Cognitive Neuropsychiatry

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/pcnp20

Validation of the Questionnaire of Cognitive and

Affective Empathy in patients with schizophrenia,
major depressive disorder and bipolar disorder

Yun-si Liang , Han-xue Yang , Yi-jing Zhang , Xin-lu Cai , Yan-yu Wang , Ke Ni ,
Cheng-cheng Pu , Shu-zhe Zhou , Yan-tao Ma , Simon S. Y. Lui , Yi Wang , Xin
Yu & Raymond C. K. Chan

To cite this article: Yun-si Liang , Han-xue Yang , Yi-jing Zhang , Xin-lu Cai , Yan-yu Wang , Ke
Ni , Cheng-cheng Pu , Shu-zhe Zhou , Yan-tao Ma , Simon S. Y. Lui , Yi Wang , Xin Yu & Raymond
C. K. Chan (2020): Validation of the Questionnaire of Cognitive and Affective Empathy in patients
with schizophrenia, major depressive disorder and bipolar disorder, Cognitive Neuropsychiatry,
DOI: 10.1080/13546805.2020.1846025

To link to this article: https://doi.org/10.1080/13546805.2020.1846025

Published online: 10 Nov 2020.

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COGNITIVE NEUROPSYCHIATRY
https://doi.org/10.1080/13546805.2020.1846025

Validation of the Questionnaire of Cognitive and Affective

Empathy in patients with schizophrenia, major depressive
disorder and bipolar disorder
Yun-si Lianga,b,c,d, Han-xue Yanga,d, Yi-jing Zhanga,d, Xin-lu Caia,b,c,d, Yan-yu Wange,
Ke Nif, Cheng-cheng Pug,h,i,j, Shu-zhe Zhoug,h,i,j, Yan-tao Mag,h,i,j, Simon S. Y. Luik,l,
Yi Wang a,d, Xin Yug,h,i,j and Raymond C. K. Chan a,b,d
a
Neuropsychology and Applied Cognitive Neuroscience Laboratory, CAS Key Laboratory of Mental Health,
Institute of Psychology, Beijing, People’s Republic of China; bSino-Danish College, University of Chinese
Academy of Sciences, Beijing, People’s Republic of China; cSino-Danish Center for Education and Research,
Beijing, People’s Republic of China; dDepartment of Psychology, University of Chinese Academy of Sciences,
Beijing, People’s Republic of China; eSchool of Psychology, Weifang Medical University, Shandong, People’s
Republic of China; fQiqihar Mental Health Center, Heilongjiang, People’s Republic of China; gPeking
University Sixth Hospital, Beijing, People’s Republic of China; hPeking University Institute of Mental Health,
Beijing, People’s Republic of China; iNHC Key Laboratory of Mental Health (Peking University), Beijing,
People’s Republic of China; jNational Clinical Research Center for Mental Disorders (Peking University Sixth
Hospital), Beijing, People’s Republic of China; kDepartment of Psychiatry, the University of Hong Kong, Hong
Kong Special Administrative Region, People’s Republic of China; lCastle Peak Hospital, Hong Kong Special
Administrative Region, People’s Republic of China

ABSTRACT ARTICLE HISTORY

Introduction: Alteration of empathy is common in patients with Received 9 June 2020
psychiatric disorders. Reliable and valid assessment tools for Accepted 29 October 2020
measuring empathy of clinical samples is needed. The
KEYWORDS
Questionnaire of Cognitive and Affective Empathy (QCAE) is a QCAE; confirmatory factor
newly-developed instrument to capture cognitive and affective analysis; reliability; validity;
components of empathy. This study aimed to validate the QCAE clinical sample
and compared self-reported empathy between clinical groups
with varied psychiatric diagnoses and healthy sample.
Methods: The present study performed factor analysis for the QCAE
on clinical samples in the Chinese setting (n = 534), including
patients with schizophrenia (n = 158), bipolar disorder (n = 213)
and major depressive disorder (n = 163). Internal consistency,
internal correlation and convergent validity was examined in the
subsample (n = 361). Group comparison among patients with
schizophrenia, bipolar disorder, major depressive disorder and
healthy controls (n = 107) was conducted to assess the
discriminant validity.
Results: Our results indicated acceptable factor model, good
reliability and validity of the QCAE. Impaired cognitive empathy
was found in clinical samples, especially in patients with
schizophrenia, while higher affective empathy was found in
patients with bipolar disorder and major depressive disorder.

CONTACT Raymond C. K. Chan rckchan@psych.ac.cn Institute of Psychology, Chinese Academy of Sciences, 16

Lincui Road, Beijing 100101, People’s Republic of China; Yi Wang wangyi@psych.ac.cn Institute of Psychology,
Chinese Academy of Sciences, 16 Lincui Road, Beijing 100101, People’s Republic of China; Xin Yu yuxin@bjmu.edu.cn
Institute of Mental Health, Peking University, No. 51 Huayuanbeilu, Haidian District, Beijing 100191, People’s Republic
of China
© 2020 Informa UK Limited, trading as Taylor & Francis Group
2 Y.-S. LIANG ET AL.

Conclusion: The QCAE is a useful tool in assessing empathy in

patients with varied psychiatric diagnoses.

Introduction
Empathy is an ability to infer other’s mental states (cognitive empathy) and responds
affectively to others’ emotions (affective empathy) (Reniers et al., 2011). It is essential
for prosocial behaviours and social functioning (Carlo et al., 2010; Mori & Cigala,
2019). Impairments of empathy have been observed in patients with various psychiatric
disorders (Farrow & Woodruff, 2007), including schizophrenia (meta-analysis: Bonfils
et al., 2017), bipolar disorder (Cusi et al., 2010; Seidel et al., 2012) and major depressive
disorder (Cusi et al., 2010). Reliable and valid instruments are needed for assessing cog-
nitive and affective empathy in psychiatric populations.
The Questionnaire of Cognitive and Affective Empathy (QCAE) (Reniers et al., 2011)
is a newly-developed yet widely-used assessment tool for empathy. Sixty-five items were
chosen from several existing empathy-related scales, such as the Empathy Quotient
(Baron-Cohen et al., 2003), the Hogan Empathy Scale (Hogan, 1969), the Empathy sub-
scale of the Impulsiveness-Venturesomeness-Empathy Inventory (Eysenck & Eysenck,
1979), and the Interpersonal Reactivity Index (IRI; Davis, 1983). The authors of the
QCAE conducted an Exploratory Factor Analysis (EFA) in 640 healthy individuals,
and retained 31 items for the final version of the QCAE (Reniers et al., 2011). In the sub-
sequent Confirmatory Factor Analysis (CFA), they verified the five-factor model but
further suggested a two-factor model (comprising cognitive and affective empathy) as
the second-order structure (Reniers et al., 2011). According to the five-factor model,
the “Perspective Taking” subscale assesses an individual’s ability to see things in
another person’s perspectives, whilst the “Online Simulation” subscale assesses a con-
struct similar to the former subscale but focuses more on the individual’s intentions to
put himself/herself into others’ shoes in the future. The “Emotion Contagion” subscale
captures an individual’s automatic responses to others’ emotions, whilst the “Proximal
Responsivity” and the “Peripheral Responsivity” subscales measure an individual’s
affective reactions to others’ emotions in a close or detached social context respectively
(Reniers et al., 2011). Whilst the first two subscales are believed to be related to cognitive
empathy, the remaining three subscales are related to affective empathy.
The QCAE has been validated and translated into different languages (Korean: Lee
et al., 2016; French: Myszkowski et al., 2017; Italian: Di Girolamo et al., 2019; Portuguese:
Queirós et al., 2018; Chinese: Liang et al., 2019), and the five-factor model has been
repeatedly observed in healthy samples using EFA and CFA (Di Girolamo et al., 2019;
Liang et al., 2019; Myszkowski et al., 2017; Queirós et al., 2018). Previous studies
showed good internal consistency of the QCAE total scale, and the Cronbach’s alpha
coefficients ranged from 0.86 to 0.87 (Di Girolamo et al., 2019; Liang et al., 2019;
Queirós et al., 2018). Regarding the two-factor model, the subscales of QCAE corre-
sponding to cognitive empathy appeared to have relatively higher level of internal con-
sistency (Cronbach’s alpha: 0.86–0.87) than the subscales corresponding to affective
empathy (Cronbach’s alpha: 0.79–0.80) (Di Girolamo et al., 2019; Queirós et al., 2018).
 COGNITIVE NEUROPSYCHIATRY 3

Regarding the five-factor model, most subscales showed acceptable Cronbach’s alpha
coefficients (ranged 0.61–0.89), except the “Peripheral Responsivity” subscale (Cron-
bach’s alpha ranged 0.52-0.80) (Di Girolamo et al., 2019; Liang et al., 2019; Myszkowski
et al., 2017; Queirós et al., 2018). All the subscales showed good test-retest reliability
(0.65–0.75) within a four-week interval (Liang et al., 2019). The QCAE has also been
found to have an acceptable convergent validity, because it was significantly correlated
with other self-report scales capturing empathy, such as the IRI (Di Girolamo et al.,
2019; Liang et al., 2019; Reniers et al., 2011).
To-date, two previous studies have been conducted to examine the psychometric prop-
erties of the QCAE in patients with schizophrenia using the English version (Horan et al.,
2015; Michaels et al., 2014) and the French version (Brunet-Gouet et al., 2019), and
findings of both studies supported the two-factor model of the QCAE. Moreover, the
Cronbach’s alpha coefficients for all subscales of the English version of the QCAE
ranged from 0.64 to 0.89 in schizophrenia patients, except the “Peripheral Responsivity”
subscale (Cronbach’s alpha ranged 0.19–0.28)(Horan et al., 2015; Michaels et al., 2014).
The Chinese version of the QCAE has been validated in healthy samples (Liang et al.,
2019), but its psychometric properties in clinical samples remain unclear. Moreover, pre-
vious studies which investigated the psychometric properties of the QCAE in clinical
populations only recruited patients with schizophrenia (Horan et al., 2015; Michaels
et al., 2014) rather than patients with other diagnostic entities. In view of the empirical
evidence for impaired ability of empathy in patients with other psychiatric disorders,
such as mood disorders and autism (Farrow & Woodruff, 2007), it is clinically important
to extend the investigations on the psychometric properties of the QCAE to samples with
different diagnostic entities. This study therefore aimed to examine the reliability and
structure validity of the Chinese version of the QCAE in psychiatric patients with
different diagnoses, including schizophrenia, major depressive disorder and bipolar dis-
order. In addition, we aimed to investigate the impairments of empathy using this self-
report questionnaire across patients with different diagnostic entities, and to investigate
the relationship between self-report empathy and clinical symptoms. We hypothesised
that the Chinese version of the QCAE would have acceptable reliability and structure val-
idity. Specifically, the QCAE would show the five-factor first-order model and the two-
factor second-order model, as reported in previous studies. Moreover, as previous studies
suggested poorer cognitive empathy in patients with major depressive disorder (Cohen’s
d = 0.52) (Bora & Berk, 2016), bipolar disorder (Cohen’s d = 0.63) (Bora et al., 2016), and
schizophrenia (Cohen’s d = 0.72) (Bora et al., 2009), we hypothesised that psychiatric
patients with different diagnoses would report lower scores of cognitive empathy than
healthy controls, and patients with schizophrenia would exhibit the most severe impair-
ments of empathy among our clinical groups.

Methods
Participants
The entire clinical sample (n = 534) consisted of 158 patients with schizophrenia, 213
patients with bipolar disorder and 163 patients with major depressive disorder. Clinical
participants were recruited from three different sites including the Qiqihar Mental
4 Y.-S. LIANG ET AL.

Health Center, the Mental Health Center of Weifang City, and Peking University Sixth
Hospital. In addition, 107 healthy participants were recruited from the neighbouring
communities. For the clinical participants, inclusion criteria were (a) aged from 18 to
55; (b) more than nine years of education; (c) DSM-IV (American Psychiatric Associ-
ation, 1994) diagnosis of schizophrenia, bipolar disorder, or major depressive disorder
ascertained using the Structured Clinical Interview for DSM-IV (SCID-IV) (Spitzer
et al., 1994) by experienced psychiatrists. Exclusion criteria for all participants were (a)
a history of head trauma or neurological disorders; (b) the presence of comorbidity;
(c) a history of substance or alcohol dependence; (c) mental retardation; and (d) a
history of transcranial magnetic stimulation or electroconvulsive therapy in the past
12 weeks. The study was approved by the Ethic Committee of Peking University Sixth
Hospital (Protocol 2014-30).

Measures
The Chinese version of the QCAE comprises 31 items, of which 20 of them capture cog-
nitive empathy and the other 11 items capture affective empathy. Each item was rated on
a four-point Likert scale, ranging from 1 (“strongly disagree”) to 4 (“strongly agree”). The
Chinese version has been reported to have good reliability, structural validity and con-
vergent validity in healthy individuals (Liang et al., 2019). The Chinese version of the
IRI (Davis, 1983; Zhang et al., 2010) was administered to 361 clinical participants of
the sample. The IRI consists of 22 items in four subscales, namely the “Personal Distress”,
the “Perspective Taking”, the “Fantasy” and the “Empathic Concern” subscales. Each
item was rated on a five-point Likert scale, ranging from 0 (“strongly disagree”) to 4
(“strongly agree”). The Chinese version of the IRI has been reported to have good
reliability and structural validity (Zhang et al., 2010). All self-report data were collected
using a paper-and-pencil format.
The severity of clinical symptoms was assessed by experienced psychiatrists using the
Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987), the Hamilton Rating
Scale for Depression (HAMD, Hamilton, 1960) and the Young Mania Rating Scale
(YMRS; Young et al., 1978). The PANSS measured positive, negative and general symp-
toms in participants with schizophrenia, whilst the HAMD measured depressive symp-
toms in participants with bipolar disorder and major depressive disorder. The YMRS
measured manic symptoms in participants with bipolar disorder.

Statistical analysis
To fill in missing values of item score, we used the mean value of that particular item, and
this exercise was conducted on a group-by-group basis. Statistical analyses were carried
out using SPSS v19.0 and Mplus v7.4. Firstly, the EFA with direct oblimin rotation was
performed in a subsample of clinical participants (n = 368, all recruited from Qiqihar
Mental Health Center). Consistent with previous study which validated the Chinese
version of the QCAE in healthy population (Liang et al., 2019), a four-factor solution
was fixed in the current EFA. Then, the CFA was performed to validate both four-
factor and five-factor models of the QCAE in another subsample of clinical participants
(n = 166, all recruited from the Mental Health Center of Weifang City and Peking
 COGNITIVE NEUROPSYCHIATRY 5

University Sixth Hospital). To reduce the possibility of estimation error, this study
adopted the item parcelling technique (Sass & Smith, 2006). The comparative fit index
(CFI), the Tucker–Lewis index (TLI), the root-mean-square error of approximation
(RMSEA), and the chi-square statistic were computed to evaluate the goodness of fit.
Given the chi-square tests were sensitive to sample size, the standardised root mean
square residual (SRMR) (Milfont & Fischer, 2010) was also calculated in our study.
Indices of RMSEA < .08, CFI > .9, TLI > .9, and SRMR < .08 would be regarded as evi-
dence for good fit of the model. Lastly, internal correlation analyses between the subscales
of the QCAE were conducted to investigate the structural validity of the QCAE. The con-
vergent validity was examined by estimating the correlation coefficients of the QCAE
with the IRI. In addition, we performed multivariate analysis of covariance
(MANCOVA) to examine differences among four groups with gender as a covariate.
Pearson’s correlations between clinical symptoms and the QCAE total and subscale
scores were conducted. To correct for multiple testing, Bonferroni corrections were
applied with adjusted p < (0.05/N), where N denotes the number of correlations.

Results
The QCAE total and subscale scores for our clinical sample are presented in Table 1. The
EFA of four-factor model showed a Kaiser–Meyer–Olkin value of .803, significant Bar-
tlett’s Test of Sphericity (p < .001) and 44.74% of the total variance was explained. In
terms of the CFA, fit indices of both the five-factor model (first order: χ 2 (68) =
124.56, p < .001, RMSEA = .071, CFI = .937, TLI = .915, SRMR = .067, second order: χ 2
(72) = 140.87, p < .001, RMSEA = .076, CFI = .923, TLI = .902, SRMR = .081) and the
four-factor model (first order: χ 2 (71) = 146.70, p < .001, RMSEA = .080, CFI = .916,
TLI = .892, SRMR = .077, second order: χ 2 (72) = 147.43, p < .001, RMSEA = .079,
CFI = .916, TLI = .894, SRMR = .078) were acceptable. Then we compared the perform-
ances of these two models and found that the five-factor model showed a better goodness

Table 1. Descriptive statistics and reliability of the QCAE in clinical sample.

Mean (SD) Range Cronbach’s alpha
Gender (Male/Female) 212/322
Age (years) 30.31 (6.48) 18∼53
Education (years) 12.04 (2.88) 9∼27
QCAE
Perspective taking 29.90 (6.70) 12∼44 0.86
Online simulation 24.89 (4.83) 9∼36 0.76
Emotion contagion 11.38 (2.56) 4∼16 0.64
Proximal responsivity 8.73 (2.09) 3∼12 0.63
Peripheral responsivity 10.21 (2.22) 5∼16 0.37
Cognitive empathy 54.79 (10.45) 22∼80 0.89
Affective empathy 30.32 (4.57) 15∼43 0.60
Total scale 85.11 (12.76) 43∼115 0.86
IRIa
Personal Distress 11.54 (4.14) 0∼20 0.70
Perspective Taking 11.68 (3.27) 2∼20 0.56
Fantasy 12.85 (3.68) 4∼23 0.43
Empathic Concern 15.24 (4.18) 5∼24 0.65
Note: a: for the Cronbach’s alpha for the IRI, a subsample of 361 clinical patients were included in the analysis.
Abbreviation: QCAE = Questionnaire of Cognitive and Affective Empathy; IRI = Interpersonal Reactivity Index.
6 Y.-S. LIANG ET AL.

of fit than the four-factor model, Δχ 2 = 22.15, Δdf = 3, p < 0.001. Figure 1 shows the five-
factor model of the QCAE.
As shown in Table 1, the internal consistency of the QCAE was examined in the entire
clinical sample. The Cronbach’s alpha coefficients for the total scale, the cognitive
empathy component and the affective empathy component were 0.86, 0.89 and 0.60
respectively. On the other hand, the five subscales of the QCAE (Perspective Taking,
Online Simulation, Emotional Contagion, Proximal Responsivity, and Peripheral
Responsivity) yielded the Cronbach’s alpha coefficients of 0.86, 0.76, 0.64, 0.63 and
0.37 respectively.
The internal correlations between subscales of the QCAE are shown in Table 2. We
found moderate correlations between “Perspective Taking” and “Online Simulation”
subscales (r = 0.63, p < 0.001) and between “Emotion Contagion” and “Proximal Respon-
sivity” subscales (r = 0.53, p < 0.001).
The correlation coefficients between the QCAE and the IRI are shown in Table 2. The
“Perspective Taking” subscale of the IRI was positively correlated with both the cognitive
(r = 0.48, p < 0.001) and the affective empathy scores (r = 0.24, p < 0.001) of the QCAE,
but the correlation coefficient was relatively larger for cognitive empathy than for
affective empathy. On the other hand, the “Empathic Concern” subscale of the IRI was
positively correlated with both the affective (r = 0.45, p < 0.001) and the cognitive

Figure 1. Schematic diagram of five-factor model in the QCAE. (A). first-order five-factor model of the
QCAE. (B). second-order two-0factor model of the QCAE. Boxes de0note observed variables (parcels of
items). Circles denote latent factors. Long, straight and single-headed arrows indicate regressions and
short represents the residual error variance. Curved double-headed arrows indicate co-variation of
each two factors. The sequence of item parcellation was: Parcel 11 used the mean value of item 16
and 26; Parcel 12 used item 20 and 19; Parcel 13 used item 27 and 22; Parcel 14 used item 25 and
21; Parcel 15 used item 23, 24 and 15; Parcel 21 used item 5 and 6; Parcel 22 used item 4 and 3;
Parcel 23 used item 30 and 31; Parcel 24 used item 18, 1 and 28; Parcel 31 used item 9 and 8;
Parcel 32 used item 13 and 14; Parcel 41 used item 10, 12 and 7; Parcel 51 used item 2 and 29;
Parcel 52 used item 11 and 17. Abbreviations: P11 represents the first parcel of the first factor, and
P12 represents the second parcel of the first factor, P21 represents the first parcel of the second
factor, and so on.
Table 2. Pearson’s correlations between scores of the QCAE and the IRI in clinical sample.
Perspective Online Emotion Proximal Peripheral Cognitive Affective QCAE Total
Taking Simulation Contagion Responsivity Responsivity Empathy Empathy score
QCAE Perspective Taking 1 – – – – – – –
Online Simulation .63** 1 – – – – – –
Emotion Contagion .44** .20** 1 – – – – –
Proximal .40** .36** .53** 1 – – – –
Responsivity
Peripheral −.14** −.09* −.10* 0.06 1 – – –
Responsivity
IRIa Perspective Taking .41** .47** .20** .24** 0.02 .48** .24** .47**
Empathic Concern .28** .31** .27** .40** .22** .32** .45** .41**
Note: a: for the correlations between the IRI and the QCAE, a subsample of 361 clinical patients were included in the analysis.

COGNITIVE NEUROPSYCHIATRY
Numbers in bold represents the correlations survived the Bonferroni correction.
Abbreviation: QCAE = Questionnaire of Cognitive and Affective Empathy; IRI = Interpersonal Reactivity Index.

7
8 Y.-S. LIANG ET AL.

empathy scores (r = 0.32, p < 0.001) of QCAE, which was relatively stronger for affective
empathy than for cognitive empathy.
Results of group comparisons between clinical groups and healthy controls (HC) in
self-report empathy are presented in Table 3. Schizophrenia patients exhibited signifi-
cantly poorer cognitive empathy than HC (p < 0.01), while no significant difference in
affective empathy was found between the schizophrenia group and HC (p > 0.1). Com-
pared to HC, both clinical groups with bipolar disorder (p < 0.01) and major depressive
disorder (p < 0.05) reported significantly higher scores on affective empathy, while
bipolar disorder patients reported lower scores on “Online Simulation” subscale than
HC (p < 0.01).
Compared to schizophrenia group, patients with major depressive disorder reported
higher scores on cognitive empathy (p < 0.05) and patients with bipolar disorder reported
higher scores on affective empathy (p < 0.05). Patients with major depressive disorder
reported significantly higher scores on the “Emotion Contagion” subscale than patients
with bipolar disorder (p < 0.05).
In terms of the correlations between clinical symptoms and the QCAE scores, we
found that “Proximal Responsivity” subscale scores were positively correlated with the
YMRS scores in patients with bipolar disorder (r = 0.33, p < 0.001) (see Table 4).

Discussion
In this study, we examined the psychometric properties of the Chinese version of the
QCAE in clinical patients with different diagnoses (schizophrenia, bipolar disorder
and major depressive disorder) and investigated the profiles of empathy across diagnostic
entities. The confirmatory factor analysis suggested that the five-factor first-order struc-
ture of the QCAE had the optimal model fit compared to the four-factor model. The posi-
tive associations between the QCAE and the IRI provided evidence for convergent
validity of the QCAE in clinical patients with different diagnoses.
It is noteworthy that this study is one of the first few systematic investigations of self-
report cognitive and affective components of empathy across different diagnostic cat-
egories. Compared with healthy individuals, schizophrenia patients showed severe
impairments on the cognitive empathy factor of the QCAE, which is consistent with pre-
vious findings (Horan et al., 2015; Michaels et al., 2014). Although Murphy and Lilie-
nfield suggested a dissociation between self-report scales and behavioural measures of
empathy, previous meta-analysis showed that schizophrenia patients exhibited deficit
in both self-report and task-based cognitive empathy (Bonfils et al., 2017; Bora et al.,
2009). Functional imaging studies also showed that patients with schizophrenia exhibited
reduced activation in the ventrolateral prefrontal cortex and temporal parietal junction
(Vucurovic et al., 2019). The reduced brain activation as such may explain the difficulties
that patients with schizophrenia encounter in inferring other people’s perspectives (Bier-
voye et al., 2016). In terms of the affective empathy factor of the QCAE, we did not find
any significant difference between schizophrenia patients and healthy individuals, which
is consistent with Michaels et al. (2014)’s earlier findings.
On the other hand, our findings that patients with bipolar disorder and major depress-
ive disorder showing higher scores on affective empathy than healthy individuals appear
to suggest that having a mood disorder may enhance an individual’s ability to empathise
Table 3. Comparisons between clinical groups and healthy controls on the QCAE with gender as covariate.
SCZ BD MDD HC
(n = 158) (n = 213) (n = 163) (n = 107) F/χ2 p partial eta square post-hoc
Gender (M/F) 67/91 74/139 71/92 54/53 7.89 0.048 – –
Age (year) 29.82 ± 7.1 30.47 ± 6.28 30.64 ± 6.14 29.42 ± 6.25 1.07 0.362 – –
Education (year) 11.9 ± 2.73 12.35 ± 3.15 11.8 ± 2.63 12.38 ± 2.89 1.70 0.165 – –
PANSS positive 18.60 ± 7.14
PANSS negative 16.77 ± 6.11
PANSS general 34.10 ± 9.43
PANSS total 69.48 ± 18.99
HAMD 19.60 ± 11.03 25.09 ± 8.89
YMRS 18.84 ± 9.45
Perspective taking 28.71 ± 6.93 30.01 ± 6.94 30.89 ± 5.99 31.18 ± 4.34 4.35 0.005 0.02 SCZ < MDD, HC
Online simulation 24.42 ± 5.14 24.70 ± 4.64 25.61 ± 4.71 26.6 ± 3.67 6.00 < 0.001 0.03 BD, SCZ < HC
Emotion contagion 10.97 ± 2.63 11.26 ± 2.45 11.94 ± 2.55 10.24 ± 2.06 10.79 <0.001 0.05 SCZ, BD < MDD;
HC < BD, MDD
Proximal responsivity 8.27 ± 1.98 9.08 ± 1.83 8.72 ± 2.41 8.30 ± 1.46 6.11 <0.001 0.03 SCZ, HC < BD
Peripheral responsivity 10.15 ± 2.10 10.45 ± 2.49 9.95 ± 1.91 10.46 ± 1.63 2.15 0.093 0.01

COGNITIVE NEUROPSYCHIATRY
Cognitive empathy 53.13 ± 11.05 54.72 ± 10.37 56.5 ± 9.73 57.78 ± 6.86 5.76 0.001 0.03 SCZ < MDD, HC
Affective empathy 29.39 ± 4.66 30.79 ± 4.30 30.61 ± 4.73 29.00 ± 3.85 5.59 0.001 0.03 SCZ < BD;
HC < BD, MDD
QCAE total 82.52 ± 13.18 85.51 ± 12.42 87.11 ± 12.46 86.78 ± 8.21 4.61 0.003 0.02 SCZ < MDD, HC
Abbreviation: SCZ = schizophrenia; BD = bipolar disorder; MDD = major depressive disorder; PANSS = Positive and Negative Syndrome Scale; HAMD = Hamilton Rating Scale for Depression;
YMRS = Young Mania Rating Scale; QCAE = Questionnaire of Cognitive and Affective Empathy.

9
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Y.-S. LIANG ET AL.
Table 4. Pearson’s correlations between scores of self-reported empathy and clinical symptoms.
QCAE (n = 517) IRI (n = 361)
Perspective Online Emotion Proximal Peripheral Cognitive Affective Perspective Empathic
taking Simulation Contagion Responsivity Responsivity empathy Empathy QCAE Taking Concern
PANSS positive 0.05 −0.06 0.15 0.06 0.03 0.00 0.13 0.04 −0.05 0.07
PANSS negative −0.05 −0.14 0.13 0.07 0.01 −0.09 0.11 −0.04 −0.01 0.13
PANSS general −0.01 −0.11 0.09 −0.01 −0.10 −0.05 0.00 −0.05 −0.03 0.06
PANSS total 0.00 −0.12 0.15 0.04 −0.03 −0.06 0.08 −0.02 −0.04 0.10
HAMD BD + MDD −0.06 0.01 .11* 0.07 −0.10* −0.04 0.04 −0.02 −0.05 0.09
BD −0.10 0.01 0.06 .19** −0.10 −0.07 0.06 −0.04 −0.05 −0.01
MDD −0.05 −0.07 0.10 −0.03 −0.03 −0.07 0.03 −0.04 −0.09 0.12
YMRS −0.02 0.03 0.07 .31** −.15* 0.00 0.08 0.03 0.08 0.01
Note: Numbers in bold represents the correlations survived the Bonferroni correction.
Abbreviation: PANSS = Positive and Negative Syndrome Scale; HAMD = Hamilton Rating Scale for Depression; YMRS = Young Mania Rating Scale; QCAE = Questionnaire of Cognitive and
Affective Empathy; IRI = Interpersonal Reactivity Index; BD = Bipolar disorder; MDD = Major Depressive Disorder.
 COGNITIVE NEUROPSYCHIATRY 11

with others’ emotions. This is consistent with previous studies that patients with mood
disorders showing higher scores on the “Personal Distress” subscale (affective empathy)
of the IRI than healthy individuals (Cusi et al., 2010; Derntl et al., 2012; Seidel et al., 2012;
Shamay-Tsoory et al., 2009). We found positive correlation between affective empathy
and mood symptoms in patients with bipolar disorder and major depressive disorder.
Patients with bipolar disorder showed strong positive correlation between affective
empathy and manic symptoms, and positive correlation (which did not survive Bonfer-
roni correction) between affective empathy and depressive symptoms in this study, which
was partly consistent with previous findings (Bennik et al., 2019). Increased emotional
response towards others was found in the manic patients with bipolar disorder, who
may have problems of “over-empathizing” (Bodnar & Rybakowski, 2017).
Regarding the structure of the Chinese version of the QCAE, the results of EFA sup-
ported a four-factor model, in which the items belonging to the “Emotional Contagion”
and “Proximal Responsivity” subscales were mixed together in a single factor. However,
the five-factor model of the QCAE showed a better fit in CFA than four-factor model,
consistent with the previous findings (Liang et al., 2019) which validated the Chinese
version of the QCAE in a healthy sample, and the previous findings (Brunet-Gouet
et al., 2019) which validated the French version of the QCAE in a sample with schizo-
phrenia. Taken together the empirical findings of this and earlier studies, and the original
design of the QCAE (Reniers et al., 2011), the five-factor solution appears to be the
optimal model. Future application of the QCAE should better follow the five-factor struc-
ture, in both clinical and non-clinical settings.
In our study, acceptable internal consistency and reliability were found in all sub-
scales of the QCAE except for the “Peripheral Responsivity” subscale, consistent with
previous findings (Horan et al., 2015; Michaels et al., 2014). Because of the low
reliability of the “Peripheral Responsivity” subscale, the two-factor solution has been
suggested by previous studies of the English and French versions of the QCAE
(Brunet-Gouet et al., 2019; Horan et al., 2015). In our study, the second-order
model of the QCAE was also validated by CFA, supporting the two-facet construct
of empathy, differentiating the cognitive and affective components. Therefore, future
studies using the QCAE in clinical samples should report the factor scores of both cog-
nitive and affective empathy, in addition to the five subscale scores. Test-retest
reliability and the difference among subtypes of the clinical groups have not been eval-
uated in our study. Future studies should investigate this area. In addition, limitation
of self-report measurements should be borne in mind, and our findings may be
affected by the fact that patients with schizophrenia having poor insight might
under-report their impairments of empathy ability. In fact, Murphy and Lilienfeld
found a dissociation between self-report empathy and behavioural empathy (Murphy
& Lilienfeld, 2019). Future studies should adopt an improved design, using the
QCAE together with validated behavioural paradigms for cognitive and affective
empathy (Ho et al., 2018).
In conclusion, the Chinese version of the QCAE shows acceptable internal consistency
and reliability, as well as good discriminant validity in clinical samples with schizo-
phrenia, bipolar disorder and major depressive disorder. The QCAE is a useful tool to
measure self-report cognitive and affective empathy in patients with different psychiatric
diagnoses in the Chinese setting.
12 Y.-S. LIANG ET AL.

Acknowledgements
This work was supported by the National Natural Science Foundation of China (31871114,
81571317, 31400884), the Beijing Municipal Science & Technology Commission Grant
(Z161100000216138), the National Key Research and Development Programme
(2016YFC0906402), the Beijing Training Project for the Leading Talents in S & T
(Z151100000315020), China Scholarship Council and CAS Key Laboratory of Mental Health,
Institute of Psychology.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
This work was supported by the National Natural Science Foundation of China (31871114,
81571317, 31400884), the Beijing Municipal Science & Technology Commission Grant
(Z161100000216138), the National Key Research and Development Programme
(2016YFC0906402), the Beijing Training Project for the Leading Talents in S & T
(Z151100000315020), China Scholarship Council and CAS Key Laboratory of Mental Health,
Institute of Psychology.

ORCID
Yi Wang http://orcid.org/0000-0001-6880-5831
Raymond C. K. Chan http://orcid.org/0000-0002-3414-450X

References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders :
DSM-IV-TR.
Baron-Cohen, S., Richler, J., Bisarya, D., Gurunathan, N., & Wheelwright, S. (2003). The system-
izing quotient: An investigation of adults with Asperger syndrome or high-functioning autism,
and normal sex differences. Journal of Autism & Developmental Disorders, 33(5), 509–517.
https://doi.org/10.1023/A:1025879411971
Bennik, E. C., Jeronimus, B. F., & Aan Het Rot, M. (2019). The relation between empathy and
depressive symptoms in a Dutch population sample. Journal of Affective Disorders, 242, 48–
51. https://doi.org/10.1016/j.jad.2018.08.008
Biervoye, A., Dricot, L., Ivanoiu, A., & Samson, D. (2016). Impaired spontaneous belief inference
following acquired damage to the left posterior temporoparietal junction. Social Cognitive &
Affective Neuroscience, 11(10), 1513–1520. https://doi.org/10.1093/scan/nsw076
Bodnar, A., & Rybakowski, J. K. (2017). Increased affective empathy in bipolar patients during a
manic episode. Revista Brasileira De Psiquiatria, 39(4), 342–345. https://doi.org/10.1590/1516-
4446-2016-2101
Bonfils, K. A., Lysaker, P. H., Minor, K. S., & Salyers, M. P. (2017). Empathy in schizophrenia: A
meta-analysis of the Interpersonal Reactivity Index. Psychiatry Research, 249, 293–303. https://
doi.org/10.1016/j.psychres.2016.12.033
Bora, E., Bartholomeusz, C, & Pantelis, C. (2016). Meta-analysis of Theory of Mind (ToM) impair-
ment in bipolar disorder. Psychological Medicine, 46(2), 253–264.
Bora, E., & Berk, M. (2016). Theory of mind in major depressive disorder: A meta-analysis. Journal
of Affective Disorders, 191, 49–55.
 COGNITIVE NEUROPSYCHIATRY 13

Bora, E., Yucel, M., & Pantelis, C. (2009). Theory of mind impairment in schizophrenia: Meta-
analysis. Schizophrenia Research, 109(1), 1–9. https://doi.org/10.1016/j.schres.2008.12.020
Brunet-Gouet, E., Myszkowski, N., Ehrminger, M., Urbach, M., Aouizerate, B., Brunel, L.,
Capdevielle, D., Chereau, I., Dubertret, C., Dubreucq, J., Fond, G., Lançon, C., Leignier, S.,
Mallet, J., Misdrahi, D., Pires, S., Schneider, P., Schurhoff, F., Yazbek, H., … Roux, P. (2019).
Confirmation of a two-factor solution to the Questionnaire of Cognitive and Affective
Empathy in a French population of patients with schizophrenia spectrum disorders. Frontiers
in Psychiatry, 10, 751. https://doi.org/10.3389/fpsyt.2019.00751
Carlo, G., Knight, G. P., Mcginley, M., Goodvin, R., & Roesch, S. C. (2010). The Developmental
relations between perspective taking and prosocial behaviors: A meta-Analytic examination of
the task-Specificity hypothesis. Oxford University Press.
Cusi, A., Macqueen, G. M., & Mckinnon, M. C. (2010). Altered self-report of empathic responding
in patients with bipolar disorder. Psychiatry Research, 178(2), 354–358. https://doi.org/10.1016/
j.psychres.2009.07.009
Davis, M. H. (1983). Measuring individual differences in empathy: Evidence for a multidimen-
sional approach. Journal of Personality & Social Psychology, 44(1), 113–126. https://doi.org/
10.1037/0022-3514.44.1.113
Derntl, B., Seidel, E.-M., Schneider, F., & Habel, U. (2012). How specific are emotional deficits? A
comparison of empathic abilities in schizophrenia, bipolar and depressed patients.
Schizophrenia Research, 142(1–3), 58–64. https://doi.org/10.1016/j.schres.2012.09.020
Di Girolamo, M., Giromini, L., Winters, C. L., Serie, C. M. B., & de Ruiter, C. (2019). The
Questionnaire of Cognitive and Affective Empathy: A comparison between paper-and-pencil
versus online formats in Italian samples. Journal of Personality Assessment, 101(2), 159–170.
https://doi.org/10.1080/00223891.2017.1389745
Eysenck, S. B., & Eysenck, H. J. (1979). Impulsiveness and venturesomeness: Their position in a
dimensional system of personality description. Psychological Reports, 43(2), 1247–1255.
https://doi.org/10.2466/pr0.1978.43.3f.1247
Farrow, E. D., & Woodruff, P. R. (2007). Empathy in mental illness. Cambridge University Press.
Hamilton, M. (1960). A rating scale for depression. Journal of Neurology Neurosurgery &
Psychiatry, 23(1), 56–62. https://doi.org/10.1136/jnnp.23.1.56
Ho, K. K., Lui, S. S., Wang, Y., Yeung, H. K., Wong, P. T., Cheung, E. F., & Chan, R. C. (2018).
Theory of mind performances in first-episode schizophrenia patients: An 18-month follow-
up study. Psychiatry Research, 261, 357–360. https://doi.org/10.1016/j.psychres.2018.01.014
Hogan, R. (1969). Development of an empathy scale. Journal of Consulting & Clinical Psychology,
33(3), 307–316. https://doi.org/10.1037/h0027580
Horan, W. P., Reise, S. P., Kern, R. S., Lee, J., Penn, D. L., & Green, M. F. (2015). Structure and
correlates of self-reported empathy in schizophrenia. Journal of Psychiatric Research, 66-67,
60–66. https://doi.org/10.1016/j.jpsychires.2015.04.016
Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The positive and negative Syndrome Scale (PANSS)
for schizophrenia. Schizophrenia Bulletin, 13(2), 261–276. https://doi.org/10.1093/schbul/13.2.
261
Lee, J. Y., Kim, S. W., Hong, J. E., Lee, S. I., Park, M. K., Kim, J. M., & Yoon, J. S. (2016). The Effects
of affective empathy and Resilience on Burnout in School Counselors. Journal of the Korean
Society of Biological Therapies in Psychiatry, 22(3), 163–172.
Liang, Y., Yang, H., Ma, Y., Lui, S. S. Y., Cheung, E. F. C., Wang, Y., & Chan, R. C. K. (2019).
Validation and extension of the Questionnaire of Cognitive and Affective Empathy in the
Chinese setting. PsyCh Journal, 8(4), 439–448. https://doi.org/10.1002/pchj.281
Michaels, T. M., Horan, W. P., Ginger, E. J., Martinovich, Z., Pinkham, A. E., & Smith, M. J.
(2014). Cognitive empathy contributes to poor social functioning in schizophrenia: Evidence
from a new self-report measure of cognitive and affective empathy. Psychiatry Research, 220
(3), 803–810. https://doi.org/10.1016/j.psychres.2014.08.054
Milfont, T. L., & Fischer, R. (2010). Testing measurement invariance across groups: Applications
in cross-cultural research. International Journal of Psychological Research, 3(1), 111–130.
https://doi.org/10.21500/20112084.857
14 Y.-S. LIANG ET AL.

Mori, A., & Cigala, A. (2019). ‘Putting oneself in someone else’s shoes during childhood: How to
learn it’ Training for preschool age children. British Journal of Educational Psychology, 89(4),
750–766. https://doi.org/10.1111/bjep.12255
Murphy, B. A., & Lilienfeld, S. O. (2019). Are self-report cognitive empathy ratings valid Proxies
for cognitive empathy ability? Negligible meta-Analytic relations with behavioral task perform-
ance. Psychological Assessment, 31(8), 1062–1072. https://doi.org/10.1037/pas0000732
Myszkowski, N., Brunet-Gouet, E., Roux, P., Robieux, L., Malézieux, A., Boujut, E., & Zenasni, F.
(2017). Is the Questionnaire of Cognitive and Affective Empathy measuring two or five dimen-
sions? Evidence in a French sample. Psychiatry Research, 255, 292–296. https://doi.org/10.1016/
j.psychres.2017.05.047
Queirós, A., Fernandes, E., Reniers, R., Sampaio, A., Coutinho, J., & Seara-Cardoso, A. (2018).
Psychometric properties of the Questionnaire of Cognitive and Affective Empathy in a
Portuguese sample. PLoS ONE, 13(6), https://doi.org/10.1371/journal.pone.0197755
Reniers, R. L. E. P., Corcoran, R., Drake, R., Shryane, N. M., & Völlm, B. A. (2011). The QCAE: A
Questionnaire of Cognitive and Affective Empathy. Journal of Personality Assessment, 93(1),
84–95. https://doi.org/10.1080/00223891.2010.528484
Sass, D. A., & Smith, P. L. (2006). The Effects of parceling unidimensional scales on structural par-
ameter estimates in structural equation modeling. Structural Equation Modeling A
Multidisciplinary Journal, 13(4), 566–586. https://doi.org/10.1207/s15328007sem1304_4
Seidel, E.-M., Habel, U., Finkelmeyer, A., Hasmann, A., Dobmeier, M., & Derntl, B. (2012). Risk or
resilience? Empathic abilities in patients with bipolar disorders and their first-degree relatives.
Journal of Psychiatric Research, 46(3), 382–388. https://doi.org/10.1016/j.jpsychires.2011.11.006
Shamay-Tsoory, S. G., Harari O, H., & Levkovitz, Y. (2009). Neuropsychological evidence of
impaired cognitive empathy in euthymic bipolar disorder. Journal of Neuropsychiatry &
Clinical Neurosciences, 21(1), 59–67. https://doi.org/10.1176/jnp.2009.21.1.59
Spitzer, R. L., Williams, J. B. W., Gibbon, M., & First, M. (1994). Structured clinical interview for
DSM-IV. Biometrics Research.
Vucurovic, K., Caillies, S., & Kaladjian, A. (2019). Neural correlates of theory of mind and empathy
in schizophrenia: An activation likelihood estimation meta-analysis. Journal of Psychiatric
Research, 120, 163–174. https://doi.org/10.1111/bjep.12255
Young, R. C., Biggs, J. T., Ziegler, V. E., & Meyer, D. A. (1978). A rating scale for mania: Reliability,
validity and sensitivity. British Journal of Psychiatry, 133(5), 429–435. https://doi.org/10.1192/
bjp.133.5.429
Zhang, F., Dong, Y., Wang, K., Zhan, Z., & Xie, L. (2010). Chinese version Interpersonal Reactivity
Index (IRI-C): A study of reliability and validity. Chinese Journal of Clinical Psychology, 18(2),
155–157.