Introduction. Delusional disorders are characterised by monothematic, "encapsulated" and incorrigible false beliefs and misinterpretations of social signals. Due to the rarity of cases with "pure" delusional disorder (DD) in clinical settings most studies of social cognition in delusional patients have focused on patients with paranoid schizophrenia. In the present study we sought to examine emotion recognition, theory of mind abilities, and pragmatic language comprehension in patients with delusional disorder. Methods. Social cognition was assessed in 21 patients recruited over a 3-year period who were diagnosed with delusional disorder, paranoid, erotomanic, or jealous type. In addition to an emotion recognition and theory of mind test battery, we included a novel German Proverb Test, which has been found indicative of subtle theory of mind deficits in schizophrenic patients. Executive functioning was assessed using the Wisconsin Card Sorting Test (WCST). Psychopathology was measured using the Positive and Negative Symptoms Scale (PANSS). Patients' task performance was compared to a group of 22 healthy control persons paralleled for verbal intelligence, education, and age. Results. Patients with DD made significantly more perseverative errors in the WCST, they performed more poorly on the theory of mind tasks and the proverb test, but were unimpaired in basic emotion recognition abilities relative to controls. When executive functioning was co-varied out, the group differences in theory of mind disappeared, whereas the greater propensity of patients with DD to interpret proverbs literally remained significant. Conclusions. In "pure" DD the basic social cognitive abilities appear to be preserved. Difficulties in metaphorical speech comprehension and executive functioning could, however, indicate more subtle social cognitive deficits in these patients.
Previous research has demonstrated that patients with Delusional Disorder are impaired in executive functioning that affects performance on social cognitive tasks. In patients with Parkinson's disease, poor executive control induces an increase in "Machiavellianism," a term that refers to opportunistic behaviors that aim at exploiting and manipulating others. Accordingly, the association between Machiavellianism in Delusional Disorder and executive functioning deficits was examined. Machiavellianism and executive functioning were measured in 22 patients with Delusional Disorder and compared with a group of 22 healthy controls matched for sex, (premorbid) intelligence, and education. Patients and controls did not differ regarding Machiavellianism scores, education level, or intelligence. However, patients with Delusional Disorder performed more poorly on an executive functioning task. Impaired executive functioning was associated with greater Machiavellianism, particularly cynical views on human nature, but not with intelligence or illness duration. Similar to findings in patients with Parkinson's disease, Machiavellianism in Delusional Disorder was associated with poorer executive functioning. This finding indicates that frontal lobe dysfunction may influence interpersonal attitudes and personality in Delusional Disorder.
Our results do not support either a cognitive deficit in patients with delusional disorders or a characteristic attributional style. In terms of treatment recommendations, a thorough diagnosis of comorbid depressive disorders in patients with delusional disorders is warranted.
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