Schizophrenia Research 75 (2005) 233 – 239

www.elsevier.com/locate/schres

Proverb comprehension reconsidered—dtheory of mindT and

the pragmatic use of language in schizophrenia
Martin Brqne*, Luise Bodenstein
Center for Psychiatry and Psychotherapy, University of Bochum, Alexandrinenstr. 1, 44791 Bochum, Germany
Received 24 October 2004; received in revised form 9 November 2004; accepted 12 November 2004
Available online 13 December 2004

Abstract

Background: For decades, impaired proverb comprehension has been regarded as typical of schizophrenic thought disorder.
Testing patients’ proverb understanding has widely been abandoned, however, due to poor reliability and validity of the
assessment procedures. Since the underlying cognitive deficit of impaired proverb interpretation remained obscure, this study
sought to determine the relation of proverb understanding with other cognitive domains, particularly dtheory of mindT or
dmindreadingT, in schizophrenia.
Methods: 31 patients diagnosed with schizophrenia were assessed using a novel German Proverb Test [Barth, A., Kqfferle, B.,
2001. Die Entwicklung eines Sprichworttests zur Erfassung konkretistischer Denkstfrungen bei schizophrenen Patienten.
Nervenarzt 72, 853–858.], a dtheory of mindT test battery, a variety of executive functioning tests and verbal intelligence.
Psychopathology was measured using the PANSS [Kay, S.R., Opler, L.A., Lindenmayer, J.P., 1989. The Positive and Negative
Syndrome Scale (PANSS): rationale and standardisation. Br. J. Psychiatry 158 (suppl. 7), 59–67.]. Patients’ task performance
was compared to a group of healthy control persons.
Results: dTheory of mindT, executive functioning and intelligence were strongly correlated with patients’ ability to interpret
proverbs correctly. In a regression analysis dtheory of mindT performance predicted, conservatively estimated, about 39% of the
variance of proverb comprehension in the patient group.
Conclusions: The ability to interpret such metaphorical speech that is typical of many proverbs crucially depends on
schizophrenic patients’ ability to infer mental states. Future studies may further address differences between schizophrenia
subtypes or the relation to specific symptom clusters.
D 2004 Elsevier B.V. All rights reserved.

Keywords: Proverbs; Metaphor; Pragmatics; Theory of mind; Social contract theory

1. Introduction

* Corresponding author. Tel.: +49 234 5077 155; fax: +49 234
5077 235.
E-mail address: Martin.Bruene@rub.de (M. Brqne).
0920-9964/$ - see front matter D 2004 Elsevier B.V. All rights reserved.
doi:10.1016/j.schres.2004.11.006
Psychiatrists have recognized for at least 100 years
that patients with schizophrenia tend to interpret
proverbs literally (e.g., Finckh, 1906; Vigotsky,
234 M. Brüne, L. Bodenstein / Schizophrenia Research 75 (2005) 233–239
1934; Chapman, 1960). Several scholars even asserted
that impaired proverb understanding was almost
pathognomonic for schizophrenia (Gorham, 1956),
but the use of proverbs as a diagnostic tool was
criticized due to its poor reliability and the concept was
subsequently widely abandoned (Andreasen, 1977).
However, the cognitive deficit underlying schizo-
phrenic patients’ impaired ability to accurately inter-
pret proverbs is still inadequately understood (Gibbs
and Beitel, 1995). For example, it is unclear whether
poor proverb comprehension in schizophrenia is linked
to a more general cognitive impairment such as
intelligence, poor executive functioning or to a more
specific problem in information processing, or whether
the ability to think abstractly is indispensable for
proverb comprehension at all (Gibbs and Beitel, 1995).
Research into communication disturbances has
revealed syntactical and semantic speech abnormalities
in schizophrenia (Thomas et al., 1996; Docherty et al.,
1996), as well as deficits in patients’ pragmatic use of
language (Frith and Allen, 1988; Langdon et al.,
2002a,b). The rules of pragmatics involve the capacity
to extract the figurative meaning of an utterance (Grice,
1975; Sperber and Wilson, 2002). Therefore, a speaker
and his interlocutor must be able to go beyond the
literal meaning of a phrase—precisely what many
schizophrenic patients’ so-called dconcretisticT way of
thinking is lacking (Goldstein and Scheerer, 1941).
According to what has been termed dRelevance
TheoryT, both encoding and decoding of speech
involves the expression and recognition of intentions
in both speaker and hearer. This process requires a
metapsychological inference mechanism that is com-
monly referred to as having a dtheory of self and others’
mindsT (ToM; Sperber and Wilson, 2002). Many
studies have shown that schizophrenic patients often
fail on tasks involving ToM (overviews in Lee et al.,
2004; Brüne, 2005). Poor ToM in schizophrenia has
been associated with impaired metaphor and irony
comprehension (Mitchley et al., 1998; Langdon et al.,
2002a,b; Tényi et al., 2002) and with thought, language
and communication deficits (Sarfati and Hardy-Baylé,
1999). The association of poor ToM with impaired
proverb understanding has remained under-explored,
except in a recent study using Gorham’s proverbs and a
subjective rating of dbizarrenessT of the given responses
(Greig et al., 2004). Indeed, establishing a link between
proverb comprehension and ToM could substantially
support the assumption that an intact ToM is a
prerequisite for efficient verbal communication of
schizophrenic patients as, for instance, during clinical
interviews (McCabe et al., 2004).
In this study, we sought to explore the relation-
ship between impaired proverb understanding and
ToM performance in schizophrenia. We hypothe-
sized according to dRelevance TheoryT that ToM
task performance would be specifically linked to
schizophrenic patients’ ability to interpret proverbs,
and that impaired ToM would predict deficits in
proverb comprehension in patients better than gen-
eral intelligence, executive functioning or measures
of psychopathology.
2. Methods
2.1. Participants
Thirty-one schizophrenic patients (23 males, 8
females) diagnosed with schizophrenia according to
DSM-IV (APA, 1994) participated in the study after
giving informed consent. All patients were on anti-
psychotic medication and naive to the aims of the study.
Patients’ mean age at onset of the disorder was 26.4
years (12–59 years, S.D. F9.1 years) and the mean
duration of illness was 11.8 years (0–35 years, S.D.
F8.1 years). Patients mean age at time of assessment
was 38.6 years (range 20–66 years). The comparison
group consisted of 21 healthy control subjects (10
males, 11 females; mean age 33.9 years, range 19–62
years) with no history of psychiatric disorders, who
were recruited from the community and hospital staff.
All control subjects were unaware of the study
hypotheses.
2.2. Proverb test
The proverb test used in this study was developed by
Barth and Küfferle (2001). It comprised 14 metaphor-
ical proverbs in German, of which the figurative, non-
literal meaning had to be construed by choosing 1 out
of 5 written statements given in random order. Type I
answer was meaningful and abstract (the only correct
choice). Type II answer was meaningful and partially
concretistic. Type III answer was meaningful but
highly concretistic. Type IV answer was meaningless
 M. Brüne, L. Bodenstein / Schizophrenia Research 75 (2005) 233–239
and concretistic, and type V answer was meaningless
and abstract. For example, for the proverb bif the cat’s
away, the mice will playQ, the following multiple choice
answers were presented: (1) If there’s no control
person, one can do what he/she wants (type I); (2) if
no-one’s there to watch, the mice can do what they want
(type II); (3) if the cat’s away, one can do what he/she
wants (type III); (4) cats eat mice. Thus, the mice can
play only after the cat has left the house (type IV); (5) if
no-one’s there, you are on your own (type V). In an
evaluation study of their Proverb Test, the authors
found that schizophrenic patients interpreted the
proverbs significantly more concretistically than a
comparison group of patients with major depression
(Barth and Küfferle, 2001). Only fully correct (type I)
answers were rated (max. 14 pts.).
2.3. Neuropsychological tasks
General intelligence was estimated using the
dMehrfachwahlwortschatztestT (MWT, which may
best be translated as dMultiple Choice Verbal Com-
prehension TestT; Lehrl, 1976). English readership
may note that the German MWT is similar to the
dSpot-The-Word TestT (Baddeley et al., 1993), with
the difference that in the MWT subjects have to select
the correct word from five instead of two choices.
Two tests of executive functioning were given to the
participants: (1) a computerized and simplified version
of the Wisconsin Card Sorting Test (WCST; Nelson,
1976), where changes to the rules of allocating the
cards were made known to the participants. Errors and
perseverations were recorded separately, the latter as a
measure of cognitive flexibility. In addition, the Zoo
Map Test (ZMT), which involves executive planning
skills, was taken from the Behavioural Assessment of
the Dysexecutive Syndrome (BADS; Wilson et al.,
1996). Scores ranged from 0 to 4 points (max.).
2.4. Theory of mind tasks
dTheory of mindT (ToM) was assessed using a
series of six cartoon picture stories (Brüne, 2003a),
an advanced version of the test used in a previous
study (Brüne, 2003b). The cartoons depicted scenar-
ios of mutual cooperation, deception and cooperation
of two characters while cheating a third character.
Each picture story consisted of four cards. The cards
235
were presented face down in jumbled order. The
participants were asked to turn the cards over and to
order them in a logic sequence of events. The
sequencing time was measured for each picture story.
The way of rating the sequencing task was adopted
from Langdon et al. (1997), that is, two points were
given for the first and last correctly sequenced cards,
and one point each for correct sequencing of the two
middle cards (thus, 6 pts. maximum per picture story,
max. sum score 36 pts.). Two practicing examples
were included from Langdon et al.’s (1997) picture
stories and presented prior to ToM assessment.
In addition, a ToM questionnaire comprising
twenty-three questions was given to the subjects in
order to test the participants’ ability to appreciate the
mental states of the characters involved in the cartoon
stories (Brüne, 2003a,b). The questions referred to the
mental states of the characters of the picture stories
according to different levels of complexity. For
example, a so-called dfirst order questionT was: bWhat
do you think (1) this person (pointing to the respective
character) intends?Q An example of a second order
question was: bWhat do you think (1) this person
believes (2) the other intends to do?Q Overall, questions
addressed the participants’ ability to recognize cooper-
ation, deception, to detect cheating and to comprehend
true and false beliefs of the characters in the picture
stories. A total score of sequencing and questionnaire
sub-scores was calculated (59 pts. maximum).
2.5. Behavioral measures
Psychopathology was measured using the Pos-
itive and Negative Symptom Scale (PANSS; Kay et
al., 1989). The rating of psychopathology (M.B.)
was carried out blind to the patients’ performance
on the MWT, executive tests and ToM tasks
(assessed by L.B.).
Statistical analyses were carried out using SPSS
11.0 for Windows.
3. Results
3.1. Between-group differences
IQ as measured using the MWT and age were
normally distributed in both the patient and the control
236 M. Brüne, L. Bodenstein / Schizophrenia Research 75 (2005) 233–239

group. Thus, a parametric one-way ANOVA was
carried out. Patients and controls did not differ with
respect to their index age ( F(1,51)=1.736, p=.194).
They differed, however, with respect to their IQ
( F(1,51)=4.322, p=.043) as measured using the MWT.
Due to non-parametric distributions (except for the
Zoo Map Test), partly due to ceiling effects in the
control group, we carried out Kruskal–Wallis tests for
group comparisons. In the proverb test, the patients
diagnosed with schizophrenia chose less frequently
the c orrect answer than healthy controls
(v 2(1,52)=22.947, pb.001) and interpreted the prov-
erbs more often in a dconcretisticT way. Both groups
differed significantly in their performance on the
executive functioning tests, ToM and proverb under-
standing. The schizophrenic patients made signifi-
cantly more errors (v 2(1,52)=20.836, pb.001) and
more perseverative errors (v 2(1,52)=12.101, p=.001)
in the computerized WCST, and scored significantly
lower in the Zoo Map Test ( F(1,51)=5.739, p=.02)
compared to controls (here we used a one-way
ANOVA).
In addition, the patients made significantly more
errors in sequencing the ToM picture stories
(v 2(1,52)=22.57, pb.001), they were significantly
slower in sequen cing th e cartoon stories
(v 2(1,52)=6.598, p=.01), they performed more poorly
in the ToM questionnaire (v 2(1,52)=20.5, pb.001),
and thus had significantly lower ToM sum-scores
compared to controls (v 2(1,52)=28.024, pb.001).
As expected, all psychopathology scores differed
significantly between the groups ( pb.001). Between-
group differences are summarized in Table 1.
3.2. Correlations within the patient and control group
A non-parametric correlation analysis in the patient
group revealed that proverb understanding correlated
significantly with intelligence (Spearman q=.467,
p=.008), inversely with the number of perseverative
errors in the WCST (Spearman q= .398, p=.026),
with the performance on the Zoo Map Test (Spearman
q=.534, p=.002) and with patients’ performance on
ToM tasks (Spearman q=.651, pb.001). No correla-
tion was found between proverb comprehension and
the number of errors in the WCST, the sequencing
time of the ToM cartoons or with any of the
psychopathology scores as assessed using the PANSS.
In the control group, proverb understanding only
correlated inversely with the number of errors in the
WCST (Spearman q= .551, p=.01). Unlike the
schizophrenia group, no correlations of proverb
understanding were found with intelligence, executive
functioning other than WCSTerr or ToM performance,
which was probably mainly due to ceiling effects in
the control group (see Table 1 for result details).
Partial correlation analyses in the patient group
demonstrated that proverb comprehension remained
significantly correlated with ToM performance when
controlled for IQ (r=.51, df=28, p=.004). Conversely,

Table 1
Demographic characteristics and task performance (including standard deviations) for schizophrenic patients and healthy controls
Schizophrenia Healthy controls p-values
N 31 21
Sex ratio (m/f) 23:8 10:11
Index age (years) 38.6 (F12.9) 33.9 (F12.6) p=0.194, n.s.
IQ (MWT score) 100 (26.6F4.8) 105 (29.2F4.0) p=0.043
Proverb Test (max. 14 pts.) 6.6 (F5.0) 13.2 (F1.1) pb0.001
WCST errors 11.0 (F6.1) 3.9 (F3.3) pb0.001
WCST perseverations 5.7 (F8.5) 0.7 (F1.0) p=0.001
Zoo Map Test (max. 4 pts.) 1.9 (F1.3) 2.7 (F0.8) p=0.02
ToM cartoons sequencing (max. 36 pts.) 25.3 (F8.4) 35.3 (F1.3) pb0.001
ToM cartoons sequencing time (s) 212.7 (F189.6) 83.2 (F32.4) p=0.01
ToM total score (max. 59 pts.) 40.8 (F12.0) 56.3 (F2.9) pb0.001
PANSS positive 15.2 (F4.2) 7.0 pb0.001
PANSS negative 21.0 (F6.5) 7.0 pb0.001
PANSS general 36.3 (F9.4) 16.0 pb0.001
PANSS sum 71.8 (F18.8) 30.0 pb0.001
 M. Brüne, L. Bodenstein / Schizophrenia Research 75 (2005) 233–239
proverb understanding did not correlate with IQ when
ToM performance was co-varied out (r=.275, df=28,
p=.141, n.s.), suggesting that impaired proverb under-
standing was largely independent of intelligence.
3.3. Regression analysis
Two stepwise linear regression analyses were
carried out to determine in the patient group which
of the variables predicted best schizophrenic patients’
proverb comprehension. For the sake of statistical
validity, we restricted the number of independent
variables to three in each equation. When IQ (MWT),
the ToM sum-score and the Zoo Map Test were fitted
into the equation as independent variables, the overall
model was highly significant ( F(1,29)=19.854,
pb.001). Conservatively estimated, this model pre-
dicted approximately 39% of the variance of patients’
ability to correctly interpret proverbs (R-value=.637,
adjusted R 2=.386). After stepwise regression, ToM
alone remained in the equation (b=.637, t=4.456,
pb.001), whereas IQ (b In=.246, t=1.513, p=.141)
and the Zoo Map Test (b In=.295, t=1.953, p=.061)
were successively removed.
Similarly, when the number of perseverative
errors in the WCST was fitted into the equation
instead of the Zoo Map Test, the overall model was
also highly significant ( F(2,28)=13.136, pb.001).
The number of perseverative errors in the WCST
contributed approximately additional 6% of the
amount of variance (R -value=.696, adjusted
R 2=.447). In the equation, the predictive power of
ToM was considerably higher (b=.533, t=3.682,
p=.001) than that of the number of perseverative
errors in the WCST (b= .298, t= 2.053, p=.049);
again, IQ was removed from the equation (b
In=.223, t=1.439, p=.162). In other words, under-
standing other minds (i.e. ToM) and, to some degree,
fewer perseverative errors in the WCST predicted
schizophrenic patients’ proverb comprehension best.
4. Discussion
In the present study, we sought to explore the
association of impaired proverb understanding in
schizophrenia with other cognitive impairments and
behavioral measures of psychopathology. We pre-
237
dicted, according to the dRelevance TheoryT put
forward by Sperber and Wilson (2002), that patients’
impaired dtheory of mindT, that is, their compromised
ability to represent their own and other people’s
mental states, would best explain schizophrenic
patients difficulties in interpreting metaphorical
speech of the kind found in many proverbial sayings.
In fact, we found strong correlations between patients’
intelligence, executive functioning and particularly
ToM story comprehension with their ability to
recognize the figurative meaning of proverbs. More
importantly, the correlation of proverb comprehension
with ToM remained significant even when intelli-
gence and executive functioning were co-varied out.
In a linear regression equation, ToM performance was
the single-most significant predictor of correct prov-
erb interpretation in the patient group and accounted
for approximately 39% of the variance alone.
Our results are in line with previous studies
examining the association of ToM performance with
pragmatic aspects of language such as quantity,
quality, relation and politeness (Corcoran and Frith,
1996; Abu-Akel, 1999), comprehension of irony
(Mitchley et al., 1998; Langdon et al., 2002a,b), and
with patients’ failure to recognize intentional viola-
tions of conversational rules such as the detection of a
hidden negative opinion (Tényi et al., 2002). In a
similar vein, Harrow and Miller (1985) have shown
even earlier that schizophrenic patients disregard the
shared knowledge between them and their interloc-
utors during conversation. More specifically with
respect to the present study, De Bonis et al. (1997)
revealed that schizophrenic patients have difficulties
in matching metaphors similar or contrary to abstract
proverbs, and Greig et al. (2004) have recently found
similar correlation coefficients of a different ToM test
battery with Gorham’s Proverb Test. In summary, all
these studies indicate that schizophrenic patients’
violation of conversational rules and poor under-
standing of figurative speech is associated with
impaired mental perspective taking, i.e. ToM.
In contrast to our results, however, Langdon et al.
(2002a,b) failed to detect an association of poor ToM
with impaired metaphor understanding in schizophre-
nia. This apparently divergent finding deserves further
comment. According to Sperber and Wilson (1995),
metaphors represent a descriptive use of language
(such as byou are the cream in my coffeeQ), whereas
238 M. Brüne, L. Bodenstein / Schizophrenia Research 75 (2005) 233–239
irony represents an interpretative use of language
(bhe’s a fine friendQ) (overview in Langdon et al.,
2002a,b). Thus, metaphor and irony probably reflect
different levels of language complexity. Happé (1993)
has demonstrated in children with autism that under-
standing metaphor requires a level of first-order
theory of mind, whereas irony entails an intact
second-order level (Happé, 1993). Accordingly, onto-
genetically irony comprehension develops later
(around the seventh year) than children’s understand-
ing of metaphorical speech in the sense above.
Langdon et al. (2002a,b) have argued that metaphor
and irony comprehension involve distinct cognitive
processes, which could explain why impaired under-
standing of metaphors is associated with negative
symptoms in schizophrenia and poor irony compre-
hension with positive formal thought disorder.
The finding in our study of a profound association of
ToM with proverb understanding in schizophrenia
suggests that many proverbs may be more complex
than purely descriptive metaphorical utterances. More-
over, proverbs and metaphor are not synonymous terms
in the strict sense. Although the vast majority of
proverbs are indeed metaphorical, others may be not at
all (e.g. bdo not put off until tomorrow what you can do
todayQ). However, the proverbs used in Barth and
Küfferle’s (2001) Proverb Test exclusively express
social rules, norms or behavioral instructions in the
form of implicit conceptual metaphors that are to some
degree universal across cultures (Gibbs and Beitel,
1995). In addition, we would emphasize the fact that
many proverbs convey covert meaning of so-called
dSocial ContractsT (Cosmides, 1989). According to
dSocial Contract TheoryT, social exchange in cooper-
ative species like humans is governed by domain-
specific algorithms that operate on cost-benefit repre-
sentations of exchange situations (Cosmides, 1989).
Beside a mechanism for the assessment of mutual
benefit, an additional algorithm must have evolved in
humans to detect violations of social contracts; mutual
cooperation would be selected against if an individual
were unable to discover cheaters and would therefore
experience fitness costs. Detection of perceived cheat-
ing, for instance, is perhaps precisely the cognitive
mechanism, which is overactive in the formation of
paranoid delusions. Now, the purpose of proverbs, in
part, could be the activation of social contract
algorithms as in bone good turn deserves anotherQ or
bbirds of a feather flock togetherQ (cooperation),
whereas other proverbs rather express the risk of being
cheated such as in the German proverb ba fox who
wants to catch geese wags his tailQ. Patients with
schizophrenia, we propose, have profound difficulties
in understanding this kind of social contracts, perhaps
similar to patients with damage to the ventromedial
prefrontal cortex (Adolphs, 1999; Ritter et al., 2004).
We predict, therefore, that patients with schizophrenia
are also more likely to violate the rules of social
contracts due to their impaired ToM: either by paying
an unnecessary cost (i.e. cooperating on an illogical
basis), or by defecting in an inadequate manner, e.g.
when delusions are present.
There are some limitations of the present study that
need to be mentioned. For example, while we do not
assume that schizophrenia represents a ddisease
entityT, we did not–in light of the relatively small
sample size–differentiate between different subtypes
of schizophrenia. In addition, we did not control for
medication effects or gender. Other studies did not
determine an association of ToM abilities with
medication (Sarfati et al., 1999), but our knowledge
in this area is still limited (Brüne, 2005). Furthermore,
we did not include a clinical comparison group. It
would be most interesting to address in future studies,
for example, in patients with bipolar affective disorder
with psychotic symptoms, whether the presence of
formal thought disorder would be indicative of
impaired ToM and a compromised pragmatic use of
language.
Acknowledgments
The authors are grateful to Drs. Barth and Kqfferle,
University of Vienna, Austria, for their kind permis-
sion to use the bSprichwfrtertestQ (Proverb Test).
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