The cost of mentalizing: executive contributions to social cognition performance in amyotrophic lateral sclerosis

Mentalizing deficits are common in amyotrophic lateral sclerosis (ALS). Performance at high-level socio-cognitive tasks may be particularly vulnerable to integrity of basic cognitive processes. However, the extent to which non-social functioning contributes to socio-cognitive impairment in ALS remains poorly understood. In this study, we addressed this question in a large cohort of patients.

We assessed 257 ALS patients and 120 healthy controls using the Story-based Empathy Task (SET), which dissociates intention attribution (IA), emotion attribution (EA), and basic causal inference (CI). Vectorial analyses were applied to quantify overall performance and imbalance between social and non-social components. Mediation analyses were conducted to evaluate the contribution of executive system integrity to social cognition performance in ALS.

Patients showed significantly reduced performance across all SET conditions compared to controls, with imbalance between mentalizing and basic causal inference. Distinct profiles emerged across ALS phenotypes. ALS patients with behavioral changes exhibited predominant deficits in emotion attribution, whereas cognitively unimpaired ALS showed selective impairment in intention attribution. Executive functioning was significantly associated with SET performances and mediated the relationship between basic inference and both intention and emotion attribution.

Mentalizing impairment in ALS reflects an interaction between executive processes and specialized socio-cognitive systems. The identification of dissociable profiles supports a dual-route, network-based model of ALS, involving socio-affective and inferential pathways, and underscores the importance of integrated cognitive assessment and more targeted interventions addressing both social and non-social cognitive domains.