Introduction
Among individuals with schizophrenia, those who have persistent and clinically significant negative symptoms (PNS) have the poorest functional outcomes and quality of life. The NIMH–MATRICS Consensus Statement indicated that these symptoms represent an unmet therapeutic need for large numbers of individuals with schizophrenia. No psychosocial treatment model addresses the entire constellation of PNS.
Method
51 patients with PNS were randomized into one of two groups for a period of 9 months: 1) MOtiVation and Enhancement (MOVE) or 2) treatment as usual. MOVE is a home based, manual-driven, multi-modal treatment that employs a number of cognitive and behavioral principles to address the broad range of factors contributing to PNS and their functional consequences. The components of MOVE include: Environmental supports to prompt initiation and persistence, in-vivo skills training to ameliorate deficits and encourage interaction, cognitive behavioral techniques to address self-defeating attitudes, in-vivo training in emotional processing to address affective blunting and problems in identifying emotions, and specific techniques to address the deficits in anticipatory pleasure. Patients were assessed at baseline and each 3 months with multiple measures of negative symptoms.
Results
Repeated measures analyses of variance for mixed models indicated significant Group by Time effects for the Negative Symptom Assessment (NSA; p < .02) and the Clinical Assessment Interview for Negative Symptoms (CAINS; p < .04). Group differences were not significant until 9 months of treatment and were not significant for the Brief Negative Symptom Scale (BNSS).
Conclusion
Further investigation of a comprehensive treatment for PNS, such as MOVE, is warranted.
The negative symptoms of schizophrenia are major contributors to lost productivity, poor quality of life, social deficits, poor occupational attainment and generally poor outcomes (Kirkpatrick et al., 2001, Kirkpatrick et al., 2006, Kurtz et al., 2005, Milev et al., 2005 and Buchanan, 2007). Dimensions of negative symptoms include restricted affect, diminished emotional range, poverty of speech, decreased motivation and interests, diminished sense of purpose and diminished social drive. In contrast to the positive symptoms of schizophrenia, negative symptoms are more difficult to treat and often persist long after positive symptoms have resolved or been substantially reduced (Buchanan, 2007). Negative symptoms have been found to be more predictive of concurrent and future functioning in the community than positive symptoms (Mueser et al., 1990, Breier et al., 1991, Velligan et al., 1997, Ho et al., 1998 and Milev et al., 2005). Recent factor analyses of many negative symptom instruments are composed of 2 factors, emotion expression and anhedonia/amotivation (CAINS; Forbes et al., 2010; BNSS; Kirkpatrick et al., 2011.)
The NIMH–MATRICS Consensus Statement on Negative Symptoms indicated that persistent negative symptoms (PNS) are a distinct therapeutic indication and represent an unmet therapeutic need for large numbers of individuals with schizophrenia ( Alphs, 2006, Kirkpatrick et al., 2006 and Buchanan, 2007). According to the 2009 update of the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations ( Kreyenbuhl et al., 2009) there is no sufficient evidence to recommend any current pharmacologic agent for the treatment of deficit or persistent negative symptoms in schizophrenia. With respect to psychosocial treatments, recent work on CBT has demonstrated improvements in measures of negative symptoms ( Riggs et al., 2012). Studies of Cognitive Adaptation Training (the use of environmental supports to bypass the cognitive and motivational problems underlying functional impairment) have demonstrated improvements on the Motivation factor of the Negative Symptom Assessment ( Alphs et al., 1989, Velligan et al., 2000b, Velligan et al., 2008a and Velligan et al., 2008b), with effect sizes in the moderate range. However, with respect to both CBT and CAT, design features essential to prove efficacy for PNS have not been followed ( Buchanan, 2007).
To address the need for novel treatments we developed MOtiVation and Engagement (MOVE) Training. MOVE is based upon techniques from a variety of interventions that each addresses a piece of the negative syndrome presentation. Our theoretical model of negative symptoms supporting the MOVE intervention has previously been published (Velligan et al., 2014). Briefly, negative symptoms are thought to be related to disruptions in ventral striatal reward systems (Wise, 1982, Goldstein and Volkow, 2002 and Juckel et al., 2006). Beck et al. (2009) have proposed that negative symptoms may emerge during the early experience of psychosis as a psychological defense against experiencing distress beyond one's capacity to cope. Once negative symptoms are present, our model proposes that the avolition leads to increasing difficulty for an individual to initiate action (Frith, 1992 and Maples and Velligan, 2008), if prompted to do something or if able to generate a plan, negative cognitions about the possibility of failure may prevent the individual from executing or persisting at the behavior (Beck et al., 2009 and Granholm et al., 2009). Moreover, deficits in anticipatory pleasure may prevent the individual from perceiving that they will enjoy the activity sufficiently to make it worth the effort (Gard et al., 2007). Negative thoughts as well as the atrophy of previously mastered social and work skills, may make failure more likely when a behavior is attempted (Bellack et al., 2004), and repeated negative consequences following the initiation of various activities may further prevent initiation (Beck et al., 2009).
