Negative symptoms – the motivational conundrum

Kitchen sink approach

This description was provided by Dawn Velligan, University of Texas Science Centre at San Antonio, San Antonio, Texas, USA. Dr Velligan described the MOtiVation and Engagement (MOVE) program designed to break the behavioral loop that reinforces persistent negative attitudes.

MOVE incorporates Cognitive Adaptation Training (CAT) into an expanded five-pronged therapeutic approach towards improving negative symptoms and real-world functioning in patients with schizophrenia and significant, persistent negative symptoms.

The other four approaches are:

• social skills training – the skills had to be participatory and directly apply to some aspect of the patients’ lives. As Dr Velligan explained, “There are all sorts of reasons for patients not to do something. We’re kind of pushy. We try to do decision-making but sometimes we need to push.”
• Cognitive Behavioral Techniques (CBT) – to address defeatist beliefs. “We use simple heuristics; because if it’s too difficult, it won’t happen,” Dr Velligan said.
• emotional processing – both personal reinforcement therapy (What did it feel like when you…?) and reciprocal therapies, where patients try to guess the emotions being expressed by others.
• anticipatory pleasure – reminding patients that an activity will be enjoyable based on a previously enjoyable experience.

We try to do decision-making but sometimes we need to push.

MOVE – motivation improves

To determine whether MOVE was an effective therapy, patients were assessed at outset and at regular intervals; thereafter using tools to assess negative symptoms and functional outcomes and compared to standard therapies. Only improvements in motivation (NSA) and in socialization and recreation (CAINS) were observed. Given the input of so many highly experienced therapists over 9 months of weekly sessions, these findings were disappointing. Dr Velligan believes that further investigation of treatments for the management of persistent negative symptoms is needed.

Motivational interviews approach

Felice Reddy, UCLA, Los Angeles, USA, also sought means of addressing motivational negative symptoms. Her target population were veterans, 80 of whom had schizophrenia with moderate to high levels of negative symptoms (>CAINS MAP). She compared use of CBT plus motivational interviews (MI) and mindfulness skills training in her patients over the course of 3 months of weekly sessions plus homework.

What is Motivational Interviewing (MI)?

MI is a collaborative, guiding conversational style used for strengthening intrinsic motivation and commitment to change. As Dr Reddy explained, it’s a style of therapy, where the therapist and the patient are both team members rather than therapist and patient. The therapists are trained in asking open questions, reflecting back statements, eliciting change talk, emphasizing autonomy and, lastly, summarizing, informing and advising.

MI is a collaborative, guiding conversational style used for strengthening intrinsic motivation and commitment to change

Of the 80 recruits, after assessment; 34 were randomly assigned to CBT+MI and 39 to mindfulness skills training (MST) for 12 weeks. Assessments of cognition, symptoms, motivation, community functioning and defeatist beliefs were made at baseline, at 3 months and after a further 3 months of follow-up to determine feasibility and efficacy of both approaches.

Feasible - and improved motivational negative symptoms

There was no significant difference noted between groups in terms of feasibility – both approaches were acceptable to patients. The efficacy assessment of decline in motivational negative symptoms was statistically significantly improved in those receiving MI +CBT compared to MST, and the effect was maintained; other efficacy assessments – defeatist performance beliefs and community functioning were no different between groups.

Decline in motivational negative symptoms was statistically significantly improved in those receiving MI +CBT compared to MST

As Dr Reddy concluded, the intervention is intended to change behaviors; so, it may not be surprising that changes in cognitions don’t occur. Further, the application of this therapy on a younger population, rather than mature veterans, may have different outcomes.

Apps against apathy

Those CBT interventions that specifically target defeatist attitudes are more likely to improve negative symptoms and functioning in schizophrenia than those that don’t. Thus, Jason Holden, School of Medicine San Diego Psychology Service, San Diego, California, USA, outlined a new app-based approach to targeting negative symptoms – Mobile-assisted CBT for Negative symptoms (mCBTn).

mCBTn – what is it?

mCBTn combines CBT that targets defeatist attitudes (from Dr Holden and others Cognitive-Behavioral Social Skills Training [CBSST] group therapy training program) with a previously-trialed mobile phone app (CBT2go).

A screen that logs the weekly achievements offers group CBT providers information on the patients that can be incorporated into their weekly CBT sessions

In a small trial, mCBTn was tested in 31 patients with schizophrenia, who had persistent moderate to severe negative symptoms, to determine whether defeatist attitudes could be ameliorated. Patients had to attend weekly group CBT sessions lasting 90 minutes in conjunction with use of the phone app. The app feeds into a dashboard that pushes out statements to challenge defeatist attitudes.

However, the app was designed not only to defeat defeatist attitudes, but to promote social activities, pleasurable activities (which were scheduled into daily life with reminders), physical activities and monitor homework adherence. A screen that logs the weekly achievements offers group CBT providers information on the patients that can be incorporated into their weekly CBT sessions.

App supplementation complements CBT therapy

Significant improvements in defeatist attitudes and negative and positive symptoms were seen at 12-, 18-, and 24-weeks post commencement of the study. Retention levels were maintained at above 79% throughout this time period. This preliminary study suggests that app supplementation complements CBT therapy in this group of patients. However, as Dr Holden pointed out, training for both patients and therapists was needed; some patients did not know how to use the smart phone and apps, and not all therapists used the feedback data the app was collating during sessions.

Significant improvements in defeatist attitudes and negative and positive symptoms were seen at 12-, 18-, and 24-weeks