Skip to main content
    • Aa
    • Aa

Theory of mind and social inference in children and adolescents with bipolar disorder

  • L. S. Schenkel (a1), M. Marlow-O'Connor (a1), M. Moss (a1), J. A. Sweeney (a1) and M. N. Pavuluri (a1)...

Deficits in theory of mind (ToM), or the ability to infer what another person is thinking or feeling, have been reported in manic and euthymic adults with bipolar disorder. To date, there have been no investigations of ToM in pediatric bipolar disorder (PBD). The aim of the current study was to investigate this ability in PBD patients and healthy controls.


PBD patients (n=26) and intellectually and demographically similar healthy comparison subjects (n=20) were administered two ToM tasks. In the Affective Story Task, subjects were read positive-, negative- and neutral-valenced stories, and were assessed on their ability to recognize that a misleading series of events could lead one character to develop a false belief about another character. On the Hinting Task, subjects were required to infer the real intentions behind subtle hints.


The PBD group performed significantly more poorly than controls on the Hinting Task and the positive and negative conditions of the Affective Story Task. In the PBD group only, younger age, earlier illness onset and manic symptoms were associated with poorer ToM performance.


Consistent with past findings in adult bipolar disorder (BD), PBD youth performed more poorly than controls on ToM tasks. Data suggest that ToM ability may be more impaired in affectively charged contexts. Additionally, an earlier onset of illness among PBD youth may interfere with the development of social-cognitive skills. ToM disturbances may be a useful treatment target in PBD, with the aim of facilitating more accurate assessment of social cues and better interpersonal functioning.

Corresponding author
*Address for correspondence: Dr L. S. Schenkel, Rochester Institute of Technology, 92 Lomb Memorial Drive, Rochester, NY, 14623, USA. (Email:
Linked references
Hide All

This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

R Adolphs (2001). The neurobiology of social cognition. Current Opinion in Neurobiology 11, 231239.

R Adolphs (2002). Neural systems for recognizing emotion. Current Opinion in Neurobiology 12, 169177.

J Blair (2003). Neurobiological basis of psychopathy. British Journal of Psychiatry 182, 57.

S Baron-Cohen , MK Belmonte (2005). Autism: a window onto the development of the social and the analytic brain. Annual Review of Neuroscience 28, 109126.

S Berthoz , RJR Blair (2002). Emotions: from neuropsychology to functional imaging. International Journal of Psychology 37, 193203.

E Bora , S Vahip , AS Gonul , F Akdeniz , M Alkan , M Ogut , A Eryavuz (2005). Evidence for theory of mind deficits in euthymic patients with bipolar disorder. Acta Psychiatrica Scandinavica 112, 110116.

K Chang , NE Adleman , K Dienes , DI Simeonova , V Menon , A Reiss (2004). Anomalous prefrontal-subcortical activation in familial pediatric bipolar disorder. Archives of General Psychiatry 61, 781792.

JL Craney , B Geller (2003). A prepubertal and early adolescent bipolar disorder-I phenotype: review of phenomenology and longitudinal course. Bipolar Disorders 5, 243256.

R Corcoran , G Mercer , CD Frith (1995). Schizophrenia, symptomatology and social inference: investigating ‘theory of mind’ in people with schizophrenia. Schizophrenia Research 17, 513.

DP Dickstein , EE Nelson , EB McClure , ME Grimley , L Knopf , MA Brotman , BA Rich , DS Pine , E Leibenluft (2007). Cognitive flexibility in phenotypes of pediatric bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry 46, 341355.

DP Dickstein , JE Treland , J Snow , EB McClure , MS Mehta , KE Towbin , DS Pine , E Leibenluft (2004). Neuropsychological performance in pediatric bipolar disorder. Biological Psychiatry 55, 3239.

AE Doyle , TE Wilens , A Kwon , LJ Seidman , SV Farone , R Fried , A Swezey , L Snyder , J Beiderman (2005). Neuropsychological functioning in youth with bipolar disorder. Biological Psychiatry 58, 540548.

J Dunn , J Brown , C Slomkowski , C Tesla , L Youngblade (1991). Young children's understanding of other people's feelings and beliefs: individual differences and their antecedents. Child Development 62, 13521366.

JH Flavell (1999). Cognitive development: children's knowledge about the mind. Annual Review of Psychology 50, 2145.

JH Flavell , ER Flavell , FL Green (1999). Development of children's understanding of connections between thinking and feeling. Psychological Science 12, 430432.

B Geller , K Bolhofner , JL Craney , M Williams , MP DelBello , K Gundersen (2000). Psychosocial functioning in a prepubertal and early adolescent bipolar disorder phenotype. Journal of the American Academy of Child and Adolescent Psychiatry 39, 15431548.

B Geller , JL Craney , K Bolhofner , MJ Nickelsburg , M Williams , B Zimerman (2002). Two-year prospective follow-up of children with a prepubertal and early adolescent bipolar disorder phenotype. American Journal of Psychiatry 159, 927933.

B Geller , R Tillman , JL Craney , K Bolhofner (2004). Four-year prospective outcome and natural history of mania in children with a prepubertal and early adolescent bipolar disorder phenotype. Archives of General Psychiatry 61, 459467.

B Geller , K Warner , M Williams , B Zimerman (1998). Prepubertal and young adolescent bipolarity versus ADHD: assessment and validity using the WASH-U-KSADS, CBCL, and TRF. Journal of Affective Disorders 51, 93100.

TC Greig , GJ Bryson , MD Bell (2004). Theory of mind performance in schizophrenia: diagnostic, symptom, and neuropsychological correlates. Journal of Nervous and Mental Disease 192, 1218.

CA Hynes , AA Baird , ST Grafton (2006). Differential role of the orbital frontal lobe in emotional versus cognitive perspective-taking. Neuropsychologia 44, 374383.

N Kerr , RIM Dunbar , RP Bentall (2003). Theory of mind deficits in bipolar affective disorder. Journal of Affective Disorders 73, 253259.

DM Kronhaus , NS Lawrence , AM Williams , S Frangou , MJ Brammer , SC Williams , CM Andrew , MS Phillips (2006). Stroop performance in bipolar disorder: further evidence for abnormalities in the ventral prefrontal cortex. Bipolar Disorders 8, 2839.

S Kruger , M Alda , LT Young , K Goldapple , S Parikhs , HS Mayberg (2006). Risk and resilience markers in bipolar disorder: brain responses to emotional challenge in bipolar patients and their healthy siblings. American Journal of Psychiatry 163, 177179.

E Leibenluft , DS Charney , KE Towbin , RK Bhangoo , DS Pine (2003). Defining clinical phenotypes of juvenile mania. American Journal of Psychiatry 160, 430437.

A Lembke , TA Ketter (2002). Impaired recognition of facial emotion in mania. American Journal of Psychiatry 159, 302304.

EB McClure , K Pope , AJ Hoberman , DS Pine , E Leibenluft (2003). Facial expression recognition in adolescents with mood and anxiety disorders. American Journal Psychiatry 160, 11721174.

EB McClure , JE Treland , J Snow , DP Dickstein , KE Towbin , DS Charney , DS Pine , E Leibenluft (2005 b). Memory and learning in pediatric bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry 44, 461469.

EB McClure , JE Treland , J Snow , M Schmajuk , DP Dickstein , KE Towbin , DS Charney , DS Pine , E Leibenluft (2005 a). Deficits in social cognition and response flexibility in pediatric bipolar disorder. American Journal of Psychiatry 162, 16441651.

PK McGuire , DA Silbersweig , CD Frith (1996). Functional neuroanatomy of verbal self-monitoring. Brain 119, 907917.

JP Mitchell , TF Heatherton , CN Macrae (2002). Distinct neural systems subserve person and object knowledge. Proceedings of the National Academy of Sciences USA 99, 1523815243.

AL Olley , GS Malhi , J Bachelor , CM Cahill , PB Mitchell , M Berk (2005). Executive functioning and theory of mind in euthymic bipolar disorder. Bipolar Disorders 7, 4352.

MN Pavuluri , B Birmaher , MW Naylor (2005). Pediatric bipolar disorder: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry 44, 846–71.

MN Pavuluri , DB Henry , B Devineni , JA Carbray , B Birmaher (2006 b). Child mania rating scale: development, reliability, and validity. Journal of the American Academy of Child and Adolescent Psychiatry 45, 550–60.

MN Pavuluri , ES Herbener , JA Sweeney (2004). Affect regulation: a systems neuroscience perspective. Neuropsychiatric Disease and Treatment 1, 915.

MN Pavuluri , MM O'Connor , E Harral , JA Sweeney (2007). Affective neural circuitry during facial emotion processing in pediatric bipolar disorder. Biological Psychiatry 62, 158167.

KL Phan , SF Taylor , RC Welsh , SH Ho , JC Britton , I Liberzon (2004). Neural correlates of individual ratings of emotional salience: a trial-related fMRI study. Neuroimage 21, 768780.

MN Pavuluri , LS Schenkel , S Aryal , EM Harral , SK Hill , ES Herbener , JA Sweeney (2006 a). Neurocognitive function in unmedicated manic and medicated euthymic pediatric bipolar patients. American Journal of Psychiatry 163, 286293.

BA Rich , M Schmajuk , KE Perez-Edgar , DS Pine , NA Fox , E Leibenluft (2005). The impact of reward, punishment, and frustration on attention in pediatric bipolar disorder. Biological Psychiatry 58, 532539.

BA Rich , DT Vinton , R Roberson-Nay , RE Hommer , LH Berghorst , EB McClure , SJ Fromm , DS Pine , E Leibenluft (2006). Limbic hyperactivation during processing of neutral facial expressions in children with bipolar disorder. Proceedings of the National Academy of Sciences USA 103, 89008905.

ET Rolls (2004). The functions of the orbitofrontal cortex. Brain and Cognition 55, 1129.

LS Schenkel , MN Pavuluri , ES Herbener , EM Harral , JA Sweeney (2007). Facial emotion processing in acutely ill and euthymic patients with pediatric bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry 46, 10701079.

LS Schenkel , WD Spaulding , SM Silverstein (2005). Poor premorbid social functioning and theory mind deficit in schizophrenia: evidence of reduced context processing? Journal of Psychiatric Research 39, 499508.

SG Shamay-Tsoory , S Shur , H Harari , Y Levkovitz (2007). Neurocognitive basis of impaired empathy in schizophrenia. Neuropsychology 21, 431438.

H Tager-Flushberg , KA Sullivan (2000). A componential view of theory of mind: evidence from Williams syndrome. Cognition 76, 5989.

PJ Uhlhaas , WA Phillips , LS Schenkel , SM Silverstein (2006). Theory of mind and perceptual context-processing in schizophrenia. Cognitive Neuropsychiatry 11, 416436.

BA Völlm , ANW Taylor , P Richardson , R Corcoran , J Stirling , S McKie , JFW Deakin , R Elliott (2006). Neuronal correlates of theory of mind and empathy: a functional magnetic resonance imaging study in a nonverbal task. Neuroimage 29, 9098.

D Yurgelun-Todd , S Gruber , G Kanayama , D Killgore , A Baird , A Young (2000). fMRI during affect discrimination in bipolar affective disorder. Bipolar Disorders 2, 237248.

RC Young , JT Biggs , VE Ziegeler , DA Mayer (1978). A rating scale for mania: reliability, validity and sensitivity. British Journal of Psychiatry 133, 429435.

Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Psychological Medicine
  • ISSN: 0033-2917
  • EISSN: 1469-8978
  • URL: /core/journals/psychological-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 5
Total number of PDF views: 31 *
Loading metrics...

Abstract views

Total abstract views: 203 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 25th September 2017. This data will be updated every 24 hours.