Short Report Received: September 5, 2016 Accepted after revision: July 28, 2017 Published online: September 7, 2017 Psychopathology DOI: 10.1159/000479882 Stereotype Knowledge and Endorsement in Schizophrenia Luigi Castelli a Francesca D’Alpaos a Luciana Carraro a Florencia Pavan a Giovanni Galfano a Bruno Forti b a Dipartimento di Psicologia dello Sviluppo e della Socializzazione, Università di Padova, Padova, and b Unità Locale Socio Sanitaria, Belluno, Italy Abstract Background: Social cognition is severely impaired in schizophrenia. Emotion processing, attributional biases, and theory of mind are often impaired, as well as the understanding of shared social knowledge. So far, little is known about stereotype knowledge and endorsement in schizophrenia. Sampling and Methods: White patients with schizophrenia and matched healthy respondents reported both their personal beliefs and the predicted beliefs of other people toward Black (study 1) and Gypsy individuals (study 2). Results: Results showed that respondents in the clinical sample displayed less stereotype endorsement as compared to the matched healthy respondents. Most importantly, the contents of the responses provided by the 2 samples were strongly overlapped. Conclusions: Findings indicate that individuals with schizophrenia tend to hold less negative attitudes toward stigmatized outgroups and, most notably, that knowledge about culturally transmitted stereotypes is relatively preserved in schizophrenia. Future research should address the generalizability of the findings in relation to the perception of other stigmatized social groups. Introduction Schizophrenia is a disabling illness that severely impacts all aspects of individual life. Cognitive functions are compromised , but social cognition is also significantly altered [2, 3]. Several components of social cognition appear to be impaired, including emotion processing, attributional biases, and theory of mind [4, 5]. In addition, patients with schizophrenia often display an altered understanding of shared social knowledge, defined as the “representational templates of social situations, or awareness of the roles, rules, expectations, and goals that govern social situations” [5, p. 980; see also 6, 7]. Importantly, social cognition comprises both the understanding of the internal states of others during social interactions (e.g., emotions and intentions) as well as more declarative knowledge about abstract rules and typical features associated with social groups [8; see also 9]. Recent evidence suggests that some aspects of social (declarative) knowledge might be relatively intact in schizophrenia. For instance, judgments provided by individuals with schizophrenia about the appropriateness of social behaviors in relation to existing social norms do not significantly differ from the judgments of healthy control respondents . It has been proposed that most © 2017 S. Karger AG, Basel © 2017 S. Karger AG, Basel E-Mail firstname.lastname@example.org www.karger.com/psp Luigi Castelli Dipartimento di Psicologia dello Sviluppo e della Socializzazione Università degli Studi di Padova Via Venezia 8, IT–35131 Padova (Italy) E-Mail castelli.luigi @ unipd.it Downloaded by: Florida State University 126.96.36.199 - 10/28/2017 8:29:02 PM Keywords Schizophrenia · Social cognition · Stereotypes Table 1. Demographic and clinical information of participants (study 1) Schizophrenic Healthy patients controls (n = 25) (n = 25) Mean age, years Gender M/F Mean education, years Mean age at illness onset, years Mean duration of illness, years 47.44 (9.13) 15/10 11.28 (3.32) 26.12 (4.40) 21.32 (8.50) 47.12 (9.64) 15/10 11.80 (2.98) Standard deviations in parentheses. theory of mind, children affected by this syndrome know race and gender stereotypes just like healthy children . In line with this stream of research, we specifically explored stereotype knowledge among patients with schizophrenia. In study 1, we focused on the perception of Black people among White individuals with schizophrenia and matched healthy respondents. Importantly, we not only measured the overall level of stereotype endorsement, but we also specifically examined the content of such representations in order to assess the overlap between the traits ascribed to the stigmatized outgroup by respondents in the 2 samples. Study 1 2 Psychopathology DOI: 10.1159/000479882 Methods Twenty-five White outpatient clinical participants were recruited (Table 1). Diagnosis of schizophrenia was made by a boardcertified attending research team of psychiatrists using the International Classification of Diseases (ICD-10) . They were all under antipsychotic medication treatment. Twenty-five White healthy participants who perfectly matched the clinical sample in terms of gender, age, and education were also recruited. They reported neither personal nor family history of psychiatric/neurological illness. The experiment was approved by the local ethics committee, and participants provided an informed consent. Participants were presented with 20 traits, pretested as being either stereotypical (e.g., aggressive, lazy) or counterstereotypical of Black immigrants in Italy [e.g., hard-working, educated; see 18], and asked to indicate the percentage of Black immigrants they believed could be described by each trait. Next, the same traits were presented with the request to guess the typical responses of people living in their geographical area, in order to assess the perceived level of stereotype endorsement in the population . Results As for stereotype endorsement, for each respondent 2 average scores were computed in relation to the stereotypical (i.e., the average of the percentage values that the respondent provided for each of the 10 stereotypical traits) and counterstereotypical traits (i.e., the average of the percentage values that the respondent provided for each of the 10 counterstereotypical traits) that were personally believed to be associated with Black immigrants. The scores were analyzed through a 2 (trait: stereotypical vs. counterstereotypical) × 2 (group: clinical sample vs. healthy controls) ANOVA. A main effect of trait emerged, F(1, 48) = 11.85, p < 0.001, η2p = 0.198, indicating that stereotypical traits (mean = 60.25, SD = 16.61) were attributed more than counterstereotypical traits (mean = 44.90, SD = 21.3). The main effect of group was also significant, F(1, 48) = 5.408, p = 0.024, η2p = 0.101, indicating Castelli/D’Alpaos/Carraro/Pavan/ Galfano/Forti Downloaded by: Florida State University 188.8.131.52 - 10/28/2017 8:29:02 PM people who develop schizophrenia acquire relevant social knowledge before the illness onset, and this declarative knowledge may be retained after that onset. One important category of socially shared expectations about the characteristics and behaviors of others is given by stereotypes, namely the set of features ascribed to members of social groups [10, 11]. Thus far, research has mainly examined stereotype knowledge in schizophrenia in relation to one specific context, namely the perception that patients with schizophrenia hold about their own group. Research evidence indicates that participants with schizophrenia are aware that their group is stigmatized and perceived as lacking social competence [12; see also 13]. Individuals with schizophrenia thus appear to have a relatively accurate representation about how they are perceived by people around them, at least in relation to the domain of social functioning. However, it is not yet clear whether the representation of other stigmatized social groups is preserved in schizophrenia. On the one hand, it may be predicted that deficits in social knowledge extend to the mental image about the stereotypical characteristics of other groups. On the other hand, because stereotypical representations are acquired very early in life  and are very resistant to change , they might be relatively unaltered in patients with schizophrenia. One relevant study provides preliminary evidence that stereotypes impact social judgments of patients with schizophrenia to a similar extent as compared to healthy control respondents . In particular, the authors found that social knowledge, such as the speaker occupation stereotype, was also used by patients with schizophrenia in order to understand the likely ironic intent of the speaker. It is interesting to note that research on other mental disorders showed, for instance, that although autism is associated with severe impairments in social cognition and Stereotypes in Schizophrenia Table 2. Demographic and clinical information of participants (study 2) Schizophrenic Healthy patients controls (n = 18) (n = 18) Mean age, years Gender M/F Mean education, years Mean age at illness onset, years Mean duration of illness, years 43.06 (8.37) 11/9 12.28 (4.06) 31.83 (8.47) 11.22 (6.46) 43.06 (8.37) 11/9 12.28 (4.06) Standard deviations in parentheses. tized target group of Black immigrants. In study 2 we carried out a conceptual replication focusing on the perception of another stigmatized group, namely the group of Gypsies. Study 2 Methods Eighteen outpatient clinical participants with a diagnosis of schizophrenia (ICD-10)  were recruited (Table 2). They were all under antipsychotic medication treatment. Healthy participants (n = 18) had no personal or family history of psychiatric/ neurological illness and perfectly matched the clinical sample in terms of gender, age, and education. None of the participants in the 2 groups had taken part in study 1. Participants were presented with 11 negative stereotypical (e.g., criminal, lazy) and 6 positive stereotypical (e.g., musical, close to one’s family) traits about Gypsies. The same questions as used in study 1 were administered. In addition, participants were presented with a 8.6-cm continuum from “very positive” to “very negative” and asked to report both their personal attitude and the predicted attitude of people living in their geographical area. Results The personal attribution of traits was analyzed through a 2 (trait: positive vs. negative) × 2 (group: clinical sample vs. healthy controls) ANOVA. The main effect of group was not significant, F(1, 34) = 2.949, p = 0.09, η2p = 0.08, but an inspection of the means indicated that healthy controls tended to attribute more stereotypical traits than participants in the clinical sample. This tendency was more evident in the case of negative, t(34) = 1.877, p = 0.069, than positive stereotypical traits, p > 0.72, although in no case did a significant effect emerge. As for the predicted responses of people in general, a 2 × 2 ANOVA yielded a significant main effect of the vaPsychopathology DOI: 10.1159/000479882 3 Downloaded by: Florida State University 184.108.40.206 - 10/28/2017 8:29:02 PM that, overall, patients with schizophrenia attributed more traits. Most importantly, a significant 2-way interaction emerged, F(1, 48) = 9.05, p = 0.004, η2p = 0.159, indicating that stereotypical traits were more likely attributed by healthy respondents than by people with schizophrenia (means = 64.22 and 56.28, SDs = 15.55 and 16.98, respectively), whereas the opposite occurred for counterstereotypical traits (means = 35.45 and 54.34, SDs = 16.34 and 21.75). A 2 × 2 ANOVA on the predicted responses of people in general yielded similar findings. The main effect of trait, F(1, 48) = 47.82, p < 0.001, η2p = 0.499, showed that it was believed that stereotypical traits (mean = 67.34, SD = 19.03) would be attributed to a greater extent as compared to counterstereotypical traits (mean = 37.90, SD = 21.03). The main effect of group was also significant, F(1, 48) = 4.688, p = 0.035, η2p = 0.089, indicating that people with schizophrenia believed that others would attribute more traits in general. These 2 main effects were qualified by a significant 2-way interaction, F(1, 48) = 17.61, p < 0.001, η2p = 0.268, demonstrating that respondents with schizophrenia, as compared to healthy respondents, considered stereotypical traits to be less likely attributed (means = 61.35 and 73.33, SDs = 21.64 and 14.00, respectively), whereas the opposite occurred for counterstereotypical traits (means = 49.78 and 26.03, SDs = 22.06 and 11.09). Overall, respondents with schizophrenia showed a reduced personal endorsement of stereotypical views and a belief about a more limited endorsement of stereotypes in the general population. Finally, for each sample of respondents we separately calculated the mean level of personal attribution for each of the 20 traits (i.e., the average percentage of group members who are perceived as being characterized by each specific trait). Similar scores were computed in relation to the predicted attribution of traits. As for personal attributions, the responses provided by individuals with schizophrenia and healthy controls were significantly correlated, r(20) = 0.581, p = 0.007, and the overall pattern was the same for both stereotypical, r(10) = 0.619, p = 0.06, and counterstereotypical traits, r(10) = 0.810, p = 0.004, although it was not significant in the case of stereotypical traits. As for the predicted attribution of traits, a significant correlation emerged when considering the responses about all traits, r(20) = 0.758, p < 0.001, as well as when stereotypical, r(10) = 0.730, p = 0.017, and counterstereotypical traits, r(10) = 0.894, p < 0.001, were separately analyzed. The strong overlap between the responses provided by the 2 samples demonstrated that they shared largely similar representations about the stigma- Discussion In the last 2 decades there has been a flourishing research about social cognition in schizophrenia and about how dysfunctions in this domain contribute to the relevant interpersonal problems that are characteristic of schizophrenia [5, 20]. However, social knowledge in schizophrenia has been so far relatively understudied, and, in particular, few empirical studies have addressed the expectations about the typical characteristics of members of other stigmatized social groups (i.e., stereotypes). The present studies, although based on a limited number of participants, consistently indicated that respondents with schizophrenia tend to have an overall lower level of stereotype endorsement towards stigmatized outgroups as compared to healthy respondents. Research with nonclinical samples suggests that the perception of being stigmatized and discriminated is often associated with more 4 Psychopathology DOI: 10.1159/000479882 negative attitudes towards other minorities in different domains. For instance, perceived racial discrimination leads to stronger biases towards sexual minorities  whereas the perception of being a target of sexism enhances racial biases . Interestingly, individuals with schizophrenia, even though they are severely stigmatized, did not show any increased outgroup derogation and, in contrast, they were less prone to attribute stereotypical features to both Black and Gypsy individuals as compared to healthy respondents. Most importantly, this pattern cannot be attributed to reduced stereotype knowledge, as correlational analyses from both studies showed a very strong overlap between the contents of the stereotypical representations displayed by respondents with schizophrenia and healthy controls. In sum, patients with schizophrenia and healthy controls displayed very similar perceptions about the relative typicality of the presented traits. The present findings are strongly in line with those reported by Champagne-Lavau and Charest , who found that patients with schizophrenia and healthy control respondents were equally sensitive to social stereotypes in the domain of professional occupations. Overall, this is consistent with the idea that individuals with schizophrenia have a relatively intact knowledge about socially shared stereotypes. Overall, the obtained pattern of findings supports the conclusion that, as in the case of autism , social knowledge about culturally transmitted stereotypes may be less compromised in schizophrenia as compared to other facets of social cognition. As discussed before, social cognition is a multifaceted construct that comprises both the understanding of the mental states of others in a given social context as well as more declarative knowledge about abstract rules and the typical characteristics that are associated with others as a function of their group membership [8, 11]. Importantly, both aspects are critical to social functioning. For instance, according to prevalent models of social perception [11, 23] the early activation of stereotypes represents the basic process that sets the background for all the subsequent stages of impression formation and social interaction. The present and previous findings  suggest that individuals with schizophrenia hold the same stereotypical knowledge and expectations as healthy individuals, and likely rely on them in their daily life marked by multiple interactions with other people belonging to a variety of different social groups. A notable limitation of the present studies is that participants were asked to provide rather abstract judgments about the estimated prevalence of stereotypical and counterstereotypical traits in the tarCastelli/D’Alpaos/Carraro/Pavan/ Galfano/Forti Downloaded by: Florida State University 220.127.116.11 - 10/28/2017 8:29:02 PM lence of the trait, F(1, 34) = 27.08, p < 0.001, η2p = 0.44, demonstrating that negative traits were expected to be more likely attributed (mean = 76.40, SD = 18.87) as compared to positive traits (mean = 47.56, SD = 21.86). No other effect was significant (all p values >0.13). As in study 1, for each sample of respondents we separately calculated the mean level of personal attribution for each trait. Similar scores were computed in relation to the predicted attribution of traits. As for personal attributions, the responses provided by respondents in the 2 samples were significantly correlated, r(17) = 0.661, p < 0.005, and the pattern was the same for both negative, r(11) = 0.608, p < 0.05, and positive stereotypical traits, r(6) = 0.845, p < 0.05. As for the predicted attribution of traits, a significant correlation emerged when considering the responses about all traits, r(17) = 0.898, p < 0.001. More specifically, the correlation was significant in the case of negative traits, r(11) = 0.691, p < 0.05, but not for positive traits, p = 0.57. The analysis on responses to the attitude continuum showed that healthy controls reported a more negative attitude toward Gipsy individuals as compared to participants in the clinical group, t(33) = 2.087, p < 0.05 (means = 6.18 and 4.40, SDs = 2.27 and 2.21, respectively). No difference emerged in relation to the predicted responses of people in general along the same continuum, p > 0.46, suggesting that the aforementioned difference in the reported personal attitudes is unlikely to simply reflect a difference in the way in which participants in the 2 groups used the response scale. get groups. Future studies will have to further explore the role of those stereotypical representations while people with schizophrenia are engaged in social interactions with members of stigmatized groups . This would enable to more closely explore how declarative knowledge about the perceived typical characteristics of social groups contributes to shape the attribution of mental states to interaction partners. Disclosure Statement There is no conflict of interest declared. Author Contributions Conceived the studies: L.Cas., L.Car., F.D., F.P., G.G., B.F.; collected the data: F.D., F.P.; analyzed the data: L.Cas., F.D., F.P.; wrote the paper: L.Cas., L.Car., F.D., G.G. 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