Schizophrenia Research 165 (2015) 171–174

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Schizophrenia Research

journal homepage: www.elsevier.com/locate/schres

The effect of transcranial direct current stimulation on social cognition in

schizophrenia: A preliminary study
Yuri Rassovsky a,b,⁎, Walter Dunn c,b, Jonathan Wynn c,b, Allan D. Wu d, Marco Iacoboni b,e,
Gerhard Hellemann b, Michael F. Green b,c
a
Department of Psychology and Gonda Multidisciplinary Brain Research Center, Bar-Ilan University, Ramat-Gan, Israel
b
Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
c
Department of Veteran Affairs VISN-22 Mental Illness Research Education Clinical Center, Los Angeles, CA, USA
d
Department of Neurology, University of CA, Los Angeles, USA
e
Ahmanson-Lovelace Brain Mapping Center, University of CA, Los Angeles, USA

a r t i c l e i n f o a b s t r a c t

Article history: In this preliminary study, we examined the effect of transcranial direct current stimulation (tDCS) on social
Received 22 February 2015 cognition in 36 individuals with schizophrenia. Participants received a baseline assessment and one week later
Received in revised form 9 April 2015 received either anodal, cathodal, or sham tDCS, with 12 participants randomized to each condition. A single
Accepted 12 April 2015
20-minute session tDCS was administered bilaterally over the dorsolateral prefrontal cortex (centered at
Available online 29 April 2015
positions Fp1 and Fp2) at 2 mA. Among the 4 social cognitive tasks, participants showed a significant
Keywords:
improvement on one of them, emotion identification, following anodal stimulation. Findings demonstrate the
Schizophrenia safety of this procedure and suggest potential therapeutic effects on one aspect of social cognition in
Social cognition schizophrenia.
Neurocognition © 2015 Elsevier B.V. All rights reserved.
Transcranial direct current stimulation
tDCS

1. Introduction cathode, generally enhances cortical activity and excitability,

Impairment in social functioning has been extensively docu-
mented in schizophrenia and recognized as one of the hallmarks
of the disorder (Brunet-Gouet and Decety, 2006; Thakkar et al.,
2014). Over the last decade, considerable research has focused
on social cognition, which is the ability to construct mental
representations about others, oneself, and relations between
others and oneself (Adolphs, 2001). Social cognition is thought to
facilitate social interactions and is considered a determinant of
social dysfunction among people with schizophrenia (Fett et al.,
2011; Green et al., 2012).
This preliminary study examined the effects of transcranial
direct current stimulation (tDCS), a non-invasive neurostimulation
technique, on social cognitive deficits in schizophrenia. Unlike
other non-invasive brain stimulation techniques, such as transcra-
nial magnetic stimulation, tDCS does not induce neuronal firing
by suprathreshold neuronal membrane depolarization, but rather
modulates spontaneous neuronal network activity (Priori et al.,
2009). Studies suggest that anodal-tDCS, or flow from anode to
⁎ Corresponding author at: Department of Psychology, Bar-Ilan University, Ramat-Gan
52900, Israel. Tel.: +972 3 531 8174; fax: +972 3 970 2593.
E-mail address: yurir@ucla.edu (Y. Rassovsky).
whereas cathodal-tDCS, or flow from the cathode to anode, has
the opposite effect (Nitsche and Paulus, 2000), although other fac-
tors, such as outcome measures and assessment procedures,
influence the net effect of tDCS on neural networks (Brunoni
et al., 2014). Various studies demonstrated the beneficial
therapeutic effects of tDCS in reducing epileptiform discharges
in refractory epilepsy (Fregni et al., 2006), improving aphasic
symptoms in post-stroke patients (Baker et al., 2010), diminishing
depressive symptoms in mood disorder (Brunoni et al., 2011),
reducing auditory hallucinations (Brunelin et al., 2012), and
improving working memory (Hoy et al., 2014) and association
learning (Vercammen et al., 2011) performance in schizophrenia.
To explore the effect of tDCS on several social cognitive
functions, we applied anodal and cathodal tDCS bilaterally over
the dorsolateral prefrontal cortex (DLPFC) in 36 individuals
with schizophrenia. Patients were randomly divided into three
groups who received anodal tDCS, cathodal tDCS, and sham tDCS.
Performance data on several standardized measures of social
cognition were collected immediately following stimulation. A
standardized neuropsychological battery was also administered.
As this was the first study to examine the effect of this procedure
on social cognition in schizophrenia, no directional hypotheses
were made.

http://dx.doi.org/10.1016/j.schres.2015.04.016
0920-9964/© 2015 Elsevier B.V. All rights reserved.
172 Y. Rassovsky et al. / Schizophrenia Research 165 (2015) 171–174
2. Methods
2.1. Participants
Participants were recruited through outpatient clinics at the UCLA
and the VA Greater Los Angeles Healthcare System and through
presentations in the community. All patients were administered
the Structured Clinical Interview for DSM-IV (SCID-P) (First et al.,
1997) and met the DSM-IV diagnostic criteria for Schizophrenia
(AmericanPsychiatricAssociation, 1994). All interviewers were trained
by the Treatment Unit of the Mental Illness Research, Education, and
Clinical Center (MIRECC). Patients were excluded if they had an
identifiable neurological condition, psychiatric inpatient hospitalization
in the last three months, substantial changes in their antipsychotic
medications during the previous 6 weeks (as determined by the clinical
psychiatrists during case reviews), IQ b 70 based on reading ability, or
substance dependence in the last six months.
The present study included 36 individuals with schizophrenia
(67% males), all receiving antipsychotic medications (84% atypical).
Mean age was 45.1 years (SD = 9.86), and mean education was
12.8 years (SD = 2.16). Patients' mean illness chronicity was
20.4 years (SD = 11.7). Mean symptom rating on the Brief
Psychiatric Rating Scale (BPRS) was 41.3 (SD = 12.8) and on the
Scale for the Assessment of Negative Symptoms (SANS) was 42.3
(SD = 14.4). All participants gave written informed consent after
receiving a full explanation of the research according to procedures
approved by the Institutional Review Boards.
2.2. Assessments
Symptom ratings were collected using the expanded BPRS (Ventura
et al., 1993) and SANS (Andreasen, 1984). Social cognition assessments
included measures of social cognition used previously in schizophrenia
research (Green et al., 2005). The Mayer–Salovey–Caruso Emotional
Intelligence Test (MSCEIT) (Mayer et al., 2002) assesses four compo-
nents of emotional processing. In this study, the Managing Emotions
branch was administered. Facial Emotion Identification Test (FEIT) is a
test of identification of facial emotion based on photographs from
software developed by Ekman (Ekman, 2004). Profile of Nonverbal
Sensitivity (PONS) is used to assess social perception (Rosenthal et al.,
1979; Ambady et al., 1995) using scenes that contain facial expressions,
voice intonations, and/or bodily gestures. The Awareness of Social Infer-
ence Test (TASIT) (McDonald et al., 2002) is a videotape test of theory of
mind (ToM) in various social contexts. We also administered
the MATRICS Consensus Cognitive Battery (MCCB), to obtain the non-
social Neurocognitive Composite score (Green et al., 2004; Kern et al.,
2008). Participants were also interviewed regarding the most
common side effects typically reported following tDCS using a struc-
tured interview with symptom severity ratings (0 = none, 1 = mild,
2 = moderate, 3 = considerable, 4 = severe).
2.3. Equipment
The tDCS was delivered by an Activa Dose II Iontophoresis Delivery
Unit, using a pair of saline-soaked sponge electrodes held in place by
elastic bands. The two 5 × 7 cm tDCS active electrodes (anodal or
cathodal) were placed bilaterally over the DLPFC, centered at positions
Fp1 and Fp2 of the 10/20 International System (Koenigs et al., 2009).
The current intensity was set 2 mA with a current density of
0.028 mA/cm2 at the skin. A variable resistor was included in series
with each active electrode, which allowed for continuous monitoring
of current delivered and ensured that equivalent intensity balanced at
1 mA per active electrode. The reference electrode (also 5 × 7 cm)
was placed on the upper right arm. In the sham condition, the current
was turned on for 30 s and then ramped down to 0 mA. In this way,
the participants experience the same initial sensation of mild tingling,
thus preserving the sham manipulation (Poreisz et al., 2007).
2.4. Procedures
Participants made two visits. During the first visit, they completed
the diagnostic interviews and baseline social cognitive and
neurocognitive measures. In the second session, which took place 1–
2 weeks later, participants were randomly assigned to one of three
conditions (12 per group): 1) anodal tDCS, 2) cathodal tDCS, and
3) sham stimulation. The research assistants administering the tDCS
procedures were not blinded to the type of condition. Participants
received a 20-minute stimulation session, following which they
completed the social cognitive and neurocognitive measures. The
order of administration of the social cognitive and neurocognitive
measures was randomized across participants within each group.
2.5. Statistical analyses
Analyses of variance (ANOVA) with repeated measures were
conducted to examine the effects of tDCS on patients' social cognitive
and neurocognitive performance. The stimulation condition (anodal,
cathodal, and sham) was the between-subjects factor. The primary
interest was in the time (baseline vs. post-stimulation) by condition
interaction effects. Given the small sample size and preliminary nature
of the study, no corrections for multiple analyses were made.
3. Results
The three groups (anodal vs. cathodal vs. sham) did not differ on any
demographic variables, illness chronicity, or symptom ratings. The tDCS
procedure was well tolerated by all participants, with no dropouts
associated with the procedure. The most common side effects reported
by the participants were itchiness, followed by warmth and burning
sensations. These reported side effects did not differ across the three
experimental conditions (see Table 1).
For the performance-based tasks, none of the measures showed any
main effects for condition or for time. Repeated measures ANOVA
revealed a significant condition by time interaction only for the FEIT.
No significant condition by time interactions was found for any of the
other social cognitive measures. Also, no significant differences were
noted for the Neurocognitive Composite score, or for any individual
neurocognitive domains. Table 2 presents the descriptive and inferen-
tial statistics for these analyses. (Given the primary focus on social
cognitive outcome measures in this study and the lack of statistical
significance for any of the neurocognitive measures, only the
Neurocognitive Composite score is presented in the table.) We further
explored the interaction by conducting post-hoc contrasts of the simple
main effects to evaluate the change over time within each of the three
conditions. We found that there was a significant change from baseline
to post-tDCS in the anodal condition (F (1,10) = 11.8, p b 0.01, p
(Bonferroni corrected) = 0.02), but not in either the cathodal condition
(F (1,11) = 0.7, p = 0.41, p (Bonferroni corrected) N 1.0) or in the sham
condition (F (1,11) = 0.01, p = 0.93, p (Bonferroni corrected) N 1.0).
4. Discussion
Considerable efforts have been made to find ways to enhance
cognition in schizophrenia (Green et al., 2004; Marder and Fenton,
2004; Buchanan et al., 2005), but neurostimulation has received
little attention so far. This pilot study was the first to examine the
effect of single tDCS administration on several components of social
cognition in schizophrenia. Among the 4 social cognitive tasks
administered, assessing different aspects of social cognition
(managing emotions, identification of facial emotion, social percep-
tion, and ToM), participants showed a significant improvement on
 Y. Rassovsky et al. / Schizophrenia Research 165 (2015) 171–174 173

Table 1
Demographic data and symptom ratings.

Anodal Cathodal Sham Statistic p

(n = 12) (n = 12) (n = 12)

Age (years) 45.8 ± 11.2 47.8 ± 7.48 41.6 ± 10.3 F = 1.248 0.300
Education (years) 12.2 ± 2.48 12.8 ± 2.18 13.3 ± 1.78 F = 0.872 0.428
Paternal education (years) 14.9 ± 3.66 13.5 ± 2.98 13.4 ± 1.90 F = 0.628 0.543
Males, n (%) 10 (83) 6 (50) 8 (67) χ2 = 3.00 0.223
Illness chronicity (years) 19.8 ± 13.8 24.8 ± 10.9 15.4 ± 7.73 F = 1.784 0.185
BPRS (total) 47.3 ± 13.9 38.8 ± 11.7 37.6 ± 11.4 F = 2.213 0.125
SANS (total) 49.8 ± 12.3 37.8 ± 10.4 39.3 ± 17.5 F = 2.700 0.082
Side effects
Itchiness 0.75 ± 0.62 1.58 ± 1.24 1.42 ± 1.08 F = 2.259 0.120
Pain 0.42 ± 1.00 0.42 ± 0.67 0.33 ± 0.65 F = 0.045 0.956
Burning 1.00 ± 1.21 0.75 ± 0.87 0.75 ± 1.22 F = 0.204 0.817
Warmth/heat 1.17 ± 0.72 0.50 ± 0.52 1.00 ± 1.28 F = 1.788 0.183
Pinching 0.33 ± 0.89 0.25 ± 0.62 1.08 ± 1.31 F = 2.620 0.088
Iron taste 0.50 ± 0.90 0.17 ± 0.58 0.00 ± 0.00 F = 2.028 0.148
Fatigue 0.83 ± 1.11 0.25 ± 0.45 0.25 ± 0.62 F = 2.227 0.124

BPRS: Brief Psychiatric Rating Scale; SANS: Scale for the Assessment of Negative Symptoms; shown are mean ± standard deviation or number (%) of cases.

one of them, facial emotion identification, following anodal
stimulation. Based on Cohen's benchmark (Cohen, 1988), this effect
size is considered medium to large (f 2 = 0.25). Although these
preliminary findings need to be viewed with caution, if replicated
in a larger sample, the results may indicate that tDCS-induced
changes in prefrontal activity enhance emotion identification
through interactions with other structures linked to social cue
identification, such as the fusiform and amygdala.
Neurostimulation has some advantages over psychopharmacology
in that it is relatively safe with few side effects (Dresler et al., 2013).
The tDCS procedure was well-tolerated in our study, with most
common side effects being itchiness, warmth, and burning sensations.
A few studies have started to explore the safety and potential therapeu-
tic effects of tDCS in schizophrenia. For example, a recent study reported
that bilateral stimulation improved scores on measures of auditory hal-
lucinations, as well as positive and negative symptoms, in refractory
schizophrenia (Brunelin et al., 2012). Another study investigated the
tolerability aspects of tDCS in the childhood-onset schizophrenia
(Mattai et al., 2011). The investigators administered bilateral anodal
DLPFC stimulation or bilateral cathodal superior temporal gyrus (STG)
stimulation to children ages 10–17, demonstrating the safety of this
procedure in a pediatric population. Recently, a study examined the
effects of anodal left DLPFC tDCS at different intensities (1 mA, 2 mA,
sham) and measured performance across three time points post-
stimulation (0, 20 and 40 min). There was a significant improvement
in working memory performance following 2 mA stimulation only,
demonstrating the potential value of tDCS for enhancing cognition in
schizophrenia, but also suggesting that results may depend on dose
(Hoy et al., 2014).
Given the exploratory nature of this study and the small sample size,
it would be premature to make any definitive conclusions regarding the
potentially therapeutic effects of tDCS on social cognition in schizophre-
nia. Additionally, due to concerns with dropout rates and potential
carry-forward effects in this initial phase of the study, we employed a
parallel, rather than cross-over design, which to some extent limits
the interpretability of the differential effects of the three tDCS
conditions. The lack of significant effects on some of our measures
may also result from suboptimal dose of the single tDCS administration,
as demonstrated by recent studies administering multiple tDCS sessions
(Brunelin et al., 2012; Mondino et al., 2015). Nonetheless, despite the
preliminary nature of the current findings, they demonstrate the safety
of administration of this procedure and suggest potential therapeutic
effects on one aspect of social cognition in schizophrenia. Given its
safety, tolerability, portability, relatively cheap cost, and ease of
administration, tDCS could potentially be a valuable therapeutic tool
in the treatment of neurocognitive and social cognitive deficits in
schizophrenia, leading to improved quality of life for these individuals.
Role of funding source
This study was supported by a NARSAD Independent Investigator Grant from the
Brain & Behavior Research Foundation (22017). For generous support the authors also
wish to thank the Brain Mapping Medical Research Organization, Brain Mapping Support
Foundation, Pierson-Lovelace Foundation, The Ahmanson Foundation, William M. and
Linda R. Dietel Philanthropic Fund at the Northern Piedmont Community Foundation,
Tamkin Foundation, Jennifer Jones-Simon Foundation, Capital Group Companies
Charitable Foundation, Robson Family and Northstar Fund. The project described was
supported by Grant Numbers RR12169, RR13642 and RR00865 from the National Center
for Research Resources (NCRR), a component of the National Institutes of Health (NIH);
its contents are solely the responsibility of the authors and do not necessarily represent
the official views of NCR or NIH.

Table 2
Performance data on measures of social cognition and overall neurocognition.

Anodal Cathodal Sham Statistic

(n = 12) (n = 12) (n = 12) for interaction

Baseline Post-tDCS Baseline Post-tDCS Baseline Post-tDCS

MSCEIT 33.0 ± 9.19 32.8 ± 12.4 32.7 ± 12.8 33.2 ± 10.5 36.3 ± 15.9 35.7 ± 14.8 F = 0.066
p = 0.936
FEIT 44.8 ± 6.62 47.7 ± 5.71 45.4 ± 7.49 44.5 ± 8.51 47.8 ± 5.38 47.8 ± 6.15 F = 4.011
p = 0.028
PONS 79.4 ± 8.14 79.3 ± 9.60 73.3 ± 8.88 76.3 ± 8.76 79.8 ± 14.8 81.6 ± 11.5 F = 0.546
p = 0.584
TASIT 48.0 ± 6.49 47.9 ± 4.91 43.8 ± 6.15 44.9 ± 4.80 46.0 ± 7.63 46.8 ± 7.96 F = 0.203
p = 0.817
MCCB 34.3 ± 16.9 35.7 ± 17.7 31.4 ± 10.0 34.4 ± 12.7 38.8 ± 14.5 39.0 ± 13.5 F = 1.143
p = 0.331

tDCS: transcranial direct current stimulation; MSCEIT: Mayer–Salovey–Caruso Emotional Intelligence Test; FEIT: Facial Emotion Identification Test; PONS: Profile of Nonverbal Sensitivity;
TASIT: The Awareness of Social Inference Test; MCCB: MATRICS Consensus Cognitive Battery (Neurocognitive Composite score); shown are mean ± standard deviation; statistics shown
are time (baseline, post-tDCS) by condition (anodal, cathodal, sham) interaction effects and their effect sizes.
174 Y. Rassovsky et al. / Schizophrenia Research 165 (2015) 171–174

Contributors Fregni, F., Thome-Souza, S., Nitsche, M.A., Freedman, S.D., Valente, K.D., Pascual-Leone, A.,
Yuri Rassovsky conducted the study and wrote the first draft of the manuscript. 2006. A controlled clinical trial of cathodal DC polarization in patients with refractory
Walter Dunn, Jonathan Wynn, Allan Wu, Marco Iacoboni, and Michael Green assisted epilepsy. Epilepsia 47, 335–342.
with study conceptualization, data interpretation, and manuscript preparation. Gerhard Green, M.F., Nuechterlein, K.H., Gold, J.M., Barch, D.M., Cohen, J., Essock, S., Fenton, W.S.,
Hellemann assisted with statistical analysis and data interpretation. Frese, F., Goldberg, T.E., Heaton, R.K., Keefe, R.S.E., Kern, R.S., Kraemer, H., Stover, E.,
Weinberger, D.R., Zalcman, S., Marder, S.R., 2004. Approaching a consensus cognitive
battery for clinical trials in schizophrenia: the NIMH-MATRICS conference to select
Conflict of interest cognitive domains and test criteria. Biol. Psychiatry 56, 301–307.
All authors declare that they have no conflicts of interest arising from this manuscript. Green, M.F., Olivier, B., Crawley, J.N., Penn, D.L., Silverstein, S., 2005. Social cognition in
schizophrenia: recommendations from the MATRICS New Approaches Conference.
Schizophr. Bull. 31, 882–887.
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