Measuring motivation in schizophrenia: is a general state of motivation necessary for task-specific motivation?

Evaluation of a new intrinsic and extrinsic motivation scale in youth with psychosis spectrum symptoms

BACKGROUND

Impairment in intrinsic motivation (IM), the drive to satisfy internal desires like mastery, may play a key role in disability in psychosis. However, we have limited knowledge regarding relative impairments in IM compared to extrinsic motivation (EM) or general motivation (GM), in part due to limitations in existing measures.

METHODS

Here we address this gap using a novel Trait Intrinsic and Extrinsic Motivation self-report scale in a sample of n = 243 participants including those with schizophrenia, psychosis-risk, and healthy controls. Each of the 7 IM and 6 EM items used a 7-point Likert scale assessing endorsement of dispositional statements. Bifactor analyses of these items yielded distinct IM, EM, and GM factor scores. Convergent and discriminant validity were examined in relation to General Causality Orientation Scale (GCOS-CP) and Quality of Life 3-item IM measure (QLS-IM). Utility was assessed in relation to psychosis-spectrum (PS) status and CAINS clinical amotivation.

RESULTS

IM and EM showed acceptable inter-item consistency (IM: α = 0.88; EM: α = 0.66); the bifactor model exhibited fit that varied from good to borderline to inadequate depending on the specific fit metric (SRMR = 0.038, CFI = 0.94, RMSEA = 0.106 ± 0.014). IM scores correlated with established IM measures: GCOS-CP Autonomy (rho = 0.38, p < 0.01) and QLS-IM (rho = 0.29, p < 0.01). Supporting discriminant validity, IM did not correlate with GCOS-CP Control (rho = -0.14, p > 0.05). Two-year stability in an available longitudinal subset (n = 35) was strong (IM: rho = 0.64, p < 0.01; EM: rho = 0.55, p < 0.01). Trait IM was lower in PS youth (t = 4.24, p < 0.01), and correlated with clinical amotivation (rho = -0.36, p < 0.01); EM did not show significant clinical associations.

CONCLUSIONS

These results demonstrate the clinical relevance of IM in psychosis risk. They also provide preliminary support for the reliability, validity and utility of this new Trait IM-EM scale, which addresses a measurement gap and can facilitate identification of neurobehavioral and clinical correlates of IM deficits.

Bridge centrality network structure of negative symptoms in people with schizophrenia

Negative symptoms are complex psychopathology. Although evidence generally supported the NIMH five consensus domains, research seldom examined measurement invariance of this model, and domain-specific correspondence across multiple scales. This study aimed to examine the interrelationship between negative symptom domains captured by different rating scales, and to examine the domain-specific correspondence across multiple scales. We administered the Brief Negative Symptom Scale (BNSS), the Self-evaluation of Negative Symptoms (SNS), and the Scale for Assessment of Negative Symptoms (SANS) to 204 individuals with schizophrenia. We used network analysis to examine the interrelationship between negative symptom domains. Besides regularized partial correlation network, we estimated bridge centrality indices to investigate domain-specific correspondence, while taking each scale as an independent community. The regularized partial correlation network showed that the SNS nodes clustered together, whereas the SANS and the BNSS nodes intermingled together. The SANS attention domain lied at the periphery of the network according to the Fruchterman-Reingold algorithm. The SANS anhedonia-asociality (strength = 1.48; EI = 1.48) and the SANS affective flattening (strength = 1.06; EI = 1.06) had the highest node strength and EI. Moreover, the five nodes of the BNSS bridged the nodes of the SANS and the SNS. BNSS blunted affect (strength = 0.76; EI = 0.76) and SANS anhedonia-asociality (strength = 0.76; EI = 0.74) showed the highest bridge strength and bridge EI. The BNSS captures negative symptoms and bridges the symptom domains measured by the SANS and the SNS. The three scales showed domain-specific correspondence.

Causal pathways to social and occupational functioning in the first episode of schizophrenia: uncovering unmet treatment needs

BACKGROUND

We aimed to identify unmet treatment needs for improving social and occupational functioning in early schizophrenia using a data-driven causal discovery analysis.

METHODS

Demographic, clinical, and psychosocial measures were obtained for 276 participants from the Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP) trial at baseline and 6-months, along with measures of social and occupational functioning from the Quality of Life Scale. The Greedy Fast Causal Inference algorithm was used to learn a partial ancestral graph modeling causal relationships across baseline variables and 6-month functioning. Effect sizes were estimated using a structural equation model. Results were validated in an independent dataset (N = 187).

RESULTS

In the data-generated model, greater baseline socio-affective capacity was a cause of greater baseline motivation [Effect size (ES) = 0.77], and motivation was a cause of greater baseline social and occupational functioning (ES = 1.5 and 0.96, respectively), which in turn were causes of their own 6-month outcomes. Six-month motivation was also identified as a cause of occupational functioning (ES = 0.92). Cognitive impairment and duration of untreated psychosis were not direct causes of functioning at either timepoint. The graph for the validation dataset was less determinate, but otherwise supported the findings.

CONCLUSIONS

In our data-generated model, baseline socio-affective capacity and motivation are the most direct causes of occupational and social functioning 6 months after entering treatment in early schizophrenia. These findings indicate that socio-affective abilities and motivation are specific high-impact treatment needs that must be addressed in order to promote optimal social and occupational recovery.

Association between motivation and engagement with changes in cognition and symptoms after digital cognitive training in schizophrenia

BACKGROUND

Digital cognitive training can remediate cognitive deficits present in schizophrenia. However, limited motivation and engagement may impact adherence to training. Therefore, identifying factors that may enhance (facilitators) or decrease (barriers) engagement in digital cognitive training and possibly modulate its effects are of great clinical relevance.

METHODS

We measured cognition, symptom severity, motivation (semi-structured interview), and engagement (adapted Utrecht Work Engagement Scale - UWES) of 27 patients with schizophrenia after a 40-h digital cognitive training. The interview transcript quotes were coded and categorized into facilitators and barriers. Thereafter, we tested the association of motivation and engagement with changes in cognition and symptoms after training.

RESULTS

The facilitator 'good performance' and the barrier 'difficult exercise' were associated with larger gains in attention (p = 0.03) and reasoning and problem solving (p = 0.02), respectively. 'Poor performance' was associated with smaller gains in global cognition (p < 0.01), attention (p = 0.03), and working memory (p = 0.02). The facilitator 'welcoming setting' was associated with larger reductions in the negative (p = 0.01) and total (p = 0.01) symptoms measured by the Positive and Negative Syndrome Scale. The UWES engagement scale was associated with different facilitators and barriers that emerged from the interview, an indication of consistency among both qualitative and quantitative assessments.

DISCUSSION

Using a mixed quantitative and qualitative research design, we showed associations between motivation and engagement and the response to digital cognitive training in schizophrenia. Facilitators and barriers were associated with engagement, gains in cognition, and reduced symptoms after the intervention, providing insights on how to increase engagement in the digital cognitive training delivered to subjects with schizophrenia.

The relative contributions of insight and neurocognition to intrinsic motivation in schizophrenia

Intrinsic motivation was described as the mental process of pursuing a task or an action because it is enjoyable or interesting in itself and was found to play a central role in the determination of the functional outcome of schizophrenia. Neurocognition is one of the most studied determinants of intrinsic motivation in clinically stable schizophrenia while little is known about the role of insight. Following this need we decided to focus on the contribution of different aspects of insight and of neurocognition to intrinsic motivation in a large sample (n = 176) of patients with stable schizophrenia. We performed three hierarchical linear regressions from which resulted that, among different insight aspects, the ability to correctly attribute signs and symptoms to the mental disorder made the strongest contribution to intrinsic motivation. Neurocognition, also, was significantly related to intrinsic motivation when analyzed simultaneously with insight. Moreover, even after accounting for sociodemographic and clinical variables significantly correlated with intrinsic motivation, the relationship between insight and neurocognition and intrinsic motivation remained statistically significant. These findings put the emphasis on the complex interplay between insight, neurocognition, and intrinsic motivation suggesting that interventions targeting both insight and neurocognition might possibly improve this motivational deficit in stable schizophrenia should.

Behavioural phenotypes of intrinsic motivation in schizophrenia determined by cluster analysis of objectively quantified real-world performance

Intrinsic motivation deficits are a prominent feature of schizophrenia that substantially impacts functional outcome. This study used cluster analysis of innate real-world behaviours captured during two open-field tasks to dimensionally examine heterogeneity in intrinsic motivation in schizophrenia patients (SZ) and healthy controls (HC). Wireless motion capture quantified participants' behaviours aligning with distinct aspects of intrinsic motivation: exploratory behaviour and effortful activity in the absence of external incentive. Cluster analysis of task-derived measures identified behaviourally differentiable subgroups, which were compared across standard clinical measures of general amotivation, cognition, and community functioning. Among 45 SZ and 47 HC participants, three clusters with characteristically different behavioural phenotypes emerged: low exploration (20 SZ, 19 HC), low activity (15 SZ, 8 HC), and high exploration/activity (10 SZ, 20 HC). Low performance in either dimension corresponded with similar increased amotivation. Within-cluster discrepancies emerged for amotivation (SZ > HC) within the low exploration and high performance clusters, and for functioning (SZ < HC) within all clusters, increasing from high performance to low activity to low exploration. Objective multidimensional characterization thus revealed divergent behavioural expression of intrinsic motivation deficits that may be conflated by summary clinical measures of motivation and overlooked by unidimensional evaluation. Deficits in either aspect may hinder general motivation and functioning particularly in SZ. Multidimensional phenotyping may help guide personalized remediation by discriminating between intrinsic motivation impairments that require amelioration versus unimpaired tendencies that may facilitate remediation.

Evaluation of a supported education and employment program for adolescents and young adults with mental health problems: A study protocol of the StAB project

The majority of mental illnesses begins in childhood, adolescence and young adulthood before the age of 25. The transition from adolescence to adulthood is a particularly vulnerable time for adolescents with mental illness, affecting psychosocial functioning and participation in work life. Therefore, they need—in contrast to classic standard vocational interventions—a long-term, holistic and individually oriented vocational rehabilitation program. With the innovative model project "Start in education and employment (StAB)”, adolescents and young adults with mental illnesses are to be supported with regard to their vocational perspectives and participation by a new type of individualized, holistic, long-term job coaching. It follows the Individual Placement and Support (IPS) concept, as a manualized form of the Supported Employment Approach and is based on the "first place–then train" principle. In order to evaluate the effectiveness and feasibility of the StAB program, a double-centre prospective single arm evaluation study in a mixed-methods design will be conducted. The focus is on quantitative research analysing pre-post-effects of the StAB intervention in a two-year observational study. Young people between 15 and 25 years with a psychiatric diagnosis who are currently in receipt of means-tested benefits or are entitled to them will be recruited. The study will take place in two major cities in the north-western part of Germany, Bielefeld and Dortmund. We expect to contribute to gain more empirical data about the implementation of Supported Employment and Education to severely mentally ill adolescents and young adults in German settings. Moreover, these results may also provide the scientific foundation for future measures focusing the improvement of vocational rehabilitation for young people with mental illness.

The study was registered in the German Clinical Trials Register (DRKS00027576) on March 10, 2022.

On what motivates us: a detailed review of intrinsic v. extrinsic motivation

Motivational processes underlie behaviors that enrich the human experience, and impairments in motivation are commonly observed in psychiatric illness. While motivated behavior is often examined with respect to extrinsic reinforcers, not all actions are driven by reactions to external stimuli; some are driven by 'intrinsic' motivation. Intrinsically motivated behaviors are computationally similar to extrinsically motivated behaviors, in that they strive to maximize reward value and minimize punishment. However, our understanding of the neurocognitive mechanisms that underlie intrinsically motivated behavior remains limited. Dysfunction in intrinsic motivation represents an important trans-diagnostic facet of psychiatric symptomology, but due to a lack of clear consensus, the contribution of intrinsic motivation to psychopathology remains poorly understood. This review aims to provide an overview of the conceptualization, measurement, and neurobiology of intrinsic motivation, providing a framework for understanding its potential contributions to psychopathology and its treatment. Distinctions between intrinsic and extrinsic motivation are discussed, including divergence in the types of associated rewards or outcomes that drive behavioral action and choice. A useful framework for understanding intrinsic motivation, and thus separating it from extrinsic motivation, is developed and suggestions for optimization of paradigms to measure intrinsic motivation are proposed.

The Effect of Smartphone-Based Cognitive Training on the Functional/Cognitive Markers of Schizophrenia: A One-Year Randomized Study

Background: Cognitive impairment is associated with long-term disability that results in the deterioration of both the social and professional status of individuals with schizophrenia. The impact of antipsychotic therapy on cognitive function is insufficient. Cognitive training is therefore proposed as a tool for cognitive rehabilitation in schizophrenia. In this study we investigated the effect of self-administered cognitive training using a smartphone-based application on the cognitive function of paranoid schizophrenia patients focusing on response time, correct answer rate, incorrect answer rate, and fatigability to check, if these functions can be functional markers of successful cognitive-smartphone rehabilitation. Methods: 1-year multicenter, open-label randomized study was conducted on 290 patients in a state of symptomatic remission. 191 patients were equipped with the full version of the application and conducted cognitive training twice a week. Reference group (n = 99) was provided with a version of the application having only limited functionality, testing the cognitive performance of patients every 6 months. Results: Statistically significant improvement was observed in both the rate of correct answers (by 4.8%, p = 0.0001), and cognitive fatigability (by 2.9%, p = 0.0001) in the study group, along with a slight improvement in the rate of incorrect answers (by 0.9%, p = 0.15). In contrast, the reference group, who performed cognitive training every 6 months, demonstrated no significant changes in any cognitive activities. Conclusions: Cognitive trainings facilitated by a smartphone-based application, performed regularly for a longer period of time are feasible and may have the potential to improve the cognitive functioning of individuals with schizophrenia. Correct answers and cognitive fatigability have potential to be functional markers of successful smartphone-based psychiatric rehabilitations in schizophrenia patients.

Mobile enhancement of motivation in schizophrenia: A pilot randomized controlled trial of a personalized text message intervention for motivation deficits

OBJECTIVE

Motivation deficits remain an unmet treatment need in schizophrenia. Recent research has identified mechanisms underlying motivation deficits (i.e., impaired effort-cost computations, reduced future reward-value representation maintenance) that may be effective treatment targets to improve motivation. This study tested the feasibility and preliminary effectiveness of Mobile Enhancement of Motivation in Schizophrenia (MEMS), an intervention that leverages mobile technology to target these mechanisms with text messages.

METHOD

Fifty-six participants with a schizophrenia-spectrum disorder were randomized to MEMS (n = 27) or a control condition (n = 29). All participants set recovery goals to complete over 8 weeks. Participants in the MEMS group additionally received personalized, interactive text messages on their personal cellphones each weekday.

RESULTS

Retention and engagement in MEMS were high: 92.6% completed 8 weeks of MEMS, with an 86.1% text message response rate, and 100% reported being satisfied with the text messages. Compared to participants in the control condition, the participants in the MEMS condition had significantly greater improvements in interviewer-rated motivation and anticipatory pleasure and attained significantly more recovery-oriented goals at 8 weeks. There were no significant group differences in purported mechanisms (performance-based effort-cost computations and future reward-value representations) or in self-reported motivation, quality of life, or functioning.

CONCLUSION

Results demonstrate that MEMS is feasible as a brief, low-intensity mobile intervention that could effectively improve some aspects of motivation (i.e., initiation and maintenance of goal-directed behaviors) and recovery goal attainment for those with schizophrenia-spectrum disorders. More work is needed with larger samples and to understand the mechanisms of change in MEMS. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Metacognition moderates the relationship between self-reported and clinician-rated motivation in schizophrenia

Introduction

Prior work has found varied relationships between self-reported and clinician-rated motivation measures in schizophrenia, suggesting that moderators might impact the strength of this relationship. This current study sought to identify whether metacognition – the ability to form complex representations about oneself, others, and the world – moderates the relationship between self-reported and clinician-rated motivation measures. We also explored whether clinical insight and neurocognition moderated this relationship.

Methods

Fifty-six participants with a schizophrenia-spectrum disorder completed the Motivation and Pleasure Self-Report Scale and the clinician-rated motivation index from the Heinrichs-Carpenter Quality of Life Scale.

Results

Metacognition significantly moderated the relationship; self-reported and clinician-rated motivation were positively and significantly correlated only when metacognition was relatively high. Neither clinical insight nor neurocognition moderated the relationship.

Discussion

Metacognition appears to be a key variable impacting the strength of the relationship between self-reported and clinician-rated motivation measures and may help to partly explain the varied relationships observed in prior work. Using a metacognitive framework to guide assessment interviews and targeting metacognition in psychosocial treatments may help to improve the synchrony between self-perceptions and clinician ratings of motivation.

Clarifying the overlap between motivation and negative symptom measures in schizophrenia research: A meta-analysis

Motivation and negative symptom research has recently been hampered by a series of inconsistent findings, leading to calls for a greater consensus on the type of measures used across studies. To inform this issue, we conducted a meta-analysis that quantified the association between motivation measures (self-report, performance-based) and clinician-rated negative symptom measures as well as a series of moderator analyses to develop a greater understanding of the measurement factors impacting this relationship. Forty-seven eligible studies with people with schizophrenia-spectrum disorders were included. Using a random-effects meta-analytic model, a small but significant overall effect size emerged between motivation and clinician-rated negative symptoms (r = -0.18). Several significant moderators were identified, including the generation of negative symptom measures such that there was a significantly stronger relationship between motivation and second-generation (r = -0.38) than first-generation negative symptom measures (r = -0.17). Further, the type of performance-based measure used moderated the relationship, with effort discounting tasks most strongly related to negative symptoms (r = -0.44). The domain of motivation assessed (intrinsic, extrinsic, amotivation) also moderated the relationship. These findings help to identify sources of inconsistencies observed in prior studies and point to both second-generation and effort discounting tasks as the most promising types of measures, particularly for those interested in validating motivation measures or assessing the effectiveness of motivation treatments. Although additional research is needed, our results suggest that using these measures may help to reduce inconsistencies across studies and move the field forward.

The impact of intrinsic motivation on session attendance and reliable cognitive improvement in cognitive remediation in schizophrenia

OBJECTIVE

Cognitive remediation (CR) is considered a potentially effective method of improving cognitive function in people with schizophrenia. Few studies, however, have explored the role of intrinsic motivation on treatment utilization or training outcomes in CR in this population. This study explored the impact of task-specific intrinsic motivation on attendance and reliable cognitive improvement in a controlled trial comparing CR with a computer game (CG) playing control.

METHODS

Forty-nine participants with schizophrenia or schizoaffective disorder, allocated to 10 weeks of group-based CR (n = 25) or CG control (n = 24), provided complete outcome data at baseline. Forty-three participants completed their assigned intervention. Cognition, psychopathology and intrinsic motivation were measured at baseline and end-treatment. Regression analyses explored the relative contribution of baseline motivation and other clinical factors to session attendance as well as the association of baseline and change in intrinsic motivation with the odds of reliable cognitive improvement (calculated using reliable change indices).

RESULTS

Baseline reports of perceived program value were the only significant multivariable predictor of session attendance when including global cognition and psychiatric symptomatology. The odds of reliable cognitive improvement significantly increased with greater improvements in program interest and value from baseline to end-treatment. Motivational changes over time were highly variable between participants.

CONCLUSION

Task-specific intrinsic motivation in schizophrenia may represent an important patient-related factor that contributes to session attendance and cognitive improvements in CR. Regular evaluation and enhancement of intrinsic motivation in cognitively enhancing interventions may optimize treatment engagement and the likelihood of meaningful training outcomes.

Achievement motivation in early schizophrenia: Relationship with symptoms, cognition and functional outcome

BACKGROUND

Individuals with schizophrenia engage in goal-directed activities significantly less often compared to healthy individuals in the community. There is ample evidence documenting the presence of motivational deficits in schizophrenia using observer-based ratings; however, purely self-reported accounts of patients' motivation are less well understood. This study examined subjective accounts of trait achievement motivation among relatively young, clinically stable, early-course outpatients with schizophrenia.

METHODS

Thirty-nine early-course patients and 39 healthy comparison subjects completed clinical and cognitive assessments in addition to a self-report inventory measuring achievement motivation.

RESULTS

Patients were found to endorse significantly lower levels of motivation, a mean difference which translated to a large effect size (Cohen's d = 1.1). Patients' self-reported motivation was significantly related to clinician ratings of motivational deficits which were based on behavioural output, and to vocational functioning. Within the patient sample, 33.3% of individuals were found to experience prominent or clinically significant levels of amotivation based on patients' own self-report. Self-reported achievement motivation was not associated with other clinical variables such as positive symptom severity or expressive negative symptoms.

CONCLUSIONS

Our results serve to highlight the occurrence and prevalence of motivational deficits in patients with schizophrenia who are in the early stages of their illness. Subjective accounts of motivation in this population were found to be related to important outcomes such as community functioning, highlighting the importance of this domain of illness. Targeting these deficits early in the course of the illness offers the potential to curb potential prospective poor outcomes and sets the stage for recovery.

The Relationship of Motivation and Neurocognition with Functionality in Schizophrenia: A Meta-analytic Review

The role that neurocognition plays in functionality in schizophrenia has been widely examined, although in recent years increasing attention has been paid to the influence of motivation instead. This study provides a review of the relationship of neurocognition and motivation with functionality in schizophrenia, taking into account objective/subjective functionality assessment, demographic variables, and the different terms used when referring to motivation. A search of electronic databases identified 34 studies that met the inclusion criteria for review. Correlation coefficients between motivation and functionality and between neurocognition and functionality were extracted. For a better understanding, potential moderator variables were also extracted. Meta-analysis showed that both motivation and neurocognition assessments were strongly associated with functioning, with correlations between motivation and functional outcomes being stronger. However, more than three-quarters of the variance in outcome remained unexplained by the moderating factors examined. The paper concludes with recommendations for clinical practice and future research.

Objective investigation of activity preference in schizophrenia: A pilot study

Amotivation and reduced goal-directed activity engagement are prominent features of schizophrenia. Previous investigations of patients' activities have relied on accounts of daily living activities, rather than objective measures. This study used wireless motion capture to objectively evaluate activity preference when individuals are provided an explicit choice between an active versus passive engagement option. Twenty outpatients with schizophrenia and twenty matched healthy controls completed the Activity Preference Task, in which participants play a motion-based game (active) or watch a film (passive), and were administered clinical and cognitive assessments. Schizophrenia participants' duration, intensity, and persistence of active engagement were associated with apathy and community functioning. No group differences emerged from comparisons of task measures; however, exploratory cluster analysis identified a distinct subgroup of schizophrenia patients with reduced engagement and increased apathy compared to other patients and controls. The Task provides a means of quantifying activity engagement, which may be particularly valuable given the lack of objective measures for intrinsically motivated behaviours. Our initial findings suggest that schizophrenia patients as a group are equally inclined as healthy individuals towards actively engaging activities when presented an explicit choice, but such provision may be insufficient for initiation and maintenance of functional behaviours among amotivated patients.

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.

Beck Self-Esteem Scale-Short Form: Development and psychometric evaluation of a scale for the assessment of self-concept in schizophrenia

A requisite step for testing cognitive theories regarding the role of self-concept in schizophrenia is the development of measures that follow a cognitive conceptualization and better capture the multifaceted nature of this construct. The purpose of this study was to examine the psychometric properties a new self-concept measure, the Beck Self-Esteem Scale-Short Form (BSES-SF), based on a sample of 204 individuals with schizophrenia or schizoaffective disorder. We evaluated the BSES-SF's dimensionality, internal consistency reliability, and construct and divergent validity using confirmatory factor analysis, Cronbach's alpha, Pearson correlations, independent samples t-tests, and one-way analysis of variance. Findings indicate that the 10-item BSES-SF is a reliable and valid measure of self-concept that is appropriate for a broad group of individuals with schizophrenia spectrum disorders. Following cognitive theory, the scale demonstrated significant relationships with delusion severity, motivation, and depression, further signifying its utility for research and practice efforts that are designed to address psychopathology in schizophrenia.

Motivation in rehabilitation and acquired brain injury: can theory help us understand it?

Background: In acquired brain injury (ABI) populations, low motivation to engage in rehabilitation is associated with poor rehabilitation outcomes. Motivation in ABI is thought to be influenced by internal and external factors. This is consistent with Self-determination Theory, which posits that motivation is intrinsic and extrinsic. This paper discusses the benefit of using Self-determination Theory to guide measurement of motivation in ABI. Methods: Using a narrative review of the Self-determination Theory literature and clinical rehabilitation research, this paper discusses the unique role intrinsic and extrinsic motivation has in healthcare settings and the importance of understanding both when providing rehabilitation in ABI. Results: Based on the extant literature, it is possible that two independently developed measures of motivation for ABI populations, the Brain Injury Rehabilitation Trust Motivation Questionnaire-Self and the Motivation for Traumatic Brain Injury Rehabilitation Questionnaire, may assess intrinsic and extrinsic motivation, respectively. Conclusion: Intrinsic and extrinsic motivation in ABI may be two equally important but independent factors that could provide a comprehensive understanding of motivation in individuals with ABI. This increased understanding could help facilitate behavioural approaches in rehabilitation. Implications for Rehabilitation Conceptualization of motivation in ABI would benefit from drawing upon Self-determination Theory. External factors of motivation such as the therapeutic environment or social support should be carefully considered in rehabilitation in order to increase engagement. Assessing motivation as a dual rather than a global construct may provide more precise information about the extent to which a patient is motivated.

A meta-analytic review of self-reported, clinician-rated, and performance-based motivation measures in schizophrenia: Are we measuring the same "stuff"?

An array of self-reported, clinician-rated, and performance-based measures has been used to assess motivation in schizophrenia; however, the convergent validity evidence for these motivation assessment methods is mixed. The current study is a series of meta-analyses that summarize the relationships between methods of motivation measurement in 45 studies of people with schizophrenia. The overall mean effect size between self-reported and clinician-rated motivation measures (r = 0.27, k = 33) was significant, positive, and approaching medium in magnitude, and the overall effect size between performance-based and clinician-rated motivation measures (r = 0.21, k = 11) was positive, significant, and small in magnitude. The overall mean effect size between self-reported and performance-based motivation measures was negligible and non-significant (r = -0.001, k = 2), but this meta-analysis was underpowered. Findings suggest modest convergent validity between clinician-rated and both self-reported and performance-based motivation measures, but additional work is needed to clarify the convergent validity between self-reported and performance-based measures. Further, there is likely more variability than similarity in the underlying construct that is being assessed across the three methods, particularly between the performance-based and other motivation measurement types. These motivation assessment methods should not be used interchangeably, and measures should be more precisely described as the specific motivational construct or domain they are capturing.

Neural Correlates for Intrinsic Motivational Deficits of Schizophrenia; Implications for Therapeutics of Cognitive Impairment

The ultimate goal of the treatment of schizophrenia is recovery, a notion related to improvement of cognitive and social functioning. Cognitive remediation therapies (CRT), one of the most effective cognition enhancing methods, have been shown to moderately improve social functioning. For this purpose, intrinsic motivation, related to internal values such as interest and enjoyment, has been shown to play a key role. Although the impairment of intrinsic motivation is one of the characteristics of schizophrenia, its neural mechanisms remain unclear. This is related to the lack of feasible measures of intrinsic motivation, and its response to treatment. According to the self-determination theory (SDT), not only intrinsic motivation, but extrinsic motivation has been reported to enhance learning and memory in healthy subjects to some extent. This finding suggests the contribution of different types of motivation to potentiate the ability of the CRT to treat cognitive impairment of schizophrenia. In this paper, we provide a review of psychological characteristics, assessment methods, and neural correlates of intrinsic motivation in healthy subjects and patients with schizophrenia. Particularly, we focus on neuroimaging studies of intrinsic motivation, including our own. These considerations are relevant to enhancement of functional outcomes of schizophrenia.

Metacognition Is Necessary for the Emergence of Motivation in People With Schizophrenia Spectrum Disorders: A Necessary Condition Analysis

Metacognition deficits are a putative cause of reduced motivation in people with schizophrenia spectrum disorders. However, it is unclear whether certain levels of metacognition are necessary for motivation to emerge. This study used a Necessary Condition Analysis to test whether metacognition was necessary for the presence of motivation and to identify the minimum level of metacognition necessary for high motivation to be possible in people with schizophrenia spectrum disorders (N = 175). Participants completed clinician-rated measures of metacognition and motivation. Necessary Condition Analysis revealed that metacognition is a necessary condition for motivation and that high levels of motivation were only possible, although not guaranteed, when at least a basic level of metacognition was present. The findings suggest that metacognition is a necessary building block for the development of motivation. Results suggest that targeting metacognition may be essential for improving motivation among people with schizophrenia spectrum disorders who do not meet this metacognition threshold.

Impaired prefrontal activity to regulate the intrinsic motivation-action link in schizophrenia

A core feature of schizophrenia (SCZ) is impairment in intrinsic motivation. Although intrinsic motivation plays an important role in enhancing improvement of the social functioning, its neural mechanisms of impairment have yet to be clarified. We hypothesized that abnormal function of the frontostriatal loop consisting of the striatum and lateral prefrontal cortex (LPFC) may be related to impaired intrinsic motivation in SCZ. We tested this by comparing the brain activity measured by functional magnetic resonance imaging and behavioral parameters associated with movement, motivation, and cognitive control between 18 stable SCZ patients and 17 healthy control (HC) participants during a task that elicits intrinsic motivation. We also compared the functional connectivity during resting-state and the fractional anisotropy using diffusion tensor imaging analysis between the two groups. We adopted an enjoyable timing task to stop a stopwatch at an exact time, which in our previous study has demonstrated to elicit intrinsic motivation. Although the performance level in general was not different between groups, the SCZ group performed worse than the HC group in trials following “overshoot” errors (i.e., the response was too late). SCZ participants showed lower intrinsic motivation to the task than the HC group in an inventory report. The striatal activity during the prediction at the task cue period was consistently lower in SCZ participants than in HC. The LPFC activity at the task cue period positively correlated with intrinsic motivation and also with the rate of success following overshoot errors in the HC group, but not in the SCZ group. The LPFC activity at the task cue period was also positively correlated with the striatal activity in both groups. The striatal activity during the feedback period was not significantly different between groups. These results suggest that, unlike HC, the neural activity in the LPFC fails to mediate between prediction of hedonic events and cognitive control of action plans in SCZ, whereas the hedonic response is retained.

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The neural basis of impaired motivation in schizophrenia is examined using fMRI.

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The hedonic response to a feedback in the striatum is retained in schizophrenia.

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Translating hedonic events to action plans is impeded by poor cognitive control.

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The cognitive control impairment is associated with altered prefrontal function.

Behavioural Regulation in Exercise Questionnaire in people with schizophrenia: construct validity of the Portuguese versions

PURPOSE

People with schizophrenia have low physical activity levels that can be explained by the restriction in motivation. The Behavioural Regulation in Exercise Questionnaire-2 is a 19-item scale commonly used to assess five different motivational subtypes for physical activity. However, there are limited psychometric analyses of this version in the schizophrenia context. Moreover, there is a lack of information related to the psychometric properties of version 3 of this questionnaire, with 24 items and six different motivational subtypes. The aim of this study was to examine the construct validity of both Portuguese versions in people with schizophrenia.

METHODS

A total of 118 persons with schizophrenia were included (30 women). Cronbach's alpha was used for internal consistency, Pearson's correlation for the retained motivation-types, confirmatory factor analysis for the structural validity of version 2 and exploratory factor analysis for the factor structure of version 3.

RESULTS AND CONCLUSIONS

Analyses of version 2 provided an adequate fit index for the structure of the five factors. Exploratory analyses suggested retaining 2 factors of version 3. The results of this study suggest that version 3 was an appropriate measure to assess controlled and autonomous motivation for physical activity in people with schizophrenia and support its use in clinical practice and research. Implications for Rehabilitation This study supports the need to identify the reasons why people with schizophrenia practice physical activity. For that purpose, it is important to use valid and cost-effective instruments. The Portuguese version of BREQ-2 confirmed a 5-factor model and showed adequate fit for the application in people with schizophrenia. However, the incremental indices values were lower than expected. The Portuguese version of BREQ-3 showed acceptable psychometric properties to assess controlled and autonomous motivation for physical activity in people with schizophrenia.

From neurocognition to community participation in serious mental illness: the intermediary role of dysfunctional attitudes and motivation

BACKGROUND

Evidence for a relationship between neurocognition and functional outcome in important areas of community living is robust in serious mental illness research. Dysfunctional attitudes (defeatist performance beliefs and asocial beliefs) have been identified as intervening variables in this causal chain. This study seeks to expand upon previous research by longitudinally testing the link between neurocognition and community participation (i.e. time in community-based activity) through dysfunctional attitudes and motivation.

METHOD

Adult outpatients with serious mental illness (N = 175) participated, completing follow-up assessments approximately 6 months after initial assessment. Path analysis tested relationships between baseline neurocognition, emotion perception, functional skills, dysfunctional attitudes, motivation, and outcome (i.e. community participation) at baseline and follow-up.

RESULTS

Path models demonstrated two pathways to community participation. The first linked neurocognition and community participation through functional skills, defeatist performance beliefs, and motivation. A second pathway linked asocial beliefs and community participation, via a direct path passing through motivation. Model fit was excellent for models predicting overall community participation at baseline and, importantly, at follow-up.

CONCLUSIONS

The existence of multiple pathways to community participation in a longitudinal model supports the utility of multi-modal interventions for serious mental illness (i.e. treatment packages that build upon individuals' strengths while addressing the array of obstacles to recovery) that feature dysfunctional attitudes and motivation as treatment targets.

Metacognition deficits as a risk factor for prospective motivation deficits in schizophrenia spectrum disorders

Although motivation deficits are key determinants of functional outcomes, little is known about factors that contribute to prospective motivation in people with schizophrenia. One candidate factor is metacognition, or the ability to form complex representations about oneself, others, and the world. This study aimed to assess whether metacognition deficits were a significant predictor of reduced prospective motivation, after controlling for the effects of baseline motivation, anticipatory pleasure, and antipsychotic medication dose. Fifty-one participants with a schizophrenia spectrum disorder completed measures of metacognition and anticipatory pleasure at baseline; participants also completed a measure of motivation at baseline and six months after the initial assessment. Baseline antipsychotic dose was obtained from medical charts. Hierarchical regression analysis revealed that lower levels of baseline metacognition significantly predicted reduced levels of motivation assessed six months later, after controlling for baseline levels of motivation, anticipatory pleasure, and antipsychotic dose. Higher baseline antipsychotic dose was also a significant predictor of reduced six month motivation. Results suggest that metacognition deficits and higher antipsychotic dose may be risk factors for the development of motivation deficits in schizophrenia. Implications include utilizing interventions to improve metacognition in conjunction with evaluating and possibly lowering antipsychotic dose for people struggling with motivation deficits.

Pupillary Responses as a Biomarker of Diminished Effort Associated With Defeatist Attitudes and Negative Symptoms in Schizophrenia

BACKGROUND

The hypothesis that defeatist performance attitudes are associated with decreased goal-directed task effort and negative symptoms in consumers with schizophrenia was investigated by using pupillary responses as a biomarker of task effort. Pupillary dilation during cognitive tasks provides a biomarker of effort devoted to the task, with greater dilation indicating greater effort.

METHODS

Defeatist attitudes were assessed in 149 consumers with schizophrenia or schizoaffective disorder and 50 healthy control subjects, and consumers were divided into three groups (tertile split) with respect to severity of defeatist attitudes. Pupillary dilation responses were recorded during a digit-span task with three-, six-, and nine-digit spans.

RESULTS

Effort allocation (pupillary responses) to the task increased as the processing load increased from low (three-digit) to moderate (six-digit) demands in healthy control subjects and consumers with schizophrenia with mild and moderate severity of defeatist attitudes. In contrast, consumers with severe defeatist attitudes did not increase their effort when processing demands increased from low to moderate loads. These consumers showed significantly less effort in the six-digit condition relative to consumers with mild defeatist attitudes. Moreover, consumers with severe defeatist attitudes showed significantly greater severity of negative symptoms relative to consumers with mild defeatist attitudes and negative symptoms were significantly correlated with defeatist attitudes.

CONCLUSIONS

These results suggest a relationship between defeatist performance attitudes, goal-directed task effort indexed by pupillary responses, and negative symptoms in schizophrenia. The findings have implications for using cognitive therapy to reduce defeatist attitudes that may contribute to diminished effort and negative symptoms in schizophrenia.

Addressing defeatist beliefs in work rehabilitation

BACKGROUND

Adults with serious mental illness (SMI) may struggle with expectations of failure in vocational rehabilitation. These expectations can be global and trait-like or performance-specific and related to ability.

AIMS

To date, it has not been examined whether global or performance-specific defeatist beliefs are related to functional outcomes.

METHOD

The Indianapolis Vocational Intervention Program (IVIP) is a CBT intervention used to address expectations of failure and improve work performance. We examined the relationships between defeatist beliefs, self-esteem, social functioning, and work behaviors in 54 adults with SMI who completed IVIP within a work therapy program.

RESULTS

Baseline work-specific defeatist beliefs were related to baseline self-esteem, employment attitude, and work behaviors. Decline in work-specific defeatist beliefs was associated with better social functioning, self-esteem, and work behaviors. Decline in global defeatist beliefs was only associated with improvements in social functioning.

CONCLUSIONS

Performance-specific expectations about work may be an appropriate therapeutic target to enhance work outcome in SMI.

Motivation for physical activity and exercise in severe mental illness: A systematic review of intervention studies

There has been increasing interest for research on motivation for physical activity (PA) and exercise among individuals with severe mental illness (SMI). The aim of this systematic review is to summarize findings from all intervention studies on PA or exercise that either include empirical data on motivational constructs or apply motivational techniques/theories in their intervention. Systematic searches of seven databases were conducted from database inception to February 2015. Studies were eligible if they: (i) included participants with SMI, (ii) had PA as part of the intervention, and (iii) reported empirical data on motivational constructs related to PA or incorporated motivational techniques/theory in their intervention. Of the 79 studies that met the inclusion criteria only one had motivation for PA as its main outcome. Nine additional interventions reported empirical data on motivational constructs. Altogether these studies yielded mixed results with respect to change in motivational constructs. Only one of those examined the association between motivation and PA, but found none. Sixty-four studies reported using motivational techniques/theory in their intervention. Motivational interviewing and goal-setting were the most popular techniques. Due to the exploratory nature of most of these studies, findings from intervention studies do not so far give very clear directions for motivational work with the patients. There is an urgent need for a more systematic theory based approach when developing strategies that target to increase engagement in PA among people with SMI.

Motivational Interviewing to Increase Cognitive Rehabilitation Adherence in Schizophrenia

Adherence to treatment in psychiatric populations is notoriously low. In this randomized, controlled, proof-of-concept study, we sought to examine whether motivational interviewing (MI) could be used to enhance motivation for, adherence to, and benefit obtained from cognitive rehabilitation. Dual diagnosis MI, developed specifically for individuals with psychotic symptoms and disorganization, was further adapted to focus on cognitive impairments and their impact. Sixty-four outpatients diagnosed with schizophrenia spectrum disorders completed baseline assessments and were randomized to receive either the 2-session MI focused on cognitive functioning or a 2-session sham control interview focused on assessment and feedback about preferred learning styles. Next, all participants were given 4 weeks during which they could attend up to 10 sessions of a computer-based math training program, which served as a brief analog for a full course of cognitive rehabilitation. As hypothesized, MI condition was associated with greater increases in task-specific motivation along with greater training program session attendance. Moreover, postinterview motivation level predicted session attendance. There were no significant differences in improvement on a measure of cognitive training content, which may have been due to the abbreviated nature of the training. While the literature on the efficacy of MI for individuals with psychosis has been mixed, we speculate that our positive findings may have been influenced by the adaptations made to MI as well as the focus on a nonpharmacological intervention.

Characteristics of motivation and their impacts on the functional outcomes in patients with schizophrenia

BACKGROUND

Deficits of motivation have been considered to be a core feature of schizophrenia, and recent studies have begun to reveal the biological and psychological characteristics and mechanisms underlying the deficits in motivation in schizophrenia patients. The aims of the present study were to investigate the characteristics of motivation in schizophrenia patients using the General Causality Orientations Scale (GCOS), and the impacts of motivational orientations on the functional outcomes in schizophrenia patients.

METHODS

A total of 53 outpatients with schizophrenia and 38 healthy controls were recruited for this study. The GCOS was used to assess individual tendencies in respect of three different motivational orientations: the autonomy, controlled, and impersonal orientations, corresponding to intrinsic motivation, extrinsic motivation, and amotivation, respectively. The cognitive functioning, psychiatric symptoms, social functioning, and quality of life of the subjects were also assessed.

RESULTS

The score for autonomy orientation was significantly lower in the patient group than that in the control group, while no significant differences were found between the two groups in respect of the scores for the other two orientations. The autonomy orientation was associated with various clinical variables, and regression analysis identified as one of the variables with the highest predictive accuracy for social functioning.

CONCLUSIONS

Intrinsic motivation measured by the GCOS in schizophrenia patients was significantly lower than that in healthy controls. The deficits of intrinsic motivation were broadly associated with the clinical features and were a determinant of social functioning. Development of treatments for enhancing intrinsic motivation would be essential for functional recovery in schizophrenia patients.

Intrinsic motivation as a mediator between metacognition deficits and impaired functioning in psychosis

OBJECTIVE

Poor functioning has long been observed in individuals with psychosis. Recent studies have identified metacognition - one's ability to form complex ideas about oneself and others and to use that information to respond to psychological and social challenges-as being an important determinant of functioning. However, the exact process by which deficits in metacognition lead to impaired functioning remains unclear. This study first examined whether low intrinsic motivation, or the tendency to pursue novel experiences and to engage in self-improvement, mediates the relationship between deficits in metacognition and impaired functioning. We then examined whether intrinsic motivation significantly mediated the relationship when controlling for age, education, symptoms, executive functioning, and social cognition.

DESIGN

Mediation models were examined in a cross-sectional data set.

METHODS

One hundred and seventy-five individuals with a psychotic disorder completed interview-based measures of metacognition, intrinsic motivation, symptoms, and functioning and performance-based measures of executive functioning and social cognition.

RESULTS

Analyses revealed that intrinsic motivation mediated the relationship between metacognition deficits and impaired functioning (95% CI of indirect effect [0.12-0.43]), even after controlling for the aforesaid variables (95% CI of indirect effect [0.04-0.29]).

CONCLUSIONS

Results suggest that intrinsic motivation may be a mechanism that underlies the link between deficits in metacognition and impaired functioning and indicate that metacognition and intrinsic motivation may be important treatment targets to improve functioning in individuals with psychosis.

PRACTITIONER POINTS

The findings of this study suggest that deficits in metacognition may indirectly lead to impaired functioning through their effect on intrinsic motivation in individuals with psychosis. Psychological treatments that target deficits in both metacognition and intrinsic motivation may help to alleviate impaired functioning in individuals with psychosis.

LIMITATIONS

The cross-sectional design of this study is a limitation, and additional longitudinal studies are needed to confirm the direction of the findings and rule out rival hypotheses. Generalization of the findings may be limited by the sample composition. It may be that different relationships exist between metacognition, intrinsic motivation, and functioning in those with early psychosis or among those in an acute phase or who decline treatment.

Intrinsic motivation and amotivation in first episode and prolonged psychosis

The deleterious functional implications of motivation deficits in psychosis have generated interest in examining dimensions of the construct. However, there remains a paucity of data regarding whether dimensions of motivation differ over the course of psychosis. Therefore, this study examined two motivation dimensions, trait-like intrinsic motivation, and the negative symptom of amotivation, and tested the impact of illness phase on the 1) levels of these dimensions and 2) relationship between these dimensions. Participants with first episode psychosis (FEP; n=40) and prolonged psychosis (n=66) completed clinician-rated measures of intrinsic motivation and amotivation. Analyses revealed that when controlling for group differences in gender and education, the FEP group had significantly more intrinsic motivation and lower amotivation than the prolonged psychosis group. Moreover, intrinsic motivation was negatively correlated with amotivation in both FEP and prolonged psychosis, but the magnitude of the relationship did not statistically differ between groups. These findings suggest that motivation deficits are more severe later in the course of psychosis and that low intrinsic motivation may be partially independent of amotivation in both first episode and prolonged psychosis. Clinically, these results highlight the importance of targeting motivation in early intervention services.

Measuring motivation in people with schizophrenia

Motivational deficits are a key determinant of poor functional outcomes in schizophrenia. These impairments are typically evaluated using various clinical rating scales; however, the degree of convergence between motivation scores derived from different instruments is not clear. In the present study, we measured motivational deficits in 62 patients with schizophrenia using 5 scores derived from 3 different instruments. We found that the scores from these different instruments were highly inter-correlated, and largely independent of severity of other symptom domains (e.g., depression). Our findings suggest that clinical ratings scales evaluating motivational deficits are tapping into a similar underlying construct.

Effort-Based Decision-Making Paradigms for Clinical Trials in Schizophrenia: Part 2—External Validity and Correlates

Effort-based decision making has strong conceptual links to the motivational disturbances that define a key subdomain of negative symptoms. However, the extent to which effort-based decision-making performance relates to negative symptoms, and other clinical and functionally important variables has yet to be systematically investigated. In 94 clinically stable outpatients with schizophrenia, we examined the external validity of 5 effort-based paradigms, including the Effort Expenditure for Rewards, Balloon Effort, Grip Strength Effort, Deck Choice Effort, and Perceptual Effort tasks. These tasks covered 3 types of effort: physical, cognitive, and perceptual. Correlations between effort related performance and 6 classes of variables were examined, including: (1) negative symptoms, (2) clinically rated motivation and community role functioning, (3) self-reported motivational traits, (4) neurocognition, (5) other psychiatric symptoms and clinical/demographic characteristics, and (6) subjective valuation of monetary rewards. Effort paradigms showed small to medium relationships to clinical ratings of negative symptoms, motivation, and functioning, with the pattern more consistent for some measures than others. They also showed small to medium relations with neurocognitive functioning, but were generally unrelated to other psychiatric symptoms, self-reported traits, antipsychotic medications, side effects, and subjective valuation of money. There were relatively strong interrelationships among the effort measures. In conjunction with findings from a companion psychometric article, all the paradigms warrant further consideration and development, and 2 show the strongest potential for clinical trial use at this juncture.

Motivational deficits in early schizophrenia: prevalent, persistent, and key determinants of functional outcome

Negative symptoms, in particular motivational deficits, are reported as impediments to functional recovery in patients with schizophrenia. This study examined the prevalence of motivational deficits in patients early in the illness, and the impact these deficits have on community functioning. Patients with schizophrenia between the ages of 18 and 35years, and within 5years of initiating antipsychotic treatment were included in the present investigation (N=166). The impact of motivation and cognition on concurrent and longitudinal functioning was evaluated. Motivational impairments were found in more than 75% of participants, and were not associated with receipt of social support. These deficits served as the most robust and reliable predictor of functional outcome, while neurocognition demonstrated significantly weaker associations with outcome. When considered together, motivational deficits demonstrated a reliable link with concurrent and longitudinal functioning, with cognition not offering any independent predictive value. Moreover, motivation was found to mediate the relationship between cognition and outcome. Changes in motivation were linked to changes in functioning; however, this was not the case for changes in cognitive performance. Motivation emerged as a significant predictor of functioning even after selected demographic and clinical characteristics (e.g., positive symptoms) were accounted for. These data indicate that motivational deficits are prevalent in patients with schizophrenia, even in the early stages of the illness, and these deficits stand as one of the most robust barriers to people with schizophrenia achieving functional recovery. Greater understanding of the mechanisms underlying these deficits is critical to effective treatment innovation.

Different Perspectives of Clinicians and Patients with Severe Mental Illness on Motivation for Treatment

The present study assessed motivation for engaging in treatment as rated by clinicians (n = 57) and patients with severe mental illness (SMI, n = 294) using measures based on three different motivation theories. Questionnaires were derived from self-determination theory, the transtheoretical model and the integral model of treatment motivation. It was investigated to which extent clinicians of patients with SMI were able to estimate their patient's perspective on motivation for engaging in treatment, to which extent they agreed on the patient's motivation and which factors were associated with estimation and agreement on treatment motivation. It was found that clinicians were poorly to moderately capable of estimating their patient's type of motivation and readiness for change. Further, agreement on the level of motivation between patients and clinicians was moderate. These findings were consistent across diagnostic groups (psychotic and personality disorders). A higher quality therapeutic relationship was generally associated with higher clinician-rated motivation. The patient's ethnicity and socially desirable responding were factors that differentiated between scales of different motivation theories. It is concluded that patients with SMI and their clinicians have different perceptions on the patient's motivation for engaging in psychiatric treatment, regardless of the theoretical framework that is used to measure motivation. The findings imply that a negotiated approach is needed where both perceptions of clinicians and patients on motivation for treatment are considered to ensure effective mental health interventions. Copyright © 2015 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

Clinicians show poor to moderate capability in estimating how patients perceive their motivation for engaging in treatment, especially so when the patient's motives revolve around feelings of shame and guilt. Clinicians generally give higher motivation ratings for patients where they experience a higher quality therapeutic relationships with, whereas-depending on the scale that is used to measure motivation-they give lower ratings to patients who respond in socially desirable ways and to ethnic minority patients. As patients with SMI and their clinicians have different perceptions on the patient's motivation for engaging in psychiatric treatment (regardless of the theoretical framework that is used to assess motivation), this implies that a negotiated approach is needed where both perceptions of clinicians and patients on motivation for treatment are considered to ensure effective mental health interventions.

Negative symptoms are associated with lower autonomous motivation towards physical activity in people with schizophrenia

OBJECTIVE

This cross-sectional study examined the association between psychiatric symptoms and motivation for physical activity within the self-determination theory (SDT) framework in people with schizophrenia.

METHOD

Over a 4-month period, 55 (17♀) inpatients with a DSM-V diagnosis of schizophrenia were assessed with the Psychosis Evaluation tool for Common use by Caregivers (PECC) and the Behavioural Regulation in Exercise Questionnaire (BREQ-2), that provided separate scores for amotivation, external, introjected and autonomous regulation. Spearman correlation coefficients were examined between these motivation scores and symptom ratings.

RESULTS

The BREQ-2 score for autonomous regulations (2.6±1.1) was significantly correlated with the PECC negative symptoms score (10.3±4.1) (r=-0.34, p=0.011). No other significant correlations between BREQ-2 and PECC scores were found. The BREQ-2 score for external regulations (0.7±0.9) was associated with older age (35.2±11.3years) (r=-0.30, p=0.024).

CONCLUSIONS

These findings provide evidence that negative symptoms are associated with lower autonomous motivation towards physical activity in inpatients with schizophrenia. Future longitudinal research should confirm the current findings. Such research will guide physical activity approaches aimed at facilitating enhanced physical and mental health outcomes in individuals with schizophrenia.

Serotonin and dopamine receptors in motivational and cognitive disturbances of schizophrenia

Negative symptoms (e.g., decreased spontaneity, social withdrawal, blunt affect) and disturbances of cognitive function (e.g., several types of memory, attention, processing speed, executive function, fluency) provide a major determinant of long-term outcome in patients with schizophrenia. Specifically, motivation deficits, a type of negative symptoms, have been attracting interest as (1) a moderator of cognitive performance in schizophrenia and related disorders, and (2) a modulating factor of cognitive enhancers/remediation. These considerations suggest the need to clarify neurobiological substrates regulating motivation. Genetic studies indicate a role for the monoamine systems in motivation and key cognitive domains. For example, polymorphism of genes encoding catecholamine-O-methyltransferase, an enzyme catabolizing dopamine (DA), affects performance on tests of working memory and executive function in a phenotype (schizophrenia vs. healthy controls)-dependent fashion. On the other hand, motivation to maximize rewards has been shown to be influenced by other genes encoding DA-related substrates, such as DARPP-32 and DA-D₂ receptors. Serotonin (5-HT) receptors may also play a significant role in cognitive and motivational disabilities in psychoses and mood disorders. For example, mutant mice over-expressing D₂ receptors in the striatum, an animal model of schizophrenia, exhibit both decreased willingness to work for reward and up-regulation of 5-HT_2C receptors. Taken together, genetic predisposition related to 5-HT receptors may mediate the diversity of incentive motivation that is impaired in patients receiving biological and/or psychosocial treatments. Thus, research into genetic and neurobiological measures of motivation, in association with 5-HT receptors, is likely to facilitate intervention into patients seeking better social consequences.