Theory of mind and neurocognition in early psychosis: a quasi-experimental study

The other side of the social interaction: Theory of mind impairments in people with schizophrenia are linked to other people's difficulties in understanding them

BACKGROUND

People with schizophrenia (SZ) often present with theory of mind (ToM) deficits and with speech production deficits. While a link has been established between ToM abilities and symptoms of thought disorder, much less is known about other aspects of speech production in SZ.

STUDY DESIGN

This is a case-control study in which 25 stable outpatients with recent-onset SZ (27.1 years, 22 men) and 22 matched healthy controls (25.6 years, 16 men) performed a collaborative, verbal production task with a real interaction partner. Blind raters scored how easy participants made it to understand them (Facility ratings), how interesting they were to listen to (Interest ratings) and how expressive they were (Expressivity ratings). ToM was assessed with the Combined Stories Test and Sarfati's cartoon task. Symptoms were assessed with the PANSS five-factor version.

STUDY RESULTS

Compared to healthy controls, SZ received significantly lower ratings for all three aspects of their verbal productions (Facility, Interest and Expressivity), despite the raters being blind to group membership. Interestingly, the Facility ratings were linked to ToM performance in the SZ group, which suggest that SZ participants who have difficulties understanding others (ToM deficits) also make it harder for others to understand them. Other notable findings include a strong link between the Expressivity ratings and the Interest ratings for both groups, and significant correlations between the Facility ratings and Cognitive/Disorganisation symptoms, and between the Expressivity ratings and both Negative and Depression/Anxiety symptoms in SZ.

CONCLUSION

Studying speech production during real, collaborative social interactions could help move beyond the individual approach to SZ deficits, making it possible to involve the interaction partners to promote more efficient communication for people with schizophrenia.

Disentangling the Relationships Between the Clinical Symptoms of Schizophrenia Spectrum Disorders and Theory of Mind: A Meta-analysis

BACKGROUND AND HYPOTHESIS

Previous studies have suggested links between clinical symptoms and theory of mind (ToM) impairments in schizophrenia spectrum disorders (SSD), but it remains unclear whether some symptoms are more strongly linked to ToM than others.

STUDY DESIGN

A meta-analysis (Prospero; CRD42021259723) was conducted to quantify and compare the strength of the associations between ToM and the clinical symptoms of SSD (Positive, Negative, Cognitive/Disorganization, Depression/Anxiety, Excitability/Hostility). Studies (N = 130, 137 samples) including people with SSD and reporting a correlation between clinical symptoms and ToM were retrieved from Pubmed, PsycNet, Embase, Cochrane Library, Science Direct, Proquest, WorldCat, and Open Gray. Correlations for each dimension and each symptom were entered into a random-effect model using a Fisher's r-to-z transformation and were compared using focused-tests. Publication bias was assessed with the Rosenthal failsafe and by inspecting the funnel plot and the standardized residual histogram.

STUDY RESULTS

The Cognitive/Disorganization (Zr = 0.28) and Negative (Zr = 0.24) dimensions revealed a small to moderate association with ToM, which was significantly stronger than the other dimensions. Within the Cognitive/Disorganization dimension, Difficulty in abstract thinking (Zr = 0.36) and Conceptual disorganization (Zr = 0.39) showed the strongest associations with ToM. The association with the Positive dimension (Zr = 0.16) was small and significantly stronger than the relationship with Depression/Anxiety (Zr = 0.09). Stronger associations were observed between ToM and clinical symptoms in younger patients, those with an earlier age at onset of illness and for tasks assessing a combination of different mental states.

CONCLUSIONS

The relationships between Cognitive/Disorganization, Negative symptoms, and ToM should be considered in treating individuals with SSD.

Comparison of theory of mind and neurocognition in siblings and offspring of female schizophrenia patients

This study aims to compare the Theory of Mind (ToM) functions in the siblings and offspring of female Schizophrenia patients in an evaluation of the association between neurocognitive functions and ToM. A battery of ToM tests (Reading the Mind in the Eyes Test, Hinting Test and Faux Pas Test) and neurocognitive tests (Digit Span Test, Corsi Block Test, Digit Symbol Substitution Test, Rey's Auditory Verbal Learning Test, Trail Making Test, The Stroop Test, Wisconsin Card Sorting Test) were used to assess 31 offspring, 29 siblings of female schizophrenia patients and 28 healthy controls (HC). When the ToM functions of the offspring, siblings and HC groups in the present study are compared, no significant difference is identified between the offspring and sibling groups in Hinting, Faux Pas and Eyes tests, while Hinting test performance of the sibling group was significantly lower than those of the HCs. Neurocognitive functions are more affected both in offspring and siblings than HC. Although it was determined that ToM deficits of the patients' relatives were not as prominent as their neurocognitive functions, ToM is an endophenotype candidate in schizophrenia.

What areas of everyday functioning are affected by theory of mind deficits in recent-onset schizophrenia spectrum disorders?

AIM

Functional recovery is now a recognized treatment goal for schizophrenia. It is therefore important to better understand the cognitive and psychological factors that influence functioning. Theory of mind (ToM) deficits are common in schizophrenia and have been linked to greater impairments in functioning. The current study aimed to identify which specific areas of functioning are linked to ToM in a group of 54 patients with a recent-onset of a schizophrenia spectrum disorder.

METHODS

ToM was assessed with the Combined Stories Test (COST). Several areas of functioning were rated based on an extensive semi-structured interviews.

RESULTS

Among the different areas of functioning that were examined, ToM showed a significant, positive relationship with ratings for productive activities (e.g. work or school) as well as with collaboration to psychiatric care.

CONCLUSION

These results suggest that ToM can impair functioning especially in situations in which patients need to collaborate with others, including the interactions with the clinical team.

The association of cognitive impairment with quality of life and functional impairment in Ugandan first-episode psychosis patients: a cross sectional study

Introduction

Cognitive impairment is common in first-episode psychosis patients and often associated with poor quality of life and functional impairment. However, most literature on this association is from high income countries and not low resource countries like Uganda. We aimed to determine the association between cognitive impairment with quality of life and functional impairment in Ugandan first-episode psychosis patients.

Methods

At Butabika national psychiatric hospital of Uganda, we enrolled 94 first-episode psychosis patients aged 18–60 years with a confirmed first-episode of psychosis and no previous treatment with antipsychotic medication. Neuropsychological assessment was performed using the MATRICS consensus cognitive battery (MCCB). Quality of life and functional impairment were assessed using the brief version of the World Health Organisation Quality of Life scale (WHOQOL-BREF) and the MINI International Neuropsychiatric Inventory (MINI) respectively. Linear regression analyses determined the association between impairment in different cognitive domains with various quality of life and functional impairment domains while controlling for age, gender and level of education.

Results

High scores in the reasoning and problem solving cognitive domain were associated with better quality of life in the psychological domain of WHOQOL-BREF (p = 0.029). For functional impairment, high cognitive scores in the domains of speed of processing (p = 0.018), reasoning and problem solving (p = 0.015), working memory (p = 0.017) and visual learning and memory (p = 0.002) were associated with psychosis “having a greater impact on other members of the family” on the MINI. Higher scores in the social cognition domain were associated with “less aggressive and disruptive behaviour” (p = 0.003).

Conclusion

Cognitive impairment in Ugandan first-episode psychotic patients is associated with both poorer quality of life and functional impairment. Remediation of cognitive function may be a plausible intervention to improve outcomes in Ugandan first-episode psychosis patients.

The effects of developmental trauma on theory of mind and its relationship to psychotic experiences: A behavioural study

BACKGROUND

Developmental psychological trauma induces vulnerability to psychosis. However, the mechanisms underlying this association are poorly understood. Impairments in Theory of Mind (ToM) have been observed in adult survivors of developmental trauma and individuals with psychosis. ToM is therefore a candidate mechanism underlying the association between developmental trauma and psychosis.

METHODS

We used a computerised version of the Director task - where a participant is instructed by a confederate to move an object around a 4 × 4 grid, whilst taking account of whether these objects are visible to a confederate who instructs the participant - to investigate impairments in ToM in 209 participants (age: M = 37.8, SD=13.6; 56% female). Participants were divided into a) developmental trauma-positive (DT+) and control groups (DT-) based on their history of developmental trauma and b) then further into subclinical (S) and healthy groups (H) as based on psychotic experiences indexed by the CAPE-P15. After exclusion, the numbers in each group were: DT+H (47), DT+S (84), DT-H (54), DT-S (12). (Total: 197).

RESULTS

Developmental trauma exposure was associated with psychotic experiences (OR: 7.89, p < .001), which remained significant after controlling for demographic and clinical confounds (adjusted R² = 0.452, R² change = 0.0184, p = .009). Participants with developmental trauma (F_{1, 194}) = 5.46, p = .020, ηp² = 0.027) and participants more prone to psychotic experiences (F_{1, 194}) = 4.71, p = .031, ηp² = 0.024) demonstrated significantly lower accuracy on the Director task relative to their respective control, after controlling for the effects of age.

CONCLUSIONS

ToM deficits are associated with self-reported developmental trauma and psychotic experiences. Further work is needed to explore these relationships further and whether they represent generalised or specific effect effects on developmental trauma and psychopathological domains.

Improved social functioning following social recovery therapy in first episode psychosis: Do social cognition and neurocognition change following therapy, and do they predict treatment response?

There is a need to develop and refine psychosocial interventions to improve functioning in First Episode Psychosis (FEP). Social cognition and neurocognition are closely linked to functioning in psychosis; examinations of cognition pre- and post- psychosocial intervention may provide insights into the mechanisms of these interventions, and identify which individuals are most likely to benefit.

METHOD

Cognition was assessed within a multi-site trial of Social Recovery Therapy (SRT) for individuals with FEP experiencing poor functioning (<30 h weekly structured activity). Fifty-nine participants were randomly allocated to the therapy group (SRT + Early intervention), and 64 were allocated to treatment as usual group (TAU - early intervention care). Social cognition and neurocognition were assessed at baseline and 9 months; assessors were blind to group allocation. It was hypothesized that social cognition would improve following therapy, and those with better social cognition prior to therapy would benefit the most from SRT.

RESULTS

There was no significant impact of SRT on individual neurocognitive or social cognitive variables, however, joint models addressing patterns of missingness demonstrate improvement across a number of cognitive outcomes following SRT. Further, regression analyses showed those who had better social cognition at baseline were most likely to benefit from the therapy (ß = 0.350; 95% CI = 0.830 to 8.891; p = .019).

CONCLUSION

It is not clear if SRT impacts on social cognitive or neurocognitive function, however, SRT may be beneficial in those with better social cognition at baseline.

Functional Impairments and Theory of Mind Deficits in Schizophrenia: A Meta-analysis of the Associations

Schizophrenia is associated with major functioning difficulties. Theory of mind (ToM), the ability to infer the mental states of others, is an important determinant of functioning. However, the contribution of ToM to each specific domain of functioning remains to be better understood. The objectives of this meta-analysis were to document and compare the magnitude of the associations between ToM and (1) different domains of functioning (social functioning, productive activities, and instrumental activities of daily living), each assessed separately for functional performance and functional outcome and (2) different aspects of functioning (functional performance and functional outcome) in schizophrenia. Fifty-nine studies (N = 4369) published between 1980 and May 2019 targeting patients with schizophrenia or schizoaffective disorder aged between 18 and 65 years old were included. Studies were retrieved from seven databases. Correlations were extracted from the articles, transformed into effect sizes Zr and combined as weighted and unweighted means. The strength of the associations between the domains and aspects of functioning were compared using focused tests. A moderate association was observed between ToM and all domains of functioning, with a stronger association between ToM and productive activities compared with social functioning (only for functional outcome [χ2(2) = 6.43, P = 0.040]). Regarding the different aspects of functioning, a stronger association was observed between ToM and functional performance, compared with functional outcome, for overall functioning (χ2(1) = 13.77, P < 0.001) and social functioning (χ2(1) = 18.21, P < 0.001). The results highlight a stronger association of ToM with productive activities and with functional performance, which should be considered in future studies to improve functional recovery in schizophrenia.

Social cognition in patients with first episode of psychosis in remission

AIM

The present study aimed to compare the social cognition (SC) deficits in patients with first-episode psychosis (FEP) and healthy controls and evaluate the association of SC deficits with socio-occupational functioning, insight, quality of life, and stigma.

METHODS

This study included 30 patients with FEP in remission phase and 26 healthy controls matched for age, gender, education, and intelligent quotient. SC was assessed on the domains of theory of mind (ToM), social perception, and attributional bias.

RESULTS

Compared to healthy controls, patients with FEP had significantly higher deficits in the domains of second-order ToM (unpaired t = 4.447, P < 0.001) and Faux Pas Composite Index (unpaired t = 2.824, P = 0.007). In the correlation analysis, higher age of patients with FEP was significantly associated with more externalizing bias (Pearson's correlation coefficient = 0.38, P = 0.039) and those with lower level of education had more social cognitive deficits in the domains of Faux Pas Composite Index (Pearson's correlation coefficient = 0.43, P = 0.018), Social Perception Index (Pearson's correlation coefficient = 0.38, P = 0.04), and Nonsocial Perception Index (Pearson's correlation coefficient = 0.5, P = 0.005). Duration of untreated psychosis was associated with higher deficits in the first-order ToM (Pearson's correlation coefficient = -0.38, P = 0.04) and Externalizing Bias Index (Pearson's correlation coefficient = -0.49, P = 0.006). Longer duration of treatment was associated with higher impairment in first-order ToM index (Pearson's correlation coefficient = -0.42, P = 0.02). General psychopathology and total Positive and Negative Syndrome Scale total score correlated significantly with externalizing bias, with a higher level of psychopathology associated with more severe deficits in this domain. There was no correlation of SC with the quality of life, cognitive insight, and stigma (except for occasional correlation of stereotype endorsement and externalizing bias).

CONCLUSION

The present study suggests that compared to healthy controls, patients with FEP have impairment in the domains of second-order ToM and Faux Pas Composite Index. However, social cognitive deficits have only a few correlations with various psychosocial outcomes of FEP.

Acute oxytocin effects in inferring others' beliefs and social emotions in people at clinical high risk for psychosis

Social deficits are key hallmarks of the Clinical High Risk for Psychosis (CHR-P) state and of established psychotic disorders, and contribute to impaired social functioning, indicating a potential target for interventions. However, current treatments do not significantly ameliorate social impairments in CHR-P individuals. Given its critical role in social behaviour and cognition, the oxytocinergic (OT) system is a promising target for novel interventions in CHR-P subjects. In a double-blind, placebo-controlled, crossover design, 30 CHR-P males were studied using functional magnetic resonance imaging (fMRI) on two occasions, once after 40IU self-administered intranasal OT and once after placebo. A modified version of the Sally-Anne task was used to assess brain activation during inferring others' beliefs and social emotions. The Reading the Mind in the Eyes Test was acquired prior to the first scan to test whether OT effects were moderated by baseline social-emotional abilities. OT did not modulate behavioural performances but reduced activation in the bilateral inferior frontal gyrus compared with placebo while inferring others' social emotions. Furthermore, the relationship between brain activation and task performance after OT administration was moderated by baseline social-emotional abilities. While task accuracy during inferring others' social emotion increased with decreasing activation in the left inferior frontal gyrus in CHR-P individuals with low social-emotional abilities, there was no such relationship in CHR-P individuals with high social-emotional abilities. Our findings may suggest that acute OT administration enhances neural efficiency in the inferior frontal gyrus during inferring others' social emotions in those CHR-P subjects with low baseline social-emotional abilities.

Subjective Quality of Life and Its Associations among First Episode Psychosis Patients in Singapore

Background—Mental disorders have been found to affect quality of life (QOL) in patients. The current study aimed to determine QOL among first episode psychosis (FEP) patients and explore its associations with sociodemographic as well as clinical factors. Methods—Data for this study were collected as a part of an Early Psychosis Intervention Program (EPIP)-Smoking and Alcohol use survey. At baseline, 280 outpatients aged 15–40 years old diagnosed with FEP, with no prior or minimal treatment, no history of medical or neurological disorder, and no history of substance abuse, were recruited. Sociodemographic details, diagnosis, length of duration of untreated psychosis (DUP), and World Health Organization Quality of Life assessment—abbreviated version (WHOQOL-BREF) scores were obtained. Results—After adjusting for all covariates, older age (p = 0.036), females, and participants diagnosed with brief psychotic disorder (p = 0.04) were associated positively, whereas separated/divorced participants, those with lower education, unemployed (p = 0.01), and longer DUP were seen to be negatively associated with different domains of QOL. Conclusion—Higher WHOQOL-BREF scores denote better QOL. Overall, female participants as compared to male participants and those diagnosed with brief psychotic disorder in this sample reported better QOL.

An fMRI study of theory of mind in individuals with first episode psychosis

Theory of mind (ToM), the ability to infer one's own and others' mental states, is the social cognitive process shown to have the greatest impact on functional outcome in schizophrenia. It is not yet known if neural abnormalities underlying ToM present early, during the first episode of psychosis (FEP). Fourteen FEP participants and twenty-two healthy control participants, aged 15-25, were included in analyses. All participants had a 3T magnetic resonance imaging scan and completed a block-design picture-story attribution-of-intentions ToM fMRI task, and completed a battery of behavioral social cognitive measures including a ToM task. General linear model analyses were carried out. Post-hoc regression analyses were conducted to explore whether aberrant ToM-related activation in FEP participants was associated with symptomatology and global social and occupational functioning. FEP participants, when compared to healthy controls, had significantly less activity in the right temporoparietal junction, right orbitofrontal cortex and left middle prefrontal/inferior frontal cortex, when making social attributions. Aberrant ToM-related activation in the right temporoparietal junction was associated with severity of overall psychopathology, but not functional outcome. Specific regions of the social brain network, associated with ToM, are dysfunctional in young people with FEP. Future research should determine whether alteration of normal brain functioning in relation to ToM occurs before or during illness onset.

Clinical and therapeutic role of mentalization in schizophrenia-a review

Recent empirical findings from clinical and genetic studies suggest that mentalization, a key area of social cognition, is a distinct construct, although it is closely related to the neurocognitive deficits and symptoms of schizophrenia. Mentalization contributes a great deal to impaired social functioning. Current measures often display methodological problems, and many aspects should be taken into account when assessing mentalization. Moreover, advances in cognitive and affective neurosciences have led to the development of more advanced behavioral methods to assess the relationship between cognitive functions, symptoms, and social cognition based on their underlying neural mechanisms. The development of assessment tools that better examine the neural circuitry of such relationships may lead to the development of new psychosocial and pharmacological treatments.

Effect of theory of mind and peer victimization on the schizotypy-aggression relationship

Prior longitudinal studies have established the relationship between schizophrenia and violence. However, previous studies on aggression and schizotypal personality are scarce. The present study examines whether peer victimization mediates the relationship between schizotypy and reactive-proactive aggression, and whether theory of mind (ToM) moderates this mediation. Schizotypy, peer victimization, reactive-proactive aggression, and ToM were assessed in 237 undergraduates. Peer victimization mediated the relationship between schizotypy and reactive aggression. ToM moderated this mediation effect; although peer victimization partially explains the schizotypy–aggression relationship, higher ToM skills weakened the detrimental effect of schizotypy on peer victimization which in turn reduces reactive aggression. In contrast, the moderated mediation was not significant for the proactive aggression model. Findings help delineate the underlying mechanism of the relationship between schizotypy and aggression. It is suggested that aggression could be reduced by enhancing ToM skills, thereby reducing peer victimization and the resultant schizotypy.

Factors contributing to social cognition impairment in borderline personality disorder and schizophrenia

Social cognition (SC) deficits have been described both in patients with schizophrenia and borderline personality disorder (BPD). However, while the former tend towards simplistic mental state attributions (undermentalizing), the latter are more likely to make overly complex mental state inferences (overmentalizing). Performance on complex SC tasks has been shown to correlate with neurocognitive ability, emotion perception, a history of trauma, and overconfidence in errors. However, it is unclear how these factors relate to different aspects of SC deficits. Aim of the present study was to examine the pathways of SC impairment by investigating performance profiles and their predictors comparatively in BPD and schizophrenia. Participants were 44 patients with BPD, 36 patients with schizophrenia, and 38 healthy controls. Undermentalizing and overmentalizing were assessed with an ecologically valid SC task. Patients with BPD exhibited increased overmentalizing, whereas patients with schizophrenia showed a more extensive deficit pattern, their main error type being undermentalizing. Overconfidence in errors was the most important predictor for overmentalizing, while undermentalizing depended mainly on verbal memory and emotion perception. Thus, BPD und schizophrenia exhibited different SC impairment patterns, and different types of SC errors were predicted by different factors. These findings have implications for the optimization of treatment approaches.