Motivated to do well: an examination of the relationships between motivation, effort, and cognitive performance in schizophrenia

Effects of right prefrontal theta-burst transcranial magnetic stimulation or transcranial direct current stimulation on apathy in patients with schizophrenia: A multicenter RCT

Apathy is a core negative symptom associated with an unfavorable functional outcome. Noninvasive brain stimulation has shown promise in the treatment of schizophrenia but has not been tested specifically for apathy. We conducted a randomized controlled trial of intermittent theta-burst (iTBS) transcranial magnetic stimulation and transcranial direct current stimulation (tDCS) targeted at the right dorsolateral prefrontal cortex (DLPFC) in patients diagnosed with a psychotic disorder suffering from apathy. The study was a multicenter, randomized, placebo-controlled, and rater-blinded trial. Patients (N = 88) were randomized into active iTBS, active tDCS, sham iTBS or sham tDCS treatment, daily for two weeks (excluding weekends). Effects were measured post-treatment and at four week and ten week follow-up. Primary outcome was apathy severity (Apathy Evaluation Scale, clinician-rated). Additional measures included assessment of negative symptoms, depression, anhedonia and quality of life. No significant difference in improvement of apathy or negative symptoms was observed for real versus sham treatment with either iTBS or tDCS, though all groups improved to a small extent. We conclude that two weeks of brain stimulation over the right DLPFC with either iTBS or tDCS is not effective for improving apathy or negative symptoms. Longer and more intensive protocols may yield different results.

Examining the repeatable battery for the assessment of neuropsychological status validity indices in people with schizophrenia spectrum disorders

Objective: We examined the frequency of possible invalid test scores on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) in patients with schizophrenia spectrum disorders, and whether there was an association between scores on the embedded RBANS performance validity tests (PVTs) and self-reported symptoms of apathy as measured by the Initiate Scale of the Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A). Methods: Participants included 250 patients (M = 24.4 years-old, SD = 5.7) with schizophrenia spectrum disorders. Base rates of RBANS Effort Index (EI), Effort Scale (ES), and Performance Validity Index (PVI) test scores were computed. Spearman correlations were used to examine the associations between the RBANS PVTs, the RBANS Index scores, and the BRIEF-A Initiate Scale. Regression analyses were used to investigate how well the RBANS PVTs predicted scores on the BRIEF-A Initiate Scale. Results: The frequency of invalid scores on the EI (>3) and the PVI (<42) in participants with schizophrenia spectrum disorders was 6%. The frequency of invalid ES scores (<12) was 28% in the patients compared to 15% in the U.S. standardization sample. There was a small significant correlation between the EI and the BRIEF-A Initiate Scale (rho=.158, p<.05). Conclusions: The rates of invalid scores were similar to previously published studies. Invalid scores on the BRIEF-A were uncommon. Apathy measured with the BRIEF-A Initiate Scale was not associated with performance on the RBANS validity measures or with measures of cognition.

The instrumental role of operant paradigms in translational psychiatric research: Insights from a maternal immune activation model of schizophrenia risk

Rigorous behavioral analysis is essential to the translation of research conducted using animal models of neuropsychiatric disease. Here we discuss the use of operant paradigms within our lab as a powerful approach for exploring the biobehavioral bases of disease in the maternal immune activation rat model of schizophrenia. We have investigated a range of disease features in schizophrenia including abnormal perception of time, cognition, learning, motivation, and internal state (psychosis), providing complex insights into brain and behavior. Beyond simple phenotyping, implementing sophisticated operant procedures has been effective in delineating aspects of pathological behavior, identifying interacting pathologies, and isolating contributing mechanisms of disease. We provide comment on the strengths of operant techniques to support high-quality behavioral investigations in fundamental neuropsychiatric research.

Development and plasticity of executive functions: A value-based account

Executive functions are core to multiple aspects of daily cognitive, social and affective functioning. An extensive body of work has charted developmental trajectories and neural substrates of executive functions through the lifespan. Robust associations between executive functions early in life, and later, wellbeing and success has led to considerable efforts to improve executive functions through bespoke interventions. Here, we discuss recent findings on the role of cost-benefit computations in how executive functions are deployed in development. We propose leveraging these insights to design more effective interventions for improving executive functions.

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

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

Effect of mGluR2 positive allosteric modulation on frontostriatal working memory activation in schizophrenia

Negative symptoms and cognitive deficits contribute strongly to disability in schizophrenia, and are resistant to existing medications. Recent drug development has targeted enhanced NMDA function by increasing mGluR2/3 signaling. However, the clinical utility of such agents remains uncertain, and markers of brain circuit function are critical for clarifying mechanisms and understanding individual differences in efficacy. We conducted a double-blind, placebo-controlled, randomized cross-over (14 day washout) pilot study evaluating adjunctive use of the mGluR2 positive allosteric modulator AZD8529 (80 mg daily for 3 days), in chronic stable patients with schizophrenia (n = 26 analyzed). We focused on 3 T fMRI response in frontostriatal regions during an n-back working memory task, testing the hypothesis that AZD8529 produces fMRI changes that correlate with improvement in negative symptoms and cognition. We found that AZD8529 did not produce significant group-average effects on symptoms or cognitive accuracy. However, AZD8529 did increase n-back fMRI activation in striatum (p < 0.0001) and anterior cingulate/paracingulate (p = 0.002). Greater drug-versus-placebo effects on caudate activation significantly correlated with greater reductions in PANSS negative symptom scores (r = -0.42, p = 0.031), and exploratory correlations suggested broader effects across multiple symptom domains and regions of interest. These findings demonstrate that fMRI responses to mGluR2 positive modulation relate to individual differences in symptom reduction, and could be pursued for future biomarker development. Negative clinical results at the group level should not lead to premature termination of investigation of this mechanism, which may benefit an important subset of individuals with schizophrenia. Imaging biomarkers may reveal therapeutic mechanisms, and help guide treatment toward specific populations.

Processing of Spoken Emotions in Schizophrenia: Forensic and Non-forensic Patients Differ in Emotional Identification and Integration but Not in Selective Attention

Patients with schizophrenia (PwS) typically demonstrate deficits in visual processing of emotions. Less is known about auditory processing of spoken-emotions, as conveyed by the prosodic (tone) and semantics (words) channels. In a previous study, forensic PwS (who committed violent offenses) identified spoken-emotions and integrated the emotional information from both channels similarly to controls. However, their performance indicated larger failures of selective-attention, and lower discrimination between spoken-emotions, than controls. Given that forensic schizophrenia represents a special subgroup, the current study compared forensic and non-forensic PwS. Forty-five PwS listened to sentences conveying four basic emotions presented in semantic or prosodic channels, in different combinations. They were asked to rate how much they agreed that the sentences conveyed a predefined emotion, focusing on one channel or on the sentence as a whole. Their performance was compared to that of 21 forensic PwS (previous study). The two groups did not differ in selective-attention. However, better emotional identification and discrimination, as well as better channel integration were found for the forensic PwS. Results have several clinical implications: difficulties in spoken-emotions processing might not necessarily relate to schizophrenia; attentional deficits might not be a risk factor for aggression in schizophrenia; and forensic schizophrenia might have unique characteristics as related to spoken-emotions processing (motivation, stimulation).

Wisket rat model of schizophrenia: Impaired motivation and, altered brain structure, but no anhedonia

It is well-known that the poor cognition in schizophrenia is strongly linked to negative symptoms, including motivational deficit, which due to, at least partially, anhedonia. The goal of this study was to explore whether the schizophrenia-like Wisket animals with impaired motivation (obtained in the reward-based hole-board test), also show decreased hedonic behavior (investigated with the sucrose preference test). While neurochemical alterations of different neurotransmitter systems have been detected in the Wisket rats, no research has been performed on structural changes. Therefore, our additional aim was to reveal potential neuroanatomical and structural alterations in different brain regions in these rats. The rats showed decreased general motor activity (locomotion, rearing and exploration) and impaired task performance in the hole-board test compared to the controls, whereas no significant difference was observed in the sucrose preference test between the groups. The Wisket rats exhibited a significant decrease in the frontal cortical thickness and the hippocampal area, and moderate increases in the lateral ventricles and cell disarray in the CA3 subfield of hippocampus. To our knowledge, this is the first study to investigate the hedonic behavior and neuroanatomical alterations in a multi-hit animal model of schizophrenia. The results obtained in the sucrose preference test suggest that anhedonic behavior might not be involved in the impaired motivation obtained in the hole-board test. The neuropathological changes agree with findings obtained in patients with schizophrenia, which refine the high face validity of the Wisket model.

Decision Making under Risk in Patients Suffering from Schizophrenia or Depression

Studies have reported difficulties in decision making for patients with schizophrenia or depression. Here, we investigated whether there are differences between schizophrenia patients, depressed patients, and healthy individuals (HC) when decisions are to be made under risk and cognitive flexibility is required. We were also interested in the relationships between decision making, cognitive functioning, and disease severity. Thirty HC, 28 schizophrenia patients, and 28 depressed patients underwent structured clinical assessments and were assessed by the Positive and Negative Syndrome Scale or Hamilton Rating Scale. They performed the Probability-Associated Gambling (PAG) Task and a neuropsychological test battery. Both patient groups obtained lower scores than HC in memory and executive function measures. In the PAG task, relative to HC, depressed patients made slower decisions but showed a comparable number of advantageous decisions or strategy flexibility. Schizophrenia patients were slower, riskier, and less flexible compared to HC. For them, the decision making behavior correlated with the symptom severity. In both groups, decision making scores correlated with memory and executive function scores. Patients with schizophrenia or depression may have difficulties under risk when quick and flexible decisions are required. These difficulties may be more pronounced in patients who have marked cognitive deficits or severe clinical symptoms.

Money talks: The influence of extrinsic motivators on social cognition in early episode psychosis

Amotivation is a central feature of psychosis that can lead to underperformance on a variety of tasks, including neurocognitive testing; however, there is some evidence that neurocognitive impairments resulting from low effort can be ameliorated with the use of monetary reinforcement. While cross-sectional data has also shown that amotivation is associated with social cognitive performance, limited research has examined the directionality of this relationship, and whether monetary reinforcement can similarly reduce these impairments. In the present study, 35 patients with early psychosis and 35 community controls were randomized to either a reward condition in which they received monetary reinforcement for every correct response on a theory of mind (ToM) task, or a non-reward condition in which no feedback was provided. A significant group by condition interaction emerged after adjusting for premorbid intelligence and global neurocognition, F(1, 63) = 7.76, p = .007. Post-hoc analyses revealed that performance on the ToM task was similar across conditions for controls, whereas early psychosis patients in the reward condition had clinically and statistically significant differences in ToM performance compared to patients in the non-reward condition. These results suggest that social cognitive task performance may underrepresent actual ability in the early stages of psychosis. Future research is needed to discriminate the relative effects of monetary reinforcement, corrective feedback, and/or a combination of these factors to better understand performance differences between conditions, which appeared to be unique to early psychosis patients.

Smoking Is Related to Reduced Motivation, But Not Global Cognition, in the First Two Years of Treatment for First Episode Psychosis

Smoking is highly prevalent in people with psychotic disorders, even in the earliest phases of the illness. The neural mechanisms of nicotine dependence and psychosis overlap and may also be linked to deficits in neurocognition and motivation in psychosis. Both neurocognition and motivation are recognized as important clinical targets, though previous research examining the effects of smoking on these features has been inconsistent. Here, we examine the relationships between smoking status and neurocognition and motivation over the first two years of treatment for psychosis through a secondary analysis of the Recovery After an Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) dataset. In a sample of 404 individuals with first-episode psychosis, we examined linear mixed-effects models with the group (smoker vs. non-smoker) by time (baseline, 12-month, 24-month) interaction as a predictor of global cognition and motivation. While all individuals showed enhanced global cognition and motivation over the 24-month course of treatment, non-smokers showed significantly greater gains in motivation. These changes in motivation also corresponded to improvements in functioning over the 24-month period. No significant effects of smoking were observed for global cognition. Our findings suggest that motivation and smoking cessation may be important early treatment targets for first-episode psychosis programs.

The C Factor: Cognitive dysfunction as a transdiagnostic dimension in psychopathology

Research into cognitive functions across psychological disorders suggests that cognitive deficiencies may be present across multiple disorders, potentially pointing to a transdiagnostic phenomenon. More recently, a single dimension model of psychopathology, the p factor, has been proposed, in which cognitive deficits are thought to be an intrinsic construct, assumed to be transdiagnostic. However, no systematic investigation to date tested this hypothesis. The aim of the present study was to systematically review meta-analyses to assess the hypothesis that the C factor (cognitive dysfunction) is transdiagnostic in psychopathology and review potential moderators that may account for such a phenomenon. We conducted a systematic review of meta-analyses examining cognitive function across all disorders for which data were available. Included meta-analyses (n = 82), comprising 97 clinical samples, yielded 1,055 effect sizes. Twelve major disorders/categories (e.g., bipolar disorder, substance use disorders) were included, comprising 29 distinct clinical entities (e.g., euthymic bipolar disorder; alcohol use disorder). Results show that all disorders reviewed are associated with underperformance across cognitive domains, supporting the hypothesis that the C factor (or cognitive dysfunction) is a transdiagnostic factor related to p. To examine moderators that may explain or contribute to c, we first consider important interpretative limitations of neuropsychological data in psychopathology. More crucially, we review oft-neglected motivational and emotional transdiagnostic constructs of p, as prominent contributing constructs to the C factor. These constructs are offered as a roadmap for future research examining these constructs related to p, that contribute, and may account for cognitive dysfunctions in psychopathology.

Neurocognitive, social cognitive, and clinical predictors of creativity in schizophrenia

BACKGROUND

Creativity is considered an essential human accomplishment and a key component for daily life problem solving. It has been suggested that impairment in working memory, cognitive flexibility, and theory of mind could lead to lower creativity in schizophrenia. Additionally, other neurocognitive and social cognitive domains, as well as clinical symptoms could play a role in this relationship. However, the extent to which each of these domains influences creativity in schizophrenia remains unknown. Therefore, the aim of this study was to simultaneously investigate the specific contribution of neurocognitive, social cognitive, and clinical variables to creativity in schizophrenia.

METHODS

One hundred and one patients with schizophrenia were assessed in terms of sociodemographic, clinical, neurocognitive, social cognitive, and creativity variables.

RESULTS

After controlling for sociodemographic variables, regression analyses showed that higher social perception (β = 0.286, p = .004) and processing speed (β = 0.219, p = .023) predicted creativity total score. Higher social perception (β = 0.298, p = .002) and processing speed (β = 0.277, p = .004) explained figural creativity. Finally, lower negative symptoms (β = -0.302, p = .002) and higher social perception (β = 0.210, p = .029) predicted verbal creativity.

CONCLUSIONS

Results suggest that neurocognitive, social cognitive, as well as clinical symptoms influence creativity of patients with schizophrenia. Moreover, these findings point out the prominent role of social cognition in creativity in schizophrenia.

Habituation during encoding: A new approach to the evaluation of memory deficits in schizophrenia

BACKGROUND

Memory is significantly impaired in schizophrenia. However, memory measures are often complex and confounded by additional impairments such as motivation and task comprehension, which can affect behavioral performance and obscure neural function during memory tasks. Neural signatures of memory encoding that are robust to potential confounds may shed additional light on neural deficits contributing to memory impairment in schizophrenia.

METHODS

Here, we investigate a potential neural signature of memory-habituation-and its relationship with healthy and impaired memory function. To limit potential confounds, we used a passive depth of encoding memory task designed to elicit neural responses associated with memory encoding while limiting other cognitive demands. To determine whether habituation during encoding was predictive of intact memory processing, we first compared neural habituation over repeated encoding exposures with subsequent explicit memory in healthy individuals. We then tested whether a similar relationship existed in patients with schizophrenia.

RESULTS

Explicit memory performance was impaired in patients with schizophrenia relative to healthy control subjects. In healthy participants, more habituation over repeated exposures during encoding was associated with greater repetition-related increases in accuracy during testing. However, in patients with schizophrenia, better performance was associated with less habituation, or a more sustained neural response during encoding.

CONCLUSIONS

These results suggest that sustained neural activity is required for normal repetition-related improvements in memory performance in schizophrenia, in line with a neural inefficiency model. Habituation may serve as a valuable index of neural processes that underlie behavioral memory performance.

A Meta-Analysis of Neuropsychological Effort Test Performance in Psychotic Disorders

Psychotic disorders are characterized by a generalized neurocognitive deficit (i.e., performance 1.5 SD below controls across neuropsychological domains with no specific profile of differential deficits). A motivational account of the generalized neurocognitive deficit has been proposed, which attributes poor neuropsychological testing performance to low effort. However, findings are inconsistent regarding effort test failure rate in individuals with psychotic disorders across studies (0-72%), and moderators are unclear, making it difficult to know whether the motivational explanation is viable. To address these issues, a meta-analysis was performed on data from 2205 individuals with psychotic disorders across 19 studies with 24 independent effects. Effort failure rate was examined along with moderators of effort test type, forensic status, IQ, positive symptoms, negative symptoms, diagnosis, age, gender, education, and antipsychotic use. The pooled weighted effort test failure rate was 18% across studies and there was a moderate pooled association between effort failure rate and global neurocognitive performance (r = .57). IQ and education significantly moderated failure rate. Collectively, these findings suggest that a nontrivial proportion of individuals with a psychotic disorder fail effort testing, and failure rate is associated with global neuropsychological impairment. However, given that effort tests are not immune to the effects of IQ in psychotic disorders, these results cannot attest to the viability of the motivational account of the generalized neurocognitive deficit. Furthermore, the significant moderating effect of IQ and education on effort test performance suggests that effort tests have questionable validity in this population and should be interpreted with caution.

Clarifying the direction of impact of negative symptoms and neurocognition on prospective work functioning in psychosis: A 20-year longitudinal study

Both neurocognition and negative symptoms have demonstrated strong links to functional outcomes, such as work functioning, among those with severe mental illness (SMI). Prior models have suggested that reduced neurocognition 1) precedes or predicts greater negative symptoms and 2) indirectly influences functional outcomes via its impact on negative symptoms. The current study sought to also test a divergent model: whether greater negative symptoms predict reduced neurocognition and indirectly influence work functioning through their impact on neurocognition. Both models were tested using cross-sectional and prospective data spanning 20-years in a sample of 277 people with a SMI with psychotic features. Results showed that both models were supported in cross-sectional analyses. However, in prospective models predicting work functioning, only the models examining the indirect influence of negative symptoms on work functioning (7.5 to up to 20-years later) through neurocognition demonstrated significant mediation (i.e., a significant indirect effect); further, higher negative symptoms significantly predicted lower prospective neurocognition, while lower neurocognition did not significantly predict greater prospective negative symptoms. Although cross-sectional data were consistent with prior models, our prospective models offered greater support for a putative causal pathway running from negative symptoms to neurocognition-rather than the reverse-to work functioning. Findings have implications for mechanisms contributing to longitudinal work functioning and suggest that targeting negative symptoms prior to neurocognition could be more beneficial for long-term work outcomes.

Evaluation of the Efficacy of BI 425809 Pharmacotherapy in Patients with Schizophrenia Receiving Computerized Cognitive Training: Methodology for a Double-blind, Randomized, Parallel-group Trial

BACKGROUND AND OBJECTIVE: Cognitive impairments associated with schizophrenia (CIAS) predict poor functional outcomes, but there are currently no approved pharmacological treatments for patients with CIAS. Additional cognitive stimulation may be required for pro-cognitive medications to improve efficacy, and computerized cognitive training (CCT) can be used to increase cognitive activity. A trial evaluating the effects of the novel glycine transporter inhibitor BI 425809 compared with placebo, on a background of regularly self-administered CCT in clinically stable patients with schizophrenia has commenced and its methodology is described here.

METHODS

This Phase II, multinational, randomized, double-blind, placebo-controlled, parallel-group trial will randomize 200 clinically stable outpatients, aged 18-50 years with established schizophrenia and no other major psychiatric disorder, 1:1 to BI 425809 or placebo once daily for 12 weeks. Following screening, which included a 2-week CCT run-in period, patients sufficiently compliant with CCT (target: ≥ 2 h of CCT per week during CCT run-in) will be randomized. During the 12-week treatment period, all patients should complete a total of approximately 30 h of CCT. The primary endpoint is change from baseline in neurocognitive function as measured by the neurocognitive composite score of the Measurement and Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Battery (MCCB), after 12 weeks of treatment. Secondary endpoints include change from baseline in overall MCCB score, Schizophrenia Cognition Rating Scale, Positive and Negative Syndrome Scale, and safety (adverse events [AEs]) and serious AEs. Primary and secondary endpoints will be analyzed using the Restricted Maximum Likelihood-based mixed model for repeated measures. Novel endpoints include the Balloon Effort Task to evaluate patients' motivation and the Virtual Reality Functional Capacity Assessment Tool to assess skills for daily functioning.

DISCUSSION

This is one of the largest and longest trials to date to combine pharmacological therapy with CCT in patients with schizophrenia and will determine the benefit of combining BI 425809 pharmacotherapy with cognitive stimulation through self-administered CCT. This trial will further evaluate whether improvements in neurocognition translate into improved everyday functioning, whether self-administered CCT can be effectively implemented in a large multinational trial, and the role of motivation in neurocognitive and functional improvements.

TRIAL REGISTRATION

Registered on Clinicaltrials.gov on March 1, 2019 (NCT03859973).

The French Integrative Psychosocial Rehabilitation Assessment for Complex Situations (FIPRACS): Modelization of an Adapted Assessment Method Toward Long-Term Psychiatric Inpatients With Disabling, Severe and Persistent Mental Illness

For the past forty years, the generalization of community-based approaches has prompted psychiatry into promoting a deinstitutionalization movement and a psychosocial rehabilitation approach (PSR) for individuals with schizophrenia and related difficulties. Unfortunately, this approach generally does not involve the most severe cognitive and psycho-affective clinical situations among this population despite an increasing number of publications advocating that all individuals should be included in PSR and deinstitutionalization programs. In this context, considering the absence of an assessment battery designed for French individuals with particularly disabling, severe, and persistent mental illness (IDSPMI), we constructed an integrative assessment model adapted to this specific population. To select the most suitable tools for this population, a literature review (inspired by the PRISMA protocol) and a systematic review were combined with a clinical assessment study. The literature review first identified the cognitive and psycho-affective functions which mainly influence the day-to-day life adaptation of individuals engaged in a PSR/deinstitutionalization program. The systematic review then gathered all of the useable French validated tools to assess the initially selected dimensions (n = 87). To finish, for each dimension, the selected 87 tools were included in a clinical assessment study performed within a French psychiatric hospital. The authors collected and verified the characteristics of each tool (validity, French norms, French version, the average speed of the test, ease of use, ability to assess other dimensions). Their suitability was also assessed when applied to IDSPMI. Based on this final clinical evaluation, the authors selected one tool per function to create the French Integrative Psychosocial Rehabilitation Assessment for Complex Situations (FIPRACS). This battery is an assessment tailored to the neurocognitive and psycho-affective potentials of IDSPMI. While further validation studies of this battery are ultimately required, the practical/clinical implications of this battery are presented and discussed.

Goal-directed planning and action impairments in schizophrenia evaluated in a virtual environment

Planning and executing goal-directed behaviours are critical final steps in translating motivation into action. Amotivation is a key feature of schizophrenia, but its impact on goal-directed functioning has not been extensively studied in an objective and ecologically valid manner. To address this, we investigated goal-directed planning and action in schizophrenia using a virtual reality task, the Multitasking in the City Test (MCT). The MCT was administered to 49 outpatients with schizophrenia and 55 healthy controls, and required participants to complete a series of errands in a virtual city. Ability to complete the task as directed was assessed by a performance score based on errands completed and errors committed. Task efficiency was evaluated by the total distance travelled, and an index of path efficiency comparing an optimal route with the traversed route. Schizophrenia participants had lower performance scores, travelled farther, and had reduced path efficiency compared to healthy controls. Greater distance travelled and lower path efficiency in schizophrenia were related to amotivation. Path efficiency in schizophrenia was also related to neurocognition, including planning ability; notably, this relationship appeared to be independent of the relationship with amotivation. Individuals with schizophrenia demonstrated impaired goal-directed planning and action in the context of a simulated everyday errands task, both in terms of reduced capacity to complete errands and reduced efficiency in doing so. The latter may manifest as diminished real-world motivated and functional behaviour in patients with schizophrenia and indicates a specific deficit in the execution of planned behaviour.

What accounts for poor functioning in people with schizophrenia: a re-evaluation of the contributions of neurocognitive v. attitudinal and motivational factors

BACKGROUND

Neurocognitive deficits are often seen as core features of schizophrenia, and as primary determinants of poor functioning. Yet, our clinical observations suggest that individuals who score within the impaired range on standardized tests can reliably perform better in complex real-world situations, especially when performance is embedded within a positive socio-affective context.

METHODS

We analyzed literature on the influence of non-neurocognitive factors on test performance in order to clarify their contributions.

RESULTS

We identified seven non-neurocognitive factors that significantly contribute to neurocognitive test performance: avolition, dysfunctional attitudes, effort, stress, negative emotions, asociality, and disorganized symptoms. We then proposed an alternative model based on dysfunctional (e.g. defeatist) attitudes and their consequences for motivation and sustained task engagement. We demonstrated that these factors account for substantial variance in negative symptoms, neurocognitive test performance, and functional outcomes. We then demonstrated that recovery-oriented cognitive therapy - which is derived from this alternative model and primarily targets dysfunctional beliefs - has been successful in the treatment of low functioning individuals with schizophrenia.

CONCLUSION

The contributions of neurocognitive impairments to poor real-world functioning in people with schizophrenia may be overstated in the literature, and may even be limited relative to non-neurocognitive factors. We offer suggestions for further research to more precisely quantify the contributions of attitudinal/motivation v. neurocognitive factors in schizophrenia.

Objective investigation of activity preference in schizophrenia: A pilot study

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

Functional connectivity of the ventral tegmental area and avolition in subjects with schizophrenia: a resting state functional MRI study

Avolition, a deficit in goal-directed behavior, is a key aspect of negative symptoms. It is highly prevalent in schizophrenia and is associated to poor functional outcome and to measures of real life motivation, indicating that central to the concept is the lack of interest and motivation. In this study we tested the hypothesis that avolition is related to altered connectivity within dopaminergic cortico-striatal circuits involved in motivation processes. Since dopamine input to these circuits derives mostly from the ventro-tegmental area (VTA), we investigated the relationships between the resting-state functional connectivity (RS-FC) of the VTA and avolition in twenty-six subjects with schizophrenia (SCZ), treated with second-generation antipsychotics only, compared to twenty-two healthy controls (HC). SCZ, in comparison to HC, showed significantly reduced RS-FC of the VTA with bilateral ventro-lateral prefrontal cortex (VLPFC), bilateral insular cortex (IC) and right (R) lateral occipital complex (LOC) and increased RS-FC of the VTA with bilateral dorso-lateral prefrontal cortex (DLPFC). Significant negative correlations were found between avolition and RS-FC of the VTA with the bilateral IC, R VLPFC and R LOC. According to our findings, avolition is linked to a disconnectivity of the VTA from several key cortical regions involved in the integration of value information with action selection. These findings are in line with translational animal models of "auto-activation apathy".

A multicenter, randomized controlled trial of individualized occupational therapy for patients with schizophrenia in Japan

The individualized occupational therapy (IOT) program is a psychosocial program that we developed to facilitate proactive participation in treatment and improve cognitive functioning and other outcomes for inpatients with acute schizophrenia. The program consists of motivational interviewing, self-monitoring, individualized visits, handicraft activities, individualized psychoeducation, and discharge planning. This multicenter, open-labeled, blinded-endpoint, randomized controlled trial evaluated the impact of adding IOT to a group OT (GOT) program as usual for outcomes in recently hospitalized patients with schizophrenia in Japanese psychiatric hospitals setting compared with GOT alone. Patients with schizophrenia were randomly assigned to the GOT+IOT group or the GOT alone group. Among 136 randomized patients, 129 were included in the intent-to-treat population: 66 in the GOT+IOT and 63 in the GOT alone groups. Outcomes were administered at baseline and discharge or 3 months following hospitalization including the Brief Assessment of Cognition in Schizophrenia Japanese version (BACS-J), the Schizophrenia Cognition Rating Scale Japanese version, the Social Functioning Scale Japanese version, the Global Assessment of Functioning scale, the Intrinsic Motivation Inventory Japanese version (IMI-J), the Morisky Medication Adherence Scale-8 (MMAS-8), the Positive and Negative Syndrome Scale (PANSS), and the Japanese version of Client Satisfaction Questionnaire-8 (CSQ-8J). Results of linear mixed effects models indicated that the IOT+GOT showed significant improvements in verbal memory (p <0.01), working memory (p = 0.02), verbal fluency (p < 0.01), attention (p < 0.01), and composite score (p < 0.01) on the BACS-J; interest/enjoyment (p < 0.01), value/usefulness (p < 0.01), perceived choice (p < 0.01), and IMI-J total (p < 0.01) on the IMI-J; MMAS-8 score (p < 0.01) compared with the GOT alone. Patients in the GOT+IOT demonstrated significant improvements on the CSQ-8J compared with the GOT alone (p < 0.01). The present findings provide support for the feasibility in implementing an IOT program and its effectiveness for improving cognitive impairment and other outcomes in patients with schizophrenia.

Overlapping and disease specific trait, response, and reflection impulsivity in adolescents with first-episode schizophrenia spectrum disorders or attention-deficit/hyperactivity disorder

BACKGROUND

Schizophrenia and attention-deficit/hyperactivity disorder (ADHD) are developmental disorders with shared clinical characteristics such as cognitive impairments and impulsivity. Impulsivity is a core feature of ADHD and an important factor in aggression, violence, and substance use in schizophrenia. Based on the hypothesis that schizophrenia and ADHD represent a continuum of neurodevelopmental impairments, the aim was to identify overlapping and disease specific forms of impulsivity.

METHODS

Adolescents between 12 and 17 years of age were assessed with the Schedule for Affective Disorders and Schizophrenia for School-aged Children - Present and Lifetime Version. Subjects with early-onset, first-episode schizophrenia spectrum disorders (EOS) (N = 29) or ADHD (N = 29) and healthy controls (N = 45) were compared on two performance measures (Information Sampling Task, Stop Signal Task) and a subjective personality trait measure of impulsivity (Barratt Impulsiveness Scale, Version 11 (BIS-11)).

RESULTS

Significantly increased reflection impulsivity was observed in ADHD but not in the EOS group. No significant response inhibition deficits (stop signal reaction time) were found in the two clinical groups. The ADHD and the EOS group showed significantly increased motor, attentional, and non-planning subtraits of impulsivity.

CONCLUSIONS

Impaired pre-decisional information gathering appeared to be specific for ADHD while the information gathering was not significantly reduced in subjects with EOS. Neither the ADHD nor EOS group showed impaired response inhibition but shared increased personality subtraits of attentional, non-planning, and motor impulsivity although the latter was significantly more pronounced in ADHD. These increased subtraits of impulsivity may reflect diagnostic non-specific neurodevelopmental impairments in ADHD and EOS in adolescence.

Relationship between effortful motivation and neurocognition in schizophrenia

Effortful motivation and reward valuation learning deficits are associated with negative symptoms and impaired cognition in schizophrenia (SZ) patients. Whereas clinical assessments of motivation and reward value typically rely upon clinician ratings or self-report scales, behavioral measures often confound these constructs. Simple reverse-translated behavioral tasks that independently quantify motivation and reward valuation-which could then be linked to cognition-may facilitate the development of pro-cognitive therapeutics by bridging the "preclinical-to-clinical" gap. This study determined whether novel behavioral measures of effortful motivation and reward valuation are associated with impaired cognition in SZ patients (n=36). Patients completed the Progressive Ratio Breakpoint task (PRBT; physical effort motivation) and the Probabilistic Learning Task (PLT; reward learning/valuation) in conjunction with the MATRICS Consensus Cognitive Battery (MCCB). SZ patients exhibited statistically significant deficits in global cognition and all individual MCCB subdomains. Significant correlations were observed between PRBT and MCCB global cognition (r=0.52), speed of processing (r=0.56) and attention vigilance (r=0.48) subdomains, but not with PLT or clinical symptoms. Results indicate that effort and reward learning deficits are dissociable targets that can improve our understanding of cognitive impairments associated among patients with SZ. More importantly, the results support the long-standing notion that the measurement of cognitive impairments in SZ is highly linked to a willingness to expend effort. The availability of a PRBT designed for use in both rodents and humans could improve our understanding of the nature of cognitive impairments in neuropsychiatric disorders and accelerate the development of novel pro-cognitive therapeutics.

Trends in the Study of Motivation in Schizophrenia: A Bibliometric Analysis of Six Decades of Research (1956-2017)

Motivation in schizophrenia has been a key research aim for several decades. Motivation is a very complex process underlying negative symptoms that has been assessed and identified using very different instruments and terminologies. This study provides a comprehensive overview of the growing literature production and highlights an extensive set of variables to better understand the study of motivation. Electronic databases were searched in order to compile relevant studies of motivation in individuals with schizophrenia. The initial search identified 3,248 potentially interesting records, and of these, 161 articles published between 1956 and 2017 were finally included. Information such as year of publication, journal, country, and number of authors was codified. Variables related to sample characteristics, methodological aspects, and motivational terms were also extracted. The results revealed a significant growth trend in literature production, especially since the 2000s, with reward as the main term studied. In addition, questionnaires were identified as the preferred instrument to assess motivation in patients with schizophrenia. Other aspects such as country of publication, authors, journals of publication, and co-citation network analysis were also examined. The discussion offers recommendations for future research.

Prospective Relationships Between Motivation and Functioning in Recovery After a First Episode of Schizophrenia

Diminished motivation is associated with robust impairment in psychosocial functioning in schizophrenia (SZ). Little is known about the reciprocal relationships between motivation and functioning, particularly following a first episode of psychosis. We tested bidirectional associations between motivation and social and occupational functioning in the year following a first episode of SZ spectrum disorder among patients in the Recovery After an Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study. Four hundred four individuals (aged 15-40) who presented with a first episode of SZ spectrum disorder (eg, SZ, schizoaffective or schizophreniform disorder, psychotic disorder not otherwise specified) completed assessments of work and school functioning, social functioning, and motivation at 6- and 12-month follow-up, controlling for assessments at study entry. Controlling for cognition, and psychotic and depressive symptoms measured at each time point, motivation at 6 months was associated with work and school participation at 12 months, but work and school participation at 6 months was not associated with motivation at 12 months. Conversely, social functioning at 6 months was associated with motivation at 12 months, but motivation at 6 months was not associated with social functioning at 12 months. Findings suggest that motivation is associated with later occupational, but not social, functioning in the first year following an initial episode of psychosis. Social functioning, on the other hand, is associated with later motivation. Future intervention trials focused on improving occupational functioning in this population may benefit from targeting patient motivation directly (eg, through motivational interviewing), or indirectly by improving relationships and support networks.

Interactions of Motivation and Cognitive Control

There is general agreement that both motivation and cognitive control play critical roles in shaping goal-directed behavior, but only recently has scientific interest focused around the question of motivation-control interactions. Here we briefly survey this literature, organizing contemporary findings around three issues: 1) whether motivation preferentially impacts cognitive control processes, 2) the neural mechanisms that underlie motivation-cognition interactions, and 3) why motivation might be relevant for overcoming the costs of control. Dopamine (DA) is discussed as a key neuromodulator in these motivation-cognition interactions. We conclude by highlighting open issues, specifically Pavlovian versus instrumental control distinctions and effects of motivational valence and conflict, which could benefit from future research attention.

Dopamine and Proximity in Motivation and Cognitive Control

Cognitive control - the ability to override a salient or prepotent action to execute a more deliberate one - is required for flexible, goal-directed behavior, and yet it is subjectively costly: decision-makers avoid allocating control resources, even when doing so affords more valuable outcomes. Dopamine likely offsets effort costs just as it does for physical effort. And yet, dopamine can also promote impulsive action, undermining control. We propose a novel hypothesis that reconciles opposing effects of dopamine on cognitive control: during action selection, striatal dopamine biases benefits relative to costs, but does so preferentially for "proximal" motor and cognitive actions. Considering the nature of instrumental affordances and their dynamics during action selection facilitates a parsimonious interpretation and conserved corticostriatal mechanisms across physical and cognitive domains.

Predictors and Impact of Self-Reported Suboptimal Effort on Estimates of Prevalence of HIV-Associated Neurocognitive Disorders

BACKGROUND

Prevalence estimates of HIV-associated neurocognitive disorders (HAND) may be inflated. Estimates are determined via cohort studies in which participants may apply suboptimal effort on neurocognitive testing, thereby inflating estimates. Additionally, fluctuating HAND severity over time may be related to inconsistent effort. To address these hypotheses, we characterized effort in the Multicenter AIDS Cohort Study.

METHODS

After neurocognitive testing, 935 participants (525 HIV- and 410 HIV+) completed the visual analog effort scale (VAES), rating their effort from 0% to 100%. Those with <100% then indicated the reason(s) for suboptimal effort. K-means cluster analysis established 3 groups: high (mean = 97%), moderate (79%), and low effort (51%). Rates of HAND and other characteristics were compared between the groups. Linear regression examined the predictors of VAES score. Data from 57 participants who completed the VAES at 2 visits were analyzed to characterize the longitudinal relationship between effort and HAND severity.

RESULTS

Fifty-two percent of participants reported suboptimal effort (<100%), with no difference between serostatus groups. Common reasons included "tired" (43%) and "distracted" (36%). The lowest effort group had greater asymptomatic neurocognitive impairment and minor neurocognitive disorder diagnosis (25% and 33%) as compared with the moderate (23% and 15%) and the high (12% and 9%) effort groups. Predictors of suboptimal effort were self-reported memory impairment, African American race, and cocaine use. Change in effort between baseline and follow-up correlated with change in HAND severity.

CONCLUSIONS

Suboptimal effort seems to inflate estimated HAND prevalence and explain fluctuation of severity over time. A simple modification of study protocols to optimize effort is indicated by the results.

EPICOG-SCH: A brief battery to screen cognitive impact of schizophrenia in stable outpatients

Brief batteries in schizophrenia, are needed to screen for the cognitive impact of schizophrenia. We aimed to validate and co-norm the Epidemiological Study of Cognitive Impairment in Schizophrenia (EPICOG-SCH) derived brief cognitive battery. A cross-sectional outpatient evaluation was conducted of six-hundred-seventy-two patients recruited from 234 centers. The brief battery included well-known subtests available worldwide that cover cognitive domains related to functional outcomes: WAIS-III-Letter-Number-Sequencing-LNS, Category Fluency Test-CFT, Logical-Memory Immediate Recall-LM, and Digit-Symbol-Coding-DSC. CGI-SCH Severity and WHO-DAS-S were used to assess clinical severity and functional impairment, respectively. Unit Composite Score (UCS) and functional regression-weighted Composite Scores (FWCS) were obtained; discriminant properties of FWCS to identify patients with different levels of functional disability were analyzed using receiver-operating characteristic (ROC) technique. The battery showed good internal consistency, Cronbach's alpha = 0.78. The differences between cognitive performance across CGI-SCH severity level subscales ranged from 0.5 to 1 SD. Discriminant capacity of the battery in identifying patients with up to moderate disability levels showed fair discriminant accuracy with areas under the curve (AUC) > 0.70, p < 0.0001. An FWCS mean cut-off score ≥ 100 showed likelihood ratios (LR) up to 4.7, with an LR + of 2.3 and a LR - of 0.5. An FWCS cut-off ≥ 96 provided the best balance between sensitivity (0.74) and specificity (0.62). The EPICOG-SCH proved to be a useful brief tool to screen for the cognitive impact of schizophrenia, and its regression-weighted Composite Score was an efficient complement to clinical interviews for confirming patients' potential functional outcomes and can be useful for monitoring cognition during routine outpatient follow-up visits.

The Course of Neurocognitive Changes in Acute Psychosis: Relation to Symptomatic Improvement

INTRODUCTION

Cognitive impairment is a core aspect of psychosis, but the course of cognitive functioning during acute psychosis remains poorly understood, as does the association between symptom change and neurocognitive change. Some studies have found cognitive improvement to be related to improvement in negative symptoms, but few have examined cognitive changes in the early acute phase, when clinical improvement mainly happens. This study's aim was to investigate the relation between cognitive and symptomatic change in clinically heterogeneous patients during the early acute phase of psychosis.

METHOD

Participants (n = 84), including both first-episode and previously ill patients, were recruited from consecutive admissions to the acute psychiatric emergency ward of Haukeland University Hospital, Bergen, Norway, as part of the Bergen Psychosis Project (BPP). The RBANS neurocognitive test battery was administered on admission and again at discharge from the acute ward (mean time 4.1 weeks, SD 1.86 weeks). Symptomatic change was measured by PANSS.

RESULTS

The proportion of subjects with cognitive impairment (t < 35) was 28.6% in the acute phase and 13.1% at follow-up. A sequential multiple linear regression model with RBANS change as the dependent variable found PANSS negative symptoms change to significantly predict total RBANS performance improvement (beta = -.307, p = .016). There was no significant difference between subjects with schizophrenia and those with other psychotic disorders in terms of cognitive change.

CONCLUSION

The proportion of subjects with mild to moderate impairment in cognitive test performance is reduced across the acute phase of psychosis, with improvement related to amelioration of negative symptoms.

Exploratory analysis of CVLT-II forced-choice recognition and RBANS EI base rates for forensically-committed, psychotic-disordered inpatients: Implications on clinical decision-making

Within the inpatient forensic setting, requests for a neuropsychological evaluation are common to determine cognitive strengths and weaknesses. However, variable effort proves to be a prominent issue in this setting. Thus, assessment of effort becomes an essential component of a neuropsychological evaluation. The California Verbal Learning Test, 2nd Edition (CVLT-II) and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) are widely utilized cognitive measures in the inpatient setting. The purpose of this study is to establish the local base rates and predictive abilities of the CVLT-II Forced-Choice Recognition (FCR) measure and RBANS Effort Index (EI). Participants included 56 and 595 forensically-committed, psychotic-disordered inpatients who completed the CVLT-II FCR and RBANS EI, respectively. Results indicated that the estimated local base rate for a positive CVLT-II FCR score was 8%, which resulted in 97% negative predictive power and 50% positive predictive power. The estimated local base rate for a positive RBANS EI score was 16%, which resulted in 91.7% negative predictive power and 57.1% positive predictive power. Given their low sensitivity and predictive power, the results suggest that much more confidence can be placed in negative FCR and EI results as opposed to positive findings.

Development of an Individualized Occupational Therapy Programme and its Effects on the Neurocognition, Symptoms and Social Functioning of Patients with Schizophrenia

We described an individualized occupational therapy (IOT) programme and examined the effects of adding IOT to group OT (GOT) on improving neurocognition, symptoms and social functioning among recently hospitalized patients with schizophrenia. The Brief Assessment of Cognition in Schizophrenia-Japanese version (BACS-J), the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning scale were used for outcome evaluations. Fifty-one patients were voluntarily assigned to either the GOT + IOT (n = 30) or GOT alone (n = 21) groups based on their preferences. Retention in the GOT + IOT group was 100%. Three-month baseline to discharge assessments in the GOT + IOT group showed significant improvements in BACS-J verbal memory, working memory, verbal fluency, attention, executive function and composite score, and in PANSS positive subscale, general psychopathology subscale, and total score compared to the GOT alone group. Study limitations notwithstanding, the present findings provide preliminary support for the feasibility of implementing IOT and its effectiveness for improving cognitive impairment and symptoms in patients with schizophrenia. The results of this study indicate that IOT in psychiatric facilities may improve psychosocial treatment of schizophrenia. Additional study is warranted to replicate the effects of IOT as demonstrated in this Japanese study. Copyright © 2016 John Wiley & Sons, Ltd.

Exercise Improves Clinical Symptoms, Quality of Life, Global Functioning, and Depression in Schizophrenia: A Systematic Review and Meta-analysis

BACKGROUND

Physical exercise may be valuable for patients with schizophrenia spectrum disorders as it may have beneficial effect on clinical symptoms, quality of life and cognition.

METHODS

A systematic search was performed using PubMed (Medline), Embase, PsychInfo, and Cochrane Database of Systematic Reviews. Controlled and uncontrolled studies investigating the effect of any type of physical exercise interventions in schizophrenia spectrum disorders were included. Outcome measures were clinical symptoms, quality of life, global functioning, depression or cognition. Meta-analyses were performed using Comprehensive Meta-Analysis software. A random effects model was used to compute overall weighted effect sizes in Hedges' g.

RESULTS

Twenty-nine studies were included, examining 1109 patients. Exercise was superior to control conditions in improving total symptom severity (k = 14, n = 719: Hedges' g = .39, P < .001), positive (k = 15, n = 715: Hedges' g = .32, P < .01), negative (k = 18, n = 854: Hedges' g = .49, P < .001), and general (k = 10, n = 475: Hedges' g = .27, P < .05) symptoms, quality of life (k = 11, n = 770: Hedges' g = .55, P < .001), global functioning (k = 5, n = 342: Hedges' g = .32, P < .01), and depressive symptoms (k = 7, n = 337: Hedges' g = .71, P < .001). Yoga, specifically, improved the cognitive subdomain long-term memory (k = 2, n = 184: Hedges' g = .32, P < .05), while exercise in general or in any other form had no effect on cognition.

CONCLUSION

Physical exercise is a robust add-on treatment for improving clinical symptoms, quality of life, global functioning, and depressive symptoms in patients with schizophrenia. The effect on cognition is not demonstrated, but may be present for yoga.

Activational and effort-related aspects of motivation: neural mechanisms and implications for psychopathology

Motivation has been defined as the process that allows organisms to regulate their internal and external environment, and control the probability, proximity and availability of stimuli. As such, motivation is a complex process that is critical for survival, which involves multiple behavioural functions mediated by a number of interacting neural circuits. Classical theories of motivation suggest that there are both directional and activational aspects of motivation, and activational aspects (i.e. speed and vigour of both the instigation and persistence of behaviour) are critical for enabling organisms to overcome work-related obstacles or constraints that separate them from significant stimuli. The present review discusses the role of brain dopamine and related circuits in behavioural activation, exertion of effort in instrumental behaviour, and effort-related decision-making, based upon both animal and human studies. Impairments in behavioural activation and effort-related aspects of motivation are associated with psychiatric symptoms such as anergia, fatigue, lassitude and psychomotor retardation, which cross multiple pathologies, including depression, schizophrenia, and Parkinson's disease. Therefore, this review also attempts to provide an interdisciplinary approach that integrates findings from basic behavioural neuroscience, behavioural economics, clinical neuropsychology, psychiatry, and neurology, to provide a coherent framework for future research and theory in this critical field. Although dopamine systems are a critical part of the brain circuitry regulating behavioural activation, exertion of effort, and effort-related decision-making, mesolimbic dopamine is only one part of a distributed circuitry that includes multiple neurotransmitters and brain areas. Overall, there is a striking similarity between the brain areas involved in behavioural activation and effort-related processes in rodents and in humans. Animal models of effort-related decision-making are highly translatable to humans, and an emerging body of evidence indicates that alterations in effort-based decision-making are evident in several psychiatric and neurological disorders. People with major depression, schizophrenia, and Parkinson's disease show evidence of decision-making biases towards a lower exertion of effort. Translational studies linking research with animal models, human volunteers, and clinical populations are greatly expanding our knowledge about the neural basis of effort-related motivational dysfunction, and it is hoped that this research will ultimately lead to improved treatment for motivational and psychomotor symptoms in psychiatry and neurology.

Working Memory Deficit as a Risk Factor for Severe Apathy in Schizophrenia: A 1-Year Longitudinal Study

Apathy, described as impaired motivation and goal-directed behavior, is a common yet often overlooked multidimensional psychopathological state in schizophrenia. Its underlying cognitive processes remain largely unexplored. Data was drawn from a longitudinal hospital study of patients with a DSM-IV diagnosis of schizophrenia; 137 (82.5%) participated at the 1-month follow-up and 81 (59.1%) at the 1-year follow-up. Apathy was assessed with the Lille Apathy Rating Scale, validated in French and in schizophrenia. Severe apathy, overall (total score > -13) and on 4 previously identified distinct dimensions, was considered. Episodic verbal learning was assessed with the California Verbal Learning Test, executive functioning with the Trail Making Test, the Six Element Test and the Stop Signal Paradigm and working memory with the Letter-Number Sequencing Test. After controlling for confounding variables, only episodic verbal learning was associated with severe overall apathy in the cross-sectional study. At 1 year, working memory was associated with an increased risk of severe overall apathy, adjusting for baseline apathy. Using a dimensional approach to apathy, specific types of cognition were found to be associated with specific dimensions of apathy. Our findings confirm the need for a multidimensional approach of negative symptoms in schizophrenia. Moreover, cognitive functioning could be a risk factor for developing severe apathy. Cognitive remediation may thus be a useful non-pharmacological intervention for treating apathy in schizophrenia patients.

Effects of Exercise Interventions and Physical Activity Behavior on Cancer Related Cognitive Impairments: A Systematic Review

This systematic review analyzes current data on effects of exercise interventions and physical activity behavior on objective and subjective cancer related cognitive impairments (CRCI). Out of the 19 studies which met all inclusion criteria, five RCTs investigated rodents, whereas the other 14 trials explored humans and these included six RCTs, one controlled trial, two prospective noncontrolled trials, one case series, one observational study, and three cross-sectional studies. The results from animal models revealed positive effects of exercise during and after chemotherapy or radiation on structural alterations of the central nervous system, physiological as well as neuropsychological outcomes. The overall study quality in patient studies was poor. The current data on intervention studies showed preliminary positive effects of Asian-influenced movement programs (e.g., Yoga) with benefits on self-perceived cognitive functions as well as a reduction of chronic inflammation for breast cancer patients in the aftercare. Exercise potentially contributes to the prevention and rehabilitation of CRCI. Additional RCTs with standardized neuropsychological assessments and controlling for potential confounders are needed to confirm and expand preliminary findings.

Measuring motivation in people with schizophrenia

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