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Journal Article

Proverb comprehension in schizophrenia: A comprehensive review and meta-analysis


Felsenheimer,  Anne
Department for Psychiatry and Psychotherapy, Eberhard Karls University Tübingen, Germany;
Max Planck School of Cognition, Max Planck Schools, Max Planck Society;

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Felsenheimer, A., & Rapp, A. M. (2024). Proverb comprehension in schizophrenia: A comprehensive review and meta-analysis. Comprehensive Psychiatry, 129: 152444. doi:10.1016/j.comppsych.2023.152444.

Cite as: https://hdl.handle.net/21.11116/0000-000E-14B4-0
Examination of proverb comprehension has a long tradition in clinical diagnostics of individuals with schizophrenia (iSCZ). Deficits in the comprehension are considered common. Interpretations of proverbs are traditionally measured by their degree of abstraction and concreteness (‘literalness’), but iSCZ's responses may also be illogical or ‘bizarre’. Experimental research on proverb comprehension starts in the 1940s. Since then, the specificity of proverb tests has often been questioned, but has never been the subject of a meta-analysis. The aim of this meta-analysis is to include all experimental research, including historical studies, that meets quality criteria and compares the responses to proverbs in iSCZ with those in healthy controls (HC) or clinical controls (CC).

PubMed, Web of Science, and PsycInfo databases were searched. After coding 121 articles, 27 (median publication year 1982) were included and multi-level meta-analyses performed. Moderator analyses were performed on response format (multiple-choice vs. verbal responses), proverb test, scoring method, language, acute vs. chronic stage of iSCZ, time of publication, clinical vs. healthy control group, age, IQ/education, and gender. Publication bias was assessed using funnel plots, trim and fill method and Egger's test.

The search identified 27 eligible studies for inclusion. Studies were published between 1956 and 2020 and predominantly older than 30 years (median: 1982). The Gorham Proverbs Test was the most established test and predominantly conducted in English. CC mostly consisted of depressive disorders. Pooled estimates yielded statistically significant less abstract (g = −1.00; 95%CI, −1.34 to −1.67), more concrete (g = 0.69; 95%CI, 0.35–1.03), and more bizarre (g = 1.08; 95%CI, 0.74–1.41) responses in iSCZ compared to controls. The type of control group moderated all three effects, with greater differences of iSCZ compared to HC than to CC in abstraction and bizarreness, and no significant group difference between iSCZ and CC in concreteness. Meta-regressions indicated IQ/education and age as possible sources of variability in abstraction and bizarreness.

While lower abstraction and higher bizarreness seems a characteristic of iSCZ, the diagnostic specificity of a concrete response was astonishingly low. The lack of a unified definition for concretism and limited consideration of cultural diversity contributed to these complex findings. Future research should focus on exploring the qualitative aspects of proverb comprehension and the association between symptomatology types and misinterpretations to improve diagnostic accuracy.