjects self-report diminished cognitive empathy (particularly perspective-taking) while findings for affective empathy are mixed. These more variable findings for affective versus cognitive empathy are largely echoed in studies using other assessment methods, including behavioral performance (Langdon et al., 2006, Derntl et al., 2009, Derntl et al., 2012, Smith et al., 2014a), fMRI (Lee et al., 2010, Smith et al., 2014b, Horan et al., 2014a), and electrophysiological tasks (McCormick et al., 2012, Thoma et al., 2014, Corbera et al., 2014, Horan et al., 2014b).

One factor that may contribute to these inconsistent findings is the use of sub-optimal assessment tools that are not based on contemporary models of empathy. For example, the IRI, which was developed over three decades ago, defines empathy as “the reactions of one individual to the observed experiences of another” and was not originally developed to distinguish between cognitive and affective empathy (Davis, 1983). Although the IRI has been a valuable instrument, a number of concerns have been raised about the compatibility of its subscales with updated models of empathy. For example, IRI empathic concern imprecisely assumes empathy and sympathy are interchangeable constructs and primarily measures emotional reactions to the negative experiences of others rather than sharing specific affective states (Eisenberg and Strayer, 1987, Jolliffe and Farrington, 2004) (Decety, 2011). Furthermore, IRI personal distress assesses self-oriented feelings of anxiety rather than the other-oriented processes involved in sharing others׳ emotions (Batson et al., 1991, Jolliffe and Farrington, 2004). Thus, these subscales do not clearly map onto the core cognitive and affective empathic processes (Zaki and Ochsner, 2012).

Recently, Reniers and colleagues (2011) developed and validated the Questionnaire of Cognitive and Affective Empathy (QCAE) as a more comprehensive measure of cognitive and affective empathy. The QCAE was developed from a pool of items with the strongest face validity from several existing self-report measures of empathy and was refined through extensive psychometric analyses in a large healthy sample. The subscales demonstrated good reliability, as well as strong convergent and divergent validity with respect to relevant interpersonal and personality variables. Although the authors suggest that the QCAE may help clarify empathic disturbances in various forms of psychopathology, we are unaware of any studies that evaluated this scale in a clinical sample.

The current study evaluated cognitive and affective empathy in schizophrenia and healthy comparison subjects using the QCAE. There were three main aims for this study. First, we evaluated the reliability of the QCAE subscales and their relations to the IRI subscales within each group. Second, we examined whether the schizophrenia and healthy comparison groups differed on the QCAE subscales; existing literature led us to predict lower cognitive empathy subscale scores in the schizophrenia group but did not indicate a clear prediction for affective empathy. Third, we examined whether cognitive and affective empathy contributed incremental variance to social functioning after accounting for symptoms and neurocognitive functioning. Based on our prior work (Smith et al., 2012, Smith et al., 2014a), we hypothesized that cognitive, but not affective, empathy would explain unique variance in social functioning.

Section snippets

Subjects

The study included 52 individuals, aged 18–55, with a DSM-IV diagnosis of schizophrenia and 37 healthy comparison subjects. Schizophrenia subjects were recruited through the Northwestern University Schizophrenia Research Group and local community outpatient mental health service providers. Psychiatric history was assessed using the Structured Clinical Interview for the DSM-IV (SCID-IV) (First et al., 2002), which was administered by a Masters or Ph.D.-level researcher. Final consensus-based

Subject characteristics

Schizophrenia and healthy comparison subjects did not differ with respect to age, gender, race, and parental socioeconomic status (Barratt, 2005) (Table 1). As anticipated, schizophrenia subjects had lower global neurocognitive and social functioning, and higher symptom ratings than healthy comparison subjects.

Internal consistency

For healthy comparison subjects, internal consistency estimates were good for the QCAE subscales (ranging from α=0.75 to α=0.91) with the exception of a lower alpha for peripheral

Discussion

The main study findings were (1) the QCAE demonstrated generally good reliability and patterns of inter-correlation, with the exception of peripheral responsivity; (2) the QCAE and IRI showed somewhat different patterns of inter-correlation in the healthy comparison and schizophrenia groups; (3) schizophrenia subjects reported diminished cognitive empathy, particularly on the online simulation subscale, and a variable pattern of intact and abnormal scores on the affective empathy subscales; and

Acknowledgments

We would like to acknowledge the research staff at the Northwestern University Schizophrenia Research Group for study coordination and data collection, and our participants for volunteering their time. This work was funded by the Department of Psychiatry and Behavioral Sciences at Northwestern University Feinberg School of Medicine. Additional support for this study was provided by Warren Wright Adolescent Center at Northwestern Medicine's Stone Institute of Psychiatry.

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