Theory of Mind in Substance Users: A Systematic Minireview

Affective and cognitive Theory of Mind in patients with alcohol use disorder: Associations with symptoms of depression, anxiety, and somatization

INTRODUCTION

Theory of Mind (ToM) is the ability to ascribe thoughts (cognitive ToM) and feelings (affective ToM) to others. Ample evidence exists for impairments of affective and cognitive ToM in individuals with alcohol use disorder (AUD); however, evidence regarding changes of these impairments during AUD treatment and their possible relationship to comorbid symptoms is ambiguous. The current study analyzed changes in ToM during treatment and tested associations with comorbid symptoms of depression, anxiety, somatization, and social functioning.

METHODS

We analyzed data from 175 individuals with AUD. The study assessed ToM and comorbid symptoms of depression, anxiety, somatization, and social functioning at the time of admission and at the time of discharge from an approximately 60 days long abstinence-oriented inpatient treatment. We assessed affective and cognitive ToM using the Movie for the Assessment of Social Cognition, a measure with high ecological validity.

RESULTS

All symptoms, total and cognitive ToM improved following treatment; however, affective ToM did not improve. Moreover, cognitive ToM at the beginning of treatment was associated with improved symptoms of depression and somatization, while affective ToM was not.

CONCLUSIONS

Our study shows improvements in total and cognitive ToM as well as symptoms of depression, anxiety, somatization, and social functioning following long-term treatment. Furthermore, cognitive ToM was related to improvements in comorbid symptoms. This finding suggests that ToM may be an important treatment target in patients with AUD.

From existing to living: Exploring the meaning of recovery and a sober life after a long duration of a substance use disorder

Aim: The study explores how former patients with substance use disorder (SUD) experience the benefits and challenges of a reoriented identity and way of living. Methods: Semi-structured interviews were conducted with 10 participants who had completed treatment for SUD and considered themselves either recovered or in an ongoing rehabilitation process. Interview transcripts were analysed using the content analysis approach. Results: The analysis furthers our understanding of several purposeful aspects of a reorientation towards a sober life in terms of: (1) avoiding illegal drugs, (2) avoiding contact with the substance use relations and milieu, (3) renewing relations and social network, (4) daily occupation, (5) discovering the value of the great, little things in everyday life, (6) new coping strategies, and (7) developing a new identity. Conclusion: The study indicates that rehabilitation from SUDs should take a broader focus than just sobriety. With attention to the present findings, a focus on psychosocial aspects of recovery could contribute to a more overarching framework for SUD treatment.

Implications of Social Anxiety Symptoms in Adults with Autism Spectrum Disorder: Is There a Predictive Role of Interpersonal Sensitivity and Substance Abuse?

Social anxiety disorder (SAD) has been frequently reported by subjects with Autism Spectrum Disorder (ASD). However, interestingly, the overlap between social anxiety and autistic traits may sometimes impede ASD diagnosis in subjects without intellectual or language impairment. The aim of the present work was to evaluate the presence and correlates of social phobic features among subjects with ASD, with a specific focus on evaluating which social anxiety symptoms may be statistically predictive of an ASD diagnosis. With this purpose, 48 subjects with ASD and 48 gender- and age- matched healthy controls (HCs) were recruited and assessed with the SHY-SV and the AdAS Spectrum questionnaires. Results highlighted higher scores in all SHY-SV Spectrum domains and total scores for the ASD group. Moreover, AdAS Spectrum scores were significantly correlated with all SHY-SV domain and total scores. A logistic regression analysis highlighted the SHY-SV Interpersonal sensitivity and Substance Abuse domains scores as significant positive predictors of an ASD diagnosis. These results confirm the link between ASD and SAD. Because of this association, particular attention should be paid to subjects with high interpersonal sensitivity traits and substance abuse problems.

Theory of Mind in migraine and medication-overuse headache: A cross-sectional study

Background

Theory of Mind (ToM) is the ability to predict and anticipate others' behaviors through the mental state attribution process. This study aims to investigate the ToM in patients with medication-overuse headache (MOH) and episodic migraine (EM) and to compare it with healthy controls (HC).

Methods

This study enrolled patients with MOH, patients with EM, and HC. ToM was assessed through the Theory of Mind Assessment Scale (ThOMAS), which includes four subscales: Scale A, I-Me, Scale B, Other-Self, Scale C, I-Other, and Scale D, Other-Me, through the Reading the Mind in the Eyes test (RMET), which measures complex emotion recognition, and through the Toronto Alexithymia Scale (TAS-20), which measures alexithymia. Concomitant psychiatric disturbances were evaluated through the Hamilton Anxiety Rating Scale, the Hamilton Depression Rating Scale, and the Dissociative Experiences Scale-II.

Results

The study involved 21 patients with EM, 22 patients with MOH, and 18 HC. In all the four subscales of the ThOMAS, there was a significant difference between HC, EM, and MOH patients: Scale A (p = 0.009), Scale B (p = 0.004), Scale C (p = 0.039), and Scale D (p = 0.008). In the RMET, MOH patients had worse performances than EM patients and HC (p = 0.039). MOH group exhibited higher levels of alexithymia when compared to the HC (p = 0.033) and higher levels of anxiety than HC (p = 0.001).

Conclusion

MOH patients showed a subtle psychopathological pattern characterized by impaired social adaptation.

How Individual and Situational Factors Influence Measures of Affective and Cognitive Theory of Mind in Psychiatric Inpatients

Mental disorders are associated with difficulties to correctly infer the mental states of other’s (theory of mind; ToM). These inferences either relate to affective states of others (affective ToM) or to their thoughts, intentions, or beliefs (cognitive ToM) and can be associated with mental disorder. The current study explores the influence of individual and situational effects on the measurement of ToM abilities within two clinical samples, to increase generalizability. We analyzed data from 229 in-patients; 103 patients treated for alcohol use disorder and 126 patients treated for a personality disorder. ToM was assessed with the Movie for the Assessment of Social Cognition (MASC). We analyzed changes in test performance over the course of the test using a logistic linear mixed effects model. Performance on the cognitive ToM items decreased over time, while performance on the affective ToM items increased over time. This difference was more pronounced among older individuals. The results show important moderators of ToM performance that might help to resolve inconsistencies in the current literature about ToM abilities in different clinical or age groups.

A systematic review and meta-analysis of 'Systems for Social Processes' in borderline personality and substance use disorders

Deficits in social processing (SP) have been proposed to underpin interpersonal dysfunction in both Borderline Personality Disorder (BPD) and Substance Use Disorders (SUD). This study aimed to explore potential transdiagnostic cognitive and behavioral phenotypes of these disorders utilizing the NIMH Research Domain Criteria 'Systems for Social Processes'. A systematic review and meta-analysis of the published research was conducted on 134 studies identified through our database searches. Four meta-analyses were conducted, which revealed significant overlapping deficits in the ability to identify facial emotions and infer the mental states of others in both BPD and SUD. Further, people with BPD displayed a higher ostracism effect following perceived social exclusion. Systematically reviewed studies also revealed significant dysfunction amongst individuals with BPD and SUD across both self and other SP constructs, which were broadly similar in magnitude. Taken together, these results support the proposition that SP dysfunction may be considered a core transdiagnostic phenotype of BPD and SUD.

Empathy and Theory of Mind in Alzheimer's Disease: A Meta-analysis

OBJECTIVE

A large literature now shows that Alzheimer's disease (AD) disrupts a number of social cognitive abilities, including social perceptual function and theory of mind (ToM). However, less well understood is how the specific subcomponents of ToM as well as both the broader and specific subcomponents of empathic processing are affected.

METHOD

The current study provides the first meta-analytic review of AD that focuses on both empathy and ToM as broad constructs, as well as their overlapping (cognitive empathy and affective ToM) and distinct (affective empathy and cognitive ToM) subcomponents.

RESULTS

Aggregated across 31 studies, the results revealed that, relative to controls, AD is associated with large-sized deficits in both cognitive ToM (g = 1.09) and affective ToM/cognitive empathy (g = 0.76). However, no statistical differences were found between the AD participants and controls on affective empathic abilities (g = 0.36).

CONCLUSIONS

These data point to a potentially important disconnect between core aspects of social cognitive processing in people with AD. The practical and theoretical implications of these findings are discussed.

Theory of mind in users of anabolic androgenic steroids

RATIONALE

Anabolic androgenic steroids are used to improve physical performance or increase lean muscle mass. About one-third of users develop a dependency syndrome, which is characterized by elevated rates of psychopathology, cognitive impairments, and aggressive and antisocial behaviors. The mechanisms behind these intra- and interpersonal problems are not known.

OBJECTIVE

To examine theory of mind (ToM), i.e., the ability to infer the mental state of others, in users of anabolic androgenic steroids. Reduced ToM may be one factor underlying the interpersonal problems that have been reported with prolonged use of anabolic androgenic steroids.

METHODS

The Movie for the Assessment of Social Cognition (MASC) was used to assess ToM. Study participants were male/female weightlifters who used anabolic androgenic steroids (AAS, n = 34/9), who were dependent on anabolic androgenic steroids (AASdep, n = 44/7), and a non-using weightlifting comparison group (WLC, n = 69/16).

RESULTS

Analyses of variance showed that the AASdep group performed significantly worse than the WLC group, for all MASC measures (total ToM, cognitive ToM, affective ToM, overmentalizing/undermentalizing errors). Sex and sex x group interaction effects were non-significant.

CONCLUSIONS

Male and female weightlifters who were dependent on anabolic androgenic steroids had impaired ToM. Their reduced social cognition may be one contributing factor to the elevated rates of antisocial behavior reported in this population.

A Patient-Tailored Evidence-Based Approach for Developing Early Neuropsychological Training Programs in Addiction Settings

Substance use disorders (SUDs) are associated with impairments of cognitive functions, and cognitive training programs are thus rapidly developing in SUD treatment. However, neuropsychological impairments observed early after withdrawal (i.e., early impairments), that is, approximately in the first six months, may be widespread. Consequently, it might not be possible to train all the identified early impairments. In these situations, we propose that the priority of cognitive training should be given to the early impairments found to be associated with early dropout or relapse (i.e., relapse-related impairments). However, substance-specific relapse-related impairments have not been singled out among all early impairments so far. Using a systematic literature search, we identified the types of established early impairments for all SUDs, and we assessed the extent to which these early impairments were found to be associated with relapse-related impairments. All cognitive functions were investigated according to a classification based on current neuropsychological models, distinguishing classical cognitive, substance-bias, and social cognition systems. According to the current evidence, demonstrated relapse-related impairments in alcohol use disorder comprised impulsivity, long-term memory, and higher-order executive functions. For cannabis use disorder, the identified relapse-related impairments were impulsivity and working memory. For stimulant use disorder, the identified relapse-related impairments were attentional abilities and higher-order executive functions. For opioid use disorder, the only identified relapse-related impairments were higher executive functions. However, many early impairments were not explored with respect to dropout/relapse, particularly for stimulant and opioid use disorders. The current literature reveals substance-specific relapse-related impairments, which supports a pragmatic patient-tailored approach for defining which early impairments should be prioritized in terms of training among patients with SUDs.

Mind reading abilities in opiate-dependent patients: An exploratory study

OBJECTIVES

Impairments in social cognition have been described as playing a major role in the maintenance of addictive behavior in substance abusers. This study aimed to investigate the Theory of Mind (ToM) ability of opiate-dependent (OD) patients and to explore whether TOM ability was correlated with length of substance abuse, age at onset of substance abuse and length of abstinence.

METHODS

OD patients (N = 29) and non-dependent individuals (NDI) (N = 29) were submitted to the Theory of Mind Assessment Scale (Th.o.m.a.s.), a semi-structured interview, and to the Versailles-Lecture Intentionnelle en Situation (V-LIS), a movie paradigm in which participants have to infer the characters' intentions.

RESULTS

The results confirmed a deficit in ToM ability in OD patients, with OD patients demonstrating poorer performance than NDI on both the V-LIS and the Th.o.m.a.s. The combination of perspective taking and reflecting on others' mental states was particularly difficult for OD patients. Furthermore, impairments in ToM abilities were not correlated with the age at onset of substance abuse or to the duration of substance abuse or abstinence.

CONCLUSIONS

The results suggest OD patients may have impaired social cognition, demonstrating deficits in even basic social interaction skills, which may constitute a risk factor for addiction. These findings underline the importance of developing interventions to improve social cognition ability during the rehabilitation of OD patients.

Oscillatory brain activity differentially reflects false belief understanding and complementation syntax processing

False belief understanding (FBU) enables people to consider conflicting beliefs about the same situation. While language has been demonstrated to be a correlate of FBU, there is still controversy about the extent to which a specific aspect of language, complementation syntax, is a necessary condition for FBU. The present study tested an important notion from the debate proposing that complementation syntax task is redundant to FBU measures. Specifically, we examined electrophysiological correlates of false belief, false complementation, and their respective true conditions in adults using electroencephalography (EEG), focusing on indices of oscillatory brain activity and large-scale connectivity. The results showed strong modulation of parieto-occipital alpha (8-12 Hz) and beta (13-20 Hz) power by the experimental manipulations, with heightened sustained alpha power reflective of effortful internal processing observed in the false compared to the true conditions and reliable beta power reductions sensitive to mentalizing and/or syntactic demands in the belief versus the complementation conditions. In addition, higher coupling between parieto-occipital regions and widespread frontal sites in the beta band was found for the false-belief condition selectively. The result of divergence in beta oscillatory activity and in connectivity between false belief and false complementation does not support the redundancy hypothesis.

Parental reflective functioning and executive functioning in mothers with substance use disorder

Having a substance use disorder (SUD) may adversely affect caregiving capacities. Reflective functioning (RF) and executive functioning (EF) are both important capacities for sensitive parenting, and are often impaired in a SUD. Only a few studies have explored the possible association between the two phenomena. In this study, we used a neuropsychological test battery to assess EF, and the Parent Development Interview to assess RF in a sample of mothers with a SUD (N = 43). Although parental RF (PRF) was associated with EF, when controlled for intelligence (IQ) and mental health, there was no significant association between EF and PRF. Mental health, however, showed a significant negative association with PRF. Splitting the group in two based on PRF level, mothers with a negative to low PRF exhibited more severe difficulties in SUD-related aspects, as well as in several EF components, compared to mothers with an adequate to high PRF, highlighting the association between EF and PRF. The results from this study contribute to enhance our understanding of the dynamics underlying vulnerability in PRF that mothers with small children may experience. We suggest EF to be a prerequisite for adequate PRF, and for interventions to be customized accordingly regarding parents with a SUD.

Neuroscience-informed psychoeducation for addiction medicine: A neurocognitive perspective

Psychoeducation (PE) is defined as an intervention with systematic, structured, and didactic knowledge transfer for an illness and its treatment, integrating emotional and motivational aspects to enable patients to cope with the illness and to improve its treatment adherence and efficacy. PE is considered an important component of treatment in both medical and psychiatric disorders, especially for mental health disorders associated with lack of insight, such as alcohol and substance use disorders (ASUDs). New advancements in neuroscience have shed light on how various aspects of ASUDs may relate to neural processes. However, the actual impact of neuroscience in the real-life clinical practice of addiction medicine is minimal. In this chapter, we provide a perspective on how PE in addiction medicine can be informed by neuroscience in two dimensions: content (knowledge we transfer in PE) and structure (methods we use to deliver PE). The content of conventional PE targets knowledge about etiology of illness, treatment process, adverse effects of prescribed medications, coping strategies, family education, and life skill training. Adding neuroscience evidence to the content of PE could be helpful in communicating not only the impact of drug use but also the beneficial impact of various treatments (i.e., on brain function), thus enhancing motivation for compliance and further destigmatizing their symptoms. PE can also be optimized in its "structure" by implicitly and explicitly engaging different neurocognitive processes, including salience/attention, memory, and self-awareness. There are many interactions between these two dimensions, structure and content, in the delivery of neuroscience-informed psychoeducation (NIPE). We explore these interactions in the development of a cartoon-based NIPE to promote brain recovery during addiction treatment as a part of the brain awareness for addiction recovery initiative.

Amphetamine-type stimulant use and conditional paths of consumption: data from the Second Brazilian National Alcohol and Drugs Survey

OBJECTIVE:

The aim of this study was to estimate nationally representative prevalence rates of amphetamine-type stimulant (ATS) use and to identify consumption-associated factors, proposing a conditional model of direct and indirect consumption paths.

METHOD:

Using data from the Second Brazilian National Alcohol and Drugs Survey, this cross-sectional study analyzed a subsample of 3,828 participants between 15 and 64 years old, gathering information on the use of psychoactive substances in a probabilistic sample of the Brazilian household population.

RESULTS:

Rates of lifetime and last-year ATS use were, respectively, 4.1 and 1.6%. Economically privileged individuals and users of other substances were more at risk for using ATS. The results suggest that higher education decreases the chances of ATS consumption. The conditional model showed that higher income increased ATS use, higher education lowered the odds of such an increase, and cocaine use cancelled that associative effect.

CONCLUSION:

Brazil presents high rates of ATS use. Prevention and treatment strategies should focus on the protective effect of higher education levels and should target polydrug use. Knowledge of ATS-associated factors and user profiles is the starting point for developing effective treatments and tailored prevention strategies.