Preserved intention understanding during moral judgments in schizophrenia

Lisa Kronbichler; Renate Stelzig-Schöler; Melanie Lenger; Stefanie Weber; Brandy-Gale Pearce; Luise-Antonia Reich; Wolfgang Aichhorn; Martin Kronbichler

doi:10.1371/journal.pone.0251180

Peer Review History

Original SubmissionAugust 13, 2020
13 Nov 2020 Decision Letter - Peter John McKenna, Editor PONE-D-20-25364 Preserved Intention Understanding During Moral Judgments in Schizophrenia PLOS ONE Dear Dr. Kronbichler, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please could you pay careful attention to both reviewers' comments (please add ToM data on the subjects, if you have this, as recommended by Reviewer 1, if not it can be omitted). I also have some editorial comments as listed below: P3. I don’t think it is correct to say that social cognition is subsumed under theory of mind – most people would feel that the former is the broader construct. P3. ‘Although there is evidence that patients show altered cortical activation during moral judgments [14], behavioral studies reveal mixed results showing fragile effects that often depend on question probe and perspective [13–16]. I don’ think it makes sense to juxtapose functional imaging and behavioural studies, especially as only one functional imaging study is cited. It might be better to have a paragraph in the discussion on functional imaging findings in healthy subjects and patients with schizophrenia. P4. ‘Given that SSD patients have difficulties with belief understanding, we suggest that their ratings rely on the action outcome while neglecting the protagonist’s belief about his action.’ Please rephrase this sentence. If this is a hypothesis of the study, please indicate that this is the case. Alternatively, it might be better to remove it altogether. P4-5. The paragraph on hypermentalizing would be better omitted, in my view. There has been almost no theoretical or experimental exploration of hypermentalizing in schizophrenia, and it is not clear what consequences it would have on a moral judgment task. P5. ‘Participants in the patient group were 23 male adults, who had received a formal ICD-10 diagnosis (which was checked before study participation by certified psychiatrists)’ This statement does not meet accepted standards for meeting diagnostic criteria. Please expand on the process used. Please also move the section on exclusion criteria here. Please separate the demographics table and the results table (which should be in a results section). Please move the text on empathy and cognition to before the table, so readers will know what the initials refer to. It is customary to give a measure like years of education or highest educational level achieved in a demographics table, so please include this if possible. Please give considerably more detail on the Moral Judgements test, with at least one example. At the moment readers have to obtain and read reference 18 to know what the features of the test are. Please plan submit your revised manuscript in around three months or sooner. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Peter John McKenna Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1.) Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2.) Please describe in your methods section how capacity to consent was determined for the participants in this study. 3.) Please include additional information regarding the vignettes used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed vignettes as part of this study and they is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. If materials, methods, and protocols are well established, authors may cite articles where those protocols are described in detail, but the submission should include sufficient information to be understood independent of these references (https://journals.plos.org/plosone/s/submission-guidelines#loc-materials-and-methods). 4.) We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. 5.)Thank you for stating the following in the Acknowledgments Section of your manuscript: [This work was supported by grants provided to Martin Kronbichler by the Austrian 315 Science Fund (FWF grant number: P 30390-B27) and the Scientific Funds of the Paracelsus 316 Medical University (grant number: E-13/18/097-KRO)] We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: [The authors received no specific funding for this work.] Please include your amended statements within your cover letter; we will change the online submission form on your behalf. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: No ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Thank you for inviting me to review this interesting manuscript, investigating a relatively neglected area of social cognition research in schizophrenia at the intersection between psy- and phil-disciplines. The study investigates differences between patients with schizophrenia-spectrum disorder (SSD) and healthy controls on a moral judgment task which requires the understanding of others’ intentions. This is an original and novel contribution to the field, which however presents some shortcomings and, in my opinion, could be improved in relation to a number of issues summarised below: 1. KEYWORDS: not fully representative. I would suggest considering, for example: “schizophrenia, moral cognition, social cognition, theory of mind, empathy”. 2. ABSTRACT: Originality, relevance and need for this research are identified and the new task is briefly introduced, along with a clear summary of the conclusions. However, the sentence “we examine whether patients with SSD reveal alterations in moral judgments when the intentions of the acting person must be considered.” is slightly misleading and needs re-reading a few times in order to grasp what component of moral reasoning or what faculty the authors are trying to investigate (and therefore the research question is not clearly defined). It seems to me that they are conflating theory of mind and moral reasoning, and that the question they are actually asking is whether lacking theory of mind impacts on moral reasoning? Research question and aims could therefore be made clearer in the abstract. 3. INTRODUCTION: The introduction lacks a rigorous and critical conceptual engagement with the neurophilosophical and neuropsychological literature on the topic. The authors seem to take for granted the evidence for deficits in ability to appreciate other people’s beliefs and intentions in relation to schizophrenia-spectrum disorders across different contexts, whereas the literature is mixed and the effect of considering different components of moral reasoning, as well as different contexts, should be discussed. See for example (McCABE et al., 2004) (Carlson & Crockett, 2018; Yu et al., 2019) (Bluhm et al., 2015). Morality judgments might occur at the intersection between different dimensions of social cognition including for example moral decision‐making, judgment, and inference (Yu et al., 2019), while the authors’ reduce the discussion to the “neuronal level” (lines 53-55). In addition, the ToM deficits evidenced in ASD and schizophrenia are not necessarily similar on a phenomenological level (Stanghellini & Ballerini, 2011) and this should be discussed. Lines 62-65 refer to different paradigms (studies 12,17,13) but then the authors fail to explicate pros/cons, just re-directing the reader to (study 13) for an example. I suggest that the complexity and challenges of investigating ethical reasoning in psychiatric disorders should be more clearly delineated and that a more balanced overview of the neuropsychological literature should be provided. 4. METHODOLOGY: The authors provide a measure of overall empathy but do not provide any information on ToM skills in their sample. This is surprising given that in the introduction they focus on impairment both in ToM and empathy. Could their sample just have normal ToM? Other measures and statistics appear adequate but I cannot see any controlling for potential confounding factors. 5. RESULTS/DISCUSSION: Results are presented clearly and logically, and discussed in a stepwise fashion. References: Bluhm, R., Raczek, G., Broome, M., & Wall, M. B. (2015, July 16). Ethical Issues in Brain Imaging in Psychiatry. The Oxford Handbook of Psychiatric Ethics. https://doi.org/10.1093/oxfordhb/9780198732372.013.21 Carlson, R. W., & Crockett, M. J. (2018). The lateral prefrontal cortex and moral goal pursuit. Current Opinion in Psychology, 24, 77–82. https://doi.org/10.1016/j.copsyc.2018.09.007 McCABE, R., Leudar, I., & Antaki, C. (2004). Do people with schizophrenia display theory of mind deficits in clinical interactions? Psychological Medicine, 34(3), 401–412. https://doi.org/10.1017/S0033291703001338 Stanghellini, G., & Ballerini, M. (2011). What is it like to be a person with schizophrenia in the social world? A first-person perspective study on schizophrenic dissociality–Part 1: State of the art. Psychopathology, 44(3), 172–182. Yu, H., Siegel, J. Z., & Crockett, M. J. (2019). Modeling Morality in 3-D: Decision-Making, Judgment, and Inference. Topics in Cognitive Science, 11(2), 409–432. https://doi.org/10.1111/tops.12382 Reviewer #2: Dear editors of PlosOne, It has been a pleasure to review the manuscript by Kronbichler et al. entitled "Preserved Intention Understanding During Moral Judgments in Schizophrenia". This work deals with a clearly stated and interesting set of hypotheses and, in general, it has been correctly conducted. My comments are related to minor methodological aspects of the work. Specifically: 1.- The nature of the main analysis (three way, repeated measures ANOVA) should be stated in the Methods section (not in the results section as it is now). 2.- Exhaustive results from the non-bayesian ANOVA should be provided in a table. 3.- Results from post-hoc tests (one per each of the 2x2 conditions, comparing patients and controls) shouldn't be included in the demographics table (table 1) but in the ANOVA table (see point 1) or in a table of its own. 4.- Boxplots from Figure 1, clearly reveal that for some of the conditions (specially intended harm and neutral acts) there are some prominent floor and ceiling effects (observations gathered at extreme values) and net differences in variances between conditions, which, may violate the assumptions for parametric analyses. Still, I understand that fitting a non-parametric version of a three way, repeated measures ANOVA may be difficult and unreliable, and we may consider results provided as valid. However, at least within condition two group comparisons (post-hoc t-test) should be supplemented with results from non-parametric tests (ideally permutation tests) . 5.- The inclusion of Bayesian results is also informative and reinforces the classic ANOVA outcome (both analyses agree in broad terms) however, due to the non-familiarity of some of the readers with Bayesian methods, a clear explanation on the different statistics reported (mainly Bayes Factors) should be included in the text. 6.- Finally, Table captions are very poor and should be improved by including extensive information on tables contents. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0251180.r001
Revision 1
8 Apr 2021 Author Response Dear Reviewers, dear Editor, Thank you so much for putting your valuable time into this review. We hope that our changes suit your expectations and we sincerely want to thank you for helping to improve our manuscript. The list of changes is attached below in the initial order of the review. Editor P3. I don’t think it is correct to say that social cognition is subsumed under theory of mind – most people would feel that the former is the broader construct. Thank you, of course you are right, the wording of this sentence was misleading. We rewrote this sentence, describing TOM as a (sub)factor or social cognition, which better fits the common description of TOM. P3. ‘Although there is evidence that patients show altered cortical activation during moral judgments [14], behavioral studies reveal mixed results showing fragile effects that often depend on question probe and perspective [13–16]. ● I don’ think it makes sense to juxtapose functional imaging and behavioural studies, especially as only one functional imaging study is cited. It might be better to have a paragraph in the discussion on functional imaging findings in healthy subjects and patients with schizophrenia. We rewrote the introduction and avoided a direct comparison between neuroimaging and behavioral data since juxtaposing behavioral and neuroimaging data is misleading. Since we nonetheless provide information on both data types, we now explicitly state in the discussion that neuroimaging does not directly map on behavior. P4. ‘Given that SSD patients have difficulties with belief understanding, we suggest that their ratings rely on the action outcome while neglecting the protagonist’s belief about his action.’ ● Please rephrase this sentence. If this is a hypothesis of the study, please indicate that this is the case. Alternatively, it might be better to remove it altogether. Since this is one of our assumptions about the task, we rephrased the sentence. It now reads: ‘If our SSD sample has difficulties understanding the intention and belief of the story protagonist, we should find that patients mostly rely their ratings on the action outcome since the intention of the protagonist (to harm or not to harm the other person) is not informative to them.’ P4-5. The paragraph on hypermentalizing would be better omitted, in my view. There has been almost no theoretical or experimental exploration of hypermentalizing in schizophrenia, and it is not clear what consequences it would have on a moral judgment task. This section was mostly added for the sake of completeness - I removed it. P5. ‘Participants in the patient group were 23 male adults, who had received a formal ICD-10 diagnosis (which was checked before study participation by certified psychiatrists)’ ● This statement does not meet accepted standards for meeting diagnostic criteria. Please expand on the process used. Patients were examined using the Mini-International Neuropsychiatric Interview (Sheehan et al. 1998) This is now stated in the Participant section. ● Please also move the section on exclusion criteria here. Exclusion criteria were moved upwards. Please separate the demographics table and the results table (which should be in a results section). Please move the text on empathy and cognition to before the table, so readers will know what the initials refer to. It is customary to give a measure like years of education or highest educational level achieved in a demographics table, so please include this if possible. Demographics and results are now presented in separate Tables (T1,T2). Education level was added to Table 1. Please give considerably more detail on the Moral Judgements test, with at least one example. At the moment readers have to obtain and read reference 18 to know what the features of the test are. The task description was rewritten and is now described using an example story. We hope that this facilitates the understanding of this task. Furthermore, two complete stories are now added to the supplementary material. 2.) Please describe in your methods section how capacity to consent was determined for the participants in this study. Thank you for pointing this out, since this is an extremely important topic. Patient capacity to participate (and give informed consent) was determined in two steps: First, only patients authorized to give informed consent were taken into account. Patients under external custody (either due to their age or their mental state) were not included. Furthermore, all patients were recruited by their treating clinical psychiatrists, and only patients whose mental state was considered stable enough were recruited. There were no exceptions to this procedure. The methods section now contains this statement: Only participants who were authorized to give informed consent themselves (>18 years, not under external custody) were included in the study. Furthermore, patient recruitment was exclusively done by an experienced team of psychiatrists. 3.) Please include additional information regarding the vignettes used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed vignettes as part of this study and they is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. If materials, methods, and protocols are well established, authors may cite articles where those protocols are described in detail, but the submission should include sufficient information to be understood independent of these references (https://journals.plos.org/plosone/s/submission-guidelines#loc-materials-and-methods). The test material is well established (Moran et al., 2011) and described in detail there. To nonetheless get a better idea of how the stories are designed, we added the english and german versions of two example vignettes in the supplementary material. 4.) We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. The following statement is also included in the cover letter: Currently, we do not have approval from the local ethical committee responsible for this study (Ethikkommission des Landes Salzburg - Ethics committee of the regional state of Salzburg) to publicly share single patients data of any sort, without the explicit consent of patients to share their individual data publicly. Since our study consent form did not include such a clause, we are not allowed to make single-subject data publicly available. For data access, please write an email to the corresponding author, which will clarify the potential to share the data with the local ethics committee. We are currently trying to obtain a more general allowance from the ethics committee for sharing at least the single subject behavioural data but this process will take a while. If a more general data sharing allowance is obtained, we will update the information with the article and share the data on a public repository (if allowed). Ethikkommission für das Bundesland Salzburg Sebastian-Stief-Gasse 2 5020 Salzburg Contact: Mag. Ulrike Wendl-Toiflhart Tel.: +43-(0)662-8042-2375 E-Mail: ethikkommission@salzburg.gv.at b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. 5.)Thank you for stating the following in the Acknowledgments Section of your manuscript: This work was supported by grants provided to Martin Kronbichler by the Austrian 315 Science Fund (FWF grant number: P 30390-B27) and the Scientific Funds of the Paracelsus 316 Medical University (grant number: E-13/18/097-KRO). We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: [The authors received no specific funding for this work.] Thank you for pointing this out. Please move below section to the Funding Statement: This work was supported by grants provided to Martin Kronbichler by the Austrian Science Fund (FWF grant number: P 30390-B27) and the Scientific Funds of the Paracelsus Medical University (grant number: E-13/18/097-KRO). Please include your amended statements within your cover letter; we will change the online submission form on your behalf. Reviewer #1: Thank you for inviting me to review this interesting manuscript, investigating a relatively neglected area of social cognition research in schizophrenia at the intersection between psy- and phil-disciplines. The study investigates differences between patients with schizophrenia-spectrum disorder (SSD) and healthy controls on a moral judgment task which requires the understanding of others’ intentions. This is an original and novel contribution to the field, which however presents some shortcomings and, in my opinion, could be improved in relation to a number of issues summarised below: 1. KEYWORDS: not fully representative. I would suggest considering, for example: “schizophrenia, moral cognition, social cognition, theory of mind, empathy”. Keywords were changed accordingly. The term “schizophrenia” was omitted since it is already present in the title. 2. ABSTRACT: Originality, relevance and need for this research are identified and the new task is briefly introduced, along with a clear summary of the conclusions. However, the sentence “we examine whether patients with SSD reveal alterations in moral judgments when the intentions of the acting person must be considered.” is slightly misleading and needs re-reading a few times in order to grasp what component of moral reasoning or what faculty the authors are trying to investigate (and therefore the research question is not clearly defined). It seems to me that they are conflating theory of mind and moral reasoning, and that the question they are actually asking is whether lacking theory of mind impacts on moral reasoning? Research question and aims could therefore be made clearer in the abstract. This section of the abstract was rewritten in order to make our research interest clearer. 3. INTRODUCTION: The introduction lacks a rigorous and critical conceptual engagement with the neurophilosophical and neuropsychological literature on the topic. The authors seem to take for granted the evidence for deficits in ability to appreciate other people’s beliefs and intentions in relation to schizophrenia-spectrum disorders across different contexts, whereas the literature is mixed and the effect of considering different components of moral reasoning, as well as different contexts, should be discussed. See for example (McCABE et al., 2004) (Carlson & Crockett, 2018; Yu et al., 2019) (Bluhm et al., 2015). Morality judgments might occur at the intersection between different dimensions of social cognition including for example moral decision‐making, judgment, and inference (Yu et al., 2019), while the authors’ reduce the discussion to the “neuronal level” (lines 53-55). In addition, the ToM deficits evidenced in ASD and schizophrenia are not necessarily similar on a phenomenological level (Stanghellini & Ballerini, 2011) and this should be discussed. Lines 62-65 refer to different paradigms (studies 12,17,13) but then the authors fail to explicate pros/cons, just re-directing the reader to (study 13) for an example. I suggest that the complexity and challenges of investigating ethical reasoning in psychiatric disorders should be more clearly delineated and that a more balanced overview of the neuropsychological literature should be provided. We mostly rewrote the introduction to provide a more sophisticated overview of the currently existing literature. We found that some of your suggestions would better fit in the discussion section of the paper, therefore we moved aspects like the link between neuroimaging and behavioral data there. We hope this is alright, since we wanted to incorporate all the valuable suggestions made by the reviewer. 4. METHODOLOGY: The authors provide a measure of overall empathy but do not provide any information on ToM skills in their sample. This is surprising given that in the introduction they focus on impairment both in ToM and empathy. Could their sample just have normal ToM? Other measures and statistics appear adequate but I cannot see any controlling for potential confounding factors. Unfortunately, data on TOM skills are not available for this sample. Correlation analyses are (and were in the first manuscript) reported examining the influence of symptom severity, medication and illness duration. We politely refer to paragraph 2 in the results section: Pearson Correlations indicate that symptom severity (PANSS) and medication (Chlorpromazine equivalent) were not related to task performance (rs < .38, ps > .09). Illness duration was moderately related to permissibility ratings in Intended Harm scenarios (r = .41, p = .052). 5. RESULTS/DISCUSSION: Results are presented clearly and logically, and discussed in a stepwise fashion. Reviewer #2: Dear editors of PlosOne, It has been a pleasure to review the manuscript by Kronbichler et al. entitled "Preserved Intention Understanding During Moral Judgments in Schizophrenia". This work deals with a clearly stated and interesting set of hypotheses and, in general, it has been correctly conducted. My comments are related to minor methodological aspects of the work. Specifically: 1.- The nature of the main analysis (three way, repeated measures ANOVA) should be stated in the Methods section (not in the results section as it is now). The description is moved to the methods section. 2.- Exhaustive results from the non-bayesian ANOVA should be provided in a table. Descriptives, results of the ANOVA and t-test are now listed in Table 2. 3.- Results from post-hoc tests (one per each of the 2x2 conditions, comparing patients and controls) shouldn't be included in the demographics table (table 1) but in the ANOVA table (see point 1) or in a table of its own. See point above. 4.- Boxplots from Figure 1, clearly reveal that for some of the conditions (specially intended harm and neutral acts) there are some prominent floor and ceiling effects (observations gathered at extreme values) and net differences in variances between conditions, which, may violate the assumptions for parametric analyses. Still, I understand that fitting a non-parametric version of a three way, repeated measures ANOVA may be difficult and unreliable, and we may consider results provided as valid. However, at least within condition two group comparisons (post-hoc t-test) should be supplemented with results from non-parametric tests (ideally permutation tests) . Thank you sincerely for pointing this out. For the sake of simplicity (we felt the results section is already pretty long), we added the permutation test results in the supplementary material and mentioned their similar outcome in our results section. 5.- The inclusion of Bayesian results is also informative and reinforces the classic ANOVA outcome (both analyses agree in broad terms) however, due to the non-familiarity of some of the readers with Bayesian methods, a clear explanation on the different statistics reported (mainly Bayes Factors) should be included in the text. Thank you for pointing this out. Although quite informative, the idea behind bayes statistics is not (yet) as popular as conventional NHST. Therefore, we added a short paragraph (2.5) where we describe the meaning of bayes factors and refer to practical guides for a more in depth description. 6.- Finally, Table captions are very poor and should be improved by including extensive information on tables contents. Table captions were rewritten and provide more information now. Attachments Attachment Submitted filename: Rebuttal_Letter.docx https://doi.org/10.1371/journal.pone.0251180.r002
14 Apr 2021 Decision Letter - Peter John McKenna, Editor PONE-D-20-25364R1 Preserved intention understanding during moral judgments in schizophrenia PLOS ONE Dear Dr. Kronbicher, Thank you for submitting your revised manuscript to PLOS ONE. It is now nearly ready for acceptance but there are few minor issues that need addressing: 1. The article is understandable but the use of English has frequent grammatical errors, particularly with regard to tense. If you were able to have a native English speaker review the text this would be helpful. 2. P7. 'The study was part of a longitudinal study including behavioral and MRI acquisitions in affective and psychotic disorders approved by the local ethics committee'. This sentence is unnecessary and confusing, as you have already stated that the study had ethics committee approval - please remove or amend. 3. P17. You begin a paragraph of the discussion with 'Probably the mainstream opener when discussing a null effect...'. It would be better to replace this with something like 'Probably the most important consideration for a null effect...'. 4. Please incorporate the two footnotes into the main body of the text. We look forward to receiving your revised manuscript. Kind regards, Peter John McKenna Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0251180.r003
Revision 2
20 Apr 2021 Author Response Dear Editorial Management, in the following, I'd like to address the issues raised in your last email: 1) the manuscript was given to a british colleague for proofreading 2) the sentence has been removed 3) the sentence was changed according to your suggestion 4) the footnotes were incorporated in the main text Note: Could you please change the name and affiliation of melanie LENGER, since there was an error in the initial version of the manuscript. I changed it in the draft but I was not able to change it in the online system. thank you very much, sincerely, lisa kronbichler Attachments Attachment Submitted filename: Rebuttal_Letter.docx https://doi.org/10.1371/journal.pone.0251180.r004
22 Apr 2021 Decision Letter - Peter John McKenna, Editor Preserved intention understanding during moral judgments in schizophrenia PONE-D-20-25364R2 Dear Dr. Kronbichler, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Peter John McKenna Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0251180.r005
Formally Accepted
26 Apr 2021 Acceptance Letter - Peter John McKenna, Editor PONE-D-20-25364R2 Preserved intention understanding during moral judgments in schizophrenia Dear Dr. Kronbichler: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Peter John McKenna Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0251180.r006

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