Exploring 'theory of mind' in people with schizophrenia

Paranoia and Data-Gathering Biases in Autism

Previous research has identified contradictory patterns in autism upon probabilistic reasoning tasks, and high levels of self-report paranoia symptoms have also been reported. To explore this relationship, the present study assessed 64 non-autistic and 39 autistic adults on two variants of a probabilistic reasoning task which examined the amount of evidence required before making a decision and 'jumping to conclusions' (a neutral beads task and an emotionally-salient words variant). The autism group was found to require significantly more evidence before making a decision and to have significantly less jumping to conclusions than the non-autistic group. For those with relatively low levels of paranoia, the emotionally-salient variant impacted on the non-autistic group, but not the autism group.

Tinnitus: Does it Lead to Impairments in Metacognitive Functions and the Theory of Mind Skills?

Objective

This study aimed to investigate theory of mind skills and metacognitive functions in patients with tinnitus compared to healthy controls.

Methods

This prospective study included patients diagnosed with tinnitus at our otolaryngology and Head and Neck Surgery clinic and healthy controls matching their demographic characteristics. Patients diagnosed with tinnitus at our otolaryngology and head and neck surgery clinic, along with healthy controls matched for demographic characteristics, were included in the study. All participants completed the Reading the Mind in the Eyes Test (RMET), the metacognition questionnaire (MCQ-30), the Beck Depression Inventory (BDI), and the Tinnitus Handicap Inventory (THI). The relationship between the scales applied to the patient group regarding tinnitus was evaluated using Spearman's and Pearson's correlation tests.

Results

A total of 90 individuals diagnosed with tinnitus and 70 healthy controls participated in the study. There was no statistically significant difference in BDI scores between the groups (p>0.05). However, in the MCQ-30, the cognitive awareness subscale and the total score were significantly higher in the tinnitus group (p=0.003 and p=0.041, respectively). Additionally, RMET performance was lower in tinnitus patients compared to healthy controls (p=0.002). Certain subscales of the MCQ-30 showed a moderate positive correlation with THI.

Conclusion

Based on these findings, we suggest that evaluating tinnitus patients from a psychiatric perspective, providing psychosocial support, and assisting them in improving their communication skills could be beneficial.

Metacognition facilitates theory of mind through optimal weighting of trait inferences

The ability to represent and infer accurately others' mental states, known as Theory of Mind (ToM), has been theorised to be associated with metacognitive ability. Here, we considered the role of metacognition in mental state inference through the lens of a recent theoretical approach to explaining ToM, the 'Mind-space' framework. The Mind-space framework posits that trait inference, representation of the qualities of the mind giving rise to the mental state, is important in forming accurate mental state inferences. We tested a potential role for metacognition in facilitating optimal weighting of trait inferences, as well as several theoretical predictions regarding factors associated with the accuracy of trait inference and confidence in those trait inferences. Participants completed a judgement-of-confidence task in the trait inference domain alongside the Interview Task, a recently-developed task for assessing the accuracy of trait and mental state inferences. A simple relationship in which increased metacognitive sensitivity is associated with increased accuracy of mental states inferences was not found. However, when predicting trial-level performance, confidence in trait inference was shown to modulate the effect of trait inference accuracy on mental state inference accuracy. This effect was greater in magnitude with lower metacognitive sensitivity, i.e., when confidence is more likely to be misplaced. Furthermore, participants' trait inference ability was associated with the accuracy of their understanding of the average mind. In addition, the accuracy of specific trait inferences was predicted by the participant's similarity to the target, but this similarity benefit was reduced in participants whose self-perception was inaccurate. Reported confidence in a given trait inference was also predicted by participant-target similarity, such that participants showed greater overconfidence in judgements made about similar targets. This overconfidence effect was larger when self-perception was more erroneous. Results support several theoretical claims made by the Mind-space theory, and further elucidate the processes underlying accurate mental state inference.

Shyness, emotion processing, and objective quality of life among adults with schizophrenia: an ERP study

Purpose: Although individual differences in temperament have been shown to influence Quality of Life (QoL) among individuals with schizophrenia, there exists considerable heterogeneity in such outcomes suggesting moderating factors. Here we used event-related potential (ERP) methodology to examine whether the processing of facial emotions moderated the association between shyness and objective QoL among adults with schizophrenia.Methods: Forty stable outpatients with schizophrenia completed measures of shyness and QoL. Early visual ERP components (P100, N170) were recorded while participants viewed emotional faces.Results: We observed a significant interaction between shyness and P100 and N170 amplitudes in response to fearful faces in predicting Intrapsychic Foundations QoL. Patients with reduced P100 and N170 amplitudes to fearful compared to neutral faces displayed the lowest QoL, but only if they were also high in shyness. We also found a significant interaction between shyness and ERP latency at the P100 and N170 in response to happy faces. Patients who displayed longer P100 and N170 latencies to happy faces compared to neutral faces and with higher shyness levels scored lower on Intrapsychic Foundations and Interpersonal Relations QoL, respectively.Conclusion: These findings suggest that the neural processing of emotional faces and shyness interact to predict aspects of QoL among outpatients with schizophrenia.

When the body fosters empathy: The interconnectivity between bodily reactivity, meditation, and embodied abstract concepts

Empathy is a fundamental social ability that allows humans to infer others' emotions and intentions. Empathy is thought to be rooted in bodily sensations coming from the autonomic nervous system. In parallel, the functionality and perceptions coming from the autonomic nervous system could be improved by practicing activities that involve mind-body interactions, such as meditation. Furthermore, perceptions from the autonomic nervous system are thought to be important in the embodiment of abstract concepts. Consequently, in the current study, we collected data online from 581 participants and explored the associations between levels of empathy and (1) the practice of meditation, music, and sports; (2) the impact of self-report measures on bodily awareness and reactivity; and (3) the embodiment of abstract concepts in interoception. In line with previous studies, Meditators were found to have higher empathy scores than Non-Meditators. In addition, lower levels of autonomic reactivity in organs above the diaphragm were associated with higher empathy. Finally, we also observed that empathy was positively associated with interoceptive components of abstract concepts in those participants with high autonomic reactivity. Taken together, the results suggest that meditation practice and having low autonomic reactivity are associated with empathy, arguably through the downregulation of autonomic responses. Implications for mind-body interaction in meditation and its role in promoting empathy are discussed.

Measures of individual differences in adult theory of mind: A systematic review

Theory of mind (ToM), the ability to understand and reason about mental states, has been extensively studied in young children and clinical populations. A growing interest in examining ToM in adults has emerged over the past two decades, but the extent to which existing measures are suitable for studying adults, especially in detecting individual differences, remains understudied. In this systematic review of 273 studies, 75 measures used to investigate individual differences in adults' ToM were identified. Their sensitivity to individual differences, reliability, and validity were examined. Results suggest that ceiling effects were prevalent, and there was limited evidence to establish the reliability or validity of these measures due to the lack of reports of psychometric properties. Interrelations among measures were inconsistent. These findings highlight the need for future empirical and theoretical work to broaden the evidence base regarding psychometric properties of measures, to develop new measures, and to lay out more specific hypotheses about the relevance of ToM for different social outcomes.

Profiles of theory of mind impairments and personality in clinical and community samples: integrating the alternative DSM-5 model for personality disorders

Introduction

Deficits in theory of mind (ToM)-the ability to infer the mental states of others-have been linked to antagonistic traits in community samples. ToM deficits have also been identified in people with personality disorders (PD), although with conflicting evidence, partly due to the use of categorical diagnoses. The DSM-5 Alternative Model for Personality Disorders (AMPD) provides an opportunity for a more precise understanding of the interplay between ToM abilities and personality pathology. Therefore, the study aims to determine whether and how individuals with diverse ToM profiles differ regarding personality impairment (AMPD Criterion A) and pathological facets (AMPD Criterion B).

Method

Adults with PD (n = 39) and from the community (n = 42) completed tests assessing ToM skills and self-reported questionnaires assessing AMPD Criteria A and B. Hierarchical agglomerative and TwoStep cluster analyses were consecutively computed using scores and subscores from ToM tests as clustering variables. Multivariate analyses of variance were subsequently performed to compare the clusters on both AMPD Criteria. Five clinically and conceptually meaningful clusters were found. The most notable differences across clusters were observed for Intimacy and Empathy dysfunctions (Criterion A), as well as for the Deceitfulness, Callousness, and Hostility facets from the Antagonism domain and the Restricted affectivity facet from the Detachment domain (Criterion B).

Discussion

The results support the association between antagonistic personality facets and ToM deficits. However, clusters showing impairments in ToM abilities did not necessarily exhibit high levels of personality dysfunction or pathological facets, emphasizing that both constructs are not isomorphic. Nevertheless, specific profiles can help refine existing interventions to make them more sensitive and specific to the nature of ToM dysfunctions while considering personality functioning and facets.

Effects of Ziprasidone or Haloperidol on Theory of Mind in Patients With Schizophrenia: A 16-week Pilot Trial

OBJECTIVES

Schizophrenia is associated with impairment in theory of mind (ToM), which is defined as the ability to make judgments about mental states and is related to medial prefrontal cortical activity. Ziprasidone, but not haloperidol, is known to have a protective effect in the medial prefrontal cortex. Thus, we hypothesized that these 2 drugs would have different efficacy in improving ToM task performance in patients with schizophrenia.

METHODS

Patients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnosis of schizophrenia matched for sex, duration of illness, and education were randomized to receive ziprasidone (n=30) or haloperidol (n=30). All patients were assessed using the Positive and Negative Syndrome Scale and the Personal and Social Functioning Scale. ToM was assessed using a first-order false belief task, a second-order false belief task, the faux-pas task, and the Reading the Mind in the Eyes Task, in order of developmental complexity and difficulty. The primary outcome was change in ToM performance from baseline to 16 weeks of treatment.

RESULTS

For the first-order false belief task, there were no significant differences between the groups (P>0.05). For the second-order false belief task, the interaction effect was significant (P<0.05), and the simple effect of time showed a significant difference only in the ziprasidone group (P<0.001). For the faux-pas task, the interaction effect was not significant (P>0.05). For the Reading the Mind in the Eyes Task, the interaction effect was significant (P<0.05), and the simple effect of time showed a significant difference only in the ziprasidone group (P<0.001). The Positive and Negative Syndrome Scale results were similar between the groups. The ziprasidone group performed better than the haloperidol group on the Personal and Social Functioning Scale. There were no major safety concerns or adverse events.

CONCLUSIONS

The findings of this study suggest that ziprasidone could improve ToM and might be superior to haloperidol for improving complex ToM as well as personal and social functioning in patients with schizophrenia.

TRIAL REGISTRATION CHINESE CLINICAL TRIAL REGISTER

ChiCTR2200060542.

Empathy and Violence in Schizophrenia and Antisocial Personality Disorder

A paucity of cognitive and affective features of empathy can be correlated with violent behavior. We aimed to identify differences in empathy among four groups in a sample of 100 male participants: (1) 27 violent offenders with schizophrenia, (2) 23 nonviolent patients with schizophrenia, (3) 25 patients with antisocial personality disorder, and (4) 25 subjects from the general population, who formed the control group. Schizophrenia symptoms were quantified with the Positive and Negative Syndrome Scale. Empathy was measured with the empathy quotient. Theory of mind was evaluated using (a) the first-order false-belief task, (b) the hinting task, (c) the faux pas recognition test and (d) the "reading the mind in the eyes" test (revised). Differences noted among the groups were age (controls were younger) and educational status (antisocials were less educated). The empathy quotient scoring (p < 0.001) and theory-of-mind tests (p < 0.001) were distinct between the control group and the three other groups of participants, but not among the three patient groups. Patients with antisocial personality disorder, violent psychotic offenders and psychotic nonviolent patients show no remarkable differences in affective or cognitive empathy tests, but they all present deficits in empathy and theory of mind when compared to controls.

A conversation analytic approach to schizophrenic interaction: methodological reflections on disruptions of the common-sense world

Certain schools of phenomenological psychiatry conceive of schizophrenia as a pathology of common-sense. Ethnomethodological enquiry, with its roots in Schutzian social phenomenology, takes as its domain, topic, and substance of study the ongoing achievement of a common-sense world between social members. Yet, dialogue between psychiatry and ethnomethodological approaches is thin. In this article, we discuss a conversation analytic approach to schizophrenic interaction which has generated and utilized a model of a five-world manifold to frame analyses of talk-in-interaction. 'Worlds' are conceived, after Schutz, as finite domains of meaning, and the model operates as a breach of natural attitude assumptions to examine mechanisms of the constitution of the one-world-in-common of common-sense. It is suggested that certain aspects of schizophrenic talk might receive account in terms of a loss of integration between these five domains of meaning. Conversation Analytic methods were applied to transcripts of audio recordings of psychiatric interviews but encountered hurdles that motivated the broadening of methodological scope. Such hurdles included a weakening of the next turn proof procedure, implicit reification of the schizophrenia construct, and problems of translation presented by the analyst's normative membership encountering non-normative life-worlds of schizophrenic experience. Strategic responses to these hurdles included exploring linkages between phenomenological psychiatry and ethnomethodological approaches, as well as an engagement of ethnomethodological self-reflection and conceptual clarification of the schizophrenia construct in line with Garfinkel's unique adequacy requirement. The manifold model is glossed, and interaction between two of its worlds - a world of concrete, situational immediacies and another of abstract organizations - is explored in more detail via analysis of conversational data. It is suggested that the five-world model, along with further micro-analysis of talk-in-interaction, might have implications in psychiatry for topics such as autism, double bookkeeping, concretism, theories of disturbed indexicality, and insight attribution. We conclude that the consideration of atypical interaction obliges the interaction analyst to take account of their own implicit normative world-frames and that the use of domain-specific top-down models in conjunction with the inductive approach of Conversation Analysis may extend the reach of CA to facilitate productive dialogue with other disciplines.

Cognitive biases as an adaptive strategy in autism and schizophrenia spectrum: the compensation perspective on neurodiversity

This article presents a novel theoretical perspective on the role of cognitive biases within the autism and schizophrenia spectrum by integrating the evolutionary and computational approaches. Against the background of neurodiversity, cognitive biases are presented as primary adaptive strategies, while the compensation of their shortcomings is a potential cognitive advantage. The article delineates how certain subtypes of autism represent a unique cognitive strategy to manage cognitive biases at the expense of rapid and frugal heuristics. In contrast, certain subtypes of schizophrenia emerge as distinctive cognitive strategies devised to navigate social interactions, albeit with a propensity for overdetecting intentional behaviors. In conclusion, the paper emphasizes that while extreme manifestations might appear non-functional, they are merely endpoints of a broader, primarily functional spectrum of cognitive strategies. The central argument hinges on the premise that cognitive biases in both autism and schizophrenia spectrums serve as compensatory mechanisms tailored for specific ecological niches.

Knowing me, knowing you: a scoping review assessing the current field of social cognition in schizophrenia

BACKGROUND

Impaired social cognition (SC) occurs frequently in schizophrenia (SCZ), yet compared to autism spectrum disorder (ASD), the research on SC in SCZ is sparse and methodologically heterogeneous. To accurately assess between-group SC differences it is further necessary to establish the relationship between nonsocial cognition (NSC) and SC, particularly as this may not be identical across disorders.

PURPOSE

The present study aimed to map, index and assess the quality of research published between 2014-2021 investigating SC in SCZ, and to summarize existing limitations and recommendations for future research.

METHOD

Following the PRISMA guidelines for scoping reviews (PRISMA-ScR) fifteen (n = 15) case-control studies were identified and included across three electronic databases. Studies additionally utilizing ASD samples were included because of their clinical utility.

RESULTS

Most studies reported significant SC impairments in SCZ relative to healthy controls (HC) with varying effect sizes. Significant differences between SCZ and ASD were not found in most studies including both samples. Weak-to-moderate correlations between SC and NSC were often found, although often only within patient samples. Across studies, SC tests were inconsistently described as measurements of "social cognition", "mentalization" and, most frequently and varyingly, "theory of mind". Most studies lacked methodological transparency. Limitations related to sample sizes and test reliability were most frequently mentioned.

CONCLUSIONS

The current research on SC in SCZ is limited by conceptual and methodological uncertainties. Future research should focus on ensuring clear and valid definitions of key terms, evaluating and clarifying SC outcome measures and further untangling the relationship between SC and NSC.

Autism and intention attribution test: a non-verbal evaluation with comic strips

BACKGROUND

Despite autism spectrum disorder (ASD) and mentalization being two words often associated in the literature, the assessment of this ability in individuals with ASD in the clinical setting is still limited. Indeed, there are no standardized Theory of Mind (ToM) tests that are adaptable to different cognitive profiles, such as individuals with language poverty, and intellectual or memory impairments. This study proposes a non-verbal test (Intentions Attribution-Comic Strip Test; IA-CST) to evaluate the ability to infer the intentions of others, a basic component of ToM, in the clinical setting.

METHOD

In Study 1, the test was administered to 261 healthy individuals and we performed structural validation using Exploratory Graph Analysis. In Study 2, the final version of the test was administered to 32 individuals with ASD to assess the known group validity of the measure by comparing their scores with a sample of IQ-matched controls. Moreover, we performed logistic regression and ROC curve to preliminarily assess the diagnostic performance of the IA-CST.

RESULTS

The IA-CST resulted in a 3-dimension measure with good structural stability. Group comparison indicated that the ASD group shows significantly lower performance in intention attribution but not in inferring causal consequences. The test demonstrated known group validity and that, preliminarily, it is suitable for implementation within the clinical practice.

CONCLUSIONS

The results support the IA-CST as a valid non-verbal task for evaluating intentions attribution in the clinical setting. Difficulties in ToM are early and relevant in ASD, so assessing these aspects is valuable for structuring individualized and evidence-based interventions.

The Interplay of Oxytocin and Attachment in Schizophrenic Patients: An fMRI Study

BACKGROUND

Attachment theory offers an important framework for understanding interpersonal interaction experiences. In the present study, we examined the neural correlates of attachment patterns and oxytocin in schizophrenic patients (SZP) compared to healthy controls (HC) using fMRI. We assumed that male SZP shows a higher proportion of insecure attachment and an altered level of oxytocin compared to HC. On a neural level, we hypothesized that SZP shows increased neural activation in memory and self-related brain regions during the activation of the attachment system compared to HC.

METHODS

We used an event-related design for the fMRI study based on stimuli that were derived from the Adult Attachment Projective Picture System to examine attachment representations and their neural and hormonal correlates in 20 male schizophrenic patients compared to 20 male healthy controls.

RESULTS

A higher proportion of insecure attachment in schizophrenic patients compared to HC could be confirmed. In line with our hypothesis, Oxytocin (OXT) levels in SZP were significantly lower than in HC. We found increasing brain activations in SZP when confronted with personal relevant sentences before attachment relevant pictures in the precuneus, TPJ, insula, and frontal areas compared to HC. Moreover, we found positive correlations between OXT and bilateral dlPFC, precuneus, and left ACC in SZP only.

CONCLUSION

Despite the small sample sizes, the patients' response might be considered as a mode of dysregulation when confronted with this kind of personalized attachment-related material. In the patient group, we found positive correlations between OXT and three brain areas (bilateral dlPFC, precuneus, left ACC) and may conclude that OXT might modulate within this neural network in SZP.

Does social cognition change? Evidence after 4 years from the Italian Network for Research on Psychoses

BACKGROUND

Deficits in social cognition (SC) are significantly related to community functioning in schizophrenia (SZ). Few studies investigated longitudinal changes in SC and its impact on recovery. In the present study, we aimed: (a) to estimate the magnitude and clinical significance of SC change in outpatients with stable SZ who were assessed at baseline and after 4 years, (b) to identify predictors of reliable and clinically significant change (RCSC), and (c) to determine whether changes in SC over 4 years predicted patient recovery at follow-up.

METHODS

The reliable change index was used to estimate the proportion of true change in SC, not attributable to measurement error. Stepwise multiple logistic regression models were used to identify the predictors of RCSC in a SC domain (The Awareness of Social Inference Test [TASIT]) and the effect of change in TASIT on recovery at follow-up.

RESULTS

In 548 participants, statistically significant improvements were found for the simple and paradoxical sarcasm of TASIT scale, and for the total score of section 2. The reliable change index was 9.8. A cut-off of 45 identified patients showing clinically significant change. Reliable change was achieved by 12.6% and RCSC by 8% of participants. Lower baseline TASIT sect. 2 score predicted reliable improvement on TASIT sect. 2. Improvement in TASIT sect. 2 scores predicted functional recovery, with a 10-point change predicting 40% increase in the probability of recovery.

CONCLUSIONS

The RCSC index provides a conservative way to assess the improvement in the ability to grasp sarcasm in SZ, and is associated with recovery.

A comparative study of theory of mind in taxon-like clusters of psychometric schizotypes and individuals at genetic risk for schizophrenia

Introduction: Clinical and family studies suggest that alterations of theory of mind (ToM) represent a marker of genetic liability to schizophrenia. Findings regarding ToM in schizotypy are less consistent. The study aimed to explore whether this might be due to an insufficient account of the heterogeneity of schizotypy in prior research and/or the fact that in psychometric schizotypy ToM alterations could manifest as subtle peculiarities rather than overt errors of mentalising.Methods: Individuals without a family history of psychosis (n = 150) were assigned to low, positive, negative, and high mixed schizotypy classes based on a cluster analysis of 1322 subjects who completed the Schizotypal Personality Questionnaire. The classes were compared on their performance of faux pas tasks with 77 adult first-degree relatives of schizophrenia patients, who represent individuals at genetic risk for schizophrenia. Besides overt errors, subtle alterations in ToM were analysed using expert judgment.Results: The relatives tended to make overt errors and demonstrated specific features of intentional reasoning. None of the schizotypal classes showed similar trends.Conclusions: The results complement the literature on the subjective-objective disjunction in psychometric schizotypes and did not provide evidence that ToM anomalies are a marker of genetic liability to schizophrenia in this cohort.

Neuropsychological functioning and suicidal behaviours in patients with first-episode psychosis: A systematic review

INTRODUCTION

Suicidal behaviour is particularly frequent in patients with psychosis. Therefore, prevention is a key objective of mental health policies. The aim of the current work is to systematically review the association between neurocognitive functioning and suicidal behaviour in patients with first-episode psychosis (FEP).

MATERIAL AND METHODS

Of the 3051 studies reviewed, only 7 met the inclusion criteria. Documents in English from their earliest date of coverage until January 2022 were searched for in the following databases: PubMed, Science Direct, Web of Science, Cochrane Library, PsycINFO (ProQuest), and Springerlink. We used the PICO strategy to collect and categorize the data from each selected manuscript.

RESULTS

Overall, the results showed that the risk of suicidal behaviour is higher for FEP patients in the presence of a number of factors: poorer general neuropsychological functioning (except for working memory), poorer social cognition, more depressive symptoms, longer duration of untreated psychosis, higher awareness of the illness, poorer premorbid adjustment, and more frequent cannabis use.

DISCUSSION

Comprehensive general neuropsychology and assessment of social cognition, together with routine clinical record keeping, may help to identify FEP patients at a greater risk of attempting suicide.

Regrouping scalets: Psychometric properties of the theory of mind picture stories task in a schizophrenic sample

Theory of mind is one of the most intensively studied phenomena in the development of schizophrenic symptoms and impairments in social adjustment. Complex theory of mind processing requires both visual and verbal aspects of the social-perceptual and social-cognitive components of mind reading. Reliable assessment methods are considered essential for the proper conduct of research. The current study aims at investigating the psychometric properties of the Theory of Mind Picture Stories Task (ToM PST). Forty-seven patients with schizophrenia were enrolled in the study from three sites. Data from ToM PST were used for computing the consistency, reliability, and internal and construct validity of the test.Our preliminary findings showed less appropriate consistency. Therefore, we attempted to carry out structural changes on the task while preserving its scales and subscales, which measure crucial factors of ToM. The newly structured task has four scales. They show proper consistency (Sequencing: Cronbach's α = 0.70, Theory of a Single Person's Mind: α = 0.74, Switching Between Minds: α = 0.70, Comprehension of Misleading Behaviour: α = 0.67, Total: α = 0.80) with appropriate internal and construct validity, a moderate test-retest reliability over a four-month-course, and a proper inter-rater reliability.

Efficacy of metacognitive training on symptom severity, neurocognition and social cognition in patients with schizophrenia: A single-blind randomized controlled trial

Over the past decades, a number of complementary treatments for schizophrenia have emerged. One of these is metacognitive training (MCT), which combines the principles of cognitive-behavioral therapies, cognitive remediation, and psychoeducation into a hybrid approach placing emphasis on increasing metacognitive awareness. The aim of our study was to investigate the efficacy of MCT on symptom severity, and neurocognitive and social cognitive functioning in schizophrenia; also, attention was paid to the assessment of subjective acceptability. Forty-six patients diagnosed with schizophrenia were included in our single-blind randomized controlled trial, who were assigned to the intervention or control group. The intervention group was provided standard MCT, while the control group received treatment as usual. We assessed symptom severity and cognitive functions before and after the training, as well as after a 6-month follow-up period. Compared to the control group, the intervention group showed improvement in overall symptom severity, and positive and disorganized symptoms. Training participans showed further improvement at the follow-up assessment. Regarding neurocognitive functions, improvement in visuospatial functions was observed between pre- and post-intervention assessments compared to the control group. Patients showed excellent adherence, and evaluated the training as useful and interesting. In line with the results of previous studies, our results demonstrate the efficacy of MCT on symptom severity in schizophrenia. Improvements in cognitive functions that are closely related to the onset and prevalence of symptoms of schizophrenia were also found.

We both say tomato: Intact lexical alignment in schizophrenia and bipolar disorder

In people with schizophrenia and related disorders, impairments in communication and social functioning can negatively impact social interactions and quality of life. In the present study, we investigated the cognitive basis of a specific aspect of linguistic communication-lexical alignment-in people with schizophrenia and bipolar disorder. We probed lexical alignment as participants played a collaborative picture-naming game with the experimenter, in which the two players alternated between naming a dual-name picture (e.g., rabbit/bunny) and listening to their partner name a picture. We found evidence of lexical alignment in all three groups, with no differences between the patient groups and the controls. We argue that these typical patterns of lexical alignment in patients were supported by preserved-and in some cases increased-bottom-up mechanisms, which balanced out impairments in top-down perspective-taking.

The Impact of Poor Nonverbal Social Perception on Functional Capacity in Schizophrenia

Background

Nonverbal social perception is the ability to interpret the intentions and dispositions of others by evaluating cues such as facial expressions, body movements, and emotional prosody. Nonverbal social perception plays a key role in social cognition and is fundamental for successful social interactions. Patients with schizophrenia have severe impairments in nonverbal social perception leading to social isolation and withdrawal. Collectively, these aforementioned deficits affect patients' quality of life. Here, we compare nonverbal social perception in patients with schizophrenia and controls and examine how nonverbal social perception relates to daily functioning.

Methods

We compared nonverbal social perception in 41 stable outpatients with schizophrenia and 30 healthy controls using the Mini Profile of Nonverbal Sensitivity (Mini-PONS). The participants evaluated 64 video clips showing a female actor demonstrating various nonverbal social cues. Participants were asked to choose one of two options that best described the observed scenario. We correlated clinical ratings (Positive and Negative Syndrome Scale, Brief Negative Syndrome Scale), Self-report of Negative Symptoms, and functional assessments (functional capacity and functional outcome) with Mini-PONS scores.

Results

Patients performed significantly poorer in the Mini-PONS compared to controls, suggesting deficits in nonverbal social perception. These deficits were not associated with either positive symptoms or negative symptoms (including self-report). However, impaired nonverbal social perception correlated with distinctive domains of BNSS (mainly avolition and blunted affect), as well as functional capacity and functional outcome in patients.

Conclusion

We demonstrate that nonverbal social perception is impaired in stable outpatients with schizophrenia. Nonverbal social perception is directly related to specific negative symptom domains, functional capacity and functional outcome. These findings underline the importance of nonverbal social perception for patients' everyday life and call for novel therapeutic approaches to alleviate nonverbal social perception deficits.

Verbal manifestations of metacognitive and social cognitive operations in patients with schizophrenia who received metacognitive training

The study investigates with inductive content analysis the verbal manifestations of schizophrenia patients, their utterances within the theory of mind modules of Metacognitive Training. Participants were recruited via psychiatrists’ verbal referrals. Four small groups were formed, two of which consented to the audio recording of their sessions. Only the sessions of these two groups of five and four patients respectively were investigated. As two participants dropped out, the verbalisations of seven participants were eventually analysed. All patients had schizophrenia diagnosis (mean age: 43 years, male: two, female: five). The verbal contents were transcribed, then two independent coders did the categorisation of the content; investigator triangulation ensured the reliability and validity of the study. As a result, a five-level hierarchy of cognitive operations was revealed in a bottom-up way. Patients attempted to interpret not only facial expressions but expressive movements, too, during emotion recognition. When deducing the state of others, patients sought contextual information; moreover, the burden of the illness and stigmatisation became easy to share. No signs of awareness of the consequences of the inferred states were found regarding future adjustment. Our hierarchical structure was consistent with related literature, and the specificities of cognitive operations of participants were also revealed.

Effects of childhood trauma on facial recognition of fear in psychosis

INTRODUCTION

Childhood trauma has been reported as a risk factor for psychosis. Different types of traumatic experiences in childhood could lead to different clinical manifestations in psychotic disorders.

METHODS

We studied differences in social cognition (emotion recognition and theory of mind) and clinical symptoms in a sample of 62 patients with psychosis (less than five years of illness) and childhood trauma, analysing performance by trauma type.

RESULTS

Psychotic patients with a history of childhood trauma other than sexual abuse were more capable of recognizing fear as a facial emotion (especially when facial stimuli were non-degraded) than participants with a history of sexual abuse or with no history of childhood trauma (P = .008). We also found that the group that had suffered sexual abuse did not show improvement in fear recognition when exposed to clearer stimuli, although this intergroup difference did not reach statistical significance (P = .064). We have not found other differences between abuse groups, neither in clinical symptoms (PANSS factors) nor in Hinting Task scores.

CONCLUSION

We have found differences in fear recognition among patients with psychotic disorders who have experienced different types of childhood trauma.

Investigating the Contribution of Decision-Making, Cognitive Insight, and Theory of Mind in Insight in Schizophrenia: A Cross-Sectional Study

INTRODUCTION

Insight in schizophrenia spectrum disorders (SSD) is associated with outcomes. Although the neurocognitive basis of insight is widely accepted, the specific contribution of decision-making (Jumping to Conclusions [JTC]), Cognitive Insight (CI), and Theory of Mind (ToM) to insight remains unclear.

METHODS

The sample included N = 77 SSD outpatients aged 18-64 years from a randomized controlled trial of metacognitive training. Assessments included JTC-Beads Task, CI-Beck Cognitive Insight Scale, ToM-Hinting Task, and the Emotions Recognition Test Faces.

STATISTICS

hierarchical multivariable linear regression models tested their contribution to total insight (TI) and three insight dimensions - illness recognition (IR), symptom relabelling (SR), and treatment compliance (TC) - measured with the Schedule for the Assessment of Insight - Expanded version, whilst adjusting for potential confounders.

RESULTS

Bivariate analyses showed that CI was associated with TI (R2 change = 0.214; p < 0.001), IR (R2 change = 0.154; p = 0.003), and SR (R2 change = 0.168; p = 0.003), while JTC predicted IR (R2 change = 0.790; p = 0.020). Multivariable regression models showed that CI predicted TI (R2 change = 0.116; p = 0.036) and SR (R2 change = 0.166, p = 0.011), whereas JTC was linked with IR (R2 change = 0.710; p = 0.026). ToM was not linked with any insight score. No cognitive variable was associated with treatment compliance.

DISCUSSION

Results supported the (meta)cognitive model of insight in SSD. JTC and CI emerged as the main (meta)cognitive processes underlying insight. Metacognitive interventions may therefore improve insight in SSD, although these therapies alone may fail to address treatment compliance.

The mirror mechanism in schizophrenia: A systematic review and qualitative meta-analysis

BACKGROUND

Mirror neuron system (MNS) consists of visuomotor neurons that are responsible for the mirror neuron activity (MNA), meaning that each time an individual observes another individual performing an action, these neurons encode that action, and are activated in the observer's cortical motor system. Previous studies report its malfunction in autism, opening doors to investigate the underlying pathophysiology of the disorder in a more elaborate way and coming up with new rehabilitation methods. The study of MNA function in schizophrenia patients has not been as frequent and conclusive as in autism. In this research, we aimed to evaluate the functional integrity of MNA and the microstructural integrity of MNS in schizophrenia patients.

METHODS

We included case-control studies that have evaluated MNA in schizophrenia patients compared to healthy controls using a variety of objective assessment tools. In August 2022, we searched Embase, PubMed, and Web of Science for eligible studies. We used an adapted version of the NIH Quality Assessment of Case-Control Studies tool to assess the quality of the included studies. Evidence was analyzed using vote counting methods of the direction of the effect and was tested statistically using the Sign test. Certainty of evidence was assessed using CERQual.

RESULTS

We included 32 studies for the analysis. Statistical tests revealed decreased MNA (p = 0.002) in schizophrenia patients. The certainty of the evidence was judged to be moderate. Investigations of heterogeneity revealed a possible relationship between the age and the positive symptoms of participants in the included studies and the direction of the observed effect.

DISCUSSION

This finding contributes to gaining a better understanding of the underlying pathophysiology of the disorder by revealing its possible relation to some of the symptoms in schizophrenia patients, while also highlighting a new commonality with autism.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO identifier: CRD42021236453.

Performance-based assessment of social skills in a large sample of participants with schizophrenia, bipolar disorder and healthy controls: Correlates of social competence and social appropriateness

INTRODUCTION

Performance-based assessments of social skills have detected impairments in people with severe mental illness and are correlated with functional outcomes in people with schizophrenia and bipolar disorder. The most common of these assessments, the Social Skills Performance Assessment (SSPA), has two communication scenarios and items measuring both social competence and appropriateness. As real-world competence and appropriateness appear to have different correlates, we hypothesized that SSPA Items measuring competence and appropriateness would be distinct and have different correlations with other outcomes.

METHODS

We aggregated data from 557 people with schizophrenia, 106 with bipolar disorder, and 378 well controls from 4 separate research studies. All participants were assessed with both SSPA scenarios and other performance based and clinician-rated measures. A single expert rated the SSPA interactions for competence and appropriateness while blind to participant diagnoses.

RESULTS

Participants with bipolar disorder and schizophrenia performed more poorly on every item of the SSPA than healthy controls. Items measuring social competence and appropriateness in communication were intercorrelated across scenarios, as were elements of socially competent communication, although the items measuring competence did not correlate substantially with appropriateness. Items assessing social competence, but not social appropriateness, correlated with better cognitive and functional performance and residential and financial independence.

DISCUSSION

Social competence and social appropriateness were distinct elements of performance-based social skills with potential differences in their functional correlates. As both social competence and appropriateness impact functional outcomes, improvement in the measurement and treatment of appropriate communication seems to be an important goal.

What Do We Know about Theory of Mind Impairment in Parkinson's Disease?

Theory of mind (ToM) is a social cognitive skill that involves the ability to attribute mental states to self and others (what they think (cognitive ToM) and feel (affective ToM)). We aim to provide an overview of previous knowledge of ToM in Parkinson's disease (PD). In the last few years more attention has been paid to the study of this construct as a non-motor manifestation of PD. In advanced stages, both components of ToM (cognitive and affective) are commonly impaired, although in early PD results remain controversial. Executive dysfunction correlates with ToM deficits and other cognitive domains such as language and visuospatial function have also been related to ToM. Recent studies have demonstrated that PD patients with mild cognitive impairment show ToM deficits more frequently in comparison with cognitively normal PD patients. In addition to the heterogeneity of ToM tests administered in different studies, depression and dopaminergic medication may also be acting as confounding factors, but there are still insufficient data to support this. Neuroimaging studies conducted to understand the underlying networks of cognitive and affective ToM deficits in PD are lacking. The study of ToM deficit in PD continues to be important, as this may worsen quality of life and favor social stigma. Future studies should be considered, including assessment of the patients' cognitive state, associated mood disorders, and the role of dopaminergic deficit.

Mentalizing Errors in Patients with Schizophrenia Who Received Psychosocial Rehabilitation: a Case-Control Study

The main objective of this study was to evaluate the mentalizing performance of patients with schizophrenia who received daily psychosocial rehabilitation treatment compared with healthy controls. Differences in mentalizing performance between men and women, and the relationship between mentalizing deficits, cognitive impairment, symptoms, and global functioning of patients were also examined. A case-control study design was utilized (N = 95). Adults with schizophrenia were recruited from psychosocial rehabilitation clinics (n = 53) and healthy controls were recruited from the community (n = 42). Mentalizing was evaluated with the Movie for the Assessment of Social Cognition, an audiovisual measure with good ecological validity. Measures of cognitive functioning, symptoms, and global functioning were also administered. Patients exhibited significant mentalizing deficits. Specifically, patients made more undermentalizing errors and more no mentalizing errors compared with healthy controls. In patients and healthy controls, no differences were found between men and women in mentalizing abilities. In patients with schizophrenia, lower cognitive functioning (i.e., immediate and delayed verbal learning, verbal fluency, and processing speed) were associated with poorer mentalizing. In patients, processing speed explained 31% of the variance in total mentalizing errors and mentalizing deterioration was associated with poorer overall functioning. Psychosocial rehabilitation interventions in people with schizophrenia should consider mentalizing deficits (especially undermentalizing and no mentalizing difficulties) and their relationship with reduced processing speed in treatment delivery (e.g., direct and organized communication). Integration of treatments targeting mentalizing deficits in a psychosocial rehabilitation setting is recommended to improve functioning in schizophrenia.

Pharmacological Treatment for Social Cognition: Current Evidence

Cognitive impairment is currently considered a core feature of schizophrenia (SZ) and is gaining attention as a fundamental therapeutic target. Standard treatment for SZ involves the use of antipsychotics that are successfully used to control positive symptoms and disorganized behaviour. However, it is still unclear whether they are effective on social cognition (SC) impairment. Furthermore, different medications are currently being studied to improve SC in patients with SZ. A literature search on this topic was conducted using the PubMed database. All kinds of publications (i.e., reviews, original contributions and case reports) written in English and published in the last 15 years were included. The aim of our literature review is to draw a picture of the current state of the pharmacological treatment of SC impairment in SZ.

A Systematic Review of the Current Measures of Theory of Mind in Adults with Schizophrenia

Adults with schizophrenia usually have impairments in theory of mind (ToM), which subsequently cause them problems in social interaction. Therefore, it is important for healthcare providers to assess their ToM using adequate measures. This systematic review evaluated current ToM measures (or ToM tasks) for adults with schizophrenia and summarized their specific characteristics, including the concept and construct, administration, and psychometric properties. From a review of 117 articles, 13 types of ToM tasks were identified, and the findings from these articles were qualitatively synthesized. The results showed that ToM tasks are diverse in their presentation modalities, answer modes, strategies of controlling cognitive confounders, and scoring. Most tasks employ cognitive and affective dimensions and target a specific, single ToM concept. The present systematic review found that psychometric evidence supporting the ToM tasks, such as internal consistency, test–retest reliability, unidimensionality, and convergent, criterion, and ecological validities, is insufficient. Based on the results, we propose several principles for selecting appropriate ToM tasks in practice, e.g., selecting a task with multiple ToM concepts, or an exclusive ToM construct containing the cognitive and affective dimensions. Moreover, future studies are needed to provide more psychometric evidence on each type of ToM task applied in people with schizophrenia.

Multimodal assessment of communicative-pragmatic features in schizophrenia: a machine learning approach

An impairment in pragmatic communication is a core feature of schizophrenia, often associated with difficulties in social interactions. The pragmatic deficits regard various pragmatic phenomena, e.g., direct and indirect communicative acts, deceit, irony, and include not only the use of language but also other expressive means such as non-verbal/extralinguistic modalities, e.g., gestures and body movements, and paralinguistic cues, e.g., prosody and tone of voice. The present paper focuses on the identification of those pragmatic features, i.e., communicative phenomena and expressive modalities, that more reliably discriminate between individuals with schizophrenia and healthy controls. We performed a multimodal assessment of communicative-pragmatic ability, and applied a machine learning approach, specifically a Decision Tree model, with the aim of identifying the pragmatic features that best separate the data into the two groups, i.e., individuals with schizophrenia and healthy controls, and represent their configuration. The results indicated good overall performance of the Decision Tree model, with mean Accuracy of 82%, Sensitivity of 76%, and Precision of 91%. Linguistic irony emerged as the most relevant pragmatic phenomenon in distinguishing between the two groups, followed by violation of the Gricean maxims, and then extralinguistic deceitful and sincere communicative acts. The results are discussed in light of the pragmatic theoretical literature, and their clinical relevance in terms of content and design of both assessment and rehabilitative training.

A revised instrument for the assessment of empathy and Theory of Mind in adolescents: Introducing the EmpaToM-Y

Empathy and Theory of Mind (ToM) are two core components of social understanding. The EmpaToM is a validated social video task that allows for independent manipulation and assessment of the two capacities. First applications revealed that empathy and ToM are dissociable constructs on a neuronal as well as on a behavioral level. As the EmpaToM has been designed for the assessment of social understanding in adults, it has a high degree of complexity and comprises topics that are inadequate for minors. For this reason, we designed a new version of the EmpaToM that is especially suited to measure empathy and ToM in youths. In experiment 1, we successfully validated the EmpaToM-Y on the original EmpaToM in an adult sample (N = 61), revealing a similar pattern of results across tasks and strong correlations of all constructs. As intended, the performance measure for ToM and the control condition of the EmpaToM-Y showed reduced difficulty. In experiment 2, we tested the feasibility of the EmpaToM-Y in a group of teenagers (N = 36). Results indicate a reliable empathy induction and higher demands of ToM questions for adolescents. We provide a promising task for future research targeting inter-individual variability of socio-cognitive and socio-affective capacities as well as their precursors and outcomes in healthy minors and clinical populations.

Usability of a Psychotherapeutic Interactive Gaming Tool Used in Facial Emotion Recognition for People with Schizophrenia

The objective of the study was to test the usability of ‘Feeling Master’ as a psychotherapeutic interactive gaming tool with LEGO cartoon faces showing the five basic emotions, for the assessment of emotional recognition in people with schizophrenia in comparison with healthy controls, and the relationship between face affect recognition (FER), attributional style, and theory of mind (ToM), which is the ability to understand the potential mental states and intentions of others. Nineteen individuals with schizophrenia (SZ) and 17 healthy control (HC) subjects completed the ‘Feeling Master’ that includes five basic emotions. To assess social cognition, the group with schizophrenia was evaluated with the Personal and Situational Attribution Questionnaire (IPSAQ) for the assessment of attributional style and the Hinting Task (ToM). Patients with SZ showed significant impairments in emotion recognition and their response time appeared to be slower than the HC in the recognition of each emotion. Taking into account the impairment in the recognition of each emotion, we only found a trend toward significance in error rates on fear recognition. The correlations between correct response on the ‘Feeling Master’ and the hinting task appeared to be significant in the correlation of surprise and theory of mind. In conclusion, this study demonstrated that the ‘Feeling Master’ could be useful for the evaluation of FER in people with schizophrenia. These results sustain the notion that impairments in emotion recognition are more prevalent in people with schizophrenia and that these are related with impairment in ToM.

Social cognition in individuals with 22q11.2 deletion syndrome and its link with psychopathology and social outcomes: a review

BACKGROUND

The 22q11.2 deletion syndrome (22q11DS) is a genetic syndrome that results in a highly variable profile of affected individuals of which impairments in the social domain and increased psychopathology are the most prominent. Notably, 25-30% of affected individuals eventually develop schizophrenia/psychosis, predisposing persons with the syndrome to increased risk for this disorder. Because social cognition is considered to underlie social behavior and to be related to psychopathology, this systematic review investigated social cognition in individuals with 22q11DS and examined reported links across its domains with psychopathology and social outcomes. This can provide the basis for a closer understanding of the path from risk to disorder and will inform on the specific domains that can be targeted with preventive intervention strategies.

METHOD

Systematic literature review of studies that reported the links between social cognitive domains and psychopathology and/or social outcomes in individuals with 22q11DS. Electronic databases searched were PubMed and PsycINFO.

RESULTS

Defined eligibility criteria identified a total of ten studies to be included in the present review. Selected studies investigated links between two domains of social cognition (emotion processing and theory of mind (ToM)) and psychopathology and/or social outcomes. With respect to the links to psychopathology, two aspects of social cognition were related primarily to negative symptoms. Results regarding the associations to positive and emotional symptoms (anxiety/depression) are limited and require further investigation. Even though both aspects of social cognition were associated with social outcomes, several studies also found no links between these two domains. Both reports invite for an additional examination of reported results and specific considerations regarding chosen constructs.

CONCLUSION

Although equivocal, results of the present review provide sufficient evidence that social cognition is a useful domain for the closer elucidation of clinical outcomes and social difficulties in this population. At the same time, longitudinal studies and consideration of other variables are also necessary for a timely understanding of affected persons in this respect.

White Matter Correlates of Theory of Mind in Patients With First-Episode Psychosis

Deficits in theory of mind (ToM) are considered as a distinctive feature of schizophrenia. Functional magnetic resonance imaging (fMRI) studies have suggested that aberrant activity among the regions comprising the mentalizing network is related to observed ToM deficits. However, the white matter structures underlying the ToM functional network in schizophrenia remain unclear. To investigate the relationship between white matter integrity and ToM impairment, 35 patients with first-episode psychosis (FEP) and 29 matched healthy controls (HCs) underwent diffusion tensor imaging (DTI). Using tract-based spatial statistics (TBSS), fractional anisotropy (FA) values of the two regions of interest (ROI)-the cingulum and superior longitudinal fasciculus (SLF)-were acquired, and correlational analysis with ToM task scores was performed. Among the patients with FEP, ToM strange story scores were positively correlated with the FA values of the left cingulum and left SLF. There was no significant correlation between FA and ToM task scores in HCs. These results suggest that the left cingulum and SLF constitute a possible neural basis for ToM deficits in schizophrenia. Our study is the first to demonstrate the white matter connectivity underlying the mentalizing network, as well as its relation to ToM ability in patients with FEP.

Sty in the Mind's Eye: A Meta-Analytic Investigation of the Nomological Network and Internal Consistency of the "Reading the Mind in the Eyes" Test

The Reading the Mind in the Eyes Test (RMET) is the most popular adult measure of individual differences in theory of mind. We present a meta-analytic investigation of the test's psychometric properties (k = 119 effect sizes, 61 studies, n_total = 8,611 persons). Using random effects models, we found the internal consistency of the test was acceptable (α = .73). However, the RMET was more strongly related with emotion perception (r = .33, ρ = .48) relative to alternative theory of mind measures (r = .29, ρ = .39), and weakly to moderately related with vocabulary (r = .25, ρ = .32), cognitive empathy (r = .14, ρ = .20), and affective empathy (r = .13, ρ = .19). Overall, we conclude that the RMET operates rather as emotion perception measure than as theory of mind measure, challenging the interpretation of RMET results.

Understanding communicative intentions in schizophrenia using an error analysis approach

Patients with schizophrenia (SCZ) have a core impairment in the communicative-pragmatic domain, characterized by severe difficulties in correctly inferring the speaker's communicative intentions. While several studies have investigated pragmatic performance of patients with SCZ, little research has analyzed the errors committed in the comprehension of different communicative acts. The present research investigated error patterns in 24 patients with SCZ and 24 healthy controls (HC) during a task assessing the comprehension of different communicative acts, i.e., sincere, deceitful and ironic, and their relationship with the clinical features of SCZ. We used signal detection analysis to quantify participants' ability to correctly detect the speakers' communicative intention, i.e., sensitivity, and their tendency to wrongly perceive a communicative intention when not present, i.e., response bias. Further, we investigated the relationship between sensitivity and response bias, and the clinical features of the disorder, namely symptom severity, pharmacotherapy, and personal and social functioning. The results showed that the ability to infer the speaker's communicative intention is impaired in SCZ, as patients exhibited lower sensitivity, compared to HC, for all the pragmatic phenomena evaluated, i.e., sincere, deceitful, and ironic communicative acts. Further, we found that the sensitivity measure for irony was related to disorganized/concrete symptoms. Moreover, patients with SCZ showed a stronger response bias for deceitful communicative acts compared to HC: when committing errors, they tended to misattribute deceitful intentions more often than sincere and ironic ones. This tendency to misattribute deceitful communicative intentions may be related to the attributional bias characterizing the disorder.

Paliperidone Compared with Haloperidol on the Theory of Mind Tasks in Schizophrenia: A Pilot Trial

PURPOSE

Theory of mind (ToM) is an important part of social cognitive function and is associated with medial prefrontal cortical (mPFC) activity. This study aimed to evaluate the efficacy of paliperidone in improving ToM task performance in patients with schizophrenia compared with haloperidol.

PATIENTS AND METHODS

This study was a single-center, single-blinded (assessor), parallel-group randomized clinical trial of patients with schizophrenia randomized to paliperidone or haloperidol. ToM was assessed at weeks 0, 8, 12, and 16 using the first-order belief, higher-order belief, faux-pas, and Reading the Mind in the Eyes tests. The primary outcome was the change in the ToM performance scores from baseline to after 16 weeks of treatment.

RESULTS

The participants received paliperidone (n = 29) or haloperidol (n = 31). For the first-order belief task, there were no between-group differences (P > 0.05) but time differences in both groups (P < 0.05). For the higher-order belief task, there were no between-group differences (P > 0.05), but there were time differences in both groups (P < 0.05) and a time×group interaction in the paliperidone group only (P < 0.05). For the faux-pas task, there was a difference between groups at week 16 (P < 0.05), and the improvement in time was significant for the paliperidone group only (P < 0.05). For the Reading the Mind in the Eyes task, there was an improvement over time for the paliperidone group only (P < 0.05). Safety was manageable in both groups.

CONCLUSION

Paliperidone treatment might be more effective than haloperidol in improving ToM task performance in schizophrenia.

TRIAL REGISTRATION

chictr.org.cn_identifier ChiCTR-IPR-15007635.

Altered brain responses to specific negative emotions in schizophrenia

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Scenic stimuli might offer a better understanding of emotional processing than faces.

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Emotional scenes were presented to schizophrenia patients and healthy controls.

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Schizophrenia patients tend to misclassify emotional images as fear.

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Schizophrenia patients hyperactivated regions involved in fear and disgust processing.

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Patients’ brain response did not differ from controls in response to happy and sad scenes.

Deficits in emotion processing are a core feature of schizophrenia, but their neurobiological bases are poorly understood. Previous research, mainly focused on emotional face processing and emotion recognition deficits, has shown controverted results. Furthermore, the use of faces has been questioned for not entailing an appropriate stimulus to study emotional processing. This highlights the importance of investigating emotional processing abnormalities using evocative stimuli. For the first time, we have studied the brain responses to scenic stimuli in patients with schizophrenia. We selected scenes from the IAPS that elicit fear, disgust, happiness, and sadness. Twenty-six patients with schizophrenia and thirty age-, sex- and premorbid IQ-matched healthy controls were included. Behavioral task results show that patients tended to misclassify disgust and sadness as fear. Brain responses in patients were different from controls in images eliciting disgust and fear. In response to disgust images, patients hyperactivated the right temporal cortex, which was not activated by the controls. With fear images, hyperactivation was observed in brain regions involved in fear processing, including midline regions from the medial frontal cortex to the anterior cingulate cortex, the superior frontal gyrus, inferior and superior temporal cortex, and visual areas. These results suggest that schizophrenia is characterized by hyper-responsivity to stimuli evoking high-arousal, negative emotions, and a bias towards fear in emotion recognition.

Theory of mind in adults with traumatic brain injury: A meta-analysis

Studies of abnormal theory of mind (ToM) performance in adult patients with traumatic brain injury (TBI) have reported inconsistent results. Therefore, we conducted a meta-analysis to characterize ToM performance in adult patients with TBI. Random-effects models were employed to estimate the overall effect size and the differential effect sizes across different ToM aspects. Based on a sample of 28 studies (1031 patients and 865 healthy controls), the meta-analytic findings revealed that ToM was significantly impaired in adult patients with TBI compared to healthy controls (g = -1.13). Besides, patients with TBI showed significant impairments in individual ToM tasks, as well as for different stimulus modes and contents involved in these ToM tasks. A meta-regression indicated a positive association between ToM performance and Glasgow Coma Scale score. The results of the current meta-analysis suggest that the performance in ToM tasks may be a good predictor of functional outcomes in adults with TBI, which is important for the identification of targets for cognitive interventions and the development of useful training intervention programs.

Linguistic alignment and theory of mind impairments in schizophrenia patients' dialogic interactions

BACKGROUND

Impairments of contextual processing and theory of mind (ToM) have both been offered as accounts of the deviant language characterising formal thought disorder (FTD) in schizophrenia. This study investigated these processes in patients' dialogue. We predicted that FTD patients would show a decrement in linguistic alignment, associated with impaired ToM in dialogue.

METHODS

Speech samples were elicited via participation in an interactive computer-based task and a semi-structured interview to assess contextual processing abilities and ToM skills in dialogue, respectively, and from an interactive card-sorting task to measure syntactic alignment. Degree of alignment in dialogue and the syntactic task, and evidence of ToM in (i) dialogue and (ii) a traditional ToM task were compared across schizophrenia patients with FTD (n = 21), non-FTD patients (n = 22) and healthy controls (n = 21).

RESULTS

FTD patients showed less alignment than the other two groups in dialogue, and than healthy controls on the syntactic task. FTD patients showed poorer performance on the ToM task than the other two groups, but only compared to the healthy controls in dialogue. The FTD group's degree of alignment in dialogue was correlated with ToM performance in dialogue but not with the traditional ToM task or with syntactic alignment.

CONCLUSIONS

In dialogue, FTD patients demonstrate an impairment in employing available contextual information to facilitate their own subsequent production, which is associated with a ToM deficit. These findings indicate that a contextual processing deficit impacts on exploiting representations via the production system impoverishing the ability to make predictions about upcoming utterances in dialogue.

Impaired social cognition in bipolar disorder: A meta-analysis of Theory of Mind in euthymic patients

OBJECTIVE

To conduct a meta-analysis of Theory of Mind studies exclusively in euthymic patients with bipolar disorder.

METHOD

After the exclusion of studies evaluating symptomatic patients during acute episodes, we performed a meta-analysis including a total of 30 studies, comparing 1294 euthymic bipolar disorder patients and 1116 healthy controls.

RESULTS

Patients with bipolar disorder presented a significant impairment in Theory of Mind performance when compared to controls (Hedge's g = -0.589, 95% confidence interval: -0.764 to -0.414, Z = -6.594, p < 0.001). When compared to controls, Theory of Mind was impaired in patients with both bipolar disorder I (Hedge's g = -0.663, 95% confidence interval: -0.954 to -0.372, Z = -4.462, p < 0.001) and bipolar disorder II (Hedge's g = -1.165, 95% confidence interval: -1.915 to -0.415, Z = -3.044, p = 0.002). Theory of Mind impairments were also significantly more severe in verbal tasks (Hedge's g = -1.077, 95% confidence interval: -1.610 to -0.544, Z = -3.961 p < 0.001) than visual tasks (Hedge's g =-0.614, 95% confidence interval: -0.844 to -0.384, Z = -5.231, p < 0.001) when compared to controls.

CONCLUSION

The results obtained confirm that Theory of Mind is impaired in remitted bipolar disorder patients, being a potential endophenotype for bipolar disorder. Moreover, we found higher deficits in verbal Theory of Mind, compared with visual Theory of Mind. Since most studies were cross-sectional, there is a need for longitudinal studies to evaluate whether the deficits detected in Theory of Mind are progressive over the course of the illness.

Cognitive and emotional empathy in individuals at clinical high risk of psychosis

BACKGROUND

Impairments of social cognition are considered core features of schizophrenia and are established predictors of social functioning. However, affective aspects of social cognition including empathy have far less been studied than its cognitive dimensions. The role of empathy in the development of schizophrenia remains largely elusive.

METHODS

Emotional and cognitive empathy were investigated in large sample of 120 individuals at Clinical High Risk of Psychosis (CHR-P) and compared with 50 patients with schizophrenia and 50 healthy controls. A behavioral empathy assessment, the Multifaceted Empathy Test, was implemented, and associations of empathy with cognition, social functioning, and symptoms were determined.

RESULTS

Our findings demonstrated significant reductions of emotional empathy in individuals at CHR-P, while cognitive empathy appeared intact. Only individuals with schizophrenia showed significantly reduced scores of cognitive empathy compared to healthy controls and individuals at CHR-P. Individuals at CHR-P were characterized by significantly lower scores of emotional empathy and unspecific arousal for both positive and negative affective valences compared to matched healthy controls and patients with schizophrenia. Results also indicated a correlation of lower scores of emotional empathy and arousal with higher scores of prodromal symptoms.

CONCLUSION

Findings suggest that the tendency to 'feel with' an interaction partner is reduced in individuals at CHR-P. Altered emotional reactivity may represent an additional, early vulnerability marker, even if cognitive mentalizing is grossly unimpaired in the prodromal stage. Different mechanisms might contribute to reductions of cognitive and emotional empathy in different stages of non-affective psychotic disorders and should be further explored.

Pragmatics, Theory of Mind and executive functions in schizophrenia: Disentangling the puzzle using machine learning

OBJECTIVE

Schizophrenia is associated with a severe impairment in the communicative-pragmatic domain. Recent research has tried to disentangle the relationship between communicative impairment and other domains usually impaired in schizophrenia, i.e. Theory of Mind (ToM) and cognitive functions. However, the results are inconclusive and this relationship is still unclear. Machine learning (ML) provides novel opportunities for studying complex relationships among phenomena and representing causality among multiple variables. The present research explored the potential of applying ML, specifically Bayesian network (BNs) analysis, to characterize the relationship between cognitive, ToM and pragmatic abilities in individuals with schizophrenia and healthy controls, and to identify the cognitive and pragmatic abilities that are most informative in discriminating between schizophrenia and controls.

METHODS

We provided a comprehensive assessment of different aspects of pragmatic performance, i.e. linguistic, extralinguistic, paralinguistic, contextual and conversational, ToM and cognitive functions, i.e. Executive Functions (EF)-selective attention, planning, inhibition, cognitive flexibility, working memory and speed processing-and general intelligence, in a sample of 32 individuals with schizophrenia and 35 controls.

RESULTS

The results showed that the BNs classifier discriminated well between patients with schizophrenia and healthy controls. The network structure revealed that only pragmatic Linguistic ability directly influenced the classification of patients and controls, while diagnosis determined performance on ToM, Extralinguistic, Paralinguistic, Selective Attention, Planning, Inhibition and Cognitive Flexibility tasks. The model identified pragmatic, ToM and cognitive abilities as three distinct domains independent of one another.

CONCLUSION

Taken together, our results confirmed the importance of considering pragmatic linguistic impairment as a core dysfunction in schizophrenia, and demonstrated the potential of applying BNs in investigating the relationship between pragmatic ability and cognition.

The Influence of Premorbid Adjustment and Autistic Traits on Social Cognitive Dysfunction in Schizophrenia

OBJECTIVES

Premorbid dysfunction during childhood and adolescence is well documented in patients with schizophrenia. Literature pointed out multiple premorbid trajectories leading to different patients' cognitive status, symptomatology, and global functioning after disease onset. This study aimed at identifying groups of premorbid trajectories and disentangling between group differences in clinical and cognitive measures, focusing on theory of mind (ToM) and autistic traits (ATs).

METHODS

Ninety-seven patients with schizophrenia were recruited and assessed for cognitive and ToM abilities, psychopathology, and ATs. A two-step cluster analysis identified three different groups of patients based on premorbid adjustment during childhood, adolescence, and late adolescence (i.e., stable-good, stable-poor, and "deteriorating").

RESULTS

Compared to 66 healthy controls, results showed a widespread impairment in cognitive and ToM abilities among all groups of patients, except for affective ToM and executive functions in the stable-good group. Moreover, the stable-poor group exhibited more pronounced ATs and a more severe ToM impairment, compared to the other two groups of patients.

CONCLUSIONS

Our findings highlight the existence of a group of patients with poor premorbid adjustment since childhood, more pronounced ATs and a severe ToM impairment affecting those basic mentalizing skills that are usually preserved in schizophrenia. Results might have intriguing implications in identifying underpinning endophenotypes and implementing cutting-edge rehabilitation programs.

The role of schizotypal traits and the OXTR gene in theory of mind in schizophrenia: A family-based study

BACKGROUND

There is consistent evidence that theory of mind (ToM) is impaired in schizophrenia (SZ); however, it remains unclear whether such deficits are trait- or state-dependent. We evaluated ToM in patients with schizophrenia spectrum disorders (SSDs), their healthy first-degree relatives, and controls to test its suitability as an endophenotypic marker. We also studied the modifying effect of markers of clinical and genetic liability to SZ (schizotypy and genetic variability in the oxytocin receptor gene: OXTR) on ToM in healthy individuals.

METHODS

The sample included 38 stable SSD patients, 80 unaffected first-degree relatives, and 81 controls. ToM was assessed using the Hinting Task (HT) and schizotypy via the Schizotypal Personality Questionnaire-Brief (SPQ-B), which generates interpersonal (SPQ-IP), cognitive-perceptual (SPQ-CP), and disorganization (SPQ-D) scores. The polymorphism rs53576 of OXTR was genotyped.

RESULTS

Patients presented poorer HT performance than relatives and controls (p = 0.003 and p < 0.001). High SPQ-IP and SPQ-CP scores correlated with poorer ToM performance in relatives (p = 0.010 and p = 0.030), but not in controls. OXTR was not associated with HT scores, but it showed a modifying effect within controls; high SPQ-CP was related to HT poorer performance conditional to GG genotype (p = 0.007).

CONCLUSIONS

ToM deficits were present in patients but not in unaffected relatives or controls. However, our data indicate the usefulness of clinical and genetic liability markers to characterize differences in ToM abilities within healthy individuals. Then, the observed link between ToM and SZ liability suggests the putative role of ToM as an endophenotypic marker. Nevertheless, new analyses in larger samples are needed.

Theory of mind, emotion recognition, delusions and the quality of the therapeutic relationship in patients with psychosis - a secondary analysis of a randomized-controlled therapy trial

BACKGROUND

Cognitive models of psychosis postulate an important role of Theory of mind (ToM) in the formation and maintenance of delusions, but research on this plausible conjecture has gathered conflicting findings. In addition, it is still an open question whether problems in emotion recognition (ER) are associated with delusions. We examined the association of problems in ToM and ER with different aspects of delusions in a large sample of patients with psychosis enrolled in a therapy trial. This also enabled us to explore the possible impact of ToM and ER on one part of patients' social life: the quality of their therapeutic relationship.

METHODS

Patients with psychotic disorders and delusions and/or hallucinations (n = 185) and healthy controls (n = 48) completed a ToM picture sequencing task and an ER task. Subsequently, patients were enrolled in a randomized-controlled Cognitive Behavior Therapy (CBT) trial (ISRCTN29242879). Patients and therapists rated the quality of the therapeutic relationship during the first five sessions of therapy.

RESULTS

In comparison to controls, patients were impaired in both ToM and ER. Patients with deficits in ER experienced more severe delusional distress, whereas ToM problems were not related to delusions. In addition, deficits in ER predicted a less favorable therapeutic relationship and interactional problems viewed by the therapist. Impaired ER also moderated (increased) the negative influence of delusions on the therapeutic relationship and interactional difficulties viewed by the therapist.

CONCLUSIONS

Cognitive models on the formation and maintenance of delusions should consider ER as a potential candidate that might be related to the formation and maintenance of delusional distress, whereas problems in ToM might not be directly related to delusions and secondary dimensions of delusions. In addition, problems in ER in patients with psychosis might have an impact on the quality of the therapeutic relationship and patients with problems in ER are more likely to be viewed as problematic by their therapists. Nevertheless, training ER might be a way to improve the quality of the therapeutic relationship and potentially the effectiveness of CBT or other interventions for patients with psychosis.