Scientific Update and Overview
Social Impairments in Mental Disorders: Recent
Developments in Studying the Mechanisms of Interactive
Behavior
Konrad Lehmann a, Lara Maliske a, Anne Böckler bc, Philipp Kanske ac
[a] Clinical Psychology and Behavioral Neuroscience, Faculty of Psychology, Technische Universität Dresden, Dresden,
Germany. [b] Institute of Psychology, Julius-Maximilians-Universität Würzburg, Würzburg, Germany. [c] Max Planck
Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.
Clinical Psychology in Europe, 2019, Vol. 1(2), Article e33143, https://doi.org/10.32872/cpe.v1i2.33143
Received: 2019-01-16 • Accepted: 2019-05-22 • Published (VoR): 2019-06-28
Handling Editor: Winfried Rief, Philipps-University of Marburg, Marburg, Germany
Corresponding Author: Lara Maliske, Clinical Psychology and Behavioral Neuroscience, Faculty of Psychology,
Technische Universität Dresden, Chemnitzer Str. 46, 01187 Dresden, Germany. E-mail: lara.maliske@tu-dresden.de
Abstract
Background: Most mental disorders are associated with impairments in social functioning.
Paradigms developed to study social functioning in laboratory settings mostly put participants in a
detached observer point of view. However, some phenomena are inherently interactive and
studying full-blown reciprocal interactions may be indispensable to understand social deficits in
psychopathology.
Method: We conducted a narrative review on recent developments in the field of experimental
clinical psychology and clinical social neuroscience that employs a second-person approach to
studying social impairments in Autism Spectrum Disorder (ASD), Personality Disorder, Social
Anxiety Disorder (SAD), and Schizophrenia.
Results: Recent developments in methodological, analytical, and technical approaches, such as
dual eye-tracking, mobile eye-tracking, live video-feed, hyperscanning, or motion capture allow for
a more ecologically valid assessment of social functioning. In individuals with ASD, these methods
revealed reduced sensitivity to the presence of a real interaction partner as well as diminished
behavioral and neural synchronicity with interaction partners. Initial evidence suggests that
interactive paradigms might be a powerful tool to reveal reduced interpersonal sensitivity in
Personality Disorders and increased interpersonal sensitivity in individuals with SAD.
Conclusion: A shift towards adapting a second-person account has clearly benefitted research on
social interaction in psychopathology. Several studies showed profound differences in behavioral
and neural measures during actual social interactions, as compared to engaging participants as
mere observers. While research using truly interactive paradigms is still in its infancy, it holds
great potential for clinical research on social interaction.
This is an open access article distributed under the terms of the Creative Commons Attribution
4.0 International License, CC BY 4.0, which permits unrestricted use, distribution, and
reproduction, provided the original work is properly cited.
Social Impairments in Mental Disorders
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Keywords
social interaction, social cognition, second-person approach, mental disorders, social immersion, ecological
validity
Highlights
• We review studies adopting a second-person account of social interaction in
clinical psychology.
• Studies show profound differences between actual social interactions and mere
observations.
• The full extent of impairments in social functioning unfolds only in complex
social interactions.
• New methodological developments hold great potential for research on social
interaction deficits.
Most mental disorders are associated with impairments in social functioning. Social diffi‐
culties are both diagnostic criteria for several disorders such as Autism, Schizophrenia,
Social Anxiety Disorder, or Personality Disorders (Kennedy & Adolphs, 2012; Skodol et
al., 2002) and also constitute risk factors for developing, sustaining, and exacerbating
clinical symptoms (Cacioppo, Hawkley, & Thisted, 2010; Fowler, Allen, Oldham, & Frueh,
2013; Hawkley & Cacioppo, 2010). Though social functioning is complex and challenging
to assess, several recent methodological advancements may allow to directly study so‐
cial-interactive behavior and its underlying (neural) mechanisms in more ecologically
valid ways. The goal of this update article is to delineate these developments and their
relevance for understanding mental disorders.
Deficits in social functioning can be based on impairments in the underlying social
affective and cognitive processes (Amodio & Frith, 2006) that range from basic social at‐
tention and memory to empathy and theory of mind (ToM; also termed mentalizing;
Happé, Cook, & Bird, 2017; Kanske, 2018). While empathy allows access to other minds
via directly sharing other persons’ emotional states (de Vignemont & Singer, 2006), men‐
talizing enables the understanding of others through abstract inference of their thoughts
and beliefs (Frith & Frith, 2005). The typical approach to studying these phenomena in
experimental clinical psychology and social neuroscience has been criticized as assessing
individual minds as detached observers (Fuchs & De Jaegher, 2009). Paradigms ask partic‐
ipants, for instance, to predict the behavior of cartoon characters, classify emotions of
static pictures of eyes, or judge the trustworthiness of face photographs. While these
tasks have certainly provided valuable insight into the mechanisms of social functioning,
they lack the reciprocal nature of full-blown interactions (Bird et al., 2010; Dziobek et al.,
2008; Kanske, Böckler, Trautwein, & Singer, 2015; von dem Hagen, Stoyanova, Rowe,
Baron-Cohen, & Calder, 2014; Walter et al., 2009).
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In contrast to this observer account of social cognition, recent developments in philos‐
ophy, experimental psychology, and neuroscience call for a second-person account that en‐
gages participants in real dynamic interactions (e.g., De Jaegher, Di Paolo, & Gallagher,
2010; Gallagher, 2008; Konvalinka & Roepstorff, 2012; Schilbach et al., 2013). Researchers
argue that making sense of another person during an embodied and ongoing social inter‐
action occurs implicitly by making use of enactive perception that takes the context of a
shared, intersubjective world into account. In real-time social interaction, implicit pro‐
cesses seem to be more relevant than the explicit forms that have been especially empha‐
sized in previous research (Schilbach, 2016). Accordingly, the full extent of deficient so‐
cial functioning in psychopathology may only manifest in complex social interactions.
For instance, autistic individuals report more problems with direct and immediate social
interactions than situations involving slow-paced interactions (e.g., email) or social ob‐
servation.
Recent research has advanced paradigms originating from an observer account of so‐
cial interaction towards implementing interactions (or at least interactive elements) with
one or more real other persons. In addition to examining real, reciprocal interaction, au‐
thors suggested that even the potential for reciprocal interaction constitutes an impor‐
tant step forward, as one becomes actively engaged through another person that is expe‐
rienced as active and salient (Krach, Müller-Pinzler, Westermann, & Paulus, 2013; Risko,
Richardson, & Kingstone, 2016) – a process that is also referred to as social immersion.
Among the novel approaches, research on gaze behavior has taken a leading role. One
prominent paradigm makes use of anthropomorphic virtual characters who respond in a
contingent way to participants’ eye movements, resulting in reciprocal interaction
(Wilms et al., 2010). Comparably, Redcay et al. (2010) developed a paradigm using live
video-feed that allows for gaze based face-to-face interaction between an experimenter
outside and a participant inside a magnetic resonance imaging (MRI) scanner. Yet another
setup even enables two participants to interact via live video-feed while simultaneously
tracking their eye-movements (Hessels, Cornelissen, Hooge, & Kemner, 2017). Such a du‐
al eye-tracking method has also been implemented in setups wherein two individuals are
lying in MRI scanners (e.g., Saito et al., 2010), enabling the simultaneous acquisition of
brain activation of two interacting persons (referred to as hyperscanning). Other ap‐
proaches rely less on technical means but establish real live interaction between partici‐
pants with, for instance, free eye contact or structured conversations while measuring
the allocation of visual attention or indicators of arousal (e.g., Freeth, Foulsham, &
Kingstone, 2013; Myllyneva, Ranta, & Hietanen, 2015). While these paradigms sometimes
differ substantially in the way they operationalize social interactions, they can be classi‐
fied along different dimensions, such as complexity of interaction, temporal dynamics,
social presence, and embodiment (Table 1).
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Table 1
Classification of Studies
Task / Study
Joint attention (Oberwelland et
Social
presence
Interaction
complexity
Temporal
dynamics
Yes
Medium low
Yes
Embodiment
Disorder
Measure
High
Medium high visual
information
Autism /
Borderline
Personality
Disorder
Neural
activity &
gaze behavior
Low
High
Medium high - Autism / Social
visual
Anxiety
information
Disorder
Yes vs. no
(experimental
condition)
Low
Low
Medium auditory
information
Autism
Neural
activity
Yes vs. no
(experimental
condition)
No
interaction
-
High - visual +
auditory
information
Autism
Gaze
behavior
Yes
High
High
Very high physically
present
Autism
Gaze
behavior
Yes
High
High
Very high physically
present
Autism
Movement
kinematics
Yes vs. no
(experimental
condition)
No
interaction
-
Yes
Low
High
Medium tactile
information
Narcissistic
Personality
Disorder
Neural
activity
Yes
High
High
Very high physically
present
Schizophrenia
Neural
activity
al., 2017; Redcay et al., 2013;
including dual eye-tracking:
Bilek et al., 2017; Tanabe et al.,
2012)
Mutual eye-gaze (Hessels et al.,
2018; Myllyneva et al., 2015)
Listening to short stories (Rice
& Redcay, 2016)
Listening to short stories (von
dem Hagen & Bright, 2017)
Live face-to-face interaction
(Freeth & Bugembe, 2019;
Freeth et al., 2013; Hanley et al.,
Gaze
behavior
2015; Hanley et al., 2014;
Magrelli et al., 2013; Nadig et
al., 2010)
Live interaction (Fitzpatrick et
al., 2017a, 2017b; Romero et al.,
2018)
Performance task, audience
present (Chib et al., 2018;
Müller-Pinzler et al., 2015)
Touch anticipation (Scalabrini
et al., 2017)
Conversation (Takei et al.,
2013)
Medium high - Social Anxiety
visual
Disorder
information
Neural
activity
Note. The table summarizes how the reviewed studies (clustered by the kind of task) vary on features of social
interaction. These features encompass the social presence of the interaction partner or audience in a mutual
social situation; the interaction complexity expresses how much information is transferred during the interac‐
tion; the temporal dynamics of the interaction provides information about how quick responses have to be inte‐
grated and reacted upon; and the embodiment of the interaction partner expresses how rich s/he is perceived
by the participant.
This update article shortly reviews recent laboratory studies that adopt a second-person
account of social interaction within clinical experimental psychology and clinical social
neuroscience. We want to delineate how novel and ecologically valid measures have hel‐
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Lehmann, Maliske, Böckler, & Kanske
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ped to gain new insight into impairments of social interaction, with a particular focus on
studies employing advanced experimental and methodological approaches. This kind of
research in the context of mental disorders is still scarce and we will focus on Autism
Spectrum Disorders, Personality Disorders, Social Anxiety Disorder, and Schizophrenia.
Autism Spectrum Disorder
Autism Spectrum Disorder (ASD) is a developmental disorder manifested particularly in
persistent patterns of deficient social interactive and communicative behavior (e.g., irreg‐
ular eye contact, behavioral inflexibility in social contexts) (American Psychiatric
Association [APA], 2013).
Deficits in joint attention are one of the core impairments in ASD (Dawson, Bernier,
& Ring, 2012). Establishing joint attention – for instance, by directing or following anoth‐
er’s gaze to an object – is a simple, but inherently interactive process (Redcay, Kleiner, &
Saxe, 2012) that can easily be implemented in truly interactive settings. Using a live vid‐
eo-feed, Tanabe and colleagues (2012) employed a dual eye-tracking joint attention task
in dyads of ASD and typically developed (TD) participants during MRI hyperscanning.
ASD participants showed reduced accuracy at detecting gaze direction, corresponding
with reduced neural activation in the left occipital pole, suggesting altered early visual
gaze processing. Furthermore, mixed pairs of TD and ASD participants revealed lower
neural synchronization in the right inferior frontal gyrus (IFG) than TD-TD pairs, which
the authors attributed to problems integrating self- and other-oriented attention in ASD
participants. In another joint attention study using a live video-feed, ASD participants
did not differ behaviorally from TD participants (Redcay et al., 2013). However, on the
neural level, ASD participants (in contrast to TD participants) did not show differential
activity between social and non-social conditions in the dorsomedial prefrontal cortex
(dmPFC) and left posterior superior temporal sulcus (lpSTS), which might play a role in
mutual engagement with a social partner. Similar patterns were observed using virtual
interacting avatars (Oberwelland et al., 2017).
Beyond simple joint attention, one study used task-independent dual eye-tracking, in‐
structing participants to look at each other for five minutes (Hessels, Holleman,
Cornelissen, Hooge, & Kemner, 2018). Pairs high in autism displayed less two-way eye
gaze (i.e., eye contact), but, interestingly, more one-way eye gaze (only one participant
looking in the eyes of the other). The interactive nature of this study design could pro‐
vide support for the so-called gaze aversion model (i.e., avoidance of eye contact) over the
gaze indifference model (i.e., insensitivity to others’ eyes) (Moriuchi, Klin, & Jones, 2017).
Directly targeting the role of true interaction, some studies investigated how different
degrees of ecological validity differentially influence behavior along autistic traits. Rice
and Redcay (2016) implemented a simulated live interaction between participants in an
MRI scanner and an experimenter, examining how brain activity is altered depending on
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whether participants think speech is addressed to them live versus pre-recorded. Increas‐
ing scores in subclinical autism went along with reduced differential dmPFC activation
for live compared to pre-recorded speech, presumably reflecting lower perceived liveness
of the speaker in high autistic individuals. Similarly, von dem Hagen and Bright (2017)
manipulated participants’ belief whether the video of a person telling a story was prerecorded or live. While these different beliefs resulted in modulated attention towards the
eye region in low autistic individuals, they did not affect the attention of persons with
high autistic traits. Using mobile eye-tracking, Freeth et al. (2013) involved participants in
a structured conversation with an experimenter whose social presence varied (live faceto-face interaction versus pre-recorded video). During the pre-recorded video ‘interac‐
tion’, the amount of time looked at the experimenter correlated negatively with subclini‐
cal autistic traits, whereas there was no such correlation in the face-to-face interaction.
These studies suggest that individuals with ASD display reduced sensitivity to the cues of
online versus offline interaction compared to TD individuals.
Several other studies have used mobile eye-tracking in the context of a more natural
social environment. During a semi-structured conversation, children with ASD looked
less to the face of the experimenter (particularly to the eyes) than children without ASD
(Hanley et al., 2014; Magrelli et al., 2013). Children were mostly listening in Hanley and
colleagues’ (2014) study, and this pattern of reduced looking at their interaction partner’s
face was not found when children were primarily speaking (Nadig, Lee, Singh, Bosshart,
& Ozonoff, 2010). During a structured face-to-face conversation, adults with ASD showed
fewer fixations on the eyes and more fixations on the mouth as compared to TD adults,
however, they showed no alterations in fixation on the face in general (Hanley et al.,
2015). Similarly, Freeth and Bugembe (2019) found no difference in fixations on the face
when the social partner’s gaze was averted. However, when participants were being
looked at directly, individuals with ASD fixated the face for a shorter time than TD indi‐
viduals. These interactive studies have helped to reveal factors that modulate social at‐
tention of autistic individuals, such as conversational phase or gaze direction of the inter‐
locutor.
To capture nonverbal interpersonal behavior beyond eye gaze, several recent studies
employed video- or device-based motion tracking (e.g., Fitzpatrick et al., 2017a; Romero
et al., 2018). Using a motion-tracking device, Fitzpatrick and colleagues (2017a) imple‐
mented a battery of imitation and motor synchronization tasks to capture dynamical
measures of synchronicity. Children with ASD showed reduced social synchronization
abilities and had difficulties producing consistently timed movements over the course of
an interaction. Interestingly, synchronization abilities correlated with performance on a
false-belief ToM task (Fitzpatrick et al., 2017b). Romero and colleagues (2018) objectively
quantified synchronization of whole-body movement from video recordings of live inter‐
actions, showing that complex whole-body synchronicity between children with ASD
and clinicians was above chance level, and correlated negatively with ASD severity, that
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Lehmann, Maliske, Böckler, & Kanske
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is, children with higher social-cognitive abilities exhibited more behavioral synchronici‐
ty. Such dynamic measures of interpersonal behavior and coordination provide interest‐
ing insights into more complex components of social interaction.
In summary, these results underline how ASD research benefits from implementing a
second-person approach: Being addressed by a social partner modulates social attention
in response to different contextual factors. Depending on the type of paradigm (e.g., joint
attention, manipulation of the degree of ecological validity), ASD compared to TD indi‐
viduals show reduced sensitivity to the presence versus absence of a real-interaction
partner, both in neural and in behavioral measures. In addition, ASD participants re‐
vealed diminished levels of neural and behavioral synchronicity with TD interaction
partners.
Personality Disorders
Personality disorders comprise a number of maladaptive behavioral patterns and cogni‐
tive styles (APA, 2013). Based on previous research, we will focus on Borderline Personal‐
ity Disorder (BPD) and Narcissistic Personality Disorder (NPD).
BPD is characterized by unstable affect and self-image as well as impulsivity, account‐
ing for severely impaired everyday social functioning (APA, 2013). Investigating social
interactions through a joint attention task, Bilek and colleagues (2017) assessed live inter‐
acting dyads in MRI hyperscanning. Neural coupling at the site of right temporo-parietal
junction (rTPJ), a core region for mentalizing processes, was lowest in BPD-healthy con‐
trol (HC) dyads, which might be a cause for difficulties in social interactions in everyday
life. Interestingly, coupling in dyads of remittent BPD and HC was at the level of HC-HC
dyads, suggesting a state specificity or reversibility of low neural coupling in BPD.
NPD is characterized by the need for admiration, a lack of empathy as well as pro‐
nounced self-absorbedness. In subclinical narcissism, Scalabrini and colleagues (2017) re‐
ported higher scores on narcissistic grandiosity going along with reduced activation in
the right anterior insula (rAI) in anticipation of touching a human hand. The rAI is a
main structure of the so-called salience network that is assumed to switch attention away
from internal towards external stimuli, indicating that narcissists might be less respon‐
sive to others and rather remain in self-reflective internal processes.
Taken together, though studies employing truly interactive tasks are still sparse in
personality disorders, initial evidence indicates the power of these paradigms in revealing
reduced interpersonal sensitivity in the respective populations.
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Social Anxiety Disorder
The diagnostic criteria for Social Anxiety Disorder (SAD) include fear in social perform‐
ance situations and the fear of behaving embarrassingly, leading to avoidance of the re‐
spective situations altogether (APA, 2013).
Experimental settings that use socially immersive environments in order to induce
the feeling of being observed by others are particularly suitable to study social evaluative
threat and embarrassment in SAD populations. In doing so, Müller-Pinzler and
colleagues (2015) applied a value estimation task to investigate neural pathways of em‐
barrassment. Participants were led to believe that feedback regarding their performance
in the experimental task was shared with three confederates outside the scanner room.
When feedback on their performance was made public, participants with higher levels of
SAD showed heightened visual attention towards their observers’ faces, as well as in‐
creased activation in medial prefrontal cortex (mPFC) and the right fusiform face area,
possibly indicating increased attention to others and mentalizing about how oneself is
perceived by the audience. Similar results were reported for the performance in a motor
task under observation (Chib, Adachi, & O’Doherty, 2018).
In a behavioral task using dual eye-tracking, pairs of participants were instructed to
look at each other for five minutes (Hessels et al., 2018; see section on autism above).
Pairs high in subclinical social anxiety were engaged in more frequent, but shorter oneway eye gaze than low social anxiety pairs. Myllyneva et al. (2015) had a person sitting
opposite the participant with an LCD screen in between that could be either transparent
or opaque. When the switching between transparent and opaque was computer control‐
led, both SAD adolescents and controls showed higher arousal to direct gaze than to
averted gaze by the other person. However, when participants were forced to initiate the
social interaction themselves by controlling when the screen turned transparent/opaque,
this difference only remained in individuals with SAD. Hence, self-initiated interaction
reduced direct-gaze related arousal in healthy participants, but not in SAD participants.
Overall, these results corroborate clinical descriptions of SAD regarding a higher con‐
cern of one’s public appearance, resulting in increased neural activation of areas associ‐
ated with mentalizing and face processing. The possibility to actively initiate contact
with an interaction partner could reveal different arousal patterns in response to direct
(versus averted) gaze between SAD patients and healthy controls.
Schizophrenia
Schizophrenia (SCZ) is a mental disorder characterized by profound changes in behavior,
communication, and cognition, with symptoms including hallucinations, disorganized
speech and behavior, and delusions that greatly impair interpersonal functioning (APA,
2013; Tandon et al., 2013).
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To investigate neural activation in SCZ during live face-to-face conversation, Takei
and colleagues (2013) used functional near infrared spectography (fNIRS) in a sample of
SCZ patients and controls to investigate neural patterns during live interaction. Specifi‐
cally, participants and experimenters spoke for fixed intervals about a previously speci‐
fied topic. SCZ participants exhibited less appropriate speech, lower production of new
topics, and spoke less overall. On a neural level, SCZ participants showed decreased ac‐
tivity in bilateral temporal lobes and right inferior frontal gyrus, co-varying with nega‐
tive symptoms and disorganization, where the authors suggest a causal role of these
brain areas.
While the field of SCZ research is still underrepresented regarding the implementa‐
tion of truly interactive paradigms, these results show an interesting trend that could not
have been revealed in other, less interactive tasks.
Conclusion
A shift towards applying a second-person account has clearly benefitted research on so‐
cial interaction in psychopathology, with the case of autism taking a prominent role. Sev‐
eral studies showed profound differences in behavioral and neural measures during ac‐
tual social interactions, as compared to engaging participants as mere observers. This
pattern suggests that the full extent and the nature of impairments in social functioning
unfolds only in complex social interactions.
Furthermore, many social phenomena are inherently interactive and can therefore
only manifest themselves in paradigms implementing real dynamic interactions. The sec‐
ond-person account aims at capturing the underlying mechanisms of these phenomena
in their entirety. A few published studies employed hyperscanning with dyads consisting
of healthy and psychopathological participants during live interaction, enabling the in‐
vestigation of co-activation patterns and synchronization of brain activity. However, the
possibilities to interact while lying in an MRI scanner are highly restricted and para‐
digms used in this context are limited in their degree of ecological validity. Likewise, the
implementation of paradigms employing more complex social interactions introduces
new methodological problems, such as complexity of data and reduced experimental con‐
trol. Here, economic games offer the chance to study social interactions in a controlled
environment but with limited flexibility within the interaction. The use of virtual reality
bears potential to regain experimental control as the behavior of a virtual character can
be manipulated gradually. Usually, this comes at the price of the participants being aware
that they interact not with another human but a virtual agent as has been done in experi‐
mental studies addressing Autism and psychotic symptoms (e.g., Forbes, Pan, &
Hamilton, 2016; Veling, Pot-Kolder, Counotte, van Os, & van der Gaag, 2016). This prob‐
lem could, however, be overcome by applying a cover story making participants believe
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Social Impairments in Mental Disorders
10
that they interact with a virtual avatar that is controlled by another human (e.g., Wilms
et al., 2010).
Outside the scanner, paradigms with real life face-to-face interaction allow assessing
the embodied and implicit nature of interactions. The use of technical means such as mo‐
bile eye-tracking or motion capturing devices as well as advanced analytical methods
represent an advancement in objective quantification of social interactions. However, it
should be noted that although these advanced methods enhance the ecological validity of
social interactions in the laboratory, assessing factors like emotions or the dynamics of
interpersonal relations remains challenging. Here, field methods and self-report measures
are still the means of choice: ecological momentary assessment (EMA) – the collection of
various types of data via portable technical devices – has the advantage of capturing reallife social interactions while (or shortly after) they are happening. Furthermore, they can
be complemented with more objective measures such as the electronically activated re‐
corder (EAR). Here, participants wear a portable audio recorder that periodically records
the acoustic environment, allowing for the analysis of, for instance, the words or prosody
used during social interaction or the number of interaction partners.
In conclusion, paradigms employing a second-person approach to the study of social
interactions in mental disorders have yielded promising results. While research using
truly interactive paradigms is still in its infancy, it holds great potential for clinical re‐
search on social interaction.
Funding: PK is supported by German Federal Ministry of Education and Research within the ASD-Net (BMBF FKZ
01EE1409A), the German Research Council (Heinz Maier-Leibnitz Prize KA 4412/1-1) and Die Junge Akademie at the
Berlin-Brandenburg Academy of Sciences and Humanities and the German National Academy of Sciences
Leopoldina.
Competing Interests: The authors declare no conflicts of interest.
Acknowledgments: The authors have no support to report.
Author Contributions: The first and second author contributed equally to this work.
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