بینش و تئوری ذهن در اسکیزوفرنی

Theory of mind (ToM) impairment is common in individuals with schizophrenia and is associated with poor social functioning. Poor insight has also been linked to poor outcome in schizophrenia. Social developmental research has shown representations of self (insight) and representations of others (ToM) are related. In schizophrenia, contradictory reports of associations between insight and ToM have emerged, possibly due to a failure to account for neurocognitive impairments and symptoms associated with both mentalization constructs. This study investigated the relationships between ToM (intentions of others on the Hinting Task) and clinical and cognitive insight, while accounting for shared variance with neurocognitive impairment and symptom severity in 193 individuals with schizophrenia. Clinical, but not cognitive, insight was associated with ToM. A unique association between Awareness of Mental Illness and Hinting Task performance was found, independent of shared variance with neurocognition and symptoms. Importantly, ToM was found to mediate Awareness of Mental Illness and neurocognition. Results suggested that treatments targeting mentalization abilities that contribute to representations of self and others may improve insight deficits associated with poor outcome in schizophrenia.

Theory of mind (ToM; also called mental state attribution) is “the ability to infer intentions, dispositions and beliefs of others” (Green et al., 2008). This ability to understand the mental states of others is important for a variety of social functions, including understanding pragmatic speech, pretending, deception, imagining, understanding jokes, and empathy (Corocan, 2001, Sperber and Wilson, 2002 and Shamay-Tsoory et al., 2007). Several studies have found ToM deficits in individuals with schizophrenia (e.g., Corcoran et al., 1995, Garety and Freeman, 1999 and Green et al., 2008), and this impairment has been shown to be associated with social functioning and social competence in schizophrenia (Roncone et al., 2002, Brüne, 2005, Couture et al., 2006, Couture et al., 2011, Brekke et al., 2007, Brüne et al., 2007 and Green et al., 2008). Therefore, ToM may be an important treatment target to improve real-world functioning in schizophrenia. Poor insight has also been linked to poor outcome in schizophrenia (Amador et al., 1991; Lysaker et al., 2002; Erikson et al., 2011; Giugiario et al., 2012; for a recent review, see Lincoln et al. (2007). Insight has been widely regarded as a multidimensional construct (Amador et al., 1991). Clinical insight refers to one׳s awareness of having a mental illness that requires treatment, and includes dimensions of Awareness of Illness, Relabeling of Symptoms, and Need for Treatment, which have been differentially associated with neurocognition and clinical symptoms (Konstantakopoulos et al., 2013). Cognitive insight involves metacognitive processes of re-evaluation and correction of distorted experiences (e.g., objective distancing and reappraisal of symptoms), and includes dimensions of Self-Reflectiveness and overconfidence in beliefs (Beck et al., 2004). Clinical and cognitive insight appear to be distinct constructs with different neurocognitive correlates (Nair et al., 2014). Clinical insight presumably requires metacognitive processes associated with cognitive insight (Beck et al., 2004). Social developmental researchers have long posited that representations of self and others׳ mental states are inextricably connected. Developmentalists propose that self-representations stem from experiental learning, reflection, and extensive engagement in social interactions, and as such, understanding others׳ motives, beliefs and actions aids in our own self-reflective mechanisms (Gallagher and Meltzoff, 1996). Moreover, social comparison theory suggests that individuals assess personal traits, opinions, and competency and derive self-attributes by evaluating oneself relative to others (Festinger, 1954). Consequently, self-representations require the representations of others and mentalization of oneself in the position of others (Decety and Sommerville, 2003). According to Barresi and Moore (1996), social understanding of self and others or ToM necessitates effective integration of first-person and third-person intentional information, that is, personal and others׳ motives. Researchers have contended that failure to converge and apply both inputs results in impairments in mentalization (Barresi and Moore, 1996), and insults or abnormal activity in neural systems linked to self and other representations may underpin deficits in control of actions in psychotic disorders such as schizophrenia (Frith, 1995 and Frith et al., 2000). The ability to understand and project intentionality of others and of self, therefore, relies on both internal and external social awareness. To date, the developmental sequence of mindreading and metacognition (which precedes the other) remains a point of contention. However, several authors have suggested that data from schizophrenia research more strongly support the view that the development of mindreading precedes maturation of insight to self (Carruthers, 2009 and Wiffen and David, 2009). If associations are found between impairments in representations of self and others in consumers with schizophrenia, this may indicate that treatments targeting the mentalization abilities that contribute to representaitons of self and others may improve insight and ToM deficits associated with poor outcome in schizophrenia. The relationship between representations of self and others׳ mental states in schizophrenia is unclear, due to conflicting findings (Drake and Lewis, 2003 and Bora et al., 2007). Bora et al. (2007) found an association between clinical insight and a narrative false belief task, but not with an adapted version of the Reading the Mind in the Eyes Test. Additional investigations further observed significant associations between clinical insight and ToM, as measured by a false belief task (Langdon et al., 2006, Pousa et al., 2008 and Langdon and Ward, 2009), and the Hinting Task (Greig et al., 2004). Drake and Lewis (2003), however, did not find a significant association between clinical insight and a joke comprehension assessment of mental state attribution, and Langdon et al. (2006) reported a significant association between clinical and ToM measured by the joke comprehension test and a false belief narrative task, but not a story comprehenion ToM test. These inconsistent findings may be due to sample differences in severity of neurocognitive impairment or symptoms or the extent to which these factors are associated with different ToM tasks. ToM task performance and cognitive and clinical insight have all been found to be associated with neurocognitive impairment (Smith et al., 2000, Roncone et al., 2002, Drake and Lewis, 2003, Rossell et al., 2003, Sergi et al., 2007, Lepage et al., 2008, Bora et al., 2009 and Nair et al., 2014), positive symptoms (Roncone et al., 2002, Mintz et al., 2003, Brüne, 2005, Sprong et al., 2007, Pousa et al., 2008 and Konstantakopoulos et al., 2014), and negative symptoms (Frith, 1992, Roncone et al., 2002, Mintz et al., 2003, Rossell et al., 2003 and Couture et al., 2011) in schizophrenia. One recent investigation (Konstantakopoulos et al., 2014) examined the association between clinical insight and ToM in individuals with schizophrenia, independent of shared variance with neurocognition and symptom severity, and found an independent association between clinical insight and ToM, indexed by a composite score from the False Belief Task, the Hinting Task, and the Faux Pas Recognition Task. The present study attempted to replicate this single prior finding (Konstantakopoulos et al., 2014) of an association between clinical insight and ToM that was independent of neurocognitive impairment and symptom severity. In addition, given that insight is widely accepted as a multidimensional construct (Amador et al., 1991), associations between ToM and multiple dimensions of both clinical and cognitive insight were examined. Based on the prior research reviewed above, we predicted that both clinical and cognitive insight would be significantly associated with ToM independent of shared variance with neurocognitive impairment and symptomatology.

Table 2 presents descriptive statistics for all variables in the regression analyses and Table 3 presents correlations among these variables. ToM (Hinting) task performance was signficantly correlated with clinical insight on Relabeling of Symptoms and Awareness of Illness indices, but not Need for Treatment. In contrast, correlations between ToM and cognitive insight were not significant. Greater severity of neurocognitive impairment was significantly correlated with poorer ToM task performance and poorer clinical insight on all three indices, but was not significantly correlated with cognitive insight. Greater severity of disorganization was significantly correlated with poorer ToM task performance and poorer clinical insight on Awareness of Illness and Relabeling of Symptoms indices, and weak but significant correlations were found between positive symptoms and ToM and excitement and Need for Treatment. In contrast, cognitive insight was not significantly correlated with any symptom factor. Both cognitive insight indices were correlated with Awareness of Illness and Self-Reflectiveness was correlated with Relabeling of Symptoms.