Evaluation of theory of mind skills in patients with obsessive-compulsive disorder with or without autism features

Aim: The concept of the social brain encompasses complex neurocognitive processes that enable individuals to interpret and regulate social interactions, and it has gained increasing attention in psychiatric literature over the past quarter century. Theory of Mind (ToM) studies, which fall under the umbrella of the social brain, have provided new perspectives for understanding the etiopathogenesis and treatment approaches of neurobiologically based psychopathologies such as schizophrenia and autism. However, ToM has been relatively understudied in Obsessive-Compulsive Disorder (OCD)—a severe disorder characterized by complex neurobiology, impaired insight, and social dysfunction, and which can co-occur with various psychopathologies. In the literature, ToM is considered one of the key theoretical frameworks for explaining the social communication and interaction difficulties observed in individuals on the autism spectrum. In clinical presentations where autism spectrum traits co-occur with OCD, examining potential differences in ToM abilities may contribute not only to a better understanding of social cognitive processes but also to the personalization of both psychotherapy and pharmacotherapy interventions in OCD. Accordingly, this study aims to compare the ToM skills of OCD patients with and without autism spectrum traits in order to explore potential differences in social cognition. Method: A total of 48 patients diagnosed with OCD according to DSM-5 diagnostic criteria were included in the study. Based on their scores on the Autism Spectrum Assessment (OSA), 24 patients scoring above 26 and 24 patients scoring below 26 were categorized into two clinical groups. Additionally, 24 healthy volunteers were included as a control group. Participants were administered the Dokuz Eylul Theory of Mind Scale and the Double Bluff Task to assess cognitive ToM, and the Reading the Mind in the Eyes Test (RMET) to assess affective ToM. Neuropsychological evaluation included the Digit Span and Visual Reproduction subtests from the WMS-R, the Stroop Test, and the Verbal Categorical Fluency Test. The Y-BOCS, OBQ-44, BDI, and BAI were used to assess clinical variables in the patient groups. All participants were also evaluated using the SCID-5/CV for DSM-5 diagnoses. Results: The results revealed that OCD patients with autism spectrum traits scored significantly lower in cognitive ToM tasks compared to both OCD patients without such traits and healthy controls. No significant impairments were observed in affective ToM. ToM performance in the OCD groups was not associated with obsessive-compulsive symptom severity or the level of obsessive beliefs. However, longer illness duration negatively affected ToM abilities. Across all participants, women performed better in affective ToM tasks than men. Both cognitive and affective ToM abilities were found to decline with increasing age. Furthermore, higher OSA scores were correlated with lower ToM performance. Notably, difficulties in communication and imagination were specifically associated with poorer cognitive ToM skills. Conclusion: This study demonstrates that impairments in Theory of Mind (ToM) abilities in individuals with OCD are largely influenced by co-occurring autism spectrum traits. The finding that ToM impairments in OCD are more strongly related to autism-related characteristics and cognitive functions, rather than to symptom clusters or illness severity, may represent an important point that underscores the significance of accompanying autism traits in the ToM phenomenology of these disorders. Keywords: Theory of Mind, Autism Spectrum Traits, Obsessive-Compulsive Disorder, Social Brain, Cognitive and Affective Theory of Mind