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Theory of mind in schizophrenia: Meta-analysis

  • Mirjam Sprong (a1), Patricia Schothorst (a1), Ellen Vos (a1), Joop Hox (a2) and Herman Van Engeland (a3)...

Mentalising impairment (an impaired ability to think about people in terms of their mental states) has frequently been associated with schizophrenia.


To assess the magnitude of the deficit and analyse associated factors.


Twenty-nine studies of mentalising in schizophrenia (combined n = 1518), published between January 1993 and May 2006, were included to estimate overall effect size. Study descriptors predicted to influence effect size were analysed using weighted regression-analysis techniques. Separate analyses were performed for symptom subgroups and task types.


The estimated overall effect size was large and statistically significant (d= –1.255, P < 0.001) and was not significantly affected by sample characteristics. All symptom subgroups showed significant mentalising impairment, but participants with symptoms of disorganisation were significantly more impaired than the other subgroups (P<0.01).


This meta-analysis showed significant and stable mentalising impairment in schizophrenia. The finding that patients in remission are also impaired favours the notion that mentalising impairment represents a possible trait marker of schizophrenia.

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Corresponding author
Ms M. Sprong, Department of Child and Adolescent Psychiatry, University Medical Centre, Heidelberglaan 100, HPA01.468, 3508 GA Utrecht, The Netherlands. Email:
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Declaration of interest

None. Funding detailed in Acknowledgements.

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Theory of mind in schizophrenia: Meta-analysis

  • Mirjam Sprong (a1), Patricia Schothorst (a1), Ellen Vos (a1), Joop Hox (a2) and Herman Van Engeland (a3)...
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Mentalising impairment as a trait marker of schizophrenia?

Esther Pousa, Clinical Psychologist
06 December 2007

One of the most controversial issues in Theory of Mind (ToM) researchin schizophrenia in recent years has been whether ToM impairment may be seen as a trait marker or rather linked to particular symptoms. In their recent quantitative review of the literature of ToM in schizophrenia, Sprong et al. (2007) conclude that evidence to date seems to favour the notion that mentalising impairment represents a possible trait marker. We believe that their meta-analysis is an excellent piece of scientific work but that this conclusion should remain tentative.

First, the existing evidence on ToM abilities in remitted patients islimited and difficult to interpret due to methodological shortcomings, such as non-explicit criteria for remission and poor control of cognitive abilities in the experimental design. A recent study by our group revealedthat as a whole, stable patients did not show ToM impairment as compared with carefully matched non-psychiatric controls. When standard consensus criteria for remission were applied to the sample, half failed to meet criteria for remission and showed a significantly worse ToM performance than remitted patients and controls. Specific ToM deficits in this group were associated with delusions. Thus, specific ToM impairment could go hand in hand with the presence of symptoms (Pousa et al., in press).

Second, findings of ToM impairment in schizophrenia high risk groups seem to support the assumption that ToM deficits represent a trait marker of the disorder. However, since these studies are mostly correlational, itis possible that the continuity of ToM deficits among “at risk” groups mayin fact derive from an intrinsic relationship between a psychotic symptomscontinuum and ToM impairment. A review of the literature of ToM and schizotypal personality traits reveals that studies finding a positive significant relationship do so mainly with respect to schizotypal positivetraits such as the cognitive-perceptual and unusual experiences dimensionsof the schizotypy instruments (for e.g. Pickup, 2006). Regarding investigations of first degree relatives, evidence is controversial (Sprong et al., 2007), with findings of impaired performance on the more common types of ToM tasks but not on the “eyes” test”. However, it should be noted from these studies that those controlling for sub-clinical symptoms or schizotypal traits conclude that the association may be linkedexclusively to the presence of sub-clinical positive symptoms (Irani et al., 2006; Marjoram et al., 2006).

In our opinion, the existing evidence in ToM research is still limited but the possibility of a state-like association should not be ruled out. The most methodologically sound means to explore this would be to carry out longitudinal studies comparing ToM abilities in different phases of the illness, defined by explicit criteria. Future studies also need to differentiate between the affective and cognitive aspects of ToM, since it is possible that these show a different pattern of relationship with symptoms clusters or schizophrenia profiles. Furthermore, it is possible that future research reveals that state-trait interactions may beoccurring.
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