A Novel Psychosocial Intervention for Motivational Negative Symptoms in Schizophrenia: Combined Motivational Interviewing and CBT.

OBJECTIVE: Negative symptoms are a primary cause of disability in schizophrenia for which there are no established pharmacotherapies. This study evaluated a novel psychosocial intervention that combined two evidence-based practices-motivational interviewing and cognitive-behavioral therapy (MI-CBT)-for the treatment of motivational negative symptoms. METHODS: Seventy-nine participants with schizophrenia and moderate to severe negative symptoms were included in a randomized controlled trial comparing the 12-session MI-CBT treatment with a mindfulness control condition. Participants were assessed at three time points through the study period, which included 12 weeks of active treatment and 12 weeks of follow-up. The primary outcome measures were motivational negative symptoms and community functioning; the secondary outcomes included a posited biomarker of negative symptoms: pupillometric response to cognitive effort. RESULTS: Compared with the control group, participants in the MI-CBT group showed significantly greater improvements in motivational negative symptoms over the acute treatment period. Their gains relative to baseline were maintained at follow-up, although the differential benefit relative to control subjects was attenuated. There were nonsignificant effects toward improvements in community functioning and differential change in the pupillometric markers of cognitive effort. CONCLUSIONS: The results show that combining motivational interviewing with CBT yields improvements in negative symptoms, a feature of schizophrenia generally thought of as resistant to intervention. Motivational negative symptoms not only responded to the novel treatment, but the gains were maintained over the follow-up period. Implications for future studies and for improving the generalization of the negative symptom gains to daily functioning domains are discussed.

Self-stigma in psychotic disorders: Clinical, cognitive, and functional correlates in a diverse sample.

Self-stigma in mental illness is linked to negative clinical and functional outcomes, but little is known about its correlates specifically in psychotic disorders. Here we investigated the role of clinical symptoms, cognition, and vocational status as correlates of self-stigma in 98 individuals with psychotic disorders (36 Black American, 32 White Hispanic, 11 White Non-Hispanic, 11 Asian American). A principal component analysis of the Internalized Stigma of Mental Illness scale yielded three components: Experiential Stigma, Stereotype Endorsement, and Stigma Resistance. Higher Experiential Stigma was associated with greater severity of affective symptoms and lower vocational status. Higher Stigma Resistance was associated with higher social and non-social cognition, and higher vocational status. Stereotype Endorsement did not significantly correlate with any predictor variable. Linear regression models showed that 13% of the variance in Experiential Stigma was explained by affective symptoms and vocational status, and 20% of the variance in Stigma Resistance was explained by non-social cognition and vocational status. These findings provide new information about the correlates of self-stigma in an ethnically and racially diverse psychotic disorder sample. Such information may lead to a better understanding of self-stigma mechanisms in this population.

The (b)link between amotivation and psychosis: Insights through phasic eye blink rate.

Motivation deficits within Schizophrenia Spectrum Disorders (SSDs) are associated with abnormal striatal dopamine responses during reward processing. Eye blink rate (EBR) has been used as a proxy for striatal dopamine; however, it is unclear whether EBR is sensitive to individual differences in amotivation. Amotivation (clinician-rated and self-reported) and EBR during an effort-based reward task were assessed in 28 outpatients with SSDs. EBR was lower during more "active" task phases relative to rest periods. Higher EBR during reward anticipation was associated with lower self-reported, but not clinician-rated, motivation. These preliminary results support a task-engagement, rather than striatal dopamine, account of EBR.

Group acceptance and commitment therapy for patients and caregivers in psychosis services: Feasibility of training and a preliminary randomized controlled evaluation.

OBJECTIVE: Psychological interventions reduce the impact of psychosis, but widescale implementation is problematic. We tested the feasibility of group acceptance and commitment therapy for Psychosis (G-ACTp), delivered by frontline staff, and co-facilitated by service-user experts-by-experience (SU-EbyE), for service-users and informal caregivers (ISRCTN: 68540929). We estimated recruitment/retention rates and outcome variability for future evaluation. METHODS: Staff and SU-EbyE facilitators completed 1-day workshops, then delivered closely supervised G-ACTp, comprising four sessions (weeks 1-4) and two boosters (10 and 12 weeks). Participants recruited from adult community psychosis services were randomized to receive G-ACTp immediately or after 12 weeks, completing outcome assessments at 0, 4, and 12 weeks. Service-use/month was calculated for 1-year pre-randomization, weeks 0-12, and 5-year uncontrolled follow-up. RESULTS: Of 41 facilitators trained (29 staff, 12 SU-EbyE), 29 (71%; 17 staff, 12 SU-EbyE) delivered 18 G-ACTp courses. Participant refusal rates were low (9% of service-users [10/112]; 5% of caregivers [4/79]); 60% of those invited to participate attended ≥1 G-ACTp session (64% of service-users [39/61]; 56% of caregivers [35/63]). Randomization of facilitators and participants proved problematic and participant follow-up was incomplete (78% [66/85]; 82% of service-users [36/44]; 73% of caregivers [30/41]). Effect sizes ranged from very small to large mostly favouring treatment. Service-use reductions require cautious interpretation, as very few participants incurred costs. CONCLUSIONS: Implementation appears feasible for service-users; for caregivers, retention needs improving. Outcome variability indicated n = 100-300/arm followed up (α = 0.05, 90% power). Methodological limitations' mean replication is needed: identified sources of potential bias may be reduced in a cluster randomized design with sessional outcome completion. PRACTITIONER POINTS: Group acceptance and commitment therapy can be successfully adapted for people with psychosis and their caregivers. Implementation (training and delivery) is possible in routine community mental health care settings. Clinical and economic outcomes are promising, but replication is needed. Recommendations are made for future studies.

Pupillary change on a cognitive effort task in schizophrenia: Associations with cognition and motivation.

Motivational negative symptoms in schizophrenia are associated with abnormalities in effort allocation. Pupillary dilation is a reliable biomarker of effort allocation and was used in this study to evaluate the associations between cognitive effort, ability, and motivation. Individuals with schizophrenia/schizoaffective disorder and moderate-to-high negative symptoms were assessed with pupillometry while performing a cognitive effort task that manipulated level of cognitive difficulty. Participants were also assessed with measures of ability (i.e., cognition and functional capacity), and motivation (i.e., defeatist beliefs and motivational negative symptoms). Pupillary change was examined as an effort modulation index in relation to the ability and motivation measures. Greater pupillary change (i.e., exerting greater amounts of effort) on the hard versus easy conditions was correlated with better cognition and functional capacity and lower motivational negative symptoms, while defeatist beliefs were not significantly correlated. In hierarchical regression analyses, ability measures were entered first and motivation measures were entered second. Motivation measures predicted variance beyond ability. Our findings indicate that both ability and motivation are significant determinants of pupillary indicators of cognitive effort exertion. Further, the results highlight the importance of controlling for cognition when using pupil dilation to index effort/motivation.

Improving treatment motivation in individuals with psychosis: Predictors of response to motivational enhancement.

We sought to evaluate the influence of demographic, symptom, functional and cognitive factors on task-specific motivation, as well as improvement in task-specific motivation that occurs in response to motivational interviewing. In the absence of any intervention, better task-specific motivation was associated with higher perceived competence and lower symptomatology. Post-motivational enhancement improvement in motivation was predicted by fewer hospitalizations and better cognitive insight, with baseline symptomatology no longer predictive. Findings suggest motivational enhancement is likely to benefit individuals with diverse clinical presentations, though may be particularly well suited to those with lesser disease severity and better cognitive insight.

Concurrent Validity of New Subscale Scores for the Booklet Category Test.

The Booklet Category Test (BCT) is a neuropsychological test of cognitive dysfunction that provides only one overall error score indicative of global impairment. It does not, however, delineate specific domains that might be impaired. The aim of this study is to concurrently validate 13 new BCT subscales using legacy instruments in patients with nonpenetrating traumatic brain injury (TBI). Eighty-nine patients with mild, moderate, and severe TBI completed a battery of neuropsychology tests. Partial correlations controlling for age were performed and there were significant correlations between the a priori selected scores from legacy measures of major cognitive domains and both BCT total errors and subscale scores. Additional analysis showed that several subscales were able to differentiate between performance levels on the legacy measures. Overall, our results showed that the subscales measured cognitive skills beyond global impairment, supporting the use of the BCT subscales in a population with TBI.

Speech deficits in serious mental illness: a cognitive resource issue?

Speech deficits, notably those involved in psychomotor retardation, blunted affect, alogia and poverty of content of speech, are pronounced in a wide range of serious mental illnesses (e.g., schizophrenia, unipolar depression, bipolar disorders). The present project evaluated the degree to which these deficits manifest as a function of cognitive resource limitations. We examined natural speech from 52 patients meeting criteria for serious mental illnesses (i.e., severe functional deficits with a concomitant diagnosis of schizophrenia, unipolar and/or bipolar affective disorders) and 30 non-psychiatric controls using a range of objective, computer-based measures tapping speech production ("alogia"), variability ("blunted vocal affect") and content ("poverty of content of speech"). Subjects produced natural speech during a baseline condition and while engaging in an experimentally-manipulated cognitively-effortful task. For correlational analysis, cognitive ability was measured using a standardized battery. Generally speaking, speech deficits did not differ as a function of SMI diagnosis. However, every speech production and content measure was significantly abnormal in SMI versus control groups. Speech variability measures generally did not differ between groups. For both patients and controls as a group, speech during the cognitively-effortful task was sparser and less rich in content. Relative to controls, patients were abnormal under cognitive load with respect only to average pause length. Correlations between the speech variables and cognitive ability were only significant for this same variable: average pause length. Results suggest that certain speech deficits, notably involving pause length, may manifest as a function of cognitive resource limitations. Implications for treatment, research and assessment are discussed.

The normalities and abnormalities associated with speech in psychometrically-defined schizotypy.

Speech deficits are thought to be an important feature of schizotypy--defined as the personality organization reflecting a putative liability for schizophrenia. There is reason to suspect that these deficits manifest as a function of limited cognitive resources. To evaluate this idea, we examined speech from individuals with psychometrically-defined schizotypy during a low cognitively-demanding task versus a relatively high cognitively-demanding task. A range of objective, computer-based measures of speech tapping speech production (silence, number and length of pauses, number and length of utterances), speech variability (global and local intonation and emphasis) and speech content (word fillers, idea density) were employed. Data for control (n=37) and schizotypy (n=39) groups were examined. Results did not confirm our hypotheses. While the cognitive-load task reduced speech expressivity for subjects as a group for most variables, the schizotypy group was not more pathological in speech characteristics compared to the control group. Interestingly, some aspects of speech in schizotypal versus control subjects were healthier under high cognitive load. Moreover, schizotypal subjects performed better, at a trend level, than controls on the cognitively demanding task. These findings hold important implications for our understanding of the neurocognitive architecture associated with the schizophrenia-spectrum. Of particular note concerns the apparent mismatch between self-reported schizotypal traits and objective performance, and the resiliency of speech under cognitive stress in persons with high levels of schizotypy.

Illusory superiority and schizotypal personality: explaining the discrepancy between subjective/objective psychopathology.

An interesting paradox has emerged from the literature regarding schizotypy--defined as the personality organization reflecting a putative liability for schizophrenia--spectrum disorders. Across certain cognitive, emotional, quality of life, and other functional variables, individuals with schizotypy report experiencing relatively severe levels of pathology. However, on objective tests of these same variables, individuals with schizotypy perform largely in the healthy range. These subjective impairments are paradoxical in that individuals with schizotypy, typically recruited from undergraduate college populations, should be healthier in virtually every conceivable measure compared to chronic, older outpatients with severe mental illness. The present study evaluated the idea that the subjective deficits associated with schizotypy largely reflect a lack of illusory superiority bias-a normally occurring bias associated with an overestimation of self-reported positive qualities and underestimation of negative qualities compared to others. In the present study, both state-measured using laboratory emotion-induction methods-and trait positive and negative emotion was assessed across self (e.g., how do you feel at this moment?) and other (e.g., how do most people feel at this moment?) domains in 39 individuals with self-reported schizotypy and 39 matched controls. Controls demonstrated an illusory superiority effect across both state and trait measures whereas individuals with schizotypy did not. These results were not explained by severity of mental health symptoms. These results suggest that a cognitive bias, or lack thereof, is a marker of schizotypy and a potential target for further research and therapy.

Investigation of the Montreal Cognitive Assessment (MoCA) as a cognitive screener in severe mental illness.

This study examined the Montreal Cognitive Assessment (MoCA) as a neurocognitive screener and its relationship with functional outcomes in a sample of outpatients diagnosed with severe mental illness (SMI). The MoCA, Brief Assessment of Cognition in Schizophrenia (BACS), UCSD Performance-Based Skills Assessment Test-2 (UPSA-2), and Global Assessment of Functioning (GAF) were administered to 28 SMI patients and 18 non-psychiatric controls. Patients obtained significantly lower scores on the MoCA, BACS, UPSA-2, and GAF compared to non-patients. The cutoff score <26 of the MoCA resulted in favorable sensitivity (89%) but lower specificity (61%) in classification of SMI patients. The MoCA was significantly correlated with UPSA scores but not GAF scores, whereas the BACS was not significantly correlated with UPSA or GAF scores. When entered into hierarchical regression analyses, the MoCA accounted for significant variance in UPSA scores above variance accounted for by the BACS. Both the MoCA and the BACS contributed unique variance in GAF scores. Overall, the MoCA demonstrated high sensitivity as a cognitive screener in SMI. Moreover, MoCA scores were related to performance-based measures of functional capacity.

The paradox of schizotypy: resemblance to prolonged severe mental illness in subjective but not objective quality of life.

An interesting paradox has emerged regarding the schizophrenia-spectrum. Put simply, college students with schizotypy (defined as the personality organization reflecting a vulnerability to schizophrenia-spectrum pathology) report experiencing pathology with respect to some key functional domains on a level that is equal to or more severe than older, outpatients with an prolonged psychiatric disorders. Notably, this self-reported pathology is not supported by objective/behavioral performance data, suggesting that the primary deficit is psychological in nature (e.g., metacognition). We evaluated whether this subjective-objective dysjunction extends to quality of life (QOL). Eighty-three college students with schizotypy were compared to 50 outpatients with severe mental illness (SMI) as well as to 82 undergraduate and 34 community control groups in subjective and objective QOL via a modified version of Lehman׳s Quality of Life Interview, which covers a range of QOL domains. The schizotypy and SMI group were equally impoverished in all measures of subjective QOL compared to the college and community control groups. In contrast, the schizotypy group was relatively normal in most measures of objective quality of life compared to the SMI group. The subjective-objective dysjunction appears to extend to QOL, and these differences do not appear to reflect a more global negativistic reporting bias.

Schizophrenia spectrum participants have reduced visual contrast sensitivity to chromatic (red/green) and luminance (light/dark) stimuli: new insights into information processing, visual channel function, and antipsychotic effects.

BACKGROUND: Individuals with schizophrenia spectrum diagnoses have deficient visual information processing as assessed by a variety of paradigms including visual backward masking, motion perception and visual contrast sensitivity (VCS). In the present study, the VCS paradigm was used to investigate potential differences in magnocellular (M) vs. parvocellular (P) channel function that might account for the observed information processing deficits of schizophrenia spectrum patients. Specifically, VCS for near threshold luminance (black/white) stimuli is known to be governed primarily by the M channel, while VCS for near threshold chromatic (red/green) stimuli is governed by the P channel. METHODS: VCS for luminance and chromatic stimuli (counterphase-reversing sinusoidal gratings, 1.22 c/degree, 8.3 Hz) was assessed in 53 patients with schizophrenia (including 5 off antipsychotic medication), 22 individuals diagnosed with schizotypal personality disorder and 53 healthy comparison subjects. RESULTS: Schizophrenia spectrum groups demonstrated reduced VCS in both conditions relative to normals, and there was no significant group by condition interaction effect. Post-hoc analyses suggest that it was the patients with schizophrenia on antipsychotic medication as well as SPD participants who accounted for the deficits in the luminance condition. CONCLUSIONS: These results demonstrate visual information processing deficits in schizophrenia spectrum populations but do not support the notion of selective abnormalities in the function of subcortical channels as suggested by previous studies. Further work is needed in a longitudinal design to further assess VCS as a vulnerability marker for psychosis as well as the effect of antipsychotic agents on performance in schizophrenia spectrum populations.