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Research on empathy in schizophrenia has relied on dated self-report scales that do not conform to contemporary social neuroscience models of empathy. The current study evaluated the structure and correlates of the recently-developed Questionnaire of Cognitive and Affective Empathy (QCAE) in schizophrenia. This measure, whose structure and validity was established in healthy individuals, includes separate scales to assess the two main components of empathy: Cognitive Empathy (assessed by two subscales) and Affective Empathy (assessed by three subscales). Stable outpatients with schizophrenia (n=145) and healthy individuals (n= 45) completed the QCAE, alternative measures of empathy, and assessments of clinical symptoms, neurocognition, and functional outcome. Exploratory and confirmatory factor analyses provided consistent support for a two-factor solution in the schizophrenia group, justifying the use of separate cognitive and affective empathy scales in this population. However, one of the three Affective Empathy subscales was not psychometrically sound and was excluded from further analyses. Patients reported significantly lower Cognitive Empathy but higher Affective Empathy than controls. Among patients, the QCAE scales showed significant correlations with an alternative self-report empathy scale, but not with performance on an empathic accuracy task. The QCAE Cognitive Empathy subscales also showed significant, though modest, correlations with negative symptoms and functional outcome. These findings indicate that structure of self-reported empathy is similar in people with schizophrenia and healthy subjects, and can be meaningfully compared between groups. They also contribute to emerging evidence that some aspects of empathy may be intact or hyper-responsive in schizophrenia.

A growing body of research on social cognition in schizophrenia has focused on empathy. Although defined in many ways (Batson, 2009), contemporary social neuroscience models define empathy as the ability to understand and share the thoughts and feelings of others. There is general agreement that empathy is a multidimensional construct, which includes distinct cognitive and affective processes (Decety, 2006; Shamay-Tsoory, 2011). Cognitive empathy refers to reflective processes that include taking the perspective of others and understanding the mental state of others, whereas affective empathy refers to relatively automatic processes through which perceived actions and social cues trigger a shared emotional response. These subprocesses involve separate neural systems, and the capacity to effectively empathize is believed to involve coordinated interaction between them (Zaki and Ochsner, 2011). This social neuroscience framework provides a foundation for translational research into empathy in schizophrenia. The vast majority of research on empathy in schizophrenia has used a self-report measures of trait empathy called the Interpersonal Reactivity Index (IRI) (Davis, 1983), which includes two subscales considered to be indicators of cognitive empathy (Perspective-Taking, Fantasy) and two considered to be indicators of affective empathy (Empathic Concern, Personal Distress). A recent meta-analysis (Achim et al., 2011) and subsequently published studies of the IRI consistently indicate that schizophrenia subjects report diminished cognitive empathy on the Perspective-Taking subscale, while findings for the Fantasy subscale are inconsistent. Furthermore, lower Perspective Taking accounts for unique variance in functional outcome, above and beyond symptoms and neurocognitive impairments (Smith et al., 2012). In contrast, individuals with schizophrenia report similar scores to healthy subjects on the affective empathy subscales in most studies, though some have reported diminished Empathic Concern and/or elevated Personal Distress (Corbera et al., 2013; Lee et al., 2011; Shamay-Tsoory et al., 2007; Sparks et al., 2010). Thus, it appears individuals with schizophrenia report functionally relevant disturbances in at least some aspects of trait empathy. It is worth noting that the IRI is over 30 years old and was not developed to distinguish between cognitive and affective empathy (Davis, 1983). In addition, concerns have been raised about its psychometric properties and the compatibility of its subscales with newer models of empathy (see (Michaels et al., 2014) for a review). For example, the IRI conflates empathy and sympathy, and it assesses emotional reactions to others’ negative experiences rather than true sharing of affective states (for Empathic Concern). Less is known about how individuals with schizophrenia respond on measures designed to assess the core cognitive and affective subcomponents of empathy described in contemporary models. To address limitations of existing self-report measures, Reniers and colleagues (2011) recently developed the Questionnaire of Cognitive and Affective Empathy (QCAE). The QCAE was developed from a pool of items with the strongest face validity from several existing self-report measures (including the IRI) and refined through extensive psychometric analyses in a large healthy sample. Based on exploratory and confirmatory factor analyses, the QCAE includes a Cognitive Empathy scale, comprised of subscales labeled Perspective Taking and On-line Simulation, and an Affective Empathy scale, comprised of subscales labeled Emotion Contagion, Proximal Responsivity, and Peripheral Responsivity. The five subscales demonstrated good reliability, as well as strong convergent and divergent validity with respect to relevant interpersonal and personality variables. The Cognitive and Emotional Empathy scales correlate in expected directions with prosocial behavior, psychopathy, and neural activity during moral judgments (Lockwood et al., 2014; Reniers et al., 2012; Yoder and Decety, 2014). We are aware of only one study that evaluated the QCAE in schizophrenia. Michaels et al. (2014) found that patients (n=52) reported significantly lower Cognitive Empathy than healthy controls (n=37), and that lower scores were associated with worse social functioning, even after accounting for neurocognition and symptoms. No group differences were found for overall Affective Empathy, though patients actually reported higher scores on the Emotional Contagion subscale, and the Peripheral Responsivity subscale had poor internal consistency and low correlations with the other subscales in the patient sample. We evaluated the QCAE in a substantially larger sample of patients (n = 145) to address three primary goals. First, we conducted a comprehensive structural analysis of the QCAE to determine whether patients’ self-reported empathy demonstrates a two-factor structure similar to healthy subjects. Second, we evaluated patient vs. control group differences on the QCAE. Third, we examined the correlates of QCAE scores, including relations to alternative measures of empathy, as well as symptoms, neurocognition, and functional outcome.