Psychiatry Research 245 (2016) 172–178

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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.,

Although motivation, which can generally be defined as an
internal state that initiates, directs, and maintains goal-directed
behavior (Kleinginna and Kleinginna, 1981), has long been a focus
of psychological theories and research (Maslow, 1943), it has only
recently gained momentum as an important area of schizophrenia
research. To date, motivation deficits in schizophrenia are gen-
erally conceptualized as largely falling under the umbrella of ne-
gative symptoms (American Psychiatric Association, 2013), and
research has found that motivation deficits represent a key nega-
tive symptom subdomain (Blanchard and Cohen, 2006; Lincoln
et al., in press). Further, research has demonstrated that
n
Correspondence to: IUPUI School of Science, Department of Psychology, LD 124,
402 N. Blackford St., Indianapolis, IN 46202, United States.
E-mail address: lutherl@iupui.edu (L. Luther).
2015; Luther et al., 2015a) and that these deficits play a critical role
in reduced treatment response (Medalia and Saperstein, 2011),
learning (Choi and Medalia, 2010; Tas et al., 2012) and functioning
(Foussias et al., 2009, 2011). Several studies have also found that
motivation mediates the relationship between both symptoms and
functional outcomes (Yamada et al., 2010) and cognitive deficits
and functional outcomes (Nakagami et al., 2008; Gard et al., 2009;
Fervaha et al., 2015a).
Despite increasing evidence that motivation is a key determi-
nant of functional outcomes in schizophrenia, there is limited
empirical research investigating prospective determinants of mo-
tivation; thus, risk factors for motivation impairments have not
been fully identified. Identifying risk factors for these deficits is
critical in order to establish novel treatment targets. This is
especially salient given the modest improvement seen in motiva-
tional deficits with many existing psychological and pharmacolo-
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
2006; Velthorst et al., 2015). Further, discerning factors that lead to
improved treatments can serve to impede motivational declines
that may occur as the course of schizophrenia progresses (Luther
et al., 2015a).
One characteristic that has been argued to play a role in the
emergence of motivation impairments is deficits in metacognition
or impairments in the capacity to integrate mental experiences
into complex representations. The term metacognition was ori-
ginally used in the education literature (Flavell, 1979), but it has
subsequently been used in the context of psychopathology re-
search to describe a spectrum of mental experiences, ranging from
reflections about more discrete mental experiences (e.g., explicit
thoughts and feelings), to more synthetic reflective acts where
intentions, thoughts, feelings, and connections between experi-
ences are continuously evolving into integrated representations of
oneself and others as distinct agents in the world (Semerari et al.,
2003; Lysaker et al., 2013). Metacognition is viewed as partly
overlapping with social cognition but diverges in that it focuses
not on the accuracy of a single social cue, such as determining
whether a thought or feeling is correct, but on the degree to which
mental experiences about the self and others are coherently in-
tegrated (Lysaker et al., 2015c). Notably, individuals with early and
prolonged schizophrenia have demonstrated unique deficits in
metacognition compared to healthy controls (Hasson-Ohayon
et al., 2015) as well as those with substance use disorders (Lysaker
et al., 2014; Wasmuth et al., 2015), bipolar disorder (Tas et al.,
2014), and post-traumatic stress disorder (Lysaker et al., 2015a).
Metacognition may be a strong candidate predictor of motiva-
tion for several reasons. First, possessing an integrated sense of
oneself and others likely guides goal-directed behavior by pro-
viding meaning and value to completing tasks or activities. Thus,
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-
quired to complete them. Second, goal-directed behavior may be
contingent on being able to view oneself as a unique agent in the
world who is capable of initiating actions and responding to
challenges. Indeed, metacognition has been argued to play a cri-
tical role in cultivating an individual's sense of agency (Lysaker
et al., 2008a, 2013). Specifically, when faced with problems or new
experiences, without an integrated sense of oneself and others to
make sense of and to respond to problems and new experiences, a
person may become increasingly confused or overwhelmed and
may withdraw or discontinue any associated activities to reduce
confusion. Over time, without intact metacognitive capacities to
guide and provide meaning to behavior, one would likely be at risk
for reductions in goal-directed behavior.
Evidence supporting the connection between metacognition
and motivation includes findings from recent cross-sectional and
longitudinal studies demonstrating a relationship between meta-
cognitive deficits and reduced motivation and overall negative
symptoms. Specifically, Tas et al. (2012) demonstrated that re-
duced metacognition was associated with lower concurrent mo-
tivation, while other studies have shown that metacognition def-
icits are related to increased concurrent and prospective negative
symptoms (Hamm et al., 2012; MacBeth et al., 2014; Rabin et al.,
2014; Lysaker et al., 2015b). Further, lower levels of metacognition
have been found to be a significant predictor of reduced levels of
concurrent motivation (Luther et al., 2016) and increased levels of
negative symptoms both six and twelve months later (McLeod
et al., 2014). Similarly, Vohs and Lysaker (2014) reported that in
those with prolonged schizophrenia engaged in a treatment trial,
participants with lower levels of mastery, a domain of metacog-
nition, had consistently lower monthly ratings of motivation than
those with higher levels of mastery over a period of six months.
Taken together, these findings are also consistent with Bleuler's
173
(1911/1950) formulation of schizophrenia where he described that
people with schizophrenia experience a disturbance in the asso-
ciative processes that are needed to integrate information and to
support meaningful goal-directed behavior.
This study sought to extend the findings of Vohs and Lysaker
(2014) by examining how a wider range of metacognition domains
was related to motivation over time in a sample that was not
engaged in a treatment trial. Specifically, we employed a more
comprehensive measure of metacognition to assess whether me-
tacognitive deficits are a potential risk factor for reduced motiva-
tion over time in a sample of fifty-one people with a schizophrenia
spectrum disorder. We predicted that reduced levels of metacog-
nition would predict lower levels of motivation six months later
even after controlling for baseline levels of motivation. Further,
although difficulty anticipating rewarding outcomes has been
thought to impact motivation in schizophrenia (Gard et al., 2007;
Barch et al., 2015), it remains to be established whether antici-
patory pleasure and motivation are empirically linked over time
and importantly, whether metacognition deficits account for re-
duced prospective motivation above and beyond the effects of
anticipatory pleasure deficits. Thus, we included a measure of
anticipatory pleasure to rule out the possibility that reduced an-
ticipatory pleasure accounted for deficits in motivation to a greater
extent than metacognition deficits. Similarly, as demographic
factors such as age, education, and gender (Faerden et al., 2010;
Choi et al., 2014) as well as antipsychotic medication dose (Kirsch
et al., 2007; Mas et al., 2013) and psychiatric symptoms (Yamada
et al., 2010; Luther et al., 2016) have been linked to motivation, we
included measures of these variables as potential covariates. We
also included a measure of consummatory pleasure to explore its
relationship with prospective motivation.
2. Methods
2.1. Participants
Fifty-one participants with SCID-confirmed (First et al., 2002)
diagnoses of schizophrenia (n ¼ 26) or schizoaffective disorder
(n ¼25) were recruited from either a Veterans' Affairs Medical
Center (n ¼45) or a community mental health center (n ¼6) for a
longitudinal study examining the correlates of metacognition in
people with a schizophrenia spectrum disorder. Participants were
in a post-acute phase of illness as defined by no hospitalizations or
changes in housing or medication within 30 days of study en-
rollment. Exclusion criteria also included active substance de-
pendence or developmental disability, as determined through a
chart review. Twenty-nine participants were taking a single anti-
psychotic medication (25 atypical, 4 typical antipsychotics), while
16 patients were taking multiple antipsychotics (8 taking one
atypical and one typical, 7 taking two atypical, 1 taking two typical
antipsychotics). Antipsychotics included aripiprazole, clozapine,
fluphenazine, haloperidol, loxapine, olanzapine, quetiapine, ris-
peridone, trifluoperazine, and ziprasidone. Six participants were
not taking any antipsychotic medication. There were no significant
changes in medication doses (i.e., chlorpromazine equivalent do-
ses) or any hospitalizations during the course of the study. Parti-
cipants were primarily male, African American, and were enrolled
in outpatient treatment. Full demographic information is reported
in Table 1.
2.2. Measures
2.2.1. Metacognition
Metacognition was assessed with a two-step process. First, the
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
variables
All correlations with baseline and six month motivation are
reported in Table 1. Baseline motivation was not significantly as-
sociated with any demographic variables; however, reduced
baseline motivation was significantly associated with increased
baseline positive, negative, and cognitive symptoms, as well as
lower metacognition. Decreased motivation at six-month follow-
up was significantly associated with higher baseline chlorproma-
zine equivalent doses and decreased baseline motivation, antici-
patory pleasure, and metacognition; accordingly, chlorpromazine
equivalent doses and anticipatory pleasure were controlled for in
the regression analysis.
3.2. Regression predicting prospective motivation
Table 2 contains the results from the hierarchical linear re-
gression analysis predicting motivation at six-month follow-up. In
the first step, baseline motivation was entered, resulting in a sig-
nificant model, F(1,45) ¼7.76, p ¼0.008. In this model, baseline
motivation was a significant predictor of increased six month
motivation and accounted for 15% of the variance in prospective
Several studies have demonstrated that motivation deficits are
among the strongest predictors of poor functioning in schizo-
phrenia (Foussias et al., 2009, 2011; Fervaha et al., 2014); however,
few studies have investigated factors that promote and sustain
motivation over time in schizophrenia. Therefore, the primary aim
of this study was to investigate the role of one candidate con-
tributor, metacognition. Consistent with our hypothesis, impaired
baseline metacognition predicted reduced prospective motivation,
even after statistically accounting for the effects of baseline levels
of motivation, anticipatory pleasure, and antipsychotic medication
dose. Although a previous study has linked reduced metacognition
to prospective motivation impairments (Vohs and Lysaker, 2014),
the present study is the first to demonstrate the importance of
metacognition deficits and antipsychotic doses on prospective
motivation above and beyond the effects of anticipatory pleasure.
One possible interpretation of these findings is that deficits in
metacognition may foster or be a risk factor for deficits in moti-
vation. Specifically, without a complex representation of oneself
and others, a person may naturally experience less drive over time
to engage in goal-directed behavior. This hypothesis is consistent
with Bleuler's (1911/1950) original model of schizophrenia which
suggested that a core element of the disorder is a disturbance in
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
consistent with the notion that motivational deficits in schizo-
phrenia are due to problems forming mental representations that
allow for reflection about the value and pleasure associated with a
task (Heerey and Gold, 2007; Gold et al., 2008). Importantly,
however, rival hypotheses cannot be ruled out, including the
possibility that other variables not measured here may be more
powerful determinants of prospective motivation. For example,
given that studies have found associations between defeatist be-
liefs and increased negative symptoms (Grant and Beck, 2009;
Luther et al., 2015b) and reduced effort allocation (Granholm et al.,
in press), future studies should also compare the relative con-
tribution of defeatist beliefs to prospective motivation. Further,
future studies may also want to consider the relationship between
motivation and developmental processes, with particular con-
sideration for the dialectical relationship between one's self-defi-
nition and sense of relatedness to others (Blatt and Blass, 1996;
Guisinger and Blatt, 1994; McAdams, 1988) and how this re-
lationship relates to the development and maintenance of moti-
vation in people with schizophrenia.
Importantly, there was no evidence that the relationship be-
tween motivation and metacognition was an artifact of the influ-
ence of deficits in anticipatory pleasure. Although previous cross-
sectional studies have found that reductions in anticipatory plea-
sure are linked to reduced concurrent levels of approach motiva-
tion (Gard et al., 2007) and negative symptoms (Favrod et al.,
2009; but also see Strauss et al., 2011), this study extends previous
studies by examining the relationship between anticipatory plea-
sure and motivation over time. We found that baseline levels of
anticipatory pleasure were moderately and significantly correlated
with motivation assessed six months later; however, anticipatory
pleasure was not a significant predictor of six month motivation
after statistically accounting for baseline motivation, metacogni-
tion, and antipsychotic dose. These findings suggest that impair-
ments in forming a complex representation of oneself and others
may be a stronger psychological determinant than difficulties
anticipating future pleasure in the development of motivation
deficits in people with schizophrenia. Thus, interventions aimed at
reducing or preventing further motivation deficits in schizo-
phrenia may benefit from targeting metacognition deficits prior to
or in addition to anticipatory pleasure deficits.
Unexpectedly, we found that increased baseline levels of anti-
psychotic doses were not significantly related to decreased moti-
vation at baseline but that increased baseline levels of anti-
psychotic doses were significantly and moderately correlated with
decreased motivation assessed six months later. However, the
cross-sectional finding is consistent with Insel et al. (2014) and
Fervaha et al. (2015b) who did not observe a relationship between
concurrent antipsychotic doses and clinician-rated motivation.
Further, we observed that baseline antipsychotic doses also re-
mained a significant predictor of prospective motivation even
when statistically accounting for the effects of baseline motivation,
anticipatory pleasure, and metacognition. This finding contrasts a
recent study that found that antipsychotic dose was not a sig-
nificant predictor of motivation assessed six months later (Fervaha
et al., 2015c). However, this discrepant finding may be due to the
fact that Fervaha et al. (2015c) examined participants who were
administered one form of antipsychotic medicine while many
participants in the current sample were prescribed more than one
antipsychotic. Our findings are also in line with Harrow and Jobe
(2007) who found that after initial improvements from anti-
psychotic medications, people who stayed on antipsychotics over a
15 year period had fewer periods of recovery and worse global
functioning than those who were off antipsychotics over the same
period; thus, it may be that while antipsychotic medication can
help initially with reductions in symptoms and improvements in
functioning, they may negatively impact recovery-related do-
mains, such as motivation, over time. Further, it may be that for
some, taking greater antipsychotic medication doses may dampen
internal or emotional states (Buck et al., 2013; Mizrahi et al., 2007)
that contribute to motivated behavior as well as support negative
illness appraisals (e.g., feeling reduced personal control over one's
illness), which can adversely impact one's sense of self and in turn
lead to reductions in motivation over time. Future longitudinal
work looking at the impact of taking antipsychotic medications on
motivation and associated processes is needed in order to clarify
the impact of antipsychotic medication on motivation over time in
individuals with schizophrenia.
There are additional unexpected findings. For instance, we
found that baseline motivation accounted for only 15% of the
variance in motivation at six-month follow-up. However, this
finding is consistent with previous studies that have found that
motivation is malleable over time (Faerden et al., 2010; Nakagami
et al., 2010; Choi et al., 2013), and our findings also suggest that
metacognition is a stronger predictor of prospective motivation
than baseline motivation. We also found that baseline negative
symptoms were significantly correlated with concurrent motiva-
tion but not prospective motivation. However, this may be due to
the fact that the negative symptom measure used, the PANSS, did
not fully assess the motivational subdomain of negative symptoms
(Blanchard et al., 2010) or that the PANSS negative symptom
subscale and the QLS motivation index are assessing slightly di-
vergent constructs (Fervaha et al., 2015c). Alternatively, it may be
that the negative symptom subdomains of motivation deficits and
expressive deficits are related to separate underlying processes
(Kirkpatrick et al., 2011) that are differentially affected over time.
Future research could replicate these findings using novel instru-
ments of negative symptoms such as the Brief Negative Symptom
Scale (Strauss et al., 2012) or the Clinical Assessment Interview for
Negative Symptoms (Horan et al., 2011).
There are also a number of limitations that should be con-
sidered when interpreting these findings. First, the sample was
relatively small and consisted largely of men with prolonged
schizophrenia who were in a post-acute, stable phase of their
disorder. Therefore, it may be that different correlates or pre-
dictors of motivation may exist in females, those that are experi-
encing early signs of schizophrenia, or those in a more acute phase
of the illness. Second, this study did not include a measure of
neurocognition; however, findings regarding the link between
motivation and neurocognition have been mixed (c.f., Choi et al.,
2014), demonstrating the need for future work in this area. Third,
while a strength of this study was that metacognition was as-
sessed across multiple domains, future research should investigate
whether specific metacognitive domains are differentially pre-
dictive of prospective motivation. Further, although motivation in
schizophrenia has been found to be dynamic over time (Nakagami
et al., 2010), in light of the moderate correlation between baseline
and six-month follow-up motivation observed in this study, ad-
ditional psychometric investigations are needed to examine the
QLS motivation index's test-retest reliability and utility as a re-
peated measure. Also, given that some previous work has found
limited convergence between self-report and clinician-rated mo-
tivation (Choi et al., 2014; Cooper et al., 2015) and other clinical
domains (Hasson-Ohayon et al., 2011) in schizophrenia samples,
future work should seek to replicate these findings using a self-
report measure of motivation, such as the Intrinsic Motivation
Inventory for Schizophrenia Research (Choi et al., 2010). Lastly,
although a six month interval is of interest to clinical work focused
on metacognition and motivation, it may be the case that different
relationships exist when examining periods of time longer than six
months.
In summary, our findings add to the increasing evidence that
 L. Luther et al. / Psychiatry Research 245 (2016) 172–178
metacognition is a key psychological determinant of motivation
and also suggest that antipsychotic doses may play an important
role in prospective motivation in schizophrenia. Further, with re-
plication, our findings may have several important clinical im-
plications. First, our findings suggest that psychological treatments
aiming to alleviate motivation deficits could benefit from in-
corporating metacognition as a treatment target. Specifically, in-
tegrated interventions (c.f., Lysaker et al., 2010; Harder and Folke,
2012; Bargenquast and Schweitzer, 2014; Brent et al., 2014) that
promote a complex understanding of oneself and others may be
well suited to address the phenomenon that promotes motivation
deficits, and these interventions may even have a protective effect
against the worsening of motivation deficits over time. Second, our
findings suggest that it may be helpful for clinicians to consider
the role of antipsychotic doses in individuals who demonstrate
motivation impairments. Perhaps in concert with interventions
aimed at targeting and improving metacognitive capacity, clin-
icians could consider that antipsychotic doses could be reduced,
which may even further affect motivation deficits.
Conflicts of interest
None.
Acknowledgement
We would like to thank the people who participated in this
research.
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