Mentalising impairment as a trait marker of schizophrenia?

One of the most controversial issues in ‘theory of mind’ research in schizophrenia in recent years has been whether theory of mind impairment may be seen as a trait marker or rather linked to particular symptoms. Sprong et al ¹ 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 theory of mind abilities in remitted patients is limited and difficult to interpret because of 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 revealed that as a whole, stable patients did not show theory of mind impairment 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 theory of mind performance than remitted patients and controls. Specific theory of mind deficits in this group were associated with delusions. Thus, specific theory of mind impairment could go hand-in-hand with the presence of symptoms. ²

Second, findings of theory of mind impairment in schizophrenia high-risk groups seem to support the assumption that theory of mind deficits represent a trait marker of the disorder. However, since these studies are mostly correlational, it is possible that the continuity of theory of mind deficits among ‘at risk’ groups may in fact derive from an intrinsic relationship between a psychotic symptoms continuum and theory of mind impairment. A review of the literature of theory of mind and schizotypal personality traits reveals that studies finding a positive significant relationship do so mainly with respect to schizotypal positive traits such as the cognitive-perceptual and unusual experiences dimensions of the schizotypy instruments. ³ Regarding investigations of first-degree relatives, evidence is controversial, ¹ with findings of impaired performance on the more common types of theory of mind tasks but not on the ‘eyes’ test. However, it should be noted from these studies that those controlling for subclinical symptoms or schizotypal traits conclude that the association may be linked exclusively to the presence of subclinical positive symptoms. ^4,5

In our opinion, the existing evidence in theory of mind 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 theory of mind abilities in different phases of the illness, defined by explicit criteria. Future studies also need to differentiate between the affective and cognitive aspects of theory of mind, since it is possible that these show a different pattern of relationship with symptom clusters or schizophrenia profiles. Furthermore, it is possible that future research reveals that state–trait interactions may be occurring.