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Schizophrenia begins in young adults, with symptoms such as delusions, hallucinations, cognitive dysfunction, decreased emotional involvement, and loss of functionality. Theory of mind and emotion recognition are important aspects of social cognition and are impaired in some psychiatric diseases. Understanding others’ facial expressions, empathic skills, understanding the pragmatic aspect of language such as irony or metaphor, and being able to make sense of others’ mental states are important in interpersonal relationships and social functioning. It is known that patients with schizophrenia have disorders in social cognition and deficiencies in these skills.
- THEORY OF MIND
Theory of Mind is the basis of understanding other people’s behaviors and thus understanding the meaning and intention of other people’s actions (Rowe, Bullock, Polkey, & Morris, 2001). In this case, people with good theory of mind ability can understand other people’s feelings, how they feel, what their intentions are, what their wishes are and what their beliefs are by reasoning, and they can take the right action in this direction (Wellman, 1986).
Theory of mind includes both positive emotions such as pity for others, sympathy, empathy, and many emotional states of being human, such as negative lying and cheating (Drubach 2007, Trivers 1971). The appearance of the human face, and especially the gaze, is important for individuals to understand each other’s intentions (Schmidt & Cohn, 2001). It provides the opportunity to predict how the other person will act with the meaning that the other person has deduced from his actions, and to predict his next step (Howlin, Baron-Cohen, Hadwin, 2016). In people with normal development, the development of mind reading progresses from infancy to development (Hale & Tager-Flusberg, 2005).
The development of the theory of mind begins to show its foundations in the 18th month with the ability of joint attention and occurs until the age of 3-4. By the age of 9-11, it is assumed to have completed its development with a faux pass grasp (Baron-Cohen, Stone, Jones, & Plaisted, 1999). If there is an inadequacy in the formation and development of theory of mind in children, it causes problems in gaining the ability to live independently in the future, establishing healthy communication and relationships with the environment, understanding social stimuli, and understanding the intentions of people’s behaviors. Theory of mind is not only necessary for us to understand the behaviors of patients, but also important for the development of cognitive development and educational materials for the diseases it is associated with. (Brüne, Cohrs, 2006).
- THEORY OF MIND ABILITIES
Theory of Mind abilities; They are listed in order of development as first-degree false belief, second-degree false belief, metaphor and irony comprehension, and faux pas comprehension.
2.1. First Degree False Belief Ability: In this ability, the person attributes his/her belief to someone else (Bach et al. 2000). In other words, it is the definition of people’s beliefs about the world (Herold et al., 2002).
2.2. Second Degree False Belief Ability: In the second degree false belief dimension, the person is the ability to reason about the second person’s thoughts about the third person’s thoughts (Bach et al., 2000). According to Wimmer and Perner, this dimension is “belief about belief”.
2.3. Faux Passing Ability: Faux Passing; Although it is translated as mistake, pot, blunder, it continues to be used as Faux Pas because it does not meet the full meaning. Faux Rust Size; developmentally, it is the most complex ability among abilities (Bach et al., 2000). The formation of Faux Pas occurs when the speaker says something that the listener may not want to hear and does not take into account that the person may be humiliated by what he says (Tomer & Aharon-Peretz, Shamay-Tsoory, 2005). As it requires higher levels of theory of mind concepts, Faux Pas is expected to have higher level of theory of mind ability (Brüne-Cohrs 2006, Bach et al., 2000).
2.4. Metaphor and Irony Ability: Since metaphor contains an implicit meaning, what is meant is not reflected, and therefore it is the ability to understand that the implicit meaning in what is said should be abstracted (Blair, Lumsden, & Fine, 2001). In irony; what is said is not said directly, but emotions are conveyed indirectly (Shamay, Tsoory et al., 2005). When a word of irony is expressed, the listener should be able to understand that the speaker is trying to express the exact opposite of the literal meaning of the word said (Frith & Frith, 2003).
- THEORY OF MIND THEORIES
3.1. Modular Theory
Modular theory, which emphasizes an innate ability, is one of the perspectives of developmental psychology (Meltzoff, 1999). According to the modular theory; There is more than one neural structure in theory of mind, and the development of the theory of mind depends on the neurological maturation of the relevant parts of the brain. In addition, it is claimed that theory of mind is a functionally distinct ability from other cognitive functions. It is also stated that the theory of mind does not determine its mechanism, but it can trigger its activity. It is emphasized that modular theory is associated with neurological maturation (Youmans 2004, Brüne, Cohrs, 2006).
3.2. Simulation Theory
According to simulation theory, people’s mental states can be internalized and people become aware of people’s mental states through introspection (Flavell, 1999). In other words, according to theory of mind, role playing is considered as the ability to attribute mental states to other people (Coltheart & Langdon, 2001). Through this theory, people try to evaluate reality from the perspective of other people. That is, they try to predict how reality appears to that person from the perspective of the person they replace (Youmans, 2004).
3.3. Theory Theory
Theory theory suggests that other minds evolve and theory of mind develops over time (Youmans, 2004). The theory theory proposition assumes that the causal principles and existence of the theory of mind are directed towards itself, similar to the modular theory for the theory of mind (Flavell, 1999). However, unlike the modular theory, it emphasizes the importance of individual experience (Brüne & Cohrs, 2006).
According to theory theory, experience provides individuals with information that cannot be supported by theory of mind ability (Völlm et al., 2006). Contrary to modular theory, theory theory states that distinguishing mental and real models enables the simultaneous comparison of theory of mind and model of mind (Brüne, 2005). Therefore, although it does not propose a modular theory of mind separate from cognitive processes, it does not suggest a separate neural system depending on the theory of mind. In other words, it predicts that neural structures support the theory of mind, similar to simulation theory (Youmans, 2004).
- Schizophrenia and Theory of Mind
Schizophrenia; It is a lifelong chronic psychiatric disease that begins in late adolescence and adulthood and is characterized by positive symptoms such as delusions and hallucinations, and negative symptoms such as disorganized speech, disorganized behavior, and cognitive disorders.
Schizophrenia is a chronic disorder that begins in young adults, affects approximately 1% of the world’s population, and presents symptoms such as delusions, hallucinations, cognitive dysfunction, decreased emotional involvement, and loss of functionality. Among all diseases, it causes the most disability, deterioration in social relations, and a decrease in the ability to work and live independently (Joyce and Roiser, 2007).
One of the areas that has attracted attention recently is the field of social cognition. Social cognition has been defined as the mental processes underlying perception, interpretation, and response during social interactions regarding the behaviors, tendencies, and intentions of others (Adolphs, 2003). The most studied areas of social cognition in schizophrenia are social knowledge, emotion recognition, theory of mind and attribution style (Pinkham, 2014).
Affective-Cognitive Theory of Mind; There are studies that divide theory of mind into two as affective and cognitive theory of mind. It has been suggested that while false belief tests are related to cognitive theory of mind, recognizing irony and potency is related to affective theory of mind. (Shamay-Tsoory,2007)
It has been shown that theory of mind skills in patients with schizophrenia are significantly worse than in healthy control groups. It has been shown that disorders in theory of mind are mostly associated with negative and disorganized symptoms. (Corcoran et al., 1995)
The findings of studies examining the relationship between theory of mind and neurocognition in schizophrenia are not consistent. There are studies showing that theory of mind deficiency is associated with IQ, executive functions and memory skills, but it has been reported that theory of mind deficiency cannot be explained only by neurocognitive symptoms and IQ. (Brüne,2005)
4.1. Face Recognition in Schizophrenia
According to a model proposed by Bruce and Young, the face recognition process consists of the interaction of 7 different information obtained from the face. These are pictorial, structural, visually acquired meaning, identity specific meaning, name, expression and facial speech code.
Facial recognition and facial emotion processes are considered as two parallel and independent processes. The analysis of expression perceptions, such as structural codes, is responsible for the classification of expressions. The perception systems responsible for identification, called face recognition parts, encode the information that identifies the face (Bruce and Young, 1986).
Deficiency in identification/matching and recognition tasks is observed in patients with schizophrenia and individuals at high risk for schizophrenia. (Ventura et al, 2013) In patients with schizophrenia, the lack of identity matching or discrimination tasks was found to be associated with the difficulty of the test and the stage of the disease. More cognitively demanding tasks are thought to impose more restrictions on matching faces for patients with schizophrenia, especially for chronic patients (Bortolon, 2015).
4.2. Emotion Recognition in Schizophrenia
Recognizing emotions from facial expressions is a component of nonverbal communication. In many studies conducted in schizophrenia, it was emphasized that there is a relationship between social competence and emotion recognition skills, and that they predict professional functionality and ability to live independently (Morris, 2009). Happy, sad, scared, angry, surprised, disgusted and neutral facial expressions are universally accepted. The most common confusion is between fear and surprise, disgust and anger, neutral and sad facial expressions. Happy is the most easily recognizable facial expression, followed by surprised. The hardest to recognize is fear.
In a study by Tsoi et al., it was shown that patients with schizophrenia were three times more likely to identify non-sad faces as sad and had difficulty recognizing happy facial expressions compared to healthy controls. Especially in healthy people, when they focus on the eye areas of fearful faces, the amygdala is activated. Studies have shown that schizophrenia patients have decreased amygdala activity when they look at fearful faces (Tsoi et al.,2008).
Facial visual scanning pathways in patients with schizophrenia are different from non-facial stimuli, resulting in more time spent gazing than non-schizophrenic patients due to shorter visual scanning paths. In particular, people with schizophrenia tend not to look at structures that attract attention, such as the eyes and lips. It has been suggested that this restrictive visual pattern may correspond to less accurate recognition of emotions. It is expected that patients with schizophrenia will have more difficulty recognizing fear expressions, especially since they have deficits related to the regions where the eyes are involved. (Morris,2009)
CONCLUSION:
In the first studies examining theory of mind skills in schizophrenia patients, it was suggested that it was associated with the clinical symptoms of the disease, and that there were no theory of mind disorders in the remission period (Corcoran et al., 1995). However, in many studies, it has been reported that deficiency in all subtypes of Theory of Mind (verbal/visual, cognitive/affective) in patients with schizophrenia continues during the remission period.(Bora et al,2009)
In a meta-analysis study, it was reported that schizophrenia patients had more ToM deficiencies during exacerbations, but persisted during remission, and residual symptoms and IQ might affect IQ performance (Bora et al, 2009).
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