You are on page 1of 7

Psychiatry Research 245 (2016) 172–178

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Metacognition deficits as a risk factor for prospective motivation


deficits in schizophrenia spectrum disorders
Lauren Luther a,n, Ruth L. Firmin a, Kyle S. Minor a, Jenifer L. Vohs b,c,d, Benjamin Buck e,
Kelly D. Buck f, Paul H. Lysaker b,f
a
Indiana University-Purdue University Indianapolis, Indianapolis, IN, United States
b
Indiana University School of Medicine, Indianapolis, IN, United States
c
Prevention and Recovery Center for Early Psychosis, Midtown Community Mental Health Centers, Eskenazi Hospital, Indianapolis, IN, United States
d
Larue D. Carter Memorial Hospital, IU Psychotic Disorders Research Program, Indianapolis, IN, United States
e
University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
f
Richard L. Roudebush Veteran's Affairs Medical Center, Indianapolis, IN, United States

art ic l e i nf o a b s t r a c t

Article history: Although motivation deficits are key determinants of functional outcomes, little is known about factors
Received 27 March 2016 that contribute to prospective motivation in people with schizophrenia. One candidate factor is meta-
Received in revised form cognition, or the ability to form complex representations about oneself, others, and the world. This study
5 August 2016
aimed to assess whether metacognition deficits were a significant predictor of reduced prospective
Accepted 8 August 2016
motivation, after controlling for the effects of baseline motivation, anticipatory pleasure, and anti-
Available online 9 August 2016
psychotic medication dose. Fifty-one participants with a schizophrenia spectrum disorder completed
Key words: measures of metacognition and anticipatory pleasure at baseline; participants also completed a measure
Schizophrenia of motivation at baseline and six months after the initial assessment. Baseline antipsychotic dose was
Motivation
obtained from medical charts. Hierarchical regression analysis revealed that lower levels of baseline
Metacognition
metacognition significantly predicted reduced levels of motivation assessed six months later, after
Antipsychotic medication
Anticipatory pleasure controlling for baseline levels of motivation, anticipatory pleasure, and antipsychotic dose. Higher
baseline antipsychotic dose was also a significant predictor of reduced six month motivation. Results
suggest that metacognition deficits and higher antipsychotic dose may be risk factors for the develop-
ment of motivation deficits in schizophrenia. Implications include utilizing interventions to improve
metacognition in conjunction with evaluating and possibly lowering antipsychotic dose for people
struggling with motivation deficits.
& 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction motivation is frequently impaired in schizophrenia (Cooper et al.,


2015; Luther et al., 2015a) and that these deficits play a critical role
Although motivation, which can generally be defined as an in reduced treatment response (Medalia and Saperstein, 2011),
internal state that initiates, directs, and maintains goal-directed learning (Choi and Medalia, 2010; Tas et al., 2012) and functioning
behavior (Kleinginna and Kleinginna, 1981), has long been a focus (Foussias et al., 2009, 2011). Several studies have also found that
of psychological theories and research (Maslow, 1943), it has only motivation mediates the relationship between both symptoms and
recently gained momentum as an important area of schizophrenia functional outcomes (Yamada et al., 2010) and cognitive deficits
and functional outcomes (Nakagami et al., 2008; Gard et al., 2009;
research. To date, motivation deficits in schizophrenia are gen-
Fervaha et al., 2015a).
erally conceptualized as largely falling under the umbrella of ne-
Despite increasing evidence that motivation is a key determi-
gative symptoms (American Psychiatric Association, 2013), and
nant of functional outcomes in schizophrenia, there is limited
research has found that motivation deficits represent a key nega- empirical research investigating prospective determinants of mo-
tive symptom subdomain (Blanchard and Cohen, 2006; Lincoln tivation; thus, risk factors for motivation impairments have not
et al., in press). Further, research has demonstrated that been fully identified. Identifying risk factors for these deficits is
critical in order to establish novel treatment targets. This is
n
Correspondence to: IUPUI School of Science, Department of Psychology, LD 124,
especially salient given the modest improvement seen in motiva-
402 N. Blackford St., Indianapolis, IN 46202, United States. tional deficits with many existing psychological and pharmacolo-
E-mail address: lutherl@iupui.edu (L. Luther). gical treatments in people with schizophrenia (Kirkpatrick et al.,

http://dx.doi.org/10.1016/j.psychres.2016.08.032
0165-1781/& 2016 Elsevier Ireland Ltd. All rights reserved.
L. Luther et al. / Psychiatry Research 245 (2016) 172–178 173

2006; Velthorst et al., 2015). Further, discerning factors that lead to (1911/1950) formulation of schizophrenia where he described that
improved treatments can serve to impede motivational declines people with schizophrenia experience a disturbance in the asso-
that may occur as the course of schizophrenia progresses (Luther ciative processes that are needed to integrate information and to
et al., 2015a). support meaningful goal-directed behavior.
One characteristic that has been argued to play a role in the This study sought to extend the findings of Vohs and Lysaker
emergence of motivation impairments is deficits in metacognition (2014) by examining how a wider range of metacognition domains
or impairments in the capacity to integrate mental experiences was related to motivation over time in a sample that was not
into complex representations. The term metacognition was ori- engaged in a treatment trial. Specifically, we employed a more
ginally used in the education literature (Flavell, 1979), but it has comprehensive measure of metacognition to assess whether me-
subsequently been used in the context of psychopathology re- tacognitive deficits are a potential risk factor for reduced motiva-
search to describe a spectrum of mental experiences, ranging from tion over time in a sample of fifty-one people with a schizophrenia
reflections about more discrete mental experiences (e.g., explicit spectrum disorder. We predicted that reduced levels of metacog-
thoughts and feelings), to more synthetic reflective acts where nition would predict lower levels of motivation six months later
intentions, thoughts, feelings, and connections between experi- even after controlling for baseline levels of motivation. Further,
ences are continuously evolving into integrated representations of although difficulty anticipating rewarding outcomes has been
oneself and others as distinct agents in the world (Semerari et al., thought to impact motivation in schizophrenia (Gard et al., 2007;
2003; Lysaker et al., 2013). Metacognition is viewed as partly Barch et al., 2015), it remains to be established whether antici-
overlapping with social cognition but diverges in that it focuses patory pleasure and motivation are empirically linked over time
not on the accuracy of a single social cue, such as determining and importantly, whether metacognition deficits account for re-
whether a thought or feeling is correct, but on the degree to which duced prospective motivation above and beyond the effects of
mental experiences about the self and others are coherently in- anticipatory pleasure deficits. Thus, we included a measure of
tegrated (Lysaker et al., 2015c). Notably, individuals with early and anticipatory pleasure to rule out the possibility that reduced an-
prolonged schizophrenia have demonstrated unique deficits in ticipatory pleasure accounted for deficits in motivation to a greater
metacognition compared to healthy controls (Hasson-Ohayon extent than metacognition deficits. Similarly, as demographic
et al., 2015) as well as those with substance use disorders (Lysaker factors such as age, education, and gender (Faerden et al., 2010;
et al., 2014; Wasmuth et al., 2015), bipolar disorder (Tas et al., Choi et al., 2014) as well as antipsychotic medication dose (Kirsch
2014), and post-traumatic stress disorder (Lysaker et al., 2015a). et al., 2007; Mas et al., 2013) and psychiatric symptoms (Yamada
Metacognition may be a strong candidate predictor of motiva- et al., 2010; Luther et al., 2016) have been linked to motivation, we
tion for several reasons. First, possessing an integrated sense of included measures of these variables as potential covariates. We
oneself and others likely guides goal-directed behavior by pro- also included a measure of consummatory pleasure to explore its
viding meaning and value to completing tasks or activities. Thus, relationship with prospective motivation.
when faced with tasks, a person without intact metacognitive
capacities to make sense of and provide meaning to these tasks
will likely have trouble evaluating and expending the effort re- 2. Methods
quired to complete them. Second, goal-directed behavior may be
contingent on being able to view oneself as a unique agent in the 2.1. Participants
world who is capable of initiating actions and responding to
challenges. Indeed, metacognition has been argued to play a cri- Fifty-one participants with SCID-confirmed (First et al., 2002)
tical role in cultivating an individual's sense of agency (Lysaker diagnoses of schizophrenia (n ¼ 26) or schizoaffective disorder
et al., 2008a, 2013). Specifically, when faced with problems or new (n ¼25) were recruited from either a Veterans' Affairs Medical
experiences, without an integrated sense of oneself and others to Center (n ¼45) or a community mental health center (n ¼6) for a
make sense of and to respond to problems and new experiences, a longitudinal study examining the correlates of metacognition in
person may become increasingly confused or overwhelmed and people with a schizophrenia spectrum disorder. Participants were
may withdraw or discontinue any associated activities to reduce in a post-acute phase of illness as defined by no hospitalizations or
confusion. Over time, without intact metacognitive capacities to changes in housing or medication within 30 days of study en-
guide and provide meaning to behavior, one would likely be at risk rollment. Exclusion criteria also included active substance de-
for reductions in goal-directed behavior. pendence or developmental disability, as determined through a
Evidence supporting the connection between metacognition chart review. Twenty-nine participants were taking a single anti-
and motivation includes findings from recent cross-sectional and psychotic medication (25 atypical, 4 typical antipsychotics), while
longitudinal studies demonstrating a relationship between meta- 16 patients were taking multiple antipsychotics (8 taking one
cognitive deficits and reduced motivation and overall negative atypical and one typical, 7 taking two atypical, 1 taking two typical
symptoms. Specifically, Tas et al. (2012) demonstrated that re- antipsychotics). Antipsychotics included aripiprazole, clozapine,
duced metacognition was associated with lower concurrent mo- fluphenazine, haloperidol, loxapine, olanzapine, quetiapine, ris-
tivation, while other studies have shown that metacognition def- peridone, trifluoperazine, and ziprasidone. Six participants were
icits are related to increased concurrent and prospective negative not taking any antipsychotic medication. There were no significant
symptoms (Hamm et al., 2012; MacBeth et al., 2014; Rabin et al., changes in medication doses (i.e., chlorpromazine equivalent do-
2014; Lysaker et al., 2015b). Further, lower levels of metacognition ses) or any hospitalizations during the course of the study. Parti-
have been found to be a significant predictor of reduced levels of cipants were primarily male, African American, and were enrolled
concurrent motivation (Luther et al., 2016) and increased levels of in outpatient treatment. Full demographic information is reported
negative symptoms both six and twelve months later (McLeod in Table 1.
et al., 2014). Similarly, Vohs and Lysaker (2014) reported that in
those with prolonged schizophrenia engaged in a treatment trial, 2.2. Measures
participants with lower levels of mastery, a domain of metacog-
nition, had consistently lower monthly ratings of motivation than 2.2.1. Metacognition
those with higher levels of mastery over a period of six months. Metacognition was assessed with a two-step process. First, the
Taken together, these findings are also consistent with Bleuler's Indiana Psychiatric Illness Interview (IPII; Lysaker et al., 2002) was
174 L. Luther et al. / Psychiatry Research 245 (2016) 172–178

Table 1 insight (Lysaker et al., 2005, 2008b) and similar to previous studies
Means, standard deviations, and correlations between baseline demographic and (Lysaker et al., 2005; Rabin et al., 2014), demonstrated good inter-
clinical variables and baseline and six-month follow-up motivation.
rater reliability in the current sample (intraclass correlations ran-
Baseline Variables Mean (SD) Correlations with ging from 0.71 to 0.91).
Motivation
2.2.2. Motivation
Baseline Six-month Motivation was assessed using the sum of three items from the
Demographic variables
clinician-rated Heinrichs-Carpenter Quality of Life Scale (QLS;
Age 50.43 (7.43) 0.06  0.02 Heinrichs et al., 1984): sense of purpose, degree of motivation, and
Education (years) 12.75 (1.60) 0.01 0.22 curiosity. This scale was originally devised by Nakagami et al.
Gender (n, % male)a 45 (88%) 0.00 0.15 (2008) as an index of intrinsic motivation, which can be generally
Race (n, % African American)a 26 (51%)  0.14 0.02
thought of as engaging in a task or action because it is enjoyable or
Parent education (years)b 12.00 (2.54) 0.01  0.12
Illness duration (years)ce:b,c 25.40 (9.00) 0.18  0.05 interesting (Ryan and Deci, 2000); however, a recent investigation
Lifetime psychiatric 8.47 (8.27)  0.22  0.17 by Choi et al. (2014) concluded that this index may more aptly
hospitalizations measure general trait-like motivation that is not limited to a
Chlorpromazine equivalent 568.70 (567.96)  0.15  0.34* specific activity but encompasses one's typical level of motivation
dosesb,d
for a diverse range of activities, including novel activities or those
Clinical variables aimed at self-improvement as well as activities of daily living.
QLS Index – Motivation 6.16 (2.78) – 0.32*
Thus, in the current investigation, we refer to this as an index of
TEPS – Anticipatory pleasure 41.06 (7.88) 0.09 0.27*
TEPS – Consummatory pleasure 35.04 (6.34) 0.06  0.01 general trait-like (i.e., not limited to a specific task) motivation.
PANSS – Positive symptoms 16.59 (4.66)  0.36*  0.14 The three items that comprise the motivation index are part of the
PANSS – Negative symptoms 18.75 (5.56)  0.41**  0.16 intrapsychic foundations subscale of the QLS and are rated on a
PANSS – Cognitive symptoms 17.39 (4.42)  0.31*  0.26 7-point scale, with higher scores indicating greater motivation.
PANSS – Hostility symptoms 7.78 (2.63)  0.11 0.05
PANSS – Emotional discomfort 12.51 (3.84)  0.23 0.04
The motivation index has been used in numerous studies with
symptoms schizophrenia samples (c.f., Gard et al., 2009; Vohs et al., 2013;
MAS-A – Metacognition total 11.68 (4.53) 0.55** 0.40** Choi et al., 2014; Luther et al., 2015a) and has demonstrated
adequate discriminant validity, predictive validity, internal con-
PANSS ¼Positive and Negative Syndrome Scale; MAS-A ¼Metacognition Assess-
sistency, and test-retest reliability (Fervaha et al., 2015c; Nakagami
ment Scale-Abbreviated; TEPS ¼Temporal Experience of Pleasure Scale; QLS In-
dex ¼Quality of Life Scale Motivation Index. et al., 2008, 2010; Saperstein et al., 2011). Good inter-rater relia-
*
p r 0.05. bility (intraclass correlation ¼0.88) was found in the current
**
po 0.01. study.
a
Point-biseral correlations. Positive number indicates women and African
Americans tend to score higher. 2.2.3. Anticipatory and consummatory pleasure
b
Parent education missing n ¼1; illness duration missing n ¼3; chlorproma-
zine equivalent doses missing n¼4.
The 18-item Temporal Experience of Pleasure Scale (TEPS; Gard
c
Based on age at first psychiatric hospitalization. et al., 2006) was used to assess self-reported anticipatory and
d
Chlorpromazine equivalents were calculated using Woods (2003) and Leh- consummatory pleasure. Ten items comprise the anticipatory
man et al. (2004). pleasure subscale (e.g., “When ordering something off the menu, I
imagine how good it will taste”), and eight items compose the
consummatory pleasure subscale (e.g., A hot cup of coffee or tea
on a cold morning is very satisfying to me”). Items are rated on a
used to assess how participants understood their experience with 6-point scale, with higher scores suggesting greater anticipatory
mental illness. The IPII is a semi-structured interview that typically pleasure or consummatory pleasure, respectively. The TEPS scores
lasts between 30 and 60 min and is broken into five main sections, have demonstrated good convergent validity with reward re-
with interviewers asking the participants to discuss: 1) their life sponsiveness and openness to different experiences (Gard et al.,
story, 2) whether they believe they have a mental illness, and if so, 2006) and had acceptable internal consistency in the current
whether it has affected different facets of living (e.g., relationships) sample (α for anticipatory pleasure¼0.68; α for consummatory
3), whether, and if so, how their illness controls and is controlled pleasure ¼0.67).
by them, 4) how their illness affects and is affected by others, and
5) what they anticipate in the future. The IPII interview is recorded 2.2.4. Symptoms
and transcribed, and responses are rated for metacognitive capa- Positive, negative, cognitive, hostility, and emotional dis-
city using the Metacognition Assessment Scale-Abbreviated (MAS- comfort symptoms were assessed by factor-analytically derived
A; Lysaker et al., 2005). The MAS-A was adapted from the Meta- subscales (Bell et al., 1994) of the Positive and Negative Syndrome
cognitive Assessment Scale (Semerari et al., 2003) in order to as- Scale (PANSS; Kay et al., 1987). Items are rated on a 7-point scale
sess metacognitive capacities that spontaneously appear within by trained clinicians following a chart-review and semi-structured
the IPII. For the current investigation, we used the total MAS-A interview. Higher scores are reflective of greater symptom sever-
score, which is the sum of its four subscales: 1) the ability to think ity. Good inter-rater reliability was found in the current study,
about and integrate information about one's mental states or self- with intra-class correlations ranging from 0.84 to 0.93.
reflectivity (score range 0–9), 2) the ability to think about and in-
tegrate information about other people's mental states or aware- 2.3. Procedure
ness of the other's mind (range 0–7), 3) the ability to recognize that
one is not the center of others’ mental states and intentions or After participants provided written informed consent, partici-
decentration (range 0–3), and 4) the capacity to use knowledge pants' diagnoses were confirmed by clinical psychologists using
about oneself and others to respond to psychological and social the SCID. At the baseline visit, participants completed the QLS,
challenges or mastery (range 0–9). Higher scores reflect greater TEPS, PANSS, and IPII, and current antipsychotic doses were ob-
metacognitive capacity (total score range 0–28). The MAS-A total tained from the participants’ medical chart. Participants also
score has exhibited validity with measures of cognitive and clinical completed the QLS again approximately six months later. There
L. Luther et al. / Psychiatry Research 245 (2016) 172–178 175

was no experimental intervention between assessments. All as- Table 2


sessments were completed with a trained (inter-rater reliability Hierarchical linear regression predicting motivation at six-month follow-up.
40.70 on all study measures) Master's-level research assistant.
R2 B SE B β R2 change
MAS-A raters were blind to all other testing. Study procedures
were approved by the local Institutional Review Board. Step one 0.15 0.15**
QLS Index – Baseline motivation 0.38 0.14 0.38**
2.4. Analyses
Step two 0.25 0.10
Analyses were conducted in several stages. First, we conducted QLS Index – Baseline motivation 0.33 0.13 0.33*
Pearson and point-biseral correlations between both demographic Chlorpromazine equivalent doses 0.00 0.00  0.26
TEPS – Anticipatory pleasure 0.05 0.05 0.14
variables and clinical measures (i.e., anticipatory and con-
summatory pleasure, symptoms, and metacognition) and motiva-
tion at baseline and six-month follow-up to examine the pattern Step three 0.32 0.07*
QLS Index – Baseline motivation 0.17 0.15 0.17
of associations and importantly, to identify any baseline variables
Chlorpromazine equivalent doses 0.00 0.00  0.28*
with significant associations with motivation at six-month follow- TEPS – Anticipatory pleasure 0.04 0.05 0.11
up; baseline variables with significant associations with motiva- MAS-A Total – Metacognition 0.19 0.09 0.31*
tion at follow-up were controlled for in regression analyses. Next,
Abbreviations are listed in Table 1.
paired t-tests were conducted to examine whether scores on
*
p o0.05.
clinical measures changed between baseline and six-month fol- **
p o 0.01.
low-up. To test our hypothesis that baseline deficits in metacog-
nition are a significant risk factor for prospective reduced moti-
vation, we conducted a hierarchical linear regression predicting
the QLS motivation index at six-month follow-up. The baseline motivation. In the second step, chlorpromazine equivalent doses
score of the QLS motivation index was entered into the first step of and anticipatory pleasure were entered, which resulted in a sig-
the regression to control for baseline levels of motivation. Any nificant model as well, F(3,43) ¼4.74, p ¼0.006, that accounted for
baseline demographic variables or clinical measures that demon- 25% of the variance in six month motivation; however, the 10%
strated significant associations with motivation at six-month fol- increase in variance accounted for was only trending towards a
low-up were entered into the second step of the regression in significant increase over the model with baseline motivation (FΔ
order to control for the effects of these variables on motivation at (2,43) ¼2.90, p ¼0.07). Baseline motivation was the sole significant
six-month follow-up. Finally, the MAS-A total score was entered predictor of six month motivation in step two. Finally, metacog-
into the third step of the regression. nition was entered in the third step, which again resulted in a
significant model, F(4,42) ¼ 4.92, p ¼0.002, that accounted for 32%
of the variance in six month motivation. The 7% increase in var-
3. Results iance accounted for over the model with baseline motivation,
chlorpromazine equivalent doses, and anticipatory pleasure (Step
Means and standard deviations for all study variables are re- 2) was a statistically significant model improvement (FΔ (1,42) ¼
ported in Table 1. No significant changes were observed between 4.37, p¼ 0.04). Reduced metacognition and greater chlorpromazine
baseline and six months scores on measures of motivation, an- equivalent doses significantly predicted lower motivation in the
ticipatory and consummatory pleasure, symptoms, and metacog- third step.
nition (all ps 4 0.05). However, 21 (41%) participants demonstrated
at least one standard deviation change in motivation scores be-
tween baseline and six month assessments. 4. Discussion

3.1. Correlations between motivation and demographic and clinical Several studies have demonstrated that motivation deficits are
variables among the strongest predictors of poor functioning in schizo-
phrenia (Foussias et al., 2009, 2011; Fervaha et al., 2014); however,
All correlations with baseline and six month motivation are few studies have investigated factors that promote and sustain
reported in Table 1. Baseline motivation was not significantly as- motivation over time in schizophrenia. Therefore, the primary aim
sociated with any demographic variables; however, reduced of this study was to investigate the role of one candidate con-
baseline motivation was significantly associated with increased tributor, metacognition. Consistent with our hypothesis, impaired
baseline positive, negative, and cognitive symptoms, as well as baseline metacognition predicted reduced prospective motivation,
lower metacognition. Decreased motivation at six-month follow- even after statistically accounting for the effects of baseline levels
up was significantly associated with higher baseline chlorproma- of motivation, anticipatory pleasure, and antipsychotic medication
zine equivalent doses and decreased baseline motivation, antici- dose. Although a previous study has linked reduced metacognition
patory pleasure, and metacognition; accordingly, chlorpromazine to prospective motivation impairments (Vohs and Lysaker, 2014),
equivalent doses and anticipatory pleasure were controlled for in the present study is the first to demonstrate the importance of
the regression analysis. metacognition deficits and antipsychotic doses on prospective
motivation above and beyond the effects of anticipatory pleasure.
3.2. Regression predicting prospective motivation One possible interpretation of these findings is that deficits in
metacognition may foster or be a risk factor for deficits in moti-
Table 2 contains the results from the hierarchical linear re- vation. Specifically, without a complex representation of oneself
gression analysis predicting motivation at six-month follow-up. In and others, a person may naturally experience less drive over time
the first step, baseline motivation was entered, resulting in a sig- to engage in goal-directed behavior. This hypothesis is consistent
nificant model, F(1,45) ¼7.76, p ¼0.008. In this model, baseline with Bleuler's (1911/1950) original model of schizophrenia which
motivation was a significant predictor of increased six month suggested that a core element of the disorder is a disturbance in
motivation and accounted for 15% of the variance in prospective the associative processes needed to integrate information and to
176 L. Luther et al. / Psychiatry Research 245 (2016) 172–178

facilitate purposeful goal-directed behavior. Further, it is also functioning, they may negatively impact recovery-related do-
consistent with the notion that motivational deficits in schizo- mains, such as motivation, over time. Further, it may be that for
phrenia are due to problems forming mental representations that some, taking greater antipsychotic medication doses may dampen
allow for reflection about the value and pleasure associated with a internal or emotional states (Buck et al., 2013; Mizrahi et al., 2007)
task (Heerey and Gold, 2007; Gold et al., 2008). Importantly, that contribute to motivated behavior as well as support negative
however, rival hypotheses cannot be ruled out, including the illness appraisals (e.g., feeling reduced personal control over one's
possibility that other variables not measured here may be more illness), which can adversely impact one's sense of self and in turn
powerful determinants of prospective motivation. For example, lead to reductions in motivation over time. Future longitudinal
given that studies have found associations between defeatist be- work looking at the impact of taking antipsychotic medications on
liefs and increased negative symptoms (Grant and Beck, 2009; motivation and associated processes is needed in order to clarify
Luther et al., 2015b) and reduced effort allocation (Granholm et al., the impact of antipsychotic medication on motivation over time in
in press), future studies should also compare the relative con- individuals with schizophrenia.
tribution of defeatist beliefs to prospective motivation. Further, There are additional unexpected findings. For instance, we
future studies may also want to consider the relationship between found that baseline motivation accounted for only 15% of the
motivation and developmental processes, with particular con- variance in motivation at six-month follow-up. However, this
sideration for the dialectical relationship between one's self-defi- finding is consistent with previous studies that have found that
nition and sense of relatedness to others (Blatt and Blass, 1996; motivation is malleable over time (Faerden et al., 2010; Nakagami
Guisinger and Blatt, 1994; McAdams, 1988) and how this re- et al., 2010; Choi et al., 2013), and our findings also suggest that
lationship relates to the development and maintenance of moti- metacognition is a stronger predictor of prospective motivation
vation in people with schizophrenia. than baseline motivation. We also found that baseline negative
Importantly, there was no evidence that the relationship be- symptoms were significantly correlated with concurrent motiva-
tween motivation and metacognition was an artifact of the influ- tion but not prospective motivation. However, this may be due to
ence of deficits in anticipatory pleasure. Although previous cross- the fact that the negative symptom measure used, the PANSS, did
sectional studies have found that reductions in anticipatory plea- not fully assess the motivational subdomain of negative symptoms
sure are linked to reduced concurrent levels of approach motiva- (Blanchard et al., 2010) or that the PANSS negative symptom
tion (Gard et al., 2007) and negative symptoms (Favrod et al., subscale and the QLS motivation index are assessing slightly di-
2009; but also see Strauss et al., 2011), this study extends previous vergent constructs (Fervaha et al., 2015c). Alternatively, it may be
studies by examining the relationship between anticipatory plea- that the negative symptom subdomains of motivation deficits and
sure and motivation over time. We found that baseline levels of expressive deficits are related to separate underlying processes
anticipatory pleasure were moderately and significantly correlated (Kirkpatrick et al., 2011) that are differentially affected over time.
with motivation assessed six months later; however, anticipatory Future research could replicate these findings using novel instru-
pleasure was not a significant predictor of six month motivation ments of negative symptoms such as the Brief Negative Symptom
after statistically accounting for baseline motivation, metacogni- Scale (Strauss et al., 2012) or the Clinical Assessment Interview for
tion, and antipsychotic dose. These findings suggest that impair- Negative Symptoms (Horan et al., 2011).
ments in forming a complex representation of oneself and others There are also a number of limitations that should be con-
may be a stronger psychological determinant than difficulties sidered when interpreting these findings. First, the sample was
anticipating future pleasure in the development of motivation relatively small and consisted largely of men with prolonged
deficits in people with schizophrenia. Thus, interventions aimed at schizophrenia who were in a post-acute, stable phase of their
reducing or preventing further motivation deficits in schizo- disorder. Therefore, it may be that different correlates or pre-
phrenia may benefit from targeting metacognition deficits prior to dictors of motivation may exist in females, those that are experi-
or in addition to anticipatory pleasure deficits. encing early signs of schizophrenia, or those in a more acute phase
Unexpectedly, we found that increased baseline levels of anti- of the illness. Second, this study did not include a measure of
psychotic doses were not significantly related to decreased moti- neurocognition; however, findings regarding the link between
vation at baseline but that increased baseline levels of anti- motivation and neurocognition have been mixed (c.f., Choi et al.,
psychotic doses were significantly and moderately correlated with 2014), demonstrating the need for future work in this area. Third,
decreased motivation assessed six months later. However, the while a strength of this study was that metacognition was as-
cross-sectional finding is consistent with Insel et al. (2014) and sessed across multiple domains, future research should investigate
Fervaha et al. (2015b) who did not observe a relationship between whether specific metacognitive domains are differentially pre-
concurrent antipsychotic doses and clinician-rated motivation. dictive of prospective motivation. Further, although motivation in
Further, we observed that baseline antipsychotic doses also re- schizophrenia has been found to be dynamic over time (Nakagami
mained a significant predictor of prospective motivation even et al., 2010), in light of the moderate correlation between baseline
when statistically accounting for the effects of baseline motivation, and six-month follow-up motivation observed in this study, ad-
anticipatory pleasure, and metacognition. This finding contrasts a ditional psychometric investigations are needed to examine the
recent study that found that antipsychotic dose was not a sig- QLS motivation index's test-retest reliability and utility as a re-
nificant predictor of motivation assessed six months later (Fervaha peated measure. Also, given that some previous work has found
et al., 2015c). However, this discrepant finding may be due to the limited convergence between self-report and clinician-rated mo-
fact that Fervaha et al. (2015c) examined participants who were tivation (Choi et al., 2014; Cooper et al., 2015) and other clinical
administered one form of antipsychotic medicine while many domains (Hasson-Ohayon et al., 2011) in schizophrenia samples,
participants in the current sample were prescribed more than one future work should seek to replicate these findings using a self-
antipsychotic. Our findings are also in line with Harrow and Jobe report measure of motivation, such as the Intrinsic Motivation
(2007) who found that after initial improvements from anti- Inventory for Schizophrenia Research (Choi et al., 2010). Lastly,
psychotic medications, people who stayed on antipsychotics over a although a six month interval is of interest to clinical work focused
15 year period had fewer periods of recovery and worse global on metacognition and motivation, it may be the case that different
functioning than those who were off antipsychotics over the same relationships exist when examining periods of time longer than six
period; thus, it may be that while antipsychotic medication can months.
help initially with reductions in symptoms and improvements in In summary, our findings add to the increasing evidence that
L. Luther et al. / Psychiatry Research 245 (2016) 172–178 177

metacognition is a key psychological determinant of motivation schizophrenia: scale development and validation. Psychiatry Res. 225, 70–78.
and also suggest that antipsychotic doses may play an important Faerden, A., Finset, A., Friis, S., Agartz, I., Barrett, E.A., Nesvåg, R., Andreassen, O.A.,
Marder, S.R., Melle, I., 2010. Apathy in first episode psychosis patients: one year
role in prospective motivation in schizophrenia. Further, with re- follow up. Schizophr. Res. 116, 20–26.
plication, our findings may have several important clinical im- Favrod, J., Ernst, F., Giuliani, F., Bonsack, C., 2009. Validation of the Temporal Ex-
plications. First, our findings suggest that psychological treatments perience of Pleasure Scale (TEPS) in a French-speaking environment [Article in
French]. Encephale 35, 241–248.
aiming to alleviate motivation deficits could benefit from in- Fervaha, G., Foussias, G., Agid, O., Remington, G., 2014. Motivational and neuro-
corporating metacognition as a treatment target. Specifically, in- cognitive deficits are central to the prediction of longitudinal functional out-
tegrated interventions (c.f., Lysaker et al., 2010; Harder and Folke, come in schizophrenia. Acta Psychiatr. Scand. 130, 290–299.
Fervaha, G., Foussias, G., Agid, O., Remington, G., 2015a. Motivational deficits in
2012; Bargenquast and Schweitzer, 2014; Brent et al., 2014) that early schizophrenia: prevalent, persistent, and key determinants of functional
promote a complex understanding of oneself and others may be outcome. Schizophr. Res. 166, 9–16.
well suited to address the phenomenon that promotes motivation Fervaha, G., Foussias, G., Takeuchi, H., Agid, O., Remington, G., 2015b. Measuring
motivation in people with schizophrenia. Schizophr. Res. 169, 423–426.
deficits, and these interventions may even have a protective effect
Fervaha, G., Takeuchi, H., Lee, J., Foussias, G., Fletcher, P.J., Agid, O., Remington, G.,
against the worsening of motivation deficits over time. Second, our 2015c. Antipsychotics and amotivation. Neuropsychopharmacology 40,
findings suggest that it may be helpful for clinicians to consider 1539–1548.
First, M.B., Spitzer, R.L., Gibbon, M., William, J.B., 2002. Structured Clinical Interview
the role of antipsychotic doses in individuals who demonstrate
for DSM-IV-TR Axis I Disorders, Research Version, Patient ed. Biometrics Re-
motivation impairments. Perhaps in concert with interventions search. New York State Psychiatric Institute, New York.
aimed at targeting and improving metacognitive capacity, clin- Flavell, J.H., 1979. Metacognition and cognitive monitoring: a new area of cogni-
icians could consider that antipsychotic doses could be reduced, tive–developmental inquiry. Am. Psychol. 34, 906–911.
Foussias, G., Mann, S., Zakzanis, K.K., van Reekum, R., Remington, G., 2009. Moti-
which may even further affect motivation deficits. vational deficits as the central link to functioning in schizophrenia: a pilot
study. Schizophr. Res. 115, 333–337.
Foussias, G., Mann, S., Zakzanis, K.K., van Reekum, R., Agid, O., Remington, G., 2011.
Prediction of longitudinal functional outcomes in schizophrenia: the impact of
Conflicts of interest baseline motivational deficits. Schizophr. Res. 132, 24–27.
Gard, D.E., Gard, M.G., Kring, A.M., John, O.P., 2006. Anticipatory and consummatory
None. components of the experience of pleasure: a scale development study. J. Res.
Pers. 40, 1086–1102.
Gard, D.E., Kring, A.M., Gard, M.G., Horan, W.P., Green, M.F., 2007. Anhedonia in
schizophrenia: distinctions between anticipatory and consummatory pleasure.
Acknowledgement Schizophr. Res. 93, 253–260.
Gard, D.E., Fisher, M., Garrett, C., Genevsky, A., Vinogradov, S., 2009. Motivation and
its relationship to neurocognition, social cognition, and functional outcome in
We would like to thank the people who participated in this schizophrenia. Schizophr. Res. 115, 74–81.
research. Gold, J.M., Waltz, J.A., Prentice, K.J., Morris, S.E., Heerey, E.A., 2008. Reward pro-
cessing in schizophrenia: a deficit in the representation of value. Schizophr.
Bull. 34, 835–847.
Granholm, E., Ruiz, I., Gallegos-Rodriguez, Y., Holden, J., Link, P.C., 2016. Pupillary
References responses as a biomarker of diminished effort associated with defeatist atti-
tudes and negative symptoms in schizophrenia. Biol. Psychiatry, http://dx.doi.
org/10.1016/j.biopsych.2015.08.037 (in press).
American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Grant, P.M., Beck, A.T., 2009. Defeatist beliefs as a mediator of cognitive impairment,
Disorders, fifth ed. American Psychiatric Publishing, Arlington, Virginia. negative symptoms, and functioning in schizophrenia. Schizophr. Bull. 35,
Barch, D.M., Pagliaccio, D., Luking, K., 2015. Mechanisms underlying motivational 798–806.
deficits in psychopathology: similarities and differences in depression and Guisinger, S., Blatt, S.J., 1994. Individuality and relatedness: evolution of a funda-
schizophrenia. In: Geyer, M.A., Ellenbroek, B.A., Marsden, C.A. (Eds.), Current mental dialectic. Am. Psychol. 49, 104–111.
Topics in Behavioral Neurosciences. Springer, Heidelberg, Germany, pp. 1–39. Hamm, J.A., Renard, S.B., Fogley, R.L., Leonhardt, B.L., Dimaggio, G., Buck, K.D., Ly-
Bargenquast, R., Schweitzer, R.D., 2014. Enhancing sense of recovery and self-re- saker, P.H., 2012. Metacognition and social cognition in schizophrenia: stability
flectivity in people with schizophrenia: a pilot study of metacognitive narrative and relationship to concurrent and prospective symptom assessments. J. Clin.
psychotherapy. Psychol. Psychother. 87, 338–356. Psychol. 68, 1303–1312.
Bell, M.D., Lysaker, P.H., Beam-Goulet, J.L., Milstein, R.M., Lindenmayer, J.P., 1994. Harder, S., Folke, S., 2012. Affect regulation and metacognition in psychotherapy of
Five-component model of schizophrenia: assessing the factorial invariance of psychosis: an integrative approach. J. Psychother. Integr. 22, 330–343.
the positive and negative syndrome scale. Psychiatry Res. 52, 295–303. Harrow, M., Jobe, T.H., 2007. Factors involved in outcome and recovery in schizo-
Blanchard, J.J., Cohen, A.S., 2006. The structure of negative symptoms within phrenia patients not on antipsychotic medications: a 15-year multifollow-up
schizophrenia: implications for assessment. Schizophr. Bull. 32, 238–245. study. J. Nerv. Ment. Dis. 195, 406–414.
Blanchard, J.J., Kring, A.M., Horan, W.P., Gur, R., 2010. Toward the next generation of Hasson-Ohayon, I., Roe, D., Kravetz, S., Levy-Frank, I., Meir, T., 2011. The relationship
negative symptom assessments: the collaboration to advance negative symp- between consumer insight and provider-consumer agreement regarding con-
tom assessment in schizophrenia. Schizophr. Bull. 37, 291–299. sumer's quality of life. Community Ment. Health J. 47, 607–612.
Blatt, S.J., Blass, R.B., 1996. Relatedness and self definition: a dialectic model of Hasson-Ohayon, I., Avidan-Msika, M., Mashiach-Eizenberg, M., Kravetz, S., Ro-
personality development. In: Noam, G.G., Fischer, K.W. (Eds.), Development and zencwaig, S., Shalev, H., Lysaker, P.H., 2015. Metacognitive and social cognition
Vulnerabilities in Close Relationships. Erlbaum, New Jersey, pp. 309–338. approaches to understanding the impact of schizophrenia on social quality of
Bleuler, E., 1911/1950. Dementia Praecox or the Group of Schizophrenias. Interna- life. Schizophr. Res. 161, 386–391.
tional Universities Press, Oxford, England. Heerey, E.A., Gold, J.M., 2007. Patients with schizophrenia demonstrate dissociation
Brent, B.K., Holt, D.J., Keshavan, M.S., Seidman, L.J., 2014. Mentalization based between affective experience and motivated behavior. J. Abnorm. Psychol. 116,
treatment for psychosis: linking an attachment-based model to the psy- 268–278.
chotherapy for impaired mental state understanding in people with psychotic Heinrichs, D.W., Hanlon, T.E., Carpenter, W.T., 1984. The quality of life scale: an
disorders. Isr. J. Psychiatry Relat. Sci. 51, 17–24. instrument for rating the schizophrenic deficit syndrome. Schizophr. Bull. 10,
Buck, K.D., Roe, D., Yanos, P., Buck, B., Fogley, R.L., Grant, M., Lysaker, P.H., 2013. 388–398.
Challenges to assisting with the recovery of personal identity and wellness for Horan, W.P., Kring, A.M., Gur, R.E., Reise, S.P., Blanchard, J.J., 2011. Development and
persons with serious mental illness: considerations for mental health profes- psychometric validation of the Clinical Assessment Interview for Negative
sionals. Psychosis 5, 134–143. Symptoms (CAINS). Schizophr. Res. 132, 140–145.
Choi, J., Medalia, A., 2010. Intrinsic motivation and learning in a schizophrenia Insel, C., Reinen, J., Weber, J., Wager, T.D., Jarskog, L.F., Shohamy, D., Smith, E.E.,
spectrum sample. Schizophr. Res. 118, 12–19. 2014. Antipsychotic dose modulates behavioral and neural responses to feed-
Choi, J., Mogami, T., Medalia, A., 2010. Intrinsic motivation inventory: an adapted back during reinforcement learning in schizophrenia. Cogn. Affect. Behav.
measure for schizophrenia research. Schizophr. Bull. 36, 966–976. Neurosci. 14, 189–201.
Choi, J., Choi, K.H., Reddy, L.F., Fiszdon, J.M., 2014. Measuring motivation in schi- Kay, S.R., Flszbein, A., Opfer, L.A., 1987. The Positive and Negative Syndrome Scale
zophrenia: is a general state of motivation necessary for task-specific motiva- (PANSS) for Schizophrenia. Schizophr. Bull. 13, 261–276.
tion? Schizophr. Res. 153, 209–213. Kirkpatrick, B., Fenton, W.S., Carpenter, W.T., Marder, S.R., 2006. The NIMH-MA-
Choi, K.H., Fiszdon, J.M., Bell, M.D., 2013. Beyond cognition: a longitudinal in- TRICS consensus statement on negative symptoms. Schizophr. Bull. 32,
vestigation of the role of motivation during a vocational rehabilitation program. 214–219.
J. Nerv. Ment. Dis. 201, 173–178. Kirkpatrick, B., Strauss, G.P., Nguyen, L., Fischer, B.A., Daniel, D.G., Cienfuegos, A.,
Cooper, S., Lavaysse, L.M., Gard, D.E., 2015. Assessing motivation orientations in Marder, S.R., 2011. The brief negative symptom scale: psychometric properties.
178 L. Luther et al. / Psychiatry Research 245 (2016) 172–178

Schizophr. Bull. 37, 300–305. controlled trial. Hum. Psychopharmacol. 28, 586–593.
Kirsch, P., Ronshausen, S., Mier, D., Gallhofer, B., 2007. The influence of anti- Maslow, A.H., 1943. A theory of human motivation. Psychol. Rev. 50, 370–396.
psychotic treatment on brain reward system reactivity in schizophrenia pa- McAdams, D.P., 1988. Personal needs and personal relationships. In: Duck, S.W.
tients. Pharmacopsychiatry 40, 196–198. (Ed.), Handbook of Personal Relationships: Theory, Research and Interventions.
Kleinginna, P.R., Kleinginna, A.M., 1981. A categorized list of motivation definitions, Wiley, New York, pp. 7–22.
with a suggestion for a consensual definition. Motiv. Emot. 5, 263–291. McLeod, H.J., Gumley, A.I., MacBeth, A., Schwannauer, M., Lysaker, P.H., 2014. Me-
Lehman, A.F., Kreyenbuhl, J., Buchanan, R.W., Dickerson, F.B., Dixon, L.B., Goldberg, tacognitive functioning predicts positive and negative symptoms over 12
R., Sandson, N., 2004. The schizophrenia patient outcomes research team months in first episode psychosis. J. Psychiatr. Res. 54, 109–115.
(PORT): updated treatment recommendations 2003. Schizophr. Bull. 30, Medalia, A., Saperstein, A., 2011. The role of motivation for treatment success.
193–217. Schizophr. Bull. 37, S122–S128.
Lincoln, T.M., Dollfus, S., Lyne, J., 2016. Current developments and challenges in the Mizrahi, R., Rusjan, P., Agid, O., Graff, A., Mamo, D.C., Zipursky, R.B., Kapur, S., 2007.
assessment of negative symptoms. Schizophr. Res., http://dx.doi.org/10.1016/j. Adverse subjective experience with antipsychotics and its relationship to
schres.2016.02.035 (in press) striatal and extrastriatal D 2 receptors: a PET study in schizophrenia. Am. J.
Luther, L., Lysaker, P.H., Firmin, R.L., Breier, A., Vohs, J.L., 2015a. Intrinsic motivation Psychiatry 164, 630–637.
and amotivation in first episode and prolonged psychosis. Schizophr. Res. 169, Nakagami, E., Hoe, M., Brekke, J.S., 2010. The prospective relationships among in-
418–422. trinsic motivation, neurocognition, and psychosocial functioning in schizo-
Luther, L., Firmin, R.L., Vohs, J.L., Buck, K.D., Rand, K.L., Lysaker, P.H., 2016. Intrinsic phrenia. Schizophr. Bull. 36, 935–948.
motivation as a mediator between metacognition deficits and impaired Func- Nakagami, E., Xie, B., Hoe, M., Brekke, J.S., 2008. Intrinsic motivation, neurocogni-
tioning in Psychosis. Br. J. Clin. Psychol. 55, 333–347. tion and psychosocial functioning in schizophrenia: testing mediator and
Luther, L., Sadaaki, F., Firmin, R.L., McGuire, A.B., White, D.A., Minor, K.S., Salyers, M. moderator effects. Schizophr. Res. 105, 95–104.
P., 2015b. Expectancies of success as a predictor of negative symptom reduction Rabin, S.J., Hasson-Ohayon, I., Avidan, M., Rozencwaig, S., Shalev, H., 2014. Meta-
in individuals with schizophrenia. Psychiatry Res. 229, 505–510. cognition in schizophrenia and schizotypy: relation to symptoms of schizo-
Lysaker, P.H., Buck, K.D., Taylor, A.C., Roe, D., 2008a. Associations of metacognition phrenia, traits of schizotypy and social quality of life. Isr. J. Psychiatry Relat. Sci.
and internalized stigma with quantitative assessments of self-experience in 51, 44–53.
narratives of schizophrenia. Psychiatry Res. 157, 31–38. Ryan, R.M., Deci, E.L., 2000. Self-determination theory and the facilitation of in-
Lysaker, P.H., Glynn, S.M., Wilkniss, S.M., Silverstein, S.M., 2010. Psychotherapy and trinsic motivation, social development, and well-being. Am. Psychologist 55,
recovery from schizophrenia: a review of potential applications and need for
68–78.
future study. Psychol. Serv. 7, 75–91.
Saperstein, A.M., Fiszdon, J.M., Bell, M.D., 2011. Intrinsic motivation as a predictor of
Lysaker, P.H., Clements, C.A., Plascak-Hallberg, C.D., Knipscheer, S.J., Wright, D.E.,
work outcome after vocational rehabilitation in schizophrenia. J. Nerv. Ment.
2002. Insight and personal narratives of illness in schizophrenia. Psychiatry 65,
Dis. 199, 672–677.
197–206.
Semerari, A., Carcione, A., Dimaggio, G., Falcone, M., Nicolo, G., Procacci, M., Alleva,
Lysaker, P.H., Carcione, A., Dimaggio, G., Johannesen, J., Nicolò, G., Procacci, M.,
G., 2003. How to evaluate metacognitive functioning in psychotherapy? The
Semerari, A., 2005. Metacognition amidst narratives of self and illness in
metacognition assessment scale and its applications. Clin. Psychol. Psychother.
schizophrenia: associations with neurocognition, symptoms, insight and qual-
10, 238–261.
ity of life. Acta Psychiatr. Scand. 112, 64–71.
Strauss, G.P., Wilbur, R.C., Warren, K.R., August, S.M., Gold, J.M., 2011. Anticipatory
Lysaker, P.H., Vohs, J.L., Ballard, R., Fogley, R., Salvatore, G., Popolo, R., Dimaggio, G.,
vs. consummatory pleasure: what is the nature of hedonic deficits in schizo-
2013. Metacognition, self-reflection and recovery in schizophrenia. Future
phrenia? Psychiatry Res. 187, 36–41.
Neurol. 8, 103–115.
Strauss, G.P., Keller, W.R., Buchanan, R.W., Gold, J.M., Fischer, B.A., McMahon, R.P.,
Lysaker, P.H., Warman, D.M., Dimaggio, G., Procacci, M., LaRocco, V.A., Clark, L.K.,
Catalano, L.T., Culbreth, A.J., Carpenter, W.T., Kirkpatrick, B., 2012. Next-gen-
Dike, C.A., Nicolò, G., 2008b. Metacognition in schizophrenia: associations with
multiple assessments of executive function. J. Nerv. Ment. Dis. 196, 384–389. eration negative symptom assessment for clinical trials: validation of the Brief
Lysaker, P.H., Leonhardt, B.L., Brüne, M., Buck, K.D., James, A., Vohs, J., Francis, M., Negative Symptom Scale. Schizophr. Res. 142, 88–92.
Hamm, J.A., Salvatore, G., Ringer, J.M., 2014. Capacities for theory of mind, Tas, C., Brown, E.C., Esen-Danaci, A., Lysaker, P.H., Brüne, M., 2012. Intrinsic moti-
metacognition, and neurocognitive function are independently related to vation and metacognition as predictors of learning potential in patients with
emotional recognition in schizophrenia. Psychiatry Res. 219, 79–85. remitted schizophrenia. J. Psychiatr. Res. 46, 1086–1092.
Lysaker, P.H., Dimaggio, G., Wickett-Curtis, A., Kukla, M., Luedtke, B., Vohs, J., Tas, C., Brown, E.C., Aydemir, O., Brüne, M., Lysaker, P.H., 2014. Metacognition in
Leonhardt, B.L., James, A.V., Buck, K.D., Davis, L.W., 2015a. Deficits in meta- psychosis: comparison of schizophrenia with bipolar disorder. Psychiatry Res.
cognitive capacity are related to subjective distress and heightened levels of 219, 464–469.
hyperarousal symptoms in adults with Posttraumatic Stress Disorder. J. Trauma Velthorst, E., Koeter, M., van der Gaag, M., Nieman, D., Fett, A.-K., Smit, F., Staring, A.,
Dissociation 16, 384–398. Meijer, C., de Haan, L., 2015. Adapted cognitive–behavioural therapy required
Lysaker, P.H., Kukla, M., Dubreucq, J., Gumley, A., McLeod, H., Vohs, J.L., Buck, K.D., for targeting negative symptoms in schizophrenia: meta-analysis and meta-
Minor, K.S., Luther, L., Leonhardt, B.L., 2015b. Metacognitive deficits predict regression. Psychol. Med. 45, 453–465.
future levels of negative symptoms in schizophrenia controlling for neuro- Vohs, J.L., Lysaker, P.H., 2014. Metacognitive mastery and intrinsic motivation in
cognition, affect recognition, and self-expectation of goal attainment. Schi- schizophrenia. J. Nerv. Ment. Dis. 202, 74–77.
zophr. Res. 168, 267–272. Vohs, J.L., Lysaker, P.H., Nabors, L., 2013. Associations of personality with intrinsic
Lysaker, P.H., Vohs, J., Minor, K.S., Irarrázaval, L., Leonhardt, B., Hamm, J.A., Kukla, motivation in schizophrenia. Psychiatry Res. 208, 78–80.
M., Popolo, R., Luther, L., Buck, K.D., 2015c. Metacognitive deficits in schizo- Wasmuth, S.L., Outcalt, J., Buck, K., Leonhardt, B.L., Vohs, J., Lysaker, P.H., 2015.
phrenia: presence and associations with psychosocial outcomes. J. Nerv. Ment. Metacognition in persons with substance abuse: findings and implications for
Dis. 203, 530–536. occupational therapists. Can. J. Occup. Ther. 82, 150–159.
MacBeth, A., Gumley, A., Schwannauer, M., Carcione, A., Fisher, R., McLeod, H.J., Woods, S.W., 2003. Chlorpromazine equivalent doses for the newer atypical anti-
Dimaggio, G., 2014. Metacognition, symptoms and premorbid functioning in a psychotics. J. Clin. Psychiatry 64, 663–667.
First Episode Psychosis sample. Compr. Psychiatry 55, 268–273. Yamada, A.-M., Lee, K.K., Dinh, T.Q., Barrio, C., Brekke, J.S., 2010. Intrinsic motivation
Mas, S., Gassó, P., Fernández de Bobadilla, R., Arnaiz, J.A., Bernardo, M., Lafuente, A., as a mediator of relationships between symptoms and functioning among in-
2013. Secondary nonmotor negative symptoms in healthy volunteers after dividuals with schizophrenia spectrum disorders in a diverse urban commu-
single doses of haloperidol and risperidone: a double-blind, crossover, placebo- nity. J. Nerv. Ment. Dis. 198, 28–34.