Schizophrenia Research 109 (2009) 19

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Schizophrenia Research
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / s c h r e s

Theory of mind impairment in schizophrenia: Meta-analysis

Emre Bora a,, Murat Yucel a,b, Christos Pantelis a
a
b

Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, VIC, Australia
ORYGEN Youth Health Research Centre, Centre for Youth Mental Health, University of Melbourne, VIC, Australia

a r t i c l e

i n f o

Article history:
Received 13 August 2008
Received in revised form 6 December 2008
Accepted 16 December 2008
Available online 4 February 2009
Keywords:
Theory of mind
Schizophrenia
Mentalising
Cognitive
Meta-analysis

a b s t r a c t
There is now substantial evidence for Theory of mind (ToM) impairment in schizophrenia.
Despite this, we know little about how dynamic (state) variables and broad clinical, cognitive
and medication characteristics moderate the precise magnitude of the observed ToM decit
during task performance. Meta-analyses were conducted using 36 studies that reported
continuous data regarding ToM performances of schizophrenia patients and healthy control
subjects. These 36 studies included 1,181 (67% male) patients with schizophrenia and 936
(58.3% male) healthy control subjects. Individual analyses were also conducted for the Hinting
and the Eyes tasks. The effects of moderator variables were studied by both subgroup and metaregression analyses. The effect sizes (Cohen's d) for overall ToM performance and the individual
tasks were large (d = 0.901.08). In remitted patients, the degree of ToM impairment was less
pronounced than non-remitted patients (d = 1.21) but it was still signicant (d = 0.80).
Moreover, the distribution of effect sizes was more homogeneous for the individual tasks,
especially in remitted patients. General intellectual decits observed in schizophrenia
patients contributed to their ToM impairment only in the remission phase of the illness. While
state variables and task specic differences explain a large degree of the heterogeneity of the
ToM ndings observed in previous studies, the persistence of ToM decits in remitted
patients suggests there are trait related mentalising impairments in schizophrenia. Our review
also suggests that future research should consider the potential moderating inuence of IQ
decits on ToM performance in remitted patients, as well as the potential effects of residual
symptoms.
2008 Elsevier B.V. All rights reserved.

1. Introduction
Theory of mind (ToM) decits in schizophrenia have been
investigated by a substantial number of studies since Frith
(1992) proposed a model suggesting a relationship between
mentalising (ToM) impairment and specic symptoms of
schizophrenia. Two systematic reviews (Brne, 2005; Harrington et al., 2005a,b) and a recent meta-analysis (Sprong
et al., 2007) showed that nearly all published empirical
studies reported ToM impairment. Sprong et al. (2007)
reported a large overall effect size (d = 1.25) for 29 published
studies. Interestingly, the magnitude of the impairment was
Corresponding author. Alan Gilbert Building NNF level 3, Carlton 3053,
Australia. Tel.: +61 3 8345 5611; fax: +61 3 8345 5610.
E-mail addresses: emrebora@hotmail.com, boremre@gmail.com (E. Bora)
0920-9964/$ see front matter 2008 Elsevier B.V. All rights reserved.
doi:10.1016/j.schres.2008.12.020

attenuated but remained signicant in remitted patients

(d = 0.69). While this result suggests that acute psychosis has
a signicant moderating inuence on ToM performance, it
also implies that mentalising decits might be trait-characteristics of schizophrenia.
While there is no doubt that schizophrenia patients perform
poorly on ToM tasks, there are important issues that were not
adequately considered in previous studies and reviews. The main
issues relate to (i) heterogeneity of ToM tasks and their
neurocognitive demands; (ii) psychometric properties of ToM
tests; and (iii) the inuence of clinical and demographic
characteristics on ToM performance. First, while the study of
Sprong et al. (2007) provided the rst attempt to qualitatively
analyze the available data, it did not adequately take the
heterogeneity of ToM tasks into account. Previous studies have
used different ToM tests comprised of very different test

E. Bora et al. / Schizophrenia Research 109 (2009) 19

characteristics. For example, different tasks rely on different

neurocognitive processes and decits of schizophrenia patients in
working memory, executive functions and attention, which could
differentially inuence (and interact with) patients` performance
on various ToM tasks. Secondly, ToM tasks are not well
standardized and their psychometric properties have not been
studied. For example, while some of the false belief tasks included
only single or a few stories, others included more stories. In
support of this, Sprong et al. (2007) reported heterogeneity for
false belief tasks that may be related to variability of these tasks.
Finally, the moderating inuence of clinical and demographic
characteristics on ToM dysfunction in schizophrenia may be
underestimated and confound interpretations. For example,
general intellectual decits of the patients with schizophrenia
could affect performance of mentalising tasks.
In this context, meta-analysis is a useful tool for systematically combining all research in this area to identify the most
robust aspects of ToM impairment in schizophrenia and to
understand how performance on such tasks is moderated by
state and trait factors. In this way, we may be better able to
understand the inuence of moderating inuences on social
cognition disturbances that characterize schizophrenia. Our
aims were to: (i) to conduct meta-analyses for individual or
more homogeneous tasks that can estimate a reliable overall
effect size for the different aspects of ToM impairment; and
(ii) to study the effects of potentially confounding factors
related to clinical and demographic characteristics on ToM
impairment in schizophrenia.
2. Method
2.1. Study selection
A literature search was conducted using the databases
Pubmed, Medline, EMBASE, SCOPUS and PsycINFO to identify
the relevant studies (January 1990 to May 2008). The following keywords were used: schizophrenia, psychosis,
Theory of Mind, mentalising and social cognition. The early
online editions of the major psychiatric journals were also
checked and reference lists of published reviews and studies
were used to identify additional relevant publications.
2.2. Inclusion criteria
1) Studies should be published in peer-reviewed journals in
English.
2) Studies should report ToM abilities in adults with diagnoses of schizophrenia, schizoaffective disorder or rstepisode psychosis according to Research Diagnostic Criteria, DSM-III, DSM-III-R, DSM-IV, ICD-9 or ICD-10 criteria.
3) Studies should also include healthy subjects as a comparison group.
4) Tasks should include at least 3 items.
5) Studies should report means and standard deviations, or F
and t values so that standardized mean differences could
be calculated. Measures with dichotomous outcomes were
excluded.
6) Tasks should be used by at least three different research
groups.
7) Studies should reect results of the independent samples.
In the case of sample overlap, the study with larger sample

size was chosen for inclusion. Where necessary, authors

were contacted to provide additional information.
To be included in individual task analysis of the study,
there was an additional inclusion criterion: tasks should be
used in at least ve different studies.
2.3. Coding of the variables
The following variables were coded prior to meta-analyses:
a- name of the rst author and year of the publication
b- number of participants and percentage of males in both
groups
c- mean and SDs for demographic variables (Age, duration of
education), clinical variables (age of onset, duration of
illness), dosage of antipsychotics (chlorpromazine equivalents) and IQ assessment
d- mean, SDs and calculated effect sizes of the individual
tasks. A total ToM score that was calculated by averaging
effect sizes of individual tasks.
2.4. Mentalising tasks
2.4.1. False-belief tasks
Most common measures used to assess ToM were falsebelief understanding tasks. In their simplest form, these tasks
measure the subject's ability to understand that someone can
act on the basis of beliefs that misrepresent reality (rst-order
false belief). In a more complicated version of these tasks,
participants have to infer the false belief of one character
about the belief of a second character (Second-order false
belief). Two types of false belief tasks were used in this metaanalysis:
False belief stories: this is a verbal measure of false belief
understanding (Frith and Corcoran, 1996). Participants must
understand and answer the questions based on a verbal story.
A separate analysis was also conducted for rst-order and
second-order false-belief tasks. There was some variability in
the stories chosen for different studies.
False belief picture sequencing: subjects are asked to
correctly complete a set of pictures based on their understanding of mental state inferences. Two different versions of
this task were used in this meta-analysis (Brne and
Bodenstein, 2005; Langdon et al., 1997).
2.4.2. Hinting task
This is a measure of indirect speech (Corcoran et al., 1995).
In this task, a series of statements are presented to participants
who are required to understand the real intended meaning.
2.4.3. Eyes test
In this task, subjects should infer complex mental states of
subjects from the pictures of their eyes (Baron-Cohen et al.,
2001). Unlike false belief tasks and indirect speech tasks, this
test depends on more automatic decoding abilities rather
than reasoning about mental states. Some authors (Bora et al.,
2006; Sabbagh, 2004; Tager-Flusberg and Sullivan, 2000)
suggest that this is a different kind of ToM ability (socialperceptual or mental state decoding).
Irony, faux pas, character intention inference tasks were
also used to calculate the total ToM score. However, they were

E. Bora et al. / Schizophrenia Research 109 (2009) 19

Table 1
Characteristics of studies included into the study and effect sizes for ToM tasks in these studies.
Study

Sample

Matched for

Illness duration

Medication

ToM tasks

Effect size

Corcoran et al., 1995

55 Sch
30 HC
20 Sch
20 HC
24 Sch
24 HC
25 Sch
15 HC
26 Sch
13 HC
5 Sch
7 HC
16 Sch
26 HC
32 Sch
24 HC
41 Sch
35 HC
25 Sch
20 HC
23 Sch
12 HC
25 Sch
25 HC
32 Sch
18 HC
59 Sch
44 HC
16 Sch
16 HC
40 Sch
40 HC
25 Sch
38 HC

Age, sex

No information

No information

Hinting

0.82

Age, sex

10.3 years dur

336 mg cpz-eq

FB-seq

0.75

All AP+

CIT

1.31

10.5 years dur

780 mg cpz-eq

CIT

1.17

Age, sex

11.5 years dur

CIT

1.11

Sex, Edu

13 years dur

888 mg cpz-eq
25/26 AP+
All AP+

Eyes

1.41

Age

12 years dur

Eyes

1.29

Age, sex, edu

12.9 years dur

FB-seq

1.23

FB

1.61

FB-seq
Irony
FB

1.54
1.28
0.86

15 Sch
15 HC
31 Sch
21 HC
52 Sch
30 HC
10 Sch
10 HC
34 Sch
21 HC
49 Sch
44 HC

Age

41 Sch
22 HC
21 Sch
15 HC
40 Sch
31 HC
38 Sch
29 HC
36 Sch
27 HC
61 Sch
51 HC
13 Sch
16 HC
16 Sch
16 HC

Age

29 Sch
22 HC

Sex

Langdon et al., 1997

Sarfati et al., 1997
Sarfati et al., 1999a
Sarfati and Harde-Bayle, 1999b
Russell et al., 2000
Kington et al., 2000
Langdon et al., 2001
Pickup & Frith, 2001
Langdon et al., 2002
Brne, 2003
Brunet et al., 2003
Randall et al., 2003
Corcoran and Frith, 2003
Craig et al., 2004
Zalla et al., 2004
Harrington et al., 2005a,b

Marjoram et al., 2005

Brne and Bodenstein, 2005
Kelemen et al., 2005
Irani et al., 2006
Langdon et al., 2006
Pinkham and Penn, 2006

Bonshtein et al., 2006

Martino et al., 2007
Zhu et al., 2007
Brne et al., 2007
Bertrand et al., 2007
Pousa et al., 2008
Kettle et al., 2008
Ba et al., 2008

Mo et al., 2008

Age

15 years dur
Age, sex, edu

9.6 years dur

Age

10 years dur

1181 mg cpz-eq
All on AP+
31/32 AP+
25/31 atypicals
40/41 AP+
888 mg cpz-eq
All on AP+
18/25 atypicals

Sex, Age

All on loxapine

CIT

0.88

Age, sex

All on AP+

FB1
FB2
FB
Hinting
Hinting
Eyes
FB-seq

0.93
1.58
1.45
0.99
1.58
1.68
2.0

FB-seq
FB1
FB2
Hinting

0.65
0.55
0.73
2.13

FB-seq
FB
Eyes

1.52
1.64
0.89

Eyes

0.85

FB-seq

1.41

Hinting
FB

0.62
0.62

FB1
FB2
Faux pas

1.25
1.70
1.33

Faux pas

1.34

FB-seq
FB
Hinting

1.0
0.97
1.09

FB-seq
FB2
Eyes

0.10
0.25
0.81

FB1
FB2

0.73
1.92

Irony

1.41

Age, sex, IQ

13.9 years dur

3/59 AP+

Age, sex, edu

16.8 years dur

Age,sex, edu

11 years dur

All AP+,
Mostly atypicals
All AP+,
22/25 typicals

Age, sex

15 AP+
9/15 typicals
11.8 years dur

Age, sex, IQ

Age, sex, edu

35/52 AP+
mostly atypicals

12.5 years dur

5.5 years dur

32/34 AP+
24/32 atypicals
47/49 AP+
88% atypicals
352 mg cpz-eq
All AP+

Age

9.2 years dur

All AP+
11/21 clozapine
All clozapine

Age

10 years dur

10.4 years dur

Age, edu

First episode
Age, sex, IQ

11 years dur

Edu

First episode
9.5 years

19.3 years dur

32/36 AP+
31/32 atypicals
All AP+
Mostly atypicals
10/13 AP+
9/13 atypicals
All AP+,
14/16 atypicals
194 mg cpz-eq
210 mg cpz-eq

(continued on next page)

E. Bora et al. / Schizophrenia Research 109 (2009) 19

Table 1 (continued)
Study

Sample

Matched for

Illness duration

Medication

ToM tasks

Effect size

Tsoi et al., 2008

30 Sch
30 HC

Sex

17.3 years dur

All AP+
22/30 atypicals
445 mg czp-eq

FB-seq

1.11

Couture et al., 2008

26 Sch
41 HC
59 Sch
33 HC
91 Sch
55 HC

Age, sex, edu,

b5 years dur

Eyes

0.44

FB-seq
FB2
Eyes
Hinting

0.69
0.62
0.73
0.96

Corcoran et al., 2008

Bora et al., 2008

Sex, Edu

14 years dur

56/59 AP+

10.7 years dur

All AP+

CIT: character intention inference, FB: False belief, seq: sequencing, AP = antipsychotic, dur = duration, Cpz-eq = chlorpromazine equivalent.

clinical variables and IQ on ToM impairment were studied using

the meta-regression method.

not included in individual analyses since there were less than

ve studies for these measures. Some other tasks like visual
jokes, Gricean language maxims, and other ToM tasks that
used animated objects were not included in the current study
since studies that used these tasks did not meet study
inclusion criteria.

3. Results

2.5. Statistical analyses

Meta-analyses were conducted with MIX software (Bax
et al., 2006). We used the standardized mean difference
method with Hedge's correction for bias in small samples.
Whenever schizophrenia patients performed poorer than
controls, we reported between-group differences as positive
effect sizes. For studies that reported more than one ToM task, a
pooled effect size was calculated. Homogeneity of the resulting
mean weighted effect sizes were tested with Q test. We used a
random effects model for the meta-analyses. Publication bias
was tested using funnel plots and Egger's test. To reduce the risk
of false positive results and to further investigate the source of
funnel plot asymmetry, tasks with a signicant asymmetry
(Egger's test, p b 0.05) were further analyzed. Individual
characteristics of the studies were further investigated and a
Fail Safe number (number of negative studies necessary to
make the group difference insignicant) was calculated. A
signicance level of p b 0.05 was used for the random effects
model, homogeneity and publication bias analyses.
Two different methods were used to study the effect of
confounding variables. The impact of state was studied by
subgroup analyses. We also calculated homogeneity statistics
Qw and Qbet. Qbet was used to test the signicance of differences
in effect size magnitude between moderator subgroups,
analogous to the F statistic. The effects of demographic and

Our extensive search strategy identied 73 studies that

investigated TOM impairment in schizophrenia. 17 of these
studies did not include a healthy control group. Another 20
were excluded since they did not meet the inclusion criteria of
the study (dichotomous variables, nonincluded tasks, sample
overlap or insufcient data). The nal sample consisted of 36
studies (Table 1). These 36 studies included 1181 (67% male)
patients with schizophrenia and 936 (58.3% male) healthy
control subjects. The study samples were matched for age
(d = 0.04, CI = 0.070.15, Z = 0.68, p = 0.50, k = 34).
Patients with schizophrenia were less educated (d = 0.40,
CI = 0.240.57, Z = 04.70, p b 0.0001, k = 17) and had signicantly lower IQ than the control group (d = 0.71, CI = 0.55
0.87, Z = 8.85, p b 0.0001, k = 28).
3.1. ToM impairment in patients
Meta-analyses of the individual ToM tasks and total ToM
score demonstrated highly signicant mentalising impairments in the schizophrenia group (Table 2). Effect sizes for
the between-group differences were large (0.901.08). There
was heterogeneity for the distribution of effect sizes for FB
stories (Fig. 1), FB-seq (Fig. 2) and total ToM score.
Distribution of the effect sizes for the Eyes task (Fig. 3) was
homogeneous and heterogeneity for the Hinting task (Fig. 4)
was marginal compared to other tasks. Egger's test showed
evidence of some publication bias for the Hinting, FB-seq
tasks and total ToM, however fail-safe numbers of both tasks

Table 2
Mean weighted effect sizes for ToM for patient-control differences.
Test

Study

Patients

Control

95% CI

Q-test p

Bias

Hinting
Eyes
FB-seq
FB stories
Total ToM

7
8
11
11
36

321
229
395
475
1181

231
191
327
363
936

1.06
0.90
1.08
1.06
1.10

0.781.34
0.641.17
0.721.43
0.761.37
0.951.25

7.3
6.8
5.9
6.8
14.8

b 0.0001
b 0.0001
b 0.0001
b 0.0001
b 0.0001

0.04
0.19
b0.001
b0.001
b0.001

0.04
0.15
0.04
0.06
0.02

Remitted patients
Hinting
Eyes
FB-seq
FB stories
Total ToM

3
4
3
6
16

148
182
124
192
514

125
142
105
174
470

0.69
0.72
0.70
0.70
0.80

0.301.08
0.480.95
0.011.42
0.401.0
0.571.03

3.5
6.0
1.9
4.5
6.4

0.0004
b 0.0001
0.05
b 0.0001
b 0.0001

0.15
0.63
0.001
0.09
0.004

0.24
0.95
0.30
0.05
0.67

E. Bora et al. / Schizophrenia Research 109 (2009) 19

Fig. 1. Forest plot of individual and pooled random effect estimates of the standardised mean differences between schizophrenia patients and controls for False
belief.

were quite high (221, 460 and 4450, respectively). When the
characteristics of individual studies were further investigated, it
became clear that signicant correlations in Egger's test
indicated there was heterogeneity of the studies rather than a
le drawer effect. Sample sizes of the remitted patients were
larger compared to other studies and separate Egger's tests in
remitted and non-remitted patients were not signicant.
For FB stories, additional analyses were conducted to
calculate separate effect sizes for rst-order and second-order
tasks. The patients with schizophrenia tended to be more
impaired on second order tasks (d = 1.09, CI = 0.541.69)
compared to rst-order tasks (d = 0.87, CI= 0.551.19). However, this difference was not signicant according to Qbet
statistic (p = 0.75). Finally, a subgroup analysis was conducted

to investigate the effect of antipsychotics on ToM impairment.

Since, many studies did not report details of antipsychotic
treatment, there was only one possible subgroup analysis
(studies that reported that their patients were predominantly
using atypicals). The effect size of the ToM impairment for
these studies (11 studies) was very similar to whole sample
(d = 1.08, CI = 0.751.41).
3.2. ToM decits in remitted patients
Only few of the studies reported data from remitted
patients according to stringent criteria. Therefore, similar to
Krabbendam et al. (2005), we dened remission as being
outpatients and/or inpatients just before discharge. Meta-

Fig. 2. Forest plot of individual and pooled random effect estimates of the standardised mean differences between schizophrenia patients and controls for FB-seq.

E. Bora et al. / Schizophrenia Research 109 (2009) 19

Fig. 3. Forest plot of individual and pooled random effect estimates of the standardised mean differences between schizophrenia patients and controls for Eyes test.

analyses of the ToM tasks in remitted patients revealed

signicant impairments compared to healthy controls
(Table 2). While the magnitudes of these decits were smaller
than the results of total sample analyses, effect sizes were still
in the medium-large range (0.690.72). Effect size for Total
ToM was slightly larger than effect sizes of the individual
tasks. This difference reected the fact that remitted
patients had more severe impairments on irony and faux
pas tasks that were not analyzed individually.
Effect size distributions of three of the four ToM measures
were homogeneous in remitted patients. The only task that
showed heterogeneity for distribution of its effect sizes was
FB-seq. There was also signicant heterogeneity for the total
ToM score. There was no statistical evidence for publication
bias in remitted patients.
3.3. The impact of acute symptoms on ToM impairment
Effect size for the ToM impairment (d = 1.21, CI = 1.05
1.37, Z = 14.42, p b 0.0001, df = 20) was larger than the decit
reported for remitted patients (d = 0.80). This difference
was highly signicant (Qbet = 19.65, p b 0.0001, df = 1) showing

that state is an important moderator for ToM impairment in

schizophrenia. However, there should remain some other
factors contributing to the between-studies heterogeneity
(i.e. heterogeneity between tasks, as above), since pooled Qw
was also signicant (Qw = 68.9, p = 0.0006, df = 35).
3.4. Meta-regression analyses
Group differences in age (34 studies), sex (33 studies) and
education (17 studies) had no impact on the magnitude of ToM
impairments. There was no effect of age at onset of illness (28
studies), however, patients with longer duration of illness
tended to be more impaired on ToM tasks (k = 28 studies,
B = 0.03, SE = 0.01, Z = 1.85, p = 0.06). Antipsychotic dose
(chlorpromazine equivalents) was not associated with ToM
performance, however only 10 studies reported data to calculate
this measure. The magnitude of the general intelligence decit
tended to increase the effect size of the ToM decit (k=28,
B=0.35 SE=0.19 Z=1.87 p=0.06) in patients with schizophrenia. This association became signicant when the analysis
was restricted to remitted patients (k=13, B=071, SE=0.30
Z=2.40 p=0.01).

Fig. 4. Forest plot of individual and pooled random effect estimates of the standardised mean differences between schizophrenia patients and controls for Hinting
task.

E. Bora et al. / Schizophrenia Research 109 (2009) 19

3.5. First-episode schizophrenia and prodrome

Since only two of the studies (Bertrand et al., 2007; Kettle
et al., 2008) included in the meta-analysis were rst-episode
samples, we were not able to calculate a summary score for
these studies. Both of these studies showed signicant
impairments (effects sizes 0.81 and 1.09) in the patient
groups. Together with the results of another study (Inoue
et al., 2006) that was not included in the meta-analysis (since
it reported non-parametric data); these preliminary results
suggest ToM impairment is comparable to chronic patients.
To our knowledge, only two studies compared ToM
performances of subjects in prodrome phase with healthy
controls. While one of these studies reported impairments for
strange stories and false belief tests (Chung et al., 2008), the
second study did not nd any signicant difference for the
Eyes test (Couture et al., 2008).
4. Discussion
Schizophrenia patients had mentalising impairments with
large effect sizes observed for all tasks. The distribution of
effect sizes was more homogeneous for individual tasks of
ToM, especially in remitted patients. One of the main
ndings of this study was that ToM impairment was strongly
inuenced by acute psychosis. Overall sample had prominent
impairment on all ToM tasks while remitted patients had
reduced but still signicant, ToM impairment. Contrasting
with the earlier views, this result suggests that ToM decits
might be trait impairments. However, there is still the
possibility that ToM impairment in remitted patients may
be secondary to other factors like cognitive decits or residual
symptoms. Consistent with this idea, in our study, impairement
of general intelligence was signicantly contributing to ToM
impairment only in remitted patients.
Results of this meta-analysis showed that ToM impairments occur with large effect sizes in schizophrenia. In a
previous study, Sprong et al. (2007) also identied signicant
ToM impairment in patients with schizophrenia. However,
their results indicated a more severe impairment than our
study. The current meta-analysis included more patients and
this might be one of the factors explaining the discrepancy.
However, several methodological differences between the
studies are also likely to contribute to different results. In
Sprong et al. (2007) included overlapping samples in their
analysis that may further reduce the actual sample size. They
also used the probit d method to estimate the effect sizes from
dichotomous variables. Since a skewed distribution of ToM
tasks seems to be characteristic of these studies (in many
cases, the control group scored 100% true), this estimation
method is likely to give unreliable results. In Sprong et al.
(2007) inclusion of multiple studies from overlapping
samples can also cause a bias in the mean effect size. For
these reasons, we believe that the results of our study may
provide a better estimation of actual effect sizes of ToM
impairment in patients with schizophrenia.
The current meta-analyses also examined two individual
tasks of ToM that have been commonly used in the literature
(i.e., Hinting and Eyes). We attempted to integrate different
tasks that assessed subjects' understanding of false-beliefs by
story comprehension (FB stories) or sequencing (FB-seq) in

order to increase homogeneity of the tasks. The estimated effect

sizes for three of the tasks (Hinting, FB seq and FB stories) and
total ToM score was very similar (1.061.08). The distributions
of effect sizes were much less heterogeneous for individual
tasks compared to combined tasks and total ToM score. This
result supports the idea that heterogeneity of the methods used
to assess ToM abilities contributes to the inconsistencies in the
reported ndings. This study also provided evidence for a
different aspect of ToM ability that is measured by the Eyes task.
The effect size for the impairment was moderately smaller for
the Eyes task compared to other tasks.
It is evident that ToM impairment is more severe in the
acute phase of schizophrenia and differences in symptom
characteristics of the various studies may therefore contribute
to the heterogeneity of the reported ndings. However, our
results suggest that ToM impairments in schizophrenia
persist after the remission of acute psychosis. This result
contradicts the earlier opinions of Frith (1992) and Harde
Bayle (Sarfati et al., 1997). Frith's concept of ToM decit in
schizophrenia suggests a state related impairment. This
model proposed that psychotic symptoms in schizophrenia
might be explained by mentalising impairment. Consistent
with this model, several studies of Frith and his colleagues
showed intact ToM performance in remitted patients. While
the model of HardeBayle suggests an association of ToM
impairment with another symptom dimension of schizophrenia (disorganized thought), it also considers ToM decit
as a state characteristic of schizophrenia. However, other
ndings demonstrating ToM impairment in remitted patients
and in people at genetic risk of schizophrenia supports the
notion that ToM dysfunction may be a trait characteristic of
schizophrenia. Results of the current meta-analysis and the
results of Sprong et al also are consistent with this opinion.
Insufcient power related to small sample size of some
studies may explain some of the previous reported negative
ndings. Differences in ToM batteries used and in criteria for
remission may also explain the divergent ndings. Denition
of remission is clearly important to the proper interpretation
of the ndings since residual positive and persistent negative
symptoms are commonly observed in stable patients with
schizophrenia. Two recent studies investigated the inuence
of residual symptoms during remission. Pousa et al. (2008)
reported a mentalising decit in patients with residual
positive symptoms but not in patients without such symptoms. Bora et al. (2008) also demonstrated a more severe ToM
impairment in patients with residual positive and negative
symptoms. However, this study also showed a less pronounced but still signicant mentalising decit (ES = 0.50) in
symptom free patients.
The nding related to the effect of IQ decits on ToM
impairment in schizophrenia is one of the important results
of this meta-analysis. A general and selective cognitive decit
observed in patients with schizophrenia is another important
factor that can contribute to ToM impairment in symptom
free patients. However, previous studies gave inconsistent
results regarding the effect of non-ToM cognitive and general
intelligence decits on ToM impairment in schizophrenia. IQ,
executive functions and memory abilities seem to be
correlated with ToM performances of schizophrenia patients,
however previous reviews suggested that cognitive decits
and IQ cannot explain the ToM impairment in schizophrenia

E. Bora et al. / Schizophrenia Research 109 (2009) 19

(Brne, 2005; Harrington et al., 2005a,b). Meta-analysis of

Sprong et al. (2007) also reported that IQ did not affect mean
effect sizes for ToM impairment. However, our study showed
a signicant inuence of IQ impairment on ToM decits when
the regression analysis was restricted to remitted patients.
In acute phases of the illness the impact of cognitive decits
on ToM impairment may be masked by the relationship
between symptoms and mentalising ability. However, in the
stable phases of illness general intellectual impairment and
other cognitive decits can mediate the observed impairments of ToM ability. Consistent with this idea, the results of
Bora et al. (2008) suggested that ToM impairment in
symptom free patients could be explained by working
memory decits of these patients. A recent study in rstdegree relatives of patients with schizophrenia also showed
ToM impairment that did not persist after correction for IQ
(Pentaraki et al., 2008). These results suggest that, before
concluding that there is a trait related ToM impairment in
schizophrenia, more careful research is needed to investigate
ToM abilities and the inuence of other cognitive decits in
symptom free patients.
One limitation of the current study is the lack of available
data for more detailed meta-regression analyses. One example for this is insufcient cognitive data that prevent us from
conducting further analyses. Besides IQ, other cognitive
abilities like executive functions and verbal memory impairment can inuence ToM impairment in schizophrenia.
Unfortunately, we were only able to examine the effects of
IQ in the present meta-analysis. Second, while we did
individual analyses for the Hinting task and the Eyes task,
there was still between-studies task heterogeneity for the two
false belief tasks included in the current meta-analysis.
Finally, there was no sufcient data to calculate effect sizes
for the ToM impairment in rst-episode patients. This is a
limitation since studies that investigate ToM impairment in
early phases and also before the onset of illness (i.e., prodrome)
are important to understand the nature of ToM dysfunction in
schizophrenia.
Our results lead to several recommendations for future
studies. One important issue is to further test the role of ToM
impairment as a trait characteristic of schizophrenia. Future
work should carefully control the inuence of residual
symptoms and, importantly, the effect of other cognitive
impairments in patients with schizophrenia. Studies in rstdegree relatives of patients and longitudinal studies in people
at high risk for developing schizophrenia will also be
important in understanding whether the ToM impairments
in schizophrenia are enduring features of the disorder. Finally,
another important step is to use ToM tasks with better
psychometric properties.
Role of funding source
None.
Contributors
Emre Bora designed the study, collected and analysed the data and wrote
the rst draft of the manuscript. Murat Yucel and Christos Pantelis
contributed to design of the meta-analysis. All authors contributed to and
approved the nal draft of the paper.

Conict of interest
All authors report no conict of interest.

Acknowledgement
Murat Ycel was supported by a National Health & Medical Research
Council (NH&MRC) Clinical Career Development Award (I.D. 509345).
NHMRC.

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