Abstract / Summary
Background Theory of mind (ToM) impairments are a core feature of schizophrenia and are strongly associated with functional outcomes. However, ToM is often treated as a unitary construct, potentially obscuring distinct patterns of mentalizing errors. This study examined whether age is differentially associated with hyper- and hypo-mentalizing in schizophrenia. Methods ToM was assessed in 177 individuals with schizophrenia and 142 healthy controls using the Movie for the Assessment of Social Cognition (MASC). Generalized linear models examined age, diagnosis, and their interaction on total ToM errors, hyper-mentalizing, hypo-mentalizing, and the hypo–hyper error ratio. Schizophrenia-only models adjusted for sex, verbal IQ, positive and negative symptoms, illness duration, and medication use. A sensitivity analysis in 156 individuals with schizophrenia with available verbal-memory data additionally adjusted for verbal memory. Results In case-control analyses, older age was associated with greater total ToM and hypo-mentalizing errors, with a stronger age–hypo-mentalizing association in schizophrenia. In schizophrenia-only analyses, age was associated with greater total ToM errors, hypo-mentalizing, and a higher hypo–hyper error ratio. Hyper-mentalizing was associated with positive symptoms and verbal IQ, but not age. In the sensitivity analysis, age remained significantly associated only with hypo-mentalizing; hyper-mentalizing remained associated with positive symptoms. No robust nonlinear age effects were observed. Conclusions Cross-sectional age differences in schizophrenia are characterized by a selective association between older age and hypo-mentalizing, whereas hyper-mentalizing shows a distinct pattern of cognitive and symptom-related correlates. These findings suggest that age is differentially associated with mentalizing error types in schizophrenia, with a selective association with hypo-mentalizing.