Psychiatry Research 210 (2013) 830–834
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Poor savouring and low self-efficacy are predictors of anhedonia in patients with schizophrenia spectrum disorders Raymond Cassar a, Eve Applegate b,n, Richard P. Bentall c a
School of Psychology, Bangor University, Adeilad Brigantia, Bangor, Gwynedd, Wales LL57 2AS, UK Institute of Brain, Behaviour & Mental Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK c Institute of Psychology, Health and Society, Liverpool University, Waterhouse Building Block B, Liverpool L69 3GL, UK b
art ic l e i nf o
a b s t r a c t
Article history: Received 12 April 2013 Received in revised form 15 September 2013 Accepted 17 September 2013
Previous research suggests that negative schizotypes may be impaired in their ability to savour pleasant events (Applegate et al., 2009) and that schizophrenia patients believe that everyday tasks are excessively difficult to complete so that they attempt these tasks less frequently (MacCarthy et al., 1986; Bentall et al., 2010). It is possible that these beliefs and behaviours underpin negative symptoms such as anhedonia, avolition, apathy and associality. In the present study, 50 schizophrenia patients and 100 matched controls (half employed and half unemployed) completed selfreport measures of self-efficacy and savouring. Patients reported savouring past, present and future events less than employed and unemployed groups, irrespective of mood state and I.Q. Patients also rated everyday tasks as more difficult to master. Inpatients compared to outpatients rated tasks more difficult but less important although they did not differ on the savouring measure. Abnormal judgements of difficulty and the reduced propensity to mentally rehearse past or future positive experiences to up-regulate mood could explain negative symptom patients' lack of engagement in everyday activities and eventual social withdrawal. These findings suggest the need to develop cognitive-behavioural savouring and self-efficacy interventions for patients experiencing the negative symptoms of schizophrenia. & 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Anhedonia Avolition Negative symptoms Psychosis Savouring Schizophrenia Self-efficacy
1. Introduction Patients with schizophrenia and their carers report that negative symptoms, such as avolition, alogia, anhedonia, apathy and associality, cause the greatest disability and distress (Kirkpatrick et al., 2006). Negative symptoms are inversely correlated with functional outcome (Herbener and Harrow, 2004; McGurk and Mueser, 2004; Rabinowitz et al., 2012) and their presence early during illness predicts a poorer outcome overall (Milev et al., 2005; Rocca et al., 2009). The response of persistent negative symptoms to cognitive remediation, family therapy and social skills training is limited (Turkington and Morrison, 2012) and, whilst alleviating positive symptoms, antipsychotic medication can worsen primary negative symptoms (Kendall, 2012). Secondary analyses of the effects of cognitive therapy on negative symptoms in schizophrenia trials suggest that patients do experience some benefit (Sensky et al., 2000; Rector et al., 2003), that may last up to 5 years, even when beneficial effects on positive symptoms have receded (Turkington et al., 2008; Spencer and Turkington, 2010). However, therapy in
n
Corresponding author. Tel.: þ 44 161 306 8006; fax: þ 44 161 306 7945. E-mail address: [email protected] (E. Applegate).
0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2013.09.017
many of these trials was not expressly designed to target negative symptoms and the cognitive processes which underpin these phenomena remain largely unknown. One cognitive model proposes that low self-efficacy potentiates negative symptoms, particularly avolition, as a consequence of reduced expectations of reward or success (MacCarthy et al., 1986; Bentall et al., 2010). As self-efficacy governs individuals' beliefs in their ability to succeed in tasks (Bandura, 1977) it is thought to contribute to how much time and effort people will expend and how many aversive experiences or obstacles they will tolerate before stopping (Morimoto et al., 2012). Consistent with this view, negative symptoms are associated with defeatist beliefs which undermine attempts to complete everyday tasks (Grant and Beck, 2009). It is also possible that self-efficacy impacts on the pleasure and reinforcement people experience following the completion of everyday tasks by increasing a reflective sense of pride or achievement. Alternatively, it may be that increased self-efficacy is associated with an initial impetus to plan activities which are reinforcing, leading to a greater likelihood of pursuing hedonic experiences overall. Empirical evidence examining self-efficacy specifically in those with negative symptoms is limited (Pratt et al., 2005) but diminished self-efficacy in groups with serious mental illness has been associated with hopelessness, a lack of control, (Davidson et al., 1997)
R. Cassar et al. / Psychiatry Research 210 (2013) 830–834
poorer quality of life, worse community functioning and reduced likelihood of employment (Hasson-Ohayon et al., 2006). Whilst it has been established that negative symptoms patients complete simple everyday tasks less frequently and report lower self-efficacy estimates for successful completion of these tasks (MacCarthy et al., 1986), this finding does not seem to be specific to avolition (Bentall et al., 2010). One implication is that cognitive interventions that manipulate estimates of self-efficacy might affect other negative symptoms as well as avolition by changing beliefs about self-worth, mastery, confidence or willingness to tolerate initial task failures prior to success (Grant et al., 2012). A community-based study in a rehabilitation service found that self-efficacy beliefs about interpersonal behaviour skills predicted actual interpersonal behaviour better than measures of neurocognitive functioning (Morimoto et al., 2012). A second study has shown that motivational interventions can be used to change self-efficacy beliefs about ability to exercise in patients diagnosed with schizophrenia (Beebe et al., 2010). An alternative attempt to understanding negative symptoms has examined reward processing. The immediate experience of pleasure in schizophrenia patients is comparable to that in healthy samples (Cohen and Minor, 2010). However, studies have suggested that patients with negative symptoms have an impairment in the ability to anticipate pleasurable experiences (Earnst and Kring, 1999) which remains stable over time, causing emotional discomfort (Buck and Lysaker, 2013) and/or an impairment in the ability to recall the affective tone of memories (Horan et al., 2006; Heerey and Gold, 2007; Strauss, 2013). Parallel research with healthy individuals conducted by Applegate et al. (2009) found that reduced cognitive savouring (the ability to mentally rehearse past present and future positive experiences) is associated with schizotypal anhedonia, (Bryant, 1989, 2003; Bryant and Veroff, 2007). A reduction in savouring might lead to limited access to memories involving prior pleasure and previous mastery, which may contribute to the development of systematised beliefs that cause future activities to appear insurmountable. When deliberately employed, savouring can be used as a strategy to up-regulate positive affect, thereby increasing the intensity of pleasurable feelings and extending the amount of time which is spent experiencing these feelings (Parrott, 1993; Bryant, 2003; Garland et al., 2010). There are individual differences in people's propensity to savour within the general population; more frequent savouring is associated with better self-esteem, (Gross and John, 2003) and, savouring strategies can be taught (Quoidbach et al., 2010). It is possible that teaching negative symptoms patients to savour could help them to experience greater levels of positive affect which in turn could improve general motivational levels. However, although savouring has been shown to predict anhedonia in nonclinical samples, no study has yet reported a comparison between clinical and non-clinical groups. The first aim of this study was to determine whether savouring is impaired in schizophrenia patients compared to controls. To control for the possibility that lifestyle factors influence savouring, two control groups were recruited, one in long-term employment and one long-term unemployed group. A second aim was to compare the relative power of savouring and poor self-efficacy in predicting subjective anhedonia. For this purpose, scores on an introverted anhedonia measure suitable for assessing both clinical and non-clinical participants were used. 2. Methods
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22 females and 28 males). The patients had a mean age of 45.8 years (S.D.¼11.1) and were recruited from psychiatric services in Malta (Mount Carmel Hospital and the psychiatric wing at Gozo General Hospital); 22 (15 males and seven females) were on long-stay wards while 28 (15 males and 13 females) were outpatients. One female patient was married and two (one male and one female) held jobs. Diagnosis was according to ICD-10 by local psychiatrists, who were asked to refer patients with predominantly negative symptoms who had been known to services for a minimum of 5 years. Exclusion criteria were obvious organic impairments such as traumatic brain injury, serious epilepsy or dementia, and illiteracy. The unemployed controls were recruited from an employment and training centre, had a mean age of 43.0 years (S.D. ¼ 9.40), had been seeking work for a minimum of 12 months and were not in receipt of psychiatric treatment. The employed group had been working for a minimum of three years, had a mean age of 44.4 years (S.D. ¼9.56), were not in receipt of psychiatric treatment, were recruited from commercial and public service organisations, and included factory floor labourers, telephone operators and clerks from government departments. Illiteracy was an exclusion criterion for both control groups. The groups did not differ in terms of age, (F[2, 147] ¼0.85, p ¼0.43) or in the proportion of male versus female participants, (χ2[2, N¼ 150]¼ 0.22, p ¼0.90). 2.2. Measures The Oxford-Liverpool Inventory of Feelings and Experiences (O-LIFE; Mason et al., 1995) is a widely used measure of schizotypal traits. Only two subscales with 104 true/false items were used in the present study: (i) the Unusual Experiences/Reality Distortion Scale, and (ii) the Introvertive Anhedonia Scale, which assesses lack of enjoyment from social activity and physical intimacy, and which is the main dependent variable in this research. This scale was chosen as a measure of anhedonia because of its suitability for both clinical and nonclinical samples. In this study Cronbach's alpha co-efficient was α ¼ 0.86 for Reality Distortion and α¼ 0.76 for Introvertive Anhedonia. The Savouring Belief Inventory (SBI; Bryant, 2003) is a 24 item, three subscale questionnaire measure of savouring the past, present and future. Example items include, “I don't like to anticipate good times before they happen,” and, “It is not difficult for me to recall good memories”. Each factor has four positively and four negatively worded items. Each item is rated on a 7-point likert scale, ranging from ‘strongly agree’ (1) to ‘strongly disagree’ (7). In this study Cronbach's alpha values were: total SBI α¼ 0.85; reminiscing α ¼ 0.67; savouring the present moment α¼ 0.72 and anticipating pleasure α¼ 0.65. MacCarthy Task Motivation Scale (MCTMS; MacCarthy et al., 1986) is constructed according to the value theory of motivation, which assumes that the performance of a particular behaviour is a function of its subjective importance and its related expectancy of successful completion (Eccles and Wigfield, 2002). Thus, abilityrelated convictions corresponding to ‘self-efficacy expectations’ (Bandura, 1997) are said to be strong predictors of performance (Multon et al., 1991). Respondents are asked to indicate the performance frequency of 10 everyday tasks (shopping; going to a restaurant for a meal; cooking a meal; doing household chores; travelling on public transport; using public amenities; any type of reading; writing e.g. a letter; managing a personal budget and managing a household budget). Participants use four point rating scales to rate the importance of each task (0 ¼ ‘not important to me at all’ to 4¼ ‘very important to me’); how difficult the task seems (0 ¼ ‘not at all difficult for me’, 4 ¼‘very difficult for me’) and the likelihood that they could successfully complete the task (0 ¼ ‘my efforts would not be successful at all’, 4¼ ‘my efforts would be very successful’). This scale has been used to assess selfefficacy expectations in previous studies of schizophrenia patients who are chronically impaired (MacCarthy et al., 1986) and suffering from negative symptoms (Bentall et al., 2010). Alpha coefficients calculated from participants' scores were α ¼0.70 for frequency judgements; α ¼0.75 for judgements of importance; α¼ 0.82 for difficulty estimates; and α ¼0.81 for success estimates. Two participants, one in the patient group and one in the employees group, only completed the frequency estimates. The Quick Test (Revised) (QT; Ammons and Ammons, 1962) is a brief test of intellectual function, included because psychosis, especially negative symptoms, is often associated with cognitive dysfunction (Donohoe et al., 2006; Green, 1996). Participants are asked to match each item on a 50 word list with one of four line drawn images. The QT was revised by Mortimer and Bowen (1999) with improved stimulus material and it was this version that was used. The Positive Affect Negative Affect Scale (PANAS: Watson et al., 1988) is a brief measure of current affect. It consists of two 10-item mood scales, measuring positive and negative affect, derived from principal components analysis of Zevon and Tellegen's (1982) affective lexicon checklist. Participants were asked to rate the extent to which they had experienced each emotion “at the present moment” on five-point scales (1¼‘not at all’ to 5¼ ‘extremely’). Alpha coefficients were α¼0.63 for PA and α¼0.64 for NA in this study.
2.1. Participants 2.3. Procedure One hundred and fifty Caucasian Maltese participants were stratified into three groups: schizophrenia patients, unemployed and employed participants, with 50 in each group (20 females and 30 males, except for the unemployed group, which had
The study was approved by Bangor University School of Psychology and the Maltese Health Authority ethics committees. The translation of all the
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instructions, questionnaires and tests was accomplished using the back translation technique. The original English version was translated into Maltese by one of the authors and back-translated into English by an independent, bilingually proficient person. Finally, an independent research assistant compared both English versions, i.e. the original and translated copies. The word list for the Quick test (Mortimer and Bowen, 1999) was translated into Maltese, using Aquilina's (1999) Maltese–English Dictionary. Participants did not receive any financial incentive for taking part.
IQ scores also differed across the three groups (F[2,147]¼ 37.32, po 0.001, partial η2 ¼ 0.34), and post hoc comparisons indicated that the patients scored lower than the employed (p o0.001) and the unemployed controls (po 0.001); again the two control groups did not differ. Positive affect, negative affect and IQ were therefore used as covariates in all subsequent analyses (results from analyses without these covariates were substantially similar).
3. Results
3.3. SBI
3.1. Analysis
For Anticipating, there was no significant association with IQ (F [1,144] ¼0.91, p ¼0.34), PA (F[1,144]¼0.39, p ¼0.54) or NA (F [1,144] ¼0.64, p ¼0.43) but the group difference was significant (F[2,144]¼ 4.27, p o0.05, Partial η2 ¼0.056). The patients reported less anticipatory savouring than the employed participants (Bonferoni p o0.02) with the unemployed participants falling between the two groups. For Savouring in the present, there was also no effect for IQ (F[1,144] ¼0.18, p ¼0.67), PA (F[1,144] ¼0.02, p ¼0.89) or NA (F[1,144] ¼2.44, p ¼0.12) and again the group effect was significant (F[2,144] ¼26.49, p o0.001, partial η2 ¼0.27). The patients differed from both control groups (po 0.001 in each comparison) but the two non-patient groups did not differ (p ¼0.99). Finally, for reminiscing, there was no effect of IQ (F [1,144] ¼1.04, p¼ 0.31), PA (F[1,144] ¼0.00, p ¼0.99) or NA (F [1,144] ¼2.27, p¼ 0.13) and the group effect was also highly significant (F[2,144]¼ 17.16, p o0.001, partial η2 ¼0.19) with the patients reporting less reminiscing than either of the other two groups (p o0.001 for each comparison).
All statistical analyses were conducted using SPSS v 21. Analyses of variance (ANOVAs) examined differences in demographic and psychiatric variables between groups, taking into account covariates. Tukey or Bonferoni post hoc tests were used to identify specific group differences. Multiple regression was used to establish which psychological measures best predicted anhedonia. Finally, to check whether savouring and self-efficacy could be affected by institutionalisation, we compared the scores of inpatients and outpatients. 3.2. Between-group comparisons Group differences on the dependent variables are shown in Table 1. There were significant differences on the Reality Distortion (F[2,147] ¼4.31, po 0.02, partial η2 ¼0.06) and the Introverted Anhedonia, (F[2,147] ¼20.50, p o0.001, partial η2 ¼ 0.22) subscales of the OLIFE. Tukey's post-hoc analyses revealed that, for Reality Distortion, the score for the schizophrenia group was greater than that of the employed group (p o0.02) with the unemployed group falling between but not significantly different from either. On the Introverted Anhedonia subscale, the schizophrenia group scored higher than both the unemployed and the employed groups (p o0.001 for both comparisons) but there was no difference between the two groups of controls. Group differences were also observed for PANAS positive affect (F[2, 147] ¼6.03, p ¼0.003, partial η2 ¼ 0.08) and negative affect (F[2,147]¼ 9.16, po0.001, partial η2 ¼0.11). Surprisingly, for positive affect, the patients' scores were lower than those of the unemployed (po0.005) but not the employed controls. In the case of negative affect, the patients scored higher than both employed (po0.005) and unemployed (po0.001) groups, which did not differ.
3.4. Task motivation There was a significant association between IQ (F[1,142]¼ 16.00, po 0.001, partial η2 ¼0.10) but not PA (F[1,142]¼ 0.28, p ¼0.60) or NA (F[1,142]¼0.34, p¼ 0.56) and the reported frequency of everyday tasks. The group effect for frequency narrowly failed to reach significance (F[2,142]¼ 2.75, p ¼0.07, partial η2 ¼0.037); this trend reflected the lower mean scores of the patients compared to the unemployed with the employed group's scores falling in between. For the perceived importance of the tasks, the association with IQ was highly significant (F[1,142]¼21.96, po0.001, partial η2 ¼ 0.13) but the associations with PA (F[1,142] ¼0.01, p¼ 0.94) and NA (F[1,142]¼1.10, p ¼0.30) were not. The group difference was not significant (F[2,142] ¼0.42, p ¼0.66). For perceived task difficulty, there was a significant effect of IQ (F[1,142]¼ 11.59, p o0.001,
Table 1 Group differences for schizophrenia, unemployed and employed groups. Schizophrenia N ¼ 50
Unemployed N¼ 50
Employed N ¼ 50
F
P
Age IQ
45.78 [11.0] 70.86 [15.79]
43.18 [9.4] 86.98 [11.03]
0.85 37.32
0.42 0.01nn
OLIFE – Reality Distortion OLIFE – Introverted Anhedonia PANAS – Positive Affect PANAS – Negative Affect SBI – Anticipating SBI – Savouring the present moment SBI – Reminiscing MCTQ – Success MCTQ – Frequency MCTQ – Importance MCTQ – Difficulty
16.00 [6.54] 14.28 [4.55] 22.78 [5.88] 24.54 [6.71] 1.74 [9.27] 2.32 [8.74] 2.52 [9.11] 15.52 [7.22] 27.82 [7.83] 15.52 [6.84] 17.90 [7.08]
14.66 [5.82] 9.60 [3.49] 26.82 [6.50] 19.72 [6.33] 6.04 [6.50] 7.96 [5.65] 11.56 [5.86] 11.86 [4.78] 34.42 [6.11] 19.10 [5.14] 10.56 [5.05]
44.22 [9.6] 91.50 [10.11] 12.42 [6.11] 9.46 [4.70] 25.36 [5.23] 20.46 [5.03] 8.26 [7.36] 9.56 [6.73] 13.08 [7.34] 10.34 [6.85] 33.94 [6.64] 18.80 [5.99] 9.12 [6.33]
4.307 20.50 6.03 9.16 9.04 40.57 28.57 8.72 14.07 5.42 28.73
0.01nn 0.01nn 0.01nn 0.01nn 0.01nn 0.01nn 0.01nn 0.01nn 0.01nn 0.01nn 0.01nn
Note: Standard deviations appear in parentheses. Means are significantly different at
nn
p o0.001 based on Tukey's post hoc paired comparisons.
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partial η2 ¼0.05) but not for PA (F[1,142] ¼0.71, p ¼0.40) or NA (F[1,142] ¼0.04, p ¼0.85). However, the group difference for difficulty was highly significant, (F[2,142] ¼13.09, po 0.001, partial η2 ¼ 0.16). No difference was observed between the two control groups but the patient group perceived the tasks to be much more difficult than both of the control groups (Bonferoni p o0.001 for each comparison). Finally, for perceived likelihood of success, IQ was a significant covariate (F[1,142]¼4.30, p o0.05, partial η2 ¼ 0.03) but PA (F[1,142]¼0.24, p ¼0.63) and NA (F[1,142] ¼0.43, p ¼0.51) were not; the group difference was also non-significant, (F[2, 142]¼1.94, p¼ 0.15). 3.5. Predictors of introverted anhedonia We used multiple regression to examine predictors of introverted anhedonia in the groups. Variables were entered in blocks, with age and IQ entered at the first stage, then PA and NA were added before, finally, the psychological measures (SBI total scores and perceived difficulty scores from the task questionnaire) were entered at stage three. The initial model was significant (F[2,145]¼ 11.35, po 0.001) and accounted for 12.3% of the variance in introverted anhedonia scores; I.Q. was a significant predictor in this model (ß ¼0.37, t ¼4.76, po 0.001). Adding the mood measures did not improve the model (Fchange[2,143]¼2.24, p ¼0.11) but adding the psychological measures did improve it (Fchange[2,141]¼ 19.59, p o0.001). The final model was significant (F[6,141] ¼2.32, p o0.001) and accounted for 59% of the variance. In this model, I.Q. was no longer a significant predictor of anhedonia but savouring (β¼ 0.33, t¼3.99, p o0.001) and perceived task difficulty (β¼0.23, t ¼ 2.72, po 0.01) were. Hence, anhedonia was associated with a self-reported failure to savour pleasurable events together with high estimates of the difficulty of everyday tasks. 3.6. Differences between inpatients and outpatients To check whether the differences observed in savouring and task motivation might be driven by institutionalisation, we compared inpatients and outpatients on these variables. No differences were found, with the exception that scores on perceived task difficulty were higher in the inpatient group (t(46) ¼2.26, p o0.05, two-tailed) whereas scores on perceived task importance were marginally lower, (t(46) ¼1.84, p ¼0.7, two-tailed).
4. Discussion We examined whether schizophrenia patients differed from employed and unemployed control groups in their ability to savour and estimate self-efficacy. Our findings suggest that those with schizophrenia savour the past, present and future less than both employed and unemployed groups. This effect remained significant when we controlled for IQ and positive and negative mood and is consistent with previous research which suggests that those who are negatively schizotypal savour less (Applegate et al., 2009). It provides evidence that patients spend less time mentally rehearsing positive experiences than those who are unaffected by psychosis and suggests that they might benefit from a savouring intervention. No differences were observed between inpatients and outpatients on these measures. The same patient group also reported that everyday tasks were more difficult to master than the two control groups, and this effect survived when we controlled for mood and IQ, although it was associated with intelligence. Two previous studies also report that patients carry out everyday tasks less often, and believe that they are more difficult to complete (MacCarthy et al., 1986; Bentall et al., 2010). In the present study, inpatients rated everyday tasks
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as more difficult than outpatients, at the same time rating the tasks as marginally less important. Hence, it is possible that patients' self-efficacy is at least partially influenced by experiences of hospitalisation and their sequalae. Again, behavioural interventions that are designed to make self-efficacy estimates more realistic might impact negative symptomatology by changing beliefs regarding worth, mastery, confidence or willingness to tolerate task failure prior to success (Grant et al., 2012). When predictive factors were examined in the same model, subjective anhedonia was predicted by high perceived task difficulty and low savouring. We attempted to control for social circumstances by including a long-term unemployed control group; however, few differences were seen between these participants and the employed controls. Although it is possible that differences between the control groups might have been more pronounced if the unemployed group were longer term unemployed (our criterion was 412 months) this finding suggests a specific association between schizophrenia and trait anhedonia and related processes. Examined together these findings suggest that savouring and low self-efficacy expectations may contribute to the negative symptoms of schizophrenia. Poor self-efficacy beliefs might potentiate negative symptoms such as anhedonia and avolition through reduced expectation of success, reduced efforts to obtain rewards, cognitive confidence and reduced tolerance of task obstacles, or aversive experiences (Applegate et al., 2009; Bentall et al., 2010; Grant et al., 2012). A reduction in savouring could give negative symptoms patients fewer opportunities to up-regulate positive affect, that is to increase the intensity of potentially rewarding experiences (Applegate et al., 2009). A cognitive style which undermines self-confidence and an increased perception that social experiences will not yield reinforcement could also explain the interpersonal communication problems such as alogia and could lead to social withdrawal (Morimoto et al., 2012). One limitation of the present study concerns our clinical assessments. Future studies would benefit from the inclusion of a clinical schedule which specifically screens negative symptoms such as the Scale for the Assessment of Negative Symptoms, SANS, (Andreasen, 1981) or Brief Psychiatric Rating Scale, BPRS, (Overall and Gorham, 1962). Additionally, patients were diagnosed by their own psychiatrist and not by the research team and a researcherverified diagnosis would have improved diagnostic certainty. We were also unable to control for or record medication so could not model antipsychotic dose as a covariate in the final regression models. Further research exploring the relationship of antipsychotic medication to self-efficacy and savouring is therefore required. Finally, we utilised self-report measures of psychological processes rather than observational or physiological measures, which are likely to be more robust. The present findings suggest that both self-efficacy expectations and savouring might be suitable targets for psychological intervention. The recent trial by Grant et al. (2012) addressed the former by targeting defeatist beliefs but so far no trial has attempted to affect savouring. It is possible that therapies using the expressive arts, which have shown some utility with negative symptom patients (Rohricht and Priebe, 2006; Gold et al., 2009), are affective because they impact both types of psychological processes. More broadly, the need to promote negative symptom patients' estimates of self-efficacy and to enhance their ability to enjoy experiences highlights the importance of changing the way in which mental health interventions are typically delivered. Consistent with this idea, the recovery movement emphasises a need for new approaches which avoid paternalistic control, dependence and stigma and which endow patients with consumer rights, thereby improving self-efficacy and hope (Bellack and Drapalski, 2012; Bentall, 2009).
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References Ammons, C.H., Ammons, R.B., 1962. The Quick Test (QT), Psychological Test Specialists, Missoula, Montana. Andreasen, N.C., 1981. Scale for the Assessment of Negative Symptoms (SANS). University of Iowa, Iowa City. Applegate, E.M., El-Deredy, W., Bentall, R.P., 2009. Reward responsiveness in psychosis-prone groups: hypomania and negative schizotypy. Personality and Individual Differences 47, 452–456. Aquilina, J., 1999. Maltese–English Dictionary. Midsea Books, Valletta, Malta. Bandura, A., 1977. Self-efficacy: towards a unified theory of behavioural change. Psychological Review 84, 191–215. Bandura, A., 1997. Self-Efficacy: The Exercise of Control. Freeman, New York. Beebe, L.H., Smith, K., Burk, R., Dessieux, O., Velligan, D., Tavakoli, A., Tennison, C., 2010. Effect of a motivational group intervention on exercise self efficacy and outcome expectations for exercise in schizophrenia spectrum disorders. Journal of the American Psychiatric Nurses Association 16, 105–113. Bellack, A.S., Drapalski, A., 2012. Issues and developments on the consumer recovery construct. World Psychiatry 11, 156–160. Bentall, R.P., 2009. Doctoring the Mind: Why Psychiatric Treatments Fail. Penguin, London. Bentall, R.P., Simpson, P.W., Lee, D.A., Williams, S., Elves, S., 2010. Motivation and avolition in schizophrenia patients: the role of self-efficacy. Psychosis 2, 12–22. Bryant, F., Veroff, J., 2007. Savoring: A New Model of Positive Experience. Lawrence Erlbaum Associates, Mahwah, NJ. Bryant, F.B., 1989. A four-factor model of perceived control: avoiding, coping, obtaining and savouring. Journal of Personality 57, 773–797. Bryant, F.B., 2003. Savoring Beliefs Inventory (SBI): a scale for measuring beliefs about savoring. Journal of Mental Health 12, 175–196. Buck, B., Lysaker, P.H., 2013. Consummatory and anticipatory anhedonia in schizophrenia: stability, and associations with emotional distress and social function over six months. Psychiatry Research 20, 30–35. Cohen, A.S., Minor, K.S., 2010. Emotional experience in patients with schizophrenia revisited: meta-analysis of laboratory studies. Schizophrenia Bulletin 36, 143–150. Davidson, L., Weingarten, R., Steiner, J., Stayner, D.A., Hoge, M.A., 1997. Integrating prosumers into clinical settings. In: Mowbray, C.T., Moxley, D.P., Jasper, C.A., Howell, L.L. (Eds.), Consumers as Providers in Psychiatric Rehabilitation. International Association for Psychosocial Rehabilitation Services, Columbia, MD, pp. 437–455. Donohoe, G., Corvin, A., Robertson, I.H., 2006. Evidence that specific executive functions predict symptom variance among schizophrenia patient individuals with a predominantly negative symptom profile. Cognitive Neuropsychiatry 11, 13–32. Eccles, J.S., Wigfield, A., 2002. Motivational beliefs, values, and goals. Annual Review of Psychology 53, 109–132. Earnst, K.S., Kring, A.M., 1999. Emotional responding in deficit and non-deficit schizophrenia. Psychiatry Research 88, 191–207. Garland, E.L., Fredrickson, B., Kring, A., Johnson, D., Meyer, P.S., Penn, D.L., 2010. Upward spirals of positive emotions counter downward spirals of negativity: insights from the broaden-and-build theory and affective neuroscience on the treatment of emotion dysfunctions and deficits in psychopathology. Clinical Psychology Review 30, 849–864. Gold, C., Solli, H.P., Kruger, V., Lie, S.A., 2009. Dose–response relationship in music therapy for people with serious mental disorders: systematic review and metaanalysis. Clinical Psychology Review 29, 193–207. Grant, P., Beck, A.T., 2009. Defeatist beliefs as a mediator of cognitive impairment, negative symptoms and functioning in schizophrenia. Schizophrenia Bulletin 35, 798–806. Grant, P.M., Huh, G.A., Perivoliotis, D., Stolar, N.M., Beck, A.T., 2012. Randomized trial to evaluate the efficacy of cognitive therapy for low-functioning patients with schizophrenia. Archives of General Psychiatry 69, 121–127. Green, M.F., 1996. What are the functional consequences of neurocognitive deficits in schizophrenia? American Journal of Psychiatry 153, 321–330. Gross, J., John, O.P., 2003. Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. Journal of Personality and Social Psychology 85, 348–362. Hasson-Ohayon, I., Walsh, S., Roe, D., Kravetz, S., Weiser, M., 2006. Personal and interpersonal perceived control and the quality of life of persons with severe mental illness. Journal of Nervous and Mental Disease 194, 538–542. Heerey, E.A., Gold, J.M., 2007. Patients with schizophrenia demonstrate dissociation between affective experience and motivated behavior. Journal of Abnormal Psychology 116, 268–278.
Herbener, E.S., Harrow, M., 2004. Are negative symptoms associated with functioning deficits in both schizophrenia and nonschizophrenia patients? A 10-year longitudinal analysis. Schizophrenia Bulletin 30, 813–825. Horan, W.P., Green, M.F., Kring, A.M., Nuechterlein, K.H., 2006. Does anhedonia in schizophrenia reflect faulty memory for subjectively experienced emotions? Journal of Abnormal Psychology 115, 496–508. Kendall, T., 2012. Treating negative symptoms of schizophrenia. British Medical Journal 344, e664. Kirkpatrick, B., Fenton, W.S., Carpenter Jr., W.T., Marder, S.R., 2006. The NIMH-MATRICS consensus statement on negative symptoms. Schizophrenia Bulletin 32, 214–219. MacCarthy, B., Benson, J., Brewin, C.R., 1986. Task motivation and problem appraisal in long-term psychiatric patients. Psychological Medicine 16, 431–438. Mason, O., Claridge, G., Jackson, M., 1995. New scales for the assessment of schizotypy. Personality and Individual Differences 18, 7–13. McGurk, S.R., Mueser, K.T., 2004. Cognitive functioning, symptoms, and work in supported employment: a review and heuristic model. Schizophrenia Research 70, 147–173. Milev, P., Ho, B.C., Arndt, S., Andreasen, N.C., 2005. Predictive values of neurocognition and negative symptoms on functional outcome in schizophrenia: a longitudinal first episode study with 7 year follow up. American Journal of Psychiatry 162, 495–506. Morimoto, T., Matsuyama, K., Ichihara-Takeda, S., Murakami, R., Ikeda, N., 2012. Influence of self-efficacy on the interpersonal behavior of schizophrenia patients undergoing rehabilitation in psychiatric day-care services. Psychiatry and Clinical Neurosciences 66, 203–209. Mortimer, A.M., Bowen, K., 1999. Measuring IQ in schizophrenia research: an update of the QuickTest in estimating IQ decline. Cognitive Neuropsychiatry 4, 81–88. Multon, K.D., Brown, S.D., Lent, R.W., 1991. Relation of self-efficacy beliefs to academic outcomes: a meta-analytic investigation. Journal of Counseling Psychology 18, 30–38. Overall, J.E., Gorham, D.R., 1962. The brief psychiatric rating scale. Psychological Reports 10, 799–812. Parrott, G.W., 1993. Beyond hedonism: motives for inhibiting good moods and for maintaining bad moods. In: Wegner, D.M., Pennebaker, J.W. (Eds.), Handbook of Mental Control. Prentice-Hall, Upper Saddle River, NJ, pp. 278–305. Pratt, S.I., Mueser, K.T., Smith, T.E., Lu, W., 2005. Self-efficacy and psychosocial functioning in schizophrenia: a mediational analysis. Schizophrenia Research 78, 187–197. Quoidbach, J., Dunn, E.W., Petrides, K.V., Mikolajczak, M., 2010. Money giveth, money taketh away: the dual effect of wealth on happiness. Psychological Science 21, 759–763. Rabinowitz, J.R., Levine, S.Z., Garibaldi, G., Bugarski-Kirola, D., Galani Bernado, C., Kapur, S., 2012. Negative symptoms have greater impact on functioning than positive symptoms in schizophrenia: analysis of CATIE data. Schizophrenia Research 137, 147–150. Rector, N.A., Seeman, M.V., Segal, Z.V., 2003. Cognitive therapy for schizophrenia: a preliminary randomized controlled trial. Schizophrenia Research 63, 1–11. Rocca, P., Montemagni, C., Castagna, F., Giugiario, M., Scalese, M., Bogetto, F., 2009. Relative contribution of antipsychotics, negative symptoms and executive functions to social functioning in stable schizophrenia. Progress in NeuroPsychopharmacology and Biological Psychiatry 33, 373–379. Rohricht, F., Priebe, S., 2006. Effect of body-oriented psychological therapy on negative symptoms in schizophrenia: a randomized controlled trial. Psychological Medicine 36, 669–678. Sensky, T., Turkington, D., Kingdon, D., Scott, J.L., Siddle, R., O’Carroll, M., Barnes, T.R. E., 2000. A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Archives of General Psychiatry 57, 165–172. Spencer, H., Turkington, D., 2010. Cognitive behavioural therapy for schizophrenia. Drug Therapy Bulletin 48, 6–9. Strauss, G., 2013. The emotion paradox of anhedonia in schizophrenia: or is it? Schizophrenia Bulletin 39, 247–250. Turkington, D., Sensky, T., Scott, J.L., Barnes, T.R.E., Nur, U., Siddle, R., Hammond, K., Samarasekara, N., Kingdon, D., 2008. A randomized controlled trial of cognitivebehavior therapy for persistent symptoms in schizophrenia: a five-year followup. Schizophrenia Research 98, 1–7. Turkington, D., Morrison, A.P., 2012. Cognitive therapy for the negative symptoms of schizophrenia. Archives of General Psychiatry 69, 119–120. Watson, D., Clark, L.A., Tellegen, A., 1988. Development and validation of a brief measure of positive and negative affect. Journal of Personality and Social Psychology 54, 1063–1070. Zevon, M.A., Tellegen, A., 1982. The structure of mood change: an idiographic/ nomothetic analysis. Journal of Personality and Social Psychology 43, 111–122.
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Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Poor savouring and low self-efficacy are predictors of anhedonia in patients with schizophrenia spectrum disorders Raymond Cassar a, Eve Applegate b,n, Richard P. Bentall c a
School of Psychology, Bangor University, Adeilad Brigantia, Bangor, Gwynedd, Wales LL57 2AS, UK Institute of Brain, Behaviour & Mental Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK c Institute of Psychology, Health and Society, Liverpool University, Waterhouse Building Block B, Liverpool L69 3GL, UK b
art ic l e i nf o
a b s t r a c t
Article history: Received 12 April 2013 Received in revised form 15 September 2013 Accepted 17 September 2013
Previous research suggests that negative schizotypes may be impaired in their ability to savour pleasant events (Applegate et al., 2009) and that schizophrenia patients believe that everyday tasks are excessively difficult to complete so that they attempt these tasks less frequently (MacCarthy et al., 1986; Bentall et al., 2010). It is possible that these beliefs and behaviours underpin negative symptoms such as anhedonia, avolition, apathy and associality. In the present study, 50 schizophrenia patients and 100 matched controls (half employed and half unemployed) completed selfreport measures of self-efficacy and savouring. Patients reported savouring past, present and future events less than employed and unemployed groups, irrespective of mood state and I.Q. Patients also rated everyday tasks as more difficult to master. Inpatients compared to outpatients rated tasks more difficult but less important although they did not differ on the savouring measure. Abnormal judgements of difficulty and the reduced propensity to mentally rehearse past or future positive experiences to up-regulate mood could explain negative symptom patients' lack of engagement in everyday activities and eventual social withdrawal. These findings suggest the need to develop cognitive-behavioural savouring and self-efficacy interventions for patients experiencing the negative symptoms of schizophrenia. & 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Anhedonia Avolition Negative symptoms Psychosis Savouring Schizophrenia Self-efficacy
1. Introduction Patients with schizophrenia and their carers report that negative symptoms, such as avolition, alogia, anhedonia, apathy and associality, cause the greatest disability and distress (Kirkpatrick et al., 2006). Negative symptoms are inversely correlated with functional outcome (Herbener and Harrow, 2004; McGurk and Mueser, 2004; Rabinowitz et al., 2012) and their presence early during illness predicts a poorer outcome overall (Milev et al., 2005; Rocca et al., 2009). The response of persistent negative symptoms to cognitive remediation, family therapy and social skills training is limited (Turkington and Morrison, 2012) and, whilst alleviating positive symptoms, antipsychotic medication can worsen primary negative symptoms (Kendall, 2012). Secondary analyses of the effects of cognitive therapy on negative symptoms in schizophrenia trials suggest that patients do experience some benefit (Sensky et al., 2000; Rector et al., 2003), that may last up to 5 years, even when beneficial effects on positive symptoms have receded (Turkington et al., 2008; Spencer and Turkington, 2010). However, therapy in
n
Corresponding author. Tel.: þ 44 161 306 8006; fax: þ 44 161 306 7945. E-mail address: [email protected] (E. Applegate).
0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2013.09.017
many of these trials was not expressly designed to target negative symptoms and the cognitive processes which underpin these phenomena remain largely unknown. One cognitive model proposes that low self-efficacy potentiates negative symptoms, particularly avolition, as a consequence of reduced expectations of reward or success (MacCarthy et al., 1986; Bentall et al., 2010). As self-efficacy governs individuals' beliefs in their ability to succeed in tasks (Bandura, 1977) it is thought to contribute to how much time and effort people will expend and how many aversive experiences or obstacles they will tolerate before stopping (Morimoto et al., 2012). Consistent with this view, negative symptoms are associated with defeatist beliefs which undermine attempts to complete everyday tasks (Grant and Beck, 2009). It is also possible that self-efficacy impacts on the pleasure and reinforcement people experience following the completion of everyday tasks by increasing a reflective sense of pride or achievement. Alternatively, it may be that increased self-efficacy is associated with an initial impetus to plan activities which are reinforcing, leading to a greater likelihood of pursuing hedonic experiences overall. Empirical evidence examining self-efficacy specifically in those with negative symptoms is limited (Pratt et al., 2005) but diminished self-efficacy in groups with serious mental illness has been associated with hopelessness, a lack of control, (Davidson et al., 1997)
R. Cassar et al. / Psychiatry Research 210 (2013) 830–834
poorer quality of life, worse community functioning and reduced likelihood of employment (Hasson-Ohayon et al., 2006). Whilst it has been established that negative symptoms patients complete simple everyday tasks less frequently and report lower self-efficacy estimates for successful completion of these tasks (MacCarthy et al., 1986), this finding does not seem to be specific to avolition (Bentall et al., 2010). One implication is that cognitive interventions that manipulate estimates of self-efficacy might affect other negative symptoms as well as avolition by changing beliefs about self-worth, mastery, confidence or willingness to tolerate initial task failures prior to success (Grant et al., 2012). A community-based study in a rehabilitation service found that self-efficacy beliefs about interpersonal behaviour skills predicted actual interpersonal behaviour better than measures of neurocognitive functioning (Morimoto et al., 2012). A second study has shown that motivational interventions can be used to change self-efficacy beliefs about ability to exercise in patients diagnosed with schizophrenia (Beebe et al., 2010). An alternative attempt to understanding negative symptoms has examined reward processing. The immediate experience of pleasure in schizophrenia patients is comparable to that in healthy samples (Cohen and Minor, 2010). However, studies have suggested that patients with negative symptoms have an impairment in the ability to anticipate pleasurable experiences (Earnst and Kring, 1999) which remains stable over time, causing emotional discomfort (Buck and Lysaker, 2013) and/or an impairment in the ability to recall the affective tone of memories (Horan et al., 2006; Heerey and Gold, 2007; Strauss, 2013). Parallel research with healthy individuals conducted by Applegate et al. (2009) found that reduced cognitive savouring (the ability to mentally rehearse past present and future positive experiences) is associated with schizotypal anhedonia, (Bryant, 1989, 2003; Bryant and Veroff, 2007). A reduction in savouring might lead to limited access to memories involving prior pleasure and previous mastery, which may contribute to the development of systematised beliefs that cause future activities to appear insurmountable. When deliberately employed, savouring can be used as a strategy to up-regulate positive affect, thereby increasing the intensity of pleasurable feelings and extending the amount of time which is spent experiencing these feelings (Parrott, 1993; Bryant, 2003; Garland et al., 2010). There are individual differences in people's propensity to savour within the general population; more frequent savouring is associated with better self-esteem, (Gross and John, 2003) and, savouring strategies can be taught (Quoidbach et al., 2010). It is possible that teaching negative symptoms patients to savour could help them to experience greater levels of positive affect which in turn could improve general motivational levels. However, although savouring has been shown to predict anhedonia in nonclinical samples, no study has yet reported a comparison between clinical and non-clinical groups. The first aim of this study was to determine whether savouring is impaired in schizophrenia patients compared to controls. To control for the possibility that lifestyle factors influence savouring, two control groups were recruited, one in long-term employment and one long-term unemployed group. A second aim was to compare the relative power of savouring and poor self-efficacy in predicting subjective anhedonia. For this purpose, scores on an introverted anhedonia measure suitable for assessing both clinical and non-clinical participants were used. 2. Methods
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22 females and 28 males). The patients had a mean age of 45.8 years (S.D.¼11.1) and were recruited from psychiatric services in Malta (Mount Carmel Hospital and the psychiatric wing at Gozo General Hospital); 22 (15 males and seven females) were on long-stay wards while 28 (15 males and 13 females) were outpatients. One female patient was married and two (one male and one female) held jobs. Diagnosis was according to ICD-10 by local psychiatrists, who were asked to refer patients with predominantly negative symptoms who had been known to services for a minimum of 5 years. Exclusion criteria were obvious organic impairments such as traumatic brain injury, serious epilepsy or dementia, and illiteracy. The unemployed controls were recruited from an employment and training centre, had a mean age of 43.0 years (S.D. ¼ 9.40), had been seeking work for a minimum of 12 months and were not in receipt of psychiatric treatment. The employed group had been working for a minimum of three years, had a mean age of 44.4 years (S.D. ¼9.56), were not in receipt of psychiatric treatment, were recruited from commercial and public service organisations, and included factory floor labourers, telephone operators and clerks from government departments. Illiteracy was an exclusion criterion for both control groups. The groups did not differ in terms of age, (F[2, 147] ¼0.85, p ¼0.43) or in the proportion of male versus female participants, (χ2[2, N¼ 150]¼ 0.22, p ¼0.90). 2.2. Measures The Oxford-Liverpool Inventory of Feelings and Experiences (O-LIFE; Mason et al., 1995) is a widely used measure of schizotypal traits. Only two subscales with 104 true/false items were used in the present study: (i) the Unusual Experiences/Reality Distortion Scale, and (ii) the Introvertive Anhedonia Scale, which assesses lack of enjoyment from social activity and physical intimacy, and which is the main dependent variable in this research. This scale was chosen as a measure of anhedonia because of its suitability for both clinical and nonclinical samples. In this study Cronbach's alpha co-efficient was α ¼ 0.86 for Reality Distortion and α¼ 0.76 for Introvertive Anhedonia. The Savouring Belief Inventory (SBI; Bryant, 2003) is a 24 item, three subscale questionnaire measure of savouring the past, present and future. Example items include, “I don't like to anticipate good times before they happen,” and, “It is not difficult for me to recall good memories”. Each factor has four positively and four negatively worded items. Each item is rated on a 7-point likert scale, ranging from ‘strongly agree’ (1) to ‘strongly disagree’ (7). In this study Cronbach's alpha values were: total SBI α¼ 0.85; reminiscing α ¼ 0.67; savouring the present moment α¼ 0.72 and anticipating pleasure α¼ 0.65. MacCarthy Task Motivation Scale (MCTMS; MacCarthy et al., 1986) is constructed according to the value theory of motivation, which assumes that the performance of a particular behaviour is a function of its subjective importance and its related expectancy of successful completion (Eccles and Wigfield, 2002). Thus, abilityrelated convictions corresponding to ‘self-efficacy expectations’ (Bandura, 1997) are said to be strong predictors of performance (Multon et al., 1991). Respondents are asked to indicate the performance frequency of 10 everyday tasks (shopping; going to a restaurant for a meal; cooking a meal; doing household chores; travelling on public transport; using public amenities; any type of reading; writing e.g. a letter; managing a personal budget and managing a household budget). Participants use four point rating scales to rate the importance of each task (0 ¼ ‘not important to me at all’ to 4¼ ‘very important to me’); how difficult the task seems (0 ¼ ‘not at all difficult for me’, 4 ¼‘very difficult for me’) and the likelihood that they could successfully complete the task (0 ¼ ‘my efforts would not be successful at all’, 4¼ ‘my efforts would be very successful’). This scale has been used to assess selfefficacy expectations in previous studies of schizophrenia patients who are chronically impaired (MacCarthy et al., 1986) and suffering from negative symptoms (Bentall et al., 2010). Alpha coefficients calculated from participants' scores were α ¼0.70 for frequency judgements; α ¼0.75 for judgements of importance; α¼ 0.82 for difficulty estimates; and α ¼0.81 for success estimates. Two participants, one in the patient group and one in the employees group, only completed the frequency estimates. The Quick Test (Revised) (QT; Ammons and Ammons, 1962) is a brief test of intellectual function, included because psychosis, especially negative symptoms, is often associated with cognitive dysfunction (Donohoe et al., 2006; Green, 1996). Participants are asked to match each item on a 50 word list with one of four line drawn images. The QT was revised by Mortimer and Bowen (1999) with improved stimulus material and it was this version that was used. The Positive Affect Negative Affect Scale (PANAS: Watson et al., 1988) is a brief measure of current affect. It consists of two 10-item mood scales, measuring positive and negative affect, derived from principal components analysis of Zevon and Tellegen's (1982) affective lexicon checklist. Participants were asked to rate the extent to which they had experienced each emotion “at the present moment” on five-point scales (1¼‘not at all’ to 5¼ ‘extremely’). Alpha coefficients were α¼0.63 for PA and α¼0.64 for NA in this study.
2.1. Participants 2.3. Procedure One hundred and fifty Caucasian Maltese participants were stratified into three groups: schizophrenia patients, unemployed and employed participants, with 50 in each group (20 females and 30 males, except for the unemployed group, which had
The study was approved by Bangor University School of Psychology and the Maltese Health Authority ethics committees. The translation of all the
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instructions, questionnaires and tests was accomplished using the back translation technique. The original English version was translated into Maltese by one of the authors and back-translated into English by an independent, bilingually proficient person. Finally, an independent research assistant compared both English versions, i.e. the original and translated copies. The word list for the Quick test (Mortimer and Bowen, 1999) was translated into Maltese, using Aquilina's (1999) Maltese–English Dictionary. Participants did not receive any financial incentive for taking part.
IQ scores also differed across the three groups (F[2,147]¼ 37.32, po 0.001, partial η2 ¼ 0.34), and post hoc comparisons indicated that the patients scored lower than the employed (p o0.001) and the unemployed controls (po 0.001); again the two control groups did not differ. Positive affect, negative affect and IQ were therefore used as covariates in all subsequent analyses (results from analyses without these covariates were substantially similar).
3. Results
3.3. SBI
3.1. Analysis
For Anticipating, there was no significant association with IQ (F [1,144] ¼0.91, p ¼0.34), PA (F[1,144]¼0.39, p ¼0.54) or NA (F [1,144] ¼0.64, p ¼0.43) but the group difference was significant (F[2,144]¼ 4.27, p o0.05, Partial η2 ¼0.056). The patients reported less anticipatory savouring than the employed participants (Bonferoni p o0.02) with the unemployed participants falling between the two groups. For Savouring in the present, there was also no effect for IQ (F[1,144] ¼0.18, p ¼0.67), PA (F[1,144] ¼0.02, p ¼0.89) or NA (F[1,144] ¼2.44, p ¼0.12) and again the group effect was significant (F[2,144] ¼26.49, p o0.001, partial η2 ¼0.27). The patients differed from both control groups (po 0.001 in each comparison) but the two non-patient groups did not differ (p ¼0.99). Finally, for reminiscing, there was no effect of IQ (F [1,144] ¼1.04, p¼ 0.31), PA (F[1,144] ¼0.00, p ¼0.99) or NA (F [1,144] ¼2.27, p¼ 0.13) and the group effect was also highly significant (F[2,144]¼ 17.16, p o0.001, partial η2 ¼0.19) with the patients reporting less reminiscing than either of the other two groups (p o0.001 for each comparison).
All statistical analyses were conducted using SPSS v 21. Analyses of variance (ANOVAs) examined differences in demographic and psychiatric variables between groups, taking into account covariates. Tukey or Bonferoni post hoc tests were used to identify specific group differences. Multiple regression was used to establish which psychological measures best predicted anhedonia. Finally, to check whether savouring and self-efficacy could be affected by institutionalisation, we compared the scores of inpatients and outpatients. 3.2. Between-group comparisons Group differences on the dependent variables are shown in Table 1. There were significant differences on the Reality Distortion (F[2,147] ¼4.31, po 0.02, partial η2 ¼0.06) and the Introverted Anhedonia, (F[2,147] ¼20.50, p o0.001, partial η2 ¼ 0.22) subscales of the OLIFE. Tukey's post-hoc analyses revealed that, for Reality Distortion, the score for the schizophrenia group was greater than that of the employed group (p o0.02) with the unemployed group falling between but not significantly different from either. On the Introverted Anhedonia subscale, the schizophrenia group scored higher than both the unemployed and the employed groups (p o0.001 for both comparisons) but there was no difference between the two groups of controls. Group differences were also observed for PANAS positive affect (F[2, 147] ¼6.03, p ¼0.003, partial η2 ¼ 0.08) and negative affect (F[2,147]¼ 9.16, po0.001, partial η2 ¼0.11). Surprisingly, for positive affect, the patients' scores were lower than those of the unemployed (po0.005) but not the employed controls. In the case of negative affect, the patients scored higher than both employed (po0.005) and unemployed (po0.001) groups, which did not differ.
3.4. Task motivation There was a significant association between IQ (F[1,142]¼ 16.00, po 0.001, partial η2 ¼0.10) but not PA (F[1,142]¼ 0.28, p ¼0.60) or NA (F[1,142]¼0.34, p¼ 0.56) and the reported frequency of everyday tasks. The group effect for frequency narrowly failed to reach significance (F[2,142]¼ 2.75, p ¼0.07, partial η2 ¼0.037); this trend reflected the lower mean scores of the patients compared to the unemployed with the employed group's scores falling in between. For the perceived importance of the tasks, the association with IQ was highly significant (F[1,142]¼21.96, po0.001, partial η2 ¼ 0.13) but the associations with PA (F[1,142] ¼0.01, p¼ 0.94) and NA (F[1,142]¼1.10, p ¼0.30) were not. The group difference was not significant (F[2,142] ¼0.42, p ¼0.66). For perceived task difficulty, there was a significant effect of IQ (F[1,142]¼ 11.59, p o0.001,
Table 1 Group differences for schizophrenia, unemployed and employed groups. Schizophrenia N ¼ 50
Unemployed N¼ 50
Employed N ¼ 50
F
P
Age IQ
45.78 [11.0] 70.86 [15.79]
43.18 [9.4] 86.98 [11.03]
0.85 37.32
0.42 0.01nn
OLIFE – Reality Distortion OLIFE – Introverted Anhedonia PANAS – Positive Affect PANAS – Negative Affect SBI – Anticipating SBI – Savouring the present moment SBI – Reminiscing MCTQ – Success MCTQ – Frequency MCTQ – Importance MCTQ – Difficulty
16.00 [6.54] 14.28 [4.55] 22.78 [5.88] 24.54 [6.71] 1.74 [9.27] 2.32 [8.74] 2.52 [9.11] 15.52 [7.22] 27.82 [7.83] 15.52 [6.84] 17.90 [7.08]
14.66 [5.82] 9.60 [3.49] 26.82 [6.50] 19.72 [6.33] 6.04 [6.50] 7.96 [5.65] 11.56 [5.86] 11.86 [4.78] 34.42 [6.11] 19.10 [5.14] 10.56 [5.05]
44.22 [9.6] 91.50 [10.11] 12.42 [6.11] 9.46 [4.70] 25.36 [5.23] 20.46 [5.03] 8.26 [7.36] 9.56 [6.73] 13.08 [7.34] 10.34 [6.85] 33.94 [6.64] 18.80 [5.99] 9.12 [6.33]
4.307 20.50 6.03 9.16 9.04 40.57 28.57 8.72 14.07 5.42 28.73
0.01nn 0.01nn 0.01nn 0.01nn 0.01nn 0.01nn 0.01nn 0.01nn 0.01nn 0.01nn 0.01nn
Note: Standard deviations appear in parentheses. Means are significantly different at
nn
p o0.001 based on Tukey's post hoc paired comparisons.
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partial η2 ¼0.05) but not for PA (F[1,142] ¼0.71, p ¼0.40) or NA (F[1,142] ¼0.04, p ¼0.85). However, the group difference for difficulty was highly significant, (F[2,142] ¼13.09, po 0.001, partial η2 ¼ 0.16). No difference was observed between the two control groups but the patient group perceived the tasks to be much more difficult than both of the control groups (Bonferoni p o0.001 for each comparison). Finally, for perceived likelihood of success, IQ was a significant covariate (F[1,142]¼4.30, p o0.05, partial η2 ¼ 0.03) but PA (F[1,142]¼0.24, p ¼0.63) and NA (F[1,142] ¼0.43, p ¼0.51) were not; the group difference was also non-significant, (F[2, 142]¼1.94, p¼ 0.15). 3.5. Predictors of introverted anhedonia We used multiple regression to examine predictors of introverted anhedonia in the groups. Variables were entered in blocks, with age and IQ entered at the first stage, then PA and NA were added before, finally, the psychological measures (SBI total scores and perceived difficulty scores from the task questionnaire) were entered at stage three. The initial model was significant (F[2,145]¼ 11.35, po 0.001) and accounted for 12.3% of the variance in introverted anhedonia scores; I.Q. was a significant predictor in this model (ß ¼0.37, t ¼4.76, po 0.001). Adding the mood measures did not improve the model (Fchange[2,143]¼2.24, p ¼0.11) but adding the psychological measures did improve it (Fchange[2,141]¼ 19.59, p o0.001). The final model was significant (F[6,141] ¼2.32, p o0.001) and accounted for 59% of the variance. In this model, I.Q. was no longer a significant predictor of anhedonia but savouring (β¼ 0.33, t¼3.99, p o0.001) and perceived task difficulty (β¼0.23, t ¼ 2.72, po 0.01) were. Hence, anhedonia was associated with a self-reported failure to savour pleasurable events together with high estimates of the difficulty of everyday tasks. 3.6. Differences between inpatients and outpatients To check whether the differences observed in savouring and task motivation might be driven by institutionalisation, we compared inpatients and outpatients on these variables. No differences were found, with the exception that scores on perceived task difficulty were higher in the inpatient group (t(46) ¼2.26, p o0.05, two-tailed) whereas scores on perceived task importance were marginally lower, (t(46) ¼1.84, p ¼0.7, two-tailed).
4. Discussion We examined whether schizophrenia patients differed from employed and unemployed control groups in their ability to savour and estimate self-efficacy. Our findings suggest that those with schizophrenia savour the past, present and future less than both employed and unemployed groups. This effect remained significant when we controlled for IQ and positive and negative mood and is consistent with previous research which suggests that those who are negatively schizotypal savour less (Applegate et al., 2009). It provides evidence that patients spend less time mentally rehearsing positive experiences than those who are unaffected by psychosis and suggests that they might benefit from a savouring intervention. No differences were observed between inpatients and outpatients on these measures. The same patient group also reported that everyday tasks were more difficult to master than the two control groups, and this effect survived when we controlled for mood and IQ, although it was associated with intelligence. Two previous studies also report that patients carry out everyday tasks less often, and believe that they are more difficult to complete (MacCarthy et al., 1986; Bentall et al., 2010). In the present study, inpatients rated everyday tasks
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as more difficult than outpatients, at the same time rating the tasks as marginally less important. Hence, it is possible that patients' self-efficacy is at least partially influenced by experiences of hospitalisation and their sequalae. Again, behavioural interventions that are designed to make self-efficacy estimates more realistic might impact negative symptomatology by changing beliefs regarding worth, mastery, confidence or willingness to tolerate task failure prior to success (Grant et al., 2012). When predictive factors were examined in the same model, subjective anhedonia was predicted by high perceived task difficulty and low savouring. We attempted to control for social circumstances by including a long-term unemployed control group; however, few differences were seen between these participants and the employed controls. Although it is possible that differences between the control groups might have been more pronounced if the unemployed group were longer term unemployed (our criterion was 412 months) this finding suggests a specific association between schizophrenia and trait anhedonia and related processes. Examined together these findings suggest that savouring and low self-efficacy expectations may contribute to the negative symptoms of schizophrenia. Poor self-efficacy beliefs might potentiate negative symptoms such as anhedonia and avolition through reduced expectation of success, reduced efforts to obtain rewards, cognitive confidence and reduced tolerance of task obstacles, or aversive experiences (Applegate et al., 2009; Bentall et al., 2010; Grant et al., 2012). A reduction in savouring could give negative symptoms patients fewer opportunities to up-regulate positive affect, that is to increase the intensity of potentially rewarding experiences (Applegate et al., 2009). A cognitive style which undermines self-confidence and an increased perception that social experiences will not yield reinforcement could also explain the interpersonal communication problems such as alogia and could lead to social withdrawal (Morimoto et al., 2012). One limitation of the present study concerns our clinical assessments. Future studies would benefit from the inclusion of a clinical schedule which specifically screens negative symptoms such as the Scale for the Assessment of Negative Symptoms, SANS, (Andreasen, 1981) or Brief Psychiatric Rating Scale, BPRS, (Overall and Gorham, 1962). Additionally, patients were diagnosed by their own psychiatrist and not by the research team and a researcherverified diagnosis would have improved diagnostic certainty. We were also unable to control for or record medication so could not model antipsychotic dose as a covariate in the final regression models. Further research exploring the relationship of antipsychotic medication to self-efficacy and savouring is therefore required. Finally, we utilised self-report measures of psychological processes rather than observational or physiological measures, which are likely to be more robust. The present findings suggest that both self-efficacy expectations and savouring might be suitable targets for psychological intervention. The recent trial by Grant et al. (2012) addressed the former by targeting defeatist beliefs but so far no trial has attempted to affect savouring. It is possible that therapies using the expressive arts, which have shown some utility with negative symptom patients (Rohricht and Priebe, 2006; Gold et al., 2009), are affective because they impact both types of psychological processes. More broadly, the need to promote negative symptom patients' estimates of self-efficacy and to enhance their ability to enjoy experiences highlights the importance of changing the way in which mental health interventions are typically delivered. Consistent with this idea, the recovery movement emphasises a need for new approaches which avoid paternalistic control, dependence and stigma and which endow patients with consumer rights, thereby improving self-efficacy and hope (Bellack and Drapalski, 2012; Bentall, 2009).
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References Ammons, C.H., Ammons, R.B., 1962. The Quick Test (QT), Psychological Test Specialists, Missoula, Montana. Andreasen, N.C., 1981. Scale for the Assessment of Negative Symptoms (SANS). University of Iowa, Iowa City. Applegate, E.M., El-Deredy, W., Bentall, R.P., 2009. Reward responsiveness in psychosis-prone groups: hypomania and negative schizotypy. Personality and Individual Differences 47, 452–456. Aquilina, J., 1999. Maltese–English Dictionary. Midsea Books, Valletta, Malta. Bandura, A., 1977. Self-efficacy: towards a unified theory of behavioural change. Psychological Review 84, 191–215. Bandura, A., 1997. Self-Efficacy: The Exercise of Control. Freeman, New York. Beebe, L.H., Smith, K., Burk, R., Dessieux, O., Velligan, D., Tavakoli, A., Tennison, C., 2010. Effect of a motivational group intervention on exercise self efficacy and outcome expectations for exercise in schizophrenia spectrum disorders. Journal of the American Psychiatric Nurses Association 16, 105–113. Bellack, A.S., Drapalski, A., 2012. Issues and developments on the consumer recovery construct. World Psychiatry 11, 156–160. Bentall, R.P., 2009. Doctoring the Mind: Why Psychiatric Treatments Fail. Penguin, London. Bentall, R.P., Simpson, P.W., Lee, D.A., Williams, S., Elves, S., 2010. Motivation and avolition in schizophrenia patients: the role of self-efficacy. Psychosis 2, 12–22. Bryant, F., Veroff, J., 2007. Savoring: A New Model of Positive Experience. Lawrence Erlbaum Associates, Mahwah, NJ. Bryant, F.B., 1989. A four-factor model of perceived control: avoiding, coping, obtaining and savouring. Journal of Personality 57, 773–797. Bryant, F.B., 2003. Savoring Beliefs Inventory (SBI): a scale for measuring beliefs about savoring. Journal of Mental Health 12, 175–196. Buck, B., Lysaker, P.H., 2013. Consummatory and anticipatory anhedonia in schizophrenia: stability, and associations with emotional distress and social function over six months. Psychiatry Research 20, 30–35. Cohen, A.S., Minor, K.S., 2010. Emotional experience in patients with schizophrenia revisited: meta-analysis of laboratory studies. Schizophrenia Bulletin 36, 143–150. Davidson, L., Weingarten, R., Steiner, J., Stayner, D.A., Hoge, M.A., 1997. Integrating prosumers into clinical settings. In: Mowbray, C.T., Moxley, D.P., Jasper, C.A., Howell, L.L. (Eds.), Consumers as Providers in Psychiatric Rehabilitation. International Association for Psychosocial Rehabilitation Services, Columbia, MD, pp. 437–455. Donohoe, G., Corvin, A., Robertson, I.H., 2006. Evidence that specific executive functions predict symptom variance among schizophrenia patient individuals with a predominantly negative symptom profile. Cognitive Neuropsychiatry 11, 13–32. Eccles, J.S., Wigfield, A., 2002. Motivational beliefs, values, and goals. Annual Review of Psychology 53, 109–132. Earnst, K.S., Kring, A.M., 1999. Emotional responding in deficit and non-deficit schizophrenia. Psychiatry Research 88, 191–207. Garland, E.L., Fredrickson, B., Kring, A., Johnson, D., Meyer, P.S., Penn, D.L., 2010. Upward spirals of positive emotions counter downward spirals of negativity: insights from the broaden-and-build theory and affective neuroscience on the treatment of emotion dysfunctions and deficits in psychopathology. Clinical Psychology Review 30, 849–864. Gold, C., Solli, H.P., Kruger, V., Lie, S.A., 2009. Dose–response relationship in music therapy for people with serious mental disorders: systematic review and metaanalysis. Clinical Psychology Review 29, 193–207. Grant, P., Beck, A.T., 2009. Defeatist beliefs as a mediator of cognitive impairment, negative symptoms and functioning in schizophrenia. Schizophrenia Bulletin 35, 798–806. Grant, P.M., Huh, G.A., Perivoliotis, D., Stolar, N.M., Beck, A.T., 2012. Randomized trial to evaluate the efficacy of cognitive therapy for low-functioning patients with schizophrenia. Archives of General Psychiatry 69, 121–127. Green, M.F., 1996. What are the functional consequences of neurocognitive deficits in schizophrenia? American Journal of Psychiatry 153, 321–330. Gross, J., John, O.P., 2003. Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. Journal of Personality and Social Psychology 85, 348–362. Hasson-Ohayon, I., Walsh, S., Roe, D., Kravetz, S., Weiser, M., 2006. Personal and interpersonal perceived control and the quality of life of persons with severe mental illness. Journal of Nervous and Mental Disease 194, 538–542. Heerey, E.A., Gold, J.M., 2007. Patients with schizophrenia demonstrate dissociation between affective experience and motivated behavior. Journal of Abnormal Psychology 116, 268–278.
Herbener, E.S., Harrow, M., 2004. Are negative symptoms associated with functioning deficits in both schizophrenia and nonschizophrenia patients? A 10-year longitudinal analysis. Schizophrenia Bulletin 30, 813–825. Horan, W.P., Green, M.F., Kring, A.M., Nuechterlein, K.H., 2006. Does anhedonia in schizophrenia reflect faulty memory for subjectively experienced emotions? Journal of Abnormal Psychology 115, 496–508. Kendall, T., 2012. Treating negative symptoms of schizophrenia. British Medical Journal 344, e664. Kirkpatrick, B., Fenton, W.S., Carpenter Jr., W.T., Marder, S.R., 2006. The NIMH-MATRICS consensus statement on negative symptoms. Schizophrenia Bulletin 32, 214–219. MacCarthy, B., Benson, J., Brewin, C.R., 1986. Task motivation and problem appraisal in long-term psychiatric patients. Psychological Medicine 16, 431–438. Mason, O., Claridge, G., Jackson, M., 1995. New scales for the assessment of schizotypy. Personality and Individual Differences 18, 7–13. McGurk, S.R., Mueser, K.T., 2004. Cognitive functioning, symptoms, and work in supported employment: a review and heuristic model. Schizophrenia Research 70, 147–173. Milev, P., Ho, B.C., Arndt, S., Andreasen, N.C., 2005. Predictive values of neurocognition and negative symptoms on functional outcome in schizophrenia: a longitudinal first episode study with 7 year follow up. American Journal of Psychiatry 162, 495–506. Morimoto, T., Matsuyama, K., Ichihara-Takeda, S., Murakami, R., Ikeda, N., 2012. Influence of self-efficacy on the interpersonal behavior of schizophrenia patients undergoing rehabilitation in psychiatric day-care services. Psychiatry and Clinical Neurosciences 66, 203–209. Mortimer, A.M., Bowen, K., 1999. Measuring IQ in schizophrenia research: an update of the QuickTest in estimating IQ decline. Cognitive Neuropsychiatry 4, 81–88. Multon, K.D., Brown, S.D., Lent, R.W., 1991. Relation of self-efficacy beliefs to academic outcomes: a meta-analytic investigation. Journal of Counseling Psychology 18, 30–38. Overall, J.E., Gorham, D.R., 1962. The brief psychiatric rating scale. Psychological Reports 10, 799–812. Parrott, G.W., 1993. Beyond hedonism: motives for inhibiting good moods and for maintaining bad moods. In: Wegner, D.M., Pennebaker, J.W. (Eds.), Handbook of Mental Control. Prentice-Hall, Upper Saddle River, NJ, pp. 278–305. Pratt, S.I., Mueser, K.T., Smith, T.E., Lu, W., 2005. Self-efficacy and psychosocial functioning in schizophrenia: a mediational analysis. Schizophrenia Research 78, 187–197. Quoidbach, J., Dunn, E.W., Petrides, K.V., Mikolajczak, M., 2010. Money giveth, money taketh away: the dual effect of wealth on happiness. Psychological Science 21, 759–763. Rabinowitz, J.R., Levine, S.Z., Garibaldi, G., Bugarski-Kirola, D., Galani Bernado, C., Kapur, S., 2012. Negative symptoms have greater impact on functioning than positive symptoms in schizophrenia: analysis of CATIE data. Schizophrenia Research 137, 147–150. Rector, N.A., Seeman, M.V., Segal, Z.V., 2003. Cognitive therapy for schizophrenia: a preliminary randomized controlled trial. Schizophrenia Research 63, 1–11. Rocca, P., Montemagni, C., Castagna, F., Giugiario, M., Scalese, M., Bogetto, F., 2009. Relative contribution of antipsychotics, negative symptoms and executive functions to social functioning in stable schizophrenia. Progress in NeuroPsychopharmacology and Biological Psychiatry 33, 373–379. Rohricht, F., Priebe, S., 2006. Effect of body-oriented psychological therapy on negative symptoms in schizophrenia: a randomized controlled trial. Psychological Medicine 36, 669–678. Sensky, T., Turkington, D., Kingdon, D., Scott, J.L., Siddle, R., O’Carroll, M., Barnes, T.R. E., 2000. A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Archives of General Psychiatry 57, 165–172. Spencer, H., Turkington, D., 2010. Cognitive behavioural therapy for schizophrenia. Drug Therapy Bulletin 48, 6–9. Strauss, G., 2013. The emotion paradox of anhedonia in schizophrenia: or is it? Schizophrenia Bulletin 39, 247–250. Turkington, D., Sensky, T., Scott, J.L., Barnes, T.R.E., Nur, U., Siddle, R., Hammond, K., Samarasekara, N., Kingdon, D., 2008. A randomized controlled trial of cognitivebehavior therapy for persistent symptoms in schizophrenia: a five-year followup. Schizophrenia Research 98, 1–7. Turkington, D., Morrison, A.P., 2012. Cognitive therapy for the negative symptoms of schizophrenia. Archives of General Psychiatry 69, 119–120. Watson, D., Clark, L.A., Tellegen, A., 1988. Development and validation of a brief measure of positive and negative affect. Journal of Personality and Social Psychology 54, 1063–1070. Zevon, M.A., Tellegen, A., 1982. The structure of mood change: an idiographic/ nomothetic analysis. Journal of Personality and Social Psychology 43, 111–122.
