Psychiatry Research ] (]]]]) ]]]–]]]

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Theory of mind and context processing in schizophrenia: The role

of cognitive flexibility
Maud Champagne-Lavau a,b,c,n, Anick Charest b,c, Karyne Anselmo c, Jean-Pierre Rodriguez c, Guy Blouin c
a
Laboratoire Parole et Langage, UMR 7309 CNRS, Aix-Marseille University, 5 Av. Pasteur, B.P. 80975, 13604 Aix-en-Provence, France
b
Department of Psychiatry, University of Montreal, Canada
c
Hôpital du Sacré-Cœur de Montréal, Pavillon Albert-Prévost, Canada

a r t i c l e i n f o abstract

Article history: The present study sought to identify whether cognitive flexibility and context processing may impact
Received 4 November 2011 theory of mind (ToM) ability in schizophrenia. Thirty two patients with schizophrenia and 29 matched
Received in revised form healthy participants were tested individually on their ToM ability using a task involving attribution and
8 June 2012
comprehension of a speaker’s ironic intent. This task made it possible to determine whether the degree
Accepted 10 June 2012
of incongruity between contextual information and a target sentence has an impact on the attribution
of ironic intent to the protagonists of a story. Participants were also assessed on their cognitive
Keywords: flexibility and working memory. The main results revealed that participants with schizophrenia
Mental state attribution correctly perceived contextual information cueing attribution of ironic intent to the protagonist of
Contextual information
the stimulus, but they showed difficulty to correctly integrate this information, performing significantly
Ironic intent
worse than healthy participants when they attributed mental states. However, some participants with
Schizophrenia
Cognitive flexibility schizophrenia performed like healthy control participants on the ToM task while others did not. A lack
of flexibility seems to differentiate the two schizophrenia subgroups thereby obtained, suggesting that
cognitive flexibility has an impact on ToM performances in schizophrenia. These difficulties were not
associated with clinical symptoms. Such results will have an impact on cognitive remediation.
& 2012 Elsevier Ltd. All rights reserved.

1. Introduction schizophrenia may be more or less impaired in their ToM skills

Patients with schizophrenia are known to be impaired in their
theory of mind (ToM) ability (Frith, 2004; Brüne, 2005a;
Harrington et al., 2005; Sprong et al., 2007; Bora et al., 2009).
ToM is the ability to form representations of other people’s
mental states (e.g. intention, thought, belief) and to use these
representations to understand, predict and judge their statements
and behaviors (Premack and Woodruff, 1978; Baron-Cohen et al.,
1985). ToM impairments have been found in schizophrenia in
natural communication situations (McCabe et al., 2004;
Champagne-Lavau et al., 2009) and also in tasks assessing first
and second order false beliefs (Mazza et al., 2001; Brüne, 2005b;
Bora et al., 2007; Champagne-Lavau and Stip, 2010), irony
comprehension (Leitman et al., 2006; Kosmidis et al., 2008;
Kerns et al., 2009; Sparks et al., 2010), hinting comprehension
(Corcoran et al., 1995; Janssen et al., 2003; Greig et al., 2004; Bora
et al., 2006) and in picture-sequencing tasks (Langdon et al., 2006;
Brüne et al., 2007). Recent findings have shown that people with
n
Corresponding author at: Laboratoire Parole et Langage, UMR 7309 CNRS,
Aix-Marseille University, 5 Av. Pasteur, B.P. 80975, 13604 Aix-en-Provence, France.
Tel.: þ33 4 13 55 27 07; fax: þ 33 4 13 55 37 44.
E-mail address: maud.champagne-lavau@lpl-aix.fr (M. Champagne-Lavau).
(Pickup and Frith, 2001; Champagne-Lavau et al., 2009; Brüne and
Schaub, 2011). Indeed, Brüne and Schaub (2011) mention that
‘‘there is evidence to suggest that about 20–50% of patients with
schizophrenia perform similar to control on a wide range of tasks
devised to examine mental state attribution skills’’. Cognitive
flexibility – among other aspects of cognition-has been recently
proposed to account for such heterogeneity of performances in
ToM tasks in schizophrenia (Bora et al., 2007; Woodwards et al.,
2009; Brüne and Schaub, (2011). Such cognitive ability to shift
between two perspectives (or two beliefs about the world)
according to the demands of the social situation may be necessary
for the attribution of mental state to others. However, no
consensus emerges in the literature concerning the link between
ToM impairments and a lack of flexibility in schizophrenia
(Pickup, 2008). Although most of the patients with schizophrenia
are impaired relative to control participants on flexibility assessed
by the Wisconsin Card Sorting Test (WCST) or the Trail-making
test, some studies have shown a relationship with flexibility
(Greig et al., 2004; Bora et al., 2006; Van Hooren et al., 2008;
Brüne et al., 2011), but others have not (Mazza et al., 2001; Brüne,
2005b; Pinkham and Penn (2006)). More consistent evidence for
cognitive flexibility is needed to investigate the influence of
cognitive flexibility on ToM ability in schizophrenia.

0165-1781/$ - see front matter & 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.psychres.2012.06.011

Please cite this article as: Champagne-Lavau, M., et al., Theory of mind and context processing in schizophrenia: The role of
cognitive flexibility. Psychiatry Research (2012), http://dx.doi.org/10.1016/j.psychres.2012.06.011
2 M. Champagne-Lavau et al. / Psychiatry Research ] (]]]]) ]]]–]]]
Furthermore, some research has shown that impairments in
context processing might underlie dysfunctions in various cogni-
tive domains and may thus represent a core disturbance in
information processing in schizophrenia (Cohen and Servan-
Schreiber, 1992; Stratta et al., 1999; Green et al., 2005). Some
authors also suggested that insensitivity to context may contri-
bute to the clinical symptoms observed in schizophrenia (Stratta
et al., 1999), particularly disorganization (Hardy-Bayle et al.,
2003). However, despite increasing evidence for impaired context
processing, there has been little research into the relevance of
these deficits for an understanding of social cognition, particularly
ToM, in schizophrenia. The present study aimed to give insight
into the specific mechanisms underlying ToM impairments in
schizophrenia by studying underlying cognitive processes, such as
context processing and cognitive flexibility. Regarding this issue,
Abu-Akel and Shamay-Tsoory (2011) propose a distinction
between the ability to represent mental states and the ability to
attribute mental states. Cognitive flexibility should be more
relevant to the attribution (or deployment) process of currently
represented mental states, as when choosing amongst competing
hypotheses.
Authors suggested that patients’ apparent inability to attribute
intention to others results from their impairment in processing
contextual information (Hardy-Bayle et al., 2003; Green et al.,
2005; Schenkel et al., 2005; Green et al., 2007). Following the
distinction proposed by Abu-Akel and Shamay-Tsoory (2011), a
deficit in context processing might be the general determinant of
the deficits in ToM processing particularly affecting processes
associated with representing mental states and/or updating of
currently represented mental states. Indeed, of all the situations
encountered in everyday life, communication with others
requires the greatest ability to adapt to the context and represent
mental states: a conversation is by definition a shifting and
uncertain context, and the data associated with it must be
consistently inferred and updated on the basis of peripheral
information (Sperber and Wilson, 1986). Interestingly, McCabe
et al. (2004) found that patients with schizophrenia showed
specific ToM problems in case of disagreement with the psychia-
trist while they seemed to be able to represent mental states of
others during clinical encounters. In other words, patients with
schizophrenia seemed unable to respond to change and incorpo-
rate newly introduced information to revise their mental states in
such a case. Some studies have found evidence for an impairment
of context processing and have indicated a potential association
between ToM deficits and impairment in context processing
(Schenkel et al., 2005; Uhlhaas et al., 2006). However, these
studies varied according to the sort of context processing they
tapped into (high- or low-level) and the sort of contextual
information they used (visual, verbal, emotional, etc.). For exam-
ple, Uhlhaas et al. (2006) suggested a link between ToM deficits
and impairment of perceptual context processing using the
Ebbinghaus illusion, while Schenkel et al. (2005) hypothesized
that ToM deficits assessed by the Hinting task were related to
deficits in context processing, assessed by the first part of the
Hayling test (Burgess and Shallice, 1996) – a verbal task – and by
the Contour Integration task (Kovacs et al., 1999) – a visual task.
These studies consisted mainly in analyzing the correlation
between ToM and visual perception task (Schenkel et al., 2005;
Uhlhaas et al., 2006) or emotional perception task (e.g. the Eyes
Test) performances (Baron-Cohen et al., 2001; Uhlhaas et al.,
2006). In no study was the context manipulated in a way that
would make it possible to know whether context processing is
important for ToM ability. Correlation data can provide only
limited evidence on how context processing is involved in ToM
ability. Manipulating contextual information in a ToM task is
needed.
Please cite this article as: Champagne-Lavau, M., et al., Theory of mind and context processing in schizophrenia: The role of
cognitive flexibility. Psychiatry Research (2012), http://dx.doi.org/10.1016/j.psychres.2012.06.011
To avoid such limitations, we used a task of irony under-
standing manipulating the level of contextual incongruity. Indeed,
several psycholinguistic studies have shown that irony can be
perceived as a result of incongruity between context and speaker
utterance (Ivanko and Pexman, 2003). It has been demonstrated
that several factors, such as the degree of incongruity between
context and speaker utterance and the intonation of the speaker
(prosody), influence the extent to which ironic intent is perceived
(Bryant and Fox Tree, 2002; Ivanko and Pexman, 2003). This
means that, among healthy adults, the more incongruent the
context is, the better irony is perceived. If a speaker says to me
‘‘you are a wonderful singer,’’ the utterance could be interpreted
as a literal compliment (i.e., you really are a good singer) or as an
ironic insult (i.e., you are a horrible singer). Interpretation of the
speaker’s intent in making this utterance could be easier if there
had been even stronger incongruity between the events and the
literal meaning of the speaker’s utterance. For instance, if I got up
and sang and people started to throw things at me, the event
could be perceived as even more negative than if I got up and sang
and a light laugh could be heard. Moreover, the first contextual
sentence would have contrasted more sharply with the positive
literal meaning of the utterance ‘‘You are a wonderful singer’’
than the second contextual sentence would have. To summarize,
the contextual incongruity is weaker when the utterance appears
after the second contextual sentence than after the first one.
This finding was used in the present study to determine the role
of insensitivity to contextual information in the attribution of
intention by patients with schizophrenia. This paradigm, unlike
those used in other studies, has an advantage in that the role of
contextual information processing does not rely on correlation
analyses, which are limited in scope.
Accordingly, the aim of the present study was twofold: to
determine whether contextual information manipulated by level
of incongruity-which has been demonstrated to cue speaker
ironic intent in healthy subjects-also cues speaker ironic intent
in patients with schizophrenia, and to determine whether a lack
of cognitive flexibility may be related to mentalizing skills in
those patients. As far as we know, no research investigating ToM
ability via irony comprehension in schizophrenia has also
assessed cognitive flexibility. We hypothesized that difficulty in
using contextual data that cue speaker ironic intent will have an
impact on the ToM ability of schizophrenia participants. In
addition, ToM impairment was expected to be associated with a
lack of cognitive flexibility in these participants.
2. Methods
2.1. Participants
The sample consisted of 61 participants: thirty two individuals with schizo-
phrenia (SZ) and twenty nine healthy control (HC) participants with no history of
psychiatric disorders. SZ patients were diagnosed by clinicians according to DSM-IV
diagnostic criteria. All SZ participants were outpatients who had been recruited from
the Pavillon Albert Prévost of the Hôpital du Sacré-Coeur of Montréal. They were stable
and on antipsychotic medication with a normal recommended range of dosage (the
average chlorpromazine equivalent was 621 mg/day7393). Severity of symptoms
was measured using the Positive and Negative Syndrome Scale (PANSS; Kay et al.,
1987). HC participants had been recruited in the local community. They were
matched with the SZ patients for age and educational level (cf. Table 1 for the
demographic data). The two groups did not significantly differ with regard to age
(t(59)¼  0.39, P40.05), educational level (t(59)¼  1.37, P40.05) and IQ estimated
using the NART (Nelson, 1982) (t(59)¼0.91, P40.05). All participants were native
French-speakers with no previous neurological history.
Written consent forms were obtained from all participants, according to ethics
guidelines set out by the University of Montreal and the Hôpital du Sacré-Coeur
de Montréal.
 M. Champagne-Lavau et al. / Psychiatry Research ] (]]]]) ]]]–]]] 3

Table 1
Demographic, clinical and neurpsychological data.

Schizophrenia Healthy control p-value

Mean S.D. Mean S.D.

Age 41.6 9.3 42.6 10.6 0.816

Educational level 12.8 2.1 13.7 2.9 0.153
Gender (male/female) (21/11) (14/15)
Duration of illness 15.8 9.4
PANSS (positive) 17.9 4.2
PANSS (negative) 20.3 4.6
PANSS (general) 38.4 6.3
NART 45.4 9.6 42.7 7.9 0.302
Trail B (completion time) 115.5 49.9 58.9 18.9 o 0.0001
Trail B–Trail A (time) 71.6 41.2 29.5 15.4 o 0.0001
WCST (categories) 3.7 1.9 4.8 1.5 0.017
WCST (% perseverative errors) 41.0 25.3 19.1 19.8 o 0.001
Digit span (forward) 9.7 2.2 11.0 1.9 0.017
Digit span (backward) 4.7 1.7 6.5 2.3 o 0.001

2.2. Measures 3. Results

2.2.1. Neuropsychological measures 3.1. Group comparison on neuropsychological measures

Cognitive flexibility was assessed in all participants using the Trail-Making
Test (Reitan and Wolfson, 1993) and the WCST (Heaton, 1981). For the Trail-
Making test, the completion times in conditions B and A were recorded and a time
score (Trail B–Trail A) was calculated as a measure of flexibility. The number of
categories and the percentage of perseveration were recorded as a measure of
flexibility for the WCST. Participants were also evaluated on their working
memory to exclude any impairment that could have an impact on the irony task.
The Digit Span subtest from the WAIS (Wechsler, 1981) was used to assess
working memory.
2.2.2. Theory of mind (ToM)
A task of irony understanding was used to test attribution of intention as the
comprehension of irony typically depends on the attribution and comprehension
of speaker intent. The 12 stories by Ivanko and Pexman (2003) controlled for
familiarity and plausibility were used in the present study. To assess how context
manipulation influenced participants’ irony understanding, context was manipu-
lated according to the strength of context incongruity (strong incongruity, weak
incongruity, no incongruity) between contextual information and target sentence
(cf. Appendix for example). Thus, the 12 stories were distributed in three context
conditions intended to trigger either the literal meaning (no incongruity) or the
ironic meaning (strong incongruity, weak incongruity) of the target sentence. Each
target sentence (e.g. Christine is a clever student) appeared in each context
condition across three versions of each stimulus (12  3 ¼36 stimuli). Contexts
were presented in random order. To control for prosody and memory effect,
stimuli were presented on a sheet of paper. Participants were asked to read each of
these 36 stimuli, and then answer the following question: ‘‘What does X
(the speaker) really mean?’’ to assess their speaker intent understanding. Then a
control question was asked cueing on relevant contextual information needed to
answer previous questions (e.g. Did Christine receive 100% on her mathematics
exam?). To prevent answers to the control question at chance level, half of the
correct answers was ‘‘yes’’ while the other half was ‘‘no’’. Answers to each
question were scored 1 if correct (for a maximum score of 12 per type of context
for each question).
All participants were tested individually over one session in a quiet room.
2.3. Data analysis
Unpaired t-tests were used to explore group differences on the different
neuropsychological variables. To determine group differences on the irony task a
two group (SZ, HC)  3 context (no incongruity, strong incongruity, weak incon-
gruity) repeated-measures ANOVA was performed on the percentage of correct
responses to the different types of question: open question on speaker ironic
intent and control question. A Spearman’s correlation analysis was conducted on
the computed percentage of responses of the SZ group to examine the relationship
between ToM and symptoms and between ToM and neuropsychological measures.
To determine the impact of flexibility on ToM ability, a final set of analyses was
performed by sub-dividing individuals in the SZ group according to their
performances on the WCST. A K-means cluster analysis was used to classify the
SZ data into relatively unimpaired (SZ-U) versus relatively impaired (SZ-I) on the
WCST. The alpha level was set at P o 0.05 for all the analyses.
Significant differences between the SZ and HC groups were found
on Trail-making test B (t(59)¼5.37, Po0.0001), Trail B–Trail
A (t(59)¼5.39, Po0.0001), the WCST-category (t(59)¼  2.31,
Po0.025), the WCST-Perseverative errors (t(59)¼3.41, Po0.001),
the Digit span forward (t(59)¼  2.21, Po0.031) and Digit span
backward (t(59)¼ 3.38, Po0.001). Thus, the SZ group performed
significantly worse than the HC group on tests that evaluate
flexibility and memory (cf. Table 1).
3.2. Group comparison on ToM
The 2  3 ANOVA on the percentage of correct responses to the
question on speaker ironic intent revealed a main effect of context
(F(2, 112) ¼55.69, Po0.0001) and a main effect of group
(F(1,59)¼22.170, Po0.0001), showing that SZ patients made
more errors than HC participants. The group  context interaction
was significant (F(2, 112) ¼7.60, Po0.001). This interaction was
decomposed according to group. The SZ group made more errors
in answering questions on speaker intent in the weak incongruity
context condition than in the no incongruity context condition
(P o0.0001) and in the strong incongruity context condition
(P o0.0001). They also made more errors in answering questions
in the strong incongruity context condition than in the no
incongruity context condition (P o0.0001). In the HC group, there
was no difference between the strong incongruity and no incon-
gruity contexts (P 40.05). However, like SZ patients, HC partici-
pants made more errors in answering questions on speaker intent
in the weak incongruity context condition than in the no incon-
gruity context condition (Po0.0001) and the strong incongruity
context condition (Po0.0001) (cf. Table 2).
The 2  3 repeated-measures ANOVA on the percentage of
correct responses to the control question on contextual informa-
tion revealed a main effect of the type of context (F(2,58)¼5.6,
Po0.005) and a main effect of group (F(1,59)¼14.85, Po0.0001),
showing that SZ patients made more errors than HC participants.
However, the group  context interaction was not significant
(F(2, 112)¼0.16, P40.05) (cf. Table 2).
To sum up, these results showed that participants with
schizophrenia made more errors in answering questions on
speaker ironic intent in the strong and weak incongruity context
conditions while they performed like HC participants in the no
incongruity context condition. As predicted, HC participants made
the same number of errors in the strong incongruity and no

Please cite this article as: Champagne-Lavau, M., et al., Theory of mind and context processing in schizophrenia: The role of
cognitive flexibility. Psychiatry Research (2012), http://dx.doi.org/10.1016/j.psychres.2012.06.011
4 M. Champagne-Lavau et al. / Psychiatry Research ] (]]]]) ]]]–]]]

Table 2
Percentage of correct responses to the question on ironic speaker intent and to the control question in schizophrenia and healthy control participants.

Schizophrenia Healthy control

Mean (raw score) SD Mean (%) SD Mean (raw score) SD Mean (%) SD

Question on ironic intent

Strong incongruity context condition 9.2 3.3 76.7 27.5 11.3 2.2 97.5 5.8
Weak incongruity context condition 7.2 3.2 60 26.7 9.8 2.4 84.2 13.3
No incongruity context condition 11.6 0.8 95.8 6.7 11.5 2.2 99.2 2.5
Control question
Strong incongruity context condition 10.8 1.3 89.2 10.8 11.1 2.2 95.8 5.8
Weak incongruity context condition 10.7 1.4 89.2 11.7 11.2 2.2 96.7 5.0
No incongruity context condition 11.2 1.3 92.5 10.0 11.5 2.2 99.2 1.7

incongruity context conditions, in contrast to participants with Table 3

schizophrenia. In addition, while SZ participants made more Correlation analyses in schizophrenia group.
errors than HC participants in answering control questions on
Strong incongruity Weak incongruity No incongruity
contextual information, the same patterns of performance were
context condition context condition context
found for the two groups, according to the type of context (no condition
incongruity context, strong incongruity context, weak incongruity
context). Trail B–Trail A r¼  0.129 r¼ 0.160 r¼  0.102
(time) P¼ 0.482 P¼ 0.382 P¼ 0.580
WCST r¼ 0.433 r¼ 0.156 r¼ 0.191
3.3. Association of ToM performances with clinical symptoms
(categories) P¼ 0.017 P¼ 0.410 P¼ 0.312
WCST (% r¼  0.483 r¼  0.292 r¼  0.240
Examination of results from correlation analyses involving perseverative P¼ 0.008 P¼ 0.124 P¼ 0.210
ToM and patient symptoms measures revealed no significant errors)
Digit span r¼  0.028 r¼ 0.045 r¼ 0.208
relationship (cf. Table 3).
(forward) P¼ 0.880 P¼ 0.808 P¼ 0.253
Digit span r¼ 0.194 r¼  0.055 r¼ 0.096
3.4. Association of ToM performances with cognitive flexibility (backward) P¼ 0.288 P¼ 0.767 P¼ 0.600
in schizophrenia NART r¼ 0.240 r¼ 0.113 r¼ 0.30
P¼ 0.189 P¼ 0.535 P¼ 0.868
PANSS r¼  0.043 r¼  0.110 r¼ 0.067
Results from the analyses of the correlation between ToM
(positive) P¼ 0.820 P¼ 0.556 P¼ 0.719
performances and neuropsychological measures of cognitive PANSS r¼ 0.187 r¼ 0.094 r¼  0.138
flexibility, memory IQ and duration of illness in the SZ group (negative) P¼ 0.315 P¼ 0.616 P¼ 0.459
are reported in Table 3. They revealed that the percentage of PANSS r¼ 0.050 r¼  0.107 r¼ 0.062
correct responses to the question on speaker ironic intent in the (general) P¼ 0.791 P¼ 0.568 P¼ 0.742
Duration of r¼  0.136 r¼  0.195 r¼ 0.259
strong incongruity condition correlated significantly with perfor- illness P¼ 0.457 P¼ 0.286 P¼ 0.155
mance on the number of categories in the WCST, and the number
of perseverative errors in the WCST. No correlation was found
with memory, IQ and duration of illness. question on speaker ironic intent and to the control question.
The 3  3 ANOVA on the percentage of correct responses to
3.5. Influence of flexibility on ToM ability the question on speaker ironic intent revealed a main effect of
context (F(2, 116) ¼73.70, Po0.0001) and a main effect of group
As correlations were only found with the scores of WCST, (F(2,58)¼19.17, Po0.0001), showing that SZ-I patients made
a K-means cluster analysis was performed using the SZ partici- more errors than SZ-U patients (Po0.001) and HC participants
pants’ WCST-perseverative errors. Results of this analysis (Po 0.0001). SZ-U patients made also more errors than HC
revealed two subgroups (F(1, 30)¼85.9; Po0.0001): The SZ-I participants (Po0.018). The group x context interaction was
group contained 17 SZ participants relatively impaired on the significant (F(4, 116) ¼10.15, Po0.0001). This interaction was
WCST-perseverative errors while the SZ-U group contained 15 SZ decomposed according to group. The SZ-I group made more errors
participants relatively unimpaired on the WCST-perseverative in answering the question on speaker ironic intent in the weak
errors. incongruity context condition than in the no incongruity context
A series of t-tests showed that the two SZ subgroups were condition (Po0.0001) and in the strong incongruity context
comparable in age (t(30)¼ 0.57, P40.05), education level (t(30)¼ condition (Po0.001). They also made more errors in answering
1.23, P40.05), symptoms (PANSS (positive): (t(30)¼0.72, P40.05), questions in the strong incongruity context condition than in the
PANSS (negative): (t(30)¼0.57, P40.05), PANSS (general): (t(30)¼ no incongruity context condition (Po0.001). SZ-U and HC parti-
0.99, P40.05)); IQ (NART (t(30)¼0.20, P40.05)), Trail-Making (TMT cipants both made more errors in answering questions on speaker
B: (t(30)¼ 1.56, P40.05); TMT (B-A): (t(30)¼0. 1.47, P40.05)), intent in the weak incongruity context condition than in the no
and memory (Digit span forward (t(30)¼0.50, P40.05) and Digit incongruity context condition (respectively Po0.0001; Po0.0001)
span backward (t(27)¼0.84, P40.05)). However, they significantly and in the strong incongruity context condition (respectively
differed on the duration of illness (t(30)¼  2.36, Po0.05), and on Po0.0001; Po0.0001). For these two groups, unlike for the SZ-I
flexibility measured by the WCST (cf. Table 4 for demographic and group, no difference was found between the strong incongruity and
cognitive data). no incongruity context conditions (P40.05) (Fig. 1).
A 3  3 repeated measures ANOVA for group (SZ-U, SZ-I, As SZ-I participants had 49% of correct responses on the
HC)  context (no incongruity, strong incongruity, weak incongruity) question on speaker ironic intent in the weak incongruity context
was performed on the percentage of correct responses to the condition (cf. Fig. 1), an additional paired t-test was made to

Please cite this article as: Champagne-Lavau, M., et al., Theory of mind and context processing in schizophrenia: The role of
cognitive flexibility. Psychiatry Research (2012), http://dx.doi.org/10.1016/j.psychres.2012.06.011
 M. Champagne-Lavau et al. / Psychiatry Research ] (]]]]) ]]]–]]] 5

Table 4
Demographic, clinical and neuropsychological data for the healthy control (HC) group compared to schizophrenia patients with unimpaired (SZ-U)
or impaired (SZ-I) flexibility.

SZ-I SZ-U Healthy control SZ-I vs SZ-U P-value

Mean SD Mean SD Mean SD

Age 42.6 9.7 40.7 9.1 42.6 10.6 0.595

Educational level 12.3 1.9 13.3 2.4 13.7 2.9 0.292
Gender (male/female) (11/6) (10/5) (14/15)
Duration of illness 19.9 10.3 12.4 7.3 0.025
PANSS (positive) 17.3 3.7 18.4 4.7 0.475
PANSS (negative) 19.8 4.2 20.7 5.1 0.575
PANSS (general) 37.2 6.6 39.4 6.0 0.330
NART 44.7 11.1 45.4 8.1 42.7 7.9 0.829
Trail B (completion time) 130.8 50.2 103.1 50.2 58.9 18.9 0.051
Trail B – Trail A (time) 84.5 32.6 63.5 46.2 29.5 15.4 0.060
WCST (categories) 2.5 1.8 4.7 1.8 4.8 1.5 o0.001
WCST (% perseverative errors) 64.0 14.4 20.3 11.8 19.1 19.8 o0.0001
Digit span (forward) 9.6 1.5 10.0 2.8 11.0 1.9 0.594
Digit span (backward) 4.5 1.8 5.1 1.7 6.5 2.3 0.465

100.0
Percentage of correct responses

90.0
80.0
70.0
60.0 Strong incongruity
50.0 Weak incongruity
40.0 No incongruity
30.0
20.0
10.0
0.0
SZ-U SZ-I HC
Type of group

Fig. 1. Percentage of correct responses to the question on ironic speaker intent for the healthy control (HC) group compared to schizophrenia patients with unimpaired
(SZ-U) and impaired (SZ-I) flexibility. SZ-U: SZ participants unimpaired on WCST assessment; SZ-I: SZ participants impaired on WCST assessment; HC: healthy control
participants.

100.0
90.0
Percentage of correct responses

80.0
70.0
60.0
50.0 Strong incongruity
40.0 Weak incongruity
30.0 No incongruity
20.0
10.0
0.0
SZ-U SZ-I HC
Type of group

Fig. 2. Percentage of correct responses to the control question for the healthy control (HC) group compared to schizophrenia patients with unimpaired (SZ-U) and
impaired (SZ-I) flexibility. SZ-U: SZ participants unimpaired on WCST assessment; SZ-I: SZ participants impaired on WCST assessment; HC: healthy control participants.

assess whether their performance in this condition differed from
random choice. The results pointed out that SZ-I participants
answered at random (t(14)¼ 0.161, P ¼0.875) when the target
sentence was preceded by context with a weak incongruity.
The 3  3 ANOVA on the percentage of correct responses to the
control question revealed a main effect of context (F(2, 116) ¼
5.92, Po0.004) and a main effect of group (F(2,58)¼7.76, Po0.001),
showing that HC participants made fewer errors than SZ-I patients
(Po0.001) and SZ-U patients (Po0.02). The group  context inter-
action was not significant (F(4, 116)¼1.64, P¼0.17) (Fig. 2).
To examine the relative contribution of flexibility on ToM
ability in schizophrenia, a linear regression analysis was also

Please cite this article as: Champagne-Lavau, M., et al., Theory of mind and context processing in schizophrenia: The role of
cognitive flexibility. Psychiatry Research (2012), http://dx.doi.org/10.1016/j.psychres.2012.06.011
6 M. Champagne-Lavau et al. / Psychiatry Research ] (]]]]) ]]]–]]]
conducted with the score obtained in the strong incongruity
context condition as the dependant variable and the SZ subgroup
variable (SZ-I versus SZ-U) as the independent variable. The score
obtained in the strong incongruity context condition was used as
ToM performance since correlation was only found between this
condition and the WCST data in the participants with schizo-
phrenia (cf. Table 3). The results showed that the subgroup
variable was a significant predictor of the patients’ performance
on the ToM task (F(1, 31)¼17.595; Po0.0001). The R2 was 0.378
(with an adjusted R2 ¼ 0.356). This indicated that the subgroup
variable can account for 37.8% of the variance of the score
obtained in the strong incongruity condition.
To sum up, these last results showed that the SZ-U group
exhibited the same pattern of performances as the HC group
across the different context conditions for the question on
speaker ironic intent. In other words, these two groups made
the same number of errors in the strong incongruity context
condition as in the no incongruity context condition. By contrast,
SZ-I patients made more errors in answering questions on speaker
ironic intent in the strong and weak incongruity context condi-
tions while they performed like HC participants and SZ-U patients
in the no incongruity context condition. In addition, concerning
demographic and cognitive data, the difference between the SZ-U
group and the SZ-I group concerned flexibility and duration of
illness. However, no correlation was found between ToM perfor-
mances and duration of illness in the SZ group.
4. Discussion
The present study sought to identify whether cognitive flex-
ibility and context processing may impact ToM ability in patients
with schizophrenia. We used a psycholinguistic paradigm show-
ing that the degree of contextual incongruity influences the
extent to which ironic intent is understood.
In general, we noted that SZ participants performed worse
than HC participants on the task assessing their ToM ability,
committing more errors than HC participants in the strong
incongruity and weak incongruity context conditions. In contrast
to HC participants, they also made more errors in the strong
incongruity context condition than in the no incongruity context
condition. Nevertheless, SZ participants were able to correctly
infer the ironic intent in 76.6% of the cases. This ToM difficulty is
consistent with previous research studies using paradigms invol-
ving irony or sarcasm understanding (Leitman et al., 2006;
Kosmidis et al., 2008; Kern et al., 2009; Sparks et al., 2010).
Interestingly, extended analyses revealed that only a subgroup of
SZ participants (SZ-I) with a lack of cognitive flexibility differed
significantly from HC participants in their ToM abilities. Such
result is consistent with recent findings showing the existence of
SZ subgroups comprising patients with either ‘‘poor’’ or ‘‘fair’’
mentalizing ability (McCabe et al., 2004; Champagne-Lavau et al.,
2009; Brüne and Schaub, 2011). In our study, neither age,
education, IQ, memory deficits or symptoms of SZ participants
made it possible to account for the difference in patterns of
performance between the SZ-I and SZ-U subgroups. However, the
association between ToM impairments and lack of flexibility
seemed to differentiate these two SZ subgroups.
4.1. Influence of contextual information processing on ToM ability
In both HC and SZ participants without a lack of flexibility
(SZ-U), strong incongruity condition cues speaker ironic intent in
the sense that no difference was found between the strong
incongruity and the no incongruity conditions. This means that
some SZ patients are able to use contextual information to infer
Please cite this article as: Champagne-Lavau, M., et al., Theory of mind and context processing in schizophrenia: The role of
cognitive flexibility. Psychiatry Research (2012), http://dx.doi.org/10.1016/j.psychres.2012.06.011
others. These expected results concurred with previous findings
in healthy individuals, showing that the greater the incongruity
between context and target utterance, the easier it was to
understand ironic intent (Ivanko and Pexman, 2003). In contrast
to these groups, SZ participants with a lack of flexibility (SZ-I)
showed a difference in performance between the strong incon-
gruity and no incongruity conditions, meaning that they are not
able to infer ironic intent about the speaker of the story. Although
SZ-I participants had difficulties attributing ironic intent to the
speaker, they seemed to be sensitive to changes in contextual
information, as evident by their performance in answering the
control questions. They generally made more errors than HC
participants in answering control questions on contextual infor-
mation but this percentage of errors was actually low (less than
9%). They also made more errors in the weak incongruity context
condition than in the strong incongruity context condition.
In other words, the weaker the degree of incongruity between
context and target utterance, the more errors they made, as HC
and SZ-U participants did.
Such sensitivity to contextual information agreed with the
results of Titone et al. (2002) showing that SZ participants are
able to decode contextual information and to use context to
facilitate contextually relevant representation. However, this
sensitivity to the degree of incongruity between context and
target utterance of the story did not help SZ-I participants to
understand the ironic intent of the protagonist of the story. The
degree of incongruity did not seem to cue SZ-I participants’
understanding of speaker intent since they made more errors in
understanding irony in the strong incongruity context condition
than in the no incongruity context condition. Thus, even if they
perceived and understood that there was an incongruity between
contextual information and speaker utterance, SZ-I participants
wrongly inferred intention of the speaker in the story. They
tended to interpret ironic utterances as errors or lies, attributing
a wrong intention to the speaker. These data are consistent with
those of Uhlhaas et al. (2006) and Green et al. (2007), showing
inefficient integration of social contextual information in schizo-
phrenia (Green et al., 2008). In the framework of the model
proposed by Abu-Akel and Shamay-Tsoory (2011), the results
would be interpreted as SZ-I participants having difficulty to
update their mental states when new information is added, and
SZ-U participants being able to represent and update adequately
their mental states.
4.2. Influence of flexibility on ToM ability
In the present study, the association between ToM impairment
and lack of flexibility assessed by the WCST seemed to differ-
entiate the two SZ subgroups, SZ-I patients showing a lack of
flexibility being those who exhibited a ToM impairment. This
result does not support those of Brüne et al. (2011), who used a
linear regression analysis to find that the number of WCST
perseveration errors could not predict mental state attribution
in schizophrenia in contrast to verbal IQ and executive planning
skills. But, interestingly, they found that both ToM impairment
measured by the MSAT-T (Brüne’s mental state sequencing task)
and lack of flexibility measured by the number of WCST perse-
verative errors were significant predictors of the odds of being a
patient with schizophrenia. Like Mo et al. (2008), we found that
comprehension of irony is relatively independent of IQ.
The present research also agrees with a body of studies
showing a correlation between ToM performances and either
WCST or Trail-making task performances in schizophrenia (Greig
et al., 2004; Bora et al., 2006; Van Hooren et al., 2008; Cham-
pagne-Lavau et al., 2010; Brüne et al., 2011). In the study by Van
Hooren et al. (2008) for example, the results from the factor
 M. Champagne-Lavau et al. / Psychiatry Research ] (]]]]) ]]]–]]]
analyses indicate a strong relationship between the Hinting task
and the neurocognition measures including cognitive flexibility,
while other measures of social cognition (i.e. jumping to conclu-
sions, source monitoring and attribution style) loaded on others
factors. Taken together, these results support the hypothesis
according to which adopting someone else’s point of view, taking
into account his/her perspective requires cognitive flexibility to
understand the state of mind of another person (Ruby and Decety,
2003). According to Russell (1996), thinking flexibly about alter-
native perspectives is at the very heart of one’s ability to attribute
mental states to others. Indeed, mentalizing would require a
distinct and effortful representation of others’ knowledge, beliefs,
and intentions. Research by Keysar et al. (2000) and Epley et al.
(2004) suggests that people adopt an egocentric perspective
relying on their privileged ground (set of information that is
known to the self but that is not known to the speaker) to make
judgments about others. They adjust away from this egocentric
starting point, and this adjustment – cognitively effortful –
requires executive functions. This is consistent with the growing
body of evidence and arguments from developmental studies
suggesting that executive functions are an integral part of
children’s mindreading competences (Apperly, 2011).
4.3. Symptoms
Brüne and Schaub (2011), who did not find any difference on
WCST performances between poor and fair mentalizers in their
sample study, suggested that conceptual disorganization rather
than cognitive flexibility or planification may differentiate ‘‘poor’’
from ‘‘fair’’ mentalizers. However, the difficulties encountered by
the patients in our sample (SZ-I) were not linked with sympto-
matology since no correlation was found between performance
on the irony understanding task and clinical symptoms in SZ
participants. Data from the present study did not show that
ToM deficits assessed by irony comprehension were associated
with disorganized symptoms, as suggested by various authors
(Sarfati and Hardy-Bayle, 1999; Schenkel et al., 2005; Uhlhaas
et al., 2006). Schenkel et al. (2005), for example, demonstrated
correlations between disorganization and ToM performances,
but their regression analysis disclosed that disorganization did
not contribute to ToM performances. The present study was
concordant with some experiments that found no correlation
between ToM deficits and symptoms (Marjoram et al., 2005;
Leitman et al., 2006; Sprong et al., 2007). Actually, the association
between ToM deficits and clinical symptoms is far from clear
(Woodward et al., 2009). Given the inherent heterogeneity of
schizophrenia and the fact that the patients included were more
or less stabilized, the literature reported that there were as many
studies showing an association between ToM ability and clinical
symptoms as investigations discerning no association (Harrington
et al., 2005; Lee et al., 2004).
To sum up, the present study provides a meaningful argument
that the ability to attribute intention to others varies as a function
of cognitive flexibility in schizophrenia. First, results of the
present study point out that some participants with schizophre-
nia performed like HC participants on the ToM task while others
did not. Second, participants with schizophrenia correctly per-
ceived contextual information cueing attribution of ironic intent
to the protagonist of the stimulus, but they did not always
correctly integrate this information to attribute mental states.
Third, a lack of flexibility seems to have an impact on ToM
performances in schizophrenia. Such pattern of impairments has
also been found in patients with Asperger’s syndrome who
exhibit an inability to appreciate the thoughts and feelings of
others. Indeed, this inability has been linked to difficulties in both
integrating contextual information, and to executive dysfunctions
Please cite this article as: Champagne-Lavau, M., et al., Theory of mind and context processing in schizophrenia: The role of
cognitive flexibility. Psychiatry Research (2012), http://dx.doi.org/10.1016/j.psychres.2012.06.011
7
tapping on their ability to shift back and forth from two different
viewpoints of the same event (Frith and Vignemont, 2005). While
some studies did not report a ToM impairment in Asperger’s
syndrome (Bowler, 1992 for example), Frith and Vignemont
(2005) underlined that the presence or not of ToM impairment
in this population depends on the task used to assess this ability.
For instance, individuals with Asperger’s syndrome have been
shown to success in Sally-Anne task and Strange Stories test
while they were unable to attribute mental states spontaneously
(Senju et al., 2009).
Following the distinction proposed by Abu-Akel and Shamay-
Tsoory (2011), between representation/updating and attribution
of mental states, ToM impairments in patients with schizophrenia
might reflect either difficulty to represent and/or update mental
states according to the context, or problem to flexibly adopt
perspective of the others to attribute mental states. According to
this hypothesis, SZ patients tested by McCabe et al. (2004) would
not have difficulty to attribute mental states to others, but rather
problems to update their mental states in some situations such as
situation of disagreement, for example. More appropriate studies
are required to assess whether patients with schizophrenia are
impaired in representing/updating mental states and/or attribut-
ing mental states to others.
An important consequence of our results concerns cognitive
remediation since ToM ability could have an impact on social
functioning in schizophrenia (Nuechterlein et al., 2004; McGurk
et al., 2007). Integration of contextual information and/or cogni-
tive flexibility seems to be a good target for cognitive remediation
aiming to increase social cognition ability, and as a consequence,
social functioning (Lecardeur et al., 2009, 2010).
The present study contains potential shortcomings that need
to be mentioned. The ToM task we used assessed the attribution
of mental states in an off-line way since participants were not
taking part in the interaction but made explicit use of mentalizing
to answer questions on the speaker ironic intent (in the story).
This way to assess ToM puts more weight on meta-cognitive
processes (Frith, 2004). Therefore, the relationship found with a
lack of flexibility might be due to such cognitive overload.
Unfortunately, except for our study, none of the studies investi-
gating ToM ability with a task assessing irony or sarcasm under-
standing has tested for cognitive flexibility to confirm such
hypothesis. To overcome such possible cognitive overload due
to the task itself and to confirm the relationship between
cognitive flexibility and ToM ability in schizophrenia, it would
be necessary to find such result with a task assessing ToM ability
in a natural situation of conversation like in Champagne-Lavau
et al. (2009).
Acknowledgments
This study was supported by the Fonds de la Recherche en
Santé du Québec (New investigator and operating grant #5793)
and the Natural Sciences and Engineering Research Council of
Canada (Operating grant #327313-06) to MCL. Further, we would
like to thank anonymous reviewers for their helpful comments on
an earlier version of this manuscript.
Appendix A. Sample stimuli
A.1. Stimuli with strong contextual incongruity
Christine and Marie wrote the same math exam. Christine
hardly studied and received 20% on the exam. The next day Marie
said to Chantal, ‘‘Christine is a clever student’’.
8 M. Champagne-Lavau et al. / Psychiatry Research ] (]]]]) ]]]–]]]
A.2. Stimuli with weak contextual incongruity
Christine and Marie wrote the same math exam. Christine
studied for 2 day and received 60% on the exam. The next day Marie
said to Chantal, ‘‘Christine is a clever student’’.
A.3. Stimuli with no contextual incongruity
Christine and Marie wrote the same math exam. Christine
studied for 1 day and received 90% on the exam. The next day Marie
says to Chantal: ‘‘Christine is a clever student’’.
Questions
 Open question on speaker ironic intent: What did Marie
really mean?
 Control question on contextual information: Did Christine
receive 100% on her mathematics exam?
References
Abu-Akel, A., Shamay-Tsoory, S., 2011. Neuroanatomical and neurochemical bases
of theory of mind. Neuropsychologia 49, 2971–2984.
Apperly, I., 2011. Mindreaders: the Cognitive Basis of ‘‘Theory of Mind’’. Psychology
Press, Sussex.
Baron-Cohen, S., Leslie, A.M, Frith, U., 1985. Does the autistic child have a ‘‘theory
of mind’’? Cognition 21, 37–46.
Baron-Cohen, S., Wheelwright, S., Hill, J., Raste, Y, Plumb, I., 2001. The ‘‘Reading the
Mind in the Eyes’’ test revised version: a study with normal adults, and adults
with Asperger syndrome or high-functioning autism. Journal of Child Psychology
and Psychiatry, and allied disciplines 42, 241–251.
Bora, E., Eryavuz, A., Kayahan, B., Sungu, G, Veznedaroglu, B., 2006. Social
functioning, theory of mind and neurocognition in outpatients with schizo-
phrenia; mental state decoding may be a better predictor of social functioning
than mental state reasoning. Psychiatry Research 145, 95–103.
Bora, E., Sehitoglu, G., Aslier, M., Atabay, I, Veznedaroglu, B., 2007. Theory of mind
and unawareness of illness in schizophrenia: is poor insight a mentalizing
deficit? European Archives of Psychiatry and Clinical Neuroscience 257,
104–111.
Bora, E., Murat, Y., Pantelis, C., 2009. Theory of mind impairment in schizophrenia:
meta-analysis. Schizophrenia Research 109, 1–9.
Bowler, D.M., 1992. Theory of mind in Aspeger’s syndrome. Journal of Child
Psychology and Psychiatry and Allied Disciplines 33, 877–893.
Brüne, M., 2005b. Emotion recognition, ‘theory of mind,’ and social behavior in
schizophrenia. Psychiatry Research 133, 135–147.
Brüne, M., 2005a. ‘‘Theory of mind’’ in schizophrenia: a review of the literature.
Schizophrenia Bulletin 31, 21–42.
Brüne, M., Abdel-Hamid, M., Lehmkamper, C, Sonntag, C., 2007. Mental state
attribution, neurocognitive functioning, and psychopathology: what predicts
poor social competence in schizophrenia best? Schizophrenia Research 92,
151–159.
Brüne, M., Schaub, D., 2011. Mental state attribution in schizophrenia: what
distinguishes patients with ‘‘poor’’ from patients with ‘‘fair’’ mentalising
skills? European Psychiatry: The Journal of the Association of European
Psychiatrists.
Brüne, M., Schaub, D., Juckel, G, Langdon, R., 2011. Social skills and behavioral
problems in schizophrenia: the role of mental state attribution, neurocogni-
tion and clinical symptomatology. Psychiatry Research 190, 9–17.
Bryant, G.A, Fox Tree, J.E., 2002. Recognizing verbal irony in spontaneous speech.
Metaphor and Symbol 17, 99–117.
Burgess, P.W, Shallice, T., 1996. Bizarre responses, rule detection and frontal lobe
lesions. Cortex 32, 241–259.
Champagne-Lavau, M., Fossard, M., Martel, G., Chapdelaine, C., Blouin, G.,
Rodriguez, J.P, Stip, E., 2009. Do patients with schizophrenia attribute mental
states in a referential communication task? Cognitive Neuropsychiatry 14,
217–239.
Champagne-Lavau, M, Stip, E., 2010. Pragmatic and executive dysfunction in
schizophrenia. Journal of Neurolinguistics 23, 285–296.
Cohen, J.D., Servan-Schreiber, D., 1992. Context, cortex, and dopamine: a connec-
tionist approach to behavior and biology in schizophrenia. Psychological
Review 99, 45–77.
Corcoran, R., Mercer, G, Frith, C.D., 1995. Schizophrenia, symptomatology and
social inference: investigating ‘‘theory of mind’’ in people with schizophrenia.
Schizophrenia Research 17, 5–13.
Frith, C.D., 2004. Schizophrenia and theory of mind. Psychological Medicine 34,
385–389.
Frith, U., Vignemont, F., 2005. Egocentrism, allocentrism, and Asperger syndrome.
Consciousness and Cognition 14, 719–738.
Please cite this article as: Champagne-Lavau, M., et al., Theory of mind and context processing in schizophrenia: The role of
cognitive flexibility. Psychiatry Research (2012), http://dx.doi.org/10.1016/j.psychres.2012.06.011
Green, M.J., Uhlhaas, P.J, Coltheart, M., 2005. Context processing and social
cognition in schizophrenia. Current Psychiatry Reviews 1, 11–22.
Green, M.J., Waldron, J.H, Coltheart, M., 2007. Emotional context processing is
impaired in schizophrenia. Cognitive Neuropsychiatry 12, 259–280.
Green, M.J., Waldron, J.H., Simpson, I, Coltheart, M., 2008. Visual processing of
social context during mental state perception in schizophrenia. Journal of
Psychiatry & Neuroscience 33, 34–42.
Greig, T.C., Bryson, G.J, Bell, M.D., 2004. Theory of mind performance in schizo-
phrenia: diagnostic, symptom, and neuropsychological correlates. The Journal
of Nervous and Mental Disease 192, 12–18.
Hardy-Bayle, M.C., Sarfati, Y, Passerieux, C., 2003. The cognitive basis of disorganiza-
tion symptomatology in schizophrenia and its clinical correlates: toward a
pathogenetic approach to disorganization. Schizophrenia Bulletin 29, 459–471.
Harrington, L., Siegert, R.J, McClure, J., 2005. Theory of mind in schizophrenia:
a critical review. Cognitive Neuropsychiatry 10, 249–286.
Heaton, R.K., 1981. Wisconsin Card Sorting Test: Manual. Neuropsychological
Assessment Resources, Odessa, FL.
Ivanko, S.L, Pexman, P.M., 2003. Context incongruity and irony processin.
Discourse Processes 35, 241–279.
Janssen, I., Krabbendam, L., Jolles, J, van Os, J., 2003. Alterations in theory of mind
in patients with schizophrenia and non-psychotic relatives. Acta Psychiatrica
Scandinavica 108, 110–117.
Kay, S.R., Fiszbein, A., Opler, L.A., 1987. The positive and negative syndrome scale
(PANSS) for schizophrenia. Schizophrenia Bulletin 13, 261–276.
Kern, R.S., Green, M.F., Fiske, A.P., Kee, K.S., Lee, J., Sergi, M.J., Horan, W.P., Subotnik,
K.L., Sugar, C.A, Nuechterlein, K.H., 2009. Theory of mind deficits for processing
counterfactual information in persons with chronic schizophrenia. Psycholo-
gical Medicine 39, 645–654.
Keysar, B., Barr, D.J., Balin, J.A, Brauner, J.S., 2000. Taking perspective in conversa-
tion: the role of mutual knowledge in comprehension. Psychological Science
11, 32–38.
Kosmidis, M.H., Aretouli, E., Bozikas, V.P., Giannakou, M, Ioannidis, P., 2008.
Studying social cognition in patients with schizophrenia and patients with
frontotemporal dementia: theory of mind and the perception of sarcasm.
Behavioural Neurology 19, 65–69.
Kovacs, I., Kozma, P., Feher, A.Benedek, G., 1999. Late maturation of visual spatial
integration in humans. Proceedings of the National Academy of Science 96,
12204-12209.
Langdon, R., Corner, T., McLaren, J., Ward, P.B, Coltheart, M., 2006. Externalizing
and personalizing biases in persecutory delusions: the relationship with poor
insight and theory-of-mind. Behaviour Research and Therapy 44, 699–713.
Lecardeur, L., Stip, E, Champagne-Lavau, M., 2010. Cognitive remediation therapy
of social cognition in schizophrenia: a critical review. Current Psychiatry
Reviews 6, 280–287.
Lecardeur, L., Stip, E., Giguere, M., Blouin, G., Rodriguez, J.P, Champagne-Lavau, M.,
2009. Effects of cognitive remediation therapies on psychotic symptoms and
cognitive complaints in patients with schizophrenia and related disorders: a
randomized study. Schizophrenia Research 111, 153–158.
Lee, K.H., Farrow, T.F., Spence, S.A, Woodruff, P.W., 2004. Social cognition, brain
networks and schizophrenia. Psychological Medicine 34, 391–400.
Leitman, D.I., Ziwich, R., Pasternak, R, Javitt, D.C., 2006. Theory of Mind (ToM) and
counterfactuality deficits in schizophrenia: misperception or misinterpreta-
tion? Psychological Medicine 36, 1075–1083.
Marjoram, D., Tansley, H., Miller, P., MacIntyre, D., Owens, D.G., Johnstone, E.C.,
Lawrie, S., 2005. A theory of mind investigation into the appreciation of visual
jokes in schizophrenia. BMC Psychiatry 5, 12.
Mazza, M., De Risio, A., Surian, L., Roncone, R, Casacchia, M., 2001. Selective
impairments of theory of mind in people with schizophrenia. Schizophrenia
Research 47, 299–308.
McCabe, R., Leudar, I, Antaki, C., 2004. Do people with schizophrenia display
theory of mind deficits in clinical interactions? Psychological Medicine 34,
401–412.
McGurk, S.R., Twamley, E.W., Sitzer, D.I., McHugo, G.J, Mueser, K.T., 2007. A meta-
analysis of cognitive remediation in schizophrenia. American Journal of
Psychiatry 164, 1791–1802.
Mo, S., Su, Y., Chan, R.C.K., Liu, J., 2008. Comprehension of metaphor and irony in
schizophrenia during remission: The role of theory of mind and IQ. Psychiatry
Research 157, 21–29.
Nelson, H.E., 1982. National Adult Reading Test (NART). Test Manuel. National
Foundation for Educational Research-Nelson, Windsor.
Nuechterlein, K.H., Barch, D.M., Gold, J.M., Goldberg, T.E., Green, M.F, Heaton, R.K.,
2004. Identification of separable cognitive factors in schizophrenia. Schizo-
phrenia Research 72, 29–39.
Pickup, G.J., 2008. Relationship between Theory of Mind and executive function in
schizophrenia: a systematic review. Psychopathology 41, 206–213.
Pickup, G.J, Frith, C.D., 2001. Theory of mind impairments in schizophrenia: sympto-
matology, severity and specificity. Psychological Medicine 31, 207–220.
Pinkham, A.E., Penn, D.L., 2006. Neurocognitive and social cognitive predictors of
interpersonal skill in schizophrenia. Psychiatry Research 143, 167–178.
Premack, D, Woodruff, G., 1978. Does the chimpanzee have a theory of mind? The
Behavioral and Brain Sciences 4, 515–526.
Reitan, R.M., Wolfson, D., 1993. The Halstead-Reitan Neuropsychological Test
Battery. Neuropsychology Press, Tucson.
Ruby, P, Decety, J., 2003. What you believe versus what you think they believe:
a neuroimaging study of conceptual perspective-taking. European Journal of
Neuroscience 17, 2475–2480.
 M. Champagne-Lavau et al. / Psychiatry Research ] (]]]]) ]]]–]]] 9

Russell, J., 1996. Agency: Its Role in Mental Development. Erlbaum, Hove.
Sarfati, Y, Hardy-Bayle, M.C., 1999. How do people with schizophrenia explain the
behaviour of others? A study of theory of mind and its relationship to thought
and speech disorganization in schizophrenia. Psychological Medicine 29,
613–620.
Schenkel, L.S., Spaulding, W.D, Silverstein, S.M., 2005. Poor premorbid social
functioning and theory of mind deficit in schizophrenia: evidence of reduced
context processing? Journal of Psychiatry Research 39, 499–508.
Senju, A., Southgate, V., White, S., Frith, U., 2009. Mindblind eyes: an absence of
spontaneous theory of mind in Asperger syndrome. Science 325, 883–885.
Sparks, A., McDonald, S., Lino, B., O’Donnelle, M, Green, M.J., 2010. Social cognition,
empathy and functional outcome in schizophrenia. Schizophrenia Research
122, 172–178.
Sperber, D., Wilson, D., 1986. Relevance: Communication and Cognition. Blackwell,
Oxford.
Sprong, M., Schothorst, P., Vos, E., Hox, J, van Engeland, H., 2007. Theory of mind in
schizophrenia: meta-analysis. The British Journal of Psychiatry: the journal of
mental science 191, 5–13.
Stratta, P., Daneluzzo, E., Bustini, M., Prosperini, P.L., Rossi, A., 1999. Schizophrenic
patients use context-independent reasoning more often than context-depen-
dent reasoning as measured by the cognitive bias task (CBT): a controlled
study. Schizophrenia Research 37, 45–51.
Titone, D., Holzman, P.S, Levy, D.L., 2002. Idiom processing in schizophrenia: literal
implausibility saves the day for idiom priming. Journal of Abnormal Psychol-
ogy 111, 313–320.
Uhlhaas, P.J., Phillips, W.A., Schenkel, L.S, Silverstein, S.M., 2006. Theory of mind
and perceptual context-processing in schizophrenia. Cognitive Neuropsychiatry
11, 416–436.
Van Hooren, S., Vermissen, D., Janssen, I., Myin-Germeys, I., Campo, J., Mengelers,
R., Vans Os, J., Krabbendam, L., 2008. Social cognition and neurocognition as
independant domains in psychosis. Schizophrenia Research 103, 257–265.
Wechsler, D., 1981. Wechsler Adult Intelligence Scale—Revised. The Psychological
Corporation, San Antonio, TX.
Woodward, T.S., Mizrahi, R., Menon, M, Christensen, B.K., 2009. Correspondences
between theory of mind, jumping to conclusions, neuropsychological mea-
sures and the symptoms of schizophrenia. Psychiatry Research 170, 119–123.

Please cite this article as: Champagne-Lavau, M., et al., Theory of mind and context processing in schizophrenia: The role of
cognitive flexibility. Psychiatry Research (2012), http://dx.doi.org/10.1016/j.psychres.2012.06.011