Research reportTheory of mind impairments in euthymic bipolar patients
Introduction
Theory of mind (ToM; Premack and Woodruff, 1978) describes the ability to represent one's own or other's epistemic, volitional or emotional mental states. Patients with severe endogenous psychoses (Brüne, 2005) and developmental disorders like autism (Baron-Cohen et al., 2001) exhibit profound ToM deficits, which may result in a decline in social reciprocity and functional outcome (Green et al., 2000, Brüne et al., 2007).
Patients with unipolar major depression and mixed samples of unipolar and bipolar depression were also shown to exhibit ToM impairments, although these results did not remain undisputed (Lee et al., 2005, Inoue et al., 2004, Doody et al., 1998, Kettle et al., 2008). Some evidence indicates a higher relapse risk in patients with affective disorders and concomitant ToM deficits (Inoue et al., 2006).
In bipolar disorder, ToM impairments were reported in symptomatic and euthymic patients (Kerr et al., 2003, Olley et al., 2005, Lahera et al., 2008). However, in euthymic patients, the question whether ToM deficits are specific or secondary to non-social cognitive problems still remains open (Kerr et al., 2003). This aspect is crucial since neurocognitive deficits, like those of sustained attention, executive function and verbal memory, persist in the euthymic phase (Robinson and Ferrier, 2006, Robinson et al., 2006) and might represent endophenotypes of bipolar disorder (Bora et al., 2009, Arts et al., 2008).
However, evidence from neuroimaging research suggests a central role of a relative loss of prefrontal modulation of subcortical and medial temporal structures within the anterior limbic network resulting in dysregulations of mood in bipolar disorder (Strakowski et al., 2005, McIntosh et al., 2008). As these brain regions largely belong to the social cognitive network (Gallagher and Frith, 2003), mentalizing deficits may also be detected in bipolar disorder.
Studies in clinical conditions like Asperger Syndrome (Rogers et al., 2007, Dziobek et al., 2008), schizophrenia (Shamay-Tsoory et al., 2007, Montag et al., 2007) or brain lesions (Shamay-Tsoory et al., 2008) have reported dissociable deficits of cognitive and affective aspects of ToM. However, in bipolar disorder few studies attempted to dissect cognitive and affective ToM (Bora et al., 2005, Shamay-Tsoory et al., 2009).
In schizophrenic psychoses, excessive mental state attribution (‘overmentalizing’) has been implicated in the formation of paranoid symptoms (Frith, 2004), but ‘reduced’ mentalizing (‘undermentalizing’) may be more prominent in patients with negative symptoms (Brüne, 2005, Montag et al., submitted for publication). Differing mentalizing mechanisms may also be causative to the assumed mentalizing deficit in bipolar disorder, dependent on the presence of psychotic symptoms or general cognitive decline.
The present study investigates theory of mind functions in an outpatient sample of euthymic patients with bipolar disorder employing a naturalistic test, the Movie for the Assessment of Social Cognition (MASC; Dziobek et al., 2006). The MASC allows 1) to simultaneously investigate the recognition of cognitive and emotional mental state modalities and 2) a qualitative analysis of error responses. It was hypothesized that bipolar patients exhibit ToM deficits compared to healthy controls.
Section snippets
Participants
The study was approved by the local ethics committee; subjects gave written informed consent. Outpatients diagnosed with bipolar-I affective disorder according to DSM-IV (Structured Clinical Interview for DSM-IV, First et al., 1995) and healthy participants, matched according to age, gender and verbal intelligence (Table 2) were screened with structured interviews in order to exclude axis-I or axis-II disorders (except bipolar-I disorder for the patients group), organic brain disease and recent
Results
Demographic and neuropsychological data are given in Table 2. Patients did not differ significantly from controls in age, gender, premorbid IQ and AVLT(1–5) and AVLT(del) scores. Bipolar patients scored significantly lower than controls on the MASC ‘sum score,’ ‘MASC control condition’ and AVLT(int) scores.
Discussion
The current study aimed at a differentiation of ToM performance in bipolar patients employing a realistic video-based examination. Data revealed deficits in cognitive, but not emotional mental state reasoning in the euthymic phase of bipolar disease which are not simply explained by general cognitive dysfunctions. Our findings are in accord with those of Shamay-Tsoory et al. (2009), who also found a pattern of altered cognitive, but intact affective ToM using “Faux Pas” recognition. Bora et
Role of the funding source
The study had no financial support.
Conflict of interest
All authors confirm that they have met the criteria for authorship as established by the International Committee of Medical Journal Editors, believe that the paper represents honest work, and are able to verify the validity of the results reported. All authors confirm that no possible conflicts of interest including financial and other relationships exist regarding this study.
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