Schizophrenia and the difficulties of social interaction
There are big differences in how successfully people with schizophrenia interact with other people socially. This is revealed by research done by the psychologist Vibeke Bliksted PhD. Based on the latest research and interdisciplinary cooperation, she is currently developing courses of treatment aimed at training social cognition in patients who suffer from schizophrenia.
“Some patients with schizophrenia master social cognition – in other words, they are able to understand and interact with other people in a relatively unproblematic way. Others can’t manage it at all – they have great difficulty in reading other people.” This is how Bliksted explains the main conclusion of her PhD dissertation, which she defended in the spring of 2014. She’s a specialised psychologist at the Department for Psychosis, Aarhus University Hospital in Risskov, which is part of AU’s interdisciplinary Interacting Minds Centre.
In her PhD project, Bliksted collaborated with linguists from the centre as well as other specialists. She drew on their knowledge of semiotics and theories about how human beings constantly decode each other’s tone of voice and facial expressions. Together they set out to examine what happens in the brains of patients with schizophrenia when they are exposed to sarcasm. The focus of the study was on young patients who had recently been diagnosed with schizophrenia. A total of 59 subjects participated, 19 of whom were given so-called functional brain scans. The patients were shown short video clips of actors enacting everyday situations. Each scene was shown in both a straight version and a sarcastic version.
“The most severely affected patients couldn’t spot the difference. They perceived all the videos as straight versions of what was going on, and brain scans revealed that this group of patients had lower levels of brain activity than healthy control subjects. Another group of patients were able to decode what the actors were doing successfully. However, brain scans of this group showed higher levels of brain activity than healthy control subjects, which might indicate that these patients have developed compensatory strategies in order to spot sarcasm,” explains Bliksted.
This knowledge is vital when deciding how to treat patients with schizophrenia, she says. “It makes it possible to diagnose patients with greater precision – and not least to design treatment for each individual patient.”
Social cognition is the key
At the moment the systematic treatment of socio-cognitive difficulties is not available for patients with schizophrenia; but international research indicates that socio-cognitive difficulties have a huge impact on how well people with schizophrenia manage their everyday lives, explains Vibeke Bliksted.
“The research indicates that patients with good socio-cognitive skills manage their lives better. The patients I work with are young people aged 18 and up with most of their lives ahead of them; so of course it would be fantastic if we could give them more tools for use in interacting with other people, thereby increasing their chance of getting an education, getting a job and improving their lives in general.”
Training the social cognition of patients also has an impact on how badly they are affected by psychotic symptoms, explains Bliksted.
“We know that when patients with schizophrenia are exposed to increased levels of stress and pressure, psychotic symptoms start to dominate their lives. And many of them find that situations requiring them to be with other people are a major source of stress. If we can teach them a few tricks about how to handle these situations better, we can probably help them with their psychotic symptoms as well.”
Tone of voice and facial expression
Vibeke Bliksted is currently engaged in applying for funding for her work, which involves developing and researching ways of training socio-cognitive skills in patients with schizophrenia. Seed money from the Interacting Minds Centre has enabled her to start this work already, and she is also starting to collaborate with a Chinese psychiatrist involved in research into newly diagnosed schizophrenia with a view to developing useful methods of measuring the effect of socio-cognitive training via brain scans. In addition, she is developing a training programme in collaboration with Birgitte Fagerlund, a senior researcher at the research unit of the Psychiatric Centre in Glostrup, and with a range of colleagues from the Interacting Minds Centre with backgrounds in the fields of philosophy, semiotics and linguistics.
These training courses help patients to interact better with other people, explains Bliksted.
“Understanding a social situation and what other people think is an extremely complex task. It’s all about decoding and understanding everything – including other people’s tone of voice and facial expressions as well as what they’re actually saying. Lots of these particular patients find this extremely difficult.”
This is why cross-disciplinary collaboration is so important for Bliksted when designing training courses and organising research designed to monitor patients and their progress.
“I’m a clinical psychologist, so I know a lot about the psychopathology of serious mental illness. But these courses are also about learning how normal people communicate and interact. Fortunately, some of my colleagues from the worlds of philosophy, language and cognitive semiotics know a lot about these areas. So I can draw on their expertise.”
Role play and homework
One of the important aspects of the treatment involves practical exercises – almost like theatrical role play, explains Bliksted. The patients are asked to practise managing social situations and decoding other people in specific, recognisable contexts.
It might just involve a few simple ideas – for instance, that it’s a good idea to look people in the eye when you’re talking to them. But not for too long – it’s rude to stare! The patients can practise this at home in a variety of specific situations.
Bliksted’s plan is that the treatment should be accompanied closely by research.
“For instance, we’ll be measuring whether the patients are better at being with other people at the end of the course. I also want to do some MEG scans to find out whether our training courses have an effect on brain activity – and if they do, I want to understand what’s going on.”
Doing mental overtime
When designing these specific and individual courses, the precise diagnosis of each patient plays an important role. And in this area Vibeke Bliksted can draw on her previous research, which showed that patients with schizophrenia could be divided into two groups depending on whether they mastered social cognition or not.
“The two groups need different types of socio-cognitive training,” she explains.
“The group that could apparently decode social situations successfully turned out to have excessive brain activity. You could say that they were constantly doing mental overtime and analysing social interaction every minute of the day – which is known as hypermentalisation.”
She explains that hypermentalising patients can be characterised by the fact that they reach erroneous decisions systematically.
“They’re always jumping to hasty conclusions when interpreting their interaction with other people. They might be thinking: ‘It looks as if he’s waving his ballpoint pen around, but what he’s really doing is giving someone a sign.’ Or: ‘You seem to be asking me a question, but what you really want to do is find out what I’ve been doing so you can call my boss and tell him to fire me.’ This is why socio-cognitive training involves teaching people to recognise and try to put a stop to these patterns themselves.”
World of Warcraft
The other group have insufficient brain activity in connection with social situations, which is known as hypomentalisation. They’re characterised by what are called negative symptoms such as a lack of energy and initiative.
“A lot of patients with these symptoms don’t think they’ve got a problem. They’re quite happy playing World of Warcraft all night long even though they and their flat are falling apart because personal hygiene and cleaning are beyond them.”
So socio-cognitive treatment for them will mostly involve more fundamental social factors. For instance, the ability to imagine that there’s any point in spending time with other people every now and then.
“They need to practise some basic aspects of social behaviour and small talk so they don’t end up being totally marginalised or even totally isolated.”