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Mentalizing deficits have often been observed in people with schizophrenia and a few recent studies suggest that such deficits are also present in patients with first episode psychosis (FEP). It is not clear, however, whether these mentalizing deficits in FEP can be accounted for by underlying processes such as social cue recognition, social knowledge and general reasoning. In this study, we assessed mentalizing abilities in 31 people with FEP and 31 matched controls using a novel, comprehensive mentalizing task validated through the present study. We also assessed social cue recognition, social knowledge and non-social (or general) reasoning performance in the same participants in order to determine if the mentalizing deficits in FEP can be at least partly explained by performance in these three underlying processes. Overall, the mentalizing task revealed the greatest impairment in FEP, an impairment that remained significant even after controlling for social cue recognition, social knowledge and non-social reasoning performance. Interestingly, non-social reasoning and social knowledge were both shown to contribute to mentalizing performance. In addition, social cognition measures were linked to social functioning in the FEP group, with the strongest correlation observed with mentalizing performance. Taken together, these results show that mentalizing is an aspect of social cognition that is particularly affected in FEP and might contribute to functional impairments in these patients. These deficits could be a prime target for cognitive remediation in FEP, and our results suggest that this could be done either directly or through improvement of related social and non-social cognitive skills such as social knowledge and general reasoning.

Social cognition can be defined as a group of processes that allow people to understand and interact with each other. The ability to attribute mental states to others, often referred to as mentalizing or theory of mind, is an important aspect of social cognition. In mentalizing tasks as in real life, mental states such as intentions, beliefs, knowledge or emotions are attributed based on all available sources of information about the person to whom these mental states are to be attributed and about the context in which that person evolves. Mentalizing judgments thus involve integrating several pieces of information in order to infer the appropriate mental state. People with schizophrenia (SZ) generally present with important impairments in their ability to mentalize, i.e., to infer the mental state of a character presented in a given situation. Mentalizing deficits have been repeatedly reported in people with SZ (Sprong et al., 2007 and Bora et al., 2009), along with other neurocognitive impairments (Heinrichs and Zakzanis, 1998), and it is now well established that these deficits have a significant negative impact on social functioning and the quality of life of patients with SZ (Green, 1996, Green et al., 2000 and Couture et al., 2006). However, most studies of social cognition in SZ have included patients in a chronic stage of illness and/or during active psychotic episodes (Sprong et al., 2007 and Bora et al., 2009), and the mentalizing deficits observed in these patients could thus be linked to biases towards the recruitment of patients with a more chronic course of illness and a poorer outcome, effects of long-term medication use, transient perturbation due to positive symptoms, etc. In an attempt to address some of these biases, a few studies have measured mentalizing in remitted SZ patients, again revealing significant deficits in these patients, though of a lesser magnitude than those observed in acutely psychotic patients according to a recent meta-analysis (Bora et al., 2009). These studies in remitted patients suggest that mentalizing deficits represent a trait of SZ, instead of being fully linked to symptomatic states. Studies in remitted patients (e.g. Herold et al., 2002) however cannot account for the effect of long-term medication use or the long duration of psychosis and it also remains unclear when in the illness process mentalizing impairments occur. One approach to minimize the impact of illness duration, get a sample representative of diverse future outcomes and address the issue of when the deficits occur is to recruit patients early after the onset of psychosis. This is precisely what several studies have done and these studies have also reported mentalizing deficits in people with first-episode psychosis (FEP) (Inoue et al., 2006 and Bertrand et al., 2007), in line with the suggestion that these deficits could be a general characteristic of patients with SZ. The first FEP study on mentalizing by Inoue et al. (2006) relied on a single cartoon story in which three mentalizing questions were asked. This simple task revealed a greater percentage of patients than controls who responded incorrectly to one of the three questions. In a subsequent study (Bertrand et al., 2007), a mentalizing deficit in FEP was again observed using the Hinting task (Corcoran et al., 1995), which includes ten short stories from which participants have to infer a character's intentions. Other more global measures of social cognition that likely involve mentalizing abilities have also revealed significant deficits in FEP relative to healthy controls (Bertrand et al., 2007 and Koelkebeck et al., 2010). With the recent focus on early intervention, and given the relationship between social cognition and social functioning, identifying and treating these mentalizing deficits early could have a significant positive impact on the functional outcome of people with SZ. The mentalizing deficits observed in people with SZ could however result from difficulties at different points in the information processing chain that leads to mental states attributions (see Bless et al., 2004 and Brunet-Gouet et al., 2011), including the ability to recognize social stimuli (social cue recognition) (Edwards et al., 2001, Kucharska-Pietura et al., 2005, Addington et al., 2006a and Kohler et al., 2010), the ability to construct and retrieve social representations (social knowledge/memory) (Cutting and Murphy, 1990, Addington et al., 2006b and Kee et al., 2009) and/or general reasoning/inferential mechanisms (Young and Bentall, 1997). The aims of the current study were thus 1) to replicate the results of mentalizing impairments in people with a FEP relative to control subjects using a novel, comprehensive mentalizing task; 2) to assess distinctively social cue recognition, social knowledge and general reasoning performance in the same two groups of participants; 3) to determine if mentalizing performance/deficits can be at least partly explained by performance in these underlying processes. These more elementary processes have not been concurrently examined in previous studies on mentalizing abilities in FEP and their assessment could provide valuable information about the pathways leading to mentalizing impairments in these patients. Since there are no standardized mentalizing tests as of yet and given that previous measures have often presented with ceiling effects and lack of sensitivity (e.g. Herold et al., 2002 and Inoue et al., 2006), mentalizing was measured here with a comprehensive task developed for the purpose of this study, i.e. the Combined stories test, for which we also present initial psychometric properties.