Indian Journal of Health and Wellbeing © 2014 Indian Association of Health,

2014, 5(12), 1505-1507 Research and Welfare

http://www.iahrw.com/index.php/home/journal_detail/19#list ISSN-p-2229-5356,e-2321-3698

Accessing role of chronicity on theory of mind in schizophrenia

Nidhi Aggarwal C. R. J. Khess Masroor Jahan
Central Institute of Psychiatry Director Professor of Psychiatry Additional Professor of Clinical Psychology
Ranchi Central Institute of Psychiatry Ranchi Institute of Neuro-Psychiatry
Ranchi and Allied Sciences, Ranchi

Theory of mind (TOM) refers to the capacity to infer one's own and other persons' mental states. Several studies
provide convincing evidence of a specific deficit in the theory of mind (ToM) in patients with schizophrenia. The
present study attempts to access role of chronicity on Theory of mind in schizophrenia patients. Total 25 patients
with ICD-10 DCR diagnosis of schizophrenia were selected as sample for the study from the inpatient department.
Theory of Mind Task was used for exploring TOM in Schizophrenia patients. To study the variables independent
samples test and chi-square (2) test were used. There was no significant correlation found between duration of
illness and Theory of mind in schizophrenia patients. Duration of illness does not influence the theory of mind
deficit in schizophrenia patients. This study adds to the growing literature on ToM by suggesting that theory of mind
deficit might represent a trait rather than a state marker in schizophrenia.

Keywords: schizophrenia, theory of mind, chronicity

Theory of mind (ToM) is the natural ability to attribute mental states
about ourselves and others, and to use such knowledge to interpret
one's own as well as others behaviors' (Premack & Woodruff, 1978).
Several researchers have highlighted the role of ToM in human
communication (Happe & Loth, 2002; Tirassa, Bosco, & Colle,
2006). To effectively use and interpret language, one usually has to
go beyond the literal meaning of words and utterances on the basis of
contextual information (Sperber & Wilson, 1986, 2002). However,
functional or structural disruption of the neural mechanisms
underlying ToM may give rise to various types of psychopathology,
including schizophrenia (Frith, 1992; Brune, 2001).
In fact, impaired ToM has been described in a variety of
neuropsychiatric disorders. The most extensive ToM studies have
been carried out in autistic spectrum disorders (Baron-Cohen et al.,
1985; Baron-Cohen, 1995) in adult patients with frontal lobe damage
(Rowe et al., 2001; Stuss et al., 2001) and in schizophrenia
(Corcoran, 2000; Brune, 2003). Lately ToM research has been
extended to patients with frontotemporal dementia, Alzheimer's
dementia or other dementing disorders (Cuerva et al., 2001; Gregory
et al., 2002; Snowden et al., 2003; Starkstein & Garau, 2003)
antisocial personality disorder (Richell et al., 2003) bipolar affective
disorder (Kerr et al., 2003) and normal aging (Happe et al. ,1998;
Maylor et al., 2002).
Schizophrenia has complex pathology, in which the distinctive
symptoms range from hallucination, delusion, catatonic behaviour
to affectivity problems; in particular a typical disturbance is
Theory of mind (ToM). Clinical findings strongly suggest that
patients with schizophrenia are impaired in social interaction
relating to their reduced capacity to effectively engage in
communication (Trognon, 1992; Sperber & Wilson, 2002). There
is good empirical evidence that ToM is specifically impaired in
schizophrenia and that many psychotic symptoms, for instance
delusions of alien control and persecution, the presence of thought
and language disorganization, and other behavioral symptoms may
best be understood in light of a disturbed capacity in patients to
Correspondence should be sent to Nidhi Aggarwal
Central Institute of Psychiatry, Ranchi
relate their own intentions to executing behavior, and to monitor
others' intentions. Frith (1992) was the first to raise the possibility
of ToM deficits underpinning schizophrenia. He offered a
comprehensive theory, with different types of ToM skill
impairments accounting for the different symptom groups-
positive, negative and disorganization symptoms. Several
empirical studies have shown that schizophrenia patients perform
poorly in ToM tasks (Doody et al., 1998; Langdon, Davies, &
Coltheart, 2002). In schizophrenia, the deficit in ToM appears to
be specific and not dependent on more general cognitive abilities,
it resembles a trait more than a state condition (Gavilan et al:
2013). There is dispute, however, over such questions as whether
ToM is impaired or exaggerated in some types of schizophrenia.
Plethora of studies can be sited investigating the relationship
between theory of mind and schizophrenia (Frith, 1992; Doody et
al., 1998; Langdon, Davies, & Coltheart, 2002), age of onset of
patients and schizophrenia (Smeets et al., 2013). At the present time
no studies in the literature seems to share any finding about the role
of chronicity on Theory of mind in schizophrenia patients and its
impact on the functional outcome of the patients. The present study
is an endeavour in the same line.
Method
Participants
Total 25 male Patients within the age range of 18 years to 50 years
diagnosed as schizophrenia according to ICD-10DCR criteria
having delusion, minimum level of 8 years of education, willing to
give informed consent for participation were purposively selected
within two weeks of treatment initiation as sample for the study from
the inpatient department. Patients with major medical illness/
psychiatric disorder or neurological illness, history of substance
/alcohol dependence except nicotine were excluded from the study.
The Socio-demographic and Clinical data sheet was prepared,
Theory Of Mind Task (Frith & Corcoran, 1996, Sarfati et al.,1997)
was used for exploring TOM in Schizophrenia patients.
Psychopathological symptoms were rated at baseline, after 4 weeks,
and on three subsequent follow ups in a span of 6 months.
1406 AGGARWAL ET AL./ ACCESSING ROLE OF CHRONICITY ON THEORY OF MIND

Instruments Table 2. The table shows no significant correlation between duration

of illness and theory of mind task (p=.205) and the attribution of
Socio-demographic and Clinical Data Sheet: Semi structured
intention task (p=.126) in schizophrenia patients. (N=25)
Performa, which included various socio-demographic variables
specially designed for this study. Table 2: Pearson's correlation of duration of illness and theory of
Theory of Mind Task: It consist of three sub tasks , False Belief Task mind tasks.
(FB) in which False Belief stories depict a story character who, Duration of illness N r p
unaware of an event that occurred in a story acted on his or her
Theory of Mind Task 25 -.262 .205
misinformation. A false- belief story intends to test subject's ability to
infer false belief and to correctly predict that others can act on the The Attribution of Intention Task 25 -.315 .126
basis of beliefs that misrepresent reality. The Task was acquired from Discussion
the stories developed by Wimmer and Prener (1983), Baron-Cohen
(1985, 89), Leslie and Frith (1986, 89). Deception Task (DT) Findings show that there was no significant correlation between
Deception entails manipulation of other persons thoughtmaking duration of illness and theory of mind task (p=.205) and the
some one believes something false. ToM stories used by Frith and attribution of intention task (p=.126) in schizophrenia patients. In
Corcoran (1996), showing the mental state and memory questions the same lines Brune (2004), found that patients' performance on the
[stories involved bluff (first order) & double bluff (second ToM questionnaire is the most significant predictor of severe social
order)].The Attribution of Intention Task : (Sarfati et al.,1997) the behavioral abnormalities independent of the duration of illness.
task consist of 4 randomly ordered short comic strips, already Koamisia et al. (2011) too found that ToM performance was
designed by Sarfati et al. for exploring Tom in Schizophrenia. independent of clinical symptoms (positive, negative,
disorganized), duration of illness, age and level of education, and
Results neuropsychological performance. Bora and Pantelis (2013) found
The aim of the study was to study the socio-demographic variables that ToM was substantially impaired at the first episode of
for this purpose independent samples test and chi-square (2) test schizophrenia, and the deficits were comparable with findings in
were used. chronic patients.
Table 1.1 shows socio-demographic variables of the group The findings tend to support the theory put forward by Perner
(N=25). There was no significant difference in terms of age (p=.184), (1991), “theory theory” which describes theory of mind as a capacity
education (p=.289) and family Income (p=.819). 28% of patients based on a distinct body of theoretical knowledge acquired during an
were Unmarried, whereas 60% of patients were married. Patients individual's ontogenetic development as against the “simulation
belonged to extended family type, were unskilled occupationally and theory”, according to which theory of mind capacity is based on
resided in rural areas. taking someone else's perspective i.e. ''put oneself into others' shoes''
and projecting one's own attitude onto someone else (Stone &
Variable Mean ± SD / n(%) Davies, 1995).
Age(years) 34.16±8.994 Despite substantial evidence for Theory of mind (ToM)
Education (years) 11.92±2.216 impairment in schizophrenia, we know little about how dynamic
Family Income 10.12±6.8697 (state) variables and broad clinical, cognitive and medication
Marital Status Married 15(60%) characteristics moderate the precise magnitude of the observed ToM
Separated 3(12%) deficit. Bora et al. (2009) conducted a meta-analysis of 36 studies, in
Un Married 7 (28%) remitted schizophrenia patients the degree of ToM impairment was
Family Type Nuclear 9(36%) less pronounced than non-remitted patients, but was still significant.
Extended 16(64%) They found evidence of a trait relating to ToM impairment. This is
Occupation Skilled 8(32) consistent with finding of Dworkin et al. (1993) of impaired social
Unskilled 12(48) functioning (but not specifically ToM) in the relatives of people with
Unemployed 5(20) schizophrenia. However, not everyone agrees (Pousa et al., 2008). In
Residence Urban 6(24%) the present study too the non-significant correlation between
Sub-Urban 2(8%) duration of illness and theory of mind can be attributed to the same.
Rural 17(68%) In contrast to this a study by Corcoran et al. (1995) suggests that
Drug Poor 12 (48%) performance on ToM tasks is a state rather than a trait variable,
Compliance Average 9 (36%) holding on the same continuum Sarfati and Hardy-Bayle (1999)
Good 2 (8%)
found that Schizophrenia patients with disorganization performed
Drug Naive 2(8%)
more poorly compared to non-disorganized schizophrenia patients,
Diagnosis F20.3 2 (8%)
manic patients, and controls on ToM tasks. Global psychopathology
F20.9 1 (4%)
score was also elevated in this group, suggesting that the ToM deficit
F20.0 22 (88%)
is a state variable rather than a trait.
Past History Present 5(20%)
This study adds to the growing literature on ToM by suggesting
Absent 20(80%)
Family History Present 8(32%)
that theory of mind deficit might represent a trait rather than a state
Absent 17(68%)
marker in schizophrenia. It replicates some earlier findings and adds
Duration of Illness 5.004±4.8 a new one too. Duration of illness does not influence the theory of
Age of onset 28.62±7.64 mind deficit in schizophrenia patients.
 Indian Journal of Health and Wellbeing 2014, 5(12), 1505-1507
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