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Psychiatry Research 145 (2006) 95 – 103

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Social functioning, theory of mind and neurocognition in outpatients


with schizophrenia; mental state decoding may be a better predictor
of social functioning than mental state reasoning
Emre Bora *, Ayse Eryavuz, Bulent Kayahan, Gulcin Sungu, Baybars Veznedaroglu
Ege University Medical School Psychiatry Department, 1833/1 Sokak no. 11/6, 35100, Karsiyaka, İzmir, Turkey
Received 4 July 2005; received in revised form 4 November 2005; accepted 11 November 2005

Abstract

Few studies have directly investigated the relationship between theory of mind (ToM) deficits and social functioning in
schizophrenia. At the same time, the impact of mental state decoding tasks on social dysfunction has also not yet been investigated.
In this study, the relationship between theory of mind deficits and social functioning was investigated among 50 patients with
schizophrenia. A mental state decoding task known as dThe Eyes testT and a mental state reasoning task dThe Hinting testT were
applied to assess ToM abilities, while the Social Functioning Scale (SFS) was used to assess social functioning. Non-ToM
neurocognitive tests were also given to the patients. Results of the study show how theory of mind and working memory
performances of patients with good functional outcome proved to be significantly better than those of inadequately functioning
patients. Results also indicate that performance on the Eyes test was the best predictor of social functioning and that negative
symptoms also contributed to poor social functioning. It is concluded in this study that mental state decoding skills appear to be the
most important cognitive mediator of social functioning.
D 2005 Elsevier Ireland Ltd. All rights reserved.

Keywords: Social cognition; Social function; Schizophrenia

1. Introduction symptoms (Hoffman and Kupper, 1997) and disorgani-


zation symptoms (Norman et al., 1999) of patients with
One of the most notable characteristics of schizo- schizophrenia contribute to social functioning deficits.
phrenia is poor functional outcome of patients. Many Neurocognitive dysfunction is a well known feature
patients with schizophrenia exhibit a poor level of of schizophrenia. Some studies suggest that cognitive
community functioning even prior to the onset of the dysfunction may be related to poor social functioning in
first psychotic episode. Social impairment generally schizophrenia (Dickerson et al., 1994; Addington and
worsens over the course of the disorder and is often Addington, 2000; Milev et al., 2005). Executive dys-
resistant to antipsychotic treatment (Addington and function, working memory, verbal memory and vigi-
Addington, 2000; Pinkham et al., 2003), while negative lance deficits may be related to poor community
functioning and problems of social skills acquisition
(Green, 1998). Despite these findings, some authors
* Corresponding author. question the precise nature of this relationship (Green
E-mail address: emrebora@hotmail.com (E. Bora). et al., 2000). It is reasonable to suggest that specific
0165-1781/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.psychres.2005.11.003
96 E. Bora et al. / Psychiatry Research 145 (2006) 95–103

aspects of cognition which are important for social social functioning. Two of these skills work in conjunc-
interaction may be more strongly linked to social func- tion in order to produce reliable inferences about
tioning (Brüne, 2005). This unique feature of cognition others’ intentions. For example, the detection of irony
is termed social cognition. involves decoding of mental state from the prosodic
Social cognitive dysfunction is an important feature cues and also involves taking into account specific facts
of schizophrenia (Pinkham et al., 2003). A key aspect about the speaker. Although mental state decoding tasks
of social cognition is the ability to conceptualize other may be related to reasoning tasks, a previous study
people’s mental states, i.e. their beliefs and intentions; (Bora et al., 2005) demonstrated that performance on
this is known as theory of mind (ToM). ToM deficit in Eyes test in patients with bipolar disorder was unrelated
schizophrenia was originally proposed by Frith (1992) to their poor performance on the Hinting task.
and subsequently many studies (Corcoran et al., 1995; Although studies have investigated the relationship
Frith and Corcoran, 1996; Mazza et al., 2001; Pickup between emotion recognition skills (Mueser et al.,
and Frith, 2001; Janssen et al., 2003) confirmed ToM 1996; Penn et al., 1996; Hooker and Park, 2002) and
deficits in schizophrenia. Although ToM deficits are mental state reasoning (Roncone et al., 2002; Brüne,
more pronounced in acute psychotic patients (Drury 2003) with poor social functioning in schizophrenia, the
et al., 1998), ToM deficits seem to persist in remitted impact of mental state decoding deficits on social func-
patients (Herold et al., 2002). tioning has not yet been studied.
Mind-reading skills have been investigated with var- The primary aim of the present study is: (1) to
ious ToM tasks since different brain networks may be investigate the relative contributions of social cognitive
critical for different ToM tasks. The importance of left and other neurocognitive abilities on social functioning
ventromedial frontal and prefrontal cortical areas has in schizophrenia. We hypothesize that, compared to
been demonstrated by neuro-imaging studies (Galla- other cognitive tasks, performances on social cognition
gher et al., 2000; Vogeley et al., 2001; Lee et al., tests will better differentiate patients with adequate
2004). Mental state reasoning is measured on tests social functioning from poor functioning patients.
that include false belief and hinting tasks. In addition Then, if this hypothesis is verified, our second objective
to reasoning about mental states, ToM skills also re- would be: (2) to compare the relative roles on different
quire ability to decode mental states on the basis of aspects of social functioning of the ToM tasks of mental
immediately available information such as facial ex- state decoding and mental state reasoning.
pression or tone of voice. Previous studies investigated
the relationship between emotion recognition deficits 2. Methods
and social functioning (Mueser et al., 1996; Ihnen et al.,
1998; Hooker and Park, 2002). Facial affect perception 2.1. Participants
seems to have a moderate association with social func-
tioning among inpatients and outpatients with schizo- Fifty patients with schizophrenia according to DSM-
phrenia. Some tasks, like the Eyes test, which can also IV criteria participated in the present study. All patients
be classified as a complex emotion recognition para- were recruited from the outpatient clinic of Psychotic
digm, can be related to this distinct aspect of social Disorders Unit of Ege University Medical School Psy-
cognition and may be termed mental state decoding chiatry Department. All patients were clinically stable
(Sabbagh, 2004; Sabbagh et al., 2004). Ability to de- and had no history of acute psychotic exacerbation for
code mental states does not only involve decoding basic at least 3 months. Subjects who had disorders that could
emotions. Examples of more complex decoding abili- influence cognitive function (significant neurological
ties include detection of sarcasm from prosodic cues and physical illnesses, substance abuse or dependence
and identifying whether, based on their facial expres- in the last year, electroconvulsive therapy in the pre-
sions, someone is serious. Unlike recognition of basic ceding year or cerebral trauma history) were excluded.
emotions, recognition of these mental states depends on The patients were evaluated by a psychiatrist using the
context; different meanings may be inferred from iden- Structured Clinical Interview for Diagnostic Symptoms
tical facial expression in different situations. Context is (SCID, DSM-IV) (Corapcioglu et al., 1999) and Posi-
defined by the multiple choices given in the Eyes test. tive and Negative Symptoms Scale (PANSS) (Kay et
Both abilities, reasoning about intentions and decoding al., 1987; Anil et al., 1999). The demographic and
of mental states, are essential in identifying social cues. clinical variables of the patients are summarized in
Since recognition of social cues has substantial impor- Table 1. Thirty-two patients were classified as schizo-
tance in social skills, both abilities may be critical for phrenia, paranoid type; other patients were classified as
E. Bora et al. / Psychiatry Research 145 (2006) 95–103 97

Table 1 addition of scores of the individual subscales. Fifty


Demographic and clinical characteristics and SFS scores of the patients were split at the median of total SFS score
patients
into a group of 25 patients with good functional out-
Mean F SD Range
come and a group of 25 patients with poor functional
Sex ratio (m:f) 33 : 17 outcome.
Duration of education (years) 11.48 F 2.92 5–17
Age (years) 30.55 F 8.70 20–44
Age at onset (years) 21.44 F 5.20 13–36 2.3. Theory of mind tasks
Duration of illness (years) 9.13 F 6.59 1–28
PANSSpositive 10.36 F 4.17 7–20 The Eyes test measures ability to identify a per-
PANSSnegative 18.36 F 6.55 7–31 son’s mental state and comprises 36 photographs of
PANSStotal 54.29 F 15.35 32–86
people with facial expressions, showing only the eye
Social Functioning scores Possible score range
SFS-total 106.53 F 28.52 0–246 region. Participants are asked to choose the appropri-
SFS Soceng1 9.48 F 2.71 0–15 ate word out of four possibilities provided. This study
SFS interper2 15.18 F 5.90 0–30 used the first 27 photographs of the revised version
SFS Socact3 12.26 F 7.23 0–66 (Baron-Cohen et al., 2001). As a control task, a sex
SFS cADLs4 30.90 F 7.45 0–39
recognition test using same 27 stimuli was given to
SFS fADLs5 25.24 F 7.72 0–39
SFS Recre6 13.57 F 4.90 0–51 patients.
SFS Occ7 0.69 F 1.82 0–6 The Hinting task is a test of ability of subjects to
Social engagement1, Interpersonal2, social activities3, Competency of infer real intentions behind indirect speech utterances.
ADLs4, frequency of ADLs5, recreational Activities6, Occupation In the original version of the task, there are 10 short
activity7. passages describing interaction between two charac-
ters that ends with one character hinting to the other.
follows: 10 were undifferentiated and 7 were residual The participant is asked what the character really
and was disorganized type. All patients were on anti- meant. An appropriate response is awarded two points
psychotic treatment (mean dose = 493.82 F 297.16 and, if the response is inappropriate, further informa-
chlorpromazine equivalent). Forty were receiving atyp- tion is given to the participant and a subsequent
ical antipsychotics and eight were taking typical appropriate answer is awarded a single point. We
antipsychotics. Two were taking typical–atypical com- used four stories from the Hinting task similar to
bination as antipsychotic treatment, 16 were in receipt Janssen et al. (2003).
of antidepressants, 5 were receiving anticholinergic
agents, 10 were prescribed valproic acid, and 11 were 2.4. Neurocognitive measures
prescribed propranolol. All participants were individu-
ally briefed on the nature of the study and signed an A battery of neuropsychological tests was adminis-
informed consent form. tered to the patients. Both social functioning and ToM
abilities may depend on other cognitive skills such as
2.2. Social functioning working memory, attention and psychomotor speed.
Auditory consonant trigrams (ACT) (Anil et al.,
Social functioning of patients was assessed by the 2003) were used to assess working memory skills. In
Social Functioning Scale (SFS) which consists of 79 this task, also known as Brown–Peterson paradigm, the
items (Birchwood et al., 1990). The scale was admin- examiner presents three consonants at a rate of one-per-
istered by a nurse who is an active member of psychoe- second and the subject is required to count backward
ducational program of the Psychosis unit, while the from a given number until signalled to stop and then to
questionnaire was administered by oral interview of report the stimulus item. In each presentation of stimuli,
the patient and a family member. The SFS consists of the subjects count up to a predesignated number of
seven subscales (range of scores): social engagement seconds (3, 9 or 18 s). The total score and the subscores
(Soceng), interpersonal communication (Interper), so- for 3 s and 18 s are reported in this study. To assess
cial activities (Socact), competence of activities of daily psychomotor speed, we used Trail Making Test (TMT)
living (ADLs) (cADLs), frequency of ADLs (fADLs), A and B tests (Reitan, 1958) and Stroop Colour–Word
recreational activities (Recre) and occupational activity Test (SCWT), while a measure of selective attention
(Occ). Patients’ scores are summarized in Table 1. and executive function was also administered (Lezak,
Besides these seven subscale scores, total score of the 2004). Only the interference score of the test is
SFS (SFS total) (0–246) was also recorded by the reported.
98 E. Bora et al. / Psychiatry Research 145 (2006) 95–103

Benton Facial Recognition Test (Short Form) (Levin impact of working memory. Two regression analyses
et al., 1978) was used to control the impact of face were performed to investigate the relationships be-
recognition ability on the Eyes test. tween ToM tasks, several cognitive measures and
Since verbal IQ may be critical for ToM skills, negative symptoms.
WAIS-R information test was used to estimate partici-
pants’ verbal IQ capacities (Wechsler, 1981). 3. Results

2.5. Statistical analyses 3.1. Differences between patients with good and poor
social functional outcome
The statistical analyses were performed by using
SPSS 11.0. The demographic, clinical, neurocognitive Demographic characteristics of the two groups were
and theory of mind abilities of the high functioning similar. The poor functioning group had the tendency to
and poor functioning schizophrenia patients were onset earlier. The only significant difference between
compared with ANOVA. The normality of the neuro- the two groups was the more severe negative symptoms
cognitive data was checked with Kolmogrov–Smirnov among poor functioning patients (Table 2).
test and necessary transformations were applied for Verbal IQ estimates of the two groups did not differ.
several measures. Effect sizes for ANOVAs were an- Performances of the poor functioning patients were
alyzed by calculating partial eta square values. Differ- significantly lower than the patients with social out-
ences between groups were tested with a p value come in the Eyes test. In two working memory mea-
b0.01 to reduce the probability of Type I errors. For sures (ACT18, ACTtot), patients with good functional
controlling the impact of verbal IQ, the neurocognitive outcome also performed significantly better than poor
scores of the two groups were also analyzed with functioning patients. Controlling for the verbal IQ esti-
ANCOVA. Relationships between SFS scores, neuro- mates did not change these group differences. Effect
cognitive, ToM and clinical variables were tested with sizes of the differences for the working memory and the
Pearson correlations. Partial correlations of ToM mea- Eyes tests were large, while the group difference for the
sures and SFS were calculated for controlling the Hinting task was nearly significant. Although trends

Table 2
ANOVA between- group comparisons for ToM, neurocognition, clinical and demographic variables
Patients with good functional Patients with poor fuctional ANOVA Effect Size1 ANCOVA
outcome (n = 25) outcome (n = 25)
Sex (M:F) 16 : 9 17 : 8
Mean SD Mean SD F P F P
Age (years) 31.4 8.7 29.8 8.8 0.41 0.52
Age of onset (years) 23.1 4.8 19.9 5.4 4.92 0.032
Education (years) 11.8 2.6 10.8 1.7 2.9 0.095
PANSS positive 9.4 0.8 11.2 0.8 2.50 0.12
PANSS negative 15.4 1.2 21.4 1.2 12.22 0.001*

Neurocognitive tests
WAIS information 10.3 2.4 9.6 2.8 0.86 0.36 0.02
ACT 3 sec 11.3 2.5 9.6 2.7 5.49 0.023 0.09 4.67 0.036
ACT 18 sec 7.3 2.7 4.8 3.1 8.99 0.004* 0.16 8.74 0.005*
ACT total 27.3 1.5 21.2 1.5 8.36 0.006* 0.15 8.22 0.006*
Trail A 42.7 12.6 50.8 15.6 3.83 0.056 0.08 3.02 0.089
Trail B 101.6 47.1 152.3 111.1 4.21 0.046 0.05 3.07 0.087
Stroop interference 55.6 17.4 90.8 75.5 4.74 0.035 0.10 3.38 0.073
Benton 43.9 3.7 41.8 4.1 3.14 0.084 0.08
Eyes (sex recognition) 24.6 0.5 24.3 0.8 0.09 0.77 0.01

ToM tasks
Eyes 16.2 0.6 12.7 0.6 16.65 0.0001* 0.26 15.41 0.0001*
Hinting 6.2 1.7 4.7 2.3 7.53 0.009* 0.14 6.79 0.012
1 partial eta square values.
E. Bora et al. / Psychiatry Research 145 (2006) 95–103 99

towards lower performances in poor functioning 3.3. Pearson correlations of cognitive measures with
patients were found in psychomotor speed, Stroop in- SFS and its subscales
terference and face recognition tests, these differences
were insignificant and reduced after ANCOVA with The only clinical variable that the SFS total score
verbal IQ estimate. correlated with was the negative score of PANSS. The
When we separated the patients into conventional SFS total score strongly correlated with the Eyes test
and atypical antipsychotic receiving groups, none of and the Hinting task, while it negatively correlated with
their ToM and other cognitive performances were sig- the Trail making A and B tests, and there were also
nificantly different. modest correlations between ACT total, ACT18, ACT3
and SFS total scores (Table 3). The SFS social engage-
3.2. Pearson correlations of social cognitive tasks with ment subscale modestly correlated with age of onset of
other neurocognitive tests and clinical variables illness and inversely correlated with positive score of
PANSS (Table 3). The SFS interpersonal communica-
The Eyes test did not correlate with verbal IQ esti- tion score negatively correlated with the negative symp-
mate and did not correlate with any clinical variables. toms. There were strong correlations between the Eyes
This test also correlated strongly with the ACT total test, the Hinting task, ACT scores and SFS interperson-
(r = 0.47, P = 0.001), ACT18 (r = 0.49, P b 0.001) and al communication score. Trail making A and B tests
other ACT scores and negatively correlated with the also negatively correlated with this subscale score. The
Trail making B test (Table 3). social activities subscale of the SFS correlated with the
The Hinting task strongly correlated with verbal IQ Eyes test, the Hinting task and inversely correlated with
estimate (r = 0.54, P b 0.001). The Hinting task inverse- negative symptoms. There were also modest correla-
ly correlated with the negative symptoms (r = 0.47, tions with the ACT total (positively) and Trail making
P = 0.001) and moderately with positive symptoms B score (inversely). The competence of ADLs subscale
(r = 0.30, P = 0.033). This task also very strongly strongly correlated with the age of onset of disease.
correlated with ACT total score (r = 0.61, P b 0.001), There were also modest correlations between this sub-
ACT18 score (r = 0.68, P b 0.001) and other ACT scale with the Hinting task and ACT9. Negative symp-
scores. There were also negative correlations between toms and the Trail making A test negatively correlated
the Trail making A (r = 0.51, P b 0.001), Trail mak- with the competence of ADLs. The frequency of ADLs
ing B (r = 0.44, P = 0.002) and the Hinting task score correlated strongly with age of illness onset and
(Table 3). negatively correlated with negative symptoms. ACT
Although the Eyes test strongly correlated with the total and ACT9 scores correlated with the frequency
Hinting task, this correlation did not persist when con- of ADLs. There were also some positive (the Hinting
trolling for ACT18 with partial correlation method task, the Eyes test) and negative (Stroop interference,
(r = 0.27, P = 0.07). Trail making tests) modest correlations with some other

Table 3
Correlations of social functioning measures and ToM tasks with neurocognitive and clinical variables
SFStot Soceng İnterper Socact cADLs fADLs Recre Occ Eyes Hinting
WAIS inf 0.19 0.20 0.24 0.20 0.05 0.10 0.13 0.36* 0.25 0.54**
ACT3 0.24 0.17 0.42** 0.28 0.04 0.22 0.05 0.05 0.37** 0.36*
ACT18 0.36* 0.29* 0.40** 0.28 0.28 0.34* 0.15 0.26 0.49** 0.68**
ACTtot 0.36* 0.26 0.42** 0.31* 0.24 0.37* 0.13 0.21 0.47** 0.61**
Trail A 0.43** 0.21 0.38** 0.27 0.37* 0.30* 0.30* 0.16 0.37* 0.51**
Trail B 0.39** 0.16 0.35* 0.31* 0.22 0.32* 0.31* 0.19 0.47** 0.44**
Stroop interference 0.26 0.09 0.13 0.20 0.27 0.33* 0.06 0.14 0.28 0.27
Benton 0.19 0.04 0.26 0.28 0.01 0.06 0.21 0.30* 0.28 0.24
Eyes (Sex) 0.07 0.10 0.04 0.01 0.01 0.04 0.21 0.27 0.19 0.22
Eyes 0.46** 0.14 0.49** 0.48** 0.17 0.30* 0.39** 0.17 0.51**
Hinting 0.43** 0.27 0.44** 0.37** 0.29* 0.30* 0.31* 0.23 0.51**
PANSS positive 0.17 0.29* 0.18 0.04 0.25 0.19 0.03 0.27 0.14 0.30*
PANSS negative 0.42** 0.24 0.43** 0.37** 0.29* 0.38** 0.30* 0.21 0.23 0.47**
Age at onset 0.28 0.31* 0.18 0.04 0.41** 0.42** 0.07 0.28 0.18 0.08
Duration of illness 0.04 0.02 0.05 0.07 0.04 0.13 0.12 0.07 0.13 0.07
Correlation is significant at the 0.05 level, ** Correlation is significant at the 0.01 level.
100 E. Bora et al. / Psychiatry Research 145 (2006) 95–103

Table 4 only 16% of variance. The Eyes was a significant


Lineer regression equation predicting the impact of ToM tasks on SFS predictor for all three subscales. The Hinting task
and its Subscales
only contributed to the interpersonal communication
F df Model r 2 Predictors Beta Predictor
subscale. (2) To examine the relative contributions of
Pb Pb
ToM, non-ToM tasks and negative symptoms on social
SFS tot 7.83 2,47 0.001 0.254 Eyes 0.34 0.03
functioning. A linear regression analysis with SFS total
SFS interper 9.65 2,47 0.0001 0.291 Eyes 0.36 0.01
Hinting 0.26 0.08 score as a dependent variable was carried out. Along
SFS socact 7.87 2,47 0.001 0.251 Eyes 0.40 0.001 with the two ToM tasks and PANSS negative score,
SFS recrea 4.53 2,47 0.016 0.164 Eyes 0.30 0.05 ACTtot and Trail A were also entered simultaneously as
predictors. The ACTtot and Trail A, the tests of work-
ing memory and psychomotor speed, respectively, were
neurocognitive tasks. The recreational activities sub- chosen since they correlated significantly with the SFS
scale of the SFS correlated strongly with the Eyes test total score. The model was significant ( F = 7.42, P =
and modestly with the Hinting task. This subscale also 0.001) and explained the 40% of the variance. The Eyes
inversely correlated with the Trail making tests and test and PANSS negative score contributed to this
negative symptoms. The occupational activities sub- model significantly (Table 5). Since the Eyes test and
scale correlated only with WAIS information score. negative symptoms did not correlate, their contributions
Since ToM tasks, especially the Hinting task, strongly to social functioning appeared to be independent.
correlated with working memory, partial correlational
analysis of SFS with ToM tasks controlled for the 4. Discussion
ACT18 was performed. While the correlation of
Eyes test (r = 0.32, P = 0.03) with SFS persisted, the The current study investigated the relationship be-
correlation with the Hinting task (r = 0.24, P = 0.1) lost tween ToM and non-ToM cognitive skills and social
significance. functioning among patients with schizophrenia. The
performances of the patients with good functional out-
3.4. Regression analyses come were significantly better on a mental state decod-
ing task. Although the between-group differences were
Regression analyses were carried out to answer two smaller, the patients with good functional outcome also
questions. (1) to further examine individual contribu- performed better on working memory and mental state
tions of mental state decoding and reasoning skills on reasoning tests. Among the cognitive tasks, only the
social functioning. Along with a linear regression anal- Eyes test significantly predicted the social functioning
ysis with SFS total score as dependent variable, the score. Negative symptoms also contributed to social
Eyes and Hinting tasks independent variables was also functioning score. The results of the current study
performed. Overall, the model was significant and supported our primary hypothesis and emphasized the
explained the quarter of the variance (Table 4). The importance of social cognitive deficits for the social
Eyes test was the only significant predictor. A series of functioning deficits in schizophrenia. The originality of
linear regression analyses with the same independent this paper resides in the second objective of the study,
variables were performed for the seven subscales of the the differentiation of ToM skills into mental state
SFS. The models for three subscales, interpersonal decoding and reasoning abilities. Mental state decoding
communication, social activities and recreational activ- tasks were significantly better than mental state reason-
ities were significant (Table 4). The model for the ing tasks for predicting social impairments.
interpersonal communication was the strongest and Two previous studies investigated the interaction of
explained the 29% of variance. The model for the ToM deficits with social functioning in schizophrenia.
recreational activities was the weakest, accounting for In the study of Roncone et al. (2002), ToM deficits

Table 5
Lineer regression equation predicting the impact of ToM, nonToM skills and negative symptoms on social functioning
F df Model Pb r2 Predictors Beta Predictors Pb
SFS total 7.24 4,41 0.001 0.414 Eyes 0.34 0.02
PANSS negative 0.30 0.04
Independent variables: The Eyes and Hinting tasks, ACT18, Trail A, PANSS negative.
E. Bora et al. / Psychiatry Research 145 (2006) 95–103 101

contributed to the deficits of social functioning (15% of speech abnormalities (Docherty et al., 1996; Thomas
variance). In this study, ToM deficit was the second et al., 1996), deficits in the patients’ pragmatic use of
important predictor after duration of illness (27% var- language were reported in schizophrenia (Langdon et
iance). Brüne (2005) demonstrated that ToM deficit was al., 2002). Language deficits may contribute to ToM
the best predictor of social behaviour problems (a quar- deficits in schizophrenia. A recent study reported that
ter of the variance). Duration of illness was again a thought disorder and verbal memory accounted for
significant predictor of social functioning (14% of the 30% of the variance in schizophrenia (Greig et al.,
variance). 2004). In this study, while a nonverbal decoding task
The current study demonstrates that a different kind was closely related to social functioning, the relation-
of social cognitive task measuring mental state decod- ship between social functioning and a task of verbal
ing, the Eyes test, is a better predictor of social mental reasoning was relatively weak. Indeed, this
functioning than a mental state reasoning task (the relationship seemed to be partly explainable, by the
Hinting task) in schizophrenia. The Eyes test is essen- working memory load of the task. Similar to previous
tially different from other dtheory of mindT tasks as findings, mental state reasoning performance was also
this test is based more on spontaneous and automatic related to verbal IQ estimate (Brüne, 2003). However,
judgement than other tasks. Also, perception of com- the relationship between hinting task and SFS total
plex visual material and basic emotion recognition is score was not explainable with verbal IQ. Future
essential to infer the mental state of the eyes correctly. studies are necessary to reveal the nature of the rela-
Since this ability requires dgut feelingsT rather than tionship between thought disorder, language deficits,
effortful verbal processing, it may be more closely reasoning about mental states and other cognitive
related to social perception and functioning. Although measures such as working memory.
decoding the basic emotions from body language Premorbid adjustment problems and social dysfunc-
and voice are shared among primates, we think tion in early life is a well known feature of schizo-
that inferring mental states from the eyes may be a phrenia. Premorbid social functioning was also
unique human ability, one which may depend on a reported to be related with ToM dysfunction among
partly distinct neural network compared to the other patients with schizophrenia (Schenkel et al., 2005).
mind-reading tasks. This ability may be more closely Since both neurocognitive (Faraone et al., 1995) and
associated with emotional aspects of empathy and ToM deficits (Janssen et al., 2003) are reported to be
mind-reading. Some evidence already exists for the present in the relatives of schizophrenia, both abilities
contribution of different brain networks to different may be traits of schizophrenia. Corcoran and Frith
ToM abilities. While left ventromedial prefrontal (2003) hypothesized that patients with prominent neg-
regions may have essential importance for reasoning ative symptoms never fully develop ToM abilities.
about mental states (Lee et al., 2004; Sabbagh et al., Social functioning deficits seem to be the result of
2004), right inferior frontal and anterior temporal neurodevelopmental nature of the disorder. The pre-
lobes may be critical for mental state decoding abili- cise nature of the developmental dysfunction in social
ties (Sabbagh et al., 2004). The lack of correlation and cognitive abilities is still unknown. Deficits in
between the Hinting task and the Eyes test in our general basic cognitive abilities may explain the neu-
previous study (Bora et al., 2005) that was also con- rocognitive and ToM deficits in schizophrenia, but
ducted into bipolar disorder may support the idea of also more specific deficits, like the context processing
the different neural mechanisms underlying these two dysfunction, may be responsible for both abilities
tasks. Although both tasks were correlated in the (Schenkel et al., 2005).
current study, the correlation decreased in significance Besides total SFS score, mental state decoding abil-
when controlled for working memory. Since both ity was a predictor for interpersonal communication,
tasks have a substantial working memory load, the recreational and social activities subscales of the SFS,
correlation of both ToM tasks in schizophrenia may which seem to measure abilities that depend more on
be related to severe working memory deficits of the social interaction. Theory of mind skills seem to have a
patients. critical importance for social communication. On the
One potential confounding factor in this study may other hand, skills of patients with schizophrenia on
be the impact of using verbal mental reasoning tasks subscales, which do not depend on social interaction
instead of cartoons or vignettes of drawings. Schizo- like ADLs, were not related to ToM abilities. Age at
phrenia patients have well known thought and lan- onset of disease, negative symptoms and some non-
guage deficits. As well as semantic and syntactical ToM abilities seemed to be more strongly correlated
102 E. Bora et al. / Psychiatry Research 145 (2006) 95–103

with these skills. Since age at onset and duration of Acknowledgement


illness may be related to cognitive deficits and negative
symptoms (Lindstrom and Von Knorring, 1994; Pante- We would like to thank to Professor Simon Baron-
lis et al., 2004) and disorganization and negative symp- Cohen for providing the Eyes test from ARC website.
toms has a relationship with cognitive deficits (Cuesta
and Peralta, 1995), the relation of ADLs to these vari- References
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