A Systematic Review of the Current Measures of Theory of Mind in Adults with Schizophrenia

Reliability of Theory of Mind Tasks in Schizophrenia, ASD, and Nonclinical Populations: A Systematic Review and Reliability Generalization Meta-analysis

Though theory of mind (ToM) is an important area of study for different disciplines, however, the psychometric evaluations of ToM tasks have yielded inconsistent results across studies and populations, raising the concerns about the accuracy, consistency, and generalizability of these tasks. This systematic review and meta-analysis examined the psychometric reliability of 27 distinct ToM tasks across 90 studies involving 2771 schizophrenia (SZ), 690 autism spectrum disorder (ASD), and 15,599 nonclinical populations (NC). Findings revealed that while all ToM tasks exhibited satisfactory internal consistency in ASD and SZ, about half of them were not satisfactory in NC, including the commonly used Reading the Mind in the Eye Test and Hinting Task. Other than that, Reading the Mind in the Eye Test showed acceptable reliability across populations, whereas Hinting Task had poor test-retest reliability. Notably, only Faux Pas Test and Movie for the Assessment of Social Cognition had satisfactory reliability across populations albeit limited numbers of studies. However, only ten studies examined the psychometric properties of ToM tasks in ASD adults, warranting additional evaluations. The study offered practical implications for selecting ToM tasks in research and clinical settings, and underscored the importance of having a robust psychometric reliability in ToM tasks across populations.

Validation of behavioral measures of social cognition in individuals diagnosed with schizophrenia

Schizophrenia, a complex neuropsychiatric disorder, manifests severe impairments in social cognition, notably in Theory of Mind (ToM), empathy, and emotion recognition, which significantly influence social competence and overall functioning. These aspects are crucial for prognosis in individuals diagnosed with schizophrenia (SZ). This study validates a comics strip paradigm for ToM and empathy assessment, the Montreal Affective Voices (MAV) for measuring emotion recognition, and a Go-NoGo task for inhibition control estimation in individuals diagnosed with SZ, comparing their performance with healthy controls. SZ participants exhibited diminished abilities in the comics strip task, especially in ToM and empathy conditions, alongside challenges in identifying emotions from vocal cues in MAV. They responded slower and tended to be less accurate in the Go-NoGo task. The validated behavioral battery addresses the limitations of previous measures and emerges as a promising tool for future investigations into the neural systems underlying social cognition in schizophrenia. Such insights can lead to the development of long-needed treatment for negative symptoms and social dysfunctions in schizophrenia.

Reliability and minimal detectable change of the Yoni task for the theory of mind assessment

Introduction

The Theory of Mind (ToM) assessment is becoming essential to evaluate the response to a social cognition intervention and to monitor the progression of social abilities impairment in atypical conditions. In the Italian setting, the Yoni task has been recently validated in its short version (the Yoni-48 task) to evaluate ToM in the clinical setting. The present study aimed to verify the test-retest reliability and the Minimal Detectable Change (MDC) of the Yoni-48 task.

Methods

The Yoni-48 task was administered to 229 healthy adults at two evaluation sessions 3 weeks apart (mean days between sessions = 20.35 ± 1.75) by a psychologist. The test-retest reliability of the Yoni-48 task accuracy and response time was tested by the Intraclass Correlation Coefficient (ICC2,1, two-way random model, absolute agreement type). Then, the MDC95 and MDC90 were computed based on the standard error of measurement. Finally, the 95% limits of agreement were plotted (LOA plot) to visualize the difference and mean score of each pair of measurements.

Results

The total Yoni-48 task accuracy, but not the response time score, showed a high ICC (>0.80), with an MDC of 0.10. By plotting the LOA plot for the accuracy score no systematic trends were observed.

Discussion

This evidence will support the adoption of the Yoni task in longitudinal designs.

Mentalizing impairments and hypermentalizing bias in individuals with first-episode schizophrenia-spectrum disorder and at-risk mental state: the differential roles of neurocognition and social anxiety

Mentalizing, or theory of mind (ToM), impairments and self-referential hypermentalizing bias are well-evident in schizophrenia. However, findings compared to individuals with at-risk mental states (ARMS) are inconsistent, and investigations into the relationship between social cognitive impairments and social anxiety in the two populations are scarce. This study aimed to examine and compare these deficits in first-episode schizophrenia-spectrum disorder (FES) and ARMS, and to explore potential specific associations with neurocognition and symptomatology. Forty patients with FES, 40 individuals with ARMS, and 40 healthy controls (HC) completed clinical assessments, a battery of neurocognitive tasks, and three social cognitive tasks. The comic strip and hinting tasks were used to measure non-verbal and verbal mentalizing abilities, and the gaze perception task was employed to assess self-referential hypermentalizing bias. FES and ARMS showed comparable mentalizing impairments and self-referential hypermentalizing bias compared to HC. However, only ambiguous self-referential gaze perception (SRGP) bias remained significantly different between three groups after controlling for covariates. Findings suggested that self-referential hypermentalizing bias could be a specific deficit and may be considered a potential behavioral indicator in early-stage and prodromal psychosis. Moreover, working memory and social anxiety were related to the social cognitive impairments in ARMS, whereas higher-order executive functions and positive symptoms were associated with the impairments in FES. The current study indicates the presence of stage-specific mechanisms of mentalizing impairments and self-referential hypermentalizing bias, providing insights into the importance of personalized interventions to improve specific neurocognitive domains, social cognition, and clinical outcomes for FES and ARMS.

Targeting metacognitive change mechanisms in acute inpatients with psychotic symptoms: feasibility and acceptability of a modularized group intervention

Emerging evidence suggests the usefulness of psychological interventions targeting metacognitive change mechanisms in patients experiencing psychosis. Although many of these patients are treated in acute psychiatric contexts, only few studies have adapted such interventions for acute inpatient settings. The present study aimed to assess the feasibility, acceptability, and preliminary clinical outcomes of a novel modularized group intervention focusing on different aspects of metacognitive change mechanisms. In particular, the intervention aims to reduce patients' acute symptoms by enhancing cognitive insight and to relieve distress via cognitive defusion (i.e. coping). A sample of 37 participants with acute psychosis received up to nine sessions of the intervention. Baseline and post-intervention assessments were conducted for general psychopathology, psychotic symptoms, global functioning, and symptom distress. Measures of change mechanisms were assessed before and after the respective treatment module. Participants' experiences were explored in feedback questionnaires and interviews. Recruitment, retention, and attendance rate met the pre-set feasibility benchmark of 80%. The intervention was well received by participants, who emphasised the group's clear structure, positive atmosphere, and helpful contents. Response rates were high and linear mixed models revealed significant medium-to-large time effects on all clinical outcomes. As expected, increase in hypothesised change mechanisms cognitive insight and decrease in cognitive fusion was found. However, the uncontrolled design limits interpreting clinical effects. The study provides evidence that an intervention based on a metacognitive model is feasible and acceptable for acute inpatients with psychosis. Positive results on clinical outcomes and change mechanisms warrant further exploration in a randomized controlled trial.

Adverse childhood experiences differently affect Theory of Mind brain networks in schizophrenia and healthy controls

Patients with schizophrenia (SZ) show impairments in both affective and cognitive dimensions of theory of mind (ToM). SZ are also particularly vulnerable to detrimental effect of adverse childhood experiences (ACE), influencing the overall course of the disorder and fostering poor social functioning. ACE associate with long-lasting detrimental effects on brain structure, function, and connectivity in regions involved in ToM. Here, we investigated whether ToM networks are differentially affected by ACEs in healthy controls (HC) and SZ, and if these effects can predict the disorder clinical outcome. 26 HC and 33 SZ performed a ToM task during an fMRI session. Whole-brain functional response and connectivity (FC) were extracted, investigating the interaction between ACEs and diagnosis. FC values significantly affected by ACEs were entered in a cross-validated LASSO regression predicting Positive and Negative Syndrome Scale (PANSS), Interpersonal Reactivity Index (IRI), and task performance. ACEs and diagnosis showed a widespread interaction at both affective and cognitive tasks, including connectivity between vmPFC, ACC, precentral and postcentral gyri, insula, PCC, precuneus, parahippocampal gyrus, temporal pole, thalamus, and cerebellum, and functional response in the ACC, thalamus, parahippocampal gyrus and putamen. FC predicted the PANSS score, the fantasy dimension of IRI, and the AToM response latency. Our results highlight the crucial role of early stress in differentially shaping ToM related brain networks in HC and SZ. These effects can also partially explain the clinical and behavioral outcomes of the disorder, extending our knowledge of the effects of ACEs.

Mentalizing in a movie for the assessment of social cognition (MASC): the validation in a taiwanese sample

BACKGROUND

The present study evaluated the psychometrics properties of a sensitive video-based test used in the evaluation of mentalizing skills, that is, the Movie for the Assessment of Social Cognition-Taiwanese version (MASC-TW).

METHODS

We recruited two independent samples of nonclinical participants (N = 167) and adult patients with schizophrenia (N = 41). The MASC-TW and two other social cognition measures, namely the Chinese version of Theory of Mind task (ToM) and the Taiwanese version of the Diagnostic Analysis of Nonverbal Accuracy-2 (DANAV-TW-2), and an executive function measure of the Wisconsin Card Sorting Test (WCST), were administered to both groups.

RESULTS

The MASC proved to be a reliable measure of mentalizing capacity, high Cronbach's α value of 0.87. The intraclass correlation coefficient for the MASC-TW total correct scores was 0.85 across three waves of data collection. Across the entire sample, the scores on the MASC-TW were significantly correlated with verbal and nonverbal scores for the ToM task and recognition of facial and prosodic emotion on the DANAV-TW-2. Both executive function and emotion recognition emerged as noteworthy predictors of mentalizing, indicating that these two variables might play crucial roles in the development of mentalizing capacities. Finally, a receiver operating characteristic analysis revealed that in patients with schizophrenia, the MASC was the most accurate discriminator of diagnostic groups, highlighting the validity of the MASC.

CONCLUSIONS

Overall, the MASC-TW is an ecologically valid and useful tool for assessing mentalizing abilities in a Taiwanese population.

Standardization and normative data of the 48-item Yoni short version for the assessment of theory of mind in typical and atypical conditions

Introduction

The Yoni task is a computerized tool assessing first-and second-order affective and cognitive Theory of Mind (ToM), accounting for the multidimensional and multi-level mentalizing features. The Italian Yoni task has been validated and standardized in its 98-item version, and a 48-item short version has been proposed for a quick digital evaluation of ToM in clinical contexts.

Methods

The present study aimed to test the Yoni-48's convergent validity, correlating the tool score with the Reading the Mind in the Eyes test (ET) and Gender Test (GT), its items discrimination ability through the Classical Test Theory, and Rash model, its reliability by evaluating the internal consistency (McDonald's ω, Cronbach's α, Guttman's λ ², and Guttman's λ ⁶) and Spearman-Brown ϱ_SP split-half analysis, and to provide standardization and normative data in the Italian population.

Results

Results suggested a good convergent validity with a statistically significant association with ET (p < 0.001), while a null correlation was observed with GT (p = 0.947). The Classical Test Theory and Rash model confirmed a good discrimination ability of the Yoni-48's second-order affective and cognitive ToM items, while weaker discrimination capacity was registered for the first-order ToM items. The inter-item reliability was optimal for clinical purposes (ω, α, λ ², λ ⁶ ≥ 0.90). Also, the split-half reliability was high (Spearman-Brown ϱ_SP = 0.90). For standardization, age and education were revealed as significant predictors of Yoni accuracy scores, except for the first-order ToM score. Instead, age was the only predictor of Yoni's response speed score. The Italian normative data showed a high Yoni accuracy in healthy adults (mean accuracy = 0.85) and speed (mean response time = 0.92). Finally, both accuracy and response time level was balanced between the affective and cognitive components of ToM.

Discussion

This study supports the psychometric properties of the Yoni-48 and provides normative data for the Italian population. Further studies are needed to test the suitability of this short version for profiling the social cognition neurocognitive phenotype.

The animated assessment of theory of mind for people with schizophrenia (AToMS): development and psychometric evaluation

Theory of mind (ToM) deficits in people with schizophrenia have been reported and associated with impaired social interactions. Thus, ToM deficits may negatively impact social functioning and warrant consideration in treatment development. However, extant ToM measures may place excessive cognitive demands on people with schizophrenia. Therefore, the study aimed to develop a comprehensible Assessment of ToM for people with Schizophrenia (AToMS) and evaluate its psychometric properties. The AToMs was developed in 5 stages, including item formation, expert review, content validity evaluation, animation production, and cognitive interviews of 25 people with schizophrenia. The psychometric properties of the 16-item AToMS (including reliability and validity) were then tested on 59 people with schizophrenia. The newly developed animated AToMS assesses 8 ToM concepts in the cognitive and affective dimensions while placing minimal neurocognitive demands on people with schizophrenia. The AToMS presented satisfactory psychometric properties, with adequate content validity (content validity index = 0.91); mostly moderate item difficulty (item difficulty index = 0.339-0.966); good discrimination (coefficients = 0.379-0.786), internal consistency (Cronbach's α = 0.850), and reliability (intraclass correlation coefficient = 0.901 for test-retest, 0.997 for inter-rater); and satisfactory convergent and divergent validity. The AToMS is reliable and valid for evaluating ToM characteristics in people with schizophrenia. Future studies are warranted to examine the AToMS in other populations (e.g., people with affective disorders) to cross-validate and extend its utility and psychometric evidence.