Teste Faux Pas
Teste Faux Pas
Teste Faux Pas
Keywords
Schizophrenia, social
cognition, Faux Pas
Recognition Test.
Objective: The aim of this study is to validate the adult version of Faux Pas Recognition Test
created by Stone and colleagues (1998) as a reliable instrument assess and discriminate social cognition among schizophrenia patients and healthy controls. Methods: This is a cross-sectional study with a total of 196 participants (mean age = 26.45; CI (95%) [25.10; 27.83]) 51%
male. From those, 44 (22.4%) patients with schizophrenia and 152 (77.6%) healthy controls.
The participants answered a short version of the Faux Pas Recognition Test, composed by
10 stories. Results: Significant differences were found between both groups regarding their
scores on Faux Pas Recognition Test (p = 0.003). Patients with schizophrenia had lower score,
compared to healthy controls. Story 14 was the best to distinguish both groups, and Story 16,
the worst. Among the questions of Faux Pas stories, the one related to intuition presented the
most significant difference between the groups (p = 0.001), followed by the one related to
understanding (p = 0.003). Conclusion: The Brazilian version of the Faux Pas Recognition Test
is a valid test to assess social cognition in schizophrenia and can be an important instrument
to be used on the clinical practice.
RESUMO
Palavras-chave
Esquizofrenia, cognio
social, Teste de
Reconhecimento de
Faux Pas.
Objetivo: O objetivo deste estudo validar a verso brasileira da verso adulta do Teste
de Reconhecimento de Faux pas criado por Stone e colaboradores (1998) como um instrumento confivel para avaliar e discriminar a cognio social entre pessoas com esquizofrenia
e controles saudveis. Mtodos: Trata-se de um estudo transversal com um total de 196
participantes (idade mdia = 26,45; IC (95%) [25,10; 27,83]), sendo 51% homens; destes, 44
(22,4%) eram pessoas com esquizofrenia e 152 (77,6%), controles saudveis. Os participantes
responderam a uma verso reduzida do Teste de Reconhecimento de Faux Pas, contendo 10
histrias. Resultados: Foram encontradas diferenas significativas entre grupos no Teste de
Reconhecimento de Faux Pas (p = 0,003). Pessoas com esquizofrenia obtiveram menor pontuao comparadas com o grupo controle. A histria 14 foi a mais eficiente para distinguir os
grupos, ao passo que a histria 16 foi a pior. Quanto s questes das histrias Faux Pas, aquela
referente intuio foi a que apresentou maior diferena entre grupos (p = 0,001) seguida
por compreenso (p = 0,003). Concluso: A verso brasileira do Teste de Reconhecimento
de Faux Pas um instrumento vlido para avaliar a cognio social em esquizofrenia e pode
ser um instrumento importante a ser usado na prtica clnica.
DOI: 10.1590/0047-2085000000098
18
ORIGINAL ARTICLE
Negro J et al.
INTRODUCTION
Schizophrenic patients suffer from impaired social functioning1, such as compromised empathy and difficulties to initiate and maintain social interactions2. These difficulties are
related to impaired social cognition, which expresses itself
in traits such as abnormal perception and interpretation of
others intentions, ability known as Theory of Mind (ToM)1.
ToM is the ability of a person to attribute mental states,
as beliefs, thoughts, intentions to oneself and others, understanding the distinction between agencies in both cases4.
Among other impaired social cognition abilities, ToM deficits
have been suggested as trait markers for schizophrenia, even
in remission patients and has been found to be present in
first degree relatives4-6.
The ability to prospect someone elses intentionality is
linked to brain activity in different areas, among which the
ventromedial prefrontal cortex (VMPC) and temporal-parietal junction (TPJ) play a prominent role7. Schizophrenia is
a pervasive syndrome with symptoms that involve serious
social cognitive deficits, which have been correlated with
impaired brain activation in the two above-mentioned areas:
VMPC and TPJ8.
ToM abilities can be evaluated using different tasks as stories or pictures reporting false beliefs, irony, faux pas or intentionality5,9. Studies with Mental State Attribution were initially
done with autistic population6. Stone et al.10 developed the
adult version of Faux Pas Recognition Test, which consists of
stories describing Faux Pas situations, where characters interact and unintentionally say socially inadequate sentences.
In order to understand the story, the subject must recognize
that the character who said the sentence did not intend to
offend the other character, and also assess the other interlocutors feelings and describe how he must have felt in face of
the socially awkward saying. After story presentation, a few
questions are made in order to evaluate this process.
Previous studies showed significant difference between
schizophrenic patients, their relatives and healthy controls
in ToM index, evaluated by the Faux Pas Recognition Test.
This index revealed a moderate to strong association with
scores in the Scale for the Assessment of Negative Symptoms (SANS), showing correlation between the intensity of
negative symptoms and worse performance in Faux Pas recognition in schizophrenic patients and even in their relatives.
Mental State Attribution deficit could be influenced by genetics, and could be considered an endophenotype of this
disease11,12.
The Faux Pas Recognition Test is a well-known instrument used to evaluate ToM in individuals with Autism
Spectrum Disorders. Although, schizophrenic patients have
similar ToM deficits, few instruments are able to target this
function in this population.
J Bras Psiquiatr. 2016;65(1):17-21.
METHODS
The ethical committee of the Federal University of So Paulo where the study was developed approved this study
(09/54836-7). All participants agreed and signed the informed consent form, which was read and explained. Participants received an identification number to preserve their
identity.
This cross-sectional study engaged 196 participants: 44
schizophrenia patients recruited from The Schizophrenia
Program of the Federal University of So Paulo (PROESQ), a
day-treatment program dedicated to schizophrenia and related disorders, and 152 healthy control volunteers.
The inclusion criteria for the clinical group (S) were: (i)
Individuals with schizophrenia, diagnosed accordingly to
the DSM-IV criteria and the Positive and Negative Syndrome
Scale13; (ii) a minimum timespan of six months, in which the
severe symptoms must be maintained. (iii) Age between 18
and 50 years. The inclusion criteria for the control group (C)
were: (i) age between 18 and 35 years; (ii) score less than 7
points on Psychiatric Screening Questionnaire (SRQ-20)14,
(iii) do not have either psychiatric or neurological disease
history. The exclusion criteria were: (i) inability to diagnose
schizophrenia, (ii) schizoaffective disorder; (iii) or inability to
provide informed consent.
Ten stories (2, 3, 5, 8, 11, 14, 16, 17, 18, and 20) of Faux
Pas Recognition Test11 were translated to Brazilian Portuguese and culturally adapted to Brazilian culture. A group composed by specialists in social cognition chose these stories
and the final version was approved by judges with at least
PhD degree. Five of the chosen stories were control conditions stories, without a faux pas (3, 5, 8, 17, 20); and five were
Faux Pas stories (2, 11, 14, 16 and 18). Each subject listened
and read the stories and answered eight standard questions
afterwards. Six of the questions were directly related to the
Faux Pas situation (1 and 2 Faux Pas detection; 3 understanding inappropriateness; 4 intention; 5 belief and 6
empathy) and the last two (questions 7 and 8), control questions, to assure the story comprehension, as described by
Stone et al. (1998)10. To ensure that the given answers were
not affected by the lack of understanding of the story, only
stories which had the last two answers correctly answered
ORIGINAL ARTICLE
RESULTS
Groups were matched by gender (2 (1) = 1.280, p = 0.297),
however, significant differences were found between age
(u = 8,807, p < 0.001) and socioeconomic status (u = -6,107,
p < 0.001). While the (S) group was composed by 59% males, mean age 39 11 years, 52% of the subjects in A or B
economic status by the ABIPEME Index (2012) the (C) group,
had 48% males, mean age 22 4 years, having 89% of the
subjects in the A or B economic status.
The five control stories (3, 5, 8, 17 and 20) were understood by both (S) and (C) groups with no significant differences (p = 0.859) (Table 1). On the other hand, story 16, one
of the five Faux Pas stories, was not understood by the (S)
group, as assessed by the control questions in this story.
19
95% CI for OR
Faux Pas
Controls
(n = 152)
Schizophrenia
(n = 44)
P-value
Odds Ratio
(OR)
Lower
Upper
FPH2*
5.81 0.51
4.09 2.23
0.040
1.82
1.03
3.22
FPH11*
5.62 1.22
4.05 2.30
0.351
1.17
0.84
1.62
FPH14*
5.89 0.71
3.11 2.64
< 0.001
3.52
1.78
6.94
FPH16*
5.63 1.22
2.64 2.63
0.001
2.38
1.44
3.92
FPH18*
5.41 1.63
3.73 2.42
0.016
1.43
1.07
1.91
FPH CONTROL
9.51 1.10
8.14 2.81
0.859
1.03
0.73
1.45
95% CI for OR
Odds Ratio
(OR)
Lower
Upper
1.07
1.36
Controls
(n = 152)
Schizophrenia
(n = 44)
P-value*
32.24 3.24
23.11 8.90
0.003
1.21
Control Question
17.75 0.57
16.18 2.58
0.081
1.88
0.92
3.81
Total
49.99 3.36
39.30 10.46
0.003
1.2
1.06
1.35
* p-value from Logistic Regression controlling by age and social economic status.
ORIGINAL ARTICLE
Negro J et al.
20
95% CI for OR
Controls
Schizophrenia
(n = 152)
(n = 44)
P-value
Odds Ratio
(OR)
Lower
Upper
Detection
7.72 0.86
5.77 2.59
0.006
1.98
1.21
3.23
Understanding
3.81 0.57
2.23 1.55
0.003
2.63
1.38
5.02
Intuition
3.74 0.59
1.98 1.55
0.001
3.76
1.75
8.07
Belief
3.77 0.55
2.64 1.46
0.010
2.69
1.26
5.74
Empathy
3.69 0.60
2.36 1.42
0.006
2.71
1.32
5.54
Story Comprehension
7.89 0.33
7.36 1.20
0.244
1.76
0.68
4.57
Stories included 1, 5, 6, 9.
p-value Logistic Regression controlling by age and social economic status.
Story Comprehension is the sum of FPH1C1, FPH1C2, FPH5C1, FPH5C2, FPH6C1, FPH6C2, FPH9C!, FPH9C2.
DISCUSSION
Studies about mental state attributions in patients with schizophrenia point to the existence of a failure in agency attribution of mental states and behaviors, which have deep
nosological connection to other symptoms of the syndrome.
From the perspective of the cognitive dimension, affected
subjects tend to have impairments in working memory, visual memory, verbal memory, verbal learning and visual stimuli, processing speed, executive functions and social cognition15,16. Other studies have shown the association of these
deficits with gray matter reduction in the anterior cingulate cortex, dorsolateral prefrontal cortex, superior temporal
gyrus and Insular; and less activation of the angular gyrus,
inferior parietal lobe, inferior frontal gyrus and left middle
temporal gyrus; thalamus, hippocampus and striatum may
and intraparietal sulcus may be affected. The cortico-striato-thalamic circuitry may be strongly related to cognitive deficits in schizophrenia17.
Several studies have shown how difficult it is for individuals suffering with acute schizophrenic manifestations to
properly deal with other peoples intentions and actions. The
Faux Pas Recognition Test is well established as an instrument that measures such qualifications through the recognition of gaffes, proved to be consolidated in the ASD (Autistic
Syndrome Disorder) field18, differentiating them from healthy individual. However, little literature is found about its use
in the assessment of schizophrenic patients, and there are no
studies using it as a validated instrument in Brazil19,20.
The selected control stories served their purpose and
were recognized by both groups. Faux Pas stories also served their purpose, allowing the discrimination between
groups, except for story 16, which was removed to avoid
interpretation biases; as both groups exhibited difficulties
in comprehending it. Within the Faux Pas stories, all questions have shown relevance in identifying flaws in assigning
mental status, being all equally important. Even with an understanding of the stories, the schizophrenic group failed to
J Bras Psiquiatr. 2016;65(1):17-21.
ORIGINAL ARTICLE
Finally, we used a single instrument to assess social cognition, as, until the moment of data collection, there was no
other validated instrument to assess social cognition availa
ble in Brazil.
21
CONCLUSION
8. Saxe R, Kanwisher N. People thinking about thinking people. The role of the temporoparietal junction in theory of mind. Neuroimage. 2003;19(4):1835-42.
INDIVIDUAL CONTRIBUTIONS
Juliana Negro Wrote the manuscript draft and conduc
ted the statistical analysis.
Henrique Teruo Akiba Translated and adapted the
instrument, collected data, supervised the statistical analysis
and critically reviewed the paper.
Vivian Renne Gerber Lederman Assisted on the composition of the manuscript draft and critically reviewed the
paper.
lvaro Machado Dias Led the team, created the study
design and critically reviewed the paper.
10. Stone VE, Baron-Cohen S, Knight RT. Frontal lobe contributions to theory of mind. J Cogn
Neurosci. 1998;10(5):640-56.
11. Martino DJ, Bucay D, Butman JT, Allegri RF. Neuropsychological frontal impairments and
negative symptoms in schizophrenia. Psychiatry Res. 152:121-8.
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processing and theory of mind in schizophrenia patients and their unaffected first-degree
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Brasil. Rev Psiq Clin. 1998;25(6):337-43.
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ConflictS of interest
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controls: preliminary data. Front Hum Neurosci. 2013;7:661.
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