The Role of Social Cognition in Major Depressive Disorder Essay
Background: Social cognition – the ability to identify, perceive, and interpret socially relevant information – is an important skill that plays a significant role in successful interpersonal functioning. Social cognitive performance is recognized to be impaired in several psychiatric conditions, but the relationship with major depressive disorder is less well understood. The aim of this review is to characterize the current understanding of: (i) the different domains of social cognition and a possible relationship with major depressive disorder, (ii) the clinical presentation of social cognition in acute and remitted depressive states, and (iii) the effect of severity of depression on social cognitive performance.
Methods: Electronic databases were searched to identify clinical studies investigating social cognition in a major depressive disorder population, yielding 31 studies for this review.
Results: Patients with major depressive disorder appear to interpret social cognitive stimuli differently to healthy controls: depressed individuals may interpret emotion through a mood-congruent bias and have difficulty with cognitive theory of mind tasks requiring interpretation of complex mental states. The Role of Social Cognition in Major Depressive Disorder Essay. Social cognitive performance appears to be inversely associated with severity of depression, whilst the bias toward negative emotions persists even in remission. Some deficits may normalize following effective pharmacotherapy.
Conclusions: The difficulties with social interaction observed in major depressive disorder may, at least in part, be due to an altered ability to correctly interpret emotional stimuli and mental states. These features seem to persist even in remission, although some may respond to intervention. Further research is required in this area to better understand the functional impact of these findings and the way in which targeted therapy could aid depressed individuals with social interactions.
Keywords: depression; facial affect; major depressive disorder; social cognition; theory of mind.
Abstract
Background: Social cognition – the ability to identify, perceive, and interpret socially relevant information – is an important skill that plays a significant role in successful interpersonal functioning. Social cognitive performance is recognized to be impaired in several psychiatric conditions, but the relationship with major depressive disorder is less well understood. The aim of this review is to characterize the current understanding of: (i) the different domains of social cognition and a possible relationship with major depressive disorder, (ii) the clinical presentation of social cognition in acute and remitted depressive states, and (iii) the effect of severity of depression on social cognitive performance.
Methods: Electronic databases were searched to identify clinical studies investigating social cognition in a major depressive disorder population, yielding 31 studies for this review. The Role of Social Cognition in Major Depressive Disorder Essay.
Results: Patients with major depressive disorder appear to interpret social cognitive stimuli differently to healthy controls: depressed individuals may interpret emotion through a mood-congruent bias and have difficulty with cognitive theory of mind tasks requiring interpretation of complex mental states. Social cognitive performance appears to be inversely associated with severity of depression, whilst the bias toward negative emotions persists even in remission. Some deficits may normalize following effective pharmacotherapy.
Conclusions: The difficulties with social interaction observed in major depressive disorder may, at least in part, be due to an altered ability to correctly interpret emotional stimuli and mental states. These features seem to persist even in remission, although some may respond to intervention. Further research is required in this area to better understand the functional impact of these findings and the way in which targeted therapy could aid depressed individuals with social interactions.
Background
Correctly interpreting social information is a crucial part of successful interpersonal interaction. This requires synthesis of a broad range of verbal and non-verbal cues, including facial expressions, prosody in speech, body language, and the mental states of others (theory of mind). Together, these skills are referred to as social cognition and are an important component of cognitive functioning. Social cognition encompasses the identification, perception, and interpretation of socially important information (1), whilst the domain of theory of mind specifically refers to the ability to infer information regarding the thoughts, intentions, and feelings of others (2). This is further conceptualized into two distinct systems – cognitive theory of mind relates to interpretation of beliefs and intentions, whilst affective theory of mind consists of inferences regarding the emotional states of others (3).
Social cognitive impairment is widely recognized to be a key feature of several psychiatric diseases, such as schizophrenia (1) and autism (4).The Role of Social Cognition in Major Depressive Disorder Essay. The impact of depression on social cognitive functioning 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 (5), individuals with depression have also been found to display profound and pervasive impairments in interpersonal functioning (6). Nevertheless, depressed patients appear to be less severely impaired in social cognition than patients with schizophrenia or autism (7–9).
The majority of data from previous reviews investigating the relationship between depression and social cognition relate primarily to the emotional domain, particularly through facial expressions or affective theory of mind. 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 (10). A larger review indicated a reasonably consistent pattern of a negative interpretive bias of facial affect (11). It appears that depressed patients may not exhibit diminished recognition accuracy when interpreting facial expressions, but rather demonstrate an increased sensitivity toward sad expressions in comparison to happy ones. Other reviews have indicated that such abnormalities appear to respond to anti-depressant therapy and may actually be detectable prior to improvements in mood (12, 13).
To our knowledge, there is a lack of similar comprehensive reviews of behavioral studies in the domains of prosody, body language, and theory of mind to determine if these findings are consistent across all components of social cognition in major depressive disorder. Evidence from individual studies indicates that patients with major depressive disorder may also struggle with verbal cues, with two studies reporting a negative bias when depressed patients interpret prosodic stimuli (14, 15). Several authors who have tested theory of mind performance in depressed cohorts have found them to be impaired, albeit less severely than psychotic or autistic participants (7, 8). It is therefore reasonable to anticipate that the impairments in social cognition in major depressive disorder may translate across the different domains.
In addition to the available behavioral data, there is also a significant body of literature that exists on functional neuroimaging in patients with depression 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 (16–19). In light of such functional changes, detailed examination is required to determine the extent to which altered processing of social stimuli may impact the quality of life or interpersonal success of an individual with major depressive disorder. The Role of Social Cognition in Major Depressive Disorder Essay.
Better understanding of the nature of social cognition in major depressive disorder is important, as it will help to further characterize the phenotype of the disease and may offer explanation for the poor social functioning observed in depression. It is also important to consider the potential therapeutic implications, as previous reviews have suggested that impairments in social cognition may be reversible (12, 13). Improvement in social cognitive functioning may become a targeted component of the treatment for depression or a useful method of monitoring improvement.
The present review of the existing literature on social cognition and major depressive disorder aims to increase the understanding of: (i) the impact of depressed mood across different domains of social cognition including facial affect, prosody, body language, and theory of mind, (ii) the clinical presentation of social cognition in acute and remitted depressive states, and (iii) the effect of severity of depression on social cognitive performance.
Methods
Search strategy
An electronic search strategy was employed to identify published studies investigating the behavioral relationship between social cognition and depression. Pertinent original research articles were identified and retrieved via the Medline, Embase, and PsycINFO databases, as well as the reference lists of included articles. The search was limited to only the most recent English literature, taking into account the 10-year period from June 2003 to June 2013. The subject headings used across the different databases were “social cognition,” “social perception,” “depression,” “major depression,” “mood disorders,” “depressive disorder,” and “affective disorders.” This was combined with the key word search terms of “social cognition,” “social perception,” “social interaction,” “depression,” “mood disorder,” “affective disorder,” “melancholia,” and “dysthymia.” Truncated search terms were included where possible to maximize results, while inclusion of broad key words such as “mood disorder,” “melancholia,” or “dysthymia” was intended to enhance the sensitivity of the search.
Study selection
The titles and abstracts of the results generated from the three databases were screened to exclude irrelevant articles.The Role of Social Cognition in Major Depressive Disorder Essay. The full articles of the remaining studies were downloaded and the methods inspected in detail to determine eligibility (Figure (Figure1).1). The identified studies were included in the analysis if they met the following criteria: firstly, the diagnosis of an acute or remitted major depressive disorder was formally made according to a standardized interview; secondly, the patient population needed to be an adult study group, defined as participants aged 18 and above; thirdly, each study was required to report behavioral data relating to a social cognitive task in one or more of the following domains only – facial affect recognition, theory of mind, prosody, or body language interpretation.
Flowchart of article inclusion procedure during review of the literature. From 1,637 individual records initially identified through the literature search of the Medline, PsychINFO, and Embase databases, 31 articles were included in the final analysis.
Studies were excluded if the patient group was co-morbid with a separate psychiatric disorder, such as schizophrenia, dementia, a learning disorder, eating disorder, or pervasive developmental disorder. Studies were also excluded if the patient group demonstrated bipolar features. Functional MRI studies with no reported behavioral results were excluded. Once selected, the article’s reference list was then scoured for further relevant articles missed in the initial database searches. The Role of Social Cognition in Major Depressive Disorder Essay.
Results
Over the past decade, much has been published to further characterize the relationship between social cognition and major depressive disorder. Following a thorough search of the literature, a total of 31 articles were included in this review (Figure (Figure11).
Social cognition is a broad term encompassing a diverse array of skills. The two most studied social cognitive domains are facial affect recognition and theory of mind, with the majority of included studies in this review investigating ability in these two areas. Some authors have applied a bimodal approach to assessing social cognition, using both a perceptual assessment of observable social information for facial affect with a more conceptual approach involving higher order functions for theory of mind (2, 7, 8, 20, 21). Others have included empathy (2, 22) among the domains of social cognition. No studies were uncovered using the above methodology that specifically investigated prosody of voice or body language, although body language was indirectly assessed in the tasks used by some authors (2, 22). This suggests a need for further research into the impact on other social cognitive domains in major depressive disorder.
Major depressive disorder and function on specific domains of social cognition
The literature remains equivocal regarding overall differences in social cognitive performance between depressed and healthy cohorts.The Role of Social Cognition in Major Depressive Disorder Essay. While there is some evidence to suggest that subjects with major depressive disorder may demonstrate poorer overall social cognitive performance compared to healthy controls (Table (Table1A),1A), numerous other authors found no group difference on a gross measure of social cognition (Table (Table1B).1B). This is further discussed below according to the domains of facial affect recognition, affective theory of mind, and cognitive theory of mind.
Table 1
Case-control studies investigating differences in social cognitive performance between patients with major depressive disorder and controls.
| References | Aim | Method | N [MA ± SD; M:F] | Social cognition task | Mood diagnosis | Results |
|---|---|---|---|---|---|---|
| (A) STUDIES INDICATING SIGNIFICANT DIFFERENCES BETWEEN ACUTELY DEPRESSED INDIVIDUALS AND HEALTHY CONTROLS | ||||||
| Anderson et al. (23) | 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. (21) | To investigate social cognitive performance in esophageal cancer patients with depression | Case-control | pMDD = 32, npMDD = 33, HC = 62 n = 127 [33.1 ± 10.5; 71M:159F] | RMET-R, FPT | BDI-II | Compared to HC, both MDD groups were impaired on affective ToM (t = 7.39, P < 0.01) and faux pas task (t = 13.75, P < 0.01) |
| Esophageal cancer patient sample | ||||||
| Csukly et al. (24) | 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. (25) | 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. (26) | 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. (27) | To determine if maternal history of depression impacts affective ToM performance | Case-control Outpatient sample | MDD = 61, HC = 30 [45.3 ± 14.5; 0M:91F] | RMET-R | DSM-IV | MDD performed significantly worse on affective ToM task than HC (F1,91 = 6.73, P = 0.01) |
| Langenecker et al. (28) | To evaluate emotion perception deficits in depressed women Outpatient sample | Case-control | 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. (29) | To examine depressed patients’ abilities to identify mental states from affective eye expressions | Case-control Outpatient sample | MDD = 67, HC = 34 [42.7 ± 14.1; 0M:82F] | RMET-R | DSM-IV | Severe MDD less accurate than HC on affective ToM task (t65 = 2.24, P = 0.03); no difference between mild/moderate MDD and HC or MDD groups |
| Leppänen et al. (30) | 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. (31) | 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 and Kéri (32) | 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. (8) | 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. (2) | 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. (33) | 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 | 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) |
| WE.EL | ||||||
| (B) STUDIES INDICATING NON-SIGNIFICANT DIFFERENCES BETWEEN ACUTELY DEPRESSED INDIVIDUALS AND HEALTHY CONTROLS | ||||||
| Bazin et al. (7) | To evaluate a new social cognitive task in a clinical sample | Case-control Inpatient sample | MDD = 12, HC = 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. (34) | To compare how depressed and schizophrenic patients recognize facial affect | Case-control Clinical sample | MDD = 20, HC = 20 [32.9 ± 9.8; 42M:27F] | Self-created | DSM-IV | MDD and HC performed equally well on facial affect recognition |
| Bertoux et al. (20) | To evaluate a new social cognitive task to distinguish depression from frontotemporal dementia | Case-control Inpatient sample | MDD = 19, HC = 30 [65.1 ± 9.0; 47M:39F] | Mini-SEA (PFA, sFPT) | DSM-IV | On total mini-SEA and component scores, MDD performed equally to HC |
| Gollan et al. (35) | 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. (36) | 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 and Gotlib (37) | To examine depression-specific biases in identification of affective facial expressions | Case-control Outpatient sample | MDD = 23, SP = 27, HC = 26 [31.9 ± 9.4; 21M:51F] | FEEST | DSM-IV | MDD, SP, and HC performed equally on facial affect recognition |
| Matthews et al. (38) | 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. (39) | To measure automatic behaviors toward affective facial expressions in depression | Case-control Inpatient sample | MDD = 24, HC = 24 [42.4; 24M:24F] | VERT-K | DSM-IV | MDD and HC performed equally well on facial affect recognition |
| Suslow et al. (40) | To examine spatial detection of facial emotion in depressed inpatients undergoing psychotherapy | Prospective longitudinal case-control Inpatient sample | MDD = 11, MDD/AD = 11, HC = 22 [32.1 ± 8.3; 14M:30F] | FITCT | DSM-IV | Both MDD groups performed equally to HC in spatial detection of facial affect, at two time points |
| Performance did not significantly improve in either group over the 7 weeks | ||||||
| Suslow et al. (41) | To assess awareness of masked facial expressions and automatic amygdala responses in depression | Case-control Inpatient sample | MDD = 30, HC = 26 [37.5 ± 12.4; 29M:27F] | PFA | DSM-IV | MDE and HC did not differ in performance when rating the valence of the masked facial expressions |
| Wilbertz et al. (22) | To explore preoperational features of ToM in depression | Case-control Clinical sample | MDD = 16, HC = 16 [43.7 ± 11.2; 16M:16F] | MASC | DSM-IV | MDD and HC performed equally on MASC multiple choice (t30 = 0.01, P = 0.924) and open answers (t30 = 0.03, P = 0.980) |
AD, anxiety disorder; BCPS, Brüne’s cartoon picture story test; BDI-II, Beck depression inventory-II; DSM-IV, diagnostic and statistical manual of mental disorders-IV; FEEST, facial expressions of emotion: stimuli and tests; FEPT, facial emotion and perception test; FERT, facial expression recognition task; FITCT, face-in-the-crowd task; FOQ, first order question; FPT, faux pas task; GP, general practice; HC, healthy controls; HRSD, Hamilton rating scale for depression; ICD-10, international classification of diseases, 10th revision; LEAS, levels of emotional awareness scale; MASC, movie for the assessment of social cognition; MA ± SD, participants’ mean age and standard deviation; MDD, major depressive disorder; MDE, major depressive episode; M:F, ratio of male to female participants; Mini-SEA, mini-social cognition and emotional assessment; N, number of participants; npMDD, non-psychotic major depressive disorder; PFA, Ekman and Friesen’s pictures of facial affect; pMDD, psychotic major depressive disorder; rMDD, remitted major depressive disorder; prMDD, major depressive disorder with psychosis risk; RMET-R, reading the mind in the eyes task, revised; sFPT, shortened faux pas task; SOQ, second-order question; SP, social phobia; ToM, theory of mind; WE.EL, Werden and Elikann test; VERT-K, Vienna emotion recognition tasks; VHI, virtual human interface; V-SIR, Versailles – situational intention reading. The Role of Social Cognition in Major Depressive Disorder Essay.
Facial affect recognition
The way in which depressed patients respond to emotional facial expressions can be broadly categorized according to valence of the emotion.
For neutral expressions, depressed patients appear to assign more negative interpretations than healthy controls (23, 30, 35), although this was not a consistent result. In some studies, depressed individuals were found to be significantly more likely to interpret a neutral stimulus as being sad (23, 35, 36, 42). In two small case-control studies involving 66 and 36 participants, respectively, Gollan et al. (35) and Leppänen et al. (30) found depressed participants identified more neutral expressions as sad than their non-depressed counterparts.
A similar bias is evident with respect to negatively valenced expressions (31), with some authors observing particular deficits for the expressions of sadness (36, 42) and fear (43). In one large case-controlled study of 230 participants, Anderson et al. (23) noted a significant bias toward the identification of negative expressions, namely anger and sadness, by those with a current or past history of depression in comparison to control participants. A case study by Csukly et al. (24) found a significant reduction in the accuracy of both sad and neutral facial recognition by the depressed patient group.
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 (25, 31), however, this is far from a consistent finding. In a case-control study of 130 inpatients, Csukly et al. (25) 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 expressions including sadness. The Role of Social Cognition in Major Depressive Disorder Essay. A similar study involving 56 inpatients by Surguladze et al. (31) also demonstrated a link between severity of depression and difficulty recognizing happy expressions, but in contrast observed an even greater impairment in recognition of negative expressions.
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 variations of intensity into the assessment of facial affect recognition. Patients with major depressive disorder were identified as more likely to misattribute the expression as being of a higher intensity (35). Furthermore, depressed patients were found to require a greater intensity of emotion than their non-depressed counterparts to identify happy expressions (37, 44) and less intensity to identify sad expressions (36, 37, 42). 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 (30, 31) and depressed patients with co-morbid anxiety to be slower in recognizing positive faces than both controls and non-anxious depressed (40). 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 milliseconds, but equal to healthy controls when the time of stimulus was increased to 2,000 milliseconds (31). In contrast, reaction times were increased in some studies when depressed patients were confronted with sad (35) or neutral (30, 40) expressions. However, these represented a minority of results with the larger portion of investigators reporting no difference in reaction time (23, 28, 38, 41), throwing doubt over any potential association.
There were little data available investigating discrepancies in the way depressed and non-depressed subjects react to emotional stimuli. 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 (39, 45). However, these studies both involved small numbers of participants (30 and 48, respectively) and only looked at instinctive reaction to facial expression without investigation of functional implications. The Role of Social Cognition in Major Depressive Disorder Essay.
Affective theory of mind
There was greater consistency in the literature regarding affective theory of mind in major depressive disorder. Almost all studies employed the Reading the Mind in the Eyes assessment task (46), which required participants to interpret the affective mental state portrayed in various cropped images of eyes. The clear majority of studies found that depressed patients were impaired in this skill compared to controls (8, 21, 27, 29, 32). However, a separate study found depressed patients to be in fact more accurate than matched controls in identifying a negative emotional state, without any difference for neutral and positive states (2). This may indicate a bias toward negative emotions similar to the phenomenon observed with interpretation of facial expressions.
The only two studies that did not reveal a difference between groups on theory of mind performance indicated instead that the depressed group showed less perceptual reasoning than controls for the affective rather than cognitive components of theory of mind (2, 22). This preference against affective theory of mind was also demonstrated by Lee et al. (29) in a case-control study of 101 patients. Such findings may suggest that theory of mind deficits in major depressive disorder may be primarily on an emotional level.
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A number of authors considered the effect of certain clinical features of depression on affective theory of mind performance, linking suicidal behaviors (47), excessive rumination (48), and anxiety (29) to impaired performance compared to patients who did not feature these symptoms. Additionally, patients with psychotic features of depression were significantly worse than depressed patients without these features (8, 21), which is in keeping with previous literature on psychotic disorders (1). However, risk of psychosis itself was not significant (32).
Cognitive theory of mind
A number of researchers also chose to use tools based on cognitive theory of mind ability in their assessment of possible social cognition impairments in depressed patients, with some evidence to suggest that patients with major depressive disorder have difficulties with these skills in comparison to healthy controls.The Role of Social Cognition in Major Depressive Disorder Essay. In a case-control study involving 60 patients, Zobel et al. (33) found that depressed patients appear to be impaired on the key cognitive theory of mind tasks of interpreting both first- and second-order questions relating to social interactions. Further case-control studies by Cao et al. (21) and Wang et al. (8) also identified deficits amongst depressed patient populations in identifying social faux pas. However, as both these researchers chose to include psychotic depressed patients as a third subgroup as well as non-psychotic depressed patients and healthy controls, interpretation of these findings was difficult. Lastly, patients with major depressive disorder also showed poorer emotional awareness of what others were thinking compared to controls, but had good insight into their own emotional state (26). This was also manifest as a difficulty in showing empathy toward the feelings of others (22). The Role of Social Cognition in Major Depressive Disorder Essay.