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Bosco, F. M. Parola, A. (2017) ‘Schizophrenia’, in L. Cummings (ed.), Research in

Clini-cal Pragmatics, Series: Perspectives in Pragmatics, Philosophy & Psychology, Vol. 11,

Cham, Switzerland: Springer-Verlag.

ISBN: 978-3-319-47487-8 (hardcover); 978-3-319-47489-2 (eBook)

Schizophrenia. (Chapter 12, Research in Clinical Pragmatics, edited by Louise

Cummings, Springer). Available from:



Francesca M. Bosco

Department of Psychology, University of Turin

Via Po 14

10126 Turin


Chapter 12 Schizophrenia

Francesca M. Bosco and Alberto Parola University and Polytechnic of Turin, Italy


Patients with schizophrenia exhibit a range of pragmatic difficulties which compromise communicative interaction. The aim of this chapter is to provide an overview of these difficulties and to analyze whether impairments of cognitive factors such as theory of mind (ToM), executive functions and intelligence quotient (IQ) could be helpful in explaining them. First, we provide an overview of the communicative-pragmatic difficulties observed in schizophrenia. We describe how impairment of ToM has been proposed to explain schizophrenic pathology, and the role that such a deficit could play in explaining these patients’ pragmatic difficulties. We then describe executive function deficits in schizophrenia and the relationship between these deficits and pragmatic impairments. We consider studies that have examined the interplay between ToM, executive function and other cognitive abilities such as IQ. Finally, we summarize the empirical evidence presented, concluding that the role of ToM in explaining patients’ difficulty in comprehending certain pragmatic phenomena still persists when the role of IQ and executive functioning is controlled. However, neither an impairment of ToM nor an impairment of executive function or IQ seems to be able to systematically explain the pragmatic difficulties of patients with schizophrenia. We suggest that other cognitive factors, such as inferential ability. could be considered in future research.

Keywords: communication disorder; executive functioning; mindreading; pragmatics; schizophrenia; theory of mind


12.1 Introduction

Schizophrenia is a disorder characterized by the impairment of several cognitive domains, such as thought, perception, language and emotion, in addition to the presence of motor disorders. The distinctive symptoms of the disorder range from deliria, hallucinations and affectivity problems to catatonic and disorganized behaviour (American Psychiatric Association 2013). Since the first description of the disorder by Bleuler (1911) and Kraepelin (1919), many different aspects of schizophrenia have been investigated. In this section, the epidemiology and aetiology of schizophrenia are described. In section 12.2, the attempts of various authors to characterize the linguistic impairments of schizophrenia are examined. One group of impairments in particular, pragmatic impairments, are the focus of this chapter and will be described in detail in section 12.3. Increasingly, investigators are relating deficits in the pragmatics of language to cognitive deficits in theory of mind and executive functions. Aside from specific cognitive deficits, there has been an attempt to relate pragmatic impairments to generalized cognitive impairments such as reduced IQ. These various cognitive deficits, and their relationship to pragmatic impairments, will be examined in sections 12.4, 12.5 and 12.6. Finally, the main points raised in the chapter will be summarized in section 12.7.

Epidemiological findings indicate that schizophrenia is a widespread disorder that occurs in several societies across different countries. A meta-analysis by McGrath et al. (2008) estimated a median incidence rate of 15.2 per 100,000/year. The distribution of incidence differs between 1) males and females, with a male to female index ratio of 1.4, 2) migrants and native-born individuals, with a migrant to native-born index ratio of 4.6, and 3) urban setting and rural-urban settings, with an estimated median rate of 19 vs. 13.3 per 100,000/year. Economic status does not seem to affect incidence estimates. As far as prevalence rates are concerned, the estimated median point prevalence and life time morbid risk are respectively 4.6 and 7.2 per 1,000 individuals. The distribution of prevalence does not show any significant difference between males and females, or between rural, urban or mixed contexts. Prevalence has instead been found to be affected by ethnicity, with a migrants to native-born ratio of 1.8, and by socio-economic status, with developed country median estimates of 3.3 per 1,000 versus less-developed country median estimates of 2.6 per 1,000. The onset of schizophrenia is generally in late adolescence and early adulthood, with differences between genders. Men typically develop the disease between the ages of 18 and 25, while women show a later onset placed between the ages of 25 and 35. Women also show a


two-peak distribution of onset, with a first two-peak after the menarche and a second (lower) two-peak after the 40s (Ochoa et al., 2012).

The exact etiology of the disease is still unclear, but recent research suggests that a combination of genetic, neurobiological and environmental risk factors can contribute to the onset of the disorder. The role of genetic factors has been supported by twin and family studies that indicated a high rate of heritability in individuals who share a common genetic pool (e.g. Cannon et al., 1998; Sullivan et al., 2003). Chromosomal abnormalities have been reported in schizophrenia, however no studies have established a stable association between specific risk genes and the expression of the disorder. Environmental risk factors include both psychosocial and biological events (Tandon et al., 2008). Maternal exposure to virus and malnutrition during the antenatal period, as well as obstetric and perinatal complications have been reported among the biological events associated with schizophrenia (Maki et al. 2005); an association between paternal age at conception and an increased risk of schizophrenia has also been found (Whol & Gorwood, 2007). Psychosocial risk factors include childhood trauma, parental separation or death, urbanicity during childhood, cannabis use during adolescence and migration. However, the exact role of each of these factors and their association with schizophrenia remain unclear. Future directions point to identifying how genetic, neurobiological and psychosocial factors might interact in causing schizophrenia.

12.2 Language impairment in schizophrenia

From phonology to pragmatics and discourse, authors have described the poor performance of adults with schizophrenia in different aspects of language production and comprehension (Rieber and Vetter 1994; Stassen et al. 1995). The term ‘schizophasia’ (or ‘word salad’) has been coined to describe a range of language impairments in patients with schizophrenia such as the use of confused utterances, clanging, i.e. the association of words with similar sounds, and the creation of bizarre neologisms (Lecours and Vanier-Clément 1976). In particular, in a review of the literature Covington et al. (2005) reported that phonological aspects are generally preserved, and that patients with schizophrenia rarely exhibit deficits in producing speech sounds. The authors concluded that morphological impairments are also quite rare, and when present can result in the loss of the end part of the word, as in this example reported by Chaika (1990: 92): “I am being help with the food and the medicate...” .


One widely investigated issue is the extent to which linguistic structure, that is, syntax (Lelekov et al. 2000; Bagner et al. 2003; Tavano et al. 2008) and semantics (Goldberg et al. 1998; Rossell and David 2006), is impaired. Syntactic structure of schizophrenic speech was traditionally described as normal (Andreasen, 1979). However, more recently, some authors have reported that the syntactic structure of speech acts of patients with schizophrenia may be more simplified than those of healthy controls (DeLisi 2001) and that semantic anomalies may also occur, for example on naming tasks, disorganized semantic storage and priming abnormalities (e.g. Rossell and David 2006; Barrera et al. 2005). A recent study by Moro et al. (2015) specifically focused on syntax and semantics in schizophrenia, showing that in patients with schizophrenia only the ability to identify syntactic anomalies (e.g. ‘Chi gli scrivi prima di incontrare/Who do you write to him before meeting’) is impaired. By contrast, the authors did not find a similar impairment in the detection of semantic anomalies (e.g. ‘Asciugherò il bucato con l'acqua/I'll dry the laundry with water’). The authors concluded that the semantic difficulty ascribed to patients with schizophrenia could be due to high-level semantic or discursive and pragmatic impairment.

Even when syntactic and semantic aspects of language are not specifically compromised, patients with schizophrenia may show pervasive difficulties at the pragmatic level of language. Andreasen et al. (1985) compared syntactic, semantic and discursive aspects of schizophrenic patients’ language and showed that these individuals only exhibited poor performance at a discursive level, whereas syntax and semantics were intact. Based on a review of research into language in schizophrenia, Frith and Allen (1988) also observed that when patients’ syntactic and semantic abilities are intact, they nonetheless show deficits in the more complex use of language. It is to an examination of these pragmatic impairments that we now turn.

12.3 Pragmatics in schizophrenia

In recent years, pragmatic aspects of language have been extensively studied in individuals with schizophrenia (Cummings 2009). Studies have examined receptive and expressive aspects of pragmatics in linguistic, extralinguistic and paralinguistic modalities. Meilijson et al. (2004) examined the communicative abilities of patients by testing linguistic, non-verbal and paralinguistic aspects of conversation. The results showed that these person exhibited inappropriate communicative abilities in using all expressive means compared with participants with mixed anxiety-depression disorder and participants with hemispheric brain damage. Using the Profile of


Functional Impairment in Communication (Linscott et al. 1996), Linscott (2005) also pointed out that patients with schizophrenia demonstrate a higher index of pragmatic impairment compared with healthy controls. Bazin et al. (2005) used the Schizophrenia Communication Disorders Scale to study patients with schizophrenia. This scale takes the form of a structured interview that consists of items relating to the patient’s difficulties in the integration of contextual information and in attributing mental states to the minds of others. It assesses a patient’s ability to manage conversation on everyday subjects such as family, professional activities, hobbies and so on. Bazin et al. found that individuals with schizophrenia performed worse on this scale than people affected by mania or depression.

Several studies in the literature have found that patients with schizophrenia perform worse than healthy controls in the comprehension of those speech acts in which the literal meaning does not correspond to the intended meaning, such as indirect speech acts (Corcoran et al. 1995; Corcoran 2003) irony and figurative language such as metaphors and idioms (Langdon et al. 2002; Tavano et al. 2008; Schettino et al. 2010). In a recent study Haas et al. (2015) evaluated pragmatic abilities of person with schizophrenia, both in comprehension and production. Production ability was evaluated through the analysis of semi-structured interviews that were audio-recorded and transcribed by the examiner. The authors analyzed different aspects of the sample discourses, such as the use of connectors and total number of words. Comprehension ability was evaluated using the Barth and Kufferle (2001) proverb test, which requires the subject to interpret the meaning of a proverb (“When the cat’s away, the mice will play”) choosing from among four alternatives provided by the examiner. Patients showed difficulties in production, producing fewer connectors and fewer total words than control subjects. They also exhibited deficits in the comprehension of proverbs, obtaining a lower score compared to controls in the proverb test. The authors also found a correlation between comprehension and production deficits, that in their view reinforced the idea of a common underlying pragmatic impairment. Patients with schizophrenia have also been shown to have difficulties in deceit comprehension (Frith and Corcoran 1996), narrative aspects (Marini et al. 2008), recognition and recovery of communicative failures (Bosco et al. 2012b) and recognition of violation of Grice’s maxims (Mazza et al. 2008). For example, Tenyi et al. (2002) showed that patients produced more errors, compared to healthy controls, in recognizing the implicit meaning of vignettes in which an actor voluntary violates the Gricean maxim of relevance


to implicate a negative hidden opinion, e.g. “A professor is asked an opinion about his junior lecturer. He says: ‘She is a female”.

Recognition of prosodic cues and facial expressions, vital components of successful communication between speakers and hearers, has also frequently been reported as impaired in patients with schizophrenia. Ross et al. (2001) examined chronic patients with a battery evaluating different prosodic aspects, such as the repetition of words and syllables expressing a certain emotion, and the recognition of affective auditory prosodic stimuli. The majority of patients exhibited deficits both in recognition and expression of affective-prosodic elements. Leitman et al. (2005) administered two tests to evaluate affective prosody in patients, i.e. a voice emotion identification and a voice emotion discrimination test, and two face emotion processing tests, i.e. a face emotion identification and a face emotion discrimination test. The results showed clearly that the ability to recognize emotional contents of vocal-auditory stimuli is severely impaired in schizophrenia, and that these impairments are related to sensory processing dysfunction in the auditory system. In addition, the authors found that individuals with schizophrenia also had difficulty in recognizing and discriminating facial emotions. Indeed alongside prosodic deficits, there is evidence of impaired recognition of facial expressions in adults with schizophrenia. Sachs et al. (2004) investigated facial recognition in individuals with schizophrenia using a computerized battery evaluating different aspects of emotion recognition, such as differentiation between emotional facial expressions, memory for emotional facial expressions and rating of emotion valence of facial expressions. Individuals with schizophrenia performed poorly, compared to healthy controls, in all emotion recognition tasks, and these deficits correlated with other cognitive deficits and negative symptoms. A meta-analysis by Kohler et al. (2009) confirmed the extent of the impairment in facial emotion perception by individuals with schizophrenia compared to healthy controls. Deficits of these functions thus constitute an integral part of schizophrenic pathology (Stein 1993; Stassen 1991; Stassen et al. 1995; for a review, see Edwards et al. 2002).

Overall, the clinical literature has principally focused on language and overlooks the possibility of using other expressive modalities – such as the extralinguistic one – to convey meaning in a given context. Furthermore, since studies in the pragmatic domain typically focus on one or two pragmatic phenomena at a time – usually only in comprehension or production – it is difficult to compare the results obtained by different experimental designs. To overcome these limitations,


Colle et al. (2013) used the Assessment Battery for Communication (ABaCo; Sacco et al. 2008; Angeleri et al. 2012; Bosco et al. 2012a) to investigate the ability of patients with schizophrenia to comprehend and produce different pragmatic phenomena. These phenomena included direct and indirect communicative acts, deceit and irony, and used different expressive means such as linguistic, extralinguistic and paralinguistic modalities.

The results showed that participants with schizophrenia performed significantly worse than a healthy population, based on the normative values of the ABaCo (Angeleri et al. 2012), on all the evaluation scales—linguistic, extralinguistic, paralinguistic, contextual and conversational—for both comprehension and production tasks. Comparing some of the pragmatic phenomena investigated, the authors detected a similar pattern of increasing difficulty on the linguistic and extralinguistic scales. Specifically, the comprehension and production of direct and indirect communication acts were the easiest tasks while the comprehension and production of deceit and irony were the most difficult tasks to complete. The authors explained this pattern of increasing difficulty in terms of demands on one’s inferential ability. Pragmatic phenomena which require more inferences to be drawn in order to fill the gap between the literal and intended meaning of an utterance were more difficult for the subjects with schizophrenia to both comprehend and produce (see also Bara 2010; Bosco et al. 2015).

There was considerable variation in the responses of patients with schizophrenia to tasks on the ABaCo. Some responses were unfocused and bizarre. Other responses revealed partial comprehension of the expressive (i.e. literal) meaning of an utterance or amounted to a not completely correct production of a specific communicative act. What follows are some examples of the responses of patients with schizophrenia to some of the tasks on the linguistic comprehension scale of the ABaCo. The tasks involve the comprehension of a specific communicative act undertaken as part of a short video-recorded communicative interaction. These examples are provided in order to illustrate the possible pragmatic difficulties of adults with schizophrenia. In each example, the experimental question posed to the participants was: ‘What did the actor mean to say to the partner?’.

Indirect (non-conventional) communication acts:


yesterday evening?”

The boy answers: “I had a very high fever!”

An example of the replies is: “I don’t know if he was trying to tell her that he was tidying the closet”.

In this case the patient failed to make the correct inference (i.e. if a person has a high fever he is not able to go jogging) that would have allowed her to understand that the boy is answering that he did not go jogging. She tried to link the utterance to the (communicatively irrelevant) behavior played out by the actor.


A girl and a boy are sitting at a table in a classroom, studying. The girl gets up and leaves the room. The boy accidentally spills some coffee on the sheets of paper on the table. The girl comes back and asks “Who spilt coffee on my notes?”

The boy answers: “I’ve no idea.”

What did the boy want to say to the girl? Why did he answer like that?

An example of the replies is: “He can’t say anything, because she knows it was him.”

In this case the patient failed to understand that the utterance was false and was performed in order to deceive the partner. The patient failed to realize that the girl did not know that it was the boy who split the coffee.


In a store, a girl is trying on a dress that is obviously too tight for her. She asks the boy who is with her “How does it look?”

The boy answers: “It’s a bit big.” An example of the replies is: “He’s stating a fact, he’s serious”

In this case the patient’s comprehension is limited to the literal aspect of the communicative act, and he fails to understand that it overtly contrasts with the fact that the dress is obviously too tight for the girl and that the utterance was intended to be ironic.

The literature discussed above provides convincing evidence that patients with schizophrenia often suffer from communicative-pragmatic difficulties. In the last decade, there has been growing


interest in determining whether such difficulties might be due to an underlying cognitive deficit in theory of mind and executive functions, or whether they might arise as a consequence of reduced IQ in patients in comparison with healthy participants. The next section will begin to focus on these issues.

12.4 Theory of mind in schizophrenia

12.4.1 Theory of mind deficits in schizophrenia

Theory of Mind (ToM) refers to the ability to attribute mental states such as beliefs, desires and emotions to one’s own mind and to the minds of others in order to predict behaviour (Premack and Woodruff 1978). Frith (1992) was the first author to propose that a deficit in the ability to infer mental states (i.e. ToM) was able to explain the cognitive and behavioural abnormalities observed in schizophrenic pathology. In particular, he proposed that an impairment of ToM is responsible both for positive symptoms (i.e. delusions, hallucinations and disordered thoughts and speech) and negative symptoms (i.e. catatonic behaviour, poverty of speech and action, flattening of affect and social withdrawal) exhibited by patients with schizophrenia. In the following years, several studies confirmed Frith’s hypothesis by demonstrating the presence of ToM impairment in schizophrenic individuals (Corcoran et al. 1995; Frith and Corcoran 1996; Corcoran et al., 1997; Mazza et al. 2001; Sarfati and Hardy-Baylé 1999; Brüne 2005b; Bosco et al. 2009c). Frith and Corcoran (1996) evaluated ToM in patients with schizophrenia using false belief and deception stories. These stories were accompanied by cartoon figures in order to reduce the memory and verbal requirements of the task. Compared with healthy controls and non-psychotic psychiatric patients, patients with schizophrenia exhibited severe impairment of the ability to infer other people’s mental states and intentions.

A review by Harrington et al. (2005) of studies that compared the performance of schizophrenic individuals and healthy controls in ToM tasks found that in almost all of the studies individuals with schizophrenia obtained significantly worse scores than healthy participants in at least one of the ToM tests administered. Brüne (2005a) reviewed evidence of ToM impairment in schizophrenia. He concluded that ToM deficits are a specific deficit in schizophrenia and should not be considered to be the consequence of general cognitive impairment, i.e. reduced IQ. Indeed, even in studies in which IQ, attention and memory have been controlled for, the difference between patients with schizophrenia and controls in ToM tasks has remained significant (Mo et al. 2008; Brüne 2005b).


In a meta-analysis, Sprong et al. (2007) examined studies of patients with schizophrenia with the aim of quantitatively summarizing findings about the relationship between ToM and schizophrenia. The results indicated that the average performance of patients with schizophrenia on ToM tasks is more than one standard deviation below that of controls, and that this result is not affected by demographical factors such as educational level, gender and age. A more recent meta-analysis was carried out by Bora et al. (2009), who adopted more rigid inclusion criteria, excluding, for example, those studies that used overlapping samples. The results confirmed the extent of ToM deficits in schizophrenia, with a large effect-size characterizing the ToM impairment. However, the deficit was less severe than that suggested by the previous meta-analysis of Sprong et al. (2007). The result also confirmed that ToM impairment is widespread in schizophrenia, and that is not only a consequence of symptomatology or medication, but also affects patients in remission.

12.4.2 Theory of mind and communicative-pragmatic ability in schizophrenia

Frith (1992) systematically explained communicative-pragmatic disorders in schizophrenia in terms of ToM deficits. This author proposed that some individuals with schizophrenia are not able to take the mental states of the listener into account correctly when they communicate, and that this deficit makes schizophrenic discourse unintelligible and obscure. In detail, Frith hypothesized that (i) disorder of willed action was responsible for poverty of speech and perseverative and incoherent communicative behaviour; (ii) abnormalities of self-monitoring were responsible for deficits in planning a discourse, difficulties in recognizing and repairing communicative failure, and difficulties in selecting the relevant contextual factors and information; and (iii) abnormalities in

the awareness of others were responsible for deficits in comprehending non-literal and figurative

expressions, in comprehending conventional social norms of communication, and in the use of referential and cohesive devices within a discourse. Frith identified in ToM the cognitive mechanism allowing for the correct functioning of all these processes.

In the years following Frith’s early study, many investigations showed that ToM deficits co-occurred with pragmatic impairments in a variety of tasks. These tasks included the comprehension of non-literal and figurative forms of language such as indirect requests and hints, metaphor, proverbs and irony (Corcoran et al. 1995; Langdon et al. 2002; Brüne and Bodenstein 2005; Mo et al. 2008; Champagne-Lavau and Stip, 2010; Gavilán and García-Albea 2011), the recognition of the violation


of Gricean maxims and social norms of communication (Corcoran and Frith 1996; Mazza et al. 2008), the use of cohesive devices and referential markers during conversation (Abu-Akel 1999; Champagne-Lavau et al. 2009), and recognition and recovery of communicative failure (Bosco et al. 2012b).

However, it should be noted that in several studies ToM has been assessed through the comprehension of pragmatic expressions such as indirect speech acts and irony. Accordingly, it has not been possible to establish a direct correlation between pragmatic ability and ToM deficits, since from a theoretical perspective and from the point of view of methodological procedure the two tasks have been collapsed into one. For example, Corcoran et al. (1995) used a hinting task, which requires patients to recognize an indirect speech act uttered by one of the protagonists at the end of a story (e.g. “Look, those sweets look very good” to say “Please mom, buy me those sweets”). The task was specifically devised for schizophrenic patients in order to reduce memory use and verbal loading. The results confirmed that the patients were impaired in recognizing the intention behind indirect speech acts compared with normal subjects and a psychiatric control group. The authors suggested that such a deficit testified to the presence of ToM impairment.

A subsequent study by Corcoran and Frith (1996) evaluated the appreciation of the Gricean maxims of quantity, quality and relation in patients with schizophrenia. The task consisted of a number of stories in which participants had to decide the most likely option between two alternatives, one adhering to the maxim and one in conflict with the maxim. Patients with schizophrenia were shown to be severely impaired in this task. Unlike controls, they were not able to recognize the correct ending of the story. Once again, the authors suggested that this deficit indicated the presence of an impairment of ToM. Champagne-Lavau et al. (2009) evaluated the ability to use referential markers during a conversation with a partner in patients with schizophrenia and healthy controls. The task required patients to describe some figures to a partner who was separated by an opaque screen. The speaker’s ability to provide correct information to his partner as well as the appropriate use of referential markers were evaluated. The authors found that participants do not use referential markers in an appropriate way, and that they do not adequately mark the information they provide. These deficits, which were exhibited only by individuals with schizophrenia and not by healthy controls, were interpreted as being related to a ToM difficulty in correctly attributing mental states to their conversational partner.


Other studies have provided independent measures of ToM and pragmatic ability in order to evaluate an association between these two abilities using correlational analysis. Langdon et al. (2002) investigated the relation between ToM and comprehension of metaphor and irony in individuals with schizophrenia. The authors used a false belief picture-sequencing task to evaluate ToM, and a story-comprehension task to evaluate irony and metaphor comprehension. Two types of ironic statement were used, i.e. banter (“Are you trying to ruin my day?”) and sarcasm (“That was clever”). Two types of metaphorical statement were also investigated, i.e. nominal metaphors (“This job is a jail”) and figurative expressions (“You have got too many balls in the air”). The results showed that patients achieved lower scores than controls for all the pragmatic phenomena investigated, and that they also produced significantly more errors than controls on the false belief tasks. Logistic regression analysis showed that patients’ performance in the ToM task predicted irony comprehension scores but not metaphor comprehension scores. In line with what Happé (1993) proposed and observed in autistic children, the authors claimed that metaphor comprehension does not involve ToM abilities whereas irony does.

Mazza et al. (2008) replicated the results of Langdon et al. (2002). They found a correlation between ToM and irony comprehension in schizophrenic patients, and concluded that an impairment of ToM can be considered to be the cause of the patients’ poor performance in the irony comprehension task. By contrast, Mo et al. (2008) evaluated ToM using false belief tasks. A story comprehension task was used to assess the comprehension of metaphorical (“You are a ship without a captain!”) and ironical (“You really are so good at making decisions!”) statements. The results showed that patients have difficulties in terms of both ToM and the comprehension of irony and metaphor. The authors also found a correlation between metaphor comprehension and ToM performance, while previous studies did not (Mazza et al. 2008; Langdon et al. 2002). In line with Mo et al., Brüne and Bodenstein (2005) also found that ToM performance predicts a significant amount of variance in the ability of patients with schizophrenia to comprehend proverbs.

When compared with healthy controls, Bosco et al. (2012b) found that patients with schizophrenia exhibited ToM deficits and difficulty in recognizing and recovering different kinds of communicative failures. These failures were (i) failure of the literal meaning of an utterance, (ii) failure of the speakers’ intended meaning, and (iii) failure of the communicative effect, that is, the unsuccessful


attempt to convince someone to do something. Furthermore, patients showed an increasing trend of difficulty both in recognizing and recovering these kinds of failures. The authors found a correlation between the patients’ ToM deficit and their difficulty in recognizing and recovering each kind of communicative failure investigated. However, there was no evidence that ToM was the factor that best explained the increasing trend of difficulty shown by patients in recognizing and recovering the communicative failures. The authors suggested that the increasing inferential demands underlying the different tasks provided a better explanation of the observed phenomenon.

In line with Frith (1992), Abu-Akel (1999) proposed a distinction between diminished use of ToM, or ‘undermentalizing’, and the hypertrophic use of ToM, or ‘overmentalizing’, arguing that this distinction plays an important role in explaining the communicative-pragmatic difficulties of individuals with schizophrenia. In the author’s view, schizophrenic patients in whom positive symptoms are predominant are characterized ‘as having representational understanding of mind but over-attributing mental states or over-generating hypotheses about mental life’ (Abu-Akel and Bailey 2000: 737). The author analyzed the conversations of patients with schizophrenia, reporting repeated failure in the use of bridging references, rapid shifting in the topic, and an inability to recognize or repair communicative failures, as if patients were not able to understand what information the listener needs. There follows an example from Abu-Akel (1999: 266-267) of an interview with a patient. It shows the disruptive use of unclear references:

Interviewer: Why? What happened to the family? (long pause) You said that you have brothers and

sisters, what else?

Patient: Eh (…) I know (…) one day I’m going to escape. I know that they all have problems, yes,

everybody has problems, that’s why I don’t love them. Do you understand?

The patient has not clarified in the previous part of text to whom the pronouns they and them (in bold) refer. The referents of these pronouns are not clear because they do not refer to information previously shared by the speakers, but only to the patient’s own private world.

An fMRI study by Brunet et al. (2003) showed that patients with schizophrenia display hypoactivation of cerebral networks which are normally active in healthy controls during a


non-verbal ToM task of intention attribution. In another fMRI study, Walter et al. (2009) showed that schizophrenic patients, like healthy controls, exhibit activation of a mentalizing network during the recognition of communicative intentions and during the perception of physical causality when the recruitment of the mentalizing network is not requested. A more recent study by Montag et al. (2011) investigated ToM deficits in schizophrenia using the Movie for Assessment of Social Cognition (MASC). This instrument distinguishes between ToM errors which are due to ‘undermentalizing’ and those which are related to ‘hypermentalizing’. The results demonstrated a correlation between positive symptoms and overmentalizing scores, while undermentalizing errors occurred more frequently in patients with negative symptoms. These data support the hypothesis that there is abnormal activity of part of the cerebral network underlying ToM. This includes the prefrontal cortex and the posterior orbital cortex.

Even if ToM impairment in patients with schizophrenia is well documented and seems to play an important role in explaining pragmatic deficits in schizophrenia, some authors have proposed that ToM deficits could more properly be referred to as a primary deficit of another cognitive component. That component is executive functioning (Thoma and Daum 2006, Thoma et al. 2009; Sponheim et al. 2003; Mossaheb et al. 2014). We will address this issue in the next section.

12.5 Executive functions in schizophrenia

12.5.1 Executive function deficits in schizophrenia

Some authors have argued that executive function deficits should be considered the core cognitive impairment of patients with schizophrenia, and that such deficits are primary to other cognitive impairments (Weickert et al. 2000; see also Reichenberg and Harvey 2007). Executive function refers to a set of complex abilities generally associated with the activity of the frontal brain areas (Eisenberg and Berman 2010). These abilities allow people to perform goal-directed behaviour in a flexible and effective way by planning actions and decisions in a sequential and hierarchical order, monitoring and correcting performance during task execution, maintaining a goal over time, and adapting it to the specific request set by the surrounding context. In the last two decades, several models of executive function have been proposed, each of them identifying different subcomponents. Miyake et al. (2000) proposed a model with three executive sub-components, namely updating, i.e. the ability to manipulate information in working memory, shifting (i.e. the ability to shift attention between multiple tasks), and inhibition (i.e. the ability to suppress


automatic or pre-potent responses). Fisk and Sharp (2004) confirmed the validity of Miyake et al.’s model. However, they found an additional executive process corresponding to the efficiency of access to information in long-term memory. Other conceptualizations include executive functions beyond those mentioned above, such as cognitive flexibility (i.e. the ability to shift between thought or action according to the demands of the task at hand), planning (i.e. the ability to formulate, evaluate and select a sequence of thoughts and actions to achieve a desired goal), and working memory (i.e. the ability to temporarily store and manage the information required to perform cognitive tasks).

A large body of evidence has shown that all the above executive functions are severely impaired in schizophrenia (for a review, see Reichenberg and Harvey 2007; Orellana and Slachevsky 2013). However, even if there is consensus that executive function deficits exist in schizophrenia, some questions remain regarding the nature and extent of these deficits. An unresolved issue concerns the possibility that executive function impairment could in fact be the consequence of a global cognitive impairment (Dickinson et al. 2008). Schizophrenic patients generally exhibit an IQ which is significantly below the normal score (Fioravanti et al. 2012; Henry and Crawford 2005) as well as a wide range of other cognitive deficits affecting attentional processes (Dickinson et al. 2007b; Fioravanti et al. 2012), long-term memory (Aleman et al. 1999), processing speed (Henry and Crawford 2005) and visuo-spatial ability (Dickinson et al. 2007b). In order to address this issue, Reichenberg and Harvey (2007) performed a meta-analytical study. The results seem to suggest that executive function impairment is more severe than the impairment of other cognitive abilities, such as IQ, attention and long-term memory.

More recently, Raffard and Bayard (2012) evaluated four executive functions (updating, shifting, inhibition and divided attention) and premorbid IQ in patients with schizophrenia and schizoaffective disorders. They found that almost all patients exhibited an impairment of at least one of the four executive functions evaluated, and that general cognitive impairment and processing speed predicted nearly 50% of the variance in the executive function tasks. This result suggests that only some executive function deficits could be explained by a general cognitive impairment. The large amount of unexplained variance points to a distinctive and unique contribution of executive function processes.


Some studies have examined whether executive function could play a role in explaining ToM deficits in schizophrenia. Pickup (2008) reviewed studies that investigated both ToM and executive function deficits in schizophrenia. It was concluded that ToM deficits are not dependent on executive function. Pickup’s review found that patients with schizophrenia have impaired cognitive and mentalizing abilities, and that these abilities are often strongly correlated. However, it was also found that most of the studies confirmed the residual presence of ToM deficits, even after controlling for executive function.

12.5.2 Executive functions and pragmatic ability in schizophrenia

Communicative-pragmatic competence requires the complex interplay of different cognitive abilities. To communicate in an effective way, it is necessary to focus attention on linguistic and non-linguistic stimuli, shifting attention from one source to another in a rapid and flexible way. The speaker must also organize the contents of discourse in a logical and sequential order, plan discourse coherently and maintain the goal of discourse over time. The speaker should also tailor his or her behaviour, adapting it to the request and the response of the listener, monitoring and adjusting communicative performance constantly and dynamically. Finally, to comprehend figurative language, such as metaphors, proverbs and idioms, it is necessary to inhibit irrelevant information, and to use abstract thinking resources and cognitive flexibility in order to grasp the figurative aspects of the message. Executive function deficits can widely disrupt the ability to communicate in an effective way within a social context, contributing to the generation of pragmatic disorders.

The study of the cognitive underpinnings of pragmatic disorders in schizophrenia has substantially increased in the last two decades. Research has focused on the comprehension of figurative forms of language such as metaphor and proverbs. Sponheim et al. (2003) evaluated proverb comprehension in a sample of patients with schizophrenia. The aim was to determine the contribution of IQ, executive function and the severity of the patients’ symptomatology to proverb comprehension. Proverb interpretations were rated as abstract, concrete, literal or bizarre-idiosyncratic. The results showed that an abstract interpretation was associated with a higher IQ, suggesting a link between abstraction ability and general intelligence. Moreover, a poor concrete interpretation was related to a low IQ, but it was more strongly associated with executive functions (planning, set-shifting and working memory). This association was not found in the control group,


reinforcing the hypothesis that the tendency to provide a concrete interpretation can be a direct consequence of executive function impairment and frontal lobe dysfunction in schizophrenia.

In line with this study, Thoma et al. (2009) found severe proverb comprehension impairment in patients with schizophrenia compared with patients with alcohol dependence and healthy controls. The authors evaluated the role of IQ, executive function and symptomatology. The results showed that IQ had a modest role in proverb interpretation, while among the executive functions (working memory, divided attention, set-shifting and inhibitory control) only divided attention correlated with proverb recognition. No association between proverb comprehension and symptomatology was found. A recent study by Mossaheb et al. (2014) assessed metaphorical comprehension in patients with schizophrenia spectrum disorders using both conventional and non-conventional (novel) metaphors. The results showed that patients were impaired in all the tasks examined, and that this impairment was related to executive dysfunction. Cognitive flexibility predicted performance in the recognition of conventional metaphor, while vocabulary predicted performance in terms of novel metaphor comprehension.

Together, these studies suggest that executive function plays a role in the comprehension of figurative language and that this role is not accounted for by other cognitive factors such as IQ. However, it has not been possible to find a consistent pattern of association between the impairment of specific executive function processes (e.g. divided attention, set-shifting and cognitive flexibility) and the impairment of specific pragmatic phenomena such as metaphors or proverbs. The variability in the experimental results can be explained in part by the different tasks used to assess figurative language comprehension. Furthermore, a specific type of figurative language, for example metaphor, can vary widely with regard to aspects such as the degree of conventionality, familiarity, concreteness and meaningfulness (see Bambini et al. 2014). While Sponheim et al. (2003) paid attention to conventionality, other variables have not been controlled for in the above studies.

The majority of studies have focused on figurative language, with only a few studies examining the relation between executive functions and other communicative-pragmatic abilities (e.g. conversations and narratives). Dickinson et al. (2007a) used a series of role-playing scenarios in which participants had to interact with the experimenter in order to achieve a specific


communicative goal (e.g. an employer has to obtain a promotion). Conversational content, non-verbal content and global effectiveness were evaluated. The authors also evaluated IQ, non-verbal ability and executive function (working memory and cognitive flexibility), and assessed their relationship to conversational tasks. The results showed that all the cognitive measures accounted for approximately 50% of the variance of the conversational task. IQ, verbal ability and cognitive flexibility were associated with the conversational task, while no association with working memory was found.

Marini et al. (2008) examined narrative ability in a sample of individuals with schizophrenia, finding that narrative impairment was more severe at the macro-linguistic level, i.e. pragmatics, than at the micro-linguistic level, i.e. phonology, morphology and syntax. The authors also examined language, verbal memory and executive function (inhibition, cognitive flexibility and attentional shifting). The results showed that impairment at the macro-linguistic level can be explained in part by executive functions, in particular by attentional shifting and planning ability.

To this point in the discussion, we have addressed studies in the literature that have separately investigated the role that ToM and executive function might play in explaining the communicative-pragmatic difficulties of individuals with schizophrenia. In order to understand the interplay among these components, we will examine in the next section a number of studies which have investigated the combined role of ToM and executive function in explaining the communicative-pragmatic difficulties of adults with schizophrenia. We will also consider studies which have investigated the role played by IQ in explaining the communicative-pragmatic difficulties of these patients.

12.6 Cognitive impairment and pragmatic disorders

The idea that communicative-pragmatic disorders might originate from the interaction between different impaired cognitive abilities has received increasing support in recent years, and has been investigated in clinical populations such as patients with traumatic brain injury and right hemisphere brain damage (e.g. Martin and McDonald 2003). Some authors have attempted to explain pragmatic disorders in schizophrenia in terms of ToM and other cognitive processes, in particular executive functions. Other authors have tested the hypothesis that a generalized


cognitive impairment of, for example, IQ could be responsible for defective communicative-pragmatic performance.

Linscott (2005) examined the hypothesis that impaired pragmatic language comprehension in patients with schizophrenia could be caused by a generalized decline in cognitive function measured in terms of IQ. He found a strong correlation between low IQ and poor pragmatic comprehension, suggesting that pragmatic language impairment can be secondary to a generalized cognitive decline. However, only a limited number of studies have confirmed the validity of the association between a low IQ and poor pragmatic comprehension (Linscott 2005; Varga et al. 2014), while other studies have not reported any relation between IQ and pragmatic performance (Brune and Bodenstein 2005; Thoma et al. 2009). The specific role of IQ is thus unclear, with pragmatic impairments still evident even after controlling for general cognitive impairment.

For example, Gavilán and García-Albea (2011) examined linguistic (lexical and syntactic) comprehension and comprehension of figurative language such as metaphors (“It’s going to cost him an arm and a leg”), proverbs (“A bird in the hand is worth two in the bush”) and irony (“I think that you work too much” to say “you are not working at all”) alongside ToM in patients with schizophrenia. The authors used verbal and non-verbal tests and controlled for the role of IQ. It was found that patients performed worse than control subjects in all language comprehension and ToM tasks. Logistic regression showed that only metaphor and irony scores and ToM abilities (but not IQ) predicted membership of the schizophrenic group. Additional correlational analyses showed that ToM, independently of the nature (verbal vs. non-verbal) of the ToM test used, strongly correlated with the comprehension of each of the different types of phenomena investigated (metaphor, proverb and irony). The authors also found that this correlation is not affected by IQ. In particular, irony showed the highest correlation with the ToM tasks followed by proverbs and metaphors.

In addition to IQ, Brüne and Bodenstein (2005) investigated the role of ToM and executive functions (i.e. cognitive flexibility and planning ability) in comprehending proverbs in patients with schizophrenia. The authors found a correlation between proverb comprehension and all the cognitive abilities investigated (i.e. IQ, executive functions and ToM). Furthermore, a partial correlation showed that the relation between ToM and proverb comprehension still persisted after


controlling for IQ. By contrast, when the authors controlled for ToM, proverb comprehension no longer correlated with IQ, suggesting that IQ exerts a modest role in patients’ pragmatic difficulties. A regression analysis also showed that ToM was the best predictor of patients’ pragmatic performance, explaining a large amount of the variance in performance, while the only significant contribution of the executive functions was provided by cognitive flexibility, which explained a significant but limited part of the variance.

Mazza et al. (2008) investigated whether ToM deficits and pragmatic disorder are stable markers of pathology in schizophrenia, and whether they are independent of other cognitive measures such as IQ and executive function. The authors administered to patients with schizophrenia and to their relatives a pragmatic conversational maxims task, consisting of short conversational exchanges, at the end of which patients were asked to choose the most pertinent answer to a question. For example, possible answers in response to the question “How would you like your tea?” were (a) With milk and (b) In a cup. The authors also used a false belief task to evaluate ToM, and tested IQ level and executive functions (planning and cognitive flexibility). Schizophrenic patients and their relatives performed worse than control subjects in both the ToM and pragmatic tasks. These differences remained after controlling for IQ and executive functions. The relatives of the patients did not perform as poorly as the patients, but they occupied an intermediate position between the patients and the controls. Moreover, the authors found a correlation between ToM and the number of errors in the Gricean maxims tasks in individuals with schizophrenia and their relatives but not in the control group.

Finally, Champagne-Lavau and Stip (2010) examined in patients with schizophrenia the role of ToM and executive function (i.e. shifting, inhibitory control and cognitive flexibility) in the comprehension of different pragmatic phenomena. The phenomena investigated were indirect requests (e.g. “It’s cold here” to say “Close the window”), idiomatic metaphor (e.g. “This bus is a

turtle”) and non-idiomatic metaphor (e.g. “My friend has a heavy heart”). The authors reported a

correlation between pragmatic comprehension and cognitive flexibility and shifting, but not with inhibitory control. The analysis clearly showed that differences in the performance of pragmatic tasks between the patients and the control subjects still persisted after controlling for the role of executive function. By contrast, after controlling for ToM, differences remained only for the comprehension of non-idiomatic metaphor. The data suggested that only indirect speech acts and


idiomatic metaphor, but not non-idiomatic metaphor, were related to ToM. The authors concluded that only idiomatic metaphors involve ToM abilities while non-idiomatic metaphors involve different cognitive processes (see also Giora 2002; Bosco et al. 2009b, 2012c). In line with the results of Brüne and Bodenstein (2005), this study indicates that the comprehension of metaphor is related to ToM processes beyond the contribution of executive functions.

12.7 Summary

Communicative impairments have been considered a hallmark of schizophrenia since the earliest characterisation of the disorder (Bleuler 1911; Kraepelin 1919). Several studies have been conducted with the aim of identifying which specific aspects of language (e.g. syntax, semantics) are impaired in these patients. The most impaired communicative domain is pragmatics (Tényi et al. 2002; Bazin et al. 2005; Mazza et al. 2008; Schettino et al. 2010; Colle et al. 2013). Pragmatic impairment compromises a number of skills including the ability to understand figurative language and others forms of non-literal language as well as the ability to sustain a conversation in everyday situations.

In recent years, investigators have begun to study the cognitive processes that contribute to communicative-pragmatic disorders in schizophrenia. Frith (1992) was the first theorist to claim that communicative disorders in schizophrenia can be related to an inability to infer other people’s mental states, i.e. impaired ToM. Results of subsequent studies have confirmed that pragmatic and ToM deficits co-occur in individuals with schizophrenia, with several studies revealing a correlation between a deficit of ToM and poor pragmatic performance (Langdon et al. 2002; Brüne and Bodenstein 2005; Mazza et al. 2008; Champagne-Lavau & Stip 2010). Some studies have found that ToM is associated with the comprehension of irony but not with the comprehension of metaphors (Langdon et al. 2002; Mazza et al. 2008), while other studies have revealed the opposite pattern of results (Brüne and Bodenstein 2005; Mo et al. 2008). The available evidence does not allow us to draw definitive conclusions about the role of ToM in explaining specific pragmatic phenomena or the extent of this relationship. Most studies have provided only correlational analyses which do not permit us to draw a causal relation between these abilities. Moreover, studies that have used multivariate statistical analysis have shown that ToM only explains a limited amount of variance in pragmatic disorders.


Some authors have tried to identify other cognitive factors that are responsible for pragmatic deficits in patients with schizophrenia. Executive functioning has been identified as one of the most likely causes of pragmatic disorders. Studies that have examined the relationship between executive functions and pragmatic deficits have found that a deficit in executive functioning, in particular, cognitive flexibility, set-shifting and working memory, can play a role in the pragmatic comprehension of figurative expressions such as metaphor and irony. However, once again it has not possible to find a stable association across studies between specific executive function processes and pragmatic phenomena.

Considering that cognitive factors can reciprocally influence each other, some authors have examined concurrently the role of ToM, executive functions and general cognitive impairment in pragmatic deficits in schizophrenia. The contribution of IQ to these deficits is uncertain, with some studies showing a correlation between IQ and pragmatic abilities (Linscott 2005; Varga et al. 2014) while other studies do not find any such association (Brüne and Bodenstein 2005; Thoma et al. 2009). Studies that examined other cognitive functions in addition to IQ, such as ToM and executive function, found that the relation between pragmatic performance and these other functions still persisted even after controlling for IQ (Gavilán and García-Albea, 2011; Brüne and Bodenstein, 2005; mazza et al. 2008). It was concluded that IQ seems not to have a specific role in pragmatic comprehension.

Studies that have analysed the role of executive functions and ToM in pragmatic performance suggest that ToM plays the most important role in explaining pragmatic disorders. However, the nature and extent of the relation between ToM and pragmatic ability in schizophrenia is still not completely clear. Several studies have examined ToM using the comprehension of pragmatic phenomena such as indirect speech acts and irony or the appreciation of Gricean maxims (Frith and Corcoran 1996; Corcoran and Frith 1996). These studies conflate the theoretical concept of ToM with the notion of pragmatics and, as a result, use the same experimental tasks to measure both abilities. Even if ToM and pragmatic tasks do involve some common processes, these abilities cannot be considered equivalent (see Sperber and Wilson 2002; Tirassa et al. 2006; Tirassa and Bosco 2008; Bosco et al. 2009a). The heterogeneity of the experimental results concerning the role of cognitive abilities such as ToM, executive functions and IQ in pragmatic interpretation indicates


that other factors which have not yet been examined could help explain poor pragmatic performance in schizophrenia.

One possible factor to be investigated is inferential ability, a process which is considered central in pragmatics (Grice 1969; Searle 1969). Numerous studies have shown that patients with schizophrenia exhibit impairments in different types of inference, such as probabilistic inference, transitive inference and associative inference (Kruck et al. 2011; see also Cummings 2014). Although few attempts have been made to control the inferential processes involved in different kinds of pragmatic phenomena, such as indirect speech acts, irony, figurative language and so on, these could play a role in explaining the pragmatic difficulties exhibited by individuals with schizophrenia. More research is needed in order to clarify the relationship between communicative disorders and the ability to draw contextually relevant inferences in schizophrenia, as well as the relationship between inferential ability and other cognitive functions such as ToM and executive function.



Francesca M. Bosco is a psychologist and clinical psychotherapist. She has a PhD in Cognitive Science from the University of Turin. She is currently Associate Professor of Psychology of Communication at the Department of Psychology at the University of Turin, a member of the Center for Cognitive Science at the University and Polytechnic of Turin and a member of the Neuroscience Institute (NIT) of Turin. At the University of Turin she is also a member of the teaching council for the Doctorate in Neuroscience. Her studies are concerned with the development of pragmatic ability, its decay and rehabilitation in brain damaged and schizophrenic patients, the normal development of theory of mind and theory of mind deficits in patients with schizophrenia.

Alberto Parola received a degree in Psychology from the University of Turin in 2012. At present, he is a PhD student in neuroscience in the Department of Psychology of the University of Turin and a member of the Center for Cognitive Science, University of Turin. His current research interest is in the field of neuropragmatics and includes the study of cognitive process underlying linguistic and pragmatic impairment in psychiatric and neurological disease.


INDEX KEYWORDS cognitive pragmatics communicative impairment executive functioning figurative language inferential ability non-literal language pragmatic disorder schizophrenia theory of mind



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