Theory of mind skill predicts anticipatory guilt-proneness in schizophrenia

Background and Hypothesis: Adaptive management of guilt and shame is regulated by social approach and withdrawal and thus relates to the quantity and quality of our social interactions. People with schizophrenia (SZ) self-report reduced guilt-proneness compared to healthy controls (HC). However, previous studies have not distinguished between anticipatory and consequential guilt, nor between guilty affect and associated action tendencies. Study Design: We compared 24 SZ with 24 HC on anticipatory guilt, (TOSCA-3, GASP); consequential guilt (PFQ-2), and empathy and Theory of Mind (ToM). Study Results: Differing profiles emerged: SZ reported higher consequential relative to anticipatory guilt, while HC reported the opposite pattern. SZ self-reported reduced repair and increased withdrawal compared to HC. In SZ, anticipatory guilt was predicted by empathic concern and ToM; consequential guilt by social withdrawal and ToM skill. Conclusion: SZ participants anticipated equal affective guilt-proneness but reduced adaptive behavioural responses to guilty feelings, resulting in more chronic guilt in daily life than would be predicted by TOSCA-3 and GASP responses. The discrepancy between emotional experience and expression may partly explain previous findings of reduced TOSCA-3 guilt-proneness, as TOSCA-3 operationalises guilt as reparative, prosocial behaviours. Results highlight perceptions of reparation potential as an intervention target, with likely downstream reductions in chronic and delusional guilt and shame.