The forgotten impairment

The stroke psychology team I work with received a referral for a patient, who I will refer to as 'Kev'. Kev had only spent a few days in the hospital after a left frontal infarct and was sent home without any further healthcare recommendations. He was physically fit – his idea of a short bike ride is 20 miles – and he had scored well on cognitive screening assessments. During a routine post-six-month review, however, it transpired that his wife, Ann, was on the brink of a breakdown. What was going on?

Before our initial meeting with the couple, Ann sent a letter to the team outlining her concerns. Ann explained that Kev often thought he was behaving 'normally', but she had noticed a change in his demeanour. It was as if Kev's 'social filter' was not working. He would say things to people that would make her cringe. Ann was eager to support any behaviour changes post-stroke, and she clearly wanted to look after Kev. But she experienced great difficulty coming to terms with Kev snapping at her for no apparent reason; they had never argued as a couple, and this was really getting her down. Ann felt that Kev had totally changed towards her and that she was viewed as the enemy. Ann had stopped Kev from attending all of the voluntary work meetings and events they used to attend as a couple as she could see these caused Kev stress, and he had made more than one faux pas. Kev went on to admit that he had begun to feel a bit worthless and like he was lacking a purpose.

My supervisor and I worked with the couple, focusing mainly on communication as well as providing some educational resources outlining frontal-lobe symptomatology after stroke. We also discussed why it was important for Kev to return to the volunteer group and how he could do so at his own pace.

Kev and Ann told me last week that they were ready to be discharged from the psychology caseload. They explained that they were feeling a lot more positive about things and that they could understand each other much better. They had also run a large-scale volunteer event that Kev was apprehensive about, but he did great on the day, which really boosted his confidence. Ann said that the major turning point was the initial appointment with the psychology team, where they were told the most basic thing; that the social cognition impairments Kev was experiencing were normal after the type of stroke he had experienced. Ann suggested that if they had had the appointment earlier, Kev's recovery and her own mental health would have been much improved.

The crux of humanity

So what is social cognition? Until I began my PhD research investigating eye-scan patterns and social cognition after traumatic brain injury (TBI), I was not familiar with the term. Trying to delineate social cognition for my thesis was challenging, as there is no categorical definition or factor structure for the process. Social cognition is a broad term that can refer to any cognitive process that mediates or facilitates the ability to understand the self, other conspecifics, or the relationship between the self and other conspecifics (Forbes & Grafman, 2010). Within the current literature, there are various definitions of social cognition, from very basic explanations such as 'simply thinking about people' (Fiske, 1995, p.151), to more advanced definitions: 'the psychological processes that are involved in the perception, encoding, storage, retrieval and regulation of information about other peo­ple and ourselves. These processes include social cue perception, experience sharing, inferring other people's thoughts and emotions, and managing emotional reac­tions to others' (Green et al., 2015, p.620).

I have become increasingly interested in social cognition. It's what allows us to sustain intimate and familial relationships, as well as to interact with the wider community. Basically, social cognition can be seen as the crux of humanity. It allows us to partake in 'simple' activities, such as sustaining conversations, understanding jokes and interpreting people's moods. Social cognition also facilitates more complex human behaviours, such as the capability to deceive other people, the production of stereotypes, and, very importantly, theory of mind (the ability to attribute mental states, intentions and knowledge to ourselves and others).

So, now I ask you to imagine a world in which you cannot use these social cognition abilities. You have lost the ability to recognise emotions, understand sarcasm and empathise with others. Your relationships dissolve at home and at work, you find it difficult to interact with people in the community, you lose your sense of purpose in life and you begin to experience social isolation. Sadly, I've learned through my PhD research and my current assistant psychologist posts that this scenario is very common after brain injury. Poor social skills are associated with a variety of neurological conditions and are often considered one of the most challenging, debilitating and persistent deficits to live with for both the patient and their family or caregivers. The current neuropsychology literature often documents that changes in emotional and social abilities are more detrimental and difficult to deal with than any cognitive or physical changes.

Overlooked

Why, then, does social cognition appear so overlooked in a healthcare setting? The DSM‑5 introduced social cognition as one of six core components of neurocognitive function, highlighting the critical nature of the process, yet it still presents as a neglected clinical area. In 2016 Michelle Kelly at the University of Newcastle in Australia led a worldwide online survey exploring clinicians' social cognition assessment practices with brain-injured patients. A large majority (84 per cent) of clinicians reported that more than half of their patients displayed some form of social cognition impairments. The following year Kelly's team documented that 78 per cent of clinicians admitted that they rarely or never assessed these deficits using standardised neuropsychological assessments.

One reason for this is a shortage of reliable tests. I struggled to find suitable assessments for my PhD research… I refused to use any black-and-white images or photos with bad 80s hairstyles! Even if assessments are completed, rehabilitation programmes do not have a strong evidence base. The research field of social cognition is still in its infancy, having only emerged at the end of the 20th century. It is therefore not surprising that definitions, assessments and rehabilitation programmes are still primitive.

Nevertheless, we are developing a sound understanding of the mechanisms underpinning social cognition and this knowledge needs to be incorporated within the healthcare setting. For instance, it would be beneficial to have a standardised social cognition screening assessment after acquired brain injury. This might be easier said than done: a major issue in developing assessments and interventions is that social cognition is complex, dynamic and uniquely human and individualised (see box, below). The autism and schizophrenia literature are leading the way for social cognition intervention, and the same principles could be applied in acquired brain injury settings, but more research is needed. 

On the brink

In summary, seeing at first hand the adverse effects of aberrant social cognition, and the impact this has on quality of life, is driving me to improve research and clinical practice. Although I am biased, my PhD research has yielded some really interesting findings. For example, my TBI participants displayed abnormal eye-scan patterns compared with controls, with fewer and shorter fixations to the eyes. Total fixation duration and counts to the eyes were correlated with more accurate emotion recognition and higher levels of empathy. These results illustrate a potential for innovative sociocognitive rehabilitation approaches post-TBI, possibly involving face-scanning training.

We're hopefully on the brink of some exciting developments within the domain of social cognition. Sometimes during neurorehabilitation, I feel we're not able to see the wood for the trees: we are so focused on recovery that we forget that our patient is a person, to the point that we do not even assess the very essence of human life. Maybe we just need to take a step back, survey the view and get social.

- Leanne Greene is a PhD researcher at Sheffield Hallam University and assistant psychologist within neurology and rehabilitation services for RDaSH NHS Trust. [email protected]

BOX: Developing assessments and interventions

Leo is a middle-aged male who underwent a craniotomy followed by 28 sessions of radiotherapy to treat a large right frontal meningioma. I met Leo when I was collecting my PhD data and I still see him regularly during my two days a week as an assistant psychologist for a neurorehabilitation outreach team. Throughout the neurorehabilitation process, Leo's family reported significant personality changes, including increased levels of aggression and defensive remarks. When questioned about these changes, Leo could identify that he was more outspoken, blunt and bossy in his social communication, explaining that he had always felt suppressed prior to his illness.

Leo can be verbose in conversation and exhibits difficulties limiting the extent and breadth of conversation, and frequently does not respond to cues to change direction in conversation or to end a conversation. Leo is also very opinionated and will frequently make inappropriate comments that can cause offence. Leo admits to feeling socially isolated and lonely, often reporting disagreements with his family.

As part of my PhD research, Leo completed The Awareness of Social Inference Test (TASIT), the Movie for the Assessment of Social Cognition, the Empathy Quotient, and an emotion recognition test using the static and dynamic stimuli from the Amsterdam Dynamic Facial Expressions Set, for all of which he scored below average compared to the control group. To try to mitigate these challenges, clinic sessions were organised with Leo's family to try to make him more aware of the changes. He also started to attend the Headway coffee mornings, which are a great source of social interaction. During sessions, my supervisor and I will often redirect or refocus Leo, but this is not possible outside of the clinic.

Despite all of these interventions Leo still struggles to reintegrate into the community. The persistent impairments are impacting on his ability to find suitable employment, and he is currently battling with the benefits system. The psychology team are in the initial stages of organising a group focused on social cognition for individuals with acquired brain injuries, where we are hoping to run parallel sessions with patients and families. If anyone has run anything similar I would love to hear from you.

Editor's note: This article was originally published online in September 2018.

References

Fiske, S.T. (1995). Social cognition. In A. Tesser (Eds.), Advanced social psychology (pp. 145- 194). New York, NY: McGraw-Hill
Forbes, C.E., & Grafman. (2010). The role of the human prefrontal cortex in social cognition and moral judgment. Annual Review of Neuroscience, 33, 299-324. doi: 10.1146/annurev-neuro-060909-153230
Green, M.F., Horan, W.P. & Lee, J. (2015). Social cognition in schizophrenia. Nature Reviews Neuroscience, 16, 620-631. doi: 10.1038/nrn4005
Kelly, M., McDonald, S., & Frith, M.H.J. (2017a). A Survey of Clinicians Working in Brain Injury Rehabilitation: Are Social Cognition Impairments on the Radar? The Journal of Head Trauma Rehabilitation, 32, 55-65. doi: 10.1097/HTR.0000000000000269
Kelly, M., McDonald, S., & Frith, M.H.J. (2017b). Assessment and Rehabilitation of Social Cognition Impairment after Brain Injury: Surveying Practices of Clinicians. Brain Impairment, 18, 11-35. doi: 10.1017/BrImp.2016.34