L. Felice Reddy

Impulsivity and Risk Taking in Bipolar Disorder and Schizophrenia

Impulsive risk taking contributes to deleterious outcomes among clinical populations. Indeed, pathological impulsivity and risk taking are common in patients with serious mental illness, and have severe clinical repercussions including novelty seeking, response disinhibition, aggression, and substance abuse. Thus, the current study seeks to examine self-reported impulsivity (Barratt Impulsivity Scale) and performance-based behavioral risk taking (Balloon Analogue Risk Task) in bipolar disorder and schizophrenia. Participants included 68 individuals with bipolar disorder, 38 with schizophrenia, and 36 healthy controls. Self-reported impulsivity was elevated in the bipolar group compared with schizophrenia patients and healthy controls, who did not differ from each other. On the risk-taking task, schizophrenia patients were significantly more risk averse than the bipolar patients and controls. Aside from the diagnostic group differences, there was a significant effect of antipsychotic (AP) medication within the bipolar group: bipolar patients taking AP medications were more risk averse than those not taking AP medications. This difference in risk taking because of AP medications was not explained by history of psychosis. Similarly, the differences in risk taking between schizophrenia and bipolar disorder were not fully explained by AP effects. Implications for clinical practice and future research are discussed.

Effort-Based Decision-Making Paradigms for Clinical Trials in Schizophrenia: Part 1—Psychometric Characteristics of 5 Paradigms

Impairments in willingness to exert effort contribute to the motivational deficits characteristic of the negative symptoms of schizophrenia. The current study evaluated the psychometric properties of 5 new or adapted paradigms to determine their suitability for use in clinical trials of schizophrenia. This study included 94 clinically stable participants with schizophrenia and 40 healthy controls. The effort-based decision-making battery was administered twice to the schizophrenia group (baseline, 4-week retest) and once to the control group. The 5 paradigms included 1 that assesses cognitive effort, 1 perceptual effort, and 3 that assess physical effort. Each paradigm was evaluated on (1) patient vs healthy control group differences, (2) test-retest reliability, (3) utility as a repeated measure (ie, practice effects), and (4) tolerability. The 5 paradigms showed varying psychometric strengths and weaknesses. The Effort Expenditure for Rewards Task showed the best reliability and utility as a repeated measure, while the Grip Effort Task had significant patient-control group differences, and superior tolerability and administration duration. The other paradigms showed weaker psychometric characteristics in their current forms. These findings highlight challenges in adapting effort and motivation paradigms for use in clinical trials.

Review of social cognitive treatments for psychosis

Social cognitive treatments for schizophrenia are a rapidly expanding area of research. In this comprehensive review of the treatment literature, we provide information on nearly 50 studies evaluating a range of social cognitive interventions, including broad-based, targeted, and comprehensive approaches. Research to date has established that some social cognitive domains are responsive to structured training, though much work still remains to be done in further refining these treatments, improving their effects on more complex social cognitive domains, and demonstrating both the durability of the training effects as well as their generalization to important social functioning outcomes. We end our review by offering hypotheses for why existing treatments may have had limited success in improving more complex social cognitive processes, and summarize ongoing issues and future directions in social cognitive treatment research.

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

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

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

Despite the important role of motivation in rehabilitation and functional outcomes in schizophrenia, to date, there has been little emphasis on how motivation is assessed. This is important, since different measures may tap potentially discrete motivational constructs, which in turn may have very different associations to important outcomes. In the current study, we used baseline data from 71 schizophrenia spectrum outpatients enrolled in a rehabilitation program to examine the relationship between task-specific motivation, as measured by the Intrinsic Motivation Inventory (IMI), and a more general state of volition/initiation, as measured by the three item Quality of Life (QLS) motivation index. We also examined the relationship of these motivation measures to demographic, clinical and functional variables relevant to rehabilitation outcomes. The two motivation measures were not correlated, and participants with low general state motivation exhibited a full range of task-specific motivation. Only the QLS motivation index correlated with variables relevant to rehabilitation outcomes. The lack of associations between QLS motivation index and IMI subscales suggests that constructs tapped by these measures may be divergent in schizophrenia, and specifically that task-specific intrinsic motivation is not contingent on a general state of motivation. That is, even in individuals with a general low motivational state (i.e. amotivation), interventions aimed at increasing task-specific motivation may still be effective. Moreover, the pattern of interrelationships between the QLS motivation index and variables relevant to psychosocial rehabilitation supports its use in treatment outcome studies.

Behavioral approach and avoidance in schizophrenia: An evaluation of motivational profiles

Schizophrenia is associated with motivational deficits that interfere with a wide range of goal directed activities. Despite their clinical importance, our current understanding of these motivational impairments is limited. Furthermore, different types of motivational problems are commonly seen among individuals within the broad diagnosis of schizophrenia. The goal of the current study was to examine whether clinically meaningful subgroups could be identified based on approach and avoidance motivational tendencies. We measured these tendencies in 151 individuals with schizophrenia. Although prior studies demonstrate elevated BIS sensitivity in schizophrenia at the overall group level, none have explored various combinations of BIS/BAS sensitivities within this disorder. Cluster analyses yielded five subgroups with different combinations of low, moderate, or high BIS and BAS. The subgroups had interpretable differences in clinically rated negative symptoms and self-reported anhedonia/socio-emotional attitudes, which were not detectable with the more commonly used linear BIS/BAS scores. Two of the subgroups had significantly elevated negative symptoms but different approach/avoidance profiles: one was characterized by markedly low BIS, low BAS and an overall lack of social approach motivation; the other had markedly high BIS but moderate BAS and elevated social avoidance motivation. The two subgroups with relatively good clinical functioning showed patterns of BAS greater than BIS. Our findings indicate that there are distinct motivational pathways that can lead to asociality in schizophrenia and highlight the value of considering profiles based on combined patterns of BIS and BAS in schizophrenia.

Memory as a moderator in the relationship between child sexual abuse and maladaptive functioning in people with severe mental illness.

Despite substantial research literature supporting the impact of child sexual abuse (CSA) on neuropsychological development and functional outcomes, severity of CSA has been neglected in the outcome analyses in people with severe mental illness. Furthermore, there is a paucity of studies examining variables that may moderate the relationship between CSA severity and functional outcomes. The purpose of the present study was to examine the influence of CSA severity on maladaptive functioning (e.g., irritability and psychoticism) in people with severe mental illness, and to explore the moderating effect of memory on the relationship between CSA and maladaptive functioning. Among 33 inpatients with severe mental illness, severity of CSA was positively associated with maladaptive functioning as measured by the Nurses’ Observation Scale for Inpatient Evaluation-30. Persons with higher memory capacity, even among those exposed to severe CSA, were less likely to display irritability and psychoticism in an in-patient psychiatric rehabilitation program. Implications for treatment and assessment in severe mental illness are discussed.

Predictors of employment in schizophrenia: The importance of intrinsic and extrinsic motivation

Unemployment is a primary functional deficit for the majority of adults with schizophrenia. Research indicates that over two-thirds of adults living in the community with schizophrenia are unemployed. Despite effective programs to assist with job identification and placement, the ability to attain and maintain employment remains a pressing concern. A contributing factor that may be relevant but has received little attention in the work rehabilitation literature is motivation. People with schizophrenia show marked deficits in both intrinsic and extrinsic motivation but these deficits have not been directly examined in relation to work outcomes. The present study sought to examine the relationship between intrinsic and extrinsic motivation and work outcome among a sample of 65 adults with schizophrenia enrolled in a supported employment program. One-third of the participants in the study obtained work. Intrinsic motivation related to valuing and feeling useful in a work role significantly predicted who would obtain employment. Extrinsic motivation related to gaining rewards and avoiding obstacles showed a non-significant trend-level relationship such that workers had higher extrinsic motivation than nonworkers. These findings highlight the importance of considering both intrinsic and extrinsic motivation in work-related interventions and supported employment for individuals with schizophrenia. The results are discussed in terms of clinical implications for improving rehabilitation and occupational outcomes in schizophrenia.

Cognitive Remediation for Schizophrenia: A Review of Recent Findings

Opinion statementSchizophrenia and related psychotic disorders are characterized by deficits in neurocognition. Deficits in domains such as attention, memory, executive functions, and speed of processing, as well as early perceptual processes, typically appear early in the course of the disorder and remain stable over time. Cognitive deficits can cause serious impairments in community functioning (i.e., work, independent living, and social relationships). For this reason, cognitive remediation (CR) is increasingly utilized to improve neurocognition. The empirical support for CR for adults with chronic schizophrenia is encouraging and growing. CR approaches are suitable for widespread dissemination and have been the focus of the majority of recent empirical research in psychoses. There are two broad categories of computerized CR approaches: those that target higher-level cognitive processes, and those that target neuroplasticity using basic auditory and visual processing. Research currently supports the efficacy of both higher-level and neuroplasticity-based CR for improving targeted cognitive domains; however, there is more consistent support for higher-level approaches in terms of generalization to untrained cognitive domains and functional outcomes. To achieve functional outcomes, CR combined with skills training or other psychosocial rehabilitation approaches is likely the most effective approach. The majority of CR interventions allow difficulty to be individually adjusted, which is an important therapeutic feature, and some provide an array of modules to allow personalized interventions. Several CR interventions appear to have durable treatment benefits, but more research is needed to clarify whether booster sessions, pharmacological augmentation, or other treatments should routinely be incorporated into treatment plans.

Clinical PhD Graduate Student Views of Their Scientist-Practitioner Training

OBJECTIVES The goal of the scientist-practitioner (S-P) training model is to produce clinical psychologists equipped to integrate and utilize both science and practice in the clinical and research domains. However, much has been written regarding the possible shortcomings of S-P training and whether clinical psychology graduate students are actually gaining the knowledge and skills to integrate science and practice during graduate training and beyond (Chang, Lee, & Hargreaves, 2008; Gelso, 2006; Merlo, Collins, & Bernstein, 2008; Phillips, 1993). METHODS As such, the present study assessed ratings of satisfaction, perception of ability, and use of the S-P training model within 653 clinical psychology graduate students enrolled in programs that are members of the Council of University Directors of Clinical Psychology. RESULTS Findings suggest that students are consistently trained in the integration of science and practice and have confidence in their abilities to apply the S-P integration to research and clinical work. However, despite understanding the ways in which science can influence practice, over one third of students reported that they rarely use science-based decisions when informing clients of the clinical services they will be providing. CONCLUSIONS The implications of these results support the need for a more detailed evaluation of clinical psychology graduate students as well as the use of research-informed practice and the process of providing clients with information they need to make informed choices about treatment.