Background
Trait empathy is integral to relationship development and maintenance. Therefore, impairment in this ability can have an adverse effect on many domains of life including social, sexual, and marital. Previous reviews show in schizophrenia, this ability to be impaired but with a high amount of heterogeneity that is yet to be explored more thoroughly.
Aim and method
Considering this, we aim to synthesise the extent literature using a meta-analytic approach and examine the source of the heterogeneity observed in previous reviews and develop taxonomy of empathy deficits in schizophrenia. Hedges’ g was calculated for cognitive and affective empathy using random effects models. Meta-regression models of key cognitive, clinical and demographic risk and protective factors were run. These included: Impact year of publication, age, gender, ethnicity, education, general IQ, verbal/pre-morbid IQ, global neuro-cognition, positive, negative and general symptoms of schizophrenia, age at schizophrenia diagnosis, duration of illness and medication has on cognitive and affective empathy.
Results
A literature search revealed 39 independent studies examining empathy in schizophrenia. Healthy controls scored higher than people with a diagnosis of schizophrenia, with a small effect size for affective empathy (Hedges’ g = 0.29) and a medium effect size for cognitive empathy (Hedges’ g = 0.53). Both components were heterogeneous. Analyses using meta-regression models found age at diagnosis and the duration of illness moderated the difference in effect size for cognitive empathy, such that those with an earlier diagnosis or a more chronic course exhibit greater difficulty in cognitive empathy compared to healthy controls.
Conclusion
We find a longer duration of illness and younger age at clinical diagnosis enhances impairments in cognitive empathy in severe and enduring schizophrenia. For affective empathy, we conclude, compared to healthy controls, some patients report having a deficit [i.e. experience lower affective empathy], others report comparable levels, and the remaining report to be experiencing higher emotional arousal. As an earlier diagnosis, prolonged illness course and dysfunctional emotional reactions are significant risk factors of poorer empathic interactions, it will be important to address the underlying mechanisms of this deficit in future work.
Citation (K = 39) |
Country (City) |
SSD N |
HC N |
% Patients in study with a Schizophrenia Diagnosis |
M Age |
M Age HC |
% Male |
% Male |
M Years in Education |
M Years |
% Ethnicity |
% Ethnicity |
Achim, et al., [10] |
Canada (Québec) |
31 |
31 |
74.2 |
24.9 |
25.2 |
83.9 |
83.8 |
|
|
|
|
Andrews, et al., [87] |
Australia (Victoria) |
18 |
18 |
61.1 |
44.1 |
38.4 |
61.1 |
44.4 |
13.3 |
15.6 |
|
|
Berrada-Baby, et al., [88] |
France (Versailles) |
20 |
20 |
100 |
46.3 |
41.5 |
54.0 |
54.0 |
12.2 |
12.5 |
|
|
Brown, et al., [24] |
USA (Baltimore) |
17 |
17 |
100 |
41.7 |
38.2 |
52.9 |
52.9 |
|
|
|
|
Chiang, et al., [68] |
Taiwan (Hualien County) |
70 |
35 |
100 |
44.5 |
46.0 |
47.1 |
48.0 |
10.9 |
13.0 |
|
|
Corbera, et al., [58] |
USA (New Haven) |
30 |
24 |
66.7 |
46.5 |
39.7 |
46.7 |
62.5 |
13.1 |
16.2 |
43.3-Caucasian 56.5 - Non- Caucasian |
54.2-Caucasian 45.8 - |
Corbera, et al., [50] |
USA (New Haven) |
21 |
26 |
100 |
32.2 |
30.1 |
61.9 |
57.7 |
14.9 |
14.9 |
45.0 -Caucasian 55.0-Non- Caucasian |
42.3-Caucasian 57.7 - Non- Caucasian |
Derntl, et al., (2012a) t[44] |
Germany (Aachen) |
15 |
15 |
100 |
34.2 |
30.4 |
66.7 |
66.7 |
|
|
100-Caucasian |
100-Caucasian |
Derntl, et al., [70] |
Germany (Aachen) |
24 |
24 |
100 |
40.1 |
39.9 |
50 |
50.0 |
|
|
100-Caucasian |
100-Caucasian |
Didehnani, et al., [75] |
USA (Dallas) |
19 |
21 |
63.2 |
32.4 |
27.1 |
88.5 |
|
12.6 |
14.6 |
|
|
Fischer-Shofty, et al., [25] |
Israel (Haifa) |
35 |
48 |
100 |
|
30.0 |
|
69.9 |
12.2 |
15.0 |
100-Non-Caucasian |
100-Non -Caucasian |
Fujino, et al., [39] |
Japan (Kyoto) |
69 |
69 |
100 |
36.6 |
24.2 |
57.9 |
57.9 |
13.9 |
14.5 |
|
|
Fujiwara, et al [40] |
Japan (Kyoto) |
24 |
20 |
100 |
37 |
34.6 |
50 |
50.0 |
13.7 |
14.3 |
|
|
Gizewski, et al., [26] |
Germany (Essen) |
12 |
12 |
100 |
37.8 |
36.6 |
100 |
100 |
9.3 |
9.8 |
|
|
Haker, et al., [65] |
Switzerland (Zurich) |
43 |
45 |
100 |
34 |
35.0 |
39.5 |
73.0 |
13 |
14.0 |
|
|
Hooker, et al., [23] |
USA (Berkeley/San Francisco) |
21 |
17 |
52 |
44.3 |
43.7 |
80.9 |
76.4 |
13.0 |
15.0 |
|
|
Horon, et al., [51] |
USA (Los Angeles) |
32 |
26 |
100 |
47.9 |
44.4 |
81.3 |
73.1 |
12.9 |
14.9 |
56.3 -Caucasian |
76.0 -Caucasian |
Horon, et al., [27] |
USA (Los Angeles and Chapel Hill) |
145 |
45 |
100 |
40.9 |
43.3 |
75 |
71.0 |
12.5 |
14.2 |
48.3-Caucasian 51.7-Non-Caucasian |
31.0 -Caucasian |
Kucharska-Pietura, et al., [61] |
Poland (Lublin) |
100 |
50 |
100 |
31.3 |
29.6 |
|
|
12.8 |
13.7 |
|
|
Lam, et al., [36] |
China (Hong Kong) |
58 |
61 |
100 |
40.1 |
41.3 |
50 |
50.8 |
10.4 |
11.3 |
100-Non- Caucasian |
100-Non-Caucasian |
Lee, et al., [28] |
South Korea (Seoul) |
15 |
18 |
100 |
26.0 |
25.8 |
46.6 |
50.0 |
15.1 |
15.4 |
|
|
Lee, et al., [69] |
USA (Los Angeles) |
30 |
22 |
100 |
46.1 |
44.3 |
83.3 |
77.2 |
12.8 |
14.7 |
|
|
Lehmann, et al., [29] |
Germany (Berlin) |
55 |
55 |
100 |
39.8 |
38.9 |
58.1 |
54.5 |
14.0 |
15.0 |
|
|
Matsumoto, et al., [30] |
Japan (Kyoto) |
17 |
18 |
100 |
40.0 |
35.0 |
35.0 |
66.6 |
|
|
|
|
McCormick, et al., [48] |
USA (Iowa City) |
16 |
16 |
88 |
37.0 |
36.6 |
88 |
87.5 |
13.9 |
15.4 |
|
|
McGuire, et al., [31] |
Australia (Sydney) |
24 |
20 |
83 |
46.6 |
38.6 |
|
|
|
|
|
|
McGuire, et al., [74] |
Australia (Sydney) |
45 |
27 |
|
43.7 |
40.7 |
82.2 |
62.9 |
|
|
|
|
Montag, et al., [42] |
Germany (Berlin) |
45 |
45 |
100 |
37.5 |
38.8 |
77.7 |
77.7 |
12.6 |
15.0 |
|
|
Montag, et al., [58] |
Germany (Berlin) |
145 |
145 |
97 |
36.9 |
37.2 |
62.7 |
54.4 |
13.0 |
15.1 |
100-Caucasian |
100-Caucasian |
Pijnenborg, et al., [60] |
The Netherlands (Groningen) |
46 |
53 |
100 |
27.4 |
31.1 |
73.0 |
46.0 |
|
|
|
|
Ramos-Loyo, et al., [62] |
Mexico (Guadalajara) |
38 |
38 |
100 |
36.1 |
34.2 |
47.3 |
47.3 |
13.1 |
13.8 |
|
|
Regenbogen, et al., [43] |
Germany (Aachen) |
20 |
24 |
100 |
37.3 |
35.2 |
54.1 |
65.0 |
11.5 |
12.3
|
|
|
Smith, et al., [47] |
USA (Chicago) |
45 |
60 |
100 |
35.3 |
33.0 |
63.3 |
53.3 |
|
|
43.3- Caucasian 56.7 - Non-Caucasian |
48.9- Caucasian 51.1 - Non-Caucasian |
Singh, et al., [32] |
India (New Delhi) |
14 |
14 |
100 |
31.5 |
27.2 |
78.5 |
71.4 |
9.6 |
11.3 |
100-Non-Caucasian |
100-Non-Caucasian |
Shamay-Tsoory, et al., [37] |
Israel (Haifa) |
26 |
31 |
100 |
|
26.6 |
69.2 |
51.6 |
|
|
|
|
Sparks, et al., [46] |
Australia (Sydney) |
28 |
25 |
89 |
45.9 |
35.7 |
57.1 |
40.0 |
13.2 |
16.7 |
|
|
Thirioux, et al., [35] |
France (Paris) |
10 |
10 |
100 |
33.3 |
32.5 |
100 |
100 |
11.8 |
|
|
|
Vistoli, et al., [59] |
Canada (Québec) |
27 |
21 |
67 |
29.7 |
29.2 |
85.1 |
80.9 |
|
|
|
|
Wojakiewicz, et al., [33] |
France (Paris) |
29 |
27 |
100 |
36.5 |
31.0 |
68.9 |
74.0 |
10.3 |
10.5 |
|
|
Country (City) |
M Age at Diagnosis |
M Duration of Illness |
M Medication Dosage (Chlorpromazine equivalents) – mg/day |
M Positive Symptom Severity Score |
M Negative Symptom Severity |
M General |
|
Achim, et al., [10] |
Canada (Québec) |
- |
1.7 |
- |
15.1 |
16.0 |
32.0 |
Andrews, et al., t[87] |
Australia (Victoria) |
21.4 |
21.1 |
- |
- |
- |
- |
Berrada-Baby, et al., [88] |
France (Versailles) |
- |
- |
406.0 |
- |
- |
- |
Brown, et al., [24] |
USA (Baltimore) |
30.5 |
9.3 |
- |
19.1 |
24.9 |
45.4 |
Corbera, et al., [58] |
USA (New Haven) |
24.3 |
22.2 |
654.0 |
18.9 |
N - 17.0 |
30.2 |
Corbera, et al., [50] |
USA (New Haven) |
- |
- |
181.3 |
15.2 |
15.2 |
29.2 |
Derntl, et al., [44] |
Germany (Aachen) |
26.8 |
7.3 |
329.9 |
12.3 |
14.6 |
24.5 |
Derntl, et al., [70] |
Germany (Aachen) |
28.9 |
11.5 |
601.4 |
14.0 |
14.2 |
28.9 |
Didehnani, et al., [75] |
USA (Dallas) |
- |
- |
- |
18.9 |
16.5 |
37.1 |
Fischer-Shofty, et al., [25] |
Israel (Haifa) |
- |
11.8 |
- |
15.4 |
19.3
|
34.5
|
Fujino, et al., [39] |
Japan (Kyoto) |
24.2 |
13.1 |
- |
14.2 |
15.9 |
31.4 |
Fujiwara, et al., [40] |
Japan (Kyoto) |
26.9 |
10.4 |
- |
14.3 |
13.9 |
32.7 |
Gizewski, et al., [26] |
Germany (Essen) |
21.0 |
16.8 |
672.3 |
14.6 |
20.5 |
31.9 |
Haker, et al., [65] |
Switzerland (Zurich) |
24.0 |
11.0 |
297.0 |
12.2 |
14.6 |
26.3 |
Hooker, et al., [23] |
USA (Berkeley/San Francisco) |
- |
24.5 |
- |
11.7 |
16.5 |
- |
Horon, et al., [51] |
USA (Los Angeles) |
20.8 |
26.8 |
282.5 |
1.5 |
1.7 |
- |
Horon, et al., [27] |
USA (Los Angeles and Chapel Hill) |
21.0 |
20.0 |
- |
2.5 |
2.1 |
- |
Kucharska-Pietura, et al., [67] |
Poland (Lublin) |
- |
8.6 |
408.1 |
39.4 |
59.8 |
- |
Lam, et al., [36] |
China (Hong Kong) |
25.9 |
13.4 |
- |
9.7 |
13.3 |
20.6 |
Lee, et al., [28] |
South Korea (Seoul) |
21.7 |
4.6 |
422.1 |
13.1 |
15.4 |
30.6 |
Lee, et al., [68] |
USA (Los Angeles) |
- |
- |
- |
5.9 |
5.3 |
- |
Lehmann, et al., [29] |
Germany (Berlin) |
29.8 |
10.0 |
407.8 |
13.2 |
15.9 |
- |
Matsumoto, et al., [30] |
Japan (Kyoto) |
- |
15.2 |
- |
16.1 |
6.6 |
10.6 |
McCormick, et al., [48] |
USA (Iowa City) |
20.7 |
15.8 |
- |
4.6 |
9.2 |
- |
McGuire, et al., [31] |
Australia (Sydney) |
22.5 |
22.7 |
- |
1.3 |
2.1 |
- |
McGuire, et al., [74] |
Australia (Sydney) |
21.6 |
21.80 |
- |
1.7 |
2.1 |
- |
Montag, et al., [42] |
Germany (Berlin) |
25.8 |
11.6 |
- |
19.7 |
19.7 |
- |
Montag, et al., [58] |
Germany (Berlin) |
26.5 |
10.4 |
453.8 |
17.0 |
19.4 |
35.6 |
Pijnenborg, et al., [60] |
The Netherlands (Groningen) |
24.2 |
7.0 |
- |
12.8 |
15.3 |
29.2 |
Ramos-Loyo, et al., [62] |
Mexico (Guadalajara) |
- |
23.4 |
200.0 |
16.9 |
17.8 |
28.9 |
Regenbogen, et al., [43] |
Germany (Aachen) |
27.8 |
9.5 |
- |
14.2 |
23.1 |
- |
Smith, et al., [47] |
USA (Chicago) |
- |
14.4 |
360.9 |
0.6 |
0.6 |
- |
Singh, et al., [32] |
India (New Delhi) |
23.7 |
9.3 |
389.3 |
8.6 |
12.6 |
- |
Shamay-Tsoory, et al., [37] |
Israel (Haifa) |
- |
- |
- |
16.5 |
21.0 |
- |
Sparks, et al., [46] |
Australia (Sydney) |
- |
- |
300.9 |
38.8 |
39.3 |
-- |
Thirioux, et al., [35] |
France (Paris) |
- |
11.8 |
664.4 |
21.6 |
32.2 |
- |
Vistoli, et al., [59] |
Canada (Québec) |
- |
7.6 |
547.7 |
16.0 |
9.6 |
- |
Wojakiewicz, et al., [33] |
France (Paris) |
- |
8.0 |
- |
14.2 |
19.2 |
- |
|
M General IQ Score in SSD |
M General IQ Score in HC |
M Pre-morbid/Verbal IQ Score in SSD |
M Pre-morbid/Verbal IQ Score in HC |
M Global Neuro-cognition Score in SSD |
M Global Neuro-cognition Score in HC |
Achim, et al., [10] |
100.4 |
101.8 |
- |
- |
- |
- |
Berrada-Baby, et al., [87] |
- |
- |
26.5 |
28.9 |
- |
- |
Chiang, et al., [68] |
83.9 |
100.4 |
- |
- |
- |
- |
Corbera, et al., [58] |
- |
- |
- |
- |
39.6 |
52.0 |
Corbera, et al., [50] |
89.5 |
- |
- |
- |
32.1 |
32.0 |
Derntl, et al., t[44] |
- |
114.2 |
30.2 |
32.0 |
- |
- |
Derntl, et al., [70] |
- |
- |
107.7 |
111.3 |
- |
- |
Didehnani, et al., [75] |
102.2 |
112.1 |
- |
- |
- |
- |
Fujino, et al., [39] |
- |
- |
103.1 |
105.3 |
- |
- |
Fujiwara, et al., [40] |
104.0 |
109.0 |
104.0 |
107.0 |
- |
- |
Gizewski, et al., [26] |
- |
- |
102.2 |
109.8 |
- |
- |
Haker, et al., [65] |
- |
- |
24.4 |
33.1 |
16.8 |
22.5 |
Hooker, et al., [23] |
101.1 |
- |
- |
- |
-0.32 |
0.4 |
Kucharska-Pietura, et al., [61] |
- |
- |
- |
- |
24.4 |
37.4 |
Lam, et al., [36] |
34.9 |
49.8 |
- |
- |
16.6 |
20.4 |
Lee, et al., [28] |
- |
- |
11.4 |
12.7 |
14.5 |
10.4 |
Lehmann, et al., [29] |
- |
- |
108.5 |
118.8 |
25.0 |
21.9 |
Matsumoto, et al., [30] |
- |
- |
101.7 |
107.9 |
- |
- |
McGuire, et al., [31] |
- |
- |
105.6 |
107.7 |
35.1 |
37.5 |
McGuire, et al., [73] |
- |
- |
103.0 |
109.5 |
27.9 |
33.5 |
Montag, et al., [42] |
- |
- |
25.8 |
29.6 |
- |
- |
Montag, et al., [58] |
- |
- |
103.9 |
108.9 |
- |
- |
Pijnenborg, et al., [60] |
90.2 |
103.4 |
41.9 |
52.1 |
36.3 |
31.3 |
Regenbogen, et al., [43] |
- |
|
71.4 |
82.1 |
22.3 |
17.7 |
Smith, et al., [47] |
- |
- |
- |
- |
0.32 |
0.4 |
Sparks. et al., [46] |
- |
- |
104.9 |
110.0 |
- |
- |
Thirioux, et al., [35] |
- |
- |
- |
- |
- |
- |
Vistoli, et al., [59] |
99.9 |
109.3 |
- |
- |
- |
- |
Wojakiewicz, et al., [33] |
90.3 |
93.6 |
- |
- |
-- |
- |
Table 3: Mean general IQ, pre-morbid/verbal IQ and global neuro cognitive scores for schizophrenia spectrum disorders and healthy controls coded from individual studies included in the meta-analysis.
Note: M = Mean. SSD = Schizophrenia Spectrum Disorder. HC = Healthy Controls. tSupplemental data was provided by authors.In this table, only studies for which was available is included. tSupplemental data was provided by authors.
|
Mean (SD)/Mean Percent (SD) |
Range |
K |
Sample Type |
|
|
|
Published Article |
94.9 |
- |
37 |
Poster (data from authors) |
5.1 |
- |
2 |
Year |
2012 |
2007-2017 |
39 |
SPD Sample Size |
37.9 (31.4) |
10-145 |
39 |
HC Sample Size |
33.2 (23.9) |
10-145 |
39 |
Location |
|
|
|
Europe |
33.3 |
- |
13 |
United States |
33.3 |
- |
13 |
Asia |
23.2 |
- |
9 |
Oceania |
10.3 |
- |
4 |
Table 4: Study characteristics of included studies in the meta-analysis.
|
Mean (SD)/Mean Percent (SD) |
Range |
K |
Diagnosis |
|
|
|
Schizophrenia |
93.2 (13.6) |
52.4-100 |
38 |
Shizo-affective |
4.65 (15.6) |
2.7-42.9 |
10 |
Other Psychoses |
1.86 (9.2) |
6.3-19.3 |
2 |
Age at Diagnosis |
24.6 (3.1) |
20.7-30.5 |
22 |
Duration of Schizophrenia |
13.5 (6.3) |
1.7-26.8 |
32 |
Symptom Severity |
|
|
|
Positive Symptoms |
13.9 (8.4) |
0.61-39.40 |
36 |
Negative Symptoms |
16.6 (10.9) |
0.66-59.80 |
36 |
General Symptoms |
31.0 (5.3) |
20.6-45.4 |
18 |
Medication Dosage (Chlorpromazine equivalents) - mg/day |
414.3 (38.02) |
162.1-642.3 |
18 |
|
Mean (SD)/Mean Percent (SD) |
Range |
K |
General IQ, Healthy Controls |
99.29 (19.6) |
49.8-14.2 |
9 |
General IQ, Schizophrenia Spectrum Disorder |
89.6 (20.4) |
34.9-04.0 |
10 |
Verbal/Pre-morbid IQ, Healthy Controls |
79.9 (40.7) |
12.7-18.8 |
15 |
Verbal/Pre-morbid IQ, Schizophrenia Spectrum Disorder |
74.9 (39.7) |
11.4-08.5 |
15 |
Global Neuro-cognition, Healthy Controls |
24.4 (15.03) |
0.43-52.1 |
13 |
Global Neuro-cognition, Schizophrenia Spectrum Disorder |
22.3 (12.6)
|
-0.32-39.5
|
13 |
Demographic variables |
Mean (SD)/Mean Percent (SD) |
Range |
K |
Age, Healthy Controls |
35.2 (5.9) |
24-46 |
39 |
Age, Schizophrenia Spectrum Disorders |
37.8 (6.1) |
25-48 |
38 |
Education, Healthy Controls |
14.0 (1.7) |
9.8-16.7 |
27 |
Education, Schizophrenia Spectrum Disorders |
12.5 (1.3) |
9.3-15.1 |
28 |
Male, Healthy Controls |
63.9 (15.2) |
40-100 |
36 |
Male, Schizophrenia Spectrum Disorder |
67.5 (15.6) |
47-100 |
36 |
Ethnicity, Healthy Controls |
Caucasian-69.1 (28.6) |
31-100 24-100 |
8 7 |
Ethnicity, Schizophrenia Spectrum Disorder |
Caucasian-67.0 (27.6) |
43.3-100 43.7-100 |
8 8 |
Table 7: Demographic characteristic of samples included in the meta-analysis.
Measures of Empathy |
Original Article |
Studies in Meta-Analysis |
Description of Tasks and Scores Produced |
Interpersonal Reactivity Index (IRI) |
[1] |
[2-35] |
A 28-item self-report scale including four sub-scales: Empathic Concern, Perspective-Taking, Personal Distress and Fantasy. The Empathic Concern sub-scale taps into ‘other-orientated’ feelings of sympathy and concern for unfortunate other. The Perspective-Taking sub-scale assesses the ability to see things from the others perspective or how the other person thinks. The Personal Distress sub-scale measures levels of anxiety, sorrow or emotional distress in emergency situations. The Fantasy sub-scale measures the ability to relate to fictional characters (e.g. books or movies). Items on these sub-scales are measured on a 5-point Likert-scale, with responses ranging between does not describe me well, to describes me very well |
Empathy Quotient (EQ) |
[36] |
[37] |
A 60-item self-report scale. 40 items measure empathy on the cognitive and affective dimension and the remaining are included as control items. Each response is measured on a 4-point Likert scale, with responses ranging between strongly agree-to-strongly disagree |
Questionnaire for Cognitive and Affective Empathy (QCAE) |
[38] |
[17,39] |
A 31-item self-report scale consisting of five sub-scales: Perspective-Taking and Online Stimulation, measuring cognitive empathy. Emotion Contagion, Proximal Responsivity and Peripheral Responsivitymeasuring affective empathy |
Balanced Emotional Empathy Scale (BEES) |
[40] |
[41] |
A 30-item self-report scale measuring spontaneous, or vicarious emotional reactions in response to another’s emotional distress (i.e. affective/emotional empathy). Each itemis rated on a 9-point extent to which you agree-disagree spectrum |
Questionnaire Measure of Emotional Empathy (QMEE) (also referred to as the emotional empathic tendency scale) |
[42] |
[43] |
A 33-item self-report scale assessing affective role-taking empathy. In other words, this scale measures the extent to which the respondent agrees with the self-orientated emotional responses someone would typically experience in response to another’s emotional distress. Items on this scale are measured on a 4-point Likert scale, ranging between strongly agree to strongly disagree |
Social context emotional recognition task |
[44] |
[44] |
In this task, participants watched short films representing a happy, sad, angry and fearful context. Participants rated their emotional reaction (affective empathy) to each film and the intensity of the emotion they felt using a rating scale. The rating scale consisted of a continuous 10 cm line on which participants had to make a mark: Scores to the extreme left corresponded to the lowest intensity (0 cm) and scores to the extreme right corresponded to the highest intensity |
Table S1: List of empathy measures used by studies included in the meta-analysis.
Symptom Assessment Measure |
Studies in meta-analysis |
Description of Measure |
Positive and Negative Syndrome Scale (PANSS) [45] |
[2-44] |
A 30-item semi-structured measure completed by clinicians in an interview or observation format. 7 items measure positive symptoms of schizophrenia, 7 items measure negative symptoms and 16 items measuresgeneral psychopathology |
Schedule for the ASSESSMENT of Positive Symptoms(SAPS) [46] |
[23-25,29,30,32,41] |
A 34-item clinician rated scale which is used to measure the followingpositive symptoms: Bizarre behaviour, formal thought disorder, hallucinations and delusions |
Schedule for the Assessment of Negative Symptoms (SANS) [47] |
[17,23-25,29,30,32,41] |
The originally published scale consisted of 25 items. Currently, SANS comprises of 19-items, representing 5 scales: Blunted/flattened affect, alogia, avolition-apathy, anhedonia/associability and inattention. Items on this scale are rated by clinicians |
Brief Psychiatric Rating Scale (BPRS)-positive symptom sub-scale [48] |
[16,17,20] |
A 24-item scale assessing positive symptoms of schizophrenia via self-report and clinical observations. Each item onthis scale is measured on a 2 (very mild) to 7 (extremely severe) anchor points |
BPRS-Negative symptom subs-cale [48] |
[16,20] |
This sub-scale consists of items assessing negative symptoms of schizophrenia and is measured in the same way as the BPRS-positive symptom sub-scale |
Table S2: List of symptom assessments used by studies included in the meta-analysis.
Neurocognitive Domain |
Neurocognitive Measures |
Description of Measure |
Studies in Meta-Analysis |
Attention/ Vigilance (reported by three studies) |
The test of everyday attention [49] |
This test included three tasks: |
[41] |
Continuous performance task-identical pairs [50] |
A computerised test assessing sustained attention. A button must be pressed each time the participant sees two numbers matching onscreen |
[6,29] |
|
2. Verbal learning (reported by six studies) |
Hopkins verbal learning test-revised [51] |
The task administrator presents 12 words from three categories (e.g. animal, colours and numbers). Participant is assessed on how many words they can recall after each of three learning trials |
[6,7,15] |
|
Rey auditory verbal learning test (english version) [52] |
Participants are presentedwith 15 words over five trials. Participants must say the words immediately. An interference trial is then presented which involved presenting new words. Participants are asked to recall words from the initial list presented |
[26,43] |
|
California verbal learning test-second edition [53]
|
Participants are presented with a list of 16 words which they recall immediately over five trials. This is followed by an interference list, in which 16 words are presented in a single trial which must be recalled immediately. 20 minutes later a recognition trial is administered. Recall can be free or category-cued |
[29] |
3a. Working Memory (verbal) (Reported by Five Studies) |
Wechsler memory scale-third edition (WMS-III): Letter-number span [54] |
Participants are instructed to mentally re-order strings of numbers and letters and repeat them orally to the test administrator |
[6,15,24,29] |
WAIS Digit Span Forward/Backwards Subtest [55] |
Participants are instructed to repeat the numbers presented to them either in the same or reverse order. Over the course of the task, the number sequence increases |
[29] |
|
Repeatable battery for the assessment of neuropsychological status-story memory sub-test [56] |
A 12-item short story is presented visually in three sperate parts over two trials. Each story is read aloud with a low reading speed. Participants recall as much of the story as they can after each presentation. A verbatim criterionis used to score participant response |
[25] |
|
3b. Working memory |
WAIS-Revised (R)-working memory subtest [57] |
This test uses an arithmetic and digit span test. For the digit span test, participant recalls a series of number in a specific order (i.e., ascending, backward or same order). For the arithmetic test, participants work within a specified time limit to mentally resolve a series of mental arithmetic problems |
[28] |
WMS-III: Spatial span [54] |
Participants are presented with 12 blocks on which a sequence is tapped by the administrator. Participants must tap the blocks in the order requested by the administer (either reverse or same order) |
[7,15,29] |
|
Short recognition memory test for faces [58] |
Participants are presented with 25 grey scale faces of male actors at a rate of 1 face every 3 seconds. Participants decide (using a forced choice option) whether the image presented is pleasant or unpleasant immediately post stimulus onset. Each stimulus item is paired with a distractor item |
[41] |
|
4. Speed of processing (reported by eight studies) |
Trail Making Test A (TMT A) [59] |
In this test, numbers a placed irregularly on a sheet of paper, which participants are instructed to join correctly? This is a timed pencil and paper test |
[6,15,28,29,43] |
|
Trail Making Test B (TMT B) [59] |
In part B, participants are presented with numbers and letters in random order, which they connect in alternating order |
[28,43] |
|
Brief Assessment of Cognition in Schizophrenia (BACS): Symbol coding [60] |
This is a timed test in which participants are required to write down the digit corresponding to nonsense symbols within 90 seconds |
[6,15] |
|
WAIS-III Digit symbol substitution sub-test [55] |
Participants are presented with a series of numbers and symbols in a grid. Participants reproduce symbolscorresponding to the numbers in the grid within a 120 second time limit |
[29] |
|
Category fluency-animal subtest [61] |
In this test, participants are instructed to generate exemplars of animals within 60 seconds. The total number of true animal exemplars within the time frame is measured |
[6,15,29] |
|
Five-point test [62] |
There are two parts to this test: Verbal and non-verbal. In the verbal test participants must make words that begin with a specific letter (e.g., “A”) within three minutes. Participants are instructed not to produce nouns or repeat words |
[14] |
|
Repeatable battery for the assessment of neuropsychological status-coding sub-set [63] |
A page filled with symbols is presented to participants. Each symbol corresponds to a number on top of the page. Participant must match the symbol to its corresponding number within 90 seconds |
[25] |
5. Cognitive flexibility (reported by Three studies) |
Stroop test [64] |
There are three sub-tests to this task: The colour word sub-test in which participants must read the colour of the word presented in black ink. The colour name sub-test, in which participants must name the colour of the triangle, and in the interference sub-test, participants ignore the word they see and say the colour of the word (e.g. if the word black is written in the colour red, then the correct answer would be red) |
[14,16] |
|
Delis-kaplan executive function scale-colour word interference sub-test [65] |
In this test, a participant must inhibit a dominant and automatic verbal response of a word presented, and instead, name the colour of the ink for the word presented |
[24] |
6. Reasoning and problem solving (reported by six studies) |
Tower of London Test [66] |
Participants are presented with coloured beads arranged vertically on pegs of different heights. How they must be arranged,andthe number of moves allowed is determined by the experimenter, which they (the participant) must follow in order to achieve a specific arrangement |
[21] |
|
Neuropsychological assessment battery: Mazes sub-test [67] |
Participants are presented with seven mazes, each increasing in difficulty. Participants complete each maze within a 300-second time limit |
[6,15] |
|
WAIS-III-Matrix reasoning sub-test [55] |
Participants are presented with different figures. Each figure must be analysed in order to determine whichfigurebest fits theorder of the sequence presented |
[29] |
|
Wisconsin card sorting test [68] |
Participants sort a series of cards by a specific rule (e.g. by colour, shape or number of shapes). Feedback on performance is provided. After ten correct sorts, the rules for sorting are changed to a new rule without warning |
[18,19] |
7. Visual learning (reported by three studies) |
Brief visuospatial memory test-revised [69] |
The instructor presents six geometric figures which participants reproduce from memory |
[6,15] |
|
The Judgement of Line Orientation test [70] |
Participants are presented with two angle lines. They are instructed to matchtheseto a set of 11 lines by re-arranging them so that all the lines are 18 degrees apart and form a semi-circle |
[21] |
Table S3: List of studies included in meta-analysis measuring neurocognition in schizophrenia and healthy controls.
Noncognitive Domain |
Neuro-cognitive Measures |
Description of Task |
Studies in Meta-Analysis |
Pre-morbid verbal IQ (reported by 13 studies) |
Multiple-choice vocabulary test (german version) [71] |
This measure presents 37 rows of five words. From each row participants pick the actual word and rule out the pseudo-words. The number of correctly identified words provides the test result |
[8,9,13,18,26-28] |
|
National adult reading test [72] |
This test comprises of 50 words with irregular spellings (e.g. aisle). Participants are assessed on their vocabulary comprehension rather than their ability to apply regular pronunciation rules |
[11,22,24,25,32,39] |
Verbal IQ (reported by two studies) |
WAIS-III- verbal subset [55] |
In this test, participants name the object in the picture or define the words presented to them |
[12,19] |
Table S4: List of the studies in the meta-analysis measuring verbal comprehension in schizophrenia and healthy controls.
Neuro-cognitive Domain |
Neurocognitive Measures |
Studies in Meta-Analysis |
Description of General IQ Tests |
General IQ (reported by 10 studies) |
Wechsler abbreviated adult intelligence scale [73] |
[12,15,37] |
The many versions of the Wechsler’s Adult Intelligence Scales measure a person’s ability to act purposefully, reason and deal effectively with his/her surrounding/environment [74]. This aim is fulfilled using several verbal ability and cognitive reasoning/style sub-tests (for a detailed description of each sub-test refer to Wechsler’s administration manual and scales [55,75,73,54,57] |
|
Wechsler Adult Intelligence Scale III [55] |
[2,5,7,35] |
|
Wechsler adult intelligence scale-IV [75] |
[34] |
|
|
Raven’s progressive matrices test [76] |
[21] |
This is a non-verbal group test designed to measure abstract reasoning |
|
Groninger Intelligence Test [77] |
[43] |
This test is used in the Netherlands as a reliable alternative to the Wechsler Adult Intelligence Tests. As such, this test includes examining the same cognitive and verbal abilities as the WAIS sub-tests [55] |
Table S5: List of studies in the meta-analysis that examined general IQ.
k |
B |
SE |
95% CI |
Z |
P |
I2 |
|
Age at Diagnosis |
20 |
-0.06 |
0.018 |
[-0.09, -0.02] |
-3.35 |
0.0008 |
28.70 |
Duration of Illness |
29 |
0.012 |
0.008 |
[0.001,0.03] |
2.11 |
0.03 |
30.55 |
Positive symptoms |
33 |
0.008 |
0.008 |
[-0.007,0.024] |
1.004 |
0.31 |
30.73 |
Negative Symptom severity |
33 |
0.004 |
0.007 |
[-0.009,0.01] |
0.67 |
0.50 |
30.04 |
General Symptom Severity |
15 |
0.01 |
0.01 |
[-0.01,0.03] |
1.06 |
0.28 |
5.04 |
CPZ-Equivalent -mg/day |
16 |
-0.0005 |
0.0006 |
[-0.001,0.0008] |
-0.77 |
0.43 |
13.50 |
Table S6: Moderating effect of clinical characteristics on the difference in performance between schizophrenia patients and healthy controls on cognitive empathy.
Note: K = Number of studies. B = regression coefficient. SE = standard error. 95% CI = 95% confidence interval. Z = indicates the extent of uncertainty in the regression coefficient. p = statistical significance, 2-tailed. I2 indicates the amount of between-study heterogeneity. CPZ-equivalent-mg/day = Chlorpromazine Equivalent, milligram per day.
Affective Empathy |
k |
B |
SE |
95% CI |
Z |
P |
I2 |
General IQ, Schizophrenia Spectrum Disorders |
9 |
0.003 |
0.003 |
[-0.002,0.010] |
1.12 |
0.25 |
4.98 |
Verbal IQ, Schizophrenia Spectrum Disorders |
15 |
0.0001 |
0.002 |
[-0.005,0.005] |
0.04 |
0.96 |
12.51 |
Global Neuro-cognition, Schizophrenia Spectrum Disorder |
11 |
-0.004 |
0.008 |
[-0.020,0.012] |
-0.52 |
0.60 |
6.54 |
Affective Empathy |
k |
B |
SE |
95% CI |
Z |
P |
I2 |
Age, Schizophrenia spectrum |
35 |
0.007 |
0.009 |
[-0.01,0.02] |
0.79 |
0.42 |
32.38 |
Lower Education in Schizophrenia compared to Healthy Controls |
21 |
-0.04 |
0.05 |
[-0.15,0.06] |
-0.75 |
0.45 |
18.47 |
Higher Proportion of Male Schizophreniathen Female Schizophrenia |
28 |
0.003 |
0.005 |
[-0.006, 0.01] |
0.71 |
0.47 |
26.14 |
Higher Proportion of Non-Caucasian Schizophrenia then Caucasian Schizophrenia |
7 |
-0.0004 |
0.006 |
[-0.01,0.01] |
0-0.06 |
0.94 |
5.05 |
Year of Study Publication |
36 |
-0.02 |
0.02 |
[-0.06,0.02] |
-1.009 |
0.31 |
33.49 |
Affective Empathy |
k |
B |
SE |
95% CI |
Z |
P |
I2 |
Age at Diagnosis |
21 |
-0.02 |
0.02 |
[-0.08, 0.02] |
-1.01 |
0.31 |
23.26 |
Duration of Illness |
32 |
0.007 |
0.01 |
[-0.01,0.02] |
0.68 |
0.49 |
33.15 |
Severity of Positive Symptom |
36 |
0.012 |
0.007 |
[-0.001,0.02] |
1.68 |
0.09 |
39.85 |
Severity of Negative Symptoms |
36 |
0.007 |
0.005 |
[-0.002,0.01] |
1.52 |
0.12 |
39.60 |
Severity of General symptom |
17 |
-0.004 |
0.01 |
[-0.03,0.02] |
-0.30 |
0.76 |
16.32 |
CPZ-Equivalent Mg/Day |
18 |
-0.00015 |
0.0006 |
[-0.001,0.001] |
-0.24 |
0.80 |
4.97 |
Affective Empathy |
k |
B |
SE |
95% CI |
Z |
P |
I2 |
General IQ, Schizophrenia |
10 |
-0.0005 |
0.003 |
[-0.007,0.005] |
-0.17 |
0.85 |
54.02 |
Pre-morbid/Verbal IQ, Schizophrenia |
15 |
-0.00009 |
0.002 |
[-0.005,0.005] |
-0.03 |
0.97 |
14.22 |
Global Neuro-cognition, Schizophrenia |
13 |
-0.005 |
0.005 |
[-0.016,0.005] |
-1.03 |
0.29 |
7.01 |
Affective Empathy |
k |
B |
SE |
95% CI |
Z |
P |
I2 |
Age, Schizophrenia |
36 |
0.01 |
0.01 |
[-0.005,0.03] |
1.43 |
0.15 |
39.60 |
Fewer Years in Education in Schizophrenia compared to Healthy Controls |
23 |
-0.04 |
0.07 |
[-0.19,0.10] |
-0.55 |
0.57 |
25.46 |
Higher Proportion of Male Schizophrenia then Female Schizophrenia |
29 |
-0.001 |
0.006 |
[-0.01,0.01] |
-0.30 |
0.76 |
31.43 |
Higher Proportion of Non-Caucasian Schizophrenia compared to Caucasian Patients |
7 |
0.005 |
0.007 |
[-0.009,0.021 |
0.74 |
0.45 |
5.28 |
Year of Study Publication |
39 |
-0.04 |
0.02 |
[-0.09,0.008] |
-1.65 |
0.09 |
41.16 |
Citation: Varachhia S, Ferguson E, Doody GA (2018) A Meta-Analysis Taxonomizing Empathy in Schizophrenia. J Psychiatry Depress Anxiety 4: 016.
Copyright: © 2018 Sumayyah Varachhia, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.