Theory of mind skill predicts anticipatory guilt-proneness in schizophrenia

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. We compared 24 SZ with 24 HC on anticipatory guilt, (TOSCA-3, GASP); consequential guilt (PFQ-2), and empathy and Theory of Mind (ToM). 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. 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.