A leopard cannot change its spots: A novel pragmatic account of concretism in schizophrenia

Language in interaction: turn-taking patterns in conversations involving individuals with schizophrenia

Individuals with schizophrenia generally show difficulties in interpersonal communication. Linguistic analyses shed new light on speech atypicalities in schizophrenia. However, very little is known about conversational interaction management by these individuals. Moreover, the relationship between linguistic features, psychopathology, and patients' subjectivity has received limited attention to date. We used a novel methodology to explore dyadic conversations involving 58 participants (29 individuals with schizophrenia and 29 control persons) and medical doctors. High-quality stereo recordings were obtained and used to quantify turn-taking patterns. We investigated psychopathological dimensions and subjective experiences using the Positive and Negative Syndrome Scale for Schizophrenia (PANSS), the Examination of Anomalous Self Experience scale (EASE), the Autism Rating Scale (ARS) and the Abnormal Bodily Phenomena questionnaire (ABPq). Different turn-taking patterns of both patients and interviewers characterised conversations involving individuals with schizophrenia. We observed higher levels of overlap and mutual silence in dialogues with the patients compared to dialogues with control persons. Mutual silence was associated with negative symptom severity; no dialogical feature was correlated with anomalous subjective experiences. Our findings suggest that individuals with schizophrenia display peculiar turn-taking behaviour, thereby enhancing our understanding of interactional coordination in schizophrenia.

Weighing the role of social cognition and executive functioning in pragmatics in the schizophrenia spectrum: A systematic review and meta-analysis

Pragmatic impairment is diffused in schizophrenia spectrum disorders, but the literature still debates its neurocognitive underpinnings. This systematic review and meta-analysis aimed to investigate the neurocognitive correlates of pragmatic disorders in schizophrenia and determine the weight of social cognition and executive functioning on such disorders. Of the 2,668 records retrieved from the literature, 16 papers were included in the systematic review, mostly focused on non-literal meanings and discourse production in schizophrenia. Ten studies were included in the meta-analysis: pragmatics was moderately associated with both social cognition and executive functions (especially inhibition), but the link with social cognition was stronger. The mediation analysis showed that social cognition mediated the relationship between executive functions and pragmatics. Based on this, we proposed a hierarchical neurocognitive model where pragmatics stems from social cognition, while executive functions are the fertile ground supporting the other two domains, and we discuss its theoretical and clinical implications.

On the specificity of figurative language comprehension impairment in schizophrenia and its relation to cognitive skills but not psychopathological symptoms - Study on metaphor, humor and irony

People with schizophrenia have difficulty understanding figurative expressions, such as metaphors, humor or irony. The present study investigated the specificity of figurative language impairment in schizophrenia and its relation with cognitive and psychotic symptoms. It included 54 schizophrenia and 54 age and sex-matched healthy subjects who performed a cognitive screening (ACE-III) and figurative language comprehension task consisting of 60 short stories with three types of endings: a figurative one and its literal and an absurd (meaningless) counterparts. Each figurative domain - metaphor, humor, irony - was split into two sub-domains, i.e., conventional and novel metaphors, intended-to-be-funny and social-norm-violation jokes, simple irony and critical sarcasm, respectively. The main findings are: i) in schizophrenia, figurative language deficit manifests itself in each domain; ii) the most pronounced subdomain-specific impairment has been found for novel vs conventional metaphors and irony vs sarcasm; iii) altered figurative language comprehension was related to diminished cognitive abilities but not to psychopathology symptoms (PANSS) or other clinical characteristics. This may suggest that figurative language impairment, as a specific part of communication deficit, may be regarded as an essential characteristic of schizophrenia, related to primary cognitive deficits but independent of psychopathology.

Evidence for the factor structure of formal thought disorder: A systematic review

Disorganised speech, or, formal thought disorder (FTD), is considered one of the core features of psychosis, yet its factor structure remains debated. This systematic review aimed to identify the core dimensions of FTD. In line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA), a systematic review was conducted on the FTD factor analytic literature. Sixteen studies were identified from PsycINFO, PubMed and Web of Science between October 1971 and January 2023. Across the 39 factor analyses investigated, findings demonstrated the prominence of a three-factor structure. Broad agreement was found for two factors within the three-factor model, which were typically referred to as disorganisation and negative, with the exact nature of the third dimension requiring further clarification. The quality assessment revealed some methodological challenges relating to the assessment of FTD and conducted factor analyses. Future research should clarify the exact nature of the third dimension across different patient groups and methodologies to determine whether a consistent transdiagnostic concept of FTD can be elucidated.

Proverb comprehension in schizophrenia: A comprehensive review and meta-analysis.2

BACKGROUND

Examination of proverb comprehension has a long tradition in clinical diagnostics of individuals with schizophrenia (iSCZ). Deficits in the comprehension are considered common. Interpretations of proverbs are traditionally measured by their degree of abstraction and concreteness ('literalness'), but iSCZ's responses may also be illogical or 'bizarre'. Experimental research on proverb comprehension starts in the 1940s. Since then, the specificity of proverb tests has often been questioned, but has never been the subject of a meta-analysis. The aim of this meta-analysis is to include all experimental research, including historical studies, that meets quality criteria and compares the responses to proverbs in iSCZ with those in healthy controls (HC) or clinical controls (CC).

METHODS

PubMed, Web of Science, and PsycInfo databases were searched. After coding 121 articles, 27 (median publication year 1982) were included and multi-level meta-analyses performed. Moderator analyses were performed on response format (multiple-choice vs. verbal responses), proverb test, scoring method, language, acute vs. chronic stage of iSCZ, time of publication, clinical vs. healthy control group, age, IQ/education, and gender. Publication bias was assessed using funnel plots, trim and fill method and Egger's test.

RESULTS

The search identified 27 eligible studies for inclusion. Studies were published between 1956 and 2020 and predominantly older than 30 years (median: 1982). The Gorham Proverbs Test was the most established test and predominantly conducted in English. CC mostly consisted of depressive disorders. Pooled estimates yielded statistically significant less abstract (g = -1.00; 95%CI, -1.34 to -1.67), more concrete (g = 0.69; 95%CI, 0.35-1.03), and more bizarre (g = 1.08; 95%CI, 0.74-1.41) responses in iSCZ compared to controls. The type of control group moderated all three effects, with greater differences of iSCZ compared to HC than to CC in abstraction and bizarreness, and no significant group difference between iSCZ and CC in concreteness. Meta-regressions indicated IQ/education and age as possible sources of variability in abstraction and bizarreness.

CONCLUSIONS

While lower abstraction and higher bizarreness seems a characteristic of iSCZ, the diagnostic specificity of a concrete response was astonishingly low. The lack of a unified definition for concretism and limited consideration of cultural diversity contributed to these complex findings. Future research should focus on exploring the qualitative aspects of proverb comprehension and the association between symptomatology types and misinterpretations to improve diagnostic accuracy.

The relationship between metaphor skills and Theory of Mind in middle childhood: Task and developmental effects

Theoretical pragmatics in the post-Gricean tradition argued that metaphor requires understanding of how another person sees the world. Yet, it is unclear what role mindreading plays in developing metaphor skills. Here we examined the relationship between metaphor and Theory of Mind (ToM) in middle childhood by using two different tasks. In addition to the Physical and Mental Metaphors task (PMM), based on the verbal explanation of physical and mental metaphors, we revived the Referential Metaphors task for children (Noveck, Bianco, & Castry, 2001), where metaphorical and literal referents are presented in a narrative context. The sample included 169 8-, 9-, and 10-year-old children, assessed also for ToM (via the Strange Stories) and other linguistic and cognitive skills as control variables. In the PMM, ToM supported the understanding of mental (but not physical) metaphors in 9-year-olds only, whereas in the Referential Metaphors task ToM supported accuracy of understanding metaphors (but not literal items) in younger children as well. At age 10, ToM effects were negligible in both tasks. These findings suggest that ToM has a task-specific role in metaphor, linked to the characteristics of the items in the task at stake, being for instance greater for metaphors with mental (compared to physical) content and for non-literal (compared to literal) referents. The findings also suggest that the relationship between ToM and metaphor skills is developmental sensitive, as children start to capitalize on ToM earlier in development when the metaphor context is richer, and these effects fade with age. Theoretically, these data argue in favor of the relevance-theoretic account of metaphor, spelling out different ways in which ToM might support metaphor resolution across tasks, for instance by providing better access to the psychological lexicon (i.e., terms referring to mental states) and better context processing, serving as a springboard to achieve sophisticated pragmatic skills in middle childhood.

Disembodiment and Language in Schizophrenia: An Integrated Psychopathological and Evolutionary Perspective

Different hypotheses have flourished to explain the evolutionary paradox of schizophrenia. In this contribution, we sought to illustrate how, in the schizophrenia spectrum, the concept of embodiment may underpin the phylogenetic and developmental pathways linking sensorimotor processes, the origin of human language, and the construction of a basic sense of the self. In particular, according to an embodied model of language, we suggest that the reuse of basic sensorimotor loops for language, while enabling the development of fully symbolic thought, has pushed the human brain close to the threshold of a severe disruption of self-embodiment processes, which are at the core of schizophrenia psychopathology. We adopted an inter-disciplinary approach (psychopathology, neuroscience, developmental biology) within an evolutionary framework, to gain an integrated, multi-perspectival model on the origin of schizophrenia vulnerability. A maladaptive over-expression of evolutionary-developmental trajectories toward language at the expense of embodiment processes would have led to the evolutionary "trade-off" of a hyper-symbolic activity to the detriment of a disembodied self. Therefore, schizophrenia psychopathology might be the cost of long-term co-evolutive interactions between brain and language.

Deconstructing heterogeneity in schizophrenia through language: a semi-automated linguistic analysis and data-driven clustering approach

Previous works highlighted the relevance of automated language analysis for predicting diagnosis in schizophrenia, but a deeper language-based data-driven investigation of the clinical heterogeneity through the illness course has been generally neglected. Here we used a semiautomated multidimensional linguistic analysis innovatively combined with a machine-driven clustering technique to characterize the speech of 67 individuals with schizophrenia. Clusters were then compared for psychopathological, cognitive, and functional characteristics. We identified two subgroups with distinctive linguistic profiles: one with higher fluency, lower lexical variety but greater use of psychological lexicon; the other with reduced fluency, greater lexical variety but reduced psychological lexicon. The former cluster was associated with lower symptoms and better quality of life, pointing to the existence of specific language profiles, which also show clinically meaningful differences. These findings highlight the importance of considering language disturbances in schizophrenia as multifaceted and approaching them in automated and data-driven ways.

Irony detection in patients with borderline personality disorder: an experimental study examining schizotypal traits, response biases and empathy

BACKGROUND

In verbal irony we often convey meanings that oppose the literal words. To look behind these words, we need to integrate perspectives of ourselves, others, and their beliefs about us. Although patients with borderline personality disorder (BPD) experience problems in social cognition and schizotypal symptoms, research on irony comprehension mainly focused on the schizophrenic spectrum. Accounting for possible negative biases in BPD, the current study examined the detection of praising and critical irony in a text messaging interface.

METHODS

The cross-sectional study included 30 patients and 30 matched controls, who completed measures of cognitive and affective empathy (Interpersonal Reactivity Index, IRI), schizotypal (Schizotypal Personality Questionnaire; SPQ), and borderline symptoms (Borderline Symptom List; BSL-23) and the irony detection task. The irony task contained critical and praising remarks embedded in text messages. Asking for literality (ironic vs. literal) and intention ratings (critical to praising) of the stimuli, it allowed to analyze the sensitivity of literality detection as well as implicit and explicit response biases in a signal detection framework.

RESULTS

Borderline symptoms explained lower sensitivity for the detection of literal and ironic statements across groups. Whereas HC showed a negativity bias when implicitly asked about the literalness of the statement, patients with BPD perceived praising utterances as less praising when explicitly asked about their perceived intention. Neither empathy nor schizotypy explained outcomes beyond borderline symptoms.

CONCLUSIONS

This was the first study to show lower detection of verbal irony in patients with BPD. While patients were less biased when asked about the literality of a statement, they perceived praising remarks as less positive on explicit measurements. The results highlight the importance of congruent, transparent communication in promoting epistemic trust in individuals with BPD.

Older and Wiser: Interpretation of Proverbs in the Face of Age-Related Cortical Atrophy

In the present study, we investigated whether interpretation of proverbs differs across the lifespan and if so, whether it is associated with age-related fronto-temporal atrophy. Using a sample of 333 healthy individuals aged 18–89 years, we found a significant effect of age on proverb interpretation [H(2) = 12.001, p = 0.002]: old adults (OA) were better than young adults (YA) (p = 0.002), and so were middle-aged-adults (MA) (p = 0.005). OA and MA had significantly less grey matter (GM) than YA in frontal and temporal lobes bilaterally, and OA less than MA in the right temporal lobe. GM volumes in these regions did not moderate the effect of age on the proverbs scores. The whole-brain analysis of groups’ GM maps revealed that the proverbs scores were associated with more GM in YA relative to OA in the right middle temporal gyrus, which is consistent with evidence on the role of this area in processing of unfamiliar proverbs. Overall, our data suggest that interpretation of proverbs is well preserved in late adulthood, despite considerable age-related cortical atrophy.

It is time to address language disorders in schizophrenia: A RCT on the efficacy of a novel training targeting the pragmatics of communication (PragmaCom)

INTRODUCTION

Language and communication disruptions in schizophrenia are at the center of a large body of investigation. Yet, the remediation of such disruptions is still in its infancy. Here we targeted what is known to be one of the most damaged language domains in schizophrenia, namely pragmatics, by conducting a pragmatics-centered intervention with a randomized controlled trial design and assessing also durability and generalization. To the best of our knowledge, this is the first study with these characteristics.

METHODS

Inspired by the Gricean account of natural language use, we tailored a novel treatment addressing the pragmatics of communication (PragmaCom) and we tested its efficacy in a sample of individuals with schizophrenia randomized to the experimental group or to an active control group. The primary outcome with respect to the efficacy of the PragmaCom was measured by changes in pragmatic abilities (as evaluated with the global score of the Assessment of Pragmatic Abilities and Cognitive Substrates test) from baseline to 12 weeks and at 3-month follow-up. The secondary outcome was measured by changes in metaphor comprehension, abstract thinking, and global functioning from baseline to 12 weeks and at 3-month follow-up.

RESULTS

Relative to the control group, at post-test the PragmaCom group showed greater and enduring improvement in global pragmatic skills and in metaphor comprehension. At follow-up, these improvements persisted and the PragmaCom exerted beneficial effects also on functioning.

CONCLUSIONS

Despite the limited sample size, we believe that these findings offer initial yet encouraging evidence of the possibility to improve pragmatic skills with a theoretically grounded approach and to obtain durable and clinically relevant benefits. We argue that it is time that therapeutic efforts embrace communicative dysfunctions in order to improve illness outcome.

The cognitive aspect of formal thought disorder and its relationship with global social functioning and the quality of life in schizophrenia

PURPOSE

It was expected that using a comprehensive scale like the Thought and Language Disorder Scale (TALD) for measurement of FTD would enable assessing its heterogeneity and its associations with cognitive impairment and functionality. This study has aimed to analyze the relationship between formal thought disorder (FTD) and cognitive functions, functionality, and quality of life in schizophrenia.

METHODS

This cross-sectional exploratory study included 46 clinical participants meeting the DSM-5 diagnostic criteria for schizophrenia and 35 healthy individuals as the control groups. Data were acquired by means of the Turkish language version of the TALD, the Positive and Negative Syndrome Scale, the Clinical Global Impression Scale, the Functioning Assessment Short Test, the Social Functioning Scale, the World Health Organization Quality of Life Instrument-Short Form, and a neuropsychological test battery on executive functions, working memory, verbal fluency, abstract thinking, and response inhibition. Correlation analyses were conducted to detect significant relationships.

RESULTS

The clinical group scored failures in all cognitive tests. The objective positive FTD was associated with deficits in executive functions and social functioning. The objective negative FTD was associated with poor performance in all cognitive domains, physical quality of life, and social and global functioning. The subjective negative FTD was negatively correlated with psychological quality of life.

CONCLUSION

This study demonstrated that objective FTD factors reflect different underlying cognitive deficits and correlate with different functioning domains. Significant correlation was determined between subjective negative FTD and psychological quality of life. Given the close relationship of FTD with functioning and quality of life, the FTD-related cognitive deficits should be the key treatment goal in 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.

On the Role of Bilateral Brain Hypofunction and Abnormal Lateralization of Cortical Information Flow as Neural Underpinnings of Conventional Metaphor Processing Impairment in Schizophrenia: An fMRI and EEG Study

Figurative language processing (e.g. metaphors) is commonly impaired in schizophrenia. In the present study, we investigated the neural activity and propagation of information within neural circuits related to the figurative speech, as a neural substrate of impaired conventional metaphor processing in schizophrenia. The study included 30 schizophrenia outpatients and 30 healthy controls, all of whom were assessed with a functional Magnetic Resonance Imaging (fMRI) and electroencephalography (EEG) punchline-based metaphor comprehension task including literal (neutral), figurative (metaphorical) and nonsense (absurd) endings. The blood oxygenation level-dependent signal was recorded with 3T MRI scanner and direction and strength of cortical information flow in the time course of task processing was estimated with a 64-channel EEG input for directed transfer function. The presented results revealed that the behavioral manifestation of impaired figurative language in schizophrenia is related to the hypofunction in the bilateral fronto-temporo-parietal brain regions (fMRI) and various differences in effective connectivity in the fronto-temporo-parietal circuit (EEG). Schizophrenia outpatients showed an abnormal pattern of connectivity during metaphor processing which was related to bilateral (but more pronounced at the left hemisphere) hypoactivation of the brain. Moreover, we found reversed lateralization patterns, i.e. a rightward-shifted pattern during metaphor processing in schizophrenia compared to the control group. In conclusion, the presented findings revealed that the impairment of the conventional metaphor processing in schizophrenia is related to the bilateral brain hypofunction, which supports the evidence on reversed lateralization of the language neural network and the existence of compensatory recruitment of alternative neural circuits in schizophrenia.

The Role of Working Memory in the Processing of Scalar Implicatures of Patients With Schizophrenia Spectrum and Other Psychotic Disorders

A number of studies have demonstrated pragmatic language difficulties in people with Schizophrenia Spectrum and Other Psychotic Disorders. However, research about how people with schizophrenia spectrum and other psychotic disorders understand scalar implicatures (SIs) is surprisingly rare, since SIs have generated much of the most recent literature. Scalar implicatures are pragmatic inferences, based on linguistic expressions like some, must, or, which are part of a scale of informativeness (e.g., some/many/all). Logically, the less informative expressions imply the more informative ones, but pragmatically people usually infer that the presence of a less informative term implies that the more informative term was not applicable. In one of the few existing studies with people with schizophrenia spectrum and other psychotic disorders, Wampers et al. (2018) observed that in general, people with schizophrenia spectrum and other psychotic disorders were less likely to derive SIs than controls. The current study has three main aims. First, we want to replicate the original finding with the scalar terms some-all. Second, we want to investigate how these patients deal with different scalar terms, that is, we want to investigate if scalar diversity is also observed in this clinical group. Third, we investigate the role of working memory, often seen as another important mechanism to enable inferring SIs. Twenty-one individuals with a psychotic disorder and 21 matched controls answered 54 under-informative statements, in which seven different pairs of scalar terms were used. In addition, working memory capacity was measured. Patients with schizophrenia spectrum and other psychotic disorders did not make more logical interpretations when processing quantifiers, disconfirming Wampers et al. (2018). However, certain scalar scales elicited more pragmatic interpretations than others, which is in line with the scalar diversity hypothesis. Additionally, we observed only partial evidence for the role of working memory. Only for the scalar scale and-or, a significant effect of working memory was observed. The implications of these results for patients with schizophrenia spectrum and other psychotic disorders are discussed, but also the role of working memory for pragmatic inferences, as well as the place of SIs in experimental pragmatics.

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.

How to improve social communication in aging: Pragmatic and cognitive interventions

Among all aspects of the linguistic and communicative competence, pragmatics seems especially vulnerable in aging, due also to cognitive decline. However, pragmatics has never been considered as an intervention target in healthy aging. Here we tested the effects of a novel training program to improve pragmatics (PragmaCom) in older adults, compared with an active cognitive control group in a randomized-controlled-trial design. Both the PragmaCom group and the control group improved in pragmatic skills such as understanding metaphors and avoiding off-topic speech, indicating that it is possible to improve pragmatics in aging both with a specific training and with a cognitive training. Individual cognitive factors predicted pragmatic improvement in the control group, while in the PragmaCom group benefits were less dependent on individual characteristics. We discuss the results in terms of pragmatic plasticity, highlighting the importance of these findings for promoting older adults' social communication and well-being.

Metaphor Processing Dysfunctions in Schizophrenia Patients With and Without Substance Use Disorders

BACKGROUND

Patients with schizophrenia have difficulties comprehending metaphors, which significantly impedes communication. However, this topic has not been thoroughly studied in people with a dual diagnosis. On this basis, we formulated two research aims: a) to compare the ability to comprehend metaphors in schizophrenia patients without (SZ) and with substance use disorder (SZ-SUD) and b) to determine the relationship between the processing of metaphorical content and the severity of psychopathological symptoms in both clinical groups.

METHODS

A total of 40 individuals with SZ and 40 individuals with SZ-SUD took part in the study. The control group was composed of 40 individuals without a psychiatric or neurological diagnosis. Four subtests from the Right Hemisphere Language Battery (Picture Metaphor Test, Written Metaphor Test, Picture Metaphor Explanation Test, Written Metaphor Explanation Test) were used to measure the ability to understand and explain metaphors.

RESULTS

Both groups of individuals with schizophrenia (SZ and SZ-SUD) scored lower than individuals from the control group on all tests of metaphor processing. However, no differences were observed between the two clinical groups. SZ-SUD patients had better results for Picture Metaphor Explanation than for Written Metaphor Explanation. Negative symptoms were found to be significant predictors of difficulties with understanding and explaining metaphors.

CONCLUSION

Individuals with schizophrenia, regardless of their substance use disorder (SUD) status, exhibit impaired metaphorical content processing. SUD in schizophrenia is not associated with significant impairments in understanding and explaining metaphorical content. Moreover, impairments in processing metaphorical content are associated with more severe negative symptoms of schizophrenia.