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Randomized Controlled Trial
. 2020 Feb 10;20(1):59.
doi: 10.1186/s12888-020-2482-z.

Theory of mind, emotion recognition, delusions and the quality of the therapeutic relationship in patients with psychosis - a secondary analysis of a randomized-controlled therapy trial

Stephanie Mehl  1   2 , Klaus Hesse  3 , Anna-Christine Schmidt  4 , Martin W Landsberg  4 , Daniel Soll  5 , Andreas Bechdolf  6   7 , Jutta Herrlich  8 , Tilo Kircher  5 , Stefan Klingberg  3 , Bernhard W Müller  9 , Georg Wiedemann  10 , Andreas Wittorf  3 , Wolfgang Wölwer  11 , Michael Wagner  4
Affiliations
Randomized Controlled Trial

Theory of mind, emotion recognition, delusions and the quality of the therapeutic relationship in patients with psychosis - a secondary analysis of a randomized-controlled therapy trial

Stephanie Mehl et al. BMC Psychiatry. .

Abstract

Background: Cognitive models of psychosis postulate an important role of Theory of mind (ToM) in the formation and maintenance of delusions, but research on this plausible conjecture has gathered conflicting findings. In addition, it is still an open question whether problems in emotion recognition (ER) are associated with delusions. We examined the association of problems in ToM and ER with different aspects of delusions in a large sample of patients with psychosis enrolled in a therapy trial. This also enabled us to explore the possible impact of ToM and ER on one part of patients' social life: the quality of their therapeutic relationship.

Methods: Patients with psychotic disorders and delusions and/or hallucinations (n = 185) and healthy controls (n = 48) completed a ToM picture sequencing task and an ER task. Subsequently, patients were enrolled in a randomized-controlled Cognitive Behavior Therapy (CBT) trial (ISRCTN29242879). Patients and therapists rated the quality of the therapeutic relationship during the first five sessions of therapy.

Results: In comparison to controls, patients were impaired in both ToM and ER. Patients with deficits in ER experienced more severe delusional distress, whereas ToM problems were not related to delusions. In addition, deficits in ER predicted a less favorable therapeutic relationship and interactional problems viewed by the therapist. Impaired ER also moderated (increased) the negative influence of delusions on the therapeutic relationship and interactional difficulties viewed by the therapist.

Conclusions: Cognitive models on the formation and maintenance of delusions should consider ER as a potential candidate that might be related to the formation and maintenance of delusional distress, whereas problems in ToM might not be directly related to delusions and secondary dimensions of delusions. In addition, problems in ER in patients with psychosis might have an impact on the quality of the therapeutic relationship and patients with problems in ER are more likely to be viewed as problematic by their therapists. Nevertheless, training ER might be a way to improve the quality of the therapeutic relationship and potentially the effectiveness of CBT or other interventions for patients with psychosis.

Keywords: Delusions; Emotion recognition; Interactional problems; Quality of the therapeutic relationship; Schizophrenia; Theory of mind.

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Conflict of interest statement

SM, AB, KH, SK, TK, AW and WW have published manuals/ chapters of textbooks and presented workshops and supervision in CBT (all) and cognitive remediation (WW) for psychosis. All authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
ToM and Emotion Recognition in patients with psychosis and healthy controls. Notes: ToM = Theory of Mind, ER = Emotion Recognition; Patients with psychosis: n = 185; Healthy controls: Theory of Mind: n = 42; Emotion Recognition: n = 39, error bars display the standard deviation
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