**5.1 ToM and emotion recognition**

Farrant et al. (2005) investigated facial emotion recognition and ToM in 14 people with FLE (8 LFLE, 5 RFLE and 1 Bilateral) and 14 healthy controls. The FLE group were recruited from a specialist epilepsy unit and were being assessed for surgery. Groups did not differ significantly on age, gender ratio, years of education, premorbid IQ or long term memory. Executive functioning was assessed using the Trail Making Task (Reitan & Wolfson, 1993) to assess sequencing (part A) and mental flexibility (part B). The FLE group were significantly slower on the sequencing aspect of this task. The Hayling and Brixton tests (Burgess & Shallice, 1996a, 1996b) were administered and the FLE were significantly slower on the section 1 of the Hayling Test though there were no group differences on response inhibition, the FLE did make more mistakes on the task. The FLE were significantly impaired in relation to controls on a verbal fluency task.

ToM was measured using Happé's Strange Stories (Happé et al., 2001; Happé et al., 1999). The ToM stories all involved human interaction where double bluff, mistakes, white lies or persuasion were evident (with two examples or each of these), participants were asked a question which required them to make an inference about the mental states of people in the story. Faux pas was assessed using a version of the task by Stone et al. (1998a). Participants were assessed on their ability to make inferences about affective and cognitive mental states and their comprehension of the stories (as a control measure).

Humour was assessed via a cartoon task which required the participant to infer the mental state of a character in six cartoons (ToM) or to acknowledge a physical anomaly or a violation of a social norm (non ToM) in six cartoons. The memory load of the ToM stories, faux pas and humour tasks was reduced as participants had a copy of the story/cartoon in front of them whilst being asked questions. The Reading the Mind in the Eyes Task by Baron-Cohen et al. (2001) was administered where participants had to match correct emotions to the photographs displayed. Recognition of facial emotion was assessed using Ekman and Friesen (1976) pictures of facial emotion depicting the following emotions; sad, happy, surprise, anger, fear, disgust. Twelve pictures were displayed, one male and female picture for each emotion and participants were required to match the correct verbal labels to the emotions displayed.

FLE did not show deficits on the story task or appreciation of faux pas though they did illustrate a trend towards impairment. FLE were impaired in both the mental state and physical state cartoons, on emotion recognition and perception of eye gaze expression. ToM was intact but appreciation of humour and emotional expression was not. Mild impairments were observed except in the appreciation of emotion expression where impairment was

Social Cognition in Epilepsy 275

Most of the studies are cross sectional in that they either investigate social cognition post surgery or pre surgery. Consequently these studies cannot differentiate between social cognitive deficits as a consequence of surgery or the pre-existing epilepsy syndrome (Kirsch,

One main criticism with all the studies cited in this review is that no single study has compared people with TLE and FLE, so none of the studies can conclusively determine whether socio-cognitive deficits are characteristic of TLE and/or FLE. Studies that have attempted to investigate the impact of side of seizure onset can all be criticised for having small sample sizes and consequently findings cannot be generalised or the power to detect an effect is greatly reduced. None of the studies reviewed recruited a group of patients with idiopathic generalised epilepsy (IGE) who could act as a clinical control group to help to establish the impact of focal epilepsy on these skills. The added advantage of using an IGE group is that they have active epilepsy, take AEDs and will also be affected by epilepsy related variables such as seizure frequency, seizure type, age of onset and duration. None of the studies that have investigated social cognition in FLE recruited a frontal head injured group without epilepsy in order to determine the impact of FLE on socio-cognitive functioning. The studies reviewed have also not evaluated socio-cognitive performance in

There is a general lack of research investigating social cognition in epilepsy as highlighted in the literature (Schacher et al., 2006; Kirsch, 2006). Research that has been conducted has not utilised designs that can adequately explore socio-cognitive functioning in focal epilepsy. The impact that socio-cognitive skills have in relation to everyday social functioning in PWE needs to be investigated (Walpole et al., 2008; Schacher et al., 2006; Farrant et al., 2005). Such research could provide valuable insight into the socio-cognitive deficits associated with

In light of the methodological problems highlighted in previous studies, the author and colleagues (McCagh et al., unpublished) designed a study to explore socio-cognitive functioning in people with seizure foci in the RF, LF, RT, LT lobes. To overcome previous sample size difficulties the minimum number of people within each group was 11. As well as a healthy control group, this study recruited an IGE and FHI (frontal head injured) group to establish the impact that focal epilepsy and in particular FLE have on these skills, as Farrant et al. (2005) argue, social cognition has not been fully explored in FLE. Information was also collected on relevant epilepsy related variables (age at onset, AEDs, seizure frequency and duration of epilepsy) in relation to the sample. The study also aimed to establish the impact that socio-cognitive functioning may have on the every day life of PWE by assessing social cognitive performance in relation to perceived impact of epilepsy using

Appreciation of false belief and deception in ToM stories and understanding veiled intentions in the Hinting Task were assessed across all clinical groups. All epilepsy groups were administered the Impact of Epilepsy Scale to compare task performance in relation to the perceived impact of epilepsy, this could then help to establish how socio-cognitive skills

To date this is the largest lesion study to investigate ToM and the largest study within the field of epilepsy to investigate social cognition. The findings of this research are currently being

epilepsy and may ultimately improve social functioning in PWE.

the Impact of Epilepsy Scale (Jacoby et al., 1993).

are related to social functioning in real life.

2006).

relation to social functioning in PWE.

**7. Current research** 

substantial. These impairments were in relation to recognising sadness, anger and fear. Verbal second order ToM was intact in the FLE group (as examined in the story task). Age of onset was not correlated with any of the socio-cognitive measures. Executive functions were not correlated with socio-cognitive tasks in the FLE group but verbal fluency was correlated with the eyes task and the non ToM cartoons in the control group.

**Evaluation:** It is unlikely that the observed deficits in social cognition can be attributed to memory or IQ or deficits in executive functioning in the FLE group. As has been supported in studies of cognitive dysfunction in FLE the sample in this study exhibited specific as opposed to general deficits in social cognition. This may be because some tests are more sensitive to detecting impairment than others, though it should be noted that a large sample may have detected more impairments across the tasks. Specific areas in the FL may support different aspects of social cognition, consequently deficits in performance may reflect those areas of damage in the brain in the FLE group. This is the main criticism of the study as it did not report any analysis based on whether people had RFLE or LFLE, due to the small sample size of the groups. The exact site of seizure foci could only be established in 9 of the 14 FLE group (6 with medial and 3 with dorsolateral abnormalities), there were no patients with orbitofrontal involvement. Consequently whether different regions of damage within the FL are associated with specific impairments in the social cognition could not be fully explored. The study did not recruit people with MTLE to compare performance on tests of social cognition in relation to FLE.

This study can also be criticised as it does not provide the reader with any background information about seizure frequency, seizure type, duration of epilepsy or AED treatment in the FLE group, all of which could impact on functioning. Analysis has not been considered in light of these epilepsy related variables.

#### **5.2 ToM and pragmatic language**

Corcoran et al. (cited in Corcoran, 2000) conducted a small scale study (unpublished) in the Chalfont Centre for Epilepsy in 1999. They compared the performance of epilepsy patients on their appreciation of veiled intention in a Hinting Task (Corcoran et al., 1995), a ToM measure. Five patients with right frontal or right fronto-temporal foci, 3 with left frontal and left fronto-temporal foci, 3 with bilateral frontal foci and 23 normal controls were tested. Despite the small sample size differences were found between the groups on performance of the Hinting Task. The right fronto-temporal group appeared to perform worse than normal controls on the Hinting Task independent of group differences in IQ.

**Evaluation:** This study had a very small sample size and consequently hinting ability was not evaluated in relation to any epilepsy related variables.

#### **6. Methodological difficulties of past research**

In critically evaluating their study Farrant et al. (2005) suggest that a larger sample is needed to enable seizure foci in FLE and social cognition to be fully explored. People with FLE need to be compared with other focal epilepsies particularly MTLE to establish if there are specific socio cognitive deficits observed in FLE. Executive impairments have been illustrated in both FLE and TLE, so it is important to determine the nature of socio-cognitive dysfunction in epilepsy. Farrant et al. (2005) also highlight that a larger sample would enable comparison of performance between right and left FLE.

substantial. These impairments were in relation to recognising sadness, anger and fear. Verbal second order ToM was intact in the FLE group (as examined in the story task). Age of onset was not correlated with any of the socio-cognitive measures. Executive functions were not correlated with socio-cognitive tasks in the FLE group but verbal fluency was

**Evaluation:** It is unlikely that the observed deficits in social cognition can be attributed to memory or IQ or deficits in executive functioning in the FLE group. As has been supported in studies of cognitive dysfunction in FLE the sample in this study exhibited specific as opposed to general deficits in social cognition. This may be because some tests are more sensitive to detecting impairment than others, though it should be noted that a large sample may have detected more impairments across the tasks. Specific areas in the FL may support different aspects of social cognition, consequently deficits in performance may reflect those areas of damage in the brain in the FLE group. This is the main criticism of the study as it did not report any analysis based on whether people had RFLE or LFLE, due to the small sample size of the groups. The exact site of seizure foci could only be established in 9 of the 14 FLE group (6 with medial and 3 with dorsolateral abnormalities), there were no patients with orbitofrontal involvement. Consequently whether different regions of damage within the FL are associated with specific impairments in the social cognition could not be fully explored. The study did not recruit people with MTLE to compare performance on tests of

This study can also be criticised as it does not provide the reader with any background information about seizure frequency, seizure type, duration of epilepsy or AED treatment in the FLE group, all of which could impact on functioning. Analysis has not been considered

Corcoran et al. (cited in Corcoran, 2000) conducted a small scale study (unpublished) in the Chalfont Centre for Epilepsy in 1999. They compared the performance of epilepsy patients on their appreciation of veiled intention in a Hinting Task (Corcoran et al., 1995), a ToM measure. Five patients with right frontal or right fronto-temporal foci, 3 with left frontal and left fronto-temporal foci, 3 with bilateral frontal foci and 23 normal controls were tested. Despite the small sample size differences were found between the groups on performance of the Hinting Task. The right fronto-temporal group appeared to perform worse than normal

**Evaluation:** This study had a very small sample size and consequently hinting ability was

In critically evaluating their study Farrant et al. (2005) suggest that a larger sample is needed to enable seizure foci in FLE and social cognition to be fully explored. People with FLE need to be compared with other focal epilepsies particularly MTLE to establish if there are specific socio cognitive deficits observed in FLE. Executive impairments have been illustrated in both FLE and TLE, so it is important to determine the nature of socio-cognitive dysfunction in epilepsy. Farrant et al. (2005) also highlight that a larger sample would

controls on the Hinting Task independent of group differences in IQ.

not evaluated in relation to any epilepsy related variables.

enable comparison of performance between right and left FLE.

**6. Methodological difficulties of past research** 

correlated with the eyes task and the non ToM cartoons in the control group.

social cognition in relation to FLE.

**5.2 ToM and pragmatic language** 

in light of these epilepsy related variables.

Most of the studies are cross sectional in that they either investigate social cognition post surgery or pre surgery. Consequently these studies cannot differentiate between social cognitive deficits as a consequence of surgery or the pre-existing epilepsy syndrome (Kirsch, 2006).

One main criticism with all the studies cited in this review is that no single study has compared people with TLE and FLE, so none of the studies can conclusively determine whether socio-cognitive deficits are characteristic of TLE and/or FLE. Studies that have attempted to investigate the impact of side of seizure onset can all be criticised for having small sample sizes and consequently findings cannot be generalised or the power to detect an effect is greatly reduced. None of the studies reviewed recruited a group of patients with idiopathic generalised epilepsy (IGE) who could act as a clinical control group to help to establish the impact of focal epilepsy on these skills. The added advantage of using an IGE group is that they have active epilepsy, take AEDs and will also be affected by epilepsy related variables such as seizure frequency, seizure type, age of onset and duration. None of the studies that have investigated social cognition in FLE recruited a frontal head injured group without epilepsy in order to determine the impact of FLE on socio-cognitive functioning. The studies reviewed have also not evaluated socio-cognitive performance in relation to social functioning in PWE.

There is a general lack of research investigating social cognition in epilepsy as highlighted in the literature (Schacher et al., 2006; Kirsch, 2006). Research that has been conducted has not utilised designs that can adequately explore socio-cognitive functioning in focal epilepsy. The impact that socio-cognitive skills have in relation to everyday social functioning in PWE needs to be investigated (Walpole et al., 2008; Schacher et al., 2006; Farrant et al., 2005). Such research could provide valuable insight into the socio-cognitive deficits associated with epilepsy and may ultimately improve social functioning in PWE.
