Social cognition in schizophrenia: The role of mentalizing in moral dilemma decision-making

Background: Patients with schizophrenia have difficulties in several aspects of social cognition, e.g. emotion recognition and mentalizing. It is yet unclear if patients also show deficits in moral decision-making and whether the two aspects interact. Deficits in moral decision-making abilities might put patients in disadvantageous positions in every-day interactions. Method: Twenty-five patients with schizophrenia and twenty-five matched healthy controls participated in six moral dilemma tasks, a standard moral competency test and two mentalizing tasks. In addition, we assessed psychopathology and empathy abilities. In a brief intervention patients were asked to empathize with characters in the moral dilemmas. We expected that the decisions made by patients with schizophrenia would be more out-come-oriented, i.e. utilitarian, as compared to those made by healthy controls. Results: Patients and healthy controls did not decide significantly differently on the moral dilemmas and patients showed normal moral competencies. Deficits in mentalizing in patients were replicated. Only in a regression analysis, however, we were able to show that PANSS positive scores and the Comic Strip task scores contributed to the moral decisions. Empathy training did not have an altering influence on decision-making. Discussion: Although an overlap between social cognition and moral decision-making networks has been proposed, deficits in moral decision-making and explicit associations with mentalizing were not present in patients. Psychopathology together with mentalizing abilities, however, contributed to decision-making in patients. Our findings suggest that in schizophrenia some aspects, e.g. mentalizing, are more strongly impaired while other aspects, e.g. moral decision-making, are preserved. Further research is needed to elucidate the different aspects forming social cognition and their mutual contributions, specifically in schizophrenia.