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Nice or effective? social problem solving Strategies In Patients with Major Depressive Disorder Patrizia Thoma, Tobias Schmidt, Georg Juckel, Christine Norra, Boris Suchan

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Received date: 20 August 2014 Revised date: 6 April 2015 Accepted date: 15 May 2015 Cite this article as: Patrizia Thoma, Tobias Schmidt, Georg Juckel, Christine Norra, Boris Suchan, Nice or effective? social problem solving Strategies In Patients with Major Depressive Disorder, Psychiatry Research, http://dx.doi.org/ 10.1016/j.psychres.2015.05.015 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Nice or Effective? Social Problem Solving Strategies in Patients with Major Depressive Disorder

Patrizia Thomaa*, Tobias Schmidta, Georg Juckelb, Christine Norrab1, Boris Suchana1

a

Institute of Cognitive Neuroscience, Dept. of Neuropsychology,

Ruhr-University Bochum, Universitätsstraße 150, D-44780 Bochum, Germany b

Dept. of Psychiatry, Ruhr-University Bochum, LWL University Hospital, Alexandrinenstraße 1-3, D-44791 Bochum, Germany

1: These authors contributed equally to the paper.

Running head: Thoma et al.

* Corresponding author Phone: +49-234-32-22674 Fax:

+ 49-234-32-14622

e-mail: [email protected]







Nice or Effective? Social Problem Solving Strategies in Patients with Major Depressive Disorder

Patrizia Thomaa*, Tobias Schmidta, Georg Juckelb, Christine Norrab1, Boris Suchana1

a

Institute of Cognitive Neuroscience, Dept. of Neuropsychology,

Ruhr-University Bochum, Universitätsstraße 150, D-44780 Bochum, Germany b

Dept. of Psychiatry, Ruhr-University Bochum, LWL University Hospital, Alexandrinenstraße 1-3, D-44791 Bochum, Germany

1: These authors contributed equally to the paper.

Running head: Thoma et al.

* Corresponding author Phone: +49-234-32-22674 Fax:

+ 49-234-32-14622

e-mail: [email protected]

Abstract Our study addressed distinct aspects of social problem solving in 28 hospitalized patients with Major Depressive Disorder (MDD) and 28 matched healthy controls. Three scenariobased tests assessed the ability to infer the mental states of story characters in difficult interpersonal situations, the capacity to freely generate good strategies for dealing with such situations and the ability to identify the best solutions among less optimal alternatives. Also, standard tests assessing attention, memory, executive function and trait empathy were administered. Compared to controls, MDD patients showed impaired interpretation of other peoples’ sarcastic remarks but not of the mental states underlying other peoples’ actions. Furthermore, MDD patients generated fewer strategies that were socially sensitive and practically effective at the same time or at least only socially sensitive. Overall, while the free generation of adequate strategies for difficult social situations was impaired, recognition of optimal solutions among alternatives was spared in MDD patients. Higher generation scores were associated with higher trait empathy and cognitive flexibility scores. We suggest that this specific pattern of impairments ought to be considered in the development of therapies addressing impaired social skills in MDD.

Keywords: Theory of Mind, social cognition, social skills, problem solving, depression

1. Introduction Major Depressive Disorder (MDD) is mainly characterized by sad or empty mood and loss of interest or pleasure in most activities (DSM V: American Psychiatric Association, 2013). Neuropsychological impairments, primarily affecting attention, executive function and memory, have been related to MDD, too (see Beblo et al., 2011). Furthermore, interpersonal problems and loss of interest in social contacts represent a hallmark feature of depressive episodes. The disorder has been associated with mood-congruent biases reflecting preferential processing of negatively valenced (Uekermann et al., 2008; Bourke et al., 2010; Peron et al., 2011), attenuated processing of positively valenced (e.g. Clark and Watson, 1991) or generally blunted processing of emotional information (Emotion Context Insensitivity Theory: Rottenberg and Gotlib, 2004). In terms of higher-order sociocognitive abilities, MDD patients show impaired Theory of Mind or mentalizing, i.e. a reduced ability to reason about other people’s mental states, during both acute and remitted stages (Inoue et al., 2004; Lee et al., 2005; Brüne and Brüne-Cohrs, 2006; Inoue et al., 2006; Uekermann et al., 2008; Szily and Keri, 2009). This is particularly the case when integration of social context information is required (Wolkenstein et al., 2011). Interestingly, cognitive empathy, i.e. the ability to identify another person’s feelings, appears to be spared, while emotional empathy is altered: MDD patients experience more personal distress in response to other people`s negative emotions (see Thoma et al., 2013). Neuroimaging studies suggest enhanced activation to socioemotional information in limbic and other emotion-processing structures, such as the ventromedial prefrontal cortex and the amygdala, during acute depression (see Cusi et al., 2012). Mentalizing and empathy constitute major prerequisites for socially skilled behaviour (Thoma et al., 2013). More specifically, social problem solving, which represents the central concept investigated in this paper, refers to the ability to detect an interpersonal conflict and to choose effective and adaptive strategies for overcoming it (D'Zurilla and Nezu, 1990). Various models of the components underlying socially skilled behaviour in problematic

interpersonal situations have been proposed (e.g. Dodge, 1986; Crick and Dodge, 1994). All share the assumption that social problem solving involves three sets of skills, of which the latter two will be addressed in this study: (1) perceptual skills (selection of salient information about the interaction partner such as his or her facial emotional expression or a specific behaviour), (2) cognitive skills (understanding the other person's perspective) and (3) performance-based processing skills (see Tse and Bond, 2004). Performance-based processing skills may involve the generation of possible solutions to a problem and the selection of the most appropriate alternative which optimally solves the problem both practically and in a socially sensitive manner (Channon and Crawford, 2010). Furthermore, implementation of the solution in the interaction and evaluation of the action in terms of goal attainment and consequences for the interpersonal relationship is important. Cognitive processes that mediate goal-directed and adaptive behaviour, such as executive functions (Channon, 2004) and memory (e.g. knowledge about social rules: Saver and Damasio, 1991), also affect social skills (see Channon and Crawford, 2010). Social skills impairment represents a vulnerability factor for MDD. In turn, depression may aggravate socially inadequate behaviour and unsatisfactory social interactions lead to more severe depressive symptoms (Segrin, 1990; 2000; Tse and Bond, 2004). The majority of findings on social skills impairment in MDD is based on self-reports and on partner/observer-/experimenter-based ratings of behavioural indicators of social skills (e.g. gaze and facial expression) during actual social interactions. Segrin (1990; 2000) concludes that patients with MDD evaluate their social skills more negatively than healthy controls do; that observers often also rate the patients’ behaviour more negatively than that of controls and that depressed mood is clearly reflected in social behaviour. On a more analytic level, populations with subclinical and clinical depression appear to show adequate understanding of social problems, but choose less effective, e.g. fewer action-oriented problem solving strategies (Marx and Schulze, 1991; Marx et al., 1992). Autobiographical memory deficits and dysfunctional state-oriented (“Why do I have this problem?”) rather than action-oriented (“What can I do to solve it?”) rumination have been discussed as the cognitive reasons

underlying maladaptive social problem solving in MDD (Watson and Andrews, 2002; Watkins and Baracaia, 2002). Few studies addressed social problem solving in more recent times. Using a role-play test, Mueser et al. (2010) found that elderly patients with MDD were less impaired in their actual problem solving behaviour than patients with schizophrenia. On the other hand, elderly depressed patients who perceived social problems as impossible to solve and showed an impulsive/careless problem solving style (Szanto et al., 2012) - as assessed by the Social Problem Solving Inventory–Revised (D'Zurilla et al., 2002) - reported more suicide attempts. These were associated with cognitive decline, further highlighting the importance of controlling for overall cognitive functioning. Evaluating the literature summarized above, several open issues can be identified: First, most studies were conducted in healthy student populations with more or less pronounced, but nevertheless subclinical depressive symptoms (see review by Tse and Bond, 2004). It is thus questionable whether the results can be generalized to clinical populations. Second, there is a lack of investigations analyzing the problem solving strategies of MDD patients specifically in terms of whether they are both socially adequate and practically effective. Third, it is important to disentangle the specific pattern of the observed social problem solving impairments. Finally, in most studies, general cognitive functioning and trait empathy have not been taken into account although these factors are known to affect social problem solving performance. We used a set of tasks that proved sensitive to impairments in everyday mentalizing and social problem solving (Channon and Crawford, 2010) to address the open issues mentioned above. These tasks involve brief vignettes describing real life social situations. They examine the understanding of mentalistic utterances and actions as well as the ability to both freely produce and to identify socially appropriate and effective solutions for difficult interpersonal situations. We also assessed attention, memory, executive function and trait empathy as these factors are known to affect social cognition. We expected poorer mentalizing and a reduced ability to generate optimal (both socially sensitive and practically effective) solutions

for difficult interpersonal situations in patients with MDD relative to healthy controls. Generation of good strategies was hypothesized to be more impaired than the recognition of optimal solutions. Furthermore, we expected significant associations between social problem solving abilities on the one hand and executive function and trait empathy on the other.

2. Methods 2.1. Participants and background assessment Twenty-eight patients with MDD (20 - 59 years) and 28 healthy controls (HC: 21 - 59 years), matched on age, gender (12 female/16 male participants per group) and education, were assessed. The demographic and clinical data are presented in Table 1. Twenty-four patients were medicated at the time of testing and the specific combinations of psychotropic drugs administered in this group are given in Supplement 1. Twenty-seven patients were hospitalized in the Department of Psychiatry, LWL-Hospital, Ruhr University Bochum; one female patient was treated as an outpatient. Patients were diagnosed with a moderate (N = 10) or severe (N = 18) episode of unipolar depression according to ICD-10 F32/F33.1-2 criteria (Dilling et al., 2000) by senior psychiatrists blind to the cognitive data. Fifteen patients fulfilled the diagnostic criteria for recurrent major depression. The diagnosis was confirmed and comorbid disorders were screened with the German version of the M.I.N.I PLUS International Neuropsychiatric Interview (Sheehan et al., 1998) (German by Ackenheil et al., 1999), administered by a trained member of the research team. Patients were excluded if they presented with a comorbid psychiatric (apart from anxiety disorder, due to high comorbidity rates) or any neurological disorder. According to the M.I.N.I, three patients fulfilled the criteria for agoraphobia and one the criteria for panic disorder with agoraphobia. A present or past psychiatric/neurological disorder, current treatment with psychotropic medication or a family history positive for depression led to exclusion from study participation for HC. Participants had to show an estimated overall

intelligence quotient (IQ) of at least 80, estimated as the average score derived from the two subtest IQs from the “Picture Completion” and “Similarities” subtests of the German abbreviated version (Dahl, 1986) of the Wechsler Intelligence Scale-Revised (Wechsler, 1981). The severity of depressive symptoms was estimated with the Revised Beck Depression Inventory (BDI-II: Hautzinger et al., 2009). In HC, a BDI score of 13 was used as a conservative cut-off score (Gallagher et al., 1983). BDI scores ranged between 4 (2 patients in remission) and 55 in the MDD group and between 0 and 8 in the HC group. A German abbreviated version (Paulus, 2007) of the Interpersonal Reactivity Index (Davis, 1980) with four items per subscale was used for the assessment of trait empathy. The scale assesses two cognitive (perspective taking, fantasy) and two affective (empathic concern, personal distress) empathy components. Standard neuropsychological assessment involved tests of cognitive flexibility (Trail Making Test: Reitan, 1992), response inhibition and working memory (GoNogo and Working Memory subtests from the German Test Battery of Attentional Functions: Zimmermann and Fimm, 2000), verbal memory (Logical Memory subtest from the Wechsler Memory Scale-Revised, Härting et al., 2000) and visuospatial memory (Rey-Osterrieth-Complex-Figure Test, Rey et al., 1944). The study was approved by the local Ethics board of the Faculty of Psychology and participants provided written informed consent. HC were recruited per advertisements placed across the university campus and from the personal environment of the investigators. They were reimbursed for travel expenses with 15 EUR. Due to hospital policy, no reimbursement was allowed for inpatients, so only the outpatient was paid 15 EUR to cover travel costs.

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2.2. Social cognition tasks Three social cognition tasks (Mentalistic Interpretation, Social Problem Resolution, Social Problem Solving Fluency) developed by Channon and Crawford (2010) were administered. Each subtask consists of a series of written vignettes and questions to which the participants responded verbally. Performance was not timed and participants were able to see the scenarios at any time to minimize memory demands. Their responses were recorded and later transcribed and scored according to the manual developed by Channon and Crawford (2010). It provides detailed scoring guidelines and a number of examples illustrating each type of scoring for the different possible responses to each item. Raters were trained thoroughly with respect to the administration and scoring procedures. As the three tasks were administered to the patients as part of a very comprehensive assessment battery and because a potential follow-up assessment after one year was originally planned, we decided to halve the number of scenarios of the original version for each task type. For this purpose, we created two parallel versions of each subtask: Version A containing one half of the scenarios and version B comprising the other half of the scenarios. Versions A or B were administered to half of the participants from each group (MDD and HC) in a counterbalanced fashion. This procedure ensured that both groups comprised equal numbers of participants assessed with the two different versions. This should limit the possibility that any group differences on the relevant measures would be due to potentially different levels of difficulty of the two parallel versions. Examples of the scenarios presented in each subtask are presented in Appendix 1.

2.2.1. Mentalistic Interpretation Task The Mentalistic Interpretation Task assesses the ability to understand other people’s mental states and intentions in the context of difficult interpersonal situations. The task comprises two types of mentalistic items (sarcastic remarks and human actions) and one set of control items (physical events). The mentalistic items briefly describe a social context involving several characters and end with either a sarcastic remark or an action performed by one of

the characters. The physical event items include a single character, but mental states do not need to be inferred to answer the questions associated with the scenario. After reading the scenario, participants were first presented with two control questions gauging whether the general facts in the story – but not the mental states of the characters involved - were understood. Afterwards, participants were asked what the main character meant by the remark, why he or she had carried out the action at the end of the story or why the physical event had happened. Clearly correct responses were scored 2, inadequate but not incorrect responses were scored 1 and incorrect or irrelevant responses were scored 0. After providing their free verbal answer, participants were presented with a set of four explanations and were asked to select the best alternative (scoring 1 or 0 for this). One of these explanations presented a correct alternative, one an incorrect, one an irrelevant and one an explanation that was not necessarily incorrect, but clearly much more general than the best explanation. Total scores were also calculated for the mentalistic items taken together (sarcastic remarks and action items). The original version of the task contains five items per item type (sarcastic, action, physical). The abbreviated version A comprised three sarcastic scenarios, two action scenarios and two physical event items. Version B involved two sarcastic scenarios, three action scenarios and three physical event items. Average scores, divided by the number of scenarios involved were computed for this subtask to account for the varying numbers of scenarios per type in the two versions.

2.2.2. Social Problem Resolution Task The Social Problem Resolution Task gauges the ability to find adequate solutions for difficult everyday interpersonal situations. After reading each scenario, which described an awkward social situation, participants were asked two control questions assessing the non-social understanding of the general line of the story (scoring 1 for each correct answer or 0). Following this, participants were asked to describe what the best thing was the main character could do in this situation. The quality of these solutions was scored on the two

dimensions of social sensitivity and practical effectiveness. Optimal solutions were both socially sensitive and practically effective (SP), scored with 2 points. Socially sensitive solutions that lacked practical effectiveness (S) as well as practically effective but not socially sensitive solutions scored 1 point and solutions that were neither sensitive nor practical (N) scored 0. These scores were added up for all scenarios to yield an overall score for the quality of the best solution. The original task contains 10 scenarios, half of which were allocated to task versions A or B respectively.

2.2.3. Social Problem Solving Fluency Task This subtask assesses the sensitivity to awkwardness in social situations, the capacity to freely generate high quality solutions to awkward social situations as well as the ability to recognize the best solution when it is presented among a range of alternative, less optimal strategies. The original version of the task comprises 10 scenarios, half of which were allocated to version A and the other half to version B of our abbreviated subtasks. The first two questions presented after each scenario assess general understanding of the story line and are scored 1 or 0 points. Awkwardness: Following the control questions, participants were asked to indicate why the situation described in the story might be awkward for the main character. The response was either scored 1 or 0 depending on whether the awkward elements in the story were detected. Afterwards, participants had to rate the degree of awkwardness on a scale ranging from not at all awkward = 0% to as awkward as it could possibly be = 100%. Solution fluency and selection of alternatives: Following the rating of awkwardness, participants had 1 minute to generate as many good ideas as they could think of to describe how the main character could handle the situation. Responses were again evaluated with regard to their social sensitivity (S) and their practical effectiveness (P). Optimal solutions again met both criteria (SP) and responses that met

neither criterion were classified as N. The total numbers of responses in each category served as dependent variables. Afterwards, participants were instructed to select the best solution out of four alternatives. Only one of these alternatives was both socially sensitive and practically effective (SP). The number of times the SP alternative was selected as the optimal response was analyzed as the dependent variable.

2.3. Statistical Analyses Univariate and multivariate analyses of variance (ANOVAs) were used to analyze betweengroup differences where appropriate. Repeated-measures ANOVAs were computed for the memory subtasks involving delayed recall. Parametric tests were used consistently as violations of normality and equal variance assumptions have been found to be less relevant with equal sample sizes (N = 28 each in our study) (Howell, 2001). Control analyses presented in Supplement 2 demonstrate that the effects are robust, even, if non-parametric tests are used. In the patient group, Pearson correlations were computed between the relevant measures of social cognition and executive function and trait empathy scores.

3. Results 3.1. Demographic and cognitive background data Demographic, clinical and Interpersonal Reactivity Index data of the MDD and HC groups are presented in Table 1 and the neuropsychological data in Table 2. MDD and HC groups were comparable with regard to age, IQ and years of education (all ps • 0.383). As expected, MDD patients scored higher on the BDI-II than HC (F(1,54) = 126.970; p ” 0.001; CI95%[29.24, -20.41]). A multivariate ANOVA involving the four IRI subscales revealed an overall significant group difference (Pillai Trace: F(4,51) = 4.674, p = 0.003). Relative to HC, MDD

patients scored lower on IRI fantasy (F(1,54) = 6.186, p = 0.016; CI95%[0.38, 3.55]) and perspective taking (F(1,54) = 7.716, p = 0.008; CI95%[0.58, 3.57]) subscales, but higher on personal distress (F(1,54) = 11.179, p = 0.002; CI95%[-4.34, -1.09]). The difference on the IRI empathy subscale was not significant (p = 0.484). There were no significant group differences regarding the performance on the attention subtasks from the Test Battery of Attentional Functions (Working Memory, GoNogo) (all ps • 0.142). Repeated-measures ANOVAs with the factors GROUP (Dep vs. HC) and DELAY (immediate vs. recall) were computed for the Logical Memory and Rey Complex Figure tasks. Patients showed overall significantly poorer verbal (F(1,54) = 5.588; p = 0.022; CI95%[-8.52, -0.70]) and marginally poorer visuospatial memory (F(1,54) = 3.411; p = 0.070; CI95%[-3.71, 1.52]) relative to HC. Performance was poorer for delayed reproduction of the REY Complex Figure (F(1,54) = 420.553; p < 0.001; CI95%[13.69, 16.65]), while there was no significant effect of DELAY for the Logical Memory Test (p = 0.476). There were no significant interactions between GROUP and DELAY on these tasks (both ps • 0.282).

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3.2. Social Cognition Tasks The descriptive data for the performance of MDD and HC groups on the three social cognition tasks are presented in Table 3.

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Insert Table 3 about here -

3.2.1. Mentalistic Interpretation Task Three separate multivariate ANOVAs were computed to analyze the percentage of correct responses on the control questions, the quality of the freely generated interpretations (percentage of maximum score) and the selection of the best interpretation out of a range of alternatives (percentage correct) for the three types of items (physical, sarcastic, mentalistic

action) in the Mentalistic Interpretation Task. There were no significant group differences regarding correct responses on the control questions (Pillai Trace: F(3,52) = 1.380, p = 0.259) or the selection of the best interpretation of the scenarios out of alternatives (Pillai Trace: F(3,52) = 0.746, p = 0.530). There was a significant group difference, however, with respect to the freely generated quality of the interpretations (Pillai Trace: F(3,52) = 3.168, p = 0.032). This was due to significantly poorer interpretation of sarcastic items by the patients relative to controls (F(1,54) = 7.102, p = 0.010; CI95%[3.91, 27.64]), while there were no significant differences for physical event or mentalistic action items (both ps • 0.104).

3.2.2. Social Problems Resolution Task Two univariate ANOVAs were computed to compare MDD and HC groups with regard to the percentage of correct responses on the control questions and the overall quality of the solutions participants generated in response to the social problems in the scenarios (percentage of maximum score). While patients and controls did not differ significantly with regard to correct responses to the control questions (p = 0.562), MDD patients showed an overall lower quality of the solutions they generated in response to the social problems presented in the scenarios (F(1,54) = 5.003, p = 0.029; CI95%[0.08, 1.49]). When the pattern of the generated solutions was examined more closely by computing a multivariate ANOVA involving the percentage of SP, S, P and N solutions as factors, the overall group difference was not significant (Pillai trace: F(3,52) = 1.617, p = 0.197). An explorative look at the posthoc outputs, however, reveals that those with MDD gave fewer optimal solutions (SP) than HC (F(1,54) = 4.566, p = 0.037; CI95%[3.00, 4.93]), while the groups did not differ with regard to the proportion of S, P and N solutions (all ps • 0.185).

3.2.3. Social Problem Solving Fluency Task Three separate univariate ANOVAs revealed that MDD and HC groups did not differ significantly with respect to the number of correct responses on the control questions, the detection of awkward elements and their subjective ratings of how awkward the situations were for the main character in the story (all ps • 0.343). When the pattern of self-generated optimal solutions for difficult social situations was analyzed by computing a multivariate ANOVA involving the number of SP, S, P and N solutions as factors, a significant group difference emerged (Pillai Trace: F(4,51) = 2.900, p = 0.031). This was due to the fact that MDD patients provided significantly fewer SP (F(1,54) = 9.306, p = 0.004; CI95%[5.73, 7.99]) and S (F(1,54) = 5.770, p = 0.020; CI95%[3.00, 4.93]) solutions than HC. The groups did not differ on the number of P or N solutions (both ps • 0.165). Furthermore, the number of times SP was chosen as the best solution among alternative answers was comparable in both groups, as revealed by a univariate ANOVA (p = 0.234).

3.2.4. Social Problem Solving Composite Scores In analogy to Channon et al. (2013), two composite scores, generation and judgment (see Figure 1), were calculated based on the key measures in each of the three social cognition tasks. The generation score was defined as the total score derived from the mentalistic interpretation score (human actions and sarcastic items considered together), the number of self-generated SP solutions on the Social Problems Resolution Task and the number of selfgenerated SP solutions on the Social Problem Solving Fluency Task. The judgment score was calculated as the sum of the total selection of alternatives score from the Mentalistic Interpretation Task (human actions and sarcastic items considered together) and the selection of alternatives score from the Social Problem Solving Fluency Task. Generation and judgment scores were entered into a single multivariate ANOVA as factors, yielding a significant group difference (Pillai Trace: F(2,53) = 6.884, p = 0.002). This was due

to significantly reduced generation (F(1,54) = 13.943, p < 0.001; CI95%[-5.54, -6.70]), but not judgment (p = 0.225) scores in MDD relative to HC groups. -

Insert Figure 1 about here -

3.3. Correlations In the MDD group, Pearson correlations were computed between the generation and judgment composite scores on the one hand and executive function (Trail Making Test B-A/ Working Memory RTs and errors/ GoNogo RTs and errors) and IRI subscale scores on the other hand. Higher generation scores were related to better cognitive flexibility (r = -0.410; p = 0.030). Furthermore, higher IRI fantasy scores were related to both better judgment (r =0.453; p = 0.015) and generation (r =0.464; p = 0.013) scores. There were no other significant correlations (all ps • 0.077).

4. DISCUSSION We assessed distinct aspects of social problem solving in MDD patients and healthy controls. Patients showed an overall lower interpretation quality of other people’s sarcastic utterances, but demonstrated good understanding of the intentions and mental states underlying interpersonal actions. Furthermore, the solutions the patients generated freely in response to the written presentation of difficult interpersonal situations were of lower quality than those of controls. More specifically, patients provided fewer strategies that were both socially sensitive and practically effective. This was the case both when they were requested to provide as many good solutions as possible and at least with a statistical tendency when they were asked to name only the best solution. Patients also generated fewer socially sensitive but not practically effective solutions in the Social Problem Solving Fluency Task. However, they did not differ from controls on the number of solutions that were only

practically effective or neither socially sensitive nor practically effective, neither on the Resolution nor on the Fluency subtask. Taken together, the most relevant findings our study adds to the literature relate to the differential impairment of the generation but spared judgment of optimal solutions for interpersonal problems on the one hand and to the differential impairment of different types of socially adequate and/or practically effective solutions. This pattern might be partly attributable to motivational deficits and difficulties to engage in goal-directed behaviour (Scheurich et al., 2008), which is more critical for the self-initiated production of high-quality solutions than for the mere identification of those. This problem might primarily manifest itself within interpersonal contexts, where MDD patients appear to be lacking clear motivational approach-avoidance tendencies (Radke et al., 2014). The ability to freely generate optimal solutions was related to higher cognitive flexibility in the patients. This confirms earlier findings emphasizing a role of executive function in social problem solving (Channon, 2004; Channon and Crawford, 2010; Thoma et al., 2013). Our results add to this by revealing a specific association of cognitive flexibility with the ability to generate optimal solutions but not with the capacity to merely identify these solutions among alternatives. On the other hand, both generation and judgment were positively related to higher IRI fantasy scores. This specific relationship with a cognitive aspect of trait empathy further suggests that impaired mentalizing might underlie poor social skills in MDD patients, which has also been proposed for patients with Asperger’s syndrome (Channon et al., 2014). Our patients’ impaired mentalizing for sarcastic remarks is in line with previous findings (e.g. Uekermann et al., 2008; Cusi et al., 2013; Ladegaard et al., 2014). Interestingly, Ladegaard et al. (2014) reported a deficit for the interpretation of paradoxical but not of simple sarcasm in their MDD cohort. Paradoxical sarcasm only makes sense if the participant understands that one of the speakers is being sarcastic. The fact that the patients investigated by Ladegaard and colleagues were selectively impaired only on this more complex form of sarcasm, while already the understanding of simple sarcastic utterances was disrupted in our

study, may be partly due to differences in the test materials. The Awareness of Social Inference Test (TASIT: McDonald et al., 2003) used by the former authors contains very specific questions to gauge the understanding of sarcastic remarks (e.g. “Did Peter really mean what he said?”), while the Mentalistic Interpretation Task employed by us resorts to more general questions (“What did Lisa mean when she said that?”), which provide fewer hints related to the non-literal nature of the utterance. Furthermore, the TASIT is based on video clips while we used written vignettes. This means that non-verbal clues as to what might be meant by an utterance (or action) were not available to support performance in our study. Taken together, our findings suggest that mentalizing might be more disrupted for the understanding of non-literal utterances than of the intentions and mental states underlying human actions. A further aspect that was comparable in MDD patients and controls referred to their ability to detect the awkward elements in the stories and to rate the degree of awkwardness the story characters experienced. In contrast to that, patients with Asperger’s syndrome, were found to be selectively impaired regarding the detection of awkwardness in the Social Problem Resolution Task (Channon et al., 2014). Thus, while, in line with previous reports (O'Connor et al., 2002; Thoma et al., 2011), MDD patients reported to experience more personal distress in response to other people’s negative emotional states (as reflected by higher IRI personal distress scores), they appear to assess the degree of discomfort other people might experience in disagreeable situations on a similar level as healthy controls do. 4.1. Limitations As pointed out in the introduction, attention, executive function and memory contribute to social problem solving abilities. We have carefully controlled for these factors and for estimated IQ. As patients and controls were well matched on demographic variables such as gender and education and as they did not differ significantly on attention or executive function subtests, these factors are unlikely to have contributed to the differences in social problem solving performance. Patients showed poorer verbal memory and marginally

significantly poorer visuospatial memory, but memory demands in the social cognition tasks were minimized by making the stories available to the participants at all times. Also, patients with MDD were able to understand non-mentalistic physical control stories in the Mentalistic Interpretation Task and non-mentalistic control questions in all subtasks. Verbal fluency, known to be impaired in patients with MDD (see Klumpp and Deldin, 2010), was not assessed in our study. Thus, it is debatable whether lower generation scores in the Social Problem Fluency Task might primarily reflect impaired verbal fluency. However, it is less obvious why this should selectively affect the generation of socially sensitive/practically effective and socially sensitive but not practically effective strategies. Twenty-four out of 28 patients were medicated at the time of testing. Antidepressant drug treatment has been suggested to improve behavioural indicators of social skills, probably by reducing depressive symptoms and dysfunctional cognitive rumination (Tse and Bond, 2004). Arguably, it cannot be excluded that the different combinations of psychotropic drugs, also involving antipsychotic and antianxiety agents, might have detrimentally affected performance. However, it is not straightforward to explain why medication should only have reduced sociocognitive performance and not overall cognitive functioning. Given the different mechanisms of action and the small number of patients (see Supplement 1) medicated with the different combinations of psychotropic agents, including medication as a control variable in the analyses did not seem reasonable. However, this issue ought to be addressed more systematically in future studies. Although patients were carefully screened for comorbid diagnoses, four presented with anxiety disorders at the time of testing. This is unlikely to have distorted the result pattern, however, as, to our knowledge, there is virtually no evidence suggesting sociocognitive impairment in this population. On the other hand, our sample included two hospitalized patients with apparently remitted symptoms (BDI scores below 9), which might contribute to an underestimation of social problem solving difficulties in our sample.

4.2. Conclusions and outlook Our study demonstrates selective impairment of MDD patients regarding the adequate understanding of sarcastic interaction partners and the free generation of both socially sensitive and practically effective solutions for difficult interpersonal situations. On the other hand, identification of optimal solutions among alternatives and the detection and subjective assessment of the awkward elements within difficult interactions seems to be spared. This differential pattern of impairments in social problem solving ought to be considered in the development of novel therapies aiming at the amelioration of social skills impairment. Psychotherapeutic strategies targeting problem solving already proved effective in the treatment of MDD (Marx et al., 1994) and the functional recovery of problem solving deficits following targeted psychotherapeutic treatment has been found to predict subsequent changes in depressive symptoms (Bellack et al., 1990; 1994; Bell and D'Zurilla, 2009). However, most current treatment programs appear to primarily target the four general problem solving skills (problem definition and formulation, generation of alternative solutions, decision making, and solution implementation and verification) (see Bell and D'Zurilla, 2009). It might also be necessary to heighten the patients’ and therapists’ awareness to subtle differences between socially sensitive and practically effective solutions.

Acknowledgement This work was supported by a grant from the German Research Foundation (Deutsche Forschungsgemeinschaft – DFG), grant number TH 1535/2-1, awarded to Patrizia Thoma and Boris Suchan. We thank Moritz Gapski and Stephanie Schulz for their assistance with data collection.

APPENDIX 1: Examples for the scenarios presented in each Social Cognition Subtask

Mentalistic Interpretation Task Example of a sarcastic item: “Lisa and her friend often played tennis. Her friend always wanted to be best at everything. One day they were playing tennis in the local park. Lisa knew that her friend expected to win the game. However, that day her friend did not win.” Lisa said: “I suppose you’ll say there’s a hole in your racket!” Control Question: “Who won the game on that day?” Mentalistic Question: “What did Lisa mean when she said that?”

Example of an action item: “Erik wanted to impress his new girlfriend Marie. He was cooking her a meal, but had never cooked before. Marie hoped it would be successful. Erik told her he had spent all day preparing it. When it came out of the oven it was badly burnt. Marie ate all her meal. Afterwards she took a second helping of the food.” Control Question: “Who ate the whole meal?” Mentalistic Question: “Why did Marie take a second helping?”

Example of a physical event item: “Charlotte was sorting out her dirty washing. She put all the white clothes in one pile. Her new white dress had a bright red flower on it. She put it in the white clothes pile. Charlotte washed the white pile and took the clothes out of the washing machine. All the white clothes had turned pink.” Control Question: “What was the color of the flower on the dress?” Question: “Why did the white clothes turn pink?”

Social Problem Resolution Task

Example: “Anton is always tired because he is kept awake by his new upstairs neighbours’ noisy dogs. The neighbours are very pleasant, but say there is nothing they can do about the dogs.” Control question: “Who is tired?” Social Problem Solving Question: “What is the best thing for Anton to do in this situation?”

Social Problem Fluency Task Example: “Bernd is on a train to work. Most people on the train are reading. The woman next to Bernd keeps telling him about herself and then starts asking Bernd personal questions.” Control Question: “Who asks personal questions?” Social Problem Solving Questions: “Why might the situation be awkward for Bernd?”; “How awkward a situation is it for Bernd, out of 100%?”; “What could Bernd do in this situation?” Suggest as many good ideas as you can for dealing with the situation. You have one minute.”

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Figure caption: Figure 1: Generation (free generation of solutions to interpersonal problems) and judgment (identification of the best solutions among less optimal alternatives) scores, derived from the three social cognition tasks, for patients with Major Depressive Disorder (MDD) and healthy controls (HC).






TABLES

Table 1 Demographic, questionnaire and clinical data for the patients with Major Depressive Disorder (MDD) and healthy controls (HC). Standard deviations are presented in brackets. MDD

HC

N

28

28

Age (years)

43.36 (11.71)

44.32 (12.01)

Sex (M : F)

16 : 12

16 : 12

IQ estimate

109.7 (6.4)

111.2 (5.8).

Education (years)

11.38 (1.63)

11.30 (1.51)

General data

Clinical data 1st admission (age)

40.44 (12.20)

No of psychiatric admissions

1.35 (2.28)

Length of current admission (days)

23.96 (12.93)

Beck Depression Inventory score

27.11 (11.46)

2.29 (2.12)

Interpersonal Reactivity Index subscores (max. 20) Fantasy Score

11.61 (2.51)

13.57 (3.33)

Perspective Taking Score

14.21 (2.71)

16.29 (2.87)

Empathic Concern Score

14.46 (2.05)

14.04 (2.49)

Personal Distress Score

11.75 (3.50)

9.04 (2.49)






Table 2 Average performance of the patients with Major Depressive Disorder (MDD) and the healthy controls (HC) on the neuropsychological tasks. Standard deviations are presented in brackets. MDD

HC

48.11 (30.02)

39.36 (22.14)

Reaction Times (msec)

415.48 (71.63)

444.19 (84.69)

Number of errors

1.20 (1.41)

0.73 (.92)

Reaction Times (msec)

620.76 (178.35)

667.64 (167.26)

Number of errors

2.44 (4.45)

2.36 (2.56)

Number of omissions

2.84 (2.76)

1.84 (1.89)

Logical Memory immediate recall

22.14 (7.25)

28.64 (5.20)

Logical Memory delayed recall

22.79 (16.45)

25.50 (5.71)

Rey Figure copy

33.95 (3.49)

35.41 (0.99)

Rey Figure delayed recall (30 minutes)

18.46 (5.50)

20.55 (6.25)

Cognitive Flexibility Trail Making Test (Reitan et al., 1992) Reaction Times B-A conditions (sec.) Response Inhibition Go/Nogo (Zimmermann & Fimm, 2012)

Working memory (Zimmermann & Fimm, 2012)

Verbal memory (Wechsler Memory Scale, Härting et al., 2000)

Visuospatial Memory







Table 3 Average scores and standard deviations (in brackets) for the patients with Major Depressive Disorder (MDD) and healthy controls (MDD) on the social cognition measures MDD

HC

Physical Events

91.07 (16.96)

96.43 (8.91)

Sarcastic Remarks

94.64 (12.05)

98.81 (4.37)

Mentalistic Actions

98.81 (4.37)

99.40 (3.15)

Physical Events

94.64 (14.20)

99.12 (4.72)

Sarcastic Remarks

63.69 (24.76)

79.46 (19.18)

Mentalistic Actions

65.77 (26.96)

76.79 (22.61)

Physical Events

96.43 (13.11)

100.00 (0.00)

Sarcastic Remarks

79.76 (27.35)

82.14 (23.54)

Mentalistic Actions

92.86 (16.62)

94.05 (13.00)

96.79 (4.76)

97.50 (4.41)

Social and Practical (SP)

67.14 (24.47)

80.0 (20.37)

Social Not Practical (S)

13.57 (13.39)

9.29 (11.52)

Practical Not Social (P)

15.00 (16.89)

9.29 (15.85)

Neither Social Nor Practical (N)

4.29 (9.97)

5.25 (1.43)

Mentalistic Interpretation Task (%) Control questions

Quality of the interpretation

Selection of best alternatives

Social Problems Resolution Task (%) Control questions Quality of best solution

Social Problem Solving Fluency (%) Detection of Awkwardness

82.86 (19.41)

87.14 (13.57)

Subjective Awkwardness

64.69 (20.45)

61.92 (15.25)

Social and Practical (SP)

6.86 (2.81)

9.29 (3.14)

Social Not Practical (S)

3.96 (2.44)

5.61 (2.67)

Practical Not Social (P)

3.36 (1.68)

4.07 (2.09)

Neither Social Nor Practical (N)

1.25 (1.29)

1.68 (1.49)

60.00 (24.94)

67.14 (19.02)

Quality of Solutions (Number of solutions)

Selection of best alternatives (%)









Highlights:




•

Social problem solving is impaired in patients with Major Depressive Disorder (MDD).

•

MDD patients generate fewer socially sensitive and practically effective solutions.

•

Patients are also less able to identify optimal solutions.

•

Overall, generation is more impaired than identification of optimal strategies.

6. Figure(s)