Psychiatry Research 216 (2014) 325332

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Empathy, depressive symptoms, and social functioning among

individuals with schizophrenia
Amy C. Abramowitz, Emily J. Ginger, Jackie K. Gollan, Matthew J. Smith n
Northwestern University Feinberg School of Medicine, Department of Psychiatry and Behavioral Sciences, 446 E. Ontario, Suite 7-100, Chicago, IL 60611, USA

art ic l e i nf o a b s t r a c t

Article history: Empathy decits have been associated with schizophrenia and depression. We compared whether
Received 17 July 2013 individuals with schizophrenia with and without co-occurring depressive symptoms differed on self-
Received in revised form reported and performance-based measures of empathy and social functioning. We also examined the
13 February 2014
relationships among depressive symptoms, empathy, clinical symptoms, and social functioning. Twenty-
Accepted 19 February 2014
Available online 28 February 2014
eight individuals with schizophrenia and depressive symptoms, 32 individuals with schizophrenia
without depressive symptoms, and 44 control subjects were compared on assessments of depressive
Keywords: symptoms, empathy, global neurocognition, clinical symptoms, and social functioning. Both groups of
Schizophrenia individuals with schizophrenia scored higher than controls on the Interpersonal Reactivity Index
Empathy
personal distress subscale. Individuals with schizophrenia and co-occurring depressive symptoms scored
Depressive symptoms
signicantly higher than individuals with schizophrenia without depressive symptoms on the personal
Social functioning
Personal distress distress subscale. Personal distress and depressive symptoms were signicantly correlated among
individuals with schizophrenia and co-occurring depressive symptoms, while both measures negatively
correlated with social functioning. Emotional empathy was related to clinical symptoms in both groups
of individuals with schizophrenia. Personal distress partially mediated the relationship between co-
occurring depressive symptoms and social functioning. Personal distress may be an important implica-
tion for social functioning among individuals with schizophrenia and co-occurring depressive symptoms,
and should be examined further as a potential treatment target.
& 2014 Elsevier Ireland Ltd. All rights reserved.

1. Introduction and the selfother distinction that underlie cognitive empathy

Empathy involves the ability to process emotional cues (verbal
and nonverbal) displayed by others and consists of both emotional
and cognitive components (Shamay-Tsoory, 2011; Zaki and
Ochsner, 2011). The emotional component involves sharing and
detecting the emotions displayed by others, and regulating the
emotional response to others, while the cognitive component
involves understanding the emotional perspective of others and
distinguishing between the feelings experienced by others from
one's own (Decety, 2011). Cognitive empathy is similar to theory-of-
mind (ToM), which can be dened as inferring the cognitive mental
states (i.e., beliefs and intentions) of others and using this informa-
tion to predict future behavior (Brune and Brune-Cohrs, 2006).
Although these constructs share some underlying neural mechan-
isms, they can be differentiated by the emotional understanding
n
Correspondence to: Northwestern University Feinberg School of Medicine,
Department of Psychiatry and Behavioral Sciences, Abbott Hall 13th Floor, Chicago,
IL 60611, USA. Tel.: 1 312 503 2542; fax: 1 312 5030 527.
E-mail address: matthewsmith@northwestern.edu (M.J. Smith).
(Shamay-Tsoory, 2011).
Individuals with schizophrenia are characterized by decits in
empathy across a range of methods, including self-report (Achim
et al., 2011; Haker et al., 2012) and performance-based measures
(Langdon et al., 2006; Shamay-Tsoory et al., 2007; Derntl et al.,
2009; Smith et al., in press). Although the literature appears to be
mixed regarding the presence of emotional empathy decits in
this group (Sparks et al., 2010; Achim et al., 2011; Smith et al.,
2012), studies have consistently observed decits in cognitive
empathy (Derntl et al., 2009; Sparks et al., 2010; Achim et al.,
2011; Smith et al., 2012). Moreover, recent studies demonstrated
that cognitive empathy, but not emotional empathy, explained
unique variance in social functioning after accounting for neuro-
cognitive decits and clinical symptoms (Smith et al., 2012; Smith
et al., in press).
Given that empathy explains unique variation in social function-
ing among individuals with schizophrenia (Smith et al., 2012; Smith
et al., in press), it is important to investigate clinical factors that
might exacerbate these empathy decits. One such factor could be
the presence of depressive symptoms, which occur more frequently
among individuals with schizophrenia compared to the general

http://dx.doi.org/10.1016/j.psychres.2014.02.028
0165-1781 & 2014 Elsevier Ireland Ltd. All rights reserved.
326 A.C. Abramowitz et al. / Psychiatry Research 216 (2014) 325332
population (Lanon et al., 2001; Kessler et al., 2003; Buckley et al.,
2009) and are associated with reduced functioning (Fervaha et al.,
2013; Kasckow et al., 2010; Simonsen et al., 2010). Moreover,
individuals with a non-psychotic major depressive disorder have
impairments in both emotional and cognitive empathy (Cusi et al.,
2011; Schreiter et al., 2013). Based on ndings of heightened
depression among individuals with schizophrenia, depressive symp-
toms in this population could be related to exacerbated impairments
in empathy (Baez et al., 2013).
In the current study, we hypothesized that (1) individuals with
schizophrenia and depressive symptoms (SCZDEP) would have
exacerbated impairments in the emotional and cognitive compo-
nents of empathy as compared to individuals with schizophrenia
and no depressive symptoms (SCZ); (2) SCZ DEP would
have poorer social functioning than SCZ; (3) among SCZ DEP,
(a) greater depressive symptoms would be related to impaired
empathy and lower social functioning; (b) impaired empathy would
be related to poorer social functioning; (c) impaired empathy would
mediate the relationship between depressive symptoms and social
functioning. We tested these hypotheses using a multimodal
approach with self-report and performance-based measures of both
empathy and social functioning. Lastly, we explored the relationship
between depressive symptoms and the clinical symptoms of schizo-
phrenia, duration of illness (years since onset of psychotic symp-
toms), and antipsychotic medication treatment.
2. Methods
2.1. Participants
Participants included 28 SCZ DEP, 32 SCZ, and 44 healthy controls (CON)
between 18 and 55 years of age. The Northwestern University Schizophrenia
Research Group recruited all participants through outpatient mental health
services, advertisements in surrounding neighborhoods, the National Alliance for
Mental Illness, and online. The Structured Clinical Interview for the DSM-IV (SCID)
(First et al., 2002) was administered by MS and PhD-level research staff and used to
determine a diagnosis of schizophrenia, other Axis-I disorders, and pharmacologi-
cal treatment. The diagnoses were validated by a semi-structured interview
performed by a research psychiatrist and by a review of available medical records.
Depressive symptoms were rated using the Montgomery Asberg Depression
Rating Scale (MADRS) (Montgomery and Asberg, 1979; Bondol et al., 2010) and
based on observations during the SCID. Ten items were rated on a seven-point
Likert scale with a possible range of 060. Using MADRS cutoff scores, 06 reected
a normal range of minor or absent depressive feelings, while scores of 719
reected mild depressive symptoms, 2034 reected moderate depressive symp-
toms, and 35 reected severe depressive symptoms. A total MADRS score and
individual ratings for apparent sadness, total sadness, inner tension, reduced sleep,
reduced appetite, concentration difculties, lassitude, inability to feel, pessimistic
thoughts, and suicidal thoughts were evaluated. The alpha reliability among
SCZ DEP was acceptable ( 0.63). Reliabilities for CON and SCZ were
unacceptable (both o 0.30), but this nding is expected given that few subjects
in these two scored above 0 on this measure. All individuals with schizophrenia
were clinically stable prior to study participation and treated with antipsychotic
medications.
Exclusion criteria for CON included having (1) a lifetime history of any Axis I
psychiatric disorder according to SCID criteria or (2) a rst-degree relative with a
psychotic disorder (including bipolar disorder). Additional exclusion criteria for
both groups were: DSM-IV criteria for substance abuse or dependence within the
past 6 months or a documented neurological injury or disorder. Northwestern
University Feinberg School of Medicine's Institutional Review Board approved the
study protocol and all participants provided informed consent. The completion of
all study measures required approximately 56 h over the course of 23 visits.
2.2. Measures
2.2.1. Self-report empathy
The 28-item Interpersonal Reactivity Index (IRI) (Davis, 1983) was used to
measure four areas theorized to reect empathy. Cognitive empathy was measured
with fantasy (i.e., shifting one's feelings to ctional characters) and perspective-
taking (i.e., understanding the perspective of others), while emotional empathy
was measured with empathic concern (i.e., generating affective concern for others)
and personal distress (i.e., becoming upset when others are in difcult situations).
The internal consistency of the IRI was generally acceptable but not strong for the
control subjects and individuals with schizophrenia (across both groups): fantasy
( 0.76, 0.70, respectively), perspective-taking ( 0.73, 0.49, respec-
tively), empathic concern ( 0.79, 0.70, respectively), and personal distress
( 0.67, 0.63, respectively).
2.2.2. Performance-based empathy
Two computerized tasks from an adapted version of the Derntl paradigm
(Derntl et al., 2009) assessed cognitive empathy with emotional perspective-taking
and emotional empathy with affective responsiveness (Smith et al., in press). The
developers translated the directions and tasks from German into English and
worked with the principal investigator (MJS) to edit the text for readability. Each
task used a two alternative, forced-choice response format with standardized face
stimuli (Gur et al., 2002) and took approximately 20 min to complete. Accuracy (i.e.,
percent correct) and response times (RT) were recorded for each task. Sample
stimuli from the two tasks can be found here (Smith et al., in press).
2.2.2.1. Affective responsiveness. Participants judged how they would feel in various
emotional scenarios presented as 150 brief sentences describing emotional (i.e.,
fear, anger, sadness, disgust, happiness, neutrality) and neutral situations (25 sti-
muli per emotion). The sentences were presented for 6 s and a response slide di-
splaying two emotional faces was presented for a maximum of 4 s. Participants
selected the emotional expression that reected how they would feel in the sce-
nario; one face correctly depicted how most people would feel in the scenario and
the other face was a randomized option.
2.2.2.2. Emotional perspective-taking. Participants were shown 60 scenes displaying
two actors engaged in social interactions depicting happiness, sadness, anger, fear,
disgust and neutrality (10 scenes each). The face of one actor was masked and
participants were prompted to select which of the two facial expressions would
best reect how the masked character would feel in each interaction. Each social
interaction scene was displayed for 4 s and followed by a response slide that pre-
sented two faces for a maximum of 4 s. The emotional empathy task was completed
prior to the cognitive empathy task.
2.2.3. Social functioning measures
Social competence was assessed using the Social Skills Performance Assess-
ment, a video-recorded test comprised of two role-play scenes that involved
meeting a new neighbor and making a request from a landlord. Based on the work
of Patterson et al. (2001), each scene was rated on a ve-point scale across eight
criteria for the rst scene and nine criteria for the second scene. A nal score was
calculated by averaging the two role-play scores (ICC 0.97 for two blinded raters
on 25% of the videos). Social attainment was assessed using the total score from a
participant interview version of the Specic Levels of Functioning (SLOF) scales,
which asks participants to consider their typical level of functioning in the areas of
interpersonal relationships, social acceptability, activities of daily living, and work
skills (Schneider and Struening, 1983). The SSPA and SLOF have been previously
validated as measures of functioning in individuals with schizophrenia (Patterson
et al., 2001; Harvey et al., 2007).
2.2.4. Global neurocognition
We used a neuropsychological test battery to approximate the six non-social
cognitive domains in the Measurement and Treatment Initiative to Improve
Cognition in Schizophrenia battery (Marder and Fenton, 2004). Speed of processing
included Trail Making Test Part A (Reitan and Wolfson, 1985), category uency
(animals) (Benton et al., 1976), and the Digit-Symbol Coding subtest from the
Wechsler Adult Intelligence Scale-Third Edition (WAIS-III) (Wechsler, 1997a).
Attention included the mean across the two, three, and four-item d0 scores from
a continuous performance task (Barch et al., 2004). Verbal Working Memory (WM)
included performance on Letter-Number Sequencing and Digit Span subtests from
the Wechsler Memory Scale-Third Edition (WMS-III) (Wechsler, 1997b). Non-verbal
WM included the Spatial Span subtest from the WMS-III (Wechsler, 1997b). Verbal
learning included the total score of trials 15 on the California Verbal Learning
Test-Second Edition (Delis et al., 1983). Reasoning and problem solving included
scores from the Matrix Reasoning subtest of the WAIS-III (Wechsler, 1997a) and the
Trail Making Test Part B (Reitan and Wolfson, 1985). Each domain was computed by
standardizing raw or scaled scores from individual subtests using z-score transfor-
mations with the current sample, and then averaging these scores within the
domains. Global neurocognition was computed as an average across the six
domains scores.
2.2.5. Clinical measures
We used the global ratings from the Scale for the Assessment of Positive
Symptoms (Andreasen, 1983b) and the Scale for the Assessment of Negative
Symptoms (Andreasen, 1983a) to provide us with positive, negative, and disorga-
nized symptoms.
 A.C. Abramowitz et al. / Psychiatry Research 216 (2014) 325332 327

2.3. Data analysis
We used an analysis of variance (ANOVAs) to examine between-group differences
related to demographics, global neurocognition, clinical symptoms for continuous
variables and chi-square analyses for categorical variables. Between-group differences
were evaluated with ANOVA's for depressive symptoms, self-reported empathy (i.e., IRI
empathic concern, IRI personal distress, IRI perspective-taking, IRI fantasy),
performance-based empathy (i.e., affective responsiveness, emotional perspective-tak-
ing), and social functioning (i.e., social competence, social attainment). We examined the
relationships among the empathy, depressive symptoms, and social functioning
measures using Pearson correlations. Based on the hypothesized associations between
empathy, depressive symptoms, and social functioning (Kasckow et al., 2010; Simonsen
et al., 2010; Smith et al., 2012), we used the Preacher and Hayes (2004) bootstrapping
technique to examine whether empathy mediated the relationship between depressive
symptoms and social functioning. This is a robust approach given the potential of small
samples to deviate from normality (Preacher & Hayes, 2004). Lastly, we also explored
the correlations between depressive symptoms and the clinical symptoms of schizo-
phrenia, duration of illness, and antipsychotic medication treatment, as well as between
empathy and clinical symptoms.
3. Results
3.1. Participant characteristics
Demographic, neurocognitive, and clinical characteristics are
presented in Table 1. The groups did not signicantly differ in
terms of age, gender, socioeconomic status, and race (all P4 0.10).
There was a signicant effect of group on global neurocognitive
function (F2,104 25.1, P o0.001). SCZ and SCZ DEP demonstrated
poorer global neurocognition than CON (both P o0.001), while
SCZ and SCZ DEP did not differ (P 40.10). SCZ and SCZ DEP did
not signicantly differ with respect to duration of illness and
treatment with rst or second-generation antipsychotic medications
(all P40.10). Furthermore, they did not differ with respect to the
specic type of rst or second generation antipsychotic medication
they were taking (all P40.10). The frequency of individuals treated
with antidepressant medication did not differ between SCZ and
SCZDEP (P40.10).
3.2. Depressive and clinical symptoms
Means and standard deviations for depressive and clinical symp-
toms are presented in Table 2. There was a signicant effect of group
on the depressive symptoms total score (Po0.001) and each indivi-
dually rated item (all Po0.01). MADRS total scores for SCZDEP were
in a mild-to-moderate range (from 7 to 34) and were signicantly
higher than CON (scores ranged from 0 to 5) (all Po0.01) and SCZ
(scores ranged from 0 to 6) (all Po0.05). The distribution of depressive
symptoms among SCZDEP was skewed to the left. Thus, we used a
square root transformation of this variable for correlation analyses.
Remaining study variables were normally distributed.
SCZDEP had higher clinical symptom ratings than SCZ for
hallucinations (Po0.05), delusions (Po0.01), bizarre behavior
(Po0.01), avolition (Po0.05) and positive formal thought disorder
(P0.06) at the trend-level. The two groups did not differ with respect
to affective attening, alogia, anhedonia, and attention (all P40.10).
3.3. Self-reported empathy
Means and standard deviations for self-reported empathy are
presented in Table 3 and their scatterplots are displayed in
Supplementary Fig. 1. There was a signicant effect of group on
fantasy (F1,104 4.8, Po0.01), with CON and SCZ DEP having higher

Table 1
Demographic, Clinical, and cognitive characteristics of study sample.

CON (n 44) SCZ (n 32) SCZ DEP (n 28) F Statistic

Mean (S.D.) Mean (S.D.) Mean (S.D.)

Mean Age (S.D.) 32.8 (8.8) 35.8 (10.3) 34.9 (7.5) 1.1
Mean years since onset of psychotic symptoms (S.D.) 16.2 (10.2) 12.4 (7.7) 2.6
Mean Parental SES (S.D.) 26.9 (11.1) 22.0 (13.3) 26.9 (10.2) 1.9
Dose Years 1st Generation APa 0.2 (1.1) 0.5 (2.2)  0.5
Dose Years 2nd Generation AP 4.1 (3.3) 5.6 (4.1)  1.6
Global Cognitive Function 0.46 (0.55)  0.37 (0.61)  0.26 (0.51) 25.1nnnb

% % % 2 Statistic

Gender (% male) 52.3 68.8 57.1 2.1

Race % Caucasian 50.0 34.4 53.6 2.8
% African-American 36.4 49.6 35.7
% other 13.6 18.8 10.7
% with lifetime MDD diagnosis 0.0 12.5 39.3 21.5nnn
% Treated with AD Medication 31.3 50.0 2.2
1st Generation AP treatmenta,c 9.3 10.7 o 0.1
% Haloperidol 3.1 0.0
% Fluphenazine 3.1 0.0
% Perphenazine 0.0 3.6
2nd Generation AP treatmentc 93.8 96.4 0.2
% Risperidone 28.1 39.3
% Olanzapine 28.1 35.7
% Aripiprazole 25.0 21.4
% Quetiapine 18.8 17.9
% Clozapine 9.4 7.1
% Ziprasidone 6.3 7.1
% Paliperidone 3.1 7.1
% Asenapine 3.1 0.0

Abbreviations.: individuals with schizophrenia with no depressive symptoms (SCZ), individuals with schizophrenia and depressive symptoms (SCZ DEP), healthy controls
(CON), standard deviation (S.D.), socioeconomic status (SES), major depressive disorder (MDD), anti-depressant (AD), antipsychotic (AP).
nnn
Po 0.001.
a
n 2 SCZ and n 1 SCZ DEP were treated with FGA only.
b
CON4 SCZ, SCZ DEP.
c
Total percentages do not sum to 100% as some subjects were treated with more than one medication.
328 A.C. Abramowitz et al. / Psychiatry Research 216 (2014) 325332

Table 2
Mean (S.D.) comparison of clinical and depressive symptoms.

CON (n 45) SCZ (n 32) SCZ DEP (n 28) F-Statistic

Clinical symptoms
Hallucinations 2.5 (2.0) 3.6 (1.9) 4.4n
Delusions 2.4 (1.9) 3.9 (1.7) 10.8nn
Bizarre Behavior 1.0 (1.6) 2.3 (2.0) 7.5nn
Positive Formal Thought Disorder 1.6 (1.6) 2.4 (1.6) 3.7
Affective Flattening 3.2 (1.3) 3.4 (1.6) 0.5
Alogia 2.2 (1.8) 2.0 (1.7) 0.1
Avolition 3.0 (1.4) 3.8 (1.3) 4.8n
Anhedonia 3.1 (1.6) 3.3 (1.5) 0.2
Attention 2.1 (1.7) 1.7 (1.8) 0.8

Depressive Symptoms
MADRS Total Score 0.9 (1.4) 3.3 (2.5) 16.9 (8.0) 117.6nnna
Apparent Sadness 0.1 (0.4) 0.6 (1.0) 1.4 (1.3) 16.2nnna
Total Sadness 0.1 (0.4) 0.7 (1.1) 2.1 (1.7) 28.0nnna
Inner Tension 0.2 (0.6) 0.2 (0.6) 2.4 (1.8) 43.4nnnb
Reduced Sleep 0.2 (0.7) 0.2 (0.7) 1.0 (1.8) 5.9nnb
Reduced Appetite o 0.1 (0.3) 0.0 (0.0) 0.4 (0.9) 5.7nnb
Concentration Issues 0.1 (0.5) 0.9 (1.3) 2.3 (1.7) 28.9nnna
Lassitude 0.1 (0.3) 0.4 (0.8) 2.8 (1.6) 77.0nnnb
Inability to Feel 0.0 (0.0) 0.2 (0.6) 1.8 (2.2) 21.5nnnb
Pessimistic Thoughts o 0.1 (0.3) 0.2 (0.5) 2.0 (1.9) 32.7nnnb
Suicidal Thoughts o 0.1 (0.0) 0.1 (0.4) 0.9 (1.5) 10.8nnnb

Abbreviations: individuals with schizophrenia with no depressive symptoms (SCZ), individuals with schizophrenia and depressive symptoms (SCZDEP), healthy controls (CON).

P o 0.10.
n
Po 0.05.
nn
Po 0.01.
nnn
Po 0.001.
a
SCZ Dep 4SCZ4CON.
b
SCZ Dep4SCZ, CON.

Table 3
Mean (S.D.) comparison of empathy and social functioning measures.

CON (n 45) SCZ (n 32) SCZ DEP (n 28) F-Statistic

Self-reported empathy
Fantasy 16.4 (6.1) 12.5 (4.7) 16.4 (6.6) 4.8nna
Perspective-Taking 21.2 (4.5) 16.3 (4.4) 18.2 (4.5) 11.5nnnb
Empathic Concern 21.5 (4.6) 18.3 (4.7) 20.3 (5.4) 4.0nc
Personal Distress 8.6 (4.4) 11.7 (5.2) 14.9 (4.8) 15.2nnnd

Performance-based Empathy
Affective responsiveness (ACC) 0.88 (0.1) 0.78 (0.1) 0.79 (0.1) 15.7nnnb
(RT) 1.3 (0.3) 1.7 (0.5) 1.4 (0.3) 11.7nnne
Emotional perspective-taking (ACC) 0.85 (0.1) 0.74 (0.1) 0.73 (0.1) 17.7nnnb
(RT) 1.4 (0.3) 1.7 (0.4) 1.6 (0.3) 9.3nnne

Social functioning
Social competence 4.5 (0.6) 3.3 (0.8) 3.5 (0.8) 21.6nnnb
Social attainment 142.5 (11.1) 126.7 (14.4) 124.6 (10.2) 37.4nnnb

Abbreviations: individuals with schizophrenia with no depressive symptoms (SCZ), individuals with schizophrenia and depressive symptoms (SCZ DEP), healthy controls
(CON), task accuracy (ACC), task response time (RT).
n
Po 0.05.
nn
Po 0.01.
nnn
Po 0.001.
a
CON and SCZ DEP 4SCZ.
b
CON4SCZ and SCZ DEP.
c
CON4SCZ.
d
CONo SCZo SCZ DEP.
e
SCZ 4SCZ DEP and CON.

levels of fantasy than SCZ (Po0.01, Po0.05, respectively), while CON
and SCZ DEP did not differ (P40.10). There was a signicant effect of
group on IRI perspective-taking (F1,104 11.5, Po0.001) with SCZ and
SCZDEP reporting lower IRI perspective-taking than controls
(Po0.001 and Po0.01, respectively), while the differences between
SCZ and SCZDEP did not differ (P40.10). There was a signicant
effect of group on empathic concern (F1,104 4.0, Po0.05). SCZ had
lower levels of empathic concern than CON (Po0.01), while SCZDEP
did not differ from CON (P40.10) or SCZ (P40.10). There was a
signicant effect of group on personal distress (F1,104 15.2, Po0.001)
with SCZDEP and SCZ having higher personal distress than CON
(Po0.001 and Po 0.01, respectively), while SCZDEP had higher
personal distress than SCZ (Po0.01).
3.4. Performance-based empathy
Means and standard deviations for performance-based empa-
thy are presented in Table 3. There was a signicant effect of group
 A.C. Abramowitz et al. / Psychiatry Research 216 (2014) 325332
on the accuracy (F2,104 15.7, P o0.001) and response time (RT)
(F2,104 11.7, P o0.001) for the affective responsiveness task. SCZ
and SCZ DEP had lower accuracies (both Po 0.001) and slower
RTs (Po 0.001 and P 0.07 (trend), respectively) than CON. SCZ
and SCZ DEP did not differ with respect to accuracy (P4 0.10),
while SCZ had a longer RT than SCZ DEP (P o0.01).
There was a signicant effect of group on the accuracy
(F2,104 17.7, P o0.001) and response time (RT) (F2,104 9.3,
P o0.001) for the emotional perspective-taking task. SCZ and
SCZ DEP had lower accuracies (both Po 0.001) and slower RTs
(P o0.001 and P o0.05, respectively) than CON. SCZ and SCZ DEP
did not differ with respect to accuracy (P4 0.10), while SCZ had a
longer RT than SCZ DEP at the trend-level (P 0.06).
3.5. Social functioning
Means and standard deviations for social functioning are
presented in Table 3. There was a signicant effect of group on
social competence (F2,84 21.6, P o0.001), with SCZ and SCZ DEP
demonstrating lower competencies than controls (both P o0.001),
but no difference between SCZ and SCZ DEP (P 40.10). There was
also a signicant effect of group on social attainment (F2,103 37.4,
P o0.001), with SCZ and SCZ DEP demonstrating lower social
attainment levels than CON (both P o0.001), but no difference
between SCZ and SCZ DEP (P 40.10).
3.6. Correlations
Among SCZ DEP, depressive symptoms signicantly correlated
with personal distress (R0.38, Po0.05), but no other empathy
measure (all P40.10). Depressive symptoms correlated with social
attainment (R  0.44, Po0.05), but not social competence (P40.10).
The IRI subscales personal distress and perspective-taking were
correlated with social attainment (R  0.50, Po0.01 and R 0.39,
Po0.05, respectively), while fantasy and empathic concern were not
(both P40.10). We observed an a bivariate outlier that was removed
from the personal distress and social attainment correlation using a
standard procedure (Fieller, 2005; Tabachnick and Fidell, 2012).
Performance-based empathy accuracies did not correlate with
social competence or social attainment (Both P 40.10). The
performance-based measures of empathy were correlated with
each other (R 0.46, P o0.05), but not with the IRI subscales
(all P4 0.10). See Supplementary Fig. 2 for scatterplots of correla-
tions among personal distress, depressive symptoms, and social
attainment.
Among SCZ, IRI perspective-taking (R 0.45, P o0.01) and
empathic concern (R0.46, P o0.01) were correlated with social
attainment, but personal distress and fantasy were not (P4 0.10).
Performance-based cognitive empathy was correlated with social
competence (R 0.44, P o0.05), while this relationship was at the
trend level for emotional empathy (R0.37, P 0.08). Neither
performance-based empathy accuracies correlated with social
attainment (both P 40.10). The two performance-based measures
of empathy were correlated with each other (R 0.63, P o0.001),
Fig. 1. The Preacher and Hayes bootstrapping approach indicates the indirect effect of depressive symptoms on social attainment through personal distress was signicant
(95% C.I. LL  4.00, UL  0.28), while the direct effect of depressive symptoms on social attainment was reduced to a trend level of signicance (highlighted by the dashed
line). P 0.08, nP o 0.05, nnP o 0.01.
329
but did not correlate with the IRI subscales (all P 40.10). The IRI
subscales did not correlate with social competence for either SCZ
group (all P 40.10).
3.7. Mediation analysis
Fig. 1 displays the mediation results. There was a direct effect of
depressive symptoms on personal distress (F1,27 4.3, P o0.05)
and social attainment (F1,27 6.3, Po0.05). A single model using
5000 bootstrap resamples revealed that depressive symptoms had
an indirect effect on social attainment through personal distress
(B  1.54, SE 0.93; 95% CI LL  4.00, UL  0.28). The direct
effect of depressive symptoms on social attainment was reduced
to a trend-level of signicance (F1,24 3.3, P 0.08), which suggests
personal distress partially mediated the relationship between
depressive symptoms and social attainment. Alternatively, we
examined whether personal distress had a signicant indirect
effect on social attainment through depressive symptoms, but this
effect did not attain signicance (B  0.29, SE 0.22; 95%
CI LL  0.86, UL 0.01).
3.8. Exploratory Correlations
Among SCZ DEP, we observed that greater depressive symp-
toms were correlated with ratings of hallucinations (R 0.45,
Po 0.05), at affect (R0.45, P o0.05), avolition (R 0.38,
Po 0.05), and delusions at the trend level (R 0.36, P 0.06).
Depressive symptoms did not correlate with the remaining clinical
symptom ratings, duration of illness, and antipsychotic treatment
(all P 40.10). Among SCZ DEP, lower affective responsiveness
task accuracy was related to higher bizarre behavior (R  0.59,
Po 0.001) and alogia (R  0.46, Po 0.05) ratings (see
Supplementary Table 1). Among SCZ, we observed that lower
affective responsiveness task accuracy was related to more severe
delusions (R  0.48, P o0.01) and anhedonia (R  0.42,
Po 0.05), while higher IRI fantasy scores were related to higher
affective attening (R 0.40, P o0.05) and avolition (R 0.44,
Po 0.05) ratings (see Supplementary Table 2). There were no
other signicant correlations between symptoms and the IRI data
or with emotional perspective-taking task accuracy for both
groups.
4. Discussion
The current study demonstrated that SCZ DEP were charac-
terized by heightened levels of self-reported personal distress
beyond the elevated level of personal distress typically associated
with schizophrenia (Achim et al., 2011). We did not observe any
differences between SCZ and SCZ DEP with respect to
performance-based empathy. Measures of empathy, social func-
tioning, and clinical symptoms were normally distributed within
each group. We found that personal distress and depressive
symptoms were both correlated with poorer social attainment
330 A.C. Abramowitz et al. / Psychiatry Research 216 (2014) 325332
among SCZ DEP, and that personal distress partially mediated the
relationship between depressive symptoms and social attainment.
Both SCZ and SCZ DEP demonstrated self-reported and
performance-based decits in empathy; however, these methods
were not related to one another. These ndings are consistent with
prior work in individuals with schizophrenia (Derntl et al., 2009;
Lee et al., 2011; Smith et al., in press) and in healthy subjects (Ickes
et al., 2000; Zaki et al., 2008). These results suggest that one's own
self-perceived empathic ability may not be related to the actual
ability to understand and be responsive to others' emotions.
Surprisingly, we did not nd that SCZ DEP were characterized
by more severe impairments in social functioning. Perhaps the
social functioning measures used in the study were not sensitive
to social impairments beyond the measurable decits typically
associated with schizophrenia and exacerbated by co-occurring
depressive symptoms.
Research suggests that regulating one's emotional responsive-
ness is a key contributor to empathy (Decety, 2011). Moreover,
abnormalities in the regulation of one's emotional responsiveness
can contribute to greater feelings of personal distress (Decety and
Jackson, 2004; Eisenberg and Eggum, 2009). Prior research sug-
gests that the IRI subscale of personal distress may be a proxy for
assessing emotional regulation rather than a measure of empathy
(Reniers et al., 2011). Our ndings suggested that SCZ and
SCZ DEP had elevated levels of personal distress (i.e., emotional
dysregulation) as compared to CON, which is consistent with prior
studies of personal distress in schizophrenia (Achim et al., 2011).
Moreover, we found that personal distress was signicantly
higher in SCZ DEP as compared to SCZ. This nding provides
some support to our hypothesis that SCZ DEP may have more
severe empathic impairments. The association between depressive
symptoms and heightened personal distress is also consistent with
previous studies of the empathic abilities of individuals with major
depressive disorder (O'Connor et al., 2002; Cusi et al., 2011; Thoma
et al., 2011; Derntl et al., 2012; Schreiter et al., 2013). Thus, the
presence of mild-to-moderate depressive symptoms could be
exacerbating the elevated personal distress already associated
with schizophrenia. However, longitudinal data is needed to assess
the direction of this relationship.
Among SCZ DEP, we found that personal distress was nega-
tively correlated with social attainment. Prior studies have not
reported a relationship between personal distress and social
functioning measures among individuals with schizophrenia or
depression (Cusi et al., 2011; Smith et al., 2012, in press). The
observed mediating properties of personal distress as well as its
relationship with social attainment in this study suggests that
personal distress could be a novel treatment target with direct
implications for improving social functioning. Regarding clinical
implications, interventions could be developed to remediate the
heightened personal distress (i.e., emotion dysregulation) linked
to depressive symptoms experienced by this group. For instance,
cognitive behavioral therapy has demonstrated preliminary ef-
cacy at improving emotion regulation in early psychosis (Khoury
et al., 2013), while dialectical behavior therapy has demonstrated
promise for improving emotion regulation among individuals with
cognitive disabilities (Brown et al., 2013). Hence, these interven-
tions could potentially be adapted for use with individuals with
schizophrenia who are experiencing depressive symptoms.
Interestingly, we found that measures of emotional empathy
were associated with social attainment in the SCZ DEP group.
This nding diverges from our prior work that emotional empathy
may be unrelated to social functioning in individuals with schizo-
phrenia (Smith et al., 2012, in press). Thus, the presence of
depressive symptoms could be disturbing this relationship. Con-
trary to our hypothesis, SCZ DEP did not demonstrate exacer-
bated decits in performance-based measures of either cognitive
or emotional empathy. These ndings add to the small literature
suggesting that depression may not be related to additional
impairments in performance-based measures of empathy
(Thoma et al., 2011; Derntl et al., 2012). Future research could
examine the empathic abilities of individuals with schizophrenia
experiencing greater severity in depressive symptoms since the
present sample was characterized by mild-to-moderate ratings of
depressive symptoms that were skewed towards being mild. The
negative core beliefs typically associated with depression may
have contributed to the depressed group providing negatively
biased responses on the measures of personal distress (Beck,
1996).
Our exploratory results suggest that SCZ DEP were character-
ized by elevated positive symptoms that were associated with
greater severity in depressive symptoms, which is consistent with
prior studies (Sax et al., 1996; Cohen et al., in press). Based on
these ndings, one could hypothesize that these individuals could
be feeling depressed due to persistently hearing voices or having
delusional beliefs. However, future research using a longitudinal
design will be needed to evaluate this potential relationship. Thus,
a potential clinical implication of these results is that clinicians
might consider monitoring their patients with schizophrenia for
increased depressive symptoms when an increased severity in
positive symptoms is observed.
The ndings should be interpreted in the context of some
limitations. First, our samples were small and have limited
explanatory power so a larger sample could help clarify the
trend-level correlations or differences in task response time that
appear to be counterintuitive. Second, the cross-sectional nature of
this study prevents us from drawing any causal conclusions. Third,
we did not assess several factors that may have inuenced
empathy or the level of depressive symptoms. For instance, we
did not assess one's motivation to empathize, which may inuence
one's ability to empathize with others (Tucker et al., 2005; Morelli
et al., 2014). Hence, elevated depressive symptoms could be
associated with reduced empathic motivation rather than impact-
ing one's empathic ability. Also, we did not evaluate the presence
of Axis II disorders (e.g., schizotypal, narcissistic, and borderline
personality disorders), which have been associated with impair-
ments in empathy (Ritter et al., 2011; Roepke et al., 2012; Ripoll
et al., 2013). Social anxiety is another factor we did not assess that
has been associated with reduced empathy (Achim et al., 2011).
Furthermore, we did not assess the extent that our participants
experienced extrapyramidal symptoms or were demoralized by
their mental health status, which have both been associated with
increased severity of depressive symptoms (Birchwood et al.,
2005; Aguilar and Siris, 2007; Shahar et al., 2010). Hence, these
factors should be considered when interpreting the results and
may be important areas for future research. Fourth, the affective
responsiveness task required participants to identify how they
would feel in response to certain emotional situations. These
responses represent cognitively determined hypothetical emo-
tional states rather than in-the-moment affective responses, and
must be considered as such when interpreting the ndings. Lastly,
the performance measures used to assess empathy may not have
been able to capture all domains of empathy affected by depres-
sion. For example, emotional contagion is a key empathic process
(Preston and de Waal, 2002), but was not well captured by the
self-reported or performance-based methods used in this study.
In conclusion, our ndings suggest that individuals with
schizophrenia and mild-to-moderate depressive symptoms have
elevated levels of personal distress that potentially mediate the
association between depressive symptoms and poor social func-
tioning. Hence, individuals with schizophrenia and co-occurring
depressive symptoms may benet from receiving services
designed to address their heightened personal distress. Future
 A.C. Abramowitz et al. / Psychiatry Research 216 (2014) 325332
research is needed to identify specic factors that contribute to
elevations in personal distress that have been associated with
schizophrenia and depressive symptoms.
Acknowledgment
We would like to acknowledge the research staff at the North-
western University Schizophrenia Research Group for study coor-
dination and data collection, and our participants for volunteering
their time. This work was funded by the Department of Psychiatry
and Behavioral Sciences at Northwestern University Feinberg
School of Medicine. Additional support for this study was provided
by the Warren Wright Adolescent Center at Northwestern Mem-
orial Hospital's Stone Institute of Psychiatry.
Appendix A. Supplementary material
Supplementary data associated with this article can be found in
the online version at http://dx.doi.org/10.1016/j.psychres.2014.02.028.
References
Achim, A.M., Ouellet, R., Roy, M.A., Jackson, P.L., 2011. Assessment of empathy in
rst-episode psychosis and meta-analytic comparison with previous studies in
schizophrenia. Psychiatry Research 190 (1), 38.
Aguilar, E.J., Siris, S.G., 2007. Do antipsychotic drugs inuence suicidal behavior in
schizophrenia? Psychopharmacology Bulletin 40 (3), 128142.
Andreasen, N.C., 1983a. The Scale for the Assessment of Negative Symptoms. The
University of Iowa, Iowa City, IA.
Andreasen, N.C., 1983b. The Scale for the Assessment of Positive Symptoms. The
University of Iowa, Iowa City, IA.
Baez, S., Herrera, E., Villarin, L., Theil, D., Gonzalez-Gadea, M.L., Gomez, P.,
Mosquera, M., Huepe, D., Strejilevich, S., Vigliecca, N.S., Matthaus, F., Decety,
J., Manes, F., Ibanez, A.M., 2013. Contextual social cognition impairments in
schizophrenia and bipolar disorder. PLoS One 8 (3), e57664.
Barch, D.M., Mitropoulou, V., Harvey, P.D., New, A.S., Silverman, J.M., Siever, L.J.,
2004. Context-processing decits in schizotypal personality disorder. Journal of
Abnormal Psychology 113 (4), 556568.
Beck, A., 1996. The past and future of cognitive therapy. Journal of Psychotherapy
Practice and Research 6 (4), 276284.
Benton, A.L., Hamsher, K., Sivan, A.B., 1976. Multilingual Aphasia Examination. AJA
Associates, Iowa City.
Birchwood, M., Iqbal, Z., Upthegrove, R., 2005. Psychological pathways to depres-
sion in schizophrenia: studies in acute psychosis, post psychotic depression and
auditory hallucinations. European Archives of Psychiatry and Clinical Neu-
roscience 255, 202212.
Bondol, G., Jermann, F., Rouget, B.W., Gex-Fabry, M., McQuillan, A., Dupont-
Willemin, A., Aubry, J.M., Nguyen, C., 2010. Self- and clinician-rated Montgom-
eryAsberg Depression Rating Scale: evaluation in clinical practice. Journal of
Affective Disorders 121 (3), 268272.
Brown, J.F., Brown, M.Z., Dibiasio, P., 2013. Treating Individuals with intellectual
disabilities and challenging behaviors with adapted dialectical behavior ther-
apy. Journal of Mental Health Research in Intellectual Disabilities 6 (4),
280303.
Brune, M., Brune-Cohrs, U., 2006. Theory of mindevolution, ontogeny, brain
mechanisms and psychopathology. Neuroscience and Biobehavioral Reviews
30 (4), 437455.
Buckley, P.F., Miller, B.J., Lehrer, D.S., Castle, D.J., 2009. Psychiatric comorbidities and
schizophrenia. Schizophrenia Bulletin 35 (2), 383402.
Cohen, C.I., Izediuno, I., Yadack, A.M., Ghosh, B., Garrett, M., 2013. Characteristics of
auditory hallucinations and associated factors in older adults with schizophre-
nia, American Journal of Geriatric Psychiatry, electronic publication 7 Septem-
ber; http://dx.doi.org/10.1016/j.jagp.2013.07.001.
Cusi, A.M., Macqueen, G.M., Spreng, R.N., McKinnon, M.C., 2011. Altered empathic
responding in major depressive disorder: relation to symptom severity, illness
burden, and psychosocial outcome. Psychiatry Research 188 (2), 231236.
Davis, M.H., 1983. Measuring individual differences in empathy: evidence for a
multidimensional approach. Journal of Personality and Social Psychology 44
(1), 113126.
Decety, J., 2011. Dissecting the neural mechanisms mediating empathy. Emotion
Review 3 (1), 92108.
Decety, J., Jackson, P.L., 2004. The functional architecture of human empathy.
Behavioral and Cognitive Neuroscience Reviews 3 (2), 71100.
Delis, D., Kramer, J.H., Kaplan, E., Ober, B., 1983. California Verbal Learning Test,
Research Edition. The Psychological Corporation, Cleveland.
331
Derntl, B., Finkelmeyer, A., Toygar, T.K., Hulsmann, A., Schneider, F., Falkenberg, D.I.,
Habel, U., 2009. Generalized decit in all core components of empathy in
schizophrenia. Schizophrenia Research 108 (13), 197206.
Derntl, B., Seidel, E.M., Schneider, F., Habel, U., 2012. How specic are emotional
decits? A comparison of empathic abilities in schizophrenia, bipolar and
depressed patients. Schizophrenia Research 142 (1-3), 5864.
Eisenberg, N., Eggum, N.D., 2009. Empathic Responding: Sympathy and Personal
Distress. In: Decety, J., Ickes, W. (Eds.), The Social Neuroscience of Empathy. The
MIT Press, Cambridge, MA, pp. 7184.
Fervaha, G., Agid, O., Takeuchi, H., Foussias, G., Remington, G., 2013. Clinical
determinants of life satisfaction in chronic schizophrenia: data from the CATIE
study. Schizophrenia Research 151 (13), 203208.
Fieller, N., 2005. Multivariate outliers. In: Everitt, B.S., Howell, D.C. (Eds.), Encyclo-
pedia of Statistics in Behavioral Science, vol. 3. John Wiley & Sons, Ltd,
Chichester, pp. 13791384.
First, M.B., Spitzer, R.L., Miriam, G., Williams, J.B.W., 2002. Structured clinical
interview for DSM-IV-TR Axis I Disorders, Research Version, Non-patient
Edition. Biometrics Research, New York State Psychiatric Institute, New York,
NY.
Gur, R.C., Sara, R., Hagendoorn, M., Marom, O., Hughett, P., Macy, L., Turner, T.,
Bajcsy, R., Posner, A., Gur, R.E., 2002. A method for obtaining 3-dimensional
facial expressions and its standardization for use in neurocognitive studies.
Journal of Neuroscience Methods 115 (2), 137143.
Haker, H., Schimansky, J., Jann, S., Rssler, W., 2012. Self-reported empathic abilities
in schizophrenia: a longitudinal perspective. Psychiatry Research 200 (23),
10281031.
Harvey, P.D., Velligan, D.I., Bellack, A.S., 2007. Performance-based measures of
functional skills: usefulness in clinical treatment studies. Schizophrenia Bulle-
tin 33 (5), 11381148.
Ickes, W., Buysse, A.H.P., Rivers, K., Erickson, J., Hankock, M., Kelleher, J., Gesn, P.R.,
2000. On the difculty of distinguishing "good" and "poor" perceivers: a social
relations analysis of empathic accuracy data. Personal Relationships 7, 219234.
Kasckow, J., Lanouette, N., Patterson, T., Fellows, I., Golshan, S., Solorzano, E., Zisook, S.,
2010. Treatment of subsyndromal depressive symptoms in middle-aged and older
adults with schizophrenia: effect on functioning. International Journal of Geriatric
Psychiatry 25 (2), 183190.
Kessler, R.C., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikangas, K.R., Rush, A.J.,
Walters, E.E., Wang, P.S., 2003. The epidemiology of major depressive disorder:
results from the National Comorbidity Survey Replication (NCS-R). Journal of
the American Medical Association 289 (23), 30953105.
Khoury, B., Lecomte, T., Comtois, G., Nicole, L., 2013. Third-wave strategies for
emotion regulation in early psychosis: a pilot study. Early Intervention in
Psychiatry.
Lanon, C., Auquier, P., Reine, G., Bernard, D., Addington, D., 2001. Relationships
between depression and psychotic symptoms of schizophrenia during an acute
episode and stable period. Schizophrenia Research 47 (23), 135140.
Langdon, R., Coltheart, M., Ward, P.B., 2006. Empathetic perspective-taking is
impaired in schizophrenia: evidence from a study of emotion attribution and
theory of mind. Cognitive Neuropsychiatry 11 (2), 133155.
Lee, J., Zaki, J., Harvey, P.O., Ochsner, K., Green, M.F., 2011. Schizophrenia patients
are impaired in empathic accuracy. Psychological Medicine 41 (11), 18.
Marder, S.R., Fenton, W., 2004. Measurement and treatment research to improve
cognition in schizophrenia: NIMH MATRICS initiative to support the develop-
ment of agents for improving cognition in schizophrenia. Schizophrenia
Research 72 (1), 59.
Montgomery, S.A., Asberg, M., 1979. A new depression scale designed to be
sensitive to change. British Journal of Psychiatry 134, 382389.
Morelli, S.A., Rameson, L.T., Lieberman, M.D., 2014. The neural components of
empathy: predicting daily prosocial behavior. Social and Cognitive Affective
Neuroscience 9 (1), 3947.
O'Connor, L.E., Berry, J.W., Weiss, J., Gilbert, P., 2002. Guilt, fear, submission, and
empathy in depression. Journal of Affective Disorders 71 (13), 1927.
Patterson, T.L., Moscona, S., McKibbin, C.L., Davidson, K., Jeste, D.V., 2001. Social
skills performance assessment among older patients with schizophrenia.
Schizophrenia Research 48 (23), 351360.
Preacher, K.J., Hayes, A.F., 2004. SPSS and SAS procedures for estimating indirect
effects in simple mediation models. Behavior Research Methods, Instruments, &
Computers: A Journal of the Psychonomic Society, Inc. 36 (4), 717731.
Preston, S.D., de Waal, F.B., 2002. Empathy: its ultimate and proximate bases.
Behavioral and Brain sciences 25 (1), 2071 (120; discussion).
Reitan, R., Wolfson, D., 1985. The Halstead-Reitan Neuropsycholoigcal Test Battery:
Theory and Clinical Interpretation. Neuropsychology Press, Tucson, AZ.
Reniers, R.L., Corcoran, R., Drake, R., Shryane, N.M., Vollm, B.A., 2011. The QCAE: a
Questionnaire of Cognitive and Affective Empathy. Journal of Personality
Assessments 93 (1), 8495.
Ripoll, L.H., Zaki, J., Perez-Rodriguez, M.M., Snyder, R., Strike, K.S., Boussi, A., Bartz, J.A.,
Ochsner, K.N., Siever, L.J., New, A.S., 2013. Empathic accuracy and cognition in
schizotypal personality disorder. Psychiatry Research 210, 232241.
Ritter, K., Dziobek, I., Preissler, S., Rter, A., Vater, A., Fydrich, T., Lammers, C.H.,
Heekeren, H.R., Roepke, S., 2011. Lack of empathy in patients with narcissistic
personality disorder. Psychiatry Research 187, 241247.
Roepke, S., Vater, A., Preiler, S., Heekeren, H.R., Dziobek, I., 2012. Social cognition
in borderline personality disorder. Frontiers in Neuroscience 6, 195.
Sax, K.W., Strakowski, S.M., Keck , P.E., Upadhyaya, V.H., West, S.A., McElroy, S.L.,
1996. Relationships among negative, positive, and depressive symptoms in
332 A.C. Abramowitz et al. / Psychiatry Research 216 (2014) 325332
schizophrenia and psychotic depression. British Journal of Psychiatry 168 (1),
6871.
Schneider, L.C., Struening, E.L., 1983. SLOF: a behavioral rating scale for assessing
the mentally ill. Social Work Research Abstracts 19 (3), 921.
Schreiter, S., Pijnenborg, G.H., Aan He tRot, M., 2013. Empathy in adults with clinical
or subclinical depressive symptoms. Journal of Affective Disorders 150 (1),
116.
Shahar, G., Weinberg, D., McGlashan, T.H., Davidson, L., 2010. Illness related stress
interacts with perception of the self as ill to predict depression in psychosis.
International Journal Cognitive Therapy 3 (2), 202210.
Shamay-Tsoory, S.G., 2011. The neural bases for empathy. Neuroscientist 17 (1),
1824.
Shamay-Tsoory, S.G., Shur, S., Harari, H., Levkovitz, Y., 2007. Neurocognitive basis of
impaired empathy in schizophrenia. Neuropsychology 21 (4), 431438.
Simonsen, C., Sundet, K., Vaskinn, A., Ueland, T., Romm, K.L., Hellvin, T., Melle, I.,
Friis, S., Andreassen, O.A., 2010. Psychosocial function in schizophrenia and
bipolar disorder: relationship to neurocognition and clinical symptoms. Journal
of International Neuropsycholology Society 16 (5), 771783.
Smith, M.J., Horan, W.P., Cobia, D.J., Karpouzian, T.M., Fox, J.M., Reilly, J.L., Breiter, H.C.,
2013. Performance-based empathy mediates the inuence of working memory
on social competence in schizophrenia. Schizophrenia Bulletin, electronic pub-
lication 31 December; http://dx.doi.org/10.1093/schbul/sbt084.
Smith, M.J., Horan, W.P., Karpouzian, T.M., Abram, S.V., Cobia, D.J., Csernansky, J.G.,
2012. Self-reported empathy decits are uniquely associated with poor func-
tioning in schizophrenia. Schizophrenia Research 137 (13), 196202.
Sparks, A., McDonald, S., Lino, B., O'Donnell, M., Green, M.J., 2010. Social cognition,
empathy and functional outcome in schizophrenia. Schizophrenia Research 122
(13), 172178.
Tabachnick, B.G., Fidell, L.S., 2012. Using multivariate statistics. In: Tabachnick, B.G.,
Fidell, L.S. (Eds.), Using Multivariate Statistics, 6th ed. Allyn and Bacon, Boston
Thoma, P., Zalewski, I., von Reventlow, H.G., Norra, C., Juckel, G., Daum, I., 2011.
Cognitive and affective empathy in depression linked to executive control.
Psychiatry Research 189 (3), 373378.
Tucker, D.M., Luu, P., Derryberry, D., 2005. Love hurts: the evolution of empathic
concern through the encephalization of nociceptive capacity. Development and
Psychopathology 17 (3), 699713.
Wechsler, D., 1997a. Wechsler Adult Intelligence Scale, Third Edition The Psycho-
logical Corporation, San Antonio.
Wechsler, D., 1997b. Wechsler Memory Scale, Third Edition The Psychological
Corporation, San Antonio.
Zaki, J., Bolger, N., Ochsner, K., 2008. It takes two: the interpersonal nature of
empathic accuracy. Psychological Science 19 (4), 399404.
Zaki, J., Ochsner, K., 2011. Reintegrating the study of accuracy into social cognition
research. Psychological Inquiry 22 (3), 159182.