Comprehension of insincere communication in
neurodegenerative disease: Lies, sarcasm, and theory of mind
Tal Shany-Ur, Pardis Poorzand, Scott N. Grossman, Matthew E. Growdon, Jung Y. Jang,
Robin S. Ketelle, Bruce L. Miller and Katherine P. Rankin*
Department of Neurology, University of California, San Francisco, USA
a r t i c l e i n f o
Received 9 March 2011
Reviewed 7 April 2011
Revised 16 July 2011
Accepted 12 August 2011
Action editor Jordan Grafman
Published online 1 September 2011
Theory of mind
a b s t r a c t
Comprehension of insincere communication is an important aspect of social cognition
requiring visual perspective taking, emotion reading, and understanding others’ thoughts,
opinions, and intentions. Someone who is lying intends to hide their insincerity from the
listener, while a sarcastic speaker wants the listener to recognize they are speaking
insincerely. We investigated whether face-to-face testing of comprehending insincere
communication would effectively discriminate among neurodegenerative disease patients
with different patterns of real-life social deficits. We examined ability to comprehend lies
and sarcasm from a third-person perspective, using contextual cues, in 102 patients with
one of four neurodegenerative diseases (behavioral variant frontotemporal dementia
[bvFTD], Alzheimer’s disease [AD], progressive supranuclear palsy [PSP], and vascular
cognitive impairment) and 77 healthy older adults (normal controls e NCs). Participants
answered questions about videos depicting social interactions involving deceptive,
sarcastic, or sincere speech using The Awareness of Social Inference Test. All subjects
equally understood sincere remarks, but bvFTD patients displayed impaired comprehen-
sion of lies and sarcasm compared with NCs. In other groups, impairment was not disease-
specific but was proportionate to general cognitive impairment. Analysis of the task
components revealed that only bvFTD patients were impaired on perspective taking and
emotion reading elements and that both bvFTD and PSP patients had impaired ability to
represent others’ opinions and intentions (i.e., theory of mind). Test performance corre-
lated with informants’ ratings of subjects’ empathy, perspective taking and neuropsychi-
atric symptoms in everyday life. Comprehending insincere communication is complex and
requires multiple cognitive and emotional processes vulnerable across neurodegenerative
diseases. However, bvFTD patients show uniquely focal and severe impairments at every
level of theory of mind and emotion reading, leading to an inability to identify obvious
examples of deception and sarcasm. This is consistent with studies suggesting this disease
targets a specific neural network necessary for perceiving social salience and predicting
negative social outcomes.
ª 2011 Elsevier Srl. All rights reserved.
* Corresponding author. Memory and Aging Center, Department of Neurology, University of California, 350 Parnassus Avenue, Suite 905,
San Francisco, CA 94143-1207, USA.
E-mail address: firstname.lastname@example.org (K.P. Rankin).
0010-9452/$ e see front matter ª 2011 Elsevier Srl. All rights reserved.
Available online at www.sciencedirect.com
Journal homepage: www.elsevier.com/locate/cortex
cortex 48 (2012) 1329e1341
Insincere speech is ubiquitous in everyday social interactions,
where people make jokes, speak sarcastically, intentionally
lie, or are honestly mistaken about reality (Harada et al., 2009).
The capacity to correctly interpret these forms of insincere
speech is an essential social skill, and inability to do so may
result in severely impaired communication (Winner et al.,
1998). Two common forms of insincere communication
occur when the literal content of a speaker’s message
contradicts with reality. A speaker who is lying wants to hide
their insincerity from the listener, while someone employing
sarcasmwantsthe listenerto recognize that they are speaking
insincerely. Detecting these insincere statements requires
interpretation of the speaker’s intention, a complex process
relying on integration of semantic and syntactic comprehen-
sion, contextual and paralinguistic information processing,
pragmatic knowledge, visual perspective taking, emotion
reading, and theory of mind (ToM; representing others’
beliefs, opinions and intentions).
A lie is a communicative act in which the speaker inten-
tionally withholds information from the listener in order to
cause the listener to either abandon a true belief or acquire
a false one (Chisholm and Feehan, 1977), and is often used to
protect oneself or others (Winner et al., 1998). Watching
a deceptive interaction may involve moral reasoning, since
lying violates the communication norm of truthfulness
(Harada et al., 2009). Although one may correctly identify a lie
based entirely on the fact that the truth is being withheld from
the listener, additional deliberation about the deceiver’s
intentions may require more complex emotion reading and
ToM processes. The neuroanatomic substrates of compre-
hending lies involve regions implicated with moral judgment,
including anteriortemporal and left inferiorfrontal gyrus(IFG)
regions (mediating semantic knowledge about social norms),
and rostromedial prefrontal cortex (rmPFC) (involved in
reasoning about the moral aspect of a deceptive act). Addi-
tionally, lie comprehension uniquely involves activity in
bilateral temporoparietal junction (TPJ), an area related to
perspective taking, right superior temporal sulcus (STS), and
left dorsolateral PFC, regions which may sub-serve the “ability
to detect an intent to deceive” (Harada et al., 2009). Patients
with right hemisphere lesions, especially in the medial
prefrontal cortex (MPFC), demonstrate poor ability to detect
lies, which has been attributed to impaired ToM (Stuss et al.,
2001; Winner et al., 1998).
Sarcasm is a social mechanism for indirectly conveying
criticism or covering up embarrassment in a dramatic or
humorous manner, and is perceived as less aggressive and
more polite than direct confrontation (McDonald, 1999;
Shamay-Tsoory et al., 2005; Winner et al., 1998). In both
lying and sarcasm the speaker says the opposite of what they
know to be true, and for both, comprehension requires using
contextual cues to make an accurate assessment of what the
speaker and listener think about the situation (i.e., a belief or
opinion). Both may also require additional ToM processing
and emotion reading to infer the speaker’s intention or
emotional state. However, unlike a lie, sarcasm is used to
emphasize reality rather than hide it, and the speaker is trying
to convey the truth to the listener (Channon et al., 2007; Grice,
1975). There is a unique set of paralinguistic cues in which
voice prosody and facial expression can be used to convey
sarcasm in the absence of contextual cues, however these are
not required for comprehension of sarcasm when sufficient
contextual cues are present (Channon et al., 2007; Grice, 1975;
Rockwell, 2007). The neuroanatomical substrates of sarcasm
comprehension include dorsal and ventral regions of the
MPFC including superior frontal gyri (SFG) as well as IFG (with
right IFG involved in representing the speaker’s intention and
integrating information about the speakers’ attitudes, inten-
tions and emotions and left IFG involved in integrating ToM
and language processing), the temporal poles (implicated in
social events-related knowledge and in empathy), posterior
parahippocampi (involved in assigning social salience to
auditory paralinguistic input), the STS (involved in ToM and
semantic processing) and the amygdala (related to perceiving
the implicitly conveyed feelings of the speaker) (Channon
et al., 2007; Kipps et al., 2009; McDonald and Pearce, 1996;
Rankin et al., 2009; Shamay-Tsoory et al., 2005; Uchiyama
et al., 2006, 2011).
Neurodegenerative diseases are often manifested by
a decline in social comprehension and behavior, especially
when they involve degeneration of frontal-insular, anterior
cingulate and anterior temporal regions underlying social-
cognitive processes. Individuals with the behavioral variant
of frontotemporal lobar degeneration (behavioral variant
frontotemporal dementia e bvFTD) present with a decline in
interpersonal behavior, impaired regulation of personal
conduct, emotional apathy, loss of insight (Neary et al., 1998),
and “lack of social awareness” (Miller et al., 2003). This disease
selectively targetsa networkof anteriorcingulate cortex (ACC)
and orbital fronto-insular regions involved in processing
emotional salience of stimuli (Seeley et al., 2007), and
considered to be part of the “social brain” network (Adolphs,
2010; Brothers, 1990). Correspondingly there is extensive
evidence that bvFTD patients perform poorly on tests of ToM,
(Adenzato et al., 2010; Kipps et al., 2009; Rosen et al., 2004;
Sturm et al., 2006; Zahn et al., 2009). Alzheimer’s disease
(AD), which initially targets posterior and medial temporal
regions, is associated with progressive cognitive deficits in
memory, language, perception, or attention, but not in socio-
emotional processes (McKhann et al., 1984; Seeley et al.,
preserved performance on tests of ToM, social comprehen-
sion, emotion reading and regulation, particularly when more
general effects of cognitive deficits are accounted for
(Goodkind et al., 2010; Lavenu et al., 1999; Rankin et al., 2009;
Zaitchik et al., 2004). Progressive supranuclear palsy (PSP) is
primarily a motor disorder, with characteristic subcortical
pathology resulting in a frontal-subcortical disconnection
syndrome (Litvan et al., 1996a). However, clinically this
disease often presents as a frontal dysexecutive disorder with
bvFTD-like behavioral and personality symptoms such as
social disinhibition and apathy (Donker Kaat et al., 2007;
Kertesz and McMonagle, 2010; Litvan et al., 1996b; Millar
et al., 2006). Vascular cognitive impairment (VCI) is charac-
terized primarily by impairment in attention and executive
with ADtypically have
cortex 48 (2012) 1329e1341
functioning in the context of vascular lacunes or periven-
tricular white matter disease, but may also include social
behavioral features including apathy, emotional lability and
social disinhibition (O’Brien et al., 2003).
Direct tests of social cognition are becoming increasingly
important for detecting and characterizing social cognition
deficits in patients with neurodegenerative disease. In
particular, tools now exist to measure comprehension of
insincere communication via face-to-face testing (McDonald
et al., 2003) and the few studies which examined this ability
in neurodegenerative diseases patients found it to be
compromised by frontotemporal lobar degeneration (Kipps
et al., 2009; Kosmidis et al., 2008; Rankin et al., 2009). Further
exploration of these findings may shed light on the social
mechanisms underlying these patients’ impaired social
comprehension and behavior, causing them for instance to
have a unique susceptibility to being cheated through scams
(McKhann et al., 2001). Thus, the goal of the current study was
to examine a large sample of patients with neurodegenerative
diseases in order to assess their ability to comprehend social
interactions involving lies or sarcasm using bedside cognitive
tests. We included patients with diseases known to cause
social behavior deficits (bvFTD, PSP, and VCI), as well as
a dementia control group with cognitive deficits but minimal
impairment in social behavior (AD), and a large sample of
healthy older adults. We evaluated the diagnostic specificity
of these tests and their relation to real-life social behavior.
We hypothesized that after controlling for general severity
of cognitive deficits, 1) patients with bvFTD would demon-
strate impairments at all levels of socio-emotional compre-
representation, and emotion reading (in accordance with
impaired comprehension of lies and sarcasm compared with
healthy older adults. 2) PSP and VCI patients, who have less
severe real-life social behavior deficits, would demonstrate
impairment only on the most complex social comprehension
tasks, including belief representation and comprehension of
lies and sarcasm. 3) AD patients would not demonstrate
significant deficits in comprehension of complex communi-
cation, and they were expected to perform normally on
realistic emotion reading tasks. 4) Subjects’ performance on
this face-to-face test would correlate with their real-life
empathic abilities and behavior.
One-hundred and seventy nine subjects participated in the
study, including 77 healthy normal controls (NCs) and 102
patients diagnosed with one of four neurodegenerative
diseases: 39 patients were diagnosed with bvFTD (Neary et al.,
1998), 32 patients met National Institute of Neurological and
Communicative Disorders and Stroke and the Alzheimer’s
Disease and Related Disorders Association (NINCDS-ADRDA)
criteria for typical AD (McKhann et al., 1984), 16 were diag-
nosed with PSP (Litvan et al., 1996a) and 15 had cognitive
impairment associated with cerebrovascular disease, with or
without dementia (VCI) (O’Brien et al., 2003). NC participants
were recruited through recruitment talks and advertisements
at the local community and media, and had to have an unre-
markable neurological exam and no functional or cognitive
indication of dementia to be considered a NC. Patients’ diag-
noses were determined by a multidisciplinary team of neurol-
ogists, neuropsychologists and nurses, following thorough
imaging assessments. Since the experimental tasks were
verbally loaded and required intact semantics, we excluded
patients who did not speak fluent English or who had primary
progressive aphasia with severe comprehension impairment.
amyotrophic lateral sclerosis, or AD mixed with Lewy body
large enough to enable inclusion in the statistical analysis.
Demographic characteristics of the study participants are pre-
completed several paper and pencil questionnaires about the
participant and will be described ahead. The study was
approved by the Committee on Human Research at the
University of California San Francisco (UCSF) and all partici-
pants and their informants gave their consent to participate.
Table 1 e Demographic characteristics of study groups, N [ 179.
n ¼ 39
n ¼ 32
n ¼ 16
n ¼ 15
n ¼ 77
CDR sum of boxes
MMSE (max ¼ 30)
GDS (max ¼ 30)
NPI total severity
c2¼ 7.25 (4,179)
Note:Post hoc pair-wise group differences were performed using a Dunnett post-hoc test. AD ¼ Alzheimer’s disease,bvFTD ¼ behavioral variant
frontotemporal dementia, CDR ¼ Clinical Dementia Rating Scale, GDS ¼ Geriatric Depression Scale, MMSE ¼ Mini-Mental State Examination,
NCs ¼ older normal controls, NPI ¼ Neuropsychiatric Inventory, PSP ¼ Progressive Supranuclear Palsy, VCI ¼ Vascular Cognitive Impairment.
a Group differs from NC group at p < .05 significance level.
cortex 48 (2012) 1329e1341
2.2. Social cognition tasks
The Social Inference-Enriched (SI-E) subtest of the TASIT
(McDonald et al., 2003) included 16 videotaped vignettes of
interpersonal interactions involving insincere speech. Half of
the videos depicted lies and the remaining videos depicted
sarcasm. Correspondingly, the speaker’s intention was to
either make the listener believe what he/she literally said or to
make the listener infer the opposite from it. Each video
included additional visual or verbal contextual information
(a physical object or a dialog), equally distributed, that helped
beliefs or opinions. When the contextual cue was a physical
object, the listener could not see the object of reference in the
deception conditions but could see the object in the sarcasm
conditions. Forinstance, inoneoftheliescenariosthespeaker
carries a plate filled with food, which the listener cannot see,
and when asked by the listener if their son had finished his
dinner, she replies “yes, he’s eaten his dinner alright. he
certainly listened to you”. Subjects were expected to infer that
since the listener could not see that the plate was still full, the
speaker intended to deceivethe listener. In one of the sarcasm
book the speaker replied “no, she didn’t write on it. you
certainly taught her a good lesson”. In this case, subjects were
expected to infer that since the listener saw the book to which
the speaker referred, the speaker’s intention was to make
a sarcastic remark. When the contextual cue was verbal, the
speakerexpressedhis/her true opinion through a precedingor
antecedent dialog which the listener did not hear. When
speaking to the listener, the speaker sounded sincere in the
deception condition, but was using paralinguistic cues to
convey their sarcasm in the sarcasm condition.
After viewing each video, subjects answered four yeseno
questions about the speaker’s intention (“do”), what they
intended the listener to comprehend from their speech
emotional state (“feel”). Each probe question was scored as
correct or incorrect (1/0) yielding a maximal score of 32 for the
eight lie items and 32 for the eight sarcasm items.
Subjects additionally viewed five videos depicting sincere
social interactions, in which the speaker meant what he/she
literally said, with no intention to be deceptive or sarcastic.
These were administered as part of the Social Inference-
Minimal (SI-M) subtest of the TASIT. Each video was fol-
lowed by the same probe questions described above, yielding
a maximal score of 20 for the five sincere (control) items.
The Awareness of Social Inference Test (TASIT)
belief (“think”)and their
To assess cognitive ToM/perspective taking ability, subjects
viewed eight short videos that involved change of an object’s
location, in accordance with existing false belief paradigms
depicted two characters in a room, both of them aware of an
object’s location. When one character left the room the
remainingcharactermovedtheobject to anewlocation.Infour
object was moved,and thus had a false beliefabout its location.
UCSF cognitive Theory of mind test (UCSF cToM)
the other character’s belief. In the remaining four videos the
thus had a true belief about its location. The character that
remained in the room did not see that the other character saw
character’s belief. A narrator explicitly described what was
occurring in the movies, thus the information was presented
both visually and verbally. Each scenario was followed by one
control question (“where is the object now”?) and two ToM
questions verifying belief representation/perspective taking
that X thinks the object is”?). Each question was scored as
correct orincorrect (1/0),yielding amaximalscore of16forToM
items and 8 for control items.
In an abbreviated form of the TASIT EET (McDonald et al.,
2003) participants viewed 14 videos of actors depicting an
emotion in a dynamic realistic way, and were asked to choose
the emotion displayed by the actor (happiness, surprise,
anger, sadness, fear, disgust or neutral).
The emotion evaluation test (EET)
Two subtests of the CATS (Froming et al., 2006) were admin-
istered. In the Name Emotional Prosody test participants
listened to sentences with an emotionally-neutral meaning,
and were required to choose the correct emotional voice
prosody that the speaker used (happy, sad, angry, frightened
or neutral). In the Affect Matching test participants were
asked to determine which of five characters who displayed
different emotions was showing the same emotion as that of
a target character.
The comprehensive affect testing system (CATS)
We analyzed group differences on the following social-
cognitive components (all based on scores derived from the
social cognition tasks described above): Control tasks verifying
fulfillment of basic task requirements (UCSF cToM control items;
TASIT SI-M sincere items); Visual perspective taking (UCSFcToM
PT items; TASIT SI-E “think” probe questions across visual cue
items, measuring representation of others’ beliefs about
objects); Theory of Mind (TASIT SI-E “think” probe questions
across verbal cue items, measuring representation of others’
all items, measuring representationofthespeaker’s intention);
Emotion reading (TASIT EET; TASIT SI-E “feel” probe questions
across all items; CATS Name Emotional Prosody and Affect
Matching); Comprehension of insincere communication (TASIT SI-E
lie and sarcasm total scores; total scores for each probe ques-
tion across all lie items and for each probe question across all
Social-cognitive components summary
2.3. Neuropsychological tests
Participants were administered a neuropsychological battery,
described elsewhere (Kramer et al., 2003), assessing various
aspects of their cognition, including general mental status,
memory, language, visuospatial, and executive functioning
abilities. Tests included the Mini Mental State Examination
cortex 48 (2012) 1329e1341
(MMSE), California Verbal Learning Test (patients were admin-
and delayed recall, Fluency (semantic, category and design),
test, abbreviated Trail making test (numbers and days of the
week), abstract reasoning (including three similarity items and
three proverbs), and the Geriatric Depression Scale (GDS).
The IRI (Davis, 1980) is a 28-item questionnaire that includes
four 7-item subscales assessing different aspects of empathy.
Informants were asked to rate how well each of 28 statements
reflected the current behavior of the study participant on
a scale of 1 (does not describe at all) to 5 (describes very well),
thus the total score for each subscale ranged from 7 to 35. We
analyzed the perspective taking (PT) and empathic concern
(EC) subscales, which are most related to real-life social func-
tioning (Davis, 1983). The PT scale measures the ability to
is likely to try to understand others better by imagining how
tendency to be emotionally affected and concerned about
advantage of, they feel kind of protective towards them”).
Interpersonal reactivity index (IRI)
The NPI (Cummings et al., 1994) assesses the presence and
severity of ten behavioral disturbances that occur among
patients with dementia. We analyzed the existence and
severity of disinhibition, euphoria, apathy, agitation, depres-
sion, anxiety, and irritability.
If a certain behavior was present, the item score ranged
from1 (leastsevere)to3 (mostsevere).A scoreof0was givenif
the behavior did not exist.
Neuropsychiatric inventory (NPI)
2.5. Data analytic approach
All dependent measures underwent regression diagnostics to
identify inappropriately influential data points, as well as to
examinethe normality, heteroscedasticity,
collinearity of residuals. Group differences on potentially
confounding covariates were analyzed using a general linear
model (SAS PROC GLM) (Table 1). Age, sex, and education were
included as standard confounds. MMSE was also used as
a proxy for disease severity to equalize this clinical factor
across patients in all analyses. Clinical differences in task
performance across diagnostic groups in each subscale were
investigated using glms controlling for age, sex, education and
MMSE, with DunnetteHsu post-hoc tests comparing each
diagnostic group to the NC group (Table 2).
To evaluate the degree to which patients were actually
impaired on each component of social cognition after
factoring out elements relating to their other cognitive defi-
cits, an additional set of analyses was performed examining
the five main ToM components controlling for age, sex,
education, MMSE, and performance on control tasks. The
UCSF cToM task was examined controlling for performance
on the matched control items for that task. The remaining
four SI-E tasks were analyzed controlling for subject perfor-
mance on the SI-M sincere subtest (Table 3).
Continuous dependent variables were examined using kernel
density plots of residuals and were found to have normal
mildly left-skewed distributions. Based on the medium to large
effect sizes seen in the analyses (partial eta-square range for
diagnostic group: .10e.33), the analyses were found to be
adequately powered to detect group differences even in the
smaller groups (Cohen and Cohen, 1983). The results are pre-
sented in Table 2.
3.1. Social cognition tasks
There were no significant group differences on the UCSF ToM
control items score, indicating that all subjects were equally
able to track the location of physical objects.
There were no significant group differences on the SI-M
Sincere score, indicating that all subjects equally understood
literal, truthful remarks.
Comprehension of control tasks
There were significant group differences on both measures of
visual perspective taking. Patients with bvFTD ( p ¼ .009) and
AD ( p ¼ .033) had significantly poorer scores than NCs on the
UCSF cToM PT items. When controlling for their performance
on the control items, the ADs’ performance was not signifi-
cantly impaired, indicating that only bvFTD patients had an
actual ToM deficit on this task. Patients with bvFTD had
significantly poorer scores than NCs on the TASIT SI-E “think”
questions across visual cue items ( p < .001), further indicating
their impaired ability to represent others’ perspective about
physical objects (whether they saw them or not).
Partial correlations (controlling for age, sex, education, and
MMSE) indicated that cToM PT score was significantly related
to SI-E lie score, r ¼ .32, p < .001, but not to SI-E sarcasm score
(though a non-partial correlation between these variables was
highly significant). SI-E “think” probe score across visual cue
items was significantly related to both lie, r ¼ .46, p < .001, and
sarcasm, r ¼ .45, p < .001.
Visual Perspective Taking
There were significant group differences on both ToM
measures. Patients with bvFTD ( p < .001) and with PSP
( p ¼ .007) had significantly poorer scores than NCs on the
TASIT SI-E “think” questions across verbal cue items, indi-
cating impaired ability to represent others’ verbalized opin-
ions/beliefs. Also, patients with bvFTD ( p < .001) and with PSP
( p ¼ .015) had significantly poorer scores than NCs on the
TASIT SI-E “do” questions across all items, indicating impaired
ability to comprehend others’ intentions. A follow up analysis
looking at responses to the “do” items on visual versus verbal
items indicated that PSP patients were only impaired at com-
prehending the speaker’s intention on the verbal cue items
( p ¼ .034) but not on the more explicit visual cue items. bvFTD
patients, however, were equally impaired on both conditions.
Theory of mind
cortex 48 (2012) 1329e1341
Partial correlations indicated that SI-E “think” probe score
across verbal cue items was significantly related to both lie,
r ¼ .51, p < .001, and sarcasm, r ¼ .46, p < .001, total scores. SI-E
“do” probe score was significantly related to both lie, r ¼ .48,
p < .001, and sarcasm, r ¼ .78, p < .001, total scores as well.
There were significant group differences on all measures of
emotion reading: TASIT EET, SI-E “feel” questions across all
items, CATS emotion prosody and affect matching tests.
bvFTD patients had significantly poorer scores than NCs on all
Table 2 e Social cognition tasks performance across groups (N [ 179).
n ¼ 39
n ¼ 32
n ¼ 16
n ¼ 15
n ¼ 77
F (df )p-value Effect size
UCSF cToM: control items (max ¼ 8)
SI-M: sincere (max ¼ 20)
Visual PT tasks
UCSF cToM: PT items (max ¼ 16)
SI-E: “think” score across visual
cue items (max ¼ 8)
SI-E: “think” score across verbal
cue items (max ¼ 8)
SI-E: “do” score across all items
(max ¼ 16)
Emotion reading tasks
EET: emotion recognition (max ¼ 14)
SI-E: “feel” score across all items
(max ¼ 16)
CATS emotion prosody (Z-score)
CATS affect matching (Z-score)
Comprehension of insincere communication: TASIT SI-E
SI-E lie “think” score (max ¼ 8)
SI-E lie “say” score (max ¼ 8)
SI-E lie “do” score (max ¼ 8)
SI-E lie “feel” score (max ¼ 8)
SI-E lie total score (max ¼ 32)
SI-E sarcasm “think” score (max ¼ 8)
SI-E sarcasm “say” score (max ¼ 8)
SI-E sarcasm “do” score (max ¼ 8)
SI-E sarcasm “feel” score (max ¼ 8)
SI-E sarcasm total score (max ¼ 32)
6.4 (1)6 (1)a
6.7 (1.4) 7.3 (0.8) 14.84 (8,178)
11.9 (2.2)11.3 (2.4)a
12.1 (2.8) 13.7 (1.8)18.55 (8,178)
18.04 (8, 174)
Note: F-statistic and p-values are for overall diagnostic group differences controlling for age, sex, education and MMSE score. Post hoc pair-wise
group differences were performed comparing each patient group’s least squares mean with the NC mean using a DunnetteHsu test. DX ¼
diagnostic group, EET ¼ TASIT emotion evaluation test, SI-M ¼ TASIT Social Inference-Minimal test, SI-E ¼ TASIT Social Inference-Enriched test.
a Group differs from NC group at p < .05 significance level.
b Group differs from NC group at p < .001 significance level.
Table 3 e ToM components and diagnostic groups’ impairment information.
Level Other’s thought
ConstructTest score Impaired groups,
when controlling for
other cognitive deficits
Visual PT (explicit) UCSF cToM: PT items bvFTD
2 Visual PT (implicit)SI-E: “think” score across
visual cue items
SI-E: “think” score across
verbal cue items
SI-E: “do” score across
SI-E “feel” score across
3Explicitly verbalized ToMbvFTD; PSP
4 Mental intention Implicitly presented ToMbvFTD; PSPa
5Emotion Implicitly presentedEmotion readingbvFTD
Note: Group impairment was determined using GLM controlling for age, sex, education, MMSE, and the control task score (UCSF cToM PT score
controlling for UCSF cToM control score, SI-E scores controlling for SI-M sincere score), with DunnetteHsu post-hoc tests.
a PSP patients were only marginally impaired in inferring the mental intention on verbal cue items ( p ¼ .072) but not on visual cue items (ns).
cortex 48 (2012) 1329e1341
tests ( p’s < .001). PSP and VCI patients had significantly poorer
scores than NCs on the CATS emotion prosody task ( p < .001
and p ¼ .019, respectively). Patients with PSP as well as those
with AD had significantly poorer scores than NCs on the CATS
affect matching task ( p < .001 and p ¼ .049, respectively).
Partial correlations indicated that EET score was signifi-
cantly related to both lie, r ¼ .47, p < .001, and sarcasm, r ¼ .47,
p < .001, total scores. CATS emotion prosody score was related
to both lie, r ¼ .28, p < .001, and sarcasm, r ¼ .45, p < .001, and
so was CATS affect matching (r ¼ .38, p < .001 and r ¼ .32,
p < .001, respectively).
There were significant group differences on all SI-E scores,
excluding the “feel” probe question score across lie items.
Patients with bvFTD were significantly impaired on all
measures of insincere communication comprehension (over-
all lie and sarcasm task scores, as well as each of the probe
questions) compared with NCs (all p’s < .001, except p < .05 on
“feel” probe questions across lie items). PSP patients per-
formed significantly poorer than NCs on their overall lie task
score ( p ¼ .026) and on “think” probe questions across lie
items ( p ¼ .030). However, when controlling for their perfor-
mance on the sincere task, their lie comprehension score was
no longer significantly impaired.
Table 3 summarizes the performance of patients with
different neurodegenerative diseases on the various ToM
componentsexaminedin the study(when controlling fortheir
performance on the control tasks).
Comprehension of insincere communication
sensitivity characteristics of patients who succeeded or
failed to comprehend insincere communication
Neuropsychological, neuropsychiatric and emotion
We computed a Z-score for each patient (one for lie and one
for sarcasm score) based on the mean and standard deviation
(SD) of the NC sample. We used a cut- point of Z ? ?1.5 to
indicate task failure and divided the patient group based on
whether each patient (1) passed or failed the lie task, and
(2) passed or failed the sarcasm task. We did not include NCs
in this analysis in order to minimize a diagnostic group effect.
The pass/fail groups were compared with regard to their
emotion sensitivity scores using GLMs, conducted separately
for lie and sarcasm. The results are presented in Table 4
(neuropsychological and demographic data) and Table 5
(neuropsychiatric and emotion sensitivity data).
Patients who failed to comprehend lies had lower MMSE and
higher Clinical Dementia Rating Scale (CDR) scores compared
with patients who passed the task. On neuropsychological
testing, when controlling for disease severity, they had poorer
scores on tests of verbal fluency and abstract reasoning,
spatial cognition, and most measures of executive func-
tioning: working memory (digits backward), letter and design
fluency, and cognitive control (Stroop interference). They also
had poorer performance on emotion reading tests (not
including prosody), and their informants rated them as more
disinhibited and apathetic.
Patients who failed to comprehend sarcasm had lower MMSE
scores, and higher CDR scores compared with patients who
passed the task. On neuropsychological testing, when
phonemic fluency. They had poorer performance on tests of
emotion reading, including emotion prosody, and reported
moredepressivesymptomsthan patients whopassedthetest.
disinhibited, euphoric, and apathetic.
sarcasm to real-life measures of empathy and
The relationship between comprehension of lies and
The relationship between lie and sarcasm scores and infor-
mants’ ratings of empathy and neuropsychiatric-behavioral
symptoms was examined with partial correlation analyses,
controlling for age, sex, education and MMSE. Pearson corre-
lation coefficients were used to calculate the relationship with
the IRI EC and PT subscale scores (each ranging from 5 to 35),
and Spearman correlation coefficients were used to calculate
the relationship with the NPI disinhibition, euphoria, apathy,
agitation, depression, anxiety and irritability subscale scores
(each ranging from 0 to 3).
Partial Pearson correlations revealed that both lie and
sarcasm overall task scores had significant positive correla-
tions with IRI PT (r ¼ .33, p < .001 and r ¼ .30, p < .001,
respectively), as well as with IRI EC (r ¼ .39, p < .001 and r ¼ .30,
p ¼ .024), indicating that people with better social compre-
hension on this face-to-face testing had better emotional
perspective taking and empathic concern in real life.
Partial Spearman correlations revealed that both lie and
sarcasm scores were negatively correlated with NPI ratings of
disinhibition (r ¼ ?.22, p ¼ .006 and r ¼ ?.33, p ¼ .001,
respectively), euphoria (r ¼ ?.17, p ¼ .036 and r ¼ ?.38,
p < .001), and apathy (r ¼ ?.31, p < .001 and r ¼ ?.41, p < .001).
Sarcasm score was also negatively correlated with agitation
(r ¼ ?.19, p ¼ .020). Neither lie nor sarcasm scores correlated
with depression, anxiety or irritability.
Our results suggest that subjects in the early stages of bvFTD,
PSP, VCI, and AD can understand literal, truthful remarks as
well as healthy older adults can. However, as hypothesized,
patients with bvFTD were impaired on tests of fundamental
social-cognitive processes involved in detecting insincere
speech, including visual perspective taking, belief represen-
tation, and emotion reading, leading to poor comprehension
of both lies and sarcasm. PSP patients showed some deficits as
well, performing poorly on complex ToM tests requiring them
to represent others’ opinions and intentions, but not on visual
perspective taking where the facts of the situation were
directly observable. Cerebrovascular and AD patients did not
demonstrate impaired social-cognitive processing or difficulty
cognitive deficits were accounted for.
cortex 48 (2012) 1329e1341
As expected, subjects with poor comprehension of lies and
sarcasm were rated by their informants as demonstrating
poorer empathic concern and emotional perspective taking
abilities, and more disinhibition, euphoria and apathy in real
life. Thus, failure to comprehend complex social interactions
may exacerbate patients’ poor social self-monitoring and
aberrant social behavior. These results also suggest that
directly testing patients’ ability to comprehend insincere
speech provides ecologically valid information about inter-
personal sensitivity and social behavior outside of the exam
room. Such testing may be sensitive and specific to early
bvFTD, and to a lesser degree to other tauopathies with
characteristic frontal-subcortical involvement such as PSP.
comprehending insincere speech: perspective taking, Theory
of mind, and emotion reading
Fundamental social-cognitive processes involved in
Traditional theories of communication suggest that listeners
initially use semantic information to understand the literal
meaning of speech, and then use pragmatic processes to
1975). Gibbs (1999) has argued that pragmatic processing is
essentially involved in both stages: we use primary pragmatic
information (common associative knowledge about the world)
isfull”, we use primary pragmaticinformation to recognize that
plates are typically filled with food). We then use secondary
pragmatic information such as specific contextual information
to determine the implication of the saying in a given situation
(e.g., when someone says “my plate is full” while purposefully
showing us their empty plate, we may infer that they are being
sarcastic). Similarly, if a child says “my plate is empty” while
trying to disguise hisfullplate, wemayinferthatthey are trying
to be deceptive. Thus, detection of both lies and sarcasm
strongly relies on processing contextual, secondary pragmatic
information in the form of visual or verbal cues.
Both lie and sarcasm tasks in this study required several
interdependent processes representing increasing levels of
cognitive complexity. First, subjects applied basic semantic/
linguistic and primary pragmatic knowledge to interpret the
literal meaning of the speaker’s words. While this can be
affected by neurodegenerative disease, our patients likely did
not fail to comprehend insincere communication due to
Table 4 e Neuropsychological and demographic characteristics of patients who passed or failed the lie and sarcasm tests
(N [ 102).
M (SD) Pass lie
(n ¼ 55)
(n ¼ 47)
F-valuep-value Pass sarcasm
(n ¼ 42)
(n ¼ 54)
MMSE (max ¼ 30)
CDR sum of boxes
Abbreviated BNT (max ¼ 15)
Semantic fluency (animals)
Abstract reasoning (max ¼ 6)
CVLT short form 10 min
recall (max ¼ 9)
CVLT recognition discriminability
(max ¼ 100%)
Benson Figure delayed recall
(max ¼ 17)
Benson Figure delayed
Benson Figure copy (max ¼ 17)
Number location (max ¼ 10)
Digit span forward
Digit span backward
Modified trails speed (lines/min)
Phonemic fluency (d-words/min)
Design fluency (designs/min)
Stroop interference (words/min)
4.3 (3.1) 3.5 (2.3)0 (4,90)ns5.3 (2.6) 2.9 (2.4) 10.48 (4,90).002
76.1 (25) 66.4 (28.3) .3 (4,90) ns80.1 (21) 65 (29.1)3.15 (4,90) ns
7.2 (4.4)5.7 (4.4) .98 (4,95) ns7.5 (2.3)5.8 (4.2) .98 (4,95)ns
c2¼ .62 ns 30/12 35/19
Note: F-statistics are derived from general linear models of neuropsychological scores controlling for age, sex, and MMSE. BNT ¼ Boston Naming
Test, CDR ¼ Clinical Dementia Rating Scale, CVLT ¼ California Verbal Learning Test, MMSE ¼ Mini-Mental State Examination.
cortex 48 (2012) 1329e1341
primary semantic processing deficits. We excluded patients
with aphasia who could not fulfill the initial requirements of
the task, and more importantly, found no significant group
differences in response to a control task verifying compre-
hending sincere speech. Thus, our subjects did not appear to
have significant deficits in comprehending the literal meaning
of the conversations they viewed, nor did they appear to lack
the pragmatic knowledge to comprehend the series of events
in the sincere videos.
Next, subjects had to identify contextual information
occurring around the speaker’s words. In the visual cue items,
they had to attend to the physical object to which the speaker
referred, and observe who could directly see that object. We
found no significant group differences in response to a control
task verifying how well the subjects could track the location of
a physical object, indicating that all subjects were equally able
to perceive this information. Also, performance on a standard
visual perception task was equal between patients who failed
or passed the tasks, suggesting they were equally able to
process the contextual visual cues, had they paid attention to
them. Although there were some minor differences between
the pass and fail groups on a spatial perception task, it did not
seem to affect their otherwise intact performance on sincere
items that were as contextually complex as the insincere
items. Thus, subjects did not appear to differ in their percep-
tion of the visual cues. However, subjects did differ in their
ability to represent the knowledge of the speaker and the
listener about the physical object (i.e., visual perspective
taking). bvFTD patients had poor ability to represent other
people’s knowledge of these objective facts, whether they
were implicitly presented to them (as determined by their
responses to the “think” probes on SI-E visual cue items) or
when they were explicitly, verbally presented to them
(determined by their responses to the cToM task PT items).
In the verbal cue items, subjects had to attend to the
additional information stated before or after the main
conversation in order to accurately represent the speaker’s
verbalized opinion. bvFTD and PSP patients had impaired
performance on questions measuring this ability (“think”
probes on verbal cue items). Thus, although patients generally
performed equivalently on both visual cue items and verbal
cue items (i.e., bvFTD patients failed both, while VCI and AD
patients failed neither), PSP patients showed a dissociation
between these two abilities. Though they did not have diffi-
culty representing others’ knowledge when the information
was explicitly presented visually, they were impaired at rep-
resenting others’ explicitly stated opinions.
In addition, to correctly identify the emotional state of the
speaker, subjects were also required to read the vocal and
facial emotional cues, which can provide additional informa-
tionto help them determine the overall attitude of the speaker.
While other groups had difficulty on static emotion tasks (e.g.,
CATS), only the bvFTD patients failed when the emotional
stimuli were presented in an ecologically realistic, dynamic
and multimodal manner (EET), and they were the only group
who had trouble understanding characters’ implicitly pre-
sented emotions during insincere speech on the SI-E task.
Finally, after processing the literal speech elements and
contextual cues, then representing the beliefs, opinions and
emotional states of the protagonists, subjects had to infer the
speaker’s intention. bvFTD patients in our study likely failed to
social-cognitive processes. Thus, perspective taking, ToM and
emotion reading, are essential for correct interpretation of
others’ complex indirect speech. PSP patients who only had
items correspondingly had poor ability to infer the speaker’s
Table 5 e Neuropsychiatric,emotion sensitivity and empathicabilitiesof patientswho passedor failed the lie and sarcasm
subtests (N [ 102).
M (SD) Pass lie
(n ¼ 55)
(n ¼ 47)
F-valuep-value Pass sarcasm
(n ¼ 34)
(n ¼ 49)
Neuropsychiatric symptoms (informant ratings)
NPI total severity
GDS (depression self rating)
Emotion sensitivity and empathy
TASIT EET (max ¼ 14)
CATS emotion prosody
CATS affect matching
IRI PT (informant ratings)
IRI EC (informant ratings)
?2.1 (1.3)9.91 (4,81).002
?2 (1.3)10.48 (4,81) .002
Note: F-statistics derived from general linear models, controlling for age, sex and MMSE. CATS ¼ Comprehensive Affect Testing System, EC ¼
Empathic Concern Subscale, GDS ¼ Geriatric Depression Scale, IRI ¼ Interpersonal Reactivity Index, NPI ¼ Neuropsychiatric Inventory, PT ¼
Perspective Taking subscale, TASIT EET ¼ The Awareness of Social Inference Test: Emotion Evaluation Test.
cortex 48 (2012) 1329e1341
intentions in the verbal cue condition, but not in the visual cue
In addition to social-cognitive deficits, our data show that
patients who failed to comprehend both lies and sarcasm had
poor scores on tests of abstract reasoning and fluency/
generation compared with patients who passed the tests. It
has been suggested before in the pragmatic linguistics litera-
ture that when subjects initially interpret the literal meaning
of a saying, they employ abstract thinking and generate
different possible linguistic meanings for a specific utterance,
and that based on contextual information they then select the
appropriate meaning for that utterance in a specific context
(Thomas, 1995). Accordingly, our findings suggest that better
abstract reasoning and generation abilities are associated
with more accurate comprehension of insincere speech.
Also, though not directly tested in this study, comprehen-
sion of lies and sarcasm both may rely on acquired social
knowledge. Over the course of development people gradually
acquire concepts for lying (Strichartz and Burton, 1990) and
sarcasm (Filippova and Astington, 2008) and increasingly
apply them in order to make accurate inferences about real-
life situations. This knowledge may be jeopardized in neuro-
degenerative diseases that specifically target social semantic
knowledge. Patients with bvFTD typically have varying
degrees of temporal involvement (Whitwell et al., 2009), thus
some may have impoverished social conceptual knowledge,
which is mediated in part by the right lateral anterior
temporal lobe (Zahn et al., 2009). Accordingly, the temporal
poles have been directly implicated in the ability to compre-
hend sarcasm (Rankin et al., 2009; Uchiyama et al., 2006) and
lies (Harada et al., 2009). It is possible, therefore, that patients
with atrophy in this region might have difficulties recognizing
these social acts partly due to degradation of the very
concepts of lying or sarcasm.
Lie detection involves sensitivity to social norm
Detecting interpersonal deception uniquely entails sensitivity
to a violation of the conversational “maxim of quality” which
assumes that all speakers are being truthful (Grice, 1975). A lie
is considered to be a morally- and value- loaded form of
speech (Lee, 2000), and its detection requires awareness of
social and moral norms, or “conventionality”. It also requires
detection of the deceiver’s intention (Harada et al., 2009),
which is common to comprehending both lies and sarcasm.
This presents an interesting contrast with other dementia
patients who may have benefited from their intact sensitivity
to violations of social norms (“conventionality”), ultimately
scoring better on this test than bvFTD patients, despite
equivalent cognitive deficits. Although patients who failed to
detect that one person was deceiving another had more
functional impairment (higher CDR and lower MMSE scores),
analyses were performed controlling for any differences in
disease severity across subjects, and these diagnostic group
differences still remained significant. Thus, the “awareness to
conventionality” aspect is another social-cognitive compo-
nent that is likely to be impaired in patients who fail to detect
interpersonal deception, i.e., patients with bvFTD.
and emotional cues
Sarcasm comprehension can rely on paralinguistic
The visual cue vignettes in the SI-E task were designed so that
the viewer could determine the intention of the speaker based
entirely on the contextual cues provided. Thus, even a viewer
without any sensitivity to the paralinguistic elements of
sarcasm should have been able to derive the correct inter-
pretation from the contextual cues alone. However, in the
verbal cue vignettes, the sarcasm scenes also included addi-
tional, sometimes subtle paralinguistic cues which facilitated
correct inference about the speaker’s intention. Sarcastic
remarks are often accompanied by specific facial expressions,
including greater gaze aversion (Williams et al., 2009) and
a pattern of vocal prosody unique to sarcasm (Rockwell, 2007).
Thus, it is likely that patients with poorer sensitivity to such
paralinguistic features, such as those who are also impaired at
sarcastic nature of the insincere remarks. Indeed, patients
who failed to comprehend sarcasm had significantly poorer
emotion prosody scores compared with patients who passed
the lie task, indicating that detection of paralinguistic cues
such as voice prosody is more relevant to sarcasm than lie
Also, a central aspect unique to the sarcasm scenarios was
that the speakers were portrayed as being angry or unhappy
about something, and used sarcasm to communicate their
displeasure to the listener. bvFTD was the only patient group
with significantly poorer scores on questions referring to the
speaker’s feelings (“is he/she annoyed”?). Correspondingly,
patients who failed to comprehend sarcasm were rated by
their informants as having poorer emotional perspective
taking and empathic concern compared with patients who
passed this task. Indeed, it has been proposed before that one
needs to acknowledge the sarcastic speaker’s feelings to fully
understand his or her sarcastic intentions (Shamay-Tsoory
et al., 2005). Our results suggest that patients with decreased
emotional sensitivity and empathic abilities are less likely to
infer that someone is using sarcasm to convey a (typically)
negative emotion. Interestingly, the study groups did not
significantly differ in responding to the “feel” probe question
on the lie task, showing that consideration of the speaker’s
emotion in order to understand their intention is more central
to comprehending sarcasm than lies.
4.4. Clinical implications
Patients with bvFTD are known to have a progressive decline
in their ability to comprehend others and interact with them,
losing their basic sense of social- and self-awareness early in
the disease (Miller et al., 2003; Neary et al., 1998). Previous
research on social cognition in bvFTD has demonstrated
deficits on various aspects of ToM (Adenzato et al., 2010) and
emotion reading abilities (Rosen et al., 2004), but in this study
we show in detail how these patients fail at distinct levels of
a cascade of increasingly complex social-cognitive processes,
including visual perspective taking, ToM, and emotion
reading, leading them to ultimately misinterpret lies and
sarcasm. A previous study found relatively preserved sarcasm
cortex 48 (2012) 1329e1341
comprehension in bvFTD patients, but only when it was
conveyedwith simpler paralinguistic
primarily interpreted using structures in the temporal lobe
(Rankin et al., 2009). Here we demonstrated that ability to
comprehend sarcasm from more complex contextual cues is
clearly deficient in bvFTD. Anatomic heterogeneity within
bvFTD is a confounding factor across studies characterizing
social cognition and behavior, because patients meeting
clinical criteria for bvFTD have highly divergent degrees of
temporal versus frontal atrophy (Whitwell et al., 2009). Thus,
in addition to the distinction between types of sarcasm
studied, the different results between the two studies could be
related to cohort inclusion and diversity factors.
In this study we demonstrated that even when bvFTD
patients are given all necessary information to detect that
someone is lying, they are unable to do so. This likely reflects
one aspect of their decreased ability to attend to salient,
socially significant cues, which is thought to depend on
connectivity in a right fronto-insular intrinsic network that is
selectively targeted by this disease (Seeley et al., 2009). bvFTD
patients tend to make more “risky” decisions on a gambling
task measure of decision making (Torralva et al., 2007), and
a recent study found that patients with bvFTD were impaired
at judging whether a social act was acceptable only when it
had a negative valence, but not in a positive social setting
(Grossman et al., 2010). In both of these studies, patients’
decreased sensitivity to the negative outcome of their deci-
sions was linked to volume in the ventromedial prefrontal
cortex(VMPFC).Thisevidencesupportsa role forthis regionin
evaluating the specifically negative consequences of social
decisions, and by extension may be relevant to bvFTD
patients’ insensitivity to rule violations such as lies.
These findings have practical implications for patients as
well. Because bvFTD patients are unable to differentiate
between sarcastic and sincere speech, and thus may interpret
sarcastic sayings literally, caregivers should be cautioned
against using such speech with these patients. In addition, the
a specific series of social-cognitive failures is consistent with
clinical observations that these patients are frequently victim-
2001). Greater vigilance by caregivers and doctors, as well as
attention to this problem from public policymakers, may be
required to better protect these vulnerable patients.
Social cognition in PSP has not been widely examined,
though a recent study reported impaired emotion recognition
in PSP patients (Ghosh et al., 2009). We found that PSP patients
had poorer lie comprehension scores than NCs, though not to
the same extent as patients with bvFTD. This difference did
not remain significant after controlling for their ability to
comprehend sincere interactions, thus their impairment on
the test appeared to be primarily an effect of general difficulty
with complex cognitive processing, rather than a specific
deficit in comprehending ToM and insincere communication.
Still, analysis of the specific components of ToM, controlling
for performance on the control tasks, indicated that PSP
patients had difficulty representing others’ explicitly verbal-
ized opinions, but not others’ knowledge of facts that were
visually presented to them. Correspondingly, they had poor
ability to infer the speaker’s intentions in the verbal cue
condition but not in the visual cue condition. These results
suggest PSP patients may have some mild but significant focal
deficits in social cognition, which is consistent with research
showingthatthey often demonstrate
personality changes, and executive dysfunction on testing,
hypothesized to occur as a result of disconnection between
subcortical structures to the PFC (Donker Kaat et al., 2007;
Grafman et al., 1990).
Patients with AD, who do not show the loss of emotional
salience network function seen in bvFTD (Seeley et al., 2007),
were relatively unimpaired on this task. Although formally
these patients showed deficits on some of the visual perspec-
tive taking and emotion reading tasks, these likely corre-
sponded with general cognitive deficits, because these deficits
did not remain significant when controlling for performance
on the control tasks. This provides evidence consistent with
previous literature suggesting that this group does not have
profound deficits in social cognition and behavior, and may
actually experience an accentuation of social sensitivity in the
of the salience network (Zhou et al., 2010).
Historically, changes in socio-emotional behavior in
neurodegenerative diseases have been assessed through
primarily indirect and subjective methods. While informants’
ratings of patients’ behavior have yielded valuable data (Mega
et al., 1996; Petry et al., 1988; Rankin et al., 2003, 2005), they are
nevertheless limited by their dependence on informants of
varying reliability. Development and validation of direct,
objective measures of socio-emotional functioning in patients
with neurodegenerative disease are becoming increasingly
valuable as indicators of clinical status and predictors of real-
life behavior in these conditions. Our finding that sensitivity
to lies and sarcasm correlates with clinically important
behavioral features suggests that this face-to-face test may be
used as a more objective clinical proxy for measurement of
real-life social dysfunction.
Because this study was designed to investigate social-cogni-
tive processes in patients with neurodegenerative diseases,
some of which are fairly rare, group sizes were necessarily
small in some instances. While this was a clear limitation to
the study, the observed effect sizes in this sample were very
large, suggesting that the study design allowed adequate
power to investigate these models. While no anatomic data
was included in this study, directly examining the neural
substrate of these deficits would be a valuable future investi-
gation to further elucidate the neurologic and cognitive
mechanisms involved in comprehension of lies and sarcasm.
In summary, patients with bvFTD demonstrate impaired
representation of others’ opinions, intentions, and emotions.
PSP patients evidence more isolated ToM deficits, and AD and
cerebrovascular disease patients do not appear to have focal
deficits in these aspects of social cognition, though perfor-
mance on these complex tasks worsens with general cognitive
a markedly decreased sensitivity to violations of communica-
tion rules in the form of lies. This is consistent with growing
cortex 48 (2012) 1329e1341
evidence that bvFTD specifically targets a neural network
sensitive to salient social-emotional information such as the
that this network is less affected by other neurodegenerative
diseases. Patients’ performance on these objective tests of
social cognition correlates highly with their real-life social
behavior, including their tendency to behave empathically and
totake others’perspective,suggesting suchtestsmaybeuseful
as objective measures of social functioning.
This research was supported in part by the National Institute
on Aging (NIA) grants 5-R01 AG029577, 5-P01 AG019724, and
P50 AG02350, the State of California Alzheimer’s Disease
Research Centerof California
NIH/NCRR UCSF-CTSI grant UL1 RR024131, and the Larry
L. Hillblom Foundation 2007/2I grant.
(ARCC) grant 03-75271,
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