Hostname: page-component-848d4c4894-cjp7w Total loading time: 0 Render date: 2024-06-13T22:56:38.082Z Has data issue: false hasContentIssue false

Theory of mind in the early course of schizophrenia: stability, symptom and neurocognitive correlates, and relationship with functioning

Published online by Cambridge University Press:  03 February 2015

J. Ventura*
UCLA Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
A. Ered
UCLA Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
D. Gretchen-Doorly
UCLA Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
K. L. Subotnik
UCLA Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
W. P. Horan
UCLA Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
G. S. Hellemann
UCLA Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
K. H. Nuechterlein
UCLA Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA UCLA Department of Psychology, Los Angeles, CA, USA
*Address for correspondence: J. Ventura, Ph.D., UCLA Department of Psychiatry, 300 Medical Plaza, Room 2243, Los Angeles, CA 90095-6968, USA. (Email:



Numerous studies have reported links between theory of mind (ToM) deficits, neurocognition and negative symptoms with functional outcome in chronic schizophrenia patients. Although the ToM deficit has been observed in first-episode patients, fewer studies have addressed ToM as a possible trait marker, neurocognitive and symptom correlations longitudinally, and associations with later functioning.


Recent-onset schizophrenia patients (n = 77) were assessed at baseline after reaching medication stabilization, and again at 6 months (n = 48). Healthy controls (n = 21) were screened, and demographically comparable with the patients. ToM was assessed with a Social Animations Task (SAT), in which the participants’ descriptions of scenes depicting abstract visual stimuli ‘interacting’ in three conditions (ToM, goal directed and random) were rated for degree of intentionality attributed to the figures and for appropriateness. Neurocognition, symptoms and role functioning were also assessed.


On the SAT, patients had lower scores than controls for both intentionality (p < 0.01) and appropriateness (p < 0.01) during the ToM condition, at baseline and 6 months. The ToM deficit was stable and present even in remitted patients. Analyses at baseline and 6 months indicated that for patients, ToM intentionality and appropriateness were significantly correlated with neurocognition, negative symptoms and role functioning. The relationship between ToM and role functioning was mediated by negative symptoms.


The ToM deficit was found in recent-onset schizophrenia patients and appears to be moderately trait-like. ToM is also moderately correlated with neurocognition, negative and positive symptoms, and role functioning. ToM appears to influence negative symptoms which in turn makes an impact on role functioning.

Original Articles
Copyright © Cambridge University Press 2015 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


Abdel-Hamid, M, Lehmkämper, C, Sonntag, C, Juckel, G, Daum, I, Brüne, M (2009). Theory of mind in schizophrenia: the role of clinical symptomatology and neurocognition in understanding other people's thoughts and intentions. Psychiatry Research 165, 1926.Google Scholar
Abell, F, Happe, F, Frith, U (2000). Do triangles play tricks? Attribution of mental states to animated shapes in normal and abnormal development. Cognitive Development 15, 116.Google Scholar
Achim, AM, Ouellet, R, Roy, M-A, Jackson, PL (2012). Mentalizing in first-episode psychosis. Psychiatry Research 196, 207213.Google Scholar
Andreasen, NC (1982). Negative symptoms in schizophrenia: definition and reliability. Archives of General Psychiatry 39, 784788.Google Scholar
Andreasen, NC, Olsen, SA (1982). Negative v positive schizophrenia: definition and validation. Archives of General Psychiatry 39, 789794.Google Scholar
Baron, RM, Kenny, DA (1986). The moderator–mediator variable distinction in social psychological research: conceptual, strategic and statistical considerations. Journal of Personality and Social Psychology 51, 11731182.Google Scholar
Bell, MD, Fiszdon, JM, Greig, TC, Wexler, BE (2010). Social Attribution Test – multiple choice (SAT-MC) in schizophrenia: comparison with community sample and relationship to neurocognitive, social cognitive and symptom measures. Schizophrenia Research 122, 164171.Google Scholar
Bertrand, M-C, Sutton, H, Achim, AM, Malla, AK, Lepage, M (2007). Social cognitive impairments in first episode psychosis. Schizophrenia Research 95, 124133.Google Scholar
Blanchard, JJ, Mueser, KT, Bellack, AS (1998). Anhedonia, positive and negative affect, and social functioning in schizophrenia. Schizophrenia Bulletin 24, 413424.Google Scholar
Bora, E, Pantelis, C (2013). Theory of mind impairments in first-episode psychosis, individuals at ultra-high risk for psychosis and in first-degree relatives of schizophrenia: systematic review and meta-analysis. Schizophrenia Research 144, 3136.CrossRefGoogle ScholarPubMed
Bora, E, Yucel, M, Pantelis, C (2009). Theory of mind impairment in schizophrenia: meta-analysis. Schizophrenia Research 109, 19.Google Scholar
Brüne, M (2005). Emotion recognition, ‘theory of mind,’ and social behavior in schizophrenia. Psychiatry Research 133, 135147.Google Scholar
Castelli, F, Frith, C, Happé, F, Frith, U (2002). Autism, Asperger syndrome and brain mechanisms for the attribution of mental states to animated shapes. Brain 125, 18391849.Google Scholar
Castelli, F, Happé, F, Frith, U, Frith, C (2000). Movement and mind: a functional imaging study of perception and interpretation of complex intentional movement patterns. NeuroImage 12, 314325.Google Scholar
Couture, SM, Penn, DL, Roberts, DL (2006). The functional significance of social cognition in schizophrenia: a review. Schizophrenia Bulletin 32 (Suppl. 1), S44S63.Google Scholar
Drury, VM, Robinson, E, Birchwood, M (1998). ‘Theory of mind’ skills during an acute episode of psychosis and following recovery. Psychological Medicine 28, 11011112.Google Scholar
Fett, AKJ, Viechtbauer, W, Dominguez, MG, Penn, DL, van Os, J, Krabbendam, L (2011). The relationship between neurocognition and social cognition with functional outcomes in schizophrenia: a meta-analysis. Neuroscience and Biobehavioral Reviews 35, 573588.Google Scholar
Frith, CD (1992). The Cognitive Neuropsychology of Schizophrenia. Lawrence Erlbaum Associates Ltd: Hove, UK.Google Scholar
Frith, CD (1994). Theory of mind in schizophrenia. In The Neuropsychology of Schizophrenia (ed. David, A. S. and Cutting, J. C.), pp. 147162. Lawrence Erlbaum Associates: Hove, UK.Google Scholar
Frith, CD (2004). Schizophrenia and theory of mind. Psychological Medicine 34, 385389.Google Scholar
Frith, CD, Frith, U (2008). Implicit and explicit processes in social cognition. Neuron 60, 503510.Google Scholar
Frith, CD, Wolpert, DM (2004). The Neuroscience of Social Interaction: Decoding, Imitating, and Influencing the Actions of Others. Oxford University Press: New York.Google Scholar
Goodman, SH, Sewell, DR, Cooley, EL (1993). Assessing levels of adaptive functioning: the role functioning scale. Community Mental Health Journal 29, 119131.Google Scholar
Green, MF, Bearden, CE, Cannon, TD, Fiske, AP, Hellemann, GS, Horan, WP, Kee, K, Kern, RS, Lee, J, Sergi, MJ, Subotnik, KL, Sugar, CA, Ventura, J, Yee, CM, Nuechterlein, KH (2012). Social cognition in schizophrenia, part 1: performance across phase of illness. Schizophrenia Bulletin 38, 854864.Google Scholar
Green, MF, Kern, RS, Braff, DL, Mintz, J (2000). Neurocognitive deficits and functional outcome in schizophrenia: are we measuring the “right stuff”? Schizophrenia Bulletin 26, 119136.Google Scholar
Green, RS, Gracely, EJ (1987). Selecting a rating scale for evaluating services to the chronically mentally ill. Community Mental Health Journal 23, 91102.CrossRefGoogle Scholar
Harrington, L, Langdon, R, Siegert, R, McClure, J (2005). Schizophrenia, theory of mind, and persecutory delusions. Cognitive Neuropsychiatry 10, 87104.CrossRefGoogle ScholarPubMed
Heider, F, Simmel, M (1944). An experimental study of apparent behavior. American Journal of Psychology 57, 243259.Google Scholar
Horan, WP, Nuechterlein, KH, Wynn, JK, Lee, J, Castelli, F, Green, MF (2009). Disturbances in the spontaneous attribution of social meaning in schizophrenia. Psychological Medicine 39, 635643.Google Scholar
Inoue, Y, Yamada, K, Hirano, M, Shinohara, M, Tamaoki, T, Iguchi, H, Tonooka, Y, Kanba, S (2006). Impairment of theory of mind in patients in remission following first episode of schizophrenia. European Archives of Psychiatry and Clinical Neuroscience 256, 326328.Google Scholar
Kettle, JW, O'Brien-Simpson, L, Allen, NB (2008). Impaired theory of mind in first-episode schizophrenia: comparison with community, university and depressed controls. Schizophrenia Research 99, 96102.Google Scholar
Klin, A (2000). Attributing social meaning to ambiguous visual stimuli in higher-functioning autism and Asperger syndrome: The Social Attribution Task. Journal of Child Psychology and Psychiatry and Allied Disciplines 41, 831846.Google Scholar
Koelkebeck, K, Pedersen, A, Suslow, T, Kueppers, KA, Arolt, V, Ohrmann, P (2010). Theory of mind in first-episode schizophrenia patients: correlations with cognition and personality traits. Schizophrenia Research 119, 115123.Google Scholar
Leslie, AM, Friedman, O, German, TP (2004). Core mechanisms in ‘theory of mind’. Trends in Cognitive Sciences 8, 528533.CrossRefGoogle ScholarPubMed
Martin, LL, Tesser, A (2013). The Construction of Social Judgments. Psychology Press: New York.Google Scholar
Mazza, M, Catalucci, A, Pino, MC, Giusti, L, Nigri, A, Pollice, R, Roncone, R, Casacchia, M, Gallucci, M (2013). Dysfunctional neural networks associated with impaired social interactions in early psychosis: an ICA analysis. Brain Imaging and Behavior 7, 248259.CrossRefGoogle ScholarPubMed
Mazza, M, Pollice, R, Pacitti, F, Pino, MC, Mariano, M, Tripaldi, S, Casacchia, M, Roncone, R (2012). New evidence in theory of mind deficits in subjects with chronic schizophrenia and first episode: correlation with symptoms, neurocognition and social function. Rivista di Psichiatria 47, 327.Google Scholar
Meehl, PE (1969). Nuisance variables and the ex post facto design. Department of Psychiatry, University of Minnesota.Google Scholar
Mehta, UM, Thirthalli, J, Subbakrishna, D, Gangadhar, BN, Eack, SM, Keshavan, MS (2013). Social and neuro-cognition as distinct cognitive factors in schizophrenia: a systematic review. Schizophrenia Research 148, 311.Google Scholar
Mizrahi, R, Korostil, M, Starkstein, SE, Zipursky, RB, Kapur, S (2007). The effect of antipsychotic treatment on theory of mind. Psychological Medicine 37, 595602.Google Scholar
Nuechterlein, KH, Barch, DM, Gold, JM, Goldberg, TE, Green, MF, Heaton, RK (2004). Identification of separable cognitive factors in schizophrenia. Schizophrenia Research 72, 2939.Google Scholar
Nuechterlein, KH, Green, MF, Kern, RS, Baade, LE, Barch, DM, Cohen, JD, Essock, S, Fenton, WS, Frese, FJ III, Gold, JM, Goldberg, T, Heaton, RK, Keefe, RS, Kraemer, H, Mesholam-Gately, R, Seidman, LJ, Stover, E, Weinberger, DR, Young, AS, Zalcman, S, Marder, SR (2008 a). The MATRICS Consensus Cognitive Battery, part 1: test selection, reliability, and validity. American Journal of Psychiatry 165, 203213.Google Scholar
Nuechterlein, KH, Miklowitz, DJ, Ventura, J, Gitlin, MJ, Stoddard, M, Lukoff, D (2006). Classifying episodes in schizophrenia and bipolar disorder: criteria for relapse and remission applied to recent-onset samples. Psychiatry Research 144, 153166.Google Scholar
Nuechterlein, KH, Subotnik, KL, Turner, LR, Ventura, J, Becker, DR, Drake, RE (2008 b). Individual placement and support for individuals with recent-onset schizophrenia: integrating supported education and supported employment. Psychiatric Rehabilitation Journal 31, 340349.Google Scholar
Preacher, KJ, Hayes, AF (2004). SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behavior Research Methods, Instruments, and Computers 36, 717731.Google Scholar
Premack, D, Woodruff, G (1978). Does the chimpanzee have a theory of mind? Behavioural and Brain Sciences 4, 515526.Google Scholar
Russell, TA, Reynaud, E, Herba, C, Morris, R, Corcoran, R (2006). Do you see what I see? Interpretations of intentional movement in schizophrenia. Schizophrenia Research 81, 101111.CrossRefGoogle Scholar
Savla, GN, Vella, L, Armstrong, CC, Penn, DL, Twamley, EW (2013). Deficits in domains of social cognition in schizophrenia: a meta-analysis of the empirical evidence. Schizophrenia Bulletin 39, 979992.Google Scholar
Schmidt, SJ, Mueller, DR, Roder, V (2011). Social cognition as a mediator variable between neurocognition and functional outcome in schizophrenia: empirical review and new results by structural equation modeling. Schizophrenia Bulletin 37 (Suppl. 2), S41S54.Google Scholar
Sprong, M, Schothorst, P, Vos, E, Hox, J, Van Engeland, H (2007). Theory of mind in schizophrenia: meta-analysis. British Journal of Psychiatry 191, 513.Google Scholar
Vauth, R, Rusch, N, Wirtz, M, Corrigan, PW (2004). Does social cognition influence the relation between neurocognitive deficits and vocational functioning in schizophrenia? Psychiatry Research 128, 155165.Google Scholar
Ventura, J, Green, MF, Shaner, A, Liberman, RP (1993). Training and quality assurance with the Brief Psychiatric Rating Scale: “The drift busters.” International Journal of Methods in Psychiatric Research 3, 221244.Google Scholar
Ventura, J, Hellemann, GS, Thames, AD, Koellner, V, Nuechterlein, KH (2009). Symptoms as mediators of the relationship between neurocognition and functional outcome in schizophrenia: a meta-analysis. Schizophrenia Research 113, 189199.Google Scholar
Ventura, J, Wood, RC, Hellemann, GS (2013). Symptom domains and neurocognitive functioning can help differentiate social cognitive processes in schizophrenia: a meta-analysis. Schizophrenia Bulletin 39, 102111.CrossRefGoogle ScholarPubMed