When “I” and “You” blur: self–other distinction failure and empathy dysregulation in schizophrenia

Potential empathy deficits in schizophrenia are often discussed in terms of impaired theory of mind, reduced emotional understanding, or an imbalance between cognitive and affective empathy. However, these accounts do not fully explain why some patients show poor perspective-taking and empathic accuracy while also reporting elevated personal distress or emotional over-involvement. This review proposes a three-factor neurobehavioral framework that explains potential empathy deficits in schizophrenia from the perspective of self–other distinction regulation.

The framework distinguishes three partially separable processes: spontaneous empathic access, inferential empathy, and attributional empathy. Spontaneous empathic access concerns whether cognitive and affective cues from another person can enter the observer’s processing system under low task demands. Inferential empathy refers to the representation of others’ beliefs, intentions, perspectives, and emotional states as distinct from the self.

Attributional empathy concerns whether activated emotions, thoughts, or perspectives are assigned to the self or to another person. These processes may also be modulated by interpersonal synchrony, which shapes the real-time coordination of self- and other-related signals during social interaction. We suggest that potential empathy deficits in schizophrenia may reflect less stable self–other distinction regulation across these stages, rather than a uniform reduction in empathic capacity.

At the neural level, the framework maps these processes onto interacting salience, affective-sharing, and mirror networks; mentalizing and frontotemporal social-inference circuits; and self–other distinction and source-attribution systems. This model clarifies the explanatory boundaries of theory-of-mind and empathic-disequilibrium accounts and generates testable predictions for behavioral, neuroimaging, and intervention research. It may also provide a mechanistic framework for identifying which stage of empathic processing is most affected in different patients with schizophrenia.

This work was supported by the National Natural Science Foundation of China [32360202, 32160202]; Sichuan Science and Technology Program (2024NSFSC2099, 2025NSFSC2113); Ministry of Education of the People's Republic of China (24XJC190010); National Natural Science Foundation of China (General Program, 12472311). These authors contributed equally: ChaoZheng Huang, Pei Xie. School of Psychology, Northwest Normal University, Lanzhou, 730070, China Hunan Police Academy, ChangSha, 410138, China School of Psychology, Sichuan Normal University, Chengdu, 610068, China Correspondence to YuHui Yang or AiBao Zhou.

The authors declare no competing interest. This study is a narrative review and did not require approval from an ethics committee. This study is a narrative review and did not involve human participants.