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Introduction
Correctly interpreting social information is a crucial part of successful interpersonal interaction. This requires synthesis of a broad range of verbal and nonverbal cues, including facial expressions, prosody in speech, body language, and the mental states of others (i.e. theory of mind). Together, these skills are referred to as social cognition and are an important domain of cognitive functioning. Social cognition encompasses the identification, perception, and interpretation of socially important information (Kandalaft et al., 2012), wherein theory of mind specifically refers to the ability to infer information regarding the thoughts, intentions, and feelings of others (Wolkenstein, Schonenberg, Schirm, & Hautzinger, 2011).
Social cognitive impairment is widely recognized to be a key feature of several psychiatric diseases, such as schizophrenia (Kandalaft et al., 2012) and autism (Holdnack, Goldstein, & Drozdick, 2011). The impact of depressive symptoms on social cognition is less well understood, although there is some evidence to suggest that a similar, albeit less severe, impairment of social cognition may be seen in patients with major depressive disorder. Whilst major depressive disorder is primarily characterized by emotional symptoms such as low mood and anhedonia (DSM-5; American Psychiatric Association, 2013), individuals with major depressive disorder have also been found to display profound and pervasive impairments in their interpersonal interactions (Tse & Bond, 2004). Nevertheless, patients with major depressive disorder appear to be less severely impaired in social cognition than patients with schizophrenia or autism (Bazin et al., 2009; Wang, Wang, Chen, Zhu, & Wang, 2008; Weniger, Lange, Ruther, & Irle, 2004).
The majority of data from previous reviews investigating the relationship between major depressive disorder and social cognition relates primarily to the domain of facial affect. One meta-analysis of eight studies found major depressive disorder to be significantly associated with impaired recognition of emotional facial expressions with a moderate overall effect size (Demenescu, Kortekaas, Den Boer, & Aleman, 2010). A larger review indicated a reasonably consistent pattern of a negative interpretive bias of facial affect (Bourke, Douglas, & Porter, 2010), potentially explaining the group difference in the meta-analysis. It appears that patients with major depressive disorder may not exhibit diminished recognition accuracy when interpreting facial expressions, but rather demonstrate an increased sensitivity toward sad expressions rather than happy ones. Other reviews have indicated that such abnormalities appear to respond to antidepressant therapy, and may actually be detectable prior to improvements in mood (Harmer, Goodwin, & Cowen, 2009; Venn, Watson, Gallagher, & Young, 2006). However, no similar comprehensive review of behavioral studies has been conducted in the domains of prosody, body language, and theory of mind to determine whether these findings translate across all components of social cognition in major depressive disorder.
In addition to the available behavioral data, there is also a significant body of literature that exists on functional neuroimaging in patients with major depressive disorder undergoing social cognitive testing. Much of this literature indicates a neural basis for the observed phenomenology, primarily centering around dysregulation of both the amygdala and ventromedial frontal cortex (Elliott, Zahn, Deakin, & Anderson, 2011; Leppänen, 2006; Phillips, Drevets, Rauch, & Lane, 2003; Stuhrmann, Suslow, & Dannlowski, 2011). Functional changes provide a basis for evaluating to what extent altered processing of social stimuli may impact the quality of life and/or interpersonal success of an individual with major depressive disorder.
Identifying the role and impact of impairments in social cognition in major depressive disorder is important to further characterizing the phenotype of the disease. Moreover, improvements in social cognition would have significant therapeutic implications for individuals with brain disorders, notably major depressive disorder, as previous reviews have suggested that impairments in social cognition may be reversible in this clinical population (Harmer et al., 2009; Venn et al., 2006). Taken together, it is a testable hypothesis that improvement in social cognition may represent a useful and targetable method of monitoring improvement in individuals with major depressive disorder.
The present chapter on social cognition and major depressive disorder aims to increase the understanding of (1) the impact of depressed mood on different domains of social cognition including facial affect, prosody, body language, and theory of mind, (2) the clinical presentation of social cognition in acute and remitted depressive states, and (3) the effect of depression severity on social cognitive performance.
Social cognition: facial affect recognition and theory of mind in major depressive disorder
The literature remains equivocal regarding overall differences in social cognitive performance between depressed and healthy cohorts. While there is some evidence to suggest that subjects with major depressive disorder may demonstrate poorer overall social cognitive performance compared with healthy controls, numerous authors found no group difference on a gross measure of social cognition. This is further discussed below according to the domains of facial affect recognition and theory of mind.
Facial affect recognition
The way in which patients with major depressive disorder respond to emotional facial expressions can be broadly categorized according to emotional valence. Results documenting the response of individuals with major depressive disorder to neutral facial expressions have been mixed; however, some reports suggest that depressed patients assign more negative interpretations to negatively valenced facial expressions when compared with healthy controls (Anderson et al., 2011; Csukly, Czobor, Szily, Takács, & Simon, 2009; Gollan, Pane, McCloskey, & Coccaro, 2008; Leppänen, Milders, Bell, Terriere, & Hietanen, 2004). For example, individuals with major depressive disorder have been reported to exhibit negatively valenced interpretations of neutral stimuli wherein subjects reported neutral stimuli as being sad (Anderson et al., 2011; Gollan, McCloskey, Hoxha, & Coccaro, 2010; Gollan et al., 2008; Milders, Bell, Platt, Serrano, & Runcie, 2010), disgusted (Surguladze et al., 2010), and/or fearful (Bhagwagar, Cowen, Goodwin, & Harmer, 2004; Surguladze et al., 2010). In a large case-control study of 230 participants, Anderson et al. (2011) noted a significant bias toward the identification of negative emotions, namely anger and sadness, by those with a current or past history of depression in comparison to control participants. In two smaller case-control studies involving 66 and 36 participants respectively, Gollan et al. (2008) and Leppänen et al. (2004) found depressed participants identified more neutral expressions as sad than their non-depressed counterparts. Further case-control studies of similar size by Csukly et al. (2009) also found a significant reduction in the accuracy of neutral expression recognition by the depressed patient group, although these patients were also noted to have a decreased recognition of sadness (p = 0.05).
Studies examining the interpretation of positively valenced expressions – such as happiness – in a depressed population show an even greater discrepancy between results. There is some evidence to suggest that patients with major depressive disorder are less likely than healthy controls to correctly identify positive emotions (Csukly et al., 2011; Surguladze et al., 2004) and may demonstrate superiority when identifying negative emotions (Szily & Keri, 2009; Wolkenstein et al., 2011); however, this is far from a consistent finding. In a case-control study of 130 inpatients, Csukly et al. (2011) found a significant negative association between recognition of happy expressions and presence of a maladaptive schema; however, no other associations of significance were found with any of the other studied emotions – including sadness. A similar study involving 56 inpatients by Surguladze et al. (2004) also demonstrated a link between depression severity and difficulty recognizing happy expressions, but in contrast observed an even greater impairment in recognition of negative emotions. Further research by both Szily and Keri (2009) and Wolkenstein et al. (2011) suggested that depressed patients were in fact more accurate than matched controls in identifying negative emotion, without any difference in neutral and positive emotion recognition.
Another important factor in social cognitive performance is the ability to detect subtle expressions of facial emotion. Several smaller case-control studies (44–66 participants) incorporated variation of intensity into the assessment of facial affect recognition. Patients with major depressive disorder were identified as more likely to incorrectly label low-intensity facial expressions than controls (Csukly et al., 2009), or to misattribute the expression as being of a higher intensity (Csukly et al., 2009; Gollan et al., 2008). Furthermore, depressed patients were found to require a greater intensity of emotion than their non-depressed counterparts to identify happy expressions (Joormann & Gotlib, 2006; LeMoult, Joormann, Sherdell, Wright, & Gotlib, 2009) and less intensity to identify sad expressions (Gollan et al., 2010; Joormann & Gotlib, 2006; Milders et al., 2010). Although the different research groups used a variety of different assessment tools, the degree of expression intensity may represent an important trend emerging within the body of literature.
Many studies incorporated assessment of reaction time, in addition to accuracy for facial affect recognition. Several case-control studies showed individuals with major depressive disorder to have slower recognition of facial expressions than healthy controls (Leppänen et al., 2004; Surguladze et al., 2004) and depressed patients with comorbid anxiety to be slower in recognizing positive faces than both controls and non-anxious depressed (Suslow et al., 2004). In a moderately sized case-control study, depressed patients were found to be significantly poorer at recognizing facial expressions when presented with an affective stimulus for 100 ms, but equal to healthy controls when the time of stimulus was increased to 2,000 ms (Surguladze et al., 2004). In contrast, reaction times were increased in some studies when depressed patients were confronted with sad (Gollan et al., 2008) or neutral (Leppänen et al., 2004; Suslow et al., 2004) expressions. However, these represented a minority of results, with the larger portion of investigators reporting no difference in reaction time (Anderson et al., 2011; Langenecker et al., 2005; Matthews, Strigo, Simmons, Yang, & Paulus, 2008; Suslow et al., 2010; Wolkenstein et al., 2011).
There was little data available regarding the way in which patients with major depressive disorder react to emotional stimuli differently to non-depressed people. One group of researchers observed that depressed individuals demonstrate more avoidant behavior on an implicit joystick task when confronted by both negative and positive emotional stimuli, even when this information was correctly interpreted by the participant (Derntl et al., 2011; Seidel et al., 2010). However, both these studies involved small numbers of participants (30 and 48, respectively) and only looked at instinctive reaction to facial expression without investigation of functional implications.
Theory of mind
Theory of mind specifically refers to the ability to infer information regarding the thoughts, intentions, and feelings of others (Wolkenstein et al., 2011). Various tools based on theory of mind have been administered by researchers in their assessment of possible social cognitive impairments in patients with major depressive disorder. Indeed, preliminary evidence suggests that patients with major depressive disorder have difficulties with inferring emotional information (e.g. intentions, thoughts, feelings) in comparison with healthy controls. In a case-control study involving 60 patients, Zobel et al. (2010) reported that depressed patients exhibited impairments while performing classical theory of mind tasks of interpreting both first- and second-order questions relating to social interactions. Furthermore, separate case-control studies by Cao et al. (2013) and Wang et al. (2008) observed that individuals with major depressive disorder displayed deficits in theory of mind; more specifically, identifying social faux pas. However, both Cao et al. (2013) and Wang et al. (2008) included depressed patients with psychoses as a third subgroup (as well as non-psychotic depressed patients and healthy controls). Taken together, the interpretations of these findings remain unclear. Patients with major depressive disorder exhibit poor emotional awareness and ability to distinguish what others are thinking when compared with controls notwithstanding insight into their own emotional state (Donges et al., 2005). This is also manifest as a difficulty in showing empathy for how others are feeling (Wilbertz, Brakemeier, Zobel, Harter, & Schramm, 2010).
On the other hand, there were also a number of studies that found little difference in theory of mind performance between the depressed and non-depressed. Wolkenstein et al. (2011) found depressed patients to have difficulty integrating contextual information about other people or sequences of events, but were unable to identify any other significant theory of mind deficit. Three other small case-control studies found depressed and healthy participants to have similar outcomes in their assessments (Bazin et al., 2009; Bertoux et al., 2012; Wilbertz et al., 2010) (Table 8.1).
Case-control studies investigating differences in social cognitive performance between patients with major depressive disorder and controls
| Author | Aim | Method | N [MA ± SD; M:F] | Social cognition task | Mood diagnosis | Results |
|---|---|---|---|---|---|---|
| Section 1.1 Studies indicating significant differences between acutely depressed individuals and healthy controls | ||||||
| Anderson et al., 2011 | To compare accuracy, discrimination, and bias in face recognition in current and remitted depression | Case-control GP sample | MDE = 30, rMDD = 99, HC = 101 [33.1 ± 10.5; 71M:159F] | FERT | DSM-IV | Significant difference between MDE, rMDD, and HC groups on facial affect recognition accuracy (F2,225 = 5.340, P = 0.005) |
| Cao et al., 2013 | To investigate social cognitive performance in esophageal cancer patients with depression | Case-control Esophageal cancer patient sample | pMDD = 32, npMDD = 33, HC = 62 | RMET-R, FPT | BDI-II | Compared to HC, both MDD groups were impaired on facial affect recognition (t = 7.39, P < 0.01) and FPT (t = 13.75, P < 0.01) |
| Csukly et al., 2009 | To determine if depressed patients perceive emotion differently to controls and if this is due to emotional intensity and arousal | Case-control Clinical sample | MDD = 23, HC = 23 [48.4 ± 12.5; 18M:28F] | VHI | DSM-IV, ICD-10 | MDD impaired at recognizing facial expressions compared to HC (F46 = 6.76, P = 0.02), particularly at low intensity or arousal |
| Csukly et al., 2011 | To identify associations between depressive severity, maladaptive schemas, and facial affect recognition | Case-control Inpatient sample | MDD = 107, HC = 23 [41.1 ± 11.3; 16M:90F] | VHI | DSM-IV | MDD impaired at recognizing facial expressions compared to HC (t = 5.2, P < 0.0001) |
| Donges et al., 2005 | To examine emotional awareness in depressed inpatients following a psychotherapy program | Prospective longitudinal case-control Inpatient sample | MDD = 22, HC = 22 [32.1 ± 8.6; 14M:30F] | LEAS | DSM-IV | MDD performed inferiorly to HC at emotional awareness of others (F1,42 = 5.5, P < 0.05). Performance of the MDD group improved over the 7 weeks of treatment (F1,42 = 5.6, P < 0.05) |
| Harkness et al., 2011 | To determine if maternal history of depression impacts facial affect recognition performance | Case-control Outpatient sample | MDD = 61, HC = 30 [45.3 ± 14.5; 0M:91F] | RMET-R | DSM-IV | MDD performed significantly worse on RMET-R than HC (F1,91 = 6.73, P = 0.01) |
| Langenecker et al., 2005 | To evaluate emotion perception deficits in depressed women | Case-control Outpatient sample | MDD = 21, HC = 20 [30.9 ± 9.2; 0M:41F] | FEPT | BDI-II, HRSD | MDD performed inferiorly to HC in facial affect recognition accuracy (F1,38 = 6.40, P = 0.02) |
| Lee et al., 2005 | To examine depressed patients’ abilities to identify mental states from affective eye expressions | Case-control Outpatient sample | MDD = 52, HC = 30 [42.7 ± 14.1; 0M:82F] | RMET-R | DSM-IV | Severe MDD less accurate than HC on RMET-R (t65 = 2.24, P = 0.03); no difference between mild/moderate MDD and HC or MDD groups |
| Leppänen et al., 2004 | To determine if depression biases the recognition of emotionally neutral faces | Case-control Inpatient sample | MDD = 18, HC = 18 [44.9 ± 9.9; 14M:22F] | PFA | ICD-10 | MDD worse than HC in facial affect recognition accuracy (F1,34 = 9.1, P < 0.006), due to misidentification of neutral faces (t34 = 4.8, P < 0.001) |
| Surguladze et al., 2004 | To investigate the accuracy and response bias of depressed people to affective facial expressions | Case-control Clinical sample | MDD = 27, HC = 29 [45.0 ± 11.6; 24M:32F] | FEEST | DSM-IV | MDD worse than HC in facial affect recognition accuracy (F1,42 = 26.2, P < 0.01) |
| Szily & Kéri, 2009 | To determine the impact of psychosis risk in depression on social cognition | Case-control Clinical sample | prMDD = 26, MDD = 42, HC = 50 [21.2 ± 7.3; 44M:73F] | RMET-R | DSM-IV | prMDD and MDD were less accurate than HC on RMET-R (F2,230 = 10.30, P < 0.001) |
| Wang et al., 2008 | To determine if psychotic features in depression impact social cognitive performance | Case-control Inpatient sample | pMDD = 23, npMDD = 33, HC = 53 [26.8 ± 4.4; 47M:62F] | RMET-R, FPT | ICD-10 | On RMET-R, pMDD inferior to both npMDD (P = 0.018) and HC (P = 0.000), npMDD superior to HC (P = 0.000). On FPT, HC superior to both pMDD (U = 0.000, P = 0.000) and npMDD (U = 128.500, P = 0.000), pMDD inferior to npMDD (U = 149.500, P = 0.000) |
| Wolkenstein et al., 2011 | To investigate difference in social cognitive performance between depressed patients and controls | Case-control Outpatient sample | MDD = 24, HC = 20 [36.4 ± 10.8; 19M:25F] | RMET-R, MASC | DSM-IV | MDD inferior to HC in performance on MASC (F1,42 = 4.57, P < 0.05), but equal on RMET-R (F1,42 = 0.74, P < 0.40) |
| Zobel et al., 2010 | To compare social cognitive performance between depressed patients and controls | Case-control Clinical sample | MDD = 30, HC = 30 [46.5 ± 12.0; 27M:33F] | BCPS WE.EL | DSM-IV | MDD inferior to HC in BCPS sequence (U = 242.5, P = 0.001), FOQ (U = 294.0, P = 0.004), SOQ (U = 183.5, P = 0.001); and WE.EL sequence (U = 282.0, P = 0.012), FOQ (U = 297.0, P = 0.016), SOQ (U = 234.0, P = 0.001) |
| Section 1.2 Studies indicating non-significant differences between acutely depressed individuals and healthy controls | ||||||
| Bazin et al., 2009 | To evaluate a new social cognitive task in a clinical sample | Case-control Inpatient sample | MDD = 12, HC = 15, BD = 15, SCZ = 15 [36.6 ± 12.8; 36M:21F] | V-SIR, ToM comic | DSM-IV | MDD performed non-significantly worse on V-SIR compared to HC. No group effect for ToM comic test |
| Bediou et al., 2005 | To compare how depressed and schizophrenic patients recognize facial affect | Case-control Clinical sample | MDD = 20, HC = 20, SCZ = 29 [32.9 ± 9.8; 42M:27F] | Self-created | DSM-IV | MDD and HC performed equally well on facial affect recognition |
| Bertoux et al., 2012 | To evaluate a new social cognitive task to distinguish depression from frontotemporal dementia | Case-control Inpatient sample | MDD = 19, HC = 30, bvFTD = 37 [65.1 ± 9.0; 47M:39F] | Mini-SEA (PFA, sFPRT) | DSM-IV | On total mini-SEA and component scores, MDD performed equally to HC |
| Gollan et al., 2008 | To identify differences in affective information processing between depressed patients and controls | Case-control Clinical sample | MDD = 37, HC = 29 [35.1 ± 9.3; 34M:32F] | PFA | DSM-IV | MDD and HC performed equally in facial affect recognition and intensity categorization |
| Gollan et al., 2010 | To investigate how depressed patients interpret facial affect of differing intensity | Case-control Clinical sample | MDD = 44, HC = 44 [29.5 ± 9.8; 33M:55F] | PFA | DSM-IV | No significant main effect for group (MDD vs. HC) on facial affect recognition accuracy |
| Joorman & Gotlib, 2006 | To examine depression-specific biases in identification of affective facial expressions | Case-control Outpatient sample | MDD = 21, SP = 26, HC = 25 [31.9 ± 9.4; 21M:51F] | FEEST | DSM-IV | MDD, SP, and HC performed equally on facial affect recognition |
| Matthews et al., 2008 | To examine amygdala-cingulate functional coupling in depression during an emotional face matching task | Case-control Community sample | MDD = 15, HC = 16 [24.4 ± 5.3; 9M:22F] | PFA | DSM-IV | No difference between MDD and HC for accuracy or reaction time on face matching task |
| Seidel et al., 2010 | To measure automatic behaviors toward affective facial expressions in depression | Case-control Related posts: Are cognitive deficits in major depressive disorder progressive?
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