Background
Schizophrenia (SCZ) is a mental disorder that affects nearly 1% of the global population and can cause severe disability [1]. Patients with SCZ often present with positive symptoms such as delusions, hallucinations, cognitive or speech disorders, negative symptoms, motivation deficits, and impaired affective function [2]. Additionally, SCZ impairs social cognition, which is considered a core feature of the disorder.
As a core component of social cognition, the Theory of Mind (ToM) refers to an individual’s ability to assess and convey the reason for their own mental state and that of others, including sentiments of desire, beliefs, and behavioral intentions [3, 4]; this manifests as the ability to imagine oneself in the positions and mental states of other people. Meta-analyses have suggested that patients with SCZ exhibit overall ToM impairment relative to the average level of performance among non-clinical controls [5, 6]. Recent studies have also shown a lower overall level of social cognition in patients with SCZ than in healthy controls, with a significant difference in ToM parameters [7]. The cause of ToM impairment remains unclear among patients with SCZ; however, some scholars believe that it may be related to different psychotic symptoms. ToM impairment has been proposed as an explanatory model for some symptoms of SCZ [8]. This model posits that the psychotic symptoms of patients with SCZ are only external manifestations of ToM impairment; in essence, it may reflect a disordered representation of their own and others’ behavioral intentions. According to its complexity, the ToM can be divided into first-order ToM and second-order ToM [9]. First-order ToM refers to the ability to understand and rationalize the mental states of others, whereas second-order ToM refers to the ability to know how others perceive the mental states of a third person. It is generally believed that the performs of first-order ToM is better than second-order ToM in patients with SCZ; however, it has also been shown that the structure of ToM may be non-hierarchical, as a few individuals with SCZ who exhibit first-order impairment can fully infer the thoughts of others during the performance of second-order tasks [10, 11]. Another study proposed that the ToM comprises two separate cognitive and affective components [12]. Cognitive ToM refers to reasoning about other people’s beliefs, intentions, and motivations, for example, whereas affective ToM refers to emotions and judgments pertaining to other people’s affective states. However, there is also controversy regarding the impairment of the ToM components in those with SCZ. In addition, previous studies have focused predominantly on the differences in ToM impairment between patients with SCZ and healthy controls, and few groups have directly investigated the types and characteristics of ToM impairment among those with SCZ. Therefore, more studies, standardized tools, and novel approaches are required to explore the impaired cognitive and affective ToM characteristics in patients with SCZ.
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Traditional correlation analyses fail to consider all of the components or dimensions when examining associations between ToM performance and symptomatology, and it is difficult to control for the influence of other relevant factors to identify independent correlations between study variables. Recently, researchers have proposed a network-based approach for understanding the psychopathology of mental disorders [13]. Network analysis methods have recently been employed in psychiatry and psychology research to examine the relationships between certain variables and symptoms [14]. Using this approach allows for the construction of a network based on partial correlations between symptoms and clinical presentations by evaluating independent correlations while simultaneously controlling for other variables, and the importance of different indicators in the symptom and clinical presentation network can be judged based on the intensity, tightness, and mediation.
The aim of this study was to compare the ToM performance of patients with SCZ with that of healthy controls using a Yoni task that was able to simultaneously differentiate between different ToM orders (first-order and second-order) and components (cognitive and affective). Simultaneously, the study aimed to conduct latent profiling analysis to identify potential categories of ToM impairment in the patient population and the differences in symptom manifestations among those with different defect types. Ultimately, network analysis was conducted to evaluate the independent relationships between patients’ clinical symptoms and ToM parameters, as this could promote the rehabilitation of patients with SCZ.
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