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Theory of Mind in Individuals with Alzheimer-Type Dementia Profiles

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Theory of Mind in Individuals with Alzheimer-Type Dementia Profiles Florida State University Libraries Electronic Theses, Treatises and Dissertations The Graduate School 2004 Theory of Mind Performance of Individuals with Alzheimer-Type Dementia Profiles Gina L. Youmans Follow this and additional works at the FSU Digital Library. For more information, please contact [email protected] THE FLORIDA STATE UNIVERSITY COLLEGE OF COMMUNICATION THEORY OF MIND PERFORMANCE OF INDIVIDUALS WITH ALZHEIMER-TYPE DEMENTIA PROFILES By GINA L. YOUMANS A Dissertation submitted to the Department of Communication Disorders in partial fulfillment of the requirements for the degree of Doctor of Philosophy Degree Awarded: Summer Semester, 2004 Copyright © 2004 Gina L. Youmans All Rights Reserved The members of the Committee approve the dissertation of Gina L. Youmans defended on June 15, 2004. Michelle S. Bourgeois Professor Directing Dissertation Michael E. Rashotte Outside Committee Member Howard Goldstein Committee Member Leonard L. LaPointe Committee Member Approved: Howard Goldstein, Chair, Department of Communication Disorders John K. Mayo, Dean, College of Communication The Office of Graduate Studies has verified and approved the above named committee members. ii TABLE OF CONTENTS List of Tables …………………………………………………………………………… v Abstract ………………………………………………………………………....… vii 1. LITERATURE REVIEW …………………………………………………………… 1 Theory of Mind………………………………………………………………….. 1 Theories of Theory of Mind……………………………...……………………… 4 Theory of Mind Assessment………………………………………..…………… 8 Acquired Theory of Mind Impairment in Neurogenic Populations…...………… 12 Summary of Evidence for Theory of Mind Impairment………………………… 29 2. INTRODUCTION …………………………………………………………………… 37 Theory of Mind………………………………………………………………….. 37 Purpose……………………………………………...…………………………… 43 3. METHOD …………………………………………………………………………… 45 Participants …………………………………………………………………… 45 Design …………………………………………………………………………… 54 Experimental Stimuli …………………………………………………………… 54 Procedures …………………………………………………………………… 57 Data Coding and Scoring …………………………………………………… 59 Reliability …………………………………………………………………… 60 Data Analysis …………………………………………………………………… 62 4. RESULTS …………………………………………………………………………… 65 Theory of Mind Impairment in AD Participants………………………………… 65 Error Pattern Analysis for Theory of Mind Testing…...………………………… 67 Error Analysis of ToM Inconclusive Trials……………………………………… 73 Correlations Between Theory of Mind Scores and Neurocognitive Tests…….… 73 Case Summaries of Results for Individual AD Participants……………..…….… 77 5. DISCUSSION …………………………………………………………………… 82 Evidence of Theory of Mind Impairment in AD Participants…………………… 82 iii Effect of Memory Support on Theory of Mind Performance ……...…………… 83 Individual Case Analyses…………………………..…………………………… 86 ToM Inconclusive Trials…………………………...…………………………… 89 Coincidence of Cognitive Impairments with Theory of Mind Impairment…...… 89 Conclusions………………………………………...…………………………… 91 Study Limitations and Future Research……..……...…………………………… 92 APPENDIX A. Example Story and Scoring for Initial Reading Screening …………… 95 APPENDIX B. First Order False Belief Scenarios…….……………….……………… 99 APPENDIX C. Second Order False Belief Scenarios.……………….………………… 104 APPENDIX D. D. Scoring Protocols………………………..………………………… 111 APPENDIX E. Individual Case Data for AD Participants………………...…………… 114 APPENDIX F. Human Subjects Approval Letter…….………………………………… 156 APPENDIX G. Informed Consent Form……………………………………………….. 158 REFERENCES …………………………………………………………………… 164 BIOGRAPHICAL SKETCH …………………………………………………………… 172 iv LIST OF TABLES 1. AD Participant Characteristics, MMSE Scores and RCF Profiling Scores ..… 50 2. AD Profiles on DRS-2 ……………………………………..…………………… 51 3. Control Group Demographics and Cognitive Test Scores ..………………… 53 4. Inter-rater Reliability for Theory of Mind and Neurocognitive Tests ......……… 63 5. First Order, Second Order, and Combined ToM Trial Scores ……………….… 66 6. Number of ToM Pass, Impairment and Inconclusive Trial Scores ………..… 67 7. Frequency of Referral to Story Text During Supported Condition ….…….… 69 8. Group Total Error Scores, and Group Question-type Specific Error Scores …. 70 9. Individual Total Error Scores on Theory of Mind Testing .……………..…… 72 10. Correlations between ToM scores and neurocognitive test scores ………….. 74 11. Scores of AD participants on neurocognitive instruments ………….......…… 76 12. Scores of AD participants on test of executive functioning …………………... 77 13. Theory of Mind Test Results for AD Participant # 1 ………………...………… 116 14. Neurocognitive Test Scores for AS # 1 …………………………………..……… 117 15. Theory of Mind Test Results for AD Participant # 2 ………………………..… 120 16. Neurocognitive Test Scores for AS # 2 ……………………………………..…… 121 17. Theory of Mind Test Results for AD Participant # 3 ………………………..… 124 18. Neurocognitive Test Scores for AS # 3 ……………………………………..…… 125 19. Theory of Mind Test Results for AD Participant # 4 ………………………… 128 v 20. Neurocognitive Test Scores for AS # 4 ………………………………………..… 129 21. Theory of Mind Test Results for AD Participant # 5 ………………………..… 132 22. Neurocognitive Test Scores for AS # 5 …………………………………………… 133 23. Theory of Mind Test Results for AD Participant # 6 …………………………… 136 24. Neurocognitive Test Scores for AS # 6 …………………………………………… 137 25. Theory of Mind Test Results for AD Participant # 7 …………………………… 140 26. Neurocognitive Test Scores for AS # 7 …………………………………………… 141 27. Theory of Mind Test Results for AD Participant # 8 …………………………… 144 28. Neurocognitive Test Scores for AS # 8 …………………………………………… 145 29. Theory of Mind Test Results for AD Participant # 9 …………………………… 148 30. Neurocognitive Test Scores for AS # 9 …………………………………………… 149 31. Theory of Mind Test Results for AD Participant # 10 …………………………… 152 32. Neurocognitive Test Scores for AS # 10 …………………………………………… 153 vi ABSTRACT Theory of Mind (ToM) involves a person’s ability to infer what another person knows, thus taking his or her perspective. Initial evidence has been presented for a ToM impairment in individuals with mild to moderate Alzheimer’s disease (AD), however preliminary investigations have failed to dissociate theory of mind difficulty from impairments in general inferencing, executive functions, and working memory. Deficits in any of these areas could be sufficient to explain the apparent ToM impairment in the AD population. Ten participants with mild to moderate AD profiles completed first order and second order false belief tasks with and without memory support, and their performances on ToM testing were compared to the performances of elderly controls. All theory of mind testing was controlled with memory, comprehension, and general inferencing questions, and AD participants completed neuropsychological testing to concurrently assess general cognitive functioning, memory, and executive functioning. Independent and paired t-tests compared experimental and control group ToM performances. Correlations assessed relations between ToM and neurocognitve test performances. Descriptive statistics were calculated, and individual case analyses for performances of AD participants were presented. Results indicated that AD participants did not exhibit a specific ToM difficulty as compared to control participants when support for memory was not provided. However, significant group differences for specific ToM impairment that appeared to be separable from comprehension, memory and general inferencing difficulties emerged during ToM testing when support for memory was provided. On individual case analysis, eight of the ten AD participants exhibited a mild, specific ToM difficulty. Correlations between ToM performance and neurocognitive test performances were not significant; however four of the eight AD participants vii who exhibited specific, ToM difficulty also had difficulty with executive function testing. The results of the current study indicate that individuals with mild to moderate AD may possess an underlying, mild, specific ToM impairment which becomes apparent during supported memory testing. Such mild ToM impairment in high to moderate AD individuals must be further investigated, and possible contributions of executive function impairments to apparent ToM difficulty further explored before the current results can be confidently generalized to a larger AD population. viii CHAPTER 1 LITERATURE REVIEW Theory of Mind Theory of mind is the ability to represent mental states, such as beliefs, intentions and desires, and to use these abstract representations to guide and form one’s own actions and beliefs. Theory of mind allows one to attribute mental states to others: to understand that other people may hold and act upon beliefs different from one’s own. This appreciation of alternate perspectives is crucial for successful social interaction and communication. It underlies the ability to comprehend and predict the behavior of other people, and to interpret the actions of others as meaningful and intentional (Rowe, Bullock, Polkey, & Morris, 2001; Wellman & Wolley, 1990). The view of the human mind as an intentional agent that contains mental states such as beliefs and desires is not new. Such distinguished historical theorists as Descartes (1637), Freud (Brook, 1992), and Piaget (1945; 1962) have wrestled with the genesis and development of this distinction between the mental world of the self and the mental world of others. However, the conceptualization of this mentalizing ability as a specific skill, distinct from other cognitive functions, and the term “theory of mind”, have emerged relatively recently from the fields of philosophy (Dennet, 1978) and
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