"I just don't look forward to anything". How anticipatory pleasure and negative beliefs contribute to goal-directed activity in patients with negative symptoms of psychosis

The Nature of Mental Imagery and Its Relationship With Amotivational Psychopathology in People With Schizophrenia Spectrum Disorders

Many people with schizophrenia spectrum disorders (SSDs) experience profound amotivation, which is strongly related to anticipatory anhedonia. Yet, the neuropsychological fundamentals of anticipatory anhedonia and amotivation are barely understood, resulting in a lack of effective treatments for these patients. Aberrancies in positive mental imagery may interfere with the anticipation of pleasure and could thus explain anticipatory anhedonia and amotivation. However, the nature of mental imagery and its relationship with amotivational psychopathology in SSD is largely unknown. In this preregistered study, we therefore examined mental imagery characteristics and their relation to anticipatory anhedonia, amotivation, and daily life activity in SSD. TheN = 86 participants included individuals with SSD (n = 43) and demographically matched healthy controls (n = 43). Mental imagery, anticipatory pleasure, amotivation, and activity engagement were assessed with structured interviews and self-report questionnaires. Ecological momentary assessment was used to measure state anticipatory pleasure and activity engagement in daily life (n = 81). Compared to the control group, the SSD group showed comparable quantity, but less vividness of mental imagery. Reduced vividness of mental imagery in SSD was significantly associated with higher anticipatory anhedonia, amotivation, and low activity engagement in cross-sectional and prospective analyses. Reduced mental imagery vividness may cause a lack of internal incentive to seek pleasurable experiences and could explain amotivation. Interventions aiming to improve mental imagery vividness and related anticipatory pleasure responses in SSD may be effective in targeting amotivation.

The Nepean Belief Scale (NBS) as a tool to investigate the intensity of beliefs in anorexia nervosa: psychometric properties of the Italian version

BACKGROUND

People with anorexia nervosa (AN) show a peculiar impairment of insight regarding their condition, often manifesting a denial of extreme emaciation and sometimes hiding or underreporting socially undesirable abnormal eating patterns. Sometimes the intensity of the beliefs held by patients with AN reach a delusional intensity.

OBJECTIVES

In this study, the Italian version of the Nepean Belief Scale was applied to a sample of patients diagnosed with AN to investigate the intensity of their beliefs and convictions and its clinical correlates.

METHODS

The Nepean Belief Scale (NBS) was translated and adapted to Italian and applied to a sample of patients diagnosed with AN based on the Structured Clinical Interview for DSM-5 (SCID-5).

RESULTS

The Italian version of the 5-item NBS showed excellent reliability. Convergent validity was proved by negative association with levels of insight measured with the Schedule for the Assessment of Insight in Eating Disorders. Beliefs of delusional intensity were reported by 10% of participants. Those with a greater intensity of beliefs, either overvalued or delusional ideas, were more likely to report poorer general cognitive performances on the Montreal Cognitive Assessment. No association was observed between NBS score and age, body mass index, symptoms of eating disorders, body dissatisfaction, or levels of depression. Fear of weight gain and control seeking were the most often reported themes at the NBS.

CONCLUSIONS

The Italian version of the NBS is a reasonably reliable, valid, and usable tool for the multidimensional assessment of insight in AN. Level of evidence Level III, Evidence obtained from well-designed cohort or case-control analytic studies.

Interplay between negative symptoms, time spent doing nothing, and negative emotions in patients with schizophrenia spectrum disorders: results from a 37-site study

This study evaluated the relationship between negative symptoms, daily time use (productive/non-productive activities, PA/NPA), and negative emotions in schizophrenia-spectrum disorders (SSDs): 618 individuals with SSDs (311 residential care patients [RCPs], 307 outpatients) were surveyed about socio-demographic, clinical (BPRS, BNSS) and daily time use (paper-and-pencil Time Use Survey completed twice/week) characteristics. Among them 57 RCPs and 46 outpatients, matched to 112 healthy controls, also underwent ecological monitoring of emotions (8 times/day for a week) through Experience Sampling Method (ESM). RCPs spent significantly less time in PA than outpatients. Patients with more negative symptomatology spent more time in NPA and less in PA compared to patients with milder symptoms. Higher time spent in NPA was associated with negative emotions (p < 0.001 during workdays) even when correcting for BNSS total and antipsychotic polypharmacy (p = 0.002 for workdays, p = 0.006 for Sundays). Future studies are needed to explore in more detail the relationship between negative emotions, negative symptoms, time use, and functioning in individuals with SSDs, providing opportunities for more informed and personalised clinical treatment planning and research into interactions between different motivational, saliency and behavioural aspects in individuals with SSDs.

Do People With Schizophrenia Enjoy Social Activities as Much as Everyone Else? A Meta-analysis of Consummatory Social Pleasure

BACKGROUND

The "emotion paradox" of schizophrenia suggests people with schizophrenia demonstrate deficits when reporting anticipated and retrospective pleasure; yet, in-the-moment, consummatory pleasure is largely intact. It is uncertain how these findings extend to social situations. This meta-analysis aimed to (1) determine the mean difference in consummatory social pleasure between people with schizophrenia and healthy controls, and (2) examine moderators of this effect, including study design and clinical characteristics of participants.

DESIGN

A literature search using PsycINFO, Web of Science, Pubmed, and EMBASE databases was conducted. Studies measuring consummatory social pleasure using experience sampling methods and laboratory social simulations were included. Random effects meta-analyses were conducted using Hedge's g.

RESULTS

Meta-analysis of 26 studies suggests people with schizophrenia exhibited a small, significant deficit in consummatory social pleasure (g = -0.38, 90% CI [-0.53, -0.22]). There was significant heterogeneity in effect sizes; magnitude was moderated by study design and type of measure used to assess social pleasure.

CONCLUSIONS

Overall, people with schizophrenia seem to exhibit less consummatory social pleasure than controls. However, this deficit is smaller than in studies of anticipated and retrospective pleasure. Thus, consummatory social pleasure may not be quite as impaired in people with schizophrenia as traditional anhedonia research suggests. Moreover, pleasure deficits observed in people with schizophrenia may result from differences in the quality of their daily social experiences rather than differences in their capacity for social pleasure. Results have important implications for clinical interventions that address barriers to social engagement, low-pleasure beliefs, and cognitive remediation to treat schizophrenia.

"Goals in Focus"-a targeted CBT approach for motivational negative symptoms of psychosis: study protocol for a randomized-controlled feasibility trial

BACKGROUND

The reduction of goal-directed behavior is the main characteristic in motivational negative symptoms of psychosis as it accounts for the long-term decline in psychological well-being and psychosocial functioning. However, the available treatment options are largely unspecific and show only small effects on motivational negative symptoms. Interventions that directly target the relevant psychological mechanisms are likely to be more effective. For "Goals in Focus", we translated findings from basic clinical research on mechanisms underlying motivational negative symptoms into a tailored and comprehensive novel psychological outpatient treatment program. With this study, we will test the feasibility of the therapy manual and the trial procedures. We also aim to examine first estimates of the effect size that can be expected from "Goals in Focus" to inform the sample size calculation of a subsequent fully powered trial.

METHODS

Thirty participants diagnosed with a schizophrenia spectrum disorder and at least moderate motivational negative symptoms will be randomly assigned to either 24 sessions of "Goals in Focus" over the course of 6 months (n = 15) or to a 6-month wait-list control group (n = 15). Single-blind assessments will be conducted at baseline (t₀) and 6 months after baseline completion (t₁). Feasibility outcomes include patient recruitment, retention, and attendance rates. Acceptability will be rated by trial therapists and by participants at end of treatment. Primary outcome for effect size estimation is the motivational negative symptom subscale sum score of the Brief Negative Symptom Scale at t₁ corrected for baseline values. Secondary outcomes include psychosocial functioning, psychological well-being, depressive symptoms, expressive negative symptoms, negative symptom factor scores, and goal pursuit in everyday life.

DISCUSSION

The feasibility and acceptability data will be used to improve trial procedures and the "Goals in Focus" intervention where necessary. The treatment effect on the primary outcome will provide the basis for the sample size calculation for a fully powered RCT.

TRIAL REGISTRATION

1) ClinicalTrials.gov, NCT05252039 . Registered on 23 February 2022. 2) Deutsches Register Klinischer Studien, DRKS00018083 . Registered on 28 August 2019.

Increased cortical structural covariance correlates with anhedonia in schizophrenia

Anhedonia is a common symptom in schizophrenia and is closely related to poor functional outcomes. Several lines of evidence reveal that the orbitofrontal cortex plays an important role in anhedonia. In the present study, we aimed to investigate abnormalities in structural covariance within the orbitofrontal subregions, and to further study their role in anticipatory and consummatory anhedonia in schizophrenia. T1 images of 35 schizophrenia patients and 45 healthy controls were obtained. The cortical thickness of 68 cerebral regions parcellated by the Desikan-Killiany (DK) atlas was calculated. The structural covariance within the orbitofrontal subregions was calculated in both schizophrenia and healthy control groups. Stepwise linear regression was performed to examine the relationship between structural covariance and anhedonia in schizophrenia patients. Patients with schizophrenia exhibited higher structural covariance between the left and right medial orbitofrontal thickness, the left lateral orbitofrontal thickness and left pars orbitalis thickness compared to healthy controls (p < 0.05, FDR corrected). This results imply that the increased structural covariance in orbitofrontal thickness may be involved in the process of developing anhedonia in schizophrenia. The result indicated that the increased structural covariance between the left and right medial orbitofrontal thickness might be a protective factor for anticipatory pleasure (B' = 0.420, p = 0.012).

Psychosocial and behavioural interventions for the negative symptoms of schizophrenia: a systematic review of efficacy meta-analyses

BACKGROUND

Currently there is no first-line treatment recommended for the negative symptoms of schizophrenia. Psychosocial and behavioural interventions are widely used to reduce the burden of negative symptoms. Meta-analytic studies have summarised the evidence for specific approaches but not compared evidence quality and benefit.

AIM

To review and evaluate the evidence from meta-analytic studies of psychosocial and behavioural interventions for the negative symptoms of schizophrenia.

METHOD

A systematic literature search was undertaken to identify all meta-analyses evaluating psychosocial and behavioural interventions reporting on negative symptom outcomes in people with schizophrenia. Data on intervention, study characteristics, acceptability and outcome were extracted. Risk of bias was evaluated. Results were summarised descriptively, and evidence ranked on methodological quality.

RESULTS

In total, 31 systematic reviews met the inclusion criteria evaluating the efficacy of negative symptom interventions on 33 141 participants. Exercise interventions showed effect sizes (reduction in negative symptoms) ranging from -0.59 to -0.24 and psychological interventions ranging from -0.65 to -0.04. Attrition ranged between 12% to 32%. Across the studies considered heterogeneity varied substantially (range 0-100). Most of the reviews were of very low to low methodological quality. Methodological quality ranking suggested that the effect size for cognitive remediation and exercise therapy may be more robust compared with other approaches.

CONCLUSIONS

Most of the interventions considered had a small-to-moderate effect size, good acceptability levels but very few had negative symptoms as the primary intervention target. To improve the confidence of these effect sizes being replicated in clinical settings future studies should minimise risk of bias.

Translating affective and cognitive mechanisms of psychotic symptoms into better therapies

For a long time, psychotic symptoms were seen as too different from normal experiences to be explicable by psychological theories, let alone modifiable by psychological therapy. In the 1990s, the epidemiological research pointing to a continuum of psychotic symptoms and the clinical success in using cognitive approaches for psychosis strongly challenged this view. This inspired the field - along with my own work - to focus on a better understanding of the psychological mechanisms of psychotic symptoms in order to develop increasingly effective interventions. Together with other researchers, I have found that negative affect and aberrant arousal play a crucial role in the formation of delusions where they appear to interact with more fundamental problems in belief updating. While our understanding of the basic mechanisms that drive psychotic symptoms is gaining precision, the challenge remains to find the most suitable ways of targeting these mechanisms.

Discrepancies between ideal and actual affect in schizophrenia: Implications for understanding negative symptoms

Anhedonia is a core symptom of schizophrenia (SZ). However, psychological mechanisms underlying anhedonia are unclear, making it difficult to develop personalized psychosocial treatments. The current study explored the novel hypothesis that anhedonia is driven by discrepancies between ideal and actual affect (i.e., how positive or negative someone wants to feel compared to how they do feel), which impact the frequency of recreational, goal-directed, and social behaviors. Participants included 32 outpatients with SZ and 29 healthy controls (CN) who completed the Affect Valuation Index and measures of negative symptom severity. Results indicated that individuals with SZ displayed greater positive and negative emotion discrepancy scores than CN, suggesting that they strongly desire to feel more positive and less negative in the future than they actually do. Additionally, greater ideal relative to actual positive and negative affect was associated with greater severity of anhedonia, avolition, and asociality. The discrepancy between ideal and actual affective states may be demotivating, leading individuals with SZ to develop dysfunctional beliefs after repeated experiences of failing to achieve their desired emotional goal state. These findings suggest that ideal affect may be a novel psychological mechanism underlying negative symptoms that could be targeted in psychosocial treatments.

Intact differentiation of responses to socially-relevant emotional stimuli across psychotic disorders: An event-related potential (ERP) study

Event-related potential (ERP) studies of motivated attention in schizophrenia typically show intact sensitivity to affective vs. non-affective images depicting diverse types of content. However, it is not known whether this ERP pattern: 1) extends to images that solely depict social content, (2) applies across a broad sample with diverse psychotic disorders, and (3) relates to self-reported trait social anhedonia. We examined late positive potential (LPP) amplitudes to images involving people that were normatively pleasant (affiliative), unpleasant (threatening), or neutral in 97 stable outpatients with various psychotic disorders and 38 healthy controls. Both groups showed enhanced LPP to pleasant and unpleasant vs. neutral images to a similar degree, despite lower overall LPP in patients. Within the patients, there were no significant LPP differences among subgroups (schizophrenia vs. other psychotic disorders; affective vs. non-affective psychosis) for the valence effect (pleasant/unpleasant vs. neutral). Higher social anhedonia showed a small, significant relation to lower LPP to pleasant images across all groups. These findings suggest intact motivated attention to social images extends across psychotic disorder subgroups. Dimensional transdiagnostic analyses revealed a modest association between self-reported trait social anhedonia and an LPP index of neural sensitivity to pleasant affiliative images.

Expanding the positivity offset theory of anhedonia to the psychosis continuum

People with schizophrenia and negative symptoms show diminished net positive emotion in low-arousing contexts (diminished positivity offset) and co-activate positive and negative emotion more frequently (increased ambivalence). Here, we investigated whether diminished positivity offset and increased ambivalence covary with negative symptoms along the continuum of psychotic symptoms. We conducted an online-study in an ad-hoc community sample (N = 261). Participants self-reported on psychotic symptoms (negative symptoms, depression, positive symptoms, anhedonia) and rated positivity, negativity, and arousal elicited by pleasant, unpleasant, and neutral stimuli. The data were analyzed with multilevel linear models. Increasing levels of all assessed symptom areas showed significant associations with diminished positivity offset. Increased ambivalence was related only to positive symptoms. Our results show that the diminished positivity offset is associated with psychotic symptoms in a community sample, including, but not limited to, negative symptoms. Ecological validity and symptom specificity require further investigation.

Psychological Dimensions Relevant to Motivation and Pleasure in Schizophrenia

Motivation and pleasure deficits are common in schizophrenia, strongly linked with poorer functioning, and may reflect underlying alterations in brain functions governing reward processing and goal pursuit. While there is extensive research examining cognitive and reward mechanisms related to these deficits in schizophrenia, less attention has been paid to psychological characteristics that contribute to resilience against, or risk for, motivation and pleasure impairment. For example, psychological tendencies involving positive future expectancies (e.g., optimism) and effective affect management (e.g., reappraisal, mindfulness) are associated with aspects of reward anticipation and evaluation that optimally guide goal-directed behavior. Conversely, maladaptive thinking patterns (e.g., defeatist performance beliefs, asocial beliefs) and tendencies that amplify negative cognitions (e.g., rumination), may divert cognitive resources away from goal pursuit or reduce willingness to exert effort. Additionally, aspects of sociality, including the propensity to experience social connection as positive reinforcement may be particularly relevant for pursuing social goals. In the current review, we discuss the roles of several psychological characteristics with respect to motivation and pleasure in schizophrenia. We argue that individual variation in these psychological dimensions is relevant to the study of motivation and reward processing in schizophrenia, including interactions between these psychological dimensions and more well-characterized cognitive and reward processing contributors to motivation. We close by emphasizing the value of considering a broad set of modulating factors when studying motivation and pleasure functions in schizophrenia.

From Memories of Past Experiences to Present Motivation? A Meta-analysis on the Association Between Episodic Memory and Negative Symptoms in People With Psychosis

Based on findings from cognitive science, it has been theorized that the reductions in motivation and goal-directed behavior in people with psychosis could stem from impaired episodic memory. In the current meta-analysis, we investigated this putative functional link between episodic memory deficits and negative symptoms. We hypothesized that episodic memory deficits in psychosis would be related to negative symptoms in general but would be more strongly related to amotivation than to reduced expressivity. We included 103 eligible studies (13,622 participants) in the analyses. Results revealed significant, moderate negative associations of episodic memory with negative symptoms in general (k = 103; r = -.23; z = -13.40; P ≤ .001; 95% CI [-.26; -.20]), with amotivation (k = 16; r = -.18; z = -6.6; P ≤ .001; 95% CI [-.23; -.13]) and with reduced expressivity (k = 15; r = -.18; z = -3.30; P ≤.001; 95% CI[-.29; -.07]). These associations were not moderated by sociodemographic characteristics, positive symptoms, depression, antipsychotic medication or type of negative symptom scale. Although these findings provide sound evidence for the association between episodic memory deficits and amotivation, the rather small magnitude and the unspecific pattern of this relationship also indicate that episodic memory deficits are unlikely to be the only factor relevant to amotivation. This implicates that future research should investigate episodic memory in conjunction with other factors that could account for the association of episodic memory deficits and amotivation in psychosis.

The stability of multidimensional subclinical apathy during a pandemic and its relations to psycho-behavioral factors

Apathy is a clinical symptom prevalent in many neuropsychiatric pathologies. Subclinical apathy is found in 35% of the general population. Despite high prevalence and negative consequences, underlying mechanisms are poorly understood, perhaps because the concept of apathy is one-dimensional. The current investigation aims to address the incidence of multidimensional apathetic trait in three distinct forms in a student population, to specify its determinants and to evaluate its stability during a global pandemic. Two online surveys, conducted 1 year apart on two separate cohorts of university students, with qualitative measures and validated scales. The final analysis included, respectively, 2789 and 1678 students. The three forms of apathetic trait were present, with the same debilitating consequences as apathetic symptom but independent determinants. Executive apathy was predicted by depressive symptoms, emotional apathy by motivational deficit and initiative apathy comprised a mixed executive-emotional form and a pure deficit of action initiation. The three forms of subclinical apathy remained similar in the context of increased depressive symptoms due to a global pandemic. This study confirmed the presence and independence of three forms of subclinical apathy in healthy students, which remained similar even in the light of increased depressive scores. These results shed light on cognitive and neuronal mechanisms underlying multidimensional apathy, allowing new, targeted treatments.

The Design, Implementation, and Acceptability of a Telehealth Comprehensive Recovery Service for People With Complex Psychosis Living in NYC During the COVID-19 Crisis

INTRODUCTION

The COVID-19 crisis and subsequent stay-at-home orders have produced unprecedented challenges to the dissemination of recovery oriented behavioral health services (RS) that support the treatment of those with complex psychosis (CP).This population has typically been managed with in-person pharmacotherapy and/or RS, with the goals of relieving symptoms, improving life satisfaction and increasing community engagement. COVID-19 related social distancing measures have required rapid shifts in care management, while easing of telehealth regulations has allowed for flexibility to approach RS differently. It is essential to learn from the RS telemedicine implementation experience, so that RSs can maintain care for this vulnerable and needy population.

METHOD

This paper describes the successful telehealth conversion of a NYC-based, university affiliated RS that serves adults with severe mental illnesses (SMI; n = 64). Results focus on the telehealth acceptance rates of the subset of participants with CP (n = 23).

RESULTS

The RS continued providing services including intake, care coordination, group psychotherapies, skills training groups, individual skills coaching, and vocational/educational supports. The telehealth conversion rates of the CP subsample indicated that 90% of CP patients accepted telehealth sessions and maintained their specific treatment plans in the virtual format. Mean comparisons between session attendance and cancellations/no-shows during the six-week period before and after telehealth conversion showed no significant differences in service utilization.

DISCUSSION

RSs play an essential role in the treatment of CP and telehealth may prove to be a viable format of care delivery even after the COVID-19 crisis subsides. The multiple factors in the inner and outer treatment setting that contributed to successful conversion to telehealth will be considered along with the challenges that clinicians and patients encountered.