Schizophrenia Research 122 (2010) 164171

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Schizophrenia Research
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / s c h r e s

Social attribution test multiple choice (SAT-MC) in schizophrenia:

Comparison with community sample and relationship to neurocognitive,
social cognitive and symptom measures
Morris D. Bell a,b,, Joanna M. Fiszdon a,b, Tamasine C. Greig b, Bruce E. Wexler b
a
b

VA Connecticut Healthcare System, Rehabilitation Research and Development Service, West Haven, CT 06517, USA
Yale University School of Medicine, Department of Psychiatry, New Haven, CT 06511, USA

a r t i c l e

i n f o

Article history:
Received 20 January 2010
Received in revised form 14 March 2010
Accepted 16 March 2010
Available online 18 April 2010

Keywords:
Social attribution
Theory of Mind
Mentalizing
Social cognition
Schizophrenia
Neuropsychology

a b s t r a c t
This is the rst report on the use of the Social Attribution Task Multiple Choice (SAT-MC) to
assess social cognitive impairments in schizophrenia. The SAT-MC was originally developed for
autism research, and consists of a 64-second animation showing geometric gures enacting a
social drama, with 19 multiple choice questions about the interactions. Responses from 85
community-dwelling participants and 66 participants with SCID conrmed schizophrenia or
schizoaffective disorders (Scz) revealed highly signicant group differences. When the two
samples were combined, SAT-MC scores were signicantly correlated with other social cognitive
measures, including measures of affect recognition, theory of mind, self-report of egocentricity
and the Social Cognition Index from the MATRICS battery. Using a cut-off score, 53% of Scz were
signicantly impaired on SAT-MC compared with 9% of the community sample. Most Scz
participants with impairment on SAT-MC also had impairment on affect recognition. Signicant
correlations were also found with neurocognitive measures but with less dependence on verbal
processes than other social cognitive measures. Logistic regression using SAT-MC scores correctly
classied 75% of both samples. Results suggest that this measure may have promise, but
alternative versions will be needed before it can be used in prepost or longitudinal designs.
Published by Elsevier B.V.

1. Introduction
Social functioning decits are among the most prominent
features of schizophrenia and play a large role in the individual's level of disability and the likelihood of relapse. Social
cognition, or how an individual processes, interprets, and
responds to social information, has repeatedly been shown to
be impaired in schizophrenia (Bora et al., 2009; Brune and
Brune, 2005; Corcoran et al., 1995a; Edwards et al., 2002;
Fiszdon et al., 2009; Penn et al., 2008; Silverstein, 1997) and to
be associated with various components of functioning (Cohen
et al., 2009; Couture et al., 2006; Hooker and Park, 2002;

Corresponding author. Psychology Service 116B, VA Connecticut, Healthcare

System, West Haven CT 06516, USA. Tel.: +203 932 5711x2281; fax: +203 937
4883.
E-mail address: morris.bell@yale.edu (M.D. Bell).
0920-9964/$ see front matter. Published by Elsevier B.V.
doi:10.1016/j.schres.2010.03.024

Mueser et al., 1996; Penn et al., 1996; Pinkham and Penn, 2006).
While some studies suggest that social cognition may mediate
the relationship between other variables (e.g. neurocognition)
and functional outcomes, other studies indicate that social
cognition may also account for a unique portion of the variance
in predicting functional outcomes (Addington et al., 2006; Bell
et al., 2009; Brekke et al., 2005; Brekke et al., 2007; Dickinson
et al., 2007; Kee et al., 2003; Meyer and Kurtz, 2009; Vauth et al.,
2004). The interrelationship between social cognition and
functional outcomes has led researchers to suggest that social
cognition may be a good proximal treatment target for interventions aimed at improving functional outcomes in schizophrenia (Horan et al., 2008).
A number of laboratory measures have been developed to
assess social cognitive function. Most of these measures have
focused on narrowly dened social cognitive processes such
as ability to recognize affect, identify interrelationships and

M.D. Bell et al. / Schizophrenia Research 122 (2010) 164171

clues in social situations, gauge social rules and expectations,

draw inferences about the causes of events, or identify the
intentions, dispositions and mental states of other people
(Green et al., 2008). While the majority of affect recognition
measures have focused on an individual's ability to recognize
or differentiate emotions from photograph stills, other social
cognitive measures most frequently rely on written or videotaped vignettes of social situations, where the examinee is
asked to make guesses about the relationship of characters to
each other, make guesses about how characters may be
feeling or what they may be thinking, or make guesses about
what caused specic events.
Recently experts concluded that most measures of social
cognition have poor or unknown psychometric properties
(Green et al., 2008). Specically, it has been suggested that
variables such as dependence on verbal ability (for example
having to read short stories and answer questions about
them), the explicit nature of tasks, and scoring issues reduce
their usefulness in capturing impairments in understanding
spontaneous complex social situations (Klin, 2000). It has also
been suggested that many of the existing social cognitive
tasks fail to measure some variables that do in fact affect reallife performance, such as whether specic skills are actually
employed in social situations, whether the individual is able
to focus on relevant aspects of social situations, and whether
the individual is capable of assimilating various pieces of
social information (D'Zurilla and Maydeu-Olivares, 1995;
Klin, 2000). Finally, existing social cognitive measures have
also been critiqued for how narrowly they target specic
social cognitive skills. This may limit their ecological validity,
since real-world situations require a combination of different
social cognitive processes as well as allow for informational
redundancies occurring through multiple sources of information and multiple modes of presentation (Bazin et al.,
2009; Bellack et al., 1996; Yager et al., 2006).
The Social Attribution Task (SAT) is a measure of social
inference that has been proposed to overcome some of the
weaknesses of social cognitive assessments noted above. The
stimulus for the SAT is based on a 1944 Heider and Simmel
(Heider and Simmel, 1944) silent cartoon animation showing
moving geometric gures. Because the task is a silent cartoon,
it does not reply on verbal ability, which may offer a purer
characterization of social cognitive decits separate from
linguistic skill or verbal memory. When originally developed
and tested, it was noted that nearly every subject experienced
the cartoon gures as animate beings enacting a social drama.
This task has since been adapted by Klin, who created a scoring
procedure for narratives made to this animation, which has
been shown sensitive to social cognitive decits in adolescents
and adults with Asperger's Syndrome and high functioning
autism (Klin, 2000; Klin et al., 2006). These decits were
unrelated to age, verbal IQ, or metalinguistic skill. Based on
these results, Klin created a multiple choice version of the task
(SAT-MC), which further reduced the task's dependence on
verbal ability.
This is the rst study using SAT-MC in adults with
schizophrenia. The multiple choice version was selected over
the narrative approach because it eliminates rating error and
allows for easier use across studies. To determine whether this
task could be useful for schizophrenia research, we wished to
determine its discriminant validity by comparing scores from

165

an urban community mental health center (CMHC) sample

with those of an urban community-dwelling sample. We also
wished to determine its degree of convergent validity with
other measures of social cognition, exploring the extent to
which it may share variance with these measures, while
perhaps capturing features of the illness that have here-tofore not been measured. We also wanted to determine its
divergent validity from neurocognitive measures. Although we
expected that neurocognitive processes would have some
association with this new social cognitive measure as they have
with other social cognitive measures used in schizophrenia
research, we speculated that because the task does not require
the examinee to remember verbal content, it might make
performance less dependent upon verbal ability, something
which we have identied as a problem with other social
cognitive measures we have used such as the Hinting Task
(Greig et al., 2004), and particularly the MayerSaloveyCaruso
Emotional Intelligence Test (MSCEIT) (Wexler et al., 2009).
Finally, we wished to determine the classication accuracy of
this new measure in being able to categorically distinguish our
schizophrenia sample from the community comparison group
alone and in combination with other social cognitive measures.
Based on these study aims, we hypothesized that: 1) our
schizophrenia sample would perform signicantly worse than
our comparison group on the SAT-MC; 2) SAT-MC performance
of our schizophrenia sample would correlate with other social
cognitive measures but have only a moderate degree of shared
variance; 3) SAT-MC scores for our schizophrenia sample
would have modest relationships with neurocognitive measures, particularly with verbal memory tasks; and, 4) schizophrenia and community samples could be accurately classied
based on SAT-MC scores alone, and classication accuracy could
be increased by using a combination of SAT-MC scores with
other social cognitive measures.
2. Methods
2.1. Participants
Participants were 66 adult outpatients with Diagnostic
and Statistical Manual of Mental Disorders, 4th revision
(DSM-IV) (American Psychiatric Association and Task Force
on DSM-IV, 1994) diagnosis of schizophrenia or schizoaffective disorder, as conrmed by the Structured Clinical
Interview (SCID) (First et al., 1996). The participants were
recruited from an urban community mental health center
for an on-going study of cognitive training and supported
employment (Clinical Trials.gov #NCT00339170). Participants were required to meet criteria for clinical stability (no
hospitalizations, emergency room visits, homelessness or
substance abuse in the past 30 days) and have an interest in
returning to work. Other exclusion criteria included evidence
of current neurological disease, brain injury or developmental
disability. English prociency was also required. Demographic and illness characteristics of these 66 participants are
presented in Table 1. Four subjects were not included in
analyses of neurocognition (n = 62) because they were
recruited from an earlier version of the parent study that
used somewhat different measures. These four subjects plus 1
subject with uncollected symptom data are not included in
the symptom analyses (n = 61).

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M.D. Bell et al. / Schizophrenia Research 122 (2010) 164171

Table 1
SAT-MC participant characteristics.
(n = 66)

(%)

Gender
Male

40

(60.6)

Female

26

(39.4)

Schizophrenia diagnosis
Disorganized
2
Paranoid
28
Residual
11
Undifferentiated
8
Schizoaffective
16
Psychosis Disorder NOS 1

(3.0)
(42.4)
(16.7)
(12.1)
(24.2)
(1.5)

Ethnicity
African
American
Caucasian
Hispanic
Other
Medications
Atypical
Conventional
Both
None

(%)

40

(60.6)

24
1
1

(36.4)
(1.5)
(1.5)

44
8
5
9

(66.7)
(12.1)
(7.6)
(13.6)

(n = 65)

Mean (SD)

Mean (SD)

PANSS
Total
Positive

Age
64.94 (15.4) Education
15.37 (5.1) Age at 1st
hospitalization
16.20 (6.9) Lifetime
number of
hospitalizations
16.52 (4.8)
6.69 (3.0)
8.75 (3.6)

42.73 (10.4)
12.58 (2.6)
23.45 (9.2)

Negative

Cognitive
Hostility
Emotional Discomfort
SANS
Total
SAPS
Total

8.63 (10.7)

35.18 (19.5)
29.11 (19.0)

In selecting a comparison group, we sought to recruit

participants who were not identied as having a psychiatric
illness and who would be similar to our schizophrenia
participants in being an ethnically diverse sample of urban
dwellers of similar age, education and socio-economic status.
Following approval by our local Institutional Review Board
(IRB) we recruited participants who were students in two
urban community college classes, and who after reading a
description of the study that explained that we were
collecting data to represent a non-psychiatric comparison
sample, felt that they qualied. Thus, there was no individual
screening for psychopathology, and it is likely that had
individual screening been performed some of these participants might have been excluded. Therefore, this is an
unscreened representative community sample. As a group,
they were somewhat younger than our schizophrenia sample
(mean age = 31.72 (8.58)), but were similar in education
(mean = 13.8 (1.50)) and similar in ethnic composition (42%
Caucasian). Unexpectedly, they differed in having a higher
percentage of women (88%).
2.2. Measures
Social cognitive measures included:
The Social Attribution Task Multiple Choice version (SATMC). Developed by Klin (Klin, 2000; Klin et al., 2006) this task
is comprised of a 64-second animation created by Heider and
Simmel (Heider and Simmel, 1944) in which a large triangle,
small triangle and small circle enact a social drama (Interested readers can nd the original on YouTube Heider and

Simmel Movie.). The animation is shown twice and then

short segments are presented followed by multiple choice
questions about the actions depicted. In all, 19 questions are
asked with 4 possible responses to each. For example, after
being shown a short segment, the respondent is presented
with the question: What is the little triangle trying to do?
and given these choices: 1. It wants to help the little circle. 2.
It wants to help the big triangle. 3. It wants to play with the
little circle and with the big triangle. 4. It wants to lock the
door.
The Bell-Lysaker Emotion Recognition Task (BLERT) (Bell
et al., 1997). This affect perception task consists of 21 short
video clips in which an actor displays one of seven emotions
with three neutral monologues, and the examinee is asked to
decide what emotion the actor is portraying. A total correct
score of 114 is categorized as indicating impairment and 15
21 as unimpaired.
The Hinting Task (Corcoran et al., 1995b). This is a Theory of
Mind measure consisting of 10 brief scenarios that describe an
interaction between two people. At the end of the scenario one
of the characters drops an obvious hint (e.g. Jane, I'd love to
wear that blue shirt, but it's very wrinkled), and the examinee
is asked what was meant by the hint. We revised the original
Hinting Task to American English. Of relevance to this report,
we found the Hinting Task to be signicantly correlated with
story memory (Wechsler Memory Scale (Wechsler, 1987)
Logical Memory I, r = 0.42, p b 0.000; Logical Memory II,
r = 0.43, p b 0.000) and with the cognitive component of the
Positive and Negative Syndrome Scale (Kay et al., 1987)
(r = 0.42, p b 0.000) (Greig et al., 2004).
Bell Object Relations Reality Testing Inventory (BORRTI) (Bell,
1995). This is a self-report measure with 90 true/false items
assessing 4 dimensions of object relations and 3 dimensions
of reality testing. It was developed initially for schizophrenia
research and has been found to have strong psychometric
properties in a wide variety of applications and to have crosscultural validity (Li and Bell, 2008). The egocentricity scale, in
particular, has been linked with performance measures of social
cognition (Bell et al., 2009). Examples of items on this scale
include: I believe a good mother should always please her
children (True); People are never honest with each other
(true); Others frequently try to humiliate me (True).
MATRICS Social Cognition Index. This is comprised of scores
from the MayerSaloveyCaruso Emotional Intelligence Test
(MSCEIT) (Mayer et al., 2002) Emotion Management Task
(Section D) and Social Management Task (Section H). The
tasks require respondents to evaluate how effective different
actions would be in achieving an outcome involving other
people (e.g. how effective would calling friends or eating
healthy be in making someone feel better). Relevant to this
report, we have found that there is a large verbal ability
contribution to these scores, with Logical Memory I scores
correlating r = 0.63 to both Emotion Management and Social
Management (Wexler et al., 2009).
Neurocognitive measures were selected to provide both
broad information about separate cognitive domains and
overall neurocognitive function as well as provide more
specic information about verbal memory function. Neurocognitive and symptom measures included:
MATRICS Consensus Cognitive Battery (MCCB) (Nuechterlein
and Green, 2006): Index scores for Speed of Processing,

M.D. Bell et al. / Schizophrenia Research 122 (2010) 164171

Attention and Vigilance, Working Memory, Verbal Learning,

Visual Learning, Reasoning, and Neurocognitive Composite
Score (average of Index scores excluding Social Cognition).
Wechsler Adult Intelligence Scale-III (WAIS-III) (Wechsler,
1997): Scaled scores for Vocabulary, Digit Span, Block Design,
Matrix Reasoning.
Wechsler Memory Scale, revised (Wechsler, 1987): Scaled
Scores for Logical Memory I, Logical Memory II, and Mental
Control.
Wisconsin Card Sorting Task (WCST) (Heaton, 1981): Scaled
scores for Total Errors, Perseverative Errors, Non-perseverative
Errors, and Conceptual Level.
Symptom assessments were performed at intake by Ph.D.
level clinical psychologists who had been trained to high
levels of inter-rater agreement (intra class correlation =
0.82 to 0.93). Measures included the Positive and Negative
Syndrome Scale (PANSS) (Kay et al., 1987) with 5 component
scoring (Bell et al., 1994) and the Schedule for the Assessment
of Positive Symptoms (SAPS) (Andreasen, 1984b) and Schedule
for the Assessment of Negative Symptoms (SANS) (Andreasen,
1984a).

167

tion and gender. Relationship of convergent and divergent

validity measures to SAT-MC scores was determined using
bivariate correlations. Only standardized scores were used in
correlational analyses and were assumed to meet parametric
assumptions. Categorical agreement between BLERT impaired/unimpaired and SAT-MC impaired/unimpaired was
determined using chi-square, percent agreement, Kappa and
Eta. Logistic regression was used to determine the classication accuracy of SAT-MC and of SAT-MC combined with the
other social cognitive measures (BLERT, Hinting Task, and
Egocentricity). All tests were two-tailed and alpha was set at
0.05. Because of the exploratory nature of this study, correlations were not corrected for multiple comparisons.
3. Results
3.1. Internal consistency
SAT-MC items were evaluated for internal consistency for
both samples combined. Cronbach's Alpha for item to scale
consistency was 0.83. Split-half reliability using Spearman
Brown coefcient was 0.75.

2.3. Procedures
3.2. Discriminant validity
Following written informed consent, schizophrenia participants were individually administered all measures over several
assessment sessions. Neurocognitive assessments were usually
performed over at least two testing sessions, but additional
breaks were taken if there was concern about the participant's
fatigue or alertness. Symptom evaluations and social cognitive
measures were generally performed on different assessment
days.
The community sample was provided with a description
of the study by their classroom teacher. Group administration
of the SAT-MC, BORRTI, BLERT and Hinting Task was done by
study personnel during a single classroom session. Community participants were not administered any neurocognitive
or symptom measures. For the SAT-MC, a large TV monitor
placed at the front of the 40-person classroom displayed the
task, and each student had a copy of the answer sheet. The
SAT-MC was paused at each question and administration did
not resume until it was clear that all participants had circled a
response. All forms were reviewed to determine that they had
been lled out correctly and with sincere intent (e.g. not all
items scored false).

The distributions of SAT-MC scores for both samples are

presented in Fig. 1.
Correct scores for the schizophrenia sample are normally
distributed with a mean, median and mode of 11, standard
deviation of 4, and a range from 2 to 19. The community sample
has a mean, median and mode of 15, standard deviation of 3,
with 6 outliers with scores below 9.
Demographic differences were not signicant for education,
but the community comparison sample had a signicantly
higher proportion of women (88% versus 39%) and were
signicantly younger (32 versus 43 years of age). Controlling
for group membership, ANCOVA did not reveal a signicant
difference on SAT-MC scores by gender (F(1,147)= 1.36, p =
0.25). Men had a slightly higher mean score (mean = 14.0)
than women (mean = 13.11). Age was also not signicantly
correlated with SAT-MC performance (r = 0.13, p = 0.13). To
be conservative, between groups analysis of variance was
performed with age, education and gender as covariates. Group
differences were statistically signicant (F(1,144) = 20.26,
p b 0.001). As expected, the covariates in the model were not

2.4. Data analysis

Internal consistency of items on the SAT-MC was assessed
using Cronbach's alpha and SpearmanBrown coefcient for
split-half reliability. Distributions of SAT-MC scores were
examined separately for the schizophrenia and community
samples. These distributions and a receiver operating characteristic (ROC) curve analysis were used to determine the best
SAT-MC cut-off score for sensitivity and specicity to the
schizophrenia sample. Demographic variables were compared
using t-tests and chi-square analyses. Partial correlations,
correcting for group membership, were used to determine the
relationship of age, education and gender to SAT-MC scores.
Discriminant validity between samples was determined using
analysis of covariance (ANCOVA), controlling for age, educa-

Fig. 1. SAT-MC correct score distributions for community sample (CS) and
schizophrenia sample (Scz).

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M.D. Bell et al. / Schizophrenia Research 122 (2010) 164171

signicant. Removing the demographics from the model,

the adjusted R squared was 0.26, indicating that 26% of
the between-group variance was explained by SAT-MC
performance.
An examination of the distribution of SAT-MC scores and its
ROC curve led us to choose the SAT-MC score of 11 as the cut-off
for impairment. This score identied 53% of the schizophrenia
sample as having an impairment as compared to 9.4% of the
community sample (Chi-square(1) = 34.7, p b 0.001). A score of
12 also produced good discrimination (61% schizophrenia, 14%
community sample), but we felt that specicity was to be
preferred over sensitivity.
3.3. Convergent validity
Signicant bivariate correlations were found between
SAT-MC correct scores for the combined samples with BLERT
(r = 0.47, p b 0.001) and with Hinting Task (r = 0.37, p b 0.001).
SAT-MC scores were not signicantly correlated with the
BORRTI subscales Alienation (r = 0.143, p = 0.08), Insecure
Attachment (r = 0.05, p = ns) or Social Incompetence (r =
0.07, p = ns). However, they were signicantly correlated
with Egocentricity (r = 0.37, p b 0.001); that is, with less
pathology on Egocentricity.
For the schizophrenia sample alone, SAT-MC scores had a
weaker but similar pattern of correlations to that of the
combined samples. They were signicantly correlated with
BLERT (r = 0.37, p = 0.002), but did not reach signicance
with Hinting task (r = 0.23, p = 0.07) or with Egocentricity
(r = 0.21, p = 0.10). SAT-MC scores were signicantly
correlated with the Social Cognition index score on the
MATRICS (r = 0.29, p = 0.02).
A categorical examination of the relationship between
impairment on the SAT-MC and BLERT showed 65% agreement (Chi-square (1) = 5.9, p b 0.05; Kappa = 0.30; Eta =
0.44). Twenty-eight of the 35 (80%) schizophrenia participants identied as SAT-MC impaired were also BLERT
impaired, and 15 (48%) of the 31 who were SAT-MC unimpaired were also BLERT unimpaired.
3.4. Divergent validity
For the schizophrenia sample, correlations between SATMC correct scores and neurocognitive variables are presented
in Table 2. The strongest correlation is with Matrix Reasoning,
a non-verbal problem-solving task; there is also a modest
relationship to WCST, which also involves non-verbal problem-solving. SAT-MC scores are about equally correlated with
Vocabulary and Block Design, which suggests that IQ (not
specically measured here) probably affects performance.
Logical Memory I is signicantly correlated, but Logical
Memory II, which involves delayed recall, is not. SAT-MC
scores have modest signicant correlations with MATRICS
indices of Working Memory and Reasoning and Problem
Solving (based on Mazes, also a non-verbal task) and with the
Neurocognitive Composite score. SAT-MC was not signicantly correlated with any symptom measures (PANSS Positive,
r = 0.08; Negative, r = 0.08; Cognitive, r = 0.07; Hostility,
r = 0.16; Emotional Discomfort, r = 0.05; SANS, r = 0.09;
SAPS, r = 0.07). SAT-MC was also not signicantly correlated with reality testing impairments as measured by the

Table 2
Correlations between SAT-MC correct scores and neurocognitive measures in
the schizophrenia sample.
Mean

3.0
2.7
3.3
2.6
2.1
2.9
3.3

0.38
0.29
0.37
0.18
0.26
0.36
0.47

0.003
0.02
0.003
ns
0.04
0.004
0.000

7.9
9.1
7.6

3.1
2.7
3.1

0.31
0.19
0.26

0.01
ns
0.05

WCST Standard Scores (n = 62)

Total Errors
Perseverative Errors
Non-perseverative Errors
Conceptual Level

85.6
86.5
87.5
86.7

16.2
17.4
14.5
15.4

0.31
0.25
0.34
0.32

0.02
ns
0.007
0.01

*MATRICS T Scores (n = 62)

Speed of Processing
Attention and Vigilance
Working Memory
Verbal Learning
Visual Learning
Reasoning and Problem Solving
Neurocognitive Composite

35.5
34.0
34.3
36.0
36.1
41.7
36.3

10.3
12.3
13.7
7.6
12.0
9.8
8.0

0.22
0.23
0.32
0.24
0.18
0.28
0.34

ns
ns
0.01
ns
ns
0.03
0.008

WAIS-IV Scaled Scores (n = 62)

Vocabulary
Digit Span
Letter Number Sequencing
Symbol Search
Digit Symbol Coding
Block Design
Matrix Reasoning

8.3
8.8
7.3
6.5
6.1
8.4
8.7

WMS Scaled Scores (n = 62)

Logical Memory I
Logical Memory II
Mental Control

SD

*Social Cognition Index is excluded because it is a social cognition measure.

Therefore, overall composite, which includes Social Cognition is also
excluded.

BORRTI (Reality Distortion, r = 0.04; Uncertainty of Perception, r = 0.10; Hallucinations and Delusions, r = 0.10).
3.5. Classication accuracy
Logistic Regression using SAT-MC scores to predict group
membership (Community Comparison sample vs. Schizophrenia) was highly signicant (Chi-square (1) = 44.6, p b 0.001).
Sensitivity to schizophrenia was 60.6%, specicity was 77.0%,
and overall classication accuracy was 74.8% (Table 3). This
analysis was repeated adding Hinting Task, BLERT, and
Egocentricity scores, which increased classication accuracy
slightly to 78%.
4. Discussion
This is the rst report using the Social Attribution Test
in its multiple choice form as a possible measure of social
Table 3
Logistic regression using SAT-MC scores to predict group membership
(Community sample (CS) vs. Schizophrenia (Scz)).
Observed

Scz
CC

Predicted
Scz

CS

Total

40
12
52

26
73
99

66
85
151

Chi-Sq (1) = 44.6, p b 0.001.

Sensitivity = 60.6; Specicity = 77.0; Correctly Classied = 74.8%.

M.D. Bell et al. / Schizophrenia Research 122 (2010) 164171

cognition for schizophrenia research. We found that schizophrenia participants had signicantly poorer scores than our
community sample, who had not been screened for psychopathology. Despite this lack of screening, a cut-off score for
impaired functioning on the SAT-MC successfully distinguished
our schizophrenia sample from the community sample with
more than half the schizophrenia sample designated as having
impairment while fewer than 10% of the community sample
participants were so designated. We did not expect to nd
social cognitive decits in all people with schizophrenia and
recognize these decits as a likely and important source of
heterogeneity within the disorder, so it should not be expected
that SAT-MC scores would distinguish all schizophrenia
participants from the community comparison participants. It
is also the case that such decits are related to other disorders
such as Asperger's Syndrome, so it may be that some of the
community comparison participants with poor SAT-MC scores
may have a psychiatric condition that affects social cognition
and thus were not strictly speaking false positives.
Convergent validity for the instrument was sought by
examining its relationship to other social cognitive measures
and to a self-report measure of object relations. For those
measures that were administered to both the community
comparison and the schizophrenia participants, the greatest
amount of shared variance was with our measure of affect
recognition. Most participants with schizophrenia who were
SAT-MC impaired were also BLERT impaired, although many
who were BLERT impaired were not SAT-MC impaired.
Other highly signicant relationships were also found
with our theory of mind task and with the self-report measure of Egocentricity. With the more restricted range of scores
within the schizophrenia sample, the associations were weaker
than for the combined samples but the pattern was similar. In
addition, the Social Cognition Index from the MATRICS battery
was signicantly correlated with SAT-MC scores. These ndings
lend some support to the construct validity of the SAT-MC as a
measure of social cognition, but the associations are moderate
at best. This may be because the SAT-MC is capturing features
of social cognition (e.g. anthropomorphizing, metacognitive
creation of coherent social narrative, and social attribution) that
are related to but distinct from affect recognition, theory of
mind, social problem-solving, or self-experience.
While it is generally agreed that social cognition relies on
some features of neurocognition (e.g. attention, working
memory, problem-solving), it is hoped that a social cognitive
measure would be relatively independent from basic cognition.
This is of particular concern because the Social Cognition Index
of the MATRICS and the Hinting Task have both shown highly
signicant dependence on verbal processes, particularly story
memory (Wexler et al., 2009). The SAT-MC had a modest,
but signicant relationship to Logical Memory I as it did to
a number of verbal and non-verbal tasks. Interestingly, the
strongest relationship was with Matrix Reasoning, suggesting
that correctly interpreting the actions of the geometric gures
in the SAT-MC may share some of the same problem-solving
processes required for solving the geometric sequences in
Matrix Reasoning. Based on the MATRICS index scores, it does
appear that the SAT-MC is relatively independent of Speed of
Processing, Attention and Vigilance, and Verbal and Visual
Learning, and that the total contribution of neurocognition
based on the Neurocognitive Composite is relatively modest.

169

The SAT-MC was found to have no signicant correlation

with any symptom domain measured by the PANSS and by
the SANS and SAPS. These ndings are inconsistent with the
existing literature linking social cognition to severity of various
symptoms such as paranoid delusions (Bentall et al. 2009;
Lysaker et al. 2009; Martin and Penn, 2002; Peer et al., 2004) as
well as negative and/or disorganized symptoms (Garety and
Freeman, 1999; Greig et al., 2004; Corcoran et al., 1995b). It is
possible that our divergent results may be due to the relatively low level of symptoms in this outpatient, clinically stable
sample, a hypothesis supported by literature indicating that
social cognitive impairments are still found in remitted patients
(Bora et al., 2008; Bora et al., 2009; Sprong et al., 2007). We
found that the SAT-MC was also not signicantly correlated
with any dimensions of self-reported decits in reality testing.
Thus, the scores of the SAT-MC are indicating a process that
distinguishes many people with schizophrenia from the community comparison group but that is relatively unrelated to
symptoms.
The robust relationship between SAT-MC scores and
schizophrenia was shown in its classication accuracy. When
SAT-MC scores were used in a logistic regression to predict
group membership, about 75% of participants were correctly
classied, a highly signicant nding. Adding other social cognitive measures to the model did not increase the prediction
very much, suggesting that the SAT-MC on its own is a powerful
predictor of group membership.
Taken together, these ndings offer encouragement for
further use of SAT-MC in schizophrenia research. The instrument showed strong discriminant validity, shared variance
with other social cognitive measures, particularly affect
recognition, and modest relationships to most measures of
neurocognition. In particular, it was relatively independent
of story memory as measured by Logical Memory. Thus, the
SAT-MC would appear to have promise as an additional tool
for exploring social cognition in schizophrenia.
There are a number of important limitations to this study.
The community comparison sample was not ideal. Unpredictably, there was a higher proportion of women than men,
and although this task does not appear to be sensitive to
gender differences, it would have been better to have had no
gender differences between samples. Additionally, the administration format (group versus individual) differed between the schizophrenia and community samples. While this
potentially may have affected performance, if anything, we
would speculate that the individual administration would
lead to better performance in the schizophrenia sample and
worse performance in the community comparison sample.
Thus, if there were an affect, it would have decreased the true
difference in performance of the two samples and makes the
differences we did nd all the more compelling. We also do
not know very much about the psychiatric status of the
community sample, except that they did not exclude
themselves. Thus, the differences between our samples may
be a conservative estimate of the true difference between
people with schizophrenia and those without mental illness
of any kind. Future studies should explore differences
between schizophrenia and other forms of psychopathology
where social cognition is not expected to be impaired (e.g.
late onset depression) to further clarify how distinctive this
impairment is in schizophrenia.

170

M.D. Bell et al. / Schizophrenia Research 122 (2010) 164171

A nal consideration is that this is not a repeatable

instrument. Once a respondent has answered the 19 questions, he or she may have acquired some ideas about what has
occurred in the animation, which may inuence subsequent
administrations. Therefore, testretest reliability cannot be
easily established. For the same reason, it is likely not useful as
a prepost measure in intervention trials aimed at improving
social cognition. In future research, we hope to create a second
version of the task, matched for difculty with the current
version, which will extend the SAT-MC's usefulness for longitudinal studies and interventions research. We also hope to
learn whether there are certain patterns of errors that can be
associated with decits in anthropomorphizing, weaknesses
in metacognition of social narrative, or attribution bias. This
may help us better understand whether the types of errors
made by people with schizophrenia are similar to or different
from those made by people with other disorders, particularly
by those with Autism spectrum disorders.
Role of funding source
This study was funded by the NIMH grant R01 MH061493-01 awarded to
Bell and Wexler, Research Career Scientist award and Career Development
Award from the VA Rehabilitation Research and Development Service,
awarded to Bell and Fiszdon, respectively. Neither sponsor contributed in the
study design, in the collection, analysis or interpretation of data, in the
writing of the report, or in the decision to submit the paper for publication.
Contributors
Dr. Bell designed the study, planned and executed the statistical analysis
and wrote the rst draft. Dr. Fiszdon managed the literature searches, helped
plan the study, collected the community control data, and drafted the
introduction. Dr. Greig assisted in planning the study, was the project
director, and collected data. Dr. Wexler designed the study and participated
in its oversight. All authors contributed to and have approved the nal
manuscript.
Conict of interest
There are no conicts of interest for any of the authors of this paper. No
author has any possible nancial gain for the ndings presented here.
Acknowledgements
We wish to acknowledge Ami Klin, Ph.D., Director of the Autism
Program, Professor of Child Psychology, Yale Child Study Center, for his
generously providing us with the SAT-MC for this study.

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