Theory of Mind (ToM) and counterfactuality deficits in schizophrenia: misperception or misinterpretation?

Background. Theory of Mind (ToM) refers to the ability to infer another person's mental state based upon interactional information. ToM deficits have been suggested to underlie crucial aspects of social interaction failure in disorders such as autism and schizophrenia, although the development of paradigms for demonstrating such deficits remains an ongoing area of research. Recent studies have explored the use of sarcasm perception, in which subjects must infer an individual's sincerity or lack thereof, as a 'real-life' index of ToM ability, and as an index of functioning of specific right hemispheric structures. Sarcastic detection ability has not previously been studied in schizophrenia, although patients have been shown to have deficits in ability to decode emotional information from speech ('affective prosody'). Method. Twenty-two schizophrenia patients and 17 control subjects were tested on their ability to detect sarcasm from spoken speech as well as measures of affective prosody and basic pitch perception. Results. Despite normal overall intelligence, patients performed substantially worse than controls in ability to detect sarcasm (d= 2(.)2), showing both decreased sensitivity (A) in detection of sincerity versus sarcasm and an increased bias (B) toward sincerity. Correlations across groups revealed significant relationships between impairments in sarcasm recognition, affective prosody and basic pitch perception. Conclusions. These findings demonstrate substantial deficits in ability to infer an internal subjective state based upon vocal modulation among subjects with schizophrenia. Deficits were related to, but were significantly more severe than, more general forms of prosodic and sensorial misperception, and are consistent with both right hemispheric and 'bottom-up' theories of the disorder.