Psychiatry Research 145 (2006) 95 – 103

www.elsevier.com/locate/psychres

Social functioning, theory of mind and neurocognition in outpatients

with schizophrenia; mental state decoding may be a better predictor
of social functioning than mental state reasoning
Emre Bora *, Ayse Eryavuz, Bulent Kayahan, Gulcin Sungu, Baybars Veznedaroglu
Ege University Medical School Psychiatry Department, 1833/1 Sokak no. 11/6, 35100, Karsiyaka, İzmir, Turkey
Received 4 July 2005; received in revised form 4 November 2005; accepted 11 November 2005

Abstract

Few studies have directly investigated the relationship between theory of mind (ToM) deficits and social functioning in
schizophrenia. At the same time, the impact of mental state decoding tasks on social dysfunction has also not yet been investigated.
In this study, the relationship between theory of mind deficits and social functioning was investigated among 50 patients with
schizophrenia. A mental state decoding task known as dThe Eyes testT and a mental state reasoning task dThe Hinting testT were
applied to assess ToM abilities, while the Social Functioning Scale (SFS) was used to assess social functioning. Non-ToM
neurocognitive tests were also given to the patients. Results of the study show how theory of mind and working memory
performances of patients with good functional outcome proved to be significantly better than those of inadequately functioning
patients. Results also indicate that performance on the Eyes test was the best predictor of social functioning and that negative
symptoms also contributed to poor social functioning. It is concluded in this study that mental state decoding skills appear to be the
most important cognitive mediator of social functioning.
D 2005 Elsevier Ireland Ltd. All rights reserved.

Keywords: Social cognition; Social function; Schizophrenia

1. Introduction symptoms (Hoffman and Kupper, 1997) and disorgani-

One of the most notable characteristics of schizo-
phrenia is poor functional outcome of patients. Many
patients with schizophrenia exhibit a poor level of
community functioning even prior to the onset of the
first psychotic episode. Social impairment generally
worsens over the course of the disorder and is often
resistant to antipsychotic treatment (Addington and
Addington, 2000; Pinkham et al., 2003), while negative
* Corresponding author.
E-mail address: emrebora@hotmail.com (E. Bora).
0165-1781/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.psychres.2005.11.003
zation symptoms (Norman et al., 1999) of patients with
schizophrenia contribute to social functioning deficits.
Neurocognitive dysfunction is a well known feature
of schizophrenia. Some studies suggest that cognitive
dysfunction may be related to poor social functioning in
schizophrenia (Dickerson et al., 1994; Addington and
Addington, 2000; Milev et al., 2005). Executive dys-
function, working memory, verbal memory and vigi-
lance deficits may be related to poor community
functioning and problems of social skills acquisition
(Green, 1998). Despite these findings, some authors
question the precise nature of this relationship (Green
et al., 2000). It is reasonable to suggest that specific
96 E. Bora et al. / Psychiatry Research 145 (2006) 95–103
aspects of cognition which are important for social
interaction may be more strongly linked to social func-
tioning (Brüne, 2005). This unique feature of cognition
is termed social cognition.
Social cognitive dysfunction is an important feature
of schizophrenia (Pinkham et al., 2003). A key aspect
of social cognition is the ability to conceptualize other
people’s mental states, i.e. their beliefs and intentions;
this is known as theory of mind (ToM). ToM deficit in
schizophrenia was originally proposed by Frith (1992)
and subsequently many studies (Corcoran et al., 1995;
Frith and Corcoran, 1996; Mazza et al., 2001; Pickup
and Frith, 2001; Janssen et al., 2003) confirmed ToM
deficits in schizophrenia. Although ToM deficits are
more pronounced in acute psychotic patients (Drury
et al., 1998), ToM deficits seem to persist in remitted
patients (Herold et al., 2002).
Mind-reading skills have been investigated with var-
ious ToM tasks since different brain networks may be
critical for different ToM tasks. The importance of left
ventromedial frontal and prefrontal cortical areas has
been demonstrated by neuro-imaging studies (Galla-
gher et al., 2000; Vogeley et al., 2001; Lee et al.,
2004). Mental state reasoning is measured on tests
that include false belief and hinting tasks. In addition
to reasoning about mental states, ToM skills also re-
quire ability to decode mental states on the basis of
immediately available information such as facial ex-
pression or tone of voice. Previous studies investigated
the relationship between emotion recognition deficits
and social functioning (Mueser et al., 1996; Ihnen et al.,
1998; Hooker and Park, 2002). Facial affect perception
seems to have a moderate association with social func-
tioning among inpatients and outpatients with schizo-
phrenia. Some tasks, like the Eyes test, which can also
be classified as a complex emotion recognition para-
digm, can be related to this distinct aspect of social
cognition and may be termed mental state decoding
(Sabbagh, 2004; Sabbagh et al., 2004). Ability to de-
code mental states does not only involve decoding basic
emotions. Examples of more complex decoding abili-
ties include detection of sarcasm from prosodic cues
and identifying whether, based on their facial expres-
sions, someone is serious. Unlike recognition of basic
emotions, recognition of these mental states depends on
context; different meanings may be inferred from iden-
tical facial expression in different situations. Context is
defined by the multiple choices given in the Eyes test.
Both abilities, reasoning about intentions and decoding
of mental states, are essential in identifying social cues.
Since recognition of social cues has substantial impor-
tance in social skills, both abilities may be critical for
social functioning. Two of these skills work in conjunc-
tion in order to produce reliable inferences about
others’ intentions. For example, the detection of irony
involves decoding of mental state from the prosodic
cues and also involves taking into account specific facts
about the speaker. Although mental state decoding tasks
may be related to reasoning tasks, a previous study
(Bora et al., 2005) demonstrated that performance on
Eyes test in patients with bipolar disorder was unrelated
to their poor performance on the Hinting task.
Although studies have investigated the relationship
between emotion recognition skills (Mueser et al.,
1996; Penn et al., 1996; Hooker and Park, 2002) and
mental state reasoning (Roncone et al., 2002; Brüne,
2003) with poor social functioning in schizophrenia, the
impact of mental state decoding deficits on social func-
tioning has not yet been studied.
The primary aim of the present study is: (1) to
investigate the relative contributions of social cognitive
and other neurocognitive abilities on social functioning
in schizophrenia. We hypothesize that, compared to
other cognitive tasks, performances on social cognition
tests will better differentiate patients with adequate
social functioning from poor functioning patients.
Then, if this hypothesis is verified, our second objective
would be: (2) to compare the relative roles on different
aspects of social functioning of the ToM tasks of mental
state decoding and mental state reasoning.
2. Methods
2.1. Participants
Fifty patients with schizophrenia according to DSM-
IV criteria participated in the present study. All patients
were recruited from the outpatient clinic of Psychotic
Disorders Unit of Ege University Medical School Psy-
chiatry Department. All patients were clinically stable
and had no history of acute psychotic exacerbation for
at least 3 months. Subjects who had disorders that could
influence cognitive function (significant neurological
and physical illnesses, substance abuse or dependence
in the last year, electroconvulsive therapy in the pre-
ceding year or cerebral trauma history) were excluded.
The patients were evaluated by a psychiatrist using the
Structured Clinical Interview for Diagnostic Symptoms
(SCID, DSM-IV) (Corapcioglu et al., 1999) and Posi-
tive and Negative Symptoms Scale (PANSS) (Kay et
al., 1987; Anil et al., 1999). The demographic and
clinical variables of the patients are summarized in
Table 1. Thirty-two patients were classified as schizo-
phrenia, paranoid type; other patients were classified as
 E. Bora et al. / Psychiatry Research 145 (2006) 95–103 97

Table 1 addition of scores of the individual subscales. Fifty

Demographic and clinical characteristics and SFS scores of the patients were split at the median of total SFS score
patients
into a group of 25 patients with good functional out-
Mean F SD Range
come and a group of 25 patients with poor functional
Sex ratio (m:f) 33 : 17 outcome.
Duration of education (years) 11.48 F 2.92 5–17
Age (years) 30.55 F 8.70 20–44
Age at onset (years) 21.44 F 5.20 13–36 2.3. Theory of mind tasks
Duration of illness (years) 9.13 F 6.59 1–28
PANSSpositive 10.36 F 4.17 7–20 The Eyes test measures ability to identify a per-
PANSSnegative 18.36 F 6.55 7–31 son’s mental state and comprises 36 photographs of
PANSStotal 54.29 F 15.35 32–86
people with facial expressions, showing only the eye
Social Functioning scores Possible score range
SFS-total 106.53 F 28.52 0–246 region. Participants are asked to choose the appropri-
SFS Soceng1 9.48 F 2.71 0–15 ate word out of four possibilities provided. This study
SFS interper2 15.18 F 5.90 0–30 used the first 27 photographs of the revised version
SFS Socact3 12.26 F 7.23 0–66 (Baron-Cohen et al., 2001). As a control task, a sex
SFS cADLs4 30.90 F 7.45 0–39
recognition test using same 27 stimuli was given to
SFS fADLs5 25.24 F 7.72 0–39
SFS Recre6 13.57 F 4.90 0–51 patients.
SFS Occ7 0.69 F 1.82 0–6 The Hinting task is a test of ability of subjects to
Social engagement1, Interpersonal2, social activities3, Competency of infer real intentions behind indirect speech utterances.
ADLs4, frequency of ADLs5, recreational Activities6, Occupation In the original version of the task, there are 10 short
activity7. passages describing interaction between two charac-
ters that ends with one character hinting to the other.
follows: 10 were undifferentiated and 7 were residual The participant is asked what the character really
and was disorganized type. All patients were on anti- meant. An appropriate response is awarded two points
psychotic treatment (mean dose = 493.82 F 297.16 and, if the response is inappropriate, further informa-
chlorpromazine equivalent). Forty were receiving atyp- tion is given to the participant and a subsequent
ical antipsychotics and eight were taking typical appropriate answer is awarded a single point. We
antipsychotics. Two were taking typical–atypical com- used four stories from the Hinting task similar to
bination as antipsychotic treatment, 16 were in receipt Janssen et al. (2003).
of antidepressants, 5 were receiving anticholinergic
agents, 10 were prescribed valproic acid, and 11 were 2.4. Neurocognitive measures
prescribed propranolol. All participants were individu-
ally briefed on the nature of the study and signed an A battery of neuropsychological tests was adminis-
informed consent form. tered to the patients. Both social functioning and ToM
abilities may depend on other cognitive skills such as
2.2. Social functioning working memory, attention and psychomotor speed.
Auditory consonant trigrams (ACT) (Anil et al.,
Social functioning of patients was assessed by the 2003) were used to assess working memory skills. In
Social Functioning Scale (SFS) which consists of 79 this task, also known as Brown–Peterson paradigm, the
items (Birchwood et al., 1990). The scale was admin- examiner presents three consonants at a rate of one-per-
istered by a nurse who is an active member of psychoe- second and the subject is required to count backward
ducational program of the Psychosis unit, while the from a given number until signalled to stop and then to
questionnaire was administered by oral interview of report the stimulus item. In each presentation of stimuli,
the patient and a family member. The SFS consists of the subjects count up to a predesignated number of
seven subscales (range of scores): social engagement seconds (3, 9 or 18 s). The total score and the subscores
(Soceng), interpersonal communication (Interper), so- for 3 s and 18 s are reported in this study. To assess
cial activities (Socact), competence of activities of daily psychomotor speed, we used Trail Making Test (TMT)
living (ADLs) (cADLs), frequency of ADLs (fADLs), A and B tests (Reitan, 1958) and Stroop Colour–Word
recreational activities (Recre) and occupational activity Test (SCWT), while a measure of selective attention
(Occ). Patients’ scores are summarized in Table 1. and executive function was also administered (Lezak,
Besides these seven subscale scores, total score of the 2004). Only the interference score of the test is
SFS (SFS total) (0–246) was also recorded by the reported.
98 E. Bora et al. / Psychiatry Research 145 (2006) 95–103

Benton Facial Recognition Test (Short Form) (Levin
et al., 1978) was used to control the impact of face
recognition ability on the Eyes test.
Since verbal IQ may be critical for ToM skills,
WAIS-R information test was used to estimate partici-
pants’ verbal IQ capacities (Wechsler, 1981).
impact of working memory. Two regression analyses
were performed to investigate the relationships be-
tween ToM tasks, several cognitive measures and
negative symptoms.
3. Results

2.5. Statistical analyses
The statistical analyses were performed by using
SPSS 11.0. The demographic, clinical, neurocognitive
and theory of mind abilities of the high functioning
and poor functioning schizophrenia patients were
compared with ANOVA. The normality of the neuro-
cognitive data was checked with Kolmogrov–Smirnov
test and necessary transformations were applied for
several measures. Effect sizes for ANOVAs were an-
alyzed by calculating partial eta square values. Differ-
ences between groups were tested with a p value
b0.01 to reduce the probability of Type I errors. For
controlling the impact of verbal IQ, the neurocognitive
scores of the two groups were also analyzed with
ANCOVA. Relationships between SFS scores, neuro-
cognitive, ToM and clinical variables were tested with
Pearson correlations. Partial correlations of ToM mea-
sures and SFS were calculated for controlling the
3.1. Differences between patients with good and poor
social functional outcome
Demographic characteristics of the two groups were
similar. The poor functioning group had the tendency to
onset earlier. The only significant difference between
the two groups was the more severe negative symptoms
among poor functioning patients (Table 2).
Verbal IQ estimates of the two groups did not differ.
Performances of the poor functioning patients were
significantly lower than the patients with social out-
come in the Eyes test. In two working memory mea-
sures (ACT18, ACTtot), patients with good functional
outcome also performed significantly better than poor
functioning patients. Controlling for the verbal IQ esti-
mates did not change these group differences. Effect
sizes of the differences for the working memory and the
Eyes tests were large, while the group difference for the
Hinting task was nearly significant. Although trends

Table 2
ANOVA between- group comparisons for ToM, neurocognition, clinical and demographic variables
Patients with good functional Patients with poor fuctional ANOVA Effect Size1 ANCOVA
outcome (n = 25) outcome (n = 25)
Sex (M:F) 16 : 9 17 : 8
Mean SD Mean SD F P F P
Age (years) 31.4 8.7 29.8 8.8 0.41 0.52
Age of onset (years) 23.1 4.8 19.9 5.4 4.92 0.032
Education (years) 11.8 2.6 10.8 1.7 2.9 0.095
PANSS positive 9.4 0.8 11.2 0.8 2.50 0.12
PANSS negative 15.4 1.2 21.4 1.2 12.22 0.001*

Neurocognitive tests
WAIS information 10.3 2.4 9.6 2.8 0.86 0.36 0.02
ACT 3 sec 11.3 2.5 9.6 2.7 5.49 0.023 0.09 4.67 0.036
ACT 18 sec 7.3 2.7 4.8 3.1 8.99 0.004* 0.16 8.74 0.005*
ACT total 27.3 1.5 21.2 1.5 8.36 0.006* 0.15 8.22 0.006*
Trail A 42.7 12.6 50.8 15.6 3.83 0.056 0.08 3.02 0.089
Trail B 101.6 47.1 152.3 111.1 4.21 0.046 0.05 3.07 0.087
Stroop interference 55.6 17.4 90.8 75.5 4.74 0.035 0.10 3.38 0.073
Benton 43.9 3.7 41.8 4.1 3.14 0.084 0.08
Eyes (sex recognition) 24.6 0.5 24.3 0.8 0.09 0.77 0.01

ToM tasks
Eyes 16.2 0.6 12.7 0.6 16.65 0.0001* 0.26 15.41 0.0001*
Hinting 6.2 1.7 4.7 2.3 7.53 0.009* 0.14 6.79 0.012
1 partial eta square values.
 E. Bora et al. / Psychiatry Research 145 (2006) 95–103 99

towards lower performances in poor functioning
patients were found in psychomotor speed, Stroop in-
terference and face recognition tests, these differences
were insignificant and reduced after ANCOVA with
verbal IQ estimate.
When we separated the patients into conventional
and atypical antipsychotic receiving groups, none of
their ToM and other cognitive performances were sig-
nificantly different.
3.2. Pearson correlations of social cognitive tasks with
other neurocognitive tests and clinical variables
The Eyes test did not correlate with verbal IQ esti-
mate and did not correlate with any clinical variables.
This test also correlated strongly with the ACT total
(r = 0.47, P = 0.001), ACT18 (r = 0.49, P b 0.001) and
other ACT scores and negatively correlated with the
Trail making B test (Table 3).
The Hinting task strongly correlated with verbal IQ
estimate (r = 0.54, P b 0.001). The Hinting task inverse-
ly correlated with the negative symptoms (r = 0.47,
P = 0.001) and moderately with positive symptoms
(r = 0.30, P = 0.033). This task also very strongly
correlated with ACT total score (r = 0.61, P b 0.001),
ACT18 score (r = 0.68, P b 0.001) and other ACT
scores. There were also negative correlations between
the Trail making A (r = 0.51, P b 0.001), Trail mak-
ing B (r = 0.44, P = 0.002) and the Hinting task
(Table 3).
Although the Eyes test strongly correlated with the
Hinting task, this correlation did not persist when con-
trolling for ACT18 with partial correlation method
(r = 0.27, P = 0.07).
3.3. Pearson correlations of cognitive measures with
SFS and its subscales
The only clinical variable that the SFS total score
correlated with was the negative score of PANSS. The
SFS total score strongly correlated with the Eyes test
and the Hinting task, while it negatively correlated with
the Trail making A and B tests, and there were also
modest correlations between ACT total, ACT18, ACT3
and SFS total scores (Table 3). The SFS social engage-
ment subscale modestly correlated with age of onset of
illness and inversely correlated with positive score of
PANSS (Table 3). The SFS interpersonal communica-
tion score negatively correlated with the negative symp-
toms. There were strong correlations between the Eyes
test, the Hinting task, ACT scores and SFS interperson-
al communication score. Trail making A and B tests
also negatively correlated with this subscale score. The
social activities subscale of the SFS correlated with the
Eyes test, the Hinting task and inversely correlated with
negative symptoms. There were also modest correla-
tions with the ACT total (positively) and Trail making
B score (inversely). The competence of ADLs subscale
strongly correlated with the age of onset of disease.
There were also modest correlations between this sub-
scale with the Hinting task and ACT9. Negative symp-
toms and the Trail making A test negatively correlated
with the competence of ADLs. The frequency of ADLs
score correlated strongly with age of illness onset and
negatively correlated with negative symptoms. ACT
total and ACT9 scores correlated with the frequency
of ADLs. There were also some positive (the Hinting
task, the Eyes test) and negative (Stroop interference,
Trail making tests) modest correlations with some other

Table 3
Correlations of social functioning measures and ToM tasks with neurocognitive and clinical variables
SFStot Soceng İnterper Socact cADLs fADLs Recre Occ Eyes Hinting
WAIS inf 0.19 0.20 0.24 0.20 0.05 0.10 0.13 0.36* 0.25 0.54**
ACT3 0.24 0.17 0.42** 0.28 0.04 0.22 0.05 0.05 0.37** 0.36*
ACT18 0.36* 0.29* 0.40** 0.28 0.28 0.34* 0.15 0.26 0.49** 0.68**
ACTtot 0.36* 0.26 0.42** 0.31* 0.24 0.37* 0.13 0.21 0.47** 0.61**
Trail A 0.43** 0.21 0.38** 0.27 0.37* 0.30* 0.30* 0.16 0.37* 0.51**
Trail B 0.39** 0.16 0.35* 0.31* 0.22 0.32* 0.31* 0.19 0.47** 0.44**
Stroop interference 0.26 0.09 0.13 0.20 0.27 0.33* 0.06 0.14 0.28 0.27
Benton 0.19 0.04 0.26 0.28 0.01 0.06 0.21 0.30* 0.28 0.24
Eyes (Sex) 0.07 0.10 0.04 0.01 0.01 0.04 0.21 0.27 0.19 0.22
Eyes 0.46** 0.14 0.49** 0.48** 0.17 0.30* 0.39** 0.17 0.51**
Hinting 0.43** 0.27 0.44** 0.37** 0.29* 0.30* 0.31* 0.23 0.51**
PANSS positive 0.17 0.29* 0.18 0.04 0.25 0.19 0.03 0.27 0.14 0.30*
PANSS negative 0.42** 0.24 0.43** 0.37** 0.29* 0.38** 0.30* 0.21 0.23 0.47**
Age at onset 0.28 0.31* 0.18 0.04 0.41** 0.42** 0.07 0.28 0.18 0.08
Duration of illness 0.04 0.02 0.05 0.07 0.04 0.13 0.12 0.07 0.13 0.07
Correlation is significant at the 0.05 level, ** Correlation is significant at the 0.01 level.
100 E. Bora et al. / Psychiatry Research 145 (2006) 95–103
Table 4
Lineer regression equation predicting the impact of ToM tasks on SFS
and its Subscales
F df Model r 2 Predictors Beta Predictor
Pb Pb
SFS tot 7.83 2,47 0.001 0.254 Eyes 0.34
SFS interper 9.65 2,47 0.0001 0.291 Eyes 0.36
Hinting 0.26
SFS socact 7.87 2,47 0.001 0.251 Eyes 0.40
SFS recrea 4.53 2,47 0.016 0.164 Eyes 0.30
neurocognitive tasks. The recreational activities sub-
scale of the SFS correlated strongly with the Eyes test
and modestly with the Hinting task. This subscale also
inversely correlated with the Trail making tests and
negative symptoms. The occupational activities sub-
scale correlated only with WAIS information score.
Since ToM tasks, especially the Hinting task, strongly
correlated with working memory, partial correlational
analysis of SFS with ToM tasks controlled for the
ACT18 was performed. While the correlation of
Eyes test (r = 0.32, P = 0.03) with SFS persisted, the
correlation with the Hinting task (r = 0.24, P = 0.1) lost
significance.
3.4. Regression analyses
Regression analyses were carried out to answer two
questions. (1) to further examine individual contribu-
tions of mental state decoding and reasoning skills on
social functioning. Along with a linear regression anal-
ysis with SFS total score as dependent variable, the
Eyes and Hinting tasks independent variables was also
performed. Overall, the model was significant and
explained the quarter of the variance (Table 4). The
Eyes test was the only significant predictor. A series of
linear regression analyses with the same independent
variables were performed for the seven subscales of the
SFS. The models for three subscales, interpersonal
communication, social activities and recreational activ-
ities were significant (Table 4). The model for the
interpersonal communication was the strongest and
explained the 29% of variance. The model for the
recreational activities was the weakest, accounting for
Table 5
Lineer regression equation predicting the impact of ToM, nonToM skills and negative symptoms on social functioning
F df Model Pb
SFS total 7.24 4,41 0.001
Independent variables: The Eyes and Hinting tasks, ACT18, Trail A, PANSS negative.
only 16% of variance. The Eyes was a significant
predictor for all three subscales. The Hinting task
only contributed to the interpersonal communication
subscale. (2) To examine the relative contributions of
ToM, non-ToM tasks and negative symptoms on social
0.03
functioning. A linear regression analysis with SFS total
0.01
0.08 score as a dependent variable was carried out. Along
0.001 with the two ToM tasks and PANSS negative score,
0.05 ACTtot and Trail A were also entered simultaneously as
predictors. The ACTtot and Trail A, the tests of work-
ing memory and psychomotor speed, respectively, were
chosen since they correlated significantly with the SFS
total score. The model was significant ( F = 7.42, P =
0.001) and explained the 40% of the variance. The Eyes
test and PANSS negative score contributed to this
model significantly (Table 5). Since the Eyes test and
negative symptoms did not correlate, their contributions
to social functioning appeared to be independent.
4. Discussion
The current study investigated the relationship be-
tween ToM and non-ToM cognitive skills and social
functioning among patients with schizophrenia. The
performances of the patients with good functional out-
come were significantly better on a mental state decod-
ing task. Although the between-group differences were
smaller, the patients with good functional outcome also
performed better on working memory and mental state
reasoning tests. Among the cognitive tasks, only the
Eyes test significantly predicted the social functioning
score. Negative symptoms also contributed to social
functioning score. The results of the current study
supported our primary hypothesis and emphasized the
importance of social cognitive deficits for the social
functioning deficits in schizophrenia. The originality of
this paper resides in the second objective of the study,
the differentiation of ToM skills into mental state
decoding and reasoning abilities. Mental state decoding
tasks were significantly better than mental state reason-
ing tasks for predicting social impairments.
Two previous studies investigated the interaction of
ToM deficits with social functioning in schizophrenia.
In the study of Roncone et al. (2002), ToM deficits
r2 Predictors Beta Predictors Pb
0.414 Eyes 0.34 0.02
PANSS negative 0.30 0.04
 E. Bora et al. / Psychiatry Research 145 (2006) 95–103
contributed to the deficits of social functioning (15% of
variance). In this study, ToM deficit was the second
important predictor after duration of illness (27% var-
iance). Brüne (2005) demonstrated that ToM deficit was
the best predictor of social behaviour problems (a quar-
ter of the variance). Duration of illness was again a
significant predictor of social functioning (14% of the
variance).
The current study demonstrates that a different kind
of social cognitive task measuring mental state decod-
ing, the Eyes test, is a better predictor of social
functioning than a mental state reasoning task (the
Hinting task) in schizophrenia. The Eyes test is essen-
tially different from other dtheory of mindT tasks as
this test is based more on spontaneous and automatic
judgement than other tasks. Also, perception of com-
plex visual material and basic emotion recognition is
essential to infer the mental state of the eyes correctly.
Since this ability requires dgut feelingsT rather than
effortful verbal processing, it may be more closely
related to social perception and functioning. Although
decoding the basic emotions from body language
and voice are shared among primates, we think
that inferring mental states from the eyes may be a
unique human ability, one which may depend on a
partly distinct neural network compared to the other
mind-reading tasks. This ability may be more closely
associated with emotional aspects of empathy and
mind-reading. Some evidence already exists for the
contribution of different brain networks to different
ToM abilities. While left ventromedial prefrontal
regions may have essential importance for reasoning
about mental states (Lee et al., 2004; Sabbagh et al.,
2004), right inferior frontal and anterior temporal
lobes may be critical for mental state decoding abili-
ties (Sabbagh et al., 2004). The lack of correlation
between the Hinting task and the Eyes test in our
previous study (Bora et al., 2005) that was also con-
ducted into bipolar disorder may support the idea of
the different neural mechanisms underlying these two
tasks. Although both tasks were correlated in the
current study, the correlation decreased in significance
when controlled for working memory. Since both
tasks have a substantial working memory load, the
correlation of both ToM tasks in schizophrenia may
be related to severe working memory deficits of the
patients.
One potential confounding factor in this study may
be the impact of using verbal mental reasoning tasks
instead of cartoons or vignettes of drawings. Schizo-
phrenia patients have well known thought and lan-
guage deficits. As well as semantic and syntactical
101
speech abnormalities (Docherty et al., 1996; Thomas
et al., 1996), deficits in the patients’ pragmatic use of
language were reported in schizophrenia (Langdon et
al., 2002). Language deficits may contribute to ToM
deficits in schizophrenia. A recent study reported that
thought disorder and verbal memory accounted for
30% of the variance in schizophrenia (Greig et al.,
2004). In this study, while a nonverbal decoding task
was closely related to social functioning, the relation-
ship between social functioning and a task of verbal
mental reasoning was relatively weak. Indeed, this
relationship seemed to be partly explainable, by the
working memory load of the task. Similar to previous
findings, mental state reasoning performance was also
related to verbal IQ estimate (Brüne, 2003). However,
the relationship between hinting task and SFS total
score was not explainable with verbal IQ. Future
studies are necessary to reveal the nature of the rela-
tionship between thought disorder, language deficits,
reasoning about mental states and other cognitive
measures such as working memory.
Premorbid adjustment problems and social dysfunc-
tion in early life is a well known feature of schizo-
phrenia. Premorbid social functioning was also
reported to be related with ToM dysfunction among
patients with schizophrenia (Schenkel et al., 2005).
Since both neurocognitive (Faraone et al., 1995) and
ToM deficits (Janssen et al., 2003) are reported to be
present in the relatives of schizophrenia, both abilities
may be traits of schizophrenia. Corcoran and Frith
(2003) hypothesized that patients with prominent neg-
ative symptoms never fully develop ToM abilities.
Social functioning deficits seem to be the result of
neurodevelopmental nature of the disorder. The pre-
cise nature of the developmental dysfunction in social
and cognitive abilities is still unknown. Deficits in
general basic cognitive abilities may explain the neu-
rocognitive and ToM deficits in schizophrenia, but
also more specific deficits, like the context processing
dysfunction, may be responsible for both abilities
(Schenkel et al., 2005).
Besides total SFS score, mental state decoding abil-
ity was a predictor for interpersonal communication,
recreational and social activities subscales of the SFS,
which seem to measure abilities that depend more on
social interaction. Theory of mind skills seem to have a
critical importance for social communication. On the
other hand, skills of patients with schizophrenia on
subscales, which do not depend on social interaction
like ADLs, were not related to ToM abilities. Age at
onset of disease, negative symptoms and some non-
ToM abilities seemed to be more strongly correlated
102 E. Bora et al. / Psychiatry Research 145 (2006) 95–103
with these skills. Since age at onset and duration of
illness may be related to cognitive deficits and negative
symptoms (Lindstrom and Von Knorring, 1994; Pante-
lis et al., 2004) and disorganization and negative symp-
toms has a relationship with cognitive deficits (Cuesta
and Peralta, 1995), the relation of ADLs to these vari-
ables is not surprising. Early onset of the disease pro-
cess may interfere with the acquisition of basic
instrumental and everyday skills of patients with
schizophrenia. Functional deficits such as those in the
subscales of frequency of ADLs and social engagement
may be the result of clinical symptoms like anhedonia
and depression and other secondary features of the
disorder.
Another question in this field is the specificity of
ToM deficits to schizophrenia subtypes. Previous stud-
ies reported an association of certain schizophrenia
subtypes with ToM deficits (Frith, 1992; Greig et
al., 2004). Since a larger sample of patients would
have been required, we could not investigate this
issue; small sample size may therefore be a limitation
of this study.
Although a previous study did not find a relation-
ship between emotion recognition and mental reason-
ing deficit in schizophrenia (Brüne, 2005), mental
state decoding ability may in fact be related to emo-
tion recognition. A previous study reported an associ-
ation between the facial emotion recognition task and
the Eyes test (Bora et al., 2005) in bipolar patients
and controls. Therefore, a potential limitation of this
study may be the lack of a basic emotion recognition
measure. Another confounding factor may be the
medication effects. For example, Keefe et al. (2004)
reported cognitive differences between haloperidol vs.
olanzapine taking patients. Although we could not
find a difference between atypical and conventional
antipsychotic receiving groups, we cannot completely
exclude the possible impact of medication on cogni-
tive tasks.
The mental state decoding tasks, like the Eyes test,
which depend on both emotion recognition and ToM
skills may be the most important cognitive mediators of
social functioning. Further studies are necessary to
investigate this issue. There is some evidence for emo-
tion recognition and emotion labeling training as a
potential therapeutic approach in schizophrenia (Van
der Gaag et al., 2002). Likewise, studies investigating
the impact of inclusion of mental state attribution in
cognitive behavioral therapies (Sarfati et al., 2000) and
studies on cognitive rehabilitation and social skills
training programs focusing on complex emotion recog-
nition are also warranted.
Acknowledgement
We would like to thank to Professor Simon Baron-
Cohen for providing the Eyes test from ARC website.
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