**4. Clinical assessment of social cognition in patients with MS**

Research on social cognition is experimental and focuses on intra‐individual mental process‐ ing. Studies on emotional and cognitive impairments in patients with MS are based on different test batteries. Mental schemata are used for focusing attention and facilitating information encoding and retrieval.

Empathy can be regarded as a set of interrelated constructs including social competence, self‐ assessment, emotion and sensitivity to others [29]. Therefore, there is no universal tool objectively assessing empathy in all its aspects. In a recent review of empathy measurement tools [30], 1147 citations were used to select 50 articles describing 36 empathy tests, eight of which demonstrated satisfactory reliability, internal consistency and validity.

The empathy quotient is most often determined through self‐assessment questionnaires. Interpersonal empathy is usually studied by applying the Hogan Empathy Scale (HES) [31], the Toronto Empathy Questionnaire (TEQ) and the 50 Item Interpersonal Skills Questionnaire (50 IISQ). The affective component of empathy can be assessed through the Questionnaire Measure of Emotional Empathy (QMEE), while the cognitive component is more precisely determined through HES. The Balanced Emotional Empathy Scale (BEES), developed by Mehrabian, evaluates responders' reaction to the mental state of others [32].

The instrument most often used for determining the level of self‐empathy is Neff's self‐ compassion scale, which assesses self‐kindness, common humanity and mindfulness [33]. The measurement of compassionate or altruistic love toward different targets through the Com‐ passionate Love Scale (CLS) provides additional information about the perception of close others and all of humankind [34]. The Empathy Construct Rating Scale (ECRS) can test the ability to understand accurately the feelings of others through careful listening, thus checking whether the subject properly understands what others experience.

More complex information regarding compassion to self and others is provided by Baron‐ Cohen and Wheelwright in The Empathy Quotient, which measures cognitive empathy, emotional reactivity and social skills [35] and most of all in the Interpersonal Reactivity Index (IRI), which allows measuring of multidimensional individual empathy differences [36].

Recently, tests with nonverbal stimuli have also been applied to the evaluation of empathy. They are commonly used in patients with autism and aphasia but are also an important complement to self‐assessment questionnaires, because they contribute to the greater objec‐ tivity of overall empathy assessment. Nonverbal tests provide additional information on the empathy quotient through analyzing what feelings and thoughts are inferred from facial expressions in pictures. Most often they are based on a series of photographs which depict people with different mental and emotional charge, thus measuring the cognitive and affective components of empathy. The most frequently used ones are the multifaceted empathy test (MET) [37], the visual recognition test, the Florida Affect Battery (FAB) and Ekman and Friesen's black and white stimulus set. The results of these tests minimize subjectivity in the patient's self‐assessment [38].

ToM, as a key aspect of social cognition, requires greater cognitive effort for slower and more explicit processing. In general, ToM tests are classified into three groups: attribution of epistemic mental states, attribution of intention and attribution of affective mental states [39]. They are based on verbally or visually delivered information, and in recent years, ToM movies have been developed for increasing test sensitivity and approximating the demands of everyday life social cognition [40]. Verbal tests, such as "Strange Stories" and "Faux Pas Recognition", require interpretation of auditory information for grasping false belief and deception based on short stories with social context similar to real situations. Such tasks could be accompanied by pictures. Decoding complex emotions from voice is measured by "Reading the Mind in the Voice" [41] and the "Voice Emotion Identification Test" [42] and prediction of intentions and emotions—by "Reading the Mind in the Eyes" [43] and the "Facial Symbol Test", [44] which are sensitive indicators of the socioperceptual component involved in the immediate recognition of mental states [45]. Even more informative is the "Cambridge Mind‐ reading Face Voice Battery", [46] which combines verbal and dynamic visual stimuli.

test batteries. Mental schemata are used for focusing attention and facilitating information

Empathy can be regarded as a set of interrelated constructs including social competence, self‐ assessment, emotion and sensitivity to others [29]. Therefore, there is no universal tool objectively assessing empathy in all its aspects. In a recent review of empathy measurement tools [30], 1147 citations were used to select 50 articles describing 36 empathy tests, eight of

The empathy quotient is most often determined through self‐assessment questionnaires. Interpersonal empathy is usually studied by applying the Hogan Empathy Scale (HES) [31], the Toronto Empathy Questionnaire (TEQ) and the 50 Item Interpersonal Skills Questionnaire (50 IISQ). The affective component of empathy can be assessed through the Questionnaire Measure of Emotional Empathy (QMEE), while the cognitive component is more precisely determined through HES. The Balanced Emotional Empathy Scale (BEES), developed by

The instrument most often used for determining the level of self‐empathy is Neff's self‐ compassion scale, which assesses self‐kindness, common humanity and mindfulness [33]. The measurement of compassionate or altruistic love toward different targets through the Com‐ passionate Love Scale (CLS) provides additional information about the perception of close others and all of humankind [34]. The Empathy Construct Rating Scale (ECRS) can test the ability to understand accurately the feelings of others through careful listening, thus checking

More complex information regarding compassion to self and others is provided by Baron‐ Cohen and Wheelwright in The Empathy Quotient, which measures cognitive empathy, emotional reactivity and social skills [35] and most of all in the Interpersonal Reactivity Index (IRI), which allows measuring of multidimensional individual empathy differences [36].

Recently, tests with nonverbal stimuli have also been applied to the evaluation of empathy. They are commonly used in patients with autism and aphasia but are also an important complement to self‐assessment questionnaires, because they contribute to the greater objec‐ tivity of overall empathy assessment. Nonverbal tests provide additional information on the empathy quotient through analyzing what feelings and thoughts are inferred from facial expressions in pictures. Most often they are based on a series of photographs which depict people with different mental and emotional charge, thus measuring the cognitive and affective components of empathy. The most frequently used ones are the multifaceted empathy test (MET) [37], the visual recognition test, the Florida Affect Battery (FAB) and Ekman and Friesen's black and white stimulus set. The results of these tests minimize subjectivity in the

ToM, as a key aspect of social cognition, requires greater cognitive effort for slower and more explicit processing. In general, ToM tests are classified into three groups: attribution of epistemic mental states, attribution of intention and attribution of affective mental states [39]. They are based on verbally or visually delivered information, and in recent years, ToM movies have been developed for increasing test sensitivity and approximating the demands of

which demonstrated satisfactory reliability, internal consistency and validity.

Mehrabian, evaluates responders' reaction to the mental state of others [32].

whether the subject properly understands what others experience.

encoding and retrieval.

232 Trending Topics in Multiple Sclerosis

patient's self‐assessment [38].

ToM cartoons assess the ability to understand emotions and intentions by interpreting graphic design images and/or cartoon strips. Some of these use jokes involving false beliefs [47], and others combine representations of mental and physical states [48]. The following are some video tasks appropriate for ToM assessment in patients with MS: conversations and insinua‐ tions (C&I) [49], the social inference‐enriched subtest of the TASIT, containing video‐taped social interactions in which lies and sarcasm are presented [50], the Face Puzzle—for measur‐ ing the explicit and implicit aspects of facial emotion recognition, the social cue recognition test [51] and the videotape emotion identification test [52].

In the comprehensive evaluation of social cognitive skills in patients with MS, it is necessary to take into account the level of general cognition, personal characteristics, such as individual perspective, idiosyncrasies, purpose and attitudes [53], as well as a possible genetic modula‐ tion of individual empathic ability [54].

So far ToM research has used small groups of patients with MS and a narrow range of cognitive tasks. The fact that there is no unified neuropsychological battery for the assessment of social cognitive impairments should also be taken into account. For the reasons outlined earlier, it is difficult to generalize on their results for the entire MS population, numbering about 1.3 million worldwide, as well as to reach definitive conclusions
