Theory of Mind Impairments in Youth at Clinical High Risk of Psychosis

The Effects of Cannabidiol and δ-9-Tetrahydrocannabinol in Social Cognition: A Naturalistic Controlled Study

Background: Social cognition abilities such as empathy and the Theory of Mind (ToM) have been shown to be impaired in neuropsychiatric conditions such as psychotic, autistic, and bipolar disorders. The endocannabinoid system (ECS) seems to play a role in social behavior and emotional processing while it also seems to play a role in those neuropsychiatric conditions showing social cognition impairments. Main plant cannabinoids delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) modulate the ECS and, due to their opposite effects, have been proposed as both cause and treatment for neuropsychiatric-related disorders such as schizophrenia, anxiety, or post-traumatic stress disorder (PTSD). The aim of this study was to test the effects of THC and CBD on social cognition abilities in chronic cannabis users. Method: Eighteen members from a cannabis social club were tested for social cognition effects under the effects of different full spectrum cannabis extracts containing either THC, CBD, THC+CBD, or placebo in a naturalistic randomized double-blind crossover placebo-controlled study. Results: Results showed that participants under the effects of THC showed lower cognitive empathy when compared with the effects of CBD but not when those were compared with THC+CBD or placebo. Also, participants showed higher cognitive ToM under the effects of CBD when compared with the effects of placebo, but not when those were compared with THC or THC+CBD. However, we did not find differences on the emotional scales for empathy or ToM. Conclusions: This study provides evidence for the interaction between the effects of THC and CBD and social cognition abilities in a naturalistic environment, which can be of special interest for the clinical practice of medical cannabis on neuropsychiatric disorders. We show for the first time that CBD can improve ToM abilities in chronic cannabis users. Our results might help to understand the role of the ECS in social cognition, and their association with psychiatric and neurodevelopmental disorders such as schizophrenia or autism. Finally, we demonstrate how reliable methodologies can be implemented in naturalistic environments to collect valid ecological evidence outside classic laboratory settings.

Adverse childhood experiences in patients with schizophrenia: related factors and clinical implications

The relationship between adverse childhood experiences (ACEs) and the development of psychotic symptoms is not well understood. Therefore, this study aimed to investigate the frequency and distribution of ACEs among patients with schizophrenia and their potential correlation with symptomatology and personality pathology. We conducted a cross-sectional study involving 571 patients with schizophrenia in Shanghai, China. Symptomatology was assessed using the Positive and Negative Symptoms Scale (PANSS) and personality pathology was assessed using the Personality Diagnostic Questionnaire Fourth Edition Plus (PDQ-4+). ACEs were assessed using the Child Trauma Questionnaire-Short Form (CTQ-SF). ACEs were highly prevalent, with 80.8% of the patients with schizophrenia reporting at least one ACE. The three most common types of ACE were physical neglect (69.8%), emotional neglect (28.2%), and emotional abuse (22.9%). For specific ACE, emotional abuse was significantly associated with PD traits, whereas emotional and physical neglect types of ACE was significantly associated with negative symptoms. A higher level of physical abuse was more commonly reported by men, younger individuals, and those with a higher level of antisocial PD traits. Higher levels of physical neglect were associated with more severe negative symptoms. ACEs are commonly observed in patients with schizophrenia. Therefore, it is strongly recommended that this clinical population be provided with a comprehensive assessment and individualized intervention for those exposed to specific ACEs.

Symptoms of Attenuated Psychosis Syndrome in Relatives of Clinical High-Risk Youth: Preliminary Evidence

BACKGROUND AND HYPOTHESIS

Attenuated Psychosis Syndrome (APS) impacts functioning and predicts increased risk of psychosis. Risk for developing APS itself has received minimal attention. Knowledge of familial and environmental contributions to APS symptoms would advance understanding of APS and risk for psychosis. As an initial step, this report presents the first data on APS symptoms in family members of APS patients.

STUDY DESIGN

This study utilized a discordant sibling-pair family study design. The Structured Interview for Psychosis-risk Syndromes (SIPS) was administered to 17 APS probands and 26 non-APS biological siblings. Probands and siblings were compared on positive, negative, disorganized, and general SIPS symptom scales and factors derived from those scales.

STUDY RESULTS

There was significantly greater symptom severity in probands compared to siblings on nine of 19 SIPS scales. Negative/anxiety, functioning, and positive symptom factors were identified. Probands showed significantly greater severity than siblings on the negative/anxiety and positive factors. Elevated pathology on the negative/anxiety factor best differentiated between probands and siblings, over and above the contribution of the positive factor. No difference was found for the functioning factor.

CONCLUSIONS

Results support the importance of non-familial effects on risk for APS and suggest differences in familial contribution to APS symptoms. Understanding the relative contribution of familial and environmental effects on APS symptoms may reveal important differences among APS patients, with implications for risk characterization, symptom course, and treatment selection.

Inefficient integration during multiple facial processing in pre-morbid and early phases of psychosis

OBJECTIVES

We used eye-tracking to evaluate multiple facial context processing and event-related potential (ERP) to evaluate multiple facial recognition in individuals at clinical high risk (CHR) for psychosis.

METHODS

In total, 173 subjects (83 CHRs and 90 healthy controls [HCs]) were included and their emotion perception performances were accessed. A total of 40 CHRs and 40 well-matched HCs completed an eye-tracking task where they viewed pictures depicting a person in the foreground, presented as context-free, context-compatible, and context-incompatible. During the two-year follow-up, 26 CHRs developed psychosis, including 17 individuals who developed first-episode schizophrenia (FES). Eighteen well-matched HCs were made to complete the face number detection ERP task with image stimuli of one, two, or three faces.

RESULTS

Compared to the HC group, the CHR group showed reduced visual attention to contextual processing when viewing multiple faces. With the increasing complexity of contextual faces, the differences in eye-tracking characteristics also increased. In the ERP task, the N170 amplitude decreased with a higher face number in FES patients, while it increased with a higher face number in HCs.

CONCLUSIONS

Individuals in the very early phase of psychosis showed facial processing deficits with supporting evidence of different scan paths during context processing and disruption of N170 during multiple facial recognition.

Social cognition and self-reported ASD traits in young adults who have reported psychotic experiences: A population-based, longitudinal study

OBJECTIVE

Social cognition is considered a trait marker of psychosis, and has rarely been investigated in young adults who have reported psychotic experiences (PE). The aim of the present study was to explore whether social cognition, self-reported Autism Spectrum Disorder (ASD) traits and functioning were associated with PE.

METHODS

Participants were invited to take part in a 10-year follow-up study (mean age 20.9 years), of whom 103 participants returned, including 41 who had reported PE either past or current. Social cognition (theory of mind, social perception and locus of control) was assessed and a self-report measure of ASD traits was administered. Psychopathology and global functioning were assessed using the SCID-5. Analyses investigated group differences between PE and controls, and the association between social cognition and functioning in the PE group. A mediation analysis investigated if the association between PE and social cognition was explained by ASD traits.

RESULTS

The PE group had poorer theory of mind scores (F = 4.22, p = .043), specifically for neutral and negative stimuli, and an external locus of control (F = 5.73, p = .019) in young adulthood. The PE group had a significantly greater number of self-reported ASD traits than the controls (χ²(2) = 10.65). External locus of control had a significant negative correlation with current role functioning in the PE group. The association between PE and social cognition abilities was not mediated by ASD traits.

CONCLUSION

Psychotic experiences are associated with poorer theory of mind and an external locus of control, as well as proportionally more self-reported ASD traits, in young adulthood.

Neural Correlates of Mentalizing in Individuals With Clinical High Risk for Schizophrenia: ALE Meta-Analysis

Psychotic disorder refers to a spectrum of disorders that have multiple etiologies, due to the complex interaction of biological and genetic vulnerability with familial and cultural factors. A clinical high risk (CHR) for schizophrenia is defined as the presence of brief, attenuated, or intermittent psychotic symptoms in non-schizophrenic individuals. The transition to schizophrenia appears significantly more frequent in this at-risk population than in the general population. Moreover, the ability to attribute mental states to others, known as mentalizing or theory of mind, and its neural correlates found in individuals with CHR are similar to those described in patients with schizophrenia. We have therefore explored neurofunctional correlates of mentalizing in individuals with CHR vs. healthy controls, in order to identify the differences in brain activation. A neural coordinate-based activation likelihood estimation meta-analysis of existing neuroimaging data revealed that three regions displayed decreased activation in individuals with CHR, compared with healthy controls: the right temporoparietal junction, the right middle temporal gyrus, and the left precuneus. These results, combined with those in the literature, further support the hypothesis that abnormal activation of posterior brain regions involved in mentalizing correlates with psychotic symptoms in help-seeking individuals.

Comparison of social cognition using an adapted Chinese version of the Reading the Mind in the Eyes Test in drug-naive and regularly medicated individuals with chronic schizophrenia and healthy controls in rural China

BACKGROUND

Social cognition has not previously been assessed in treatment-naive patients with chronic schizophrenia, in patients over 60 years of age, or in patients with less than 5 years of schooling.

METHODS

We revised a commonly used measure of social cognition, the Reading the Mind in the Eyes Test (RMET), by expanding the instructions, using both self-completion and interviewer-completion versions (for illiterate respondents), and classifying each test administration as 'successfully completed' or 'incomplete'. The revised instrument (RMET-CV-R) was administered to 233 treatment-naive patients with chronic schizophrenia (UT), 154 treated controls with chronic schizophrenia (TC), and 259 healthy controls (HC) from rural communities in China.

RESULTS

In bivariate and multivariate analyses, successful completion rates and RMET-CV-R scores (percent correct judgments about emotion exhibited in 70 presented slides) were highest in HC, intermediate in TC, and lowest in UT (adjusted completion rates, 97.0, 72.4, and 49.9%, respectively; adjusted RMET-CV-R scores, 45.4, 38.5, and 34.6%, respectively; all p < 0.02). Stratified analyses by the method of administration (self-completed v. interviewer-completed) and by education and age ('educated-younger' v. 'undereducated-older') show the same relationship between groups (i.e. NC>TC>UT), though not all differences remain statistically significant.

CONCLUSIONS

We find poorer social cognition in treatment-naive than in treated patients with chronic schizophrenia. The discriminant validity of RMET-CV-R in undereducated, older patients demonstrates the feasibility of administering revised versions of RMET to patients who may otherwise be considered ineligible due to education or age by changing the method of test administration and carefully assessing respondents' ability to complete the task successfully.

Impaired Performance on the Reading the Mind in the Eyes Test in First-Episode Psychosis and Clinical High Risk for Psychosis

OBJECTIVE

Although previous studies have reported impaired performance in the reading the mind in the eyes test (RMET), which measures complex emotion recognition abilities, in patients with schizophrenia, reports regarding individuals at clinical high risk (CHR) for psychosis have been inconsistent, mainly due to the interacting confounding effects of general cognitive abilities and age. We compared RMET performances across first-episode psychosis (FEP) patients, CHR individuals, and healthy controls (HCs) while controlling for the effects of both general cognitive abilities and age.

METHODS

A total of 25 FEP, 41 CHR, and 44 HC subjects matched for age participated in this study. RMET performance scores were compared across the groups using analysis of variance with sex and intelligence quotient as covariates. Exploratory Pearson's correlation analyses were performed to reveal the potential relationships of RMET scores with clinical symptom severity in the FEP and CHR groups.

RESULTS

RMET performance scores were significantly lower among FEP and CHR participants than among HCs. FEP patients and CHR subjects showed comparable RMET performance scores. RMET scores were negatively correlated with Positive and Negative Syndrome Scale (PANSS) positive symptom subscale scores in the FEP patients. No significant correlation was identified between RMET scores and other clinical scale scores.

CONCLUSION

Impaired RMET performance is present from the risk stage of psychosis, which might be related to positive symptom severity in early psychosis. Longitudinal studies are necessary to confirm the stability of complex emotion recognition impairments and their relationship with social functioning in early psychosis patients.

What Do You Have in Mind? Measures to Assess Mental State Reasoning in Neuropsychiatric Populations

Social interaction is closely associated with both functional capacity and well-being. Previous research has not only revealed evidence of social dysfunction in individuals with a wide range of psychiatric and neurological disorders but also generated an abundance of potential measures for assessing social cognition. This review explores the most popular measures used within neuropsychiatric populations to investigate the ability to recognize or reason about the mental states of others. Measures are also critically analyzed in terms of strengths and limitations to aid task selection in future clinical studies. The most frequently applied assessment tools use verbal, visual or audiovisual forms of presentation and assess recognition of mental states from facial features, self-rated empathy, the understanding of other's cognitive mental states such as beliefs and intentions, or the ability to combine knowledge of other's thoughts and emotions in order to understand subtle communications or socially inappropriate behavior. Key weaknesses of previous research include limited investigation of relationships with clinical symptoms, and underutilization of measures of everyday social functioning that offer a useful counterpart to traditional "lab" tasks. Future studies should aim to carefully select measures not only based on the range of skills to be assessed but also taking into account potential difficulties with interpretation and the need to gain insight into the application of social cognitive skills as well as ability per se. Some of the best measures include those with well-matched control trials (e.g., Yoni Task) or those that restrict the influence of verbal deficits (e.g., intentions comic strip task), elicit spontaneous mentalizing (e.g., Animations Task), and possess greater ecological validity (e.g., Movie for the Assessment of Social Cognition). Social cognitive research within psychiatric populations will be further enhanced through the development of more closely matched control tasks, and the exploration of relationships between task performance, medication, strategy use, and broader emotional and motor functions.

Progressive decline of cognition during the conversion from prodrome to psychosis with a characteristic pattern of the theory of mind compensated by neurocognition

The association between neurocognition and the theory of mind (ToM) abilities during the progression of psychosis is unclear. This study included 83 individuals with attenuated psychosis syndrome (APS), from which 26 converted to psychosis (converters) after a follow up period of 18months. Comprehensive cognitive tests (including MATRICS Consensus Cognitive Battery, Faux-Pas Task, and Reading-Mind-in-Eyes Tasks) were administered at baseline. A structural equation modeling (SEM) analysis was conducted to estimate the effects of neurocognition on the ToM functioning in both APS and healthy controls (HC) datasets. At baseline, the converters and non-converters groups differed significantly on several domains of cognitive performance. The SEM analysis demonstrated that the path from neurocognition to ToM was statistically significant in the APS dataset (p<0.001). However, in the HC dataset, the result of the same analysis was not significant (p=0.117). Positive correlations between neurocognition and ToM were observed, and the most obvious correlations were found in the converters group compared with the non-converters group (p=0.064) and compared with the HC group (p=0.002). The correlation between ToM abilities and neurocognition may be increased during the progression of the condition, especially for individuals who convert to psychosis after a short period.

Changes in correlation characteristics of time consumption and mind-reading performance in pre-onset and post-onset psychosis

There is a strong correlation between neurocognition and social cognition. However, none of these studies have examined the key role of time consumption during social cognition tasks. Participants included 84 individuals with clinical high risk of psychosis (CHR), 95 healthy controls (HC), and 66 case controls (schizophrenia patients, SZ), who were assessed through the Reading-Mind-in-Eyes Tasks (RMET) with computerized recording of the response time (RT). Neurocognitive tests were also performed for the HC and CHR groups. A comparison of RMET performance revealed significantly lower scores in the SZ group compared to the HC group, with CHR individuals scoring between these two. However, both CHR and SZ subjects spent almost twice as long of the time on RMET compared to the HC subjects. Significant positive correlation was found between RMET accuracy and RT, though only in SZ patients. Taking the RT into consideration, the RMET performances were impacted by different neurocognition domains. Our findings provide new evidence about how time consumption in mind-reading may impact the relationship between social cognition and neurocognition, and we discuss the potential importance of recording the response time during social cognition assessment in individuals with early psychosis.

Social cognition and self-other distinctions in neuropsychiatry: Insights from schizophrenia and Tourette syndrome

Impairments in social cognition may reflect dysfunction of disorder specific or disorder general mechanisms. Although cross-disorder comparison may prove insightful, few studies have compared social cognition in different neuropsychiatric disorders. Parallel investigation of schizophrenia and Tourette syndrome (TS) is encouraged by similarities including the presence of problematic social behavior, echophenomena, emotional dysregulation and dopamine dysfunction. Focusing on tests of social cognition administered in both disorders, this review aims to summarize behavioral, neurophysiological and neuroimaging findings, before exploring how these may contribute to clinical symptoms. Studies investigating social cognition (imitation, emotion recognition, and understanding of beliefs or intentions) in patients with schizophrenia or TS were identified through Web of Science and PubMed searches. Although findings indicate that social cognitive deficits are more apparent in schizophrenia, adults with TS can exhibit similar task performance to patients with paranoia. In both disorders, behavioral and neuroimaging findings raise the possibility of increased internal simulation of others' actions and emotions, in combination with a relative under-application of mentalizing. More specifically, dysfunction in neurobiological substrates such as temporo-parietal junction and inferior frontal gyrus may underlie problems with self-other distinctions in both schizophrenia and TS. Difficulties in distinguishing between actions and mental states linked to the self and other may contribute to a range of psychiatric symptoms, including emotional dysregulation, paranoia, social anhedonia and socially disruptive urges. Comparing different patient populations could therefore reveal common neuro-cognitive risk factors for the development of problematic social behaviors, in addition to markers of resilience, coping strategies and potential neuro-compensation mechanisms.