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SCHIZOPHRENIA

RESEARCH
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SchizophreniaResearch 17 (1995) 5-13

Schizophrenia, symptomatology and social inference:


Investigating "theory of mind" in people with schizophrenia
Rhiannon Corcoran a,,, Gavin Mercer b, Christopher D. Frith c
"Department of Psychology, University CollegeLondon, 26 Bedford Way, London WC1H OAT, UK
b Royal Edinburgh Hospital and Department of Psychiatry, Universityof Edinburgh, Edinburgh, UK
c WellcomeDepartment of Cognitive Neurology, Institute of Neurology, London, UK
Received 5 September 1994; revised 28 February 1995; accepted 6 March 1995

Abstract

It has been proposed that certain psychotic symptoms associated with schizophrenia reflect a deficit in the ability
to appreciate other people's mental states (Frith, 1992). This notion is tested using a newly devised task examining
the capacity to infer intentions behind indirect speech. The findings support the notion that some patients with
schizophrenia have difficulties with tasks requiring 'theory of mind' skills and that this deficiency is symptom specific.
The findings are discussed with reference to the cognitive skills which may be involved in the performance of tasks
requiring social inferences.
Keywords: Social Inference; Theory of mind; (Schizophrenia)

I. Introduction

1.1. The symptom approach


The increasing popularity of the symptom
approach in the neuropsychological study of
schizophrenia has arisen as a result of the confusing findings obtained in classical neuropsychological studies of heterogeneous schizophrenic
samples (Kolb and Wishaw, 1983; Dickerson et al.,
1991). It is typical to find poor performance in
people with schizophrenia on most standard
psychometric tests when they are compared to
normal control subjects. It is, however, often
unclear quite what these deficits mean in terms of
specific cognitive processes. By classifying schizophrenic patients in terms of their symptoms,
* Corresponding author.
0920-9964/95/$09.50 1995ElsevierScienceB.V. All rights reserved
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making predictions based upon the nature of these


symptoms and devising tests which examine the
cognitive function suspected of being deficient,
progress into the nature of this perplexing condition is more likely to occur.
A recent neuropsychological formulation of the
schizophrenic illness (Frith, 1992) claims that
schizophrenia can be understood as a disorder of
the representation of mental states. Predictions are
made as to the nature of the representational
deficit which underlies several of the typical symptoms of schizophrenia. The argument that patients
who display passivity symptoms, (such as delusions
of control) and second person auditory hallucinations fail to centrally monitor their intentions to
act has been studied experimentally (Frith and
Done, 1989) as has the explanation of negative
feature schizophrenia (Frith, 1987). However, the
proposal that an inability to represent the beliefs,

R. Corcoran et aL/Schizophrenia Research 17 (1995) 5-13

thoughts and intentions of other people underlies


delusions of reference, persecution and misidentification as well as third person auditory hallucinations and some aspects of incoherent speech has
not yet been examined. It is this aspect of the
model which is the focus of the present research.

1.2. Theory of mind and schizophrenic symptoms


By their very nature, delusions of reference,
misidentification and persecution are characterized
by a misinterpretation of another person's behavior or intentions. Thus the argument that these
symptoms arise as a result of a deficit in a system
which enables us to infer what is in the minds of
other people is straight forward. The ability to
explain the behavior of others in terms of their
mental states is often referred to as having a
'theory of mind' (Premack and Woodruff, 1978).
It is argued that third person auditory hallucinations arise when these inferences about the intentions, thoughts and beliefs of others are perceived
as coming from an external source. Thus, third
person hallucinations involve the failure of the
self-monitoring system as in second person hallucinations, but because they refer to inferences about
the thoughts of other people, they are heard in the
third person.
In an in depth study of schizophrenic discourse,
Rochester and Martin (1979) showed that the
speech of thought disordered patients is characterized by a lack of cohesive ties and a frequent
use of pronomial referents such as 'he', 'she', 'it'
without prior elaboration as to whom or what
these pronouns refer to. In other words, new
information is offered in a manner which assumes
prior knowledge of the subject matter in the listener. From this it can be argued that these speakers are failing to separate their listeners knowledge
state from their own. By failing to appreciate, or
take into account, what is currently known by the
listener, they display a failure in the social inferencing process.
It is also proposed that the asocial behavior and
blunted affect seen in patients with negative features reflects an impairment in social inference or
'theory of mind'. It is argued that these patients
are behaviourally very similar to people with

autism. Indeed, Forster et al. (1991)provide evidence to show that chronic negative feature schizophrenia is often associated with childhood social
difficulties particularly in men. Other epidemiological studies (e.g. Jones et al., 1994) have demonstrated asocial inclinations in children later to be
diagnosed as schizophrenic. This would suggest an
early developmental disruption as has been postulated for childhood autism (Wing and Gould,
1979). That children with autism are particularly
poor at inferring the beliefs and intentions of other
people is well documented and supported by thorough and convincing experimental evidence
(Baron-Cohen et al., 1985, 1986; Frith, 1989;
Perner et al., 1989).

1.3. Previous studies


While there have been no studies of 'theory of
mind' abilities per se in schizophrenia, there is a
long tradition of research focussing on the social
competence of these patients. Several of these
make explicit reference to difficulties of inferring
knowledge, thoughts, beliefs or iatentions in
others. For example, using a version of the autokinetic experiment, Diamond (1956) presented evidence to show that in comparison to nonschizophrenic, emotionally disturbed individuals,
schizophrenic patients were less able to modify
their responses in the direction of the responses of
another person in an inter-personal situation.
Diamond argued that the evidence supported the
notion that 'the schizophrenic does not adequately
internalize the points of view of others'. Along
similar lines is the work of Good (1990) who
examined the problems that arise in conversation
when the speaker must supply information to the
listener in order that he/she will understand. The
author described the case of a schizophrenic
speaker who, having recognized that his listener
had not understood, failed in continuous attempts
to supply the information that was needed.
LaRusso (1978) examined the sensitivity of
paranoid patients to nonverbal cues using video
tapes showing people expecting to receive electric
shocks or showing people simulating the same
expectation. The subjects were asked to say
whether the people on the tapes were expecting

R. Corcoran et al./Schizophrenia Research 17 (1995) 5-13

electric shocks or were pretending. Results demonstrated that while paranoid patients were more
accurate in their decisions about the genuine stimuli, normal controls were more accurate in their
decisions concerning the simulated stimuli. The
author explained this rather curious finding by
arguing that while the paranoid patients were more
sensitive to the genuine stimuli because of a processing bias, the normal controls were more sensitive to the simulated material because they were
'more accepting of stereotyped social presentation'.
Finally, Cutting and Murphy (1990) examined
the appreciation of social knowledge in patients
with schizophrenia, manic psychosis and depression. Two sets of multiple choice questions were
given to the subjects. One tested knowledge of
how people tend to act in social situations. The
other examined knowledge of non-social events or
objects. It was found that the schizophrenics performed the former task more poorly than either
of the other two groups. This was seen as reflecting
the 'social naivet6' of the subjects with schizophrenia. The authors considered two possibilities to
explain this social naivete. The first is that the
patients perform this task poorly as a result of
their lack of experience of and exposure to such
situations. The second suggestion is that poor
social judgements are an intrinsic feature of schizophrenia or, at least, of a subgroup of these patients.
It is this latter view which the authors favoured.
Clearly then there are implications from the
previous literature that patients with schizophrenia
have difficulty with situations where theory of
mind is required. A test of the hypothesis that
deficits in mental state inference are central to
certain symptoms of schizophrenia is therefore
long-awaited.
This paper reports findings on a simple social
inference task examining the comprehension of
indirect speech. As we have outlined above, Frith's
model makes clear predictions about the performance of patients with different kinds of symptoms
on tasks which require theory of mind skills. We
expecl poor performance from patients with negative features (poverty of speech, flattening of
affect), patients with incoherent speech, and
patients delusions of reference and delusions of
persecution. Patients with passivity experiences

(delusions of control, thought insertion, etc.) have


problems with their own mental states rather than
those of others and may therefore perform the
task normally. Patients in remission with no current symptomatology should certainly perform
normally.

2. Methods

2.1. The hinting task


This task was devised to test the ability of
subjects to infer the real intentions behind indirect
speech utterances. The task comprises ten short
passages presenting an interaction between two
characters. All of these end with one of the characters dropping a very obvious hint. The subject is
asked what the character really meant when he/she
said this. An appropriate response at this stage is
given a score of two and the next story is read
out. If, however, the subject fails to give the correct
response by, for example, simply paraphrasing the
'hint' and thus using no inferential skills, more is
added to the story in the shape of an even more
obvious hint. The subject is then asked what the
character wants the other one to do. If a correct
response is delivered at this stage, the subject is
given a score of one. If the subject fails again to
infer the intended meaning of the two pieces of
indirect speech, then a score of zero is given for
that item. All items on the task were read aloud
to the subjects so that appropriate prosodic information was presented. The poor prose recall of
patients with schizophrenia has been well documented (e.g. Shallice et al. 1991). To take account
of this, the stories were repeated for those subjects
with schizophrenia who requested that it be so.
This would have had the effect of ensuring an
adequate level of encoding of the information by
these patients. It can be assumed therefore that
the findings will not reflect an encoding deficit.
One of the items from the Hinting Task is shown
in the Appendix.

2.2. The subjects


Fifty five people with a DSM III R diagnosis of
schizophrenia performed this task. The majority

IE Corcoran et al./Schizophrenia Research 17 (1995) 5-13

of these were in-patients on acute psychiatric wards


at the time of testing. The current level of overall
intellectual functioning was estimated using the
Quick Test (Ammons and Ammons, 1962). The
demographic details of the patients can be seen
in Table 1.
On the day of testing the current symptomatology of the patients was assessed (by R.C. and
G.M.) using the Present State Examination (version 9; Wing et al., 1974). According to their
responses in this semi-structured interview, the
patients were classified into one of six symptom
groups in a hierarchical manner
(1) Negative features (n = 10): Any patient with
negative features including asocial behavior, poverty of speech and blunted affect.
(2) Incoherence (n=3): Patients who did not
have negative features, but manifested incoherent
speech and/or incongruous affect.
(3) Paranoid symptoms (n=23): Patients who
did not manifest any behavioral signs, but reported
delusions of persecution, delusions of reference
and/or third person hallucinations.
(4) Passivity experiences (n=7): Patients with
none of the above problems, but experiencing
symptoms such as delusions of control, thought
insertion and thought broadcasting.
(5) Other symptoms (n =4): Patients with none
of the above problems, but rare symptoms which
do not relate to the representations of mental
states (e.g. fantastic, expansive delusions and musical hallucinations).
(6) Remission (n = 8): Patients who were symptom free at the time of testing.
It was predicted that groups 1, 2 and 3 would

perform badly on the hinting task, while groups 5


and 6 would be unimpaired.
In addition to the schizophrenic patients, two
groups of control subjects were studied. First, a
group of thirty normal controls were gathered
from various sources. Second, a group of fourteen
psychiatric control patients performed the task.
These subjects were all outpatients attending a
psychiatric clinic for relief of anxiety and/or
depression. The demographic characteristics of
these two control samples are also shown in
Table 1.

3. Results

3.1. Schizophrenic patients versus controls.


The responses of the two control groups were
very similar on this task and therefore the data
were combined making a total control sample of
44. The schizophrenic and control groups did not
significantly differ on age, sex, occupation and
educational characteristics. The groups were not
however matched on estimated current level of
intellectual functioning. The estimated mean IQ
scores along with the mean scores obtained on the
Hinting task and the Pearson's correlations
between hinting score and estimated IQ are shown
in Table 2.
The difference in performance of the hinting
task between the two groups is highly significant
(t=4.16; 97 df; p<0.0001). It is of note that
although the two groups differ statistically for
current level of functioning, the mean scores of

Table 1
The demographic details of the subject groups
Group

Schizophrenic patients
Psychiatric controls
Normal controls

n (m: f)

55 (38: 17)
14 (8:6)
30 (20: 10)

Values are means; SD's in parentheses.

Age

31.8 (8.9)
46.7 (18.0)
31.2 (10.0)

Employment
(% employed)

22
50
30

Education
(% achieving:)

Estimated IQ

Degree

O-Level

13
28
23

75
72
73

98.2 (10.3)
105.3 (14.3)
107.1 (11.3)

P~ Corcoran et al./Schizophrenia Research 17 (1995) 5-13


Table 2
Performance on the hinting task and estimated IQ in schizophrenic and control groups

Hints score mean (SD)


Estimated IQ mean (SD)
Hints IQ correlation

Schizophrenic
patients (n = 55)

Controls (n =44)

Difference

15.6 (3.9)
98.2 (10.3)
0.49 (p < 0.001)

18.3 (1.6)
106.5 ( 12.1 )
0.08 (ns)

t(97)=4.2, p<0.0001
t(97) = 3.7, p < 0.0001
0.08 (ns)

both groups fall well within the normal range.


There is a striking difference in the group correlations between IQ and hinting scores which cannot
be explained as resulting from a ceiling effect in
the control group.

3.2. Symptom subgroup comparisons


The mean scores on the Hinting task, estimated
IQ and performance ranking for the subgroups of
schizophrenia and the two control groups are
shown in Table 3.
The ANOVA examining between group differences on the Hinting task is highly significant (F=
6.99; p<0.001). The between group differences
were assessed using Tukey's post hoc multiple
comparisons test. This analysis tells us that the
negative feature group score worse on the hinting
test than the patients with passivity phenomena
and those in remission as well as the two control
groups. Those patients with the paranoid delusions
perform more poorly than the control groups as
do those few patients with incoherent speech.

Although, this latter group is so small this result


will need to be confirmed with a larger sample.
The differences in IQ between the groups were
covaried out using an analysis of covariance and
the between group differences in hinting task performance remained significant (F= 4.91; p < 0.001 ).
Thus, the results obtained on this task can not be
the result of differences in overall level of
functioning.

4. Discussion

4.1. Schizophrenic versus control group findings


This comparison demonstrated that when schizophrenic patients are combined into one heterogeneous group, their performance on this simple
social inference task is poorer than that of a
combined normal and non-psychotic psychiatric
control group. The groups were not, however,
matched for current level of intellectual functioning but it is considered that this difference in

Table 3
Performance on the hinting task and estimated IQ in the symptom subgroups
Group

Hints

IQ

Rank observed

Predicted

l:
2:
3:
4:
5:
6:
7:
8:

10
3
23
7
4
8
14
30

12.8 (4.5)
12.7 (5.7)
15.4 (3.6)
18.6 (1.7)
16.5 (2.6)
18.0 (2.6)
18.6 (1.6)
18.1 (1.6)

96.6 (12.8)
95.0 (6.2)
96.6 (9.6)
103.1 (14.6)
101.5 (4.0)
100.0 (7.5)
105.3 (14.3)
107.1 (11.3)

8
7
6
1.5
5
4
1.5
3

8
7
6
5
2.5
2.5
2.5
2.5

negative
incoherent
paranoid
passivity
other
remission
psychiatric controls
normal controls

Values are means; SD's in parentheses.


ANOVA F(7,90)=7.0, p<0.001; ANCOVA F(7,89)=4.9, p<0.001 (covarying out IQ). Tukey's multiple comparisons: 1 < 4 , 6 , 7 ,
8; 2<7, 8: 3<7, 8.

10

R. Corcoran et al./Sehizophrenia Research 17 (1995) 5 13

estimated IQ cannot entirely account for the


difference found in the performance of this very
simple task. There is evidence in these data to
suggest that the two groups are performing the
task in different ways. The correlation between the
hinting task score and estimated IQ in the control
group is practically zero. This suggests that the
two tasks are executed using different skills.
However, the same correlation in the schizophrenic
group is rather more substantial. This implies that
the patients with schizophrenia are to some extent
relying upon generalized intellectual abilities to
perform this simple social task. In turn, this may
be taken as evidence favouring the argument for
a specific cognitive deficit in some of these patients.

4.2. Symptom specific findings


Our data suggests that a deficit in 'theory of
mind' skills is central to certain psychiatric symptoms. Problems performing the hinting task were
seen in patients with negative features and in those
with paranoid delusions and related positive features. There was also limited support for the
argument that patients with incoherent speech are
poor at inferring the intentions behind indirect
speech. The link between the theory of mind deficit
and these particular symptoms can be understood
by reference to previous research.

Negative features
It has been argued that patients with chronic
negative schizophrenia show evidence of poor
childhood social functioning (Forster et al., 1991).
The ability to infer the beliefs and intentions of
others is acquired in early childhood according to
the cognitive developmental literature (Leslie,
1987). Thus, the poor performance of patients
with negative features on this simple, social inference task may reflect a failure early in development
which prevented them from ever acquiring normal
'theory of mind' abilities.
Paranoid delusions and related positive features
In contrast to patients with negative features,
there is no evidence of poor childhood social
functioning in those with paranoid symptoms. It
would seem that these patients develop their schiz-

ophrenic illness de novo during adolescence or


early adulthood. Given that 'theory of mind' skills
are acquired in childhood it is likely that these
patients developed their specific mentalizing skill
quite normally until it was compromised by the
onset of schizophrenia in later life. Should this be
the case, these patients would be used to inferring
mental states in others accurately and would continue trying to make such inferences even though
their ability was impaired. Furthermore, they
might well be unaware that their inferences were
incorrect.

Incoherent speech
These patients performed the hinting task very
badly. However, more patients must be tested
before this result can be considered reliable.
Passivity experiences
The final piece of evidence which supports the
idea that a theory of mind deficit is symptom
specific comes from the performance of the patients
with passivity phenomena, such as delusions of
control. According to the model, these patients
have a representational disability involving the
monitoring of their own intentions to act (Frith
and Done, 1989). It is intriguing that these patients
were perfectly capable of inferring the intentions
of others from indirect speech in the present study.
This suggests that these two skills are dissociable.
Patients in remission
Patients who were symptom free at the time of
testing showed normal performance on the hinting
task. This observation suggests that mentalizing
ability is a state rather than a trait variable that is
closely tied to symptomatology.
4.3. Towards a neuropsychological model of
mentalizing abilities
In a recent positron emission tomography (PET)
study of the comprehension of new metaphors
compared to the comprehension of true/false functional sentences, Bottini et al. (1994) demonstrated
selective activations of prefrontal (BA 8 and 46),
precuneus (BA 31), middle temporal gyrus
(BA 21) and anterior and posterior cingulate

R. Corcoran et al./Schizophrenia Research 17 (1995) 5 13

(BA 32/31) of the right hemisphere in association


with metaphorical sentence comprehension. That
metaphors activated the right hemisphere is consistent with lesion studies and reflects the abstract
nature of these linguistic figures (Winner and
Gardner, 1977; Wapner et al., 1981).
The finding of note in this study is the simultaneous activation of the prefrontal cortex and the
precuneus. The latter is an area which has been
implicated in the retrieval of information from
long-term episodic memory (Grasby et al., 1993;
Shallice et al., 1994). The interpretation of new
metaphors implicitly involves a mental state inference because when a person is required to judge
the plausibility of a new metaphor, they must infer
the speaker's likely intended meaning when they
chose that particular figure of speech. We have
theretbre some evidence to suggest that theory of
mind or social inference judgements require us to
refer to our episodic memory store where our own
contextually specific 'items' of social information
are stored. It is suggested that the associated
activation of the prefrontal area enables this system
to deal with novelty and to make inferences about
other people's behavior on the basis of past experience. For example, we might have to infer the
intentions, or beliefs of another person in a situation that was alien to us. In this case, the information ~'hich we could glean from our episodic store
would not be sufficient to solve the problem.
Inferential processes instantiated in prefrontal
cortex would allow us to make a 'best guess' about
the intentions of the character in question. In this
sense, metarepresentation can be understood as
underlying the ability to apply old memories to
new situations. It is of note that difficulties with
episodic memory are consistent with many of the
current findings of neuropsychological research in
schizophrenia (Hemsley, 1992; Cohen and ServanSchreiber, 1991; Tamlyn et al., 1992; Baddeley
et al., in press).
By arguing for a role for both episodic memory
and inferencing skills, the proposed model can
explain the existence and the severity of the theory
of mind deficits demonstrated in this study.
First, patients with negative features are likely to
have a depleted store of episodic experiences if we
accept that their disability is neurodevelopmental

11

in nature. The social experiences to which these


patients can refer will be limited, There is also
evidence to suggest that prefrontal function in these
patients is impaired (Weinberger et al., 1986, 1992).
Thus, these two essential components of social
inferencing are both inefficient in patients with
negative features. This can explain the very poor
performance of such patients on the hinting task.
In patients with the paranoid symptoms it is
possible that the inferencing process is normal, but
that the use of the episodic store is abnormal.
Perhaps there is a bias towards retrieving episodic
information of a negative self-referential type
(Kaney and Bentall, 1989)
Finally, although the group of incoherent
patients in this study was rather small and findings
relating to this group must be speculative, there
have been suggestions in the literature of difficulties
with both memory and inferencing in such patients
(Spitzer et al., 1994; Rudge et al., 1994; Rochester
and Martin, 1979).

5. Conclusions
The argument for symptom specific difficulties
in the ability to infer what is going on in the minds
of other people is supported by the results of
performance on a task examining the comprehension of indirect speech. There appears to be a
hierarchy in the expressed severity of this deficit
consistent with Frith's (1992) model. These problems can be understood in terms of dysfunctional
episodic long term memory and inferential abilities. The breakdown of this skill in this manner is
compelling given that there is increasing evidence
to suggest that both memory and frontal functioning are typically impaired in schizophrenia.
We are currently studying the performance of
schizophrenic patients on a number of other tests
which examine the ability to infer mental states in
other people. It is hoped that this will more clearly
demonstrate the specific nature of the deficit in
relation to the symptoms of schizophrenia.

Acknowledgements
Our deepest thanks go to Dr. Sabine and Dr.
Weller of St. Ann's Hospital, London; Dr. Dolan

12

R. Corcoran et al./Schizophrenia Research 17 (1995) 5-13

of The National Hospital for Neurology and


Neurosurgery; Prof. Murray of the Institute of
Psychiatry; Prof. Johnstone of the Royal
Edinburgh Hospital and Dr. Crow of Northwick
Park Hospital for allowing us to see their patients.
We are, of course, grateful to all the subjects who
participated so willingly in this study. We would
also particularly like to thank Uta Frith, Connie
Cahill and Graham Pickup for their invaluable
advice on experimental, theoretical and clinical
issues. This work was supported by a grant
awarded by the Medical Research Council.

Appendix I
Example. One of the ten hinting task items
Paul has to go to an interview and he's running
late. While he's cleaning his shoes he says to his
wife, Jane: 'I want to wear that blue shirt, but its
very creased.'
Question: What does Paul really mean when he
says this?
Extra information: Paul goes on to say: 'Its in
the ironing basket.'
Question: What does Paul want Jane to do?

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