Mentalization and Theory of Mind in First-Degree Relatives of Patients with Schizophrenia: A Cross-Sectional Study

1. Introduction

Schizophrenia is a complex mental disorder that affects approximately 1% of the world’s population.¹ Among its most characteristic symptoms are delusions, hallucinations and disorganization of thought and behaviours. However, this condition also affects cognitive abilities, such as those responsible for understanding and navigating the social world.^2,3

Theory of mind is the skill that allows us to understand the mental and emotional states of others, including their beliefs and intentions. This ability is essential for successful social interaction, as it allows us to predict the behaviour of others and respond appropriately to them, fundamental tools for adequate personal performance in relation to others in a given environment.⁴

The concept of ToM in the context of adolescents, young adults, and psychosis is an area of interest and concern in neurodevelopmental psychiatry. In typical development, people gradually unfold the ability to ToM, which involves responding to signals that indicate the mental and emotional states of themselves and those around them. It involves the early development of cognitive processes such as joint attention, self-regulation, and the ability to attribute intentionality to the acts or behaviours of others.^5,6

There is a wide variety of data that suggests that ToM is altered in schizophrenia.^7,8 Research on the neurobiology of theory of mind in schizophrenia has found that dysfunction of the prefrontal-temporal circuit, reduction of hippocampal and thalamus volume, as well as hyperintensities in the white matter alterations related to social cognition.^9–11

Patients with this condition present difficulties in mentalization, manifested by difficulties in establishing interpersonal relationships, social isolation due to the lack of connection with the environment and others, which leads to withdrawal and functional deterioration. Daily life is affected by difficulty understanding social norms and codes.^12,13

In first-degree relatives of patients with schizophrenia, subclinical alterations have been identified in the sense of socio-emotional competencies, cognitive performance, and complex skills such as mentalization or ToM.^3,14,15 The presence of psychosis may be associated with several risk factors, including genetic predisposition, prenatal and perinatal complications, exposure to trauma or stress, and early attachment alterations.¹⁶ In relation to the latter, relatives of patients with schizophrenia could share alterations or dysfunction in complex mechanisms such as ToM, a situation that could imply important areas of study for the joint approach of families affected by this condition.¹⁷

The present study evaluates the ToM abilities in first-degree relatives of patients with schizophrenia, exploring associations with demographic factors and prior psychoeducation experience. Our premise is that first-degree relatives of patients with schizophrenia will have borderline scores the reading the mind in the eyes test.

2. Methods

This is a descriptive, cross-sectional study. It was carried out with first-degree relatives of patients with schizophrenia who had been diagnosed for less than 15 years and who were receiving care at the Fray Bernardino Álvarez Psychiatric Hospital.

2.1 Selection criteria

First-degree relatives of patients with schizophrenia whose diagnosis time was less than 15 years were included. Of both sexes and over 18 years of age. Relatives with suspected acute psychotic symptoms, cognitive impairment, or diagnosis of a mental and behavioural disorder and cases in which there was consanguinity among the patient’s family were excluded. Those who did not answer the instrument were eliminated.

2.2. Variables

Sociodemographic: Age of the responsible family member, sex, occupation, marital status, socioeconomic level, education, type of family member. Clinical: History of psychopathology in the family. Psychoeducation experience in family members and score in the reading the mind in the eyes test (RMET).

2.3. Instrument

The reading the mind in the eyes test is a neuropsychological assessment instrument designed to explore an individual’s ability to infer the emotions and mental states of others from the visual information provided by the gaze. This test has become a valuable tool for the study of ToM in different contexts.¹⁸

The RMET consists of a series of images that show human eyes in different facial expressions. The individual is asked to identify the emotion that is being expressed in each image, selecting from a list of options. The test is composed of 36 items, divided into two series: a control series with neutral expressions and an experimental series with emotional expressions.¹⁹ The interpretation criteria are: Score: 25 – 36 normal, 20 – 24 borderline, < 20 low. Regarding its psychometric properties, it was adapted to the Latin American population with a Cronbach’s alpha coefficient greater than 0.80, kappa index greater than 0.80.^20,21

2.4. Statistical analysis

The sample size calculation was conducted as follows: the prevalence of schizophrenia in the general population is 1 - 2%, using the formula for infinite population with a confidence level of 95% and a margin of error of 5%, a sample size of 45 subjects was obtained (n = [(1.96)2 x 0.03 x (1-0.03)]/ [0.05]2). Sampling was consecutive until the calculated sample size was completed.

The frequencies and percentage of the qualitative variables (sex, occupation, marital status, socioeconomic level, education, type of family member, history of psychopathology in the family, psychoeducation). The measures of central tendency and dispersion were described to the quantitative variables (age of the responsible family member and score in the reading the mind in the eyes test). The Shapiro-Wilks test is used for the RMET variable. To test the hypothesis, the description of the mean score of the result corresponding to the RMET was used, then one-factor analysis of variance (ANOVA) was performed to verify statistical significance. Student’s t-test was also performed to verify the significance of the mean difference of the variable having received psychoeducation. The accepted statistical significance was p<0.05.

3. Ethical considerations

This project was in accordance with the General Health Law on health research in force. It was considered a low-risk investigation in accordance with Article 17 of the Law. The project was approved by the Research and Research Ethics Committees, registration 1031-2024. All participants signed informed consent.

4. Results

A total of 45 first-degree relatives of patients diagnosed with schizophrenia participated in the study, of which 40% were men and 60% women. Mean age 43 years (min-max 19-70). The most prevalent occupation was employees (42%). The most frequent marital status was married (53%). 40% had high school education.

Relatives, most of them siblings (37.7%); parents (33.3%) and son (n=13, 28.8%). 95.5% reported a family history of psychopathology distributed as follows: depression (48.8%), anxiety (20%) were the most frequent. On the other hand, the history of having received some type of psychoeducation related to schizophrenia was found in only 42.2% of the relatives evaluated. Table 1. The sex of patients receiving care in the hospital was mostly male (n=28, 62.2%).

The sample had a mean of 22.2 (standard deviation 4.6) in the RMET with normal distribution (Shapiro Wilks 0.968, p=0.613). The results of the RMET show differences in the means of the three groups, the siblings had a higher mean score of 23.12 (SD 4.4) with no significant differences between the groups in the F test (F= 0.621; p=0.542). Table 2

In relation to socioeconomic status, the score was lower in those with low socioeconomic status 21.25 (SD 3.786) with significant differences in the F test (F=10, 160; p=0.0001), the post hoc test showed significant differences in the three groups, but greater between socioeconomic level and the other groups (p=0.000). Relatives with more education had rated as normal in the reading the mind in the eyes test, in this case the F test almost reached statistical significance (F=3.002; p=0.060). Table 3

Those who received or did not receive psychoeducation had a very similar mean score with no statistically significant difference in the student t-test (p>0.05).

5. Discussion

The main result of this study is that first-degree relatives of patients with schizophrenia rated borderline ability to identify emotional states, this result is consistent with what has been reported in the international literature.^14,15,22

Family members with limited mentalization abilities may have difficulty tuning into their patients’ evolving mental states.²³ This can potentially alter the formation of secure attachments between members of a nuclear family, affecting the patient’s emotional regulation and exacerbating the challenges associated with psychosis. Difficulties in mentalization skills have been identified as having an impact on the course and severity of other psychiatric disorders, such as those related to eating behaviour.²⁴

The theory of mind skills of family members is important in providing cognitive and emotional support to a patient going through the complexities related to a primary psychotic disorder such as schizophrenia. Those family members who can perceive and respond expertly and assertively to their patients’ mental states have a positive impact on the ability to make sense of their own experiences and emotions.²⁵

Another of the most representative findings was in relation to the psychoeducation experience of family members. According to the results obtained, the information about the condition that can be provided to caregivers does not seem to influence the understanding of the mental and emotional states of others. This element of the analysis could be related to other variables such as experiences during upbringing that consolidate cognitive skills such as theory of mind, as well as opportunities in the sense of education, access to basic services and health.

The variations in the cognitive functioning of first-degree relatives of patients diagnosed with primary psychosis suggest the presence of a variety of factors, among which environmental and sociocultural factors can be highlighted, in addition to those linked to the genetic inheritance received by people, which could play a determining role in changes related to the ability to understand and interpret the mental and emotional states of others.²⁶

Attachment patterns and mentalization skills can be passed down from generation to generation.²⁷ Parents who had secure attachments in their own childhood are more likely to provide a secure foundation for their children, encouraging the development of mentalization, as well as, contrary to experiences of insecure attachment.

For socioeconomic status, the most important difference was found in the score, with those people with a high level having score rated as normal, compared to those with a medium or low level who obtained qualified scores within the borderline or high low. Access to social assistance and rehabilitation services at this same level is of utmost importance to promote a greater understanding of psychopathology, associated symptoms, and the non-pharmacological measures that can be implemented to manage them.^28,29

The intersection of the capacity for theory of mind and the experience of family members with a patient suffering from schizophrenia represents a critical and underexplored domain in psychiatry and neuroscience. The cognitive and emotional processes involved in theory of mind are closely related to the development of secure relationships between family members,³⁰ and it is essential to understand the implications of effective family mentalization in the context of schizophrenia.

Finally, the difficulties associated with the ability to theory of mind can add to the intergenerational transmission of mental health problems. Patients who are members of families who thrive in environments where caregivers struggle to mentalize themselves may face an increased risk of psychopathology at any time in life, while perpetuating a cycle of vulnerability.³¹

The neurobiological underpinnings of theory of mind and its implications in the context of schizophrenia remain fully understood. Exploring the neural, functional and experiential correlates of mentalization capacity in relatives of patients with schizophrenia can provide valuable information on the mechanisms related to the interpretation of mental and emotional states and that their alterations could favour the development of psychopathology in susceptible individuals.

This study has some limitations, mainly that the sample was small, perhaps a larger sample would have shown differences in terms of schooling, another is that there was no control group of subjects without a family history of mental illness.

6. Conclusions

The timely approach to patients and relatives with a syndrome of high clinical risk for psychosis is decisive, given the high prevalence of medical and psychiatric comorbidities and complications at the cognitive and social level, so strategies aimed at patients’ relatives are transcendental. Working on cognitive functions with borderline or low functioning, such as the ability to empathize or theory of mind, makes it possible to sensitize the members of the patients’ support network to identify, firstly, their own mental and emotional states so that, secondly, they can implement it on others.

The lack of understanding related to mentalization phenomena can generate marked difficulties in understanding the subjective experiences immersed in the onset of psychosis. In the same way, this lack of knowledge can inadvertently favor stigmatization, feelings of isolation and a sense of misunderstanding, accentuating the psychosocial challenges faced by both the patient and their family.

Funding

This work did not receive funding

Conflict of interest

We declare no conflict of interest.