(PS9-74) Therapeutic outcomes for psychotic symptoms are impacted by theory of mind at admission

Abstract Text: Title: Therapeutic outcomes for psychotic symptoms are impacted by theory of mind at admission

Authors: Lydia Dorr, Courtney Beard, Chloe C. Hudson


Background: Psychotic disorders are marked by difficulty inferring others' thoughts or emotions, a skill known as theory of mind (ToM). Although less pronounced, ToM deficits also occur in patients with other forms of mental illness that are not characterized by psychosis; however, these deficits grow more prominent in severe cases where subthreshold psychotic symptoms are often present. Proposed to be associated with greater social impairments and delusions, less accurate perspective taking may influence patients’ connection and trust with therapists. Consequently, ToM may influence the quality of therapeutic alliance and subsequently the efficacy of treatment. In the current study, we examine whether ToM impacts psychotic symptoms over the course of therapy among patients with severe psychopathology. We hypothesize that more frequent self-reported ToM at admission would be associated with a greater reduction in psychotic symptoms at discharge. As an exploratory analysis, we examined if this association varied based on primary diagnosis.


Methods: Participants were 520 patients (Mage = 35.4, 58% female, 81.5% White) enrolled in a two-week cognitive behavioral therapy-based partial hospitalization program. We assessed ToM using the Interpersonal Reactivity Index at admission. We evaluated psychotic symptoms using the Behaviour and Symptom Identification Scale at admission and discharge. Primary diagnosis was assigned by the program psychiatrist.


Results: We found a significant three-way interaction between ToM, diagnosis, and time predicting psychotic symptoms (β = .52, p = .001). Among patients with a psychotic diagnosis, the effect of time on psychotic symptoms depended on ToM (β = .35, p = .04). Contrary to hypotheses, less frequent perspective taking was associated with the largest reduction in psychotic symptoms (β = -.82, p < .001), relative to those with average (β = -.52, p < .001) or above average ToM (β = -.22, p = .26). Similarly, the effect of time on psychotic symptoms depended on ToM for patients without a primary psychotic disorder (β = .08, p = .04), such that less frequent perspective taking was associated with the best symptom outcomes (β = -.17, p < .001), relative to those with average (β = -.13, p < .001) or above average ToM (β = -.09, p < .001).

Discussion: Inconsistent with hypotheses, less frequent ToM at baseline was associated with the largest reduction in psychotic symptoms. More frequent ToM judgements may be iatrogenic in treatment by contributing to persecutory delusions or paranoia. Alternatively, because perspective-taking was associated with baseline psychotic symptoms (β = -.15, p = .001), participants who make less frequent ToM judgements had more psychotic symptoms to remediate. Nevertheless, these findings elucidate factors affecting clinical outcomes and can be used to inform future interventions.