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Anticipatory pleasure and approach motivation in schizophrenia-like negative symptoms
Psychiatry Research 210 (2013) 422–426
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Anticipatory pleasure and approach motivation in schizophrenia-like negative symptoms Maike Engel n, Anja Fritzsche, Tania M. Lincoln University of Hamburg, Department of Clinical Psychology and Psychotherapy, Von-Melle-Park 5, 20146 Hamburg, Germany
art ic l e i nf o
a b s t r a c t
Article history: Received 26 December 2012 Received in revised form 7 May 2013 Accepted 12 July 2013
Previous research of negative symptoms in schizophrenia has emphasized an anticipatory pleasure deficit, yet the relationship of this deficit to patients' motivation in everyday life is poorly understood. This study tested the link between anticipatory pleasure and two broad motivational systems that are said to regulate the intensity of approach and avoidance behavior, the Behavioral Inhibition system (BIS) and the Behavioral Activation System (BAS). It was hypothesized that high vulnerability for negative symptoms would be associated with low reward responsiveness and that this association will be mediated by the amount of anticipated pleasure. Students (n ¼171) with varying vulnerability for negative symptoms (assessed by the Community Assessment of Psychic Experiences) completed questionnaires regarding (a) anticipatory and consummatory pleasure, and (b) responsiveness to threat and reward. As hypothesized, anticipatory pleasure correlated significantly negatively with subclinical negative symptoms (r¼ 0.21) and significantly positively with BAS (r¼ 0.55). Furthermore, evidence for a partial mediation effect was found. The findings support the notion of a close association between negative symptoms, the ability to anticipate pleasure and approach motivation that is evident even in healthy persons. It is suggested that the behavioral deficits immanent to negative symptoms reflect difficulties in the ability to translate emotions into motivation. & 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Subclinical negative symptoms Anticipatory pleasure Approach motivation
1. Introduction Anhedonia, defined as diminished ability to experience positive emotions (Germans and Kring, 2000) is central in patients with negative symptoms of schizophrenia (Horan et al., 2006; Mäkinen et al., 2008). It impairs patients' engagement in everyday activities and strongly affects quality of life (Rector et al., 2005; Mäkinen et al., 2008). According to Meehl (1962) anhedonia is a possible indicator of a genetic vulnerability to schizophrenia. In support of this assumption, anhedonia has been found to be elevated in unaffected relatives of patients with schizophrenia (Kendler et al., 1996; Laurent et al., 2000) and in healthy participants exhibiting clinical characteristics similar to those seen in individuals with schizophrenia spectrum disorders (Blanchard et al., 2011). Those findings imply a continuity of negative symptoms in the population and healthy individuals seem to vary in their vulnerability for anhedonia. Thus, studying anhedonia at a subclinical level may help to identify mechanisms that are involved in transition from a healthy state to negative symptoms.
n
Corresponding author. Tel.: +49 40 42838 9240. E-mail addresses: [email protected] (M. Engel), [email protected] (A. Fritzsche), [email protected] (T.M. Lincoln). 0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2013.07.025
One important aspect of anhedonia is the differentiation between its consummatory and anticipatory components (Klein, 1984; Gard et al., 2006). Consummatory pleasure is the ability to actually experience pleasure in response to a pleasurable stimulus in the moment it occurs, whereas anticipatory pleasure refers to the experience of pleasure while anticipating future events (Kring and Caponigro, 2010). Several studies based on self-report measures and experience sampling methods have shown that anticipatory (but not consummatory) deficits are associated with anhedonia in schizophrenia (Horan et al., 2006; Gard et al., 2007; Favrod et al., 2009; Chan et al., 2010). In those studies, patients with schizophrenia reported less anticipated pleasure than controls but comparable levels of positive emotion when they were actually experiencing pleasurable activities. Strauss and Gold (2012) concluded that anhedonia should no longer be defined as diminished capacity for pleasure, but rather reflects beliefs of low pleasure or elevated negative emotions. As in healthy persons, experience of emotion in schizophrenia is hypothesized to be closely linked to motivational systems (Kring and Caponigro, 2010). Based on Gray's (1970) neurobiological model there are two motivational systems that regulate the intensity of approach and avoidance behavior and are associated with specific emotions. The Behavioral Inhibition or Avoid System (BIS) is related to punishment avoidance and the Behavioral Activation or Approach System (BAS) is related to drive, fun seeking and reward responsiveness (Carver and White, 1994). Whereas BIS is said to inhibit behavior
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towards positive stimuli and to be sensitive to aversive stimuli associated with feelings such as frustration and anxiety, BAS is said to activate behavior towards positive stimuli associated with feelings such as hope and happiness (Gray, 1990). People have been found to differ in their motivation to avoid negative (potential punishing) or attend to positive (potential rewarding) stimuli (e.g., Carver and White, 1994; Derryberry and Reed, 1994; Heimpel et al., 2006). Moreover, it has been suggested that imbalances between BIS and BAS underlie affective vulnerability to psychopathological symptoms (Johnson et al., 2003; Becerra, 2010). In schizophrenia, BIS but not BAS was found to be positively associated with overall negative symptoms (Scholten et al., 2006; Depp et al., 2011). With regard to anhedonia, Gard et al. (2006, 2007) found BAS but not BIS to be positively associated with anticipatory but not consummatory pleasure in schizophrenia. Similarly, Germans and Kring (2000) found anticipatory as well as consummatory pleasure to be positively associated with BAS but not BIS in a healthy sample with varying levels of anhedonia. Thus, it seems that BIS may be linked to overall negative symptoms whereas BAS may be uniquely related to anhedonia, possibly to its anticipatory component. Furthermore, because evidence suggests that patients with negative symptoms have difficulties to initiate goal-directed behavior (Gold et al., 2008) and motivational deficits in schizophrenia reflect problems in the ability to translate positive experiences into action (Heerey and Gold, 2007), the association between negative symptoms and BAS may be mediated by pleasure anticipation. The goal of the present study was to examine the association between subclinical negative symptoms, anticipatory/consummatory pleasure and BIS/BAS motivation as well as to test if there is an interaction effect of subclinical negative symptoms and anticipatory pleasure on trait approach motivation (BAS). We studied a sample of healthy participants with varying vulnerability to negative symptoms. This approach appears justified by the fact that subclinical negative symptoms have been used as low-level criterion in high-risk studies (Yung et al., 2003; Lencz et al., 2004; Piskulic et al., 2012) and by the continuity not only of negative symptoms in general (Blanchard et al., 1998; Piskulic et al., 2012) but also of associated anhedonia (Blanchard et al., 2011; Piskulic et al., 2012). We hypothesized that (1) anticipatory, but not consummatory pleasure will be negatively related to subclinical negative symptoms, (2) BAS will be uniquely positively related to anticipatory pleasure, whereas (3) BIS will be positively related to overall subclinical negative symptoms and, (4) the association between subclinical negative symptoms and BAS will be mediated by the ability to experience anticipatory pleasure. 2. Method 2.1. Participants and procedure The sample consisted of 171 healthy psychology students from the University of Hamburg who participated for partial fulfillment of a curriculum requirement. All participants were 18 years or older. Exclusion criteria for all participants were a present or past mental disorder as assessed with two questions (i.e. “Do you have had or have a mental health problem?” and “What kind of mental health problem do you have had or have?”) before the assessment started. After written informed consent was obtained, participants completed a questionnaire battery that was part of a larger project.
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the negative and depression dimensions of the CAPE were used. The 14 items assessing vulnerability for negative symptoms are based on instruments often used in clinical studies (Stefanis et al., 2002): the Schedule Assessing Negative Symptoms (SANS; Andreasen, 1989) and the Subjective Experience of Negative Symptoms (SENS; Selten et al., 1993). Participants were asked to report the frequency of their negative symptoms on four-point Likert scales from (1) never to (4) nearly always (e.g. “Do you ever feel that you are lacking in energy?” and “Do you ever feel that you have no interest to be with other people?”) with higher scores reflecting more vulnerability towards negative symptoms. The eight items that assessed vulnerability for depressive symptoms were used as control variables in the present study. Validation studies of the CAPE within large healthy samples have found high correlations between CAPE scores and schizotypy scales as well as observer-rated symptoms (Konings et al., 2006). Participants with schizophrenia obtained higher mean scores in the negative dimension of the CAPE than healthy controls (Hanssen et al., 2003; Moritz and Laroi, 2008). The internal consistency (Cronbach's alpha ¼0.89 for the negative subscale) and discriminative validity of the German version of the CAPE is good (Woodward et al., 2008). The ability to experience anticipatory and consummatory pleasure was assessed by the Temporal Experience of Pleasure Scale (TEPS; Gard et al., 2006). The TEPS is a self-report questionnaire that comprises 10 items measuring trait anticipatory pleasure (e.g. “I look forward to a lot of things in my life.”) and eight items measuring trait consummatory pleasure (e.g. “I enjoy taking a deep breath of fresh air when I walk outside.”). Scores of anticipatory pleasure reflect the amount of pleasure experienced in anticipation of a positive stimulus, whereas scores of consummatory pleasure reflect the amount of in-the-moment pleasure in response to a stimulus. The English version of the TEPS has good internal consistency (Cronbach's alpha 40.79; Gard et al., 2006) and test-retest reliability (r¼ 0.81, po0.001; Gard et al., 2006). For the purpose of this study the TEPS was translated and back translated into German by an English native speaker. In this study, the Cronbach's alpha was 0.69 for the anticipatory pleasure subscale, 0.68 for the consummatory pleasure subscale and 0.78 for the total scale. Item-total correlation testing and examination of the scree plot revealed a two-factor solution consistent with the two-factor model proposed by Gard et al. (2006). The BIS and BAS motivation was measured using the short form of the Action Regulating Emotion Systems Scale (ARES-K; Hartig and Moosbrugger, 2003). This questionnaire is based on Carver and White's (1994) self-rating instrument that assesses the general tendency to be motivated by positive or negative emotional outcomes. The ARES-K comprises 10 BIS items and 10 BAS items. Each item has four response options ranging from one (strongly agree) to four (strongly disagree). The BIS subscale assesses “anxiety” (e.g. “Criticism makes me experience fear and nervousness.”) and “frustration” (e.g. “I feel worried when I think I have done poorly at something.”) whereas the BAS subscale measures “drive” (e.g. “If I see a chance to get something, I feel energized.”) and “gratification” (e.g. “Achieving a desired goal makes me very happy.”). Higher BIS scores are associated with more anxiety and frustration, whereas higher BAS scores are associated with more positive affect and engagement in approach behavior. The ARES-K shows excellent psychometric properties and a factorial structure consistent with Gray's neurobiological model of BIS and BAS (Hartig and Moosbrugger, 2003).
2.3. Strategy of data-analysis Correlation coefficients (Pearson) and one-tailed tests of significance were computed to assess the strength of the associations between the CAPE negative symptom subscale, the TEPS and the ARES-K subscales. Furthermore, we computed partial correlations to test whether partialing out the CAPE depression subscale and gender in the correlations reduces them to non-significance. To test whether the association between subclinical negative symptoms and BAS is mediated by anticipatory pleasure, we conducted a hierarchical multiple regression analysis and the Sobel test (Preacher and Hayes, 2004). BAS was the dependent variable (DV), the CAPE negative symptom score was the independent variable (IV) and the TEPS anticipatory score was the mediator. In a first step, the IV must be significantly associated with the DV. In the second step, the IV must be significantly associated with the potential mediating variable. In the third step, the mediator must be significantly associated with the DV. The final step is to show that the strength of the association between the IV and the DV significantly decreases when the mediator is added to the model (Muller et al., 2005). All analyses were carried out using SPSS version 20.
3. Results 2.2. Measures
3.1. Sample characteristics Vulnerability for negative symptoms of schizophrenia was measured with the Community Assessment of Psychic Experiences (CAPE; Stefanis et al., 2002). The CAPE is a 42-item self-report instrument developed to rate lifetime psychotic experiences in the general population. It includes items assessing low-grade psychotic, negative and depressive symptom experiences. This 3-factor structure has been demonstrated by Stefanis et al. (2002). For the purpose of this study only
The mean age of the sample was 24.49 (S.D. ¼5.58) and 66% were female. The TEPS and ARES-K subscales were normally distributed. Kolmogorov–Smirnov tests showed only a slightly significant deviation from a normal distribution for the CAPE
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negative symptom scale (p 40.04). The mean CAPE score for the negative symptoms subscale was 1.76 (S.D. ¼ 0.38). The mean scores for the TEPS anticipatory and consummatory pleasure subscales were 4.45 (S.D. ¼0.65) and 4.74 (S.D. ¼0.66) respectively. In the ARES-K, participants mean scores were 2.45 (S.D. ¼0.65) for the BIS and 3.46 (S.D. ¼ 0.39) for the BAS subscale. 3.2. Test of hypotheses 1 thorough 3 All correlations are displayed in Table 1. In support of the hypothesis that anticipatory, but not consummatory pleasure will be negatively related to subclinical negative symptoms (hypothesis 1), we found that the TEPS-anticipatory (p¼0.01), but not the TEPSconsummatory subscale (p¼0.88) was significantly negatively correlated with the CAPE negative symptom subscale. In regard to hypothesis 2, stating that BAS will be uniquely positively related to anticipatory pleasure, we found the BAS subscale to be significantly and positively related to the TEPS-anticipatory (p¼0.00) as well as to the TEPS-consummatory subscale (p¼ 0.00). No significant correlation was found between the BIS subscale and the TEPS-anticipatory (p¼0.87) and TEPS-consummatory (p¼ 0.48) subscale. In support of the hypothesis that BIS will be positively related to overall subclinical negative symptoms (hypothesis 3) there was a significant positive relationship between the BIS subscale and the CAPE negative symptom subscale (p¼ 0.00). Furthermore, an exploratory data analysis indicated a significant negative relationship between the BAS subscale and the CAPE negative symptom subscale (p¼0.00).
Table 1 Correlations between the CAPE negative symptom subscale, TEPS and BIS/BAS subscales.
1. CAPE negative 2. TEPS-anticipatory 3. TEPS-consummatory 4. BIS 5. BAS
1
2
3
– –0.21nn –0.01 0.42nn –0.40nn
– 0.39nn –0.01 0.55nn
– –0.05 0.32nn
4
5
The CAPE depression subscale was significantly associated with the CAPE negative symptom subscale (r ¼0.71, p ¼0.00), the BIS (r ¼0.53, p ¼0.00) and the BAS subscale (r ¼ 0.31, p¼ 0.00), and the TEPS anticipatory subscale (r ¼ 0.15, p ¼0.00). It was not associated with the TEPS consummatory subscale (r¼0.05, p¼0.51). When the CAPE depression subscale was partialed out of the correlations between the CAPE negative symptom subscale, the TEPSanticipatory and the ARES-K subscales, we found the CAPE negative symptom subscale to remain significantly and negatively associated with the TEPS-anticipatory subscale (r¼ 0.163, p¼0.05) and the BAS subscale (r¼ 0.27, p¼0.00). The correlation between the CAPE negative symptom subscale and the BIS subscale (r¼ 0.06, p¼0.43) however, was reduced to non-significance. We found no significant effect of gender on any of the correlations. 3.4. Mediating effect of anticipatory pleasure As can be seen in Table 2, the preconditions of the multiple regression analyses were fulfilled: the CAPE negative symptom score (IV) was significantly associated with the BAS score (DV) and with the TEPS anticipatory score (mediator), and the TEPS anticipatory score was significantly associated with the BAS score. In the multiple regression of the CAPE negative symptom score and the TEPS anticipatory score the direct effect of the CAPE negative symptom score on the BAS score was slightly reduced by entering the TEPS anticipatory score into the model. Furthermore, the Sobel test statistic was significant (Z¼ 2.61, p o0.01), supporting an indirect effect of subclinical negative symptoms on BAS via anticipatory pleasure. After including gender as a covariate in each equation, we found no effect of gender on the mediation effect. The mediation effect is depicted in Fig. 1. Mediator: TEPS-ant -0.25
– –0.25nn
0.29
–
Note: CAPE negative¼ Community Assessment of Psychic Experience, negative symptom subscale; TEPS¼ Temporal Experience of Pleasure Scale, anticipatory and consummatory pleasure subscale; BIS ¼ Behavioral Inhibition Scale; and BAS¼ Behavioral Activation Scale. nn
3.3. Additional analyses
p o0.01.
IV: CAPE negative
DV: BAS
-0.29 (-0.22)
Fig. 1. BAS partially mediates the relationship between the CAPE negative symptom subscale and the TEPS anticipatory pleasure subscale.
Table 2 Regression models to test the mediating hypothesis. Predictor Step 1 CAPE negative Step 2 CAPE negative Step 3 TEPS-ant Step 4 CAPE negative TEPS-ant
B
SE
βa
t
Criterion 2
–0.40 –0.21 0.55 –0.30 0.48
0.05 0.09 0.04 0.05 0.04
–0.29 –0.25 0.33 –0.22 0.29
–4.93nn –2.76n 8.52nn –4.86nn 7.80nn
R ¼ 0.16, F(1,170)¼ 32.44
nn
BAS R2 ¼ 0.04, F(1,170)¼ 7.63n TEPS-ant R2 ¼ 0.30, F(1,170)¼71.47nn BAS R2 ¼ 0.38, F(1,170)¼52.34nn BAS BAS
Note: BAS¼ Behavioral Activation Scale; CAPE negative ¼ Community Assessment of Psychic Experiences, negative symptom subscale; and TEPS-ant¼ Temporal Experience of Pleasure, anticipatory subscale. a n
We report standard β coefficients (ranging between 0 and 1) for better representation of the strength of the relationship between variables. po 0.05. p o0.01.
nn
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4. Discussion This study examined possible associations between vulnerability for negative symptoms, anticipatory pleasure and motivational tendencies. The mean TEPS and BIS/BAS scores were similar to those found in other studies within healthy populations (Hartig and Moosbrugger, 2003; Gard et al., 2006). The mean CAPE score for the negative symptoms subscale was at the higher end and comparable with previous published mean scores for non-clinical samples (Konings et al., 2006; Moritz and Laroi, 2008). Moreover, the distribution of the present CAPE negative data overlapped with the distribution of CAPE negative mean scores found for schizophrenia samples (Moritz and Laroi, 2008). The finding that anticipatory pleasure, but not consummatory pleasure was significantly negatively correlated with subclinical negative symptoms corroborates previous research demonstrating a selfreported anticipatory (but not consummatory) deficit in schizophrenia (Gard et al., 2007; Chan et al., 2010; Favrod et al., 2010). Thus, even healthy individuals who are prone to negative symptoms report a diminished ability to anticipate pleasure. Future longitudinal studies may clarify whether difficulties in anticipating emotions can be conceptualized as a vulnerability factor for negative symptoms of schizophrenia. However, the construct of anticipatory pleasure has recently been questioned by Strauss and Gold (2012) who pointed out that anticipatory pleasure might be more adequately characterized as set of appraisals of past events or beliefs related to the future than as a trait-like diminished ability to anticipate pleasure. They also suggest that anhedonia reflects, at least in part, elevated negative emotions. Further work is needed therefore to determine whether the TEPS measures anticipatory pleasure, a reduced capacity to remember pleasurable events, negative beliefs concerning the future or elevated negative affect. Also, given the fact that the BIS scale particularly taps into negative feelings, it might be still difficult to distinguish low pleasure beliefs resulting from negative experiences from behavioral inhibition. Furthermore, and consistent with the findings of Gard et al. (2006, 2007), we found that anticipatory pleasure and trait approach motivation (BAS) were related in our sample. However, BAS was also significantly and positively correlated with consummatory pleasure. This was not predicted but is in line with the research on anhedonia in healthy participants (Germans and Kring, 2000). In a recent study, Buck and Lysaker (2013) examined the stability of anticipatory and consummatory pleasure in schizophrenia over a 6-month interval. They found consummatory pleasure to be less stable than anticipatory pleasure, which implies consummatory pleasure to be a state, rather than a trait characteristic in schizophrenia. Our finding that consummatory pleasure was significantly positively associated with BAS, which was not evident in studies with schizophrenia patients (Gard et al., 2006, 2007), might implicate a distinct association between the trait BAS and the state of consummatory pleasure. It can be speculated that consummatory pleasure as a state characteristic is more closely related to BAS in healthy individuals than in patients with schizophrenia. Thus, future studies and longitudinal designs are needed to explore these questions. Consistent with our hypothesis, there was a significant positive relationship between BIS and the CAPE negative symptom subscale, indicating that participants with more vulnerability to negative symptoms reported an increased tendency to avoid negative consequences. This is in line with the previous research that found avoidance to be related to negative symptoms using similar instruments (Scholten et al., 2006; Depp et al., 2011). However, when we controlled for CAPE depression symptoms, the positive association between BIS and the vulnerability to negative symptoms was reduced to nonsignificant. This could be due to a strong overlap between negative and depressive symptoms as
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suggested in earlier research (Müller, 2002; Häfner et al., 2005). Possibly, the overlap between negative and depressive symptoms is attenuated within a subclinical sample as was used in this study. Although not hypothesized, we found that participants who were more vulnerable to negative symptoms had lower BAS scores. This association remained significant even when the CAPE depression subscale was controlled for. The results of the present study do not allow us to draw conclusions about causality, but may offer assumptions regarding vulnerability for negative symptoms. The finding that anticipatory pleasure partially mediates motivational approach tendencies may indicate that tendencies to attend to positive stimuli and experience positive feelings (BAS) seem to be reduced in the presence of a diminished ability to anticipate pleasure. This would be in line with findings suggesting that motivational deficits in schizophrenia reflect difficulties in the ability to translate emotions into motivation (Heerey and Gold, 2007). Relatedly, Buck and Lysaker (2013) found that an anticipatory pleasure deficit predicted poorer interpersonal relationships. It therefore seems reasonable to assume that difficulties to anticipate pleasure that might emerge in social activities will result in diminished approach behavior (e.g., social withdrawal) possibly reflecting a mediation effect that is similar to the one we found. However, it needs noting that Buck and Lysaker (2013) did not find a significant correlation between an anticipatory pleasure deficit and negative symptoms. Some limitations of the present study need to be mentioned: one limitation is that the sample was restricted to a university population, which might have caused reduced variance of subclinical negative symptoms. Therefore, a replication in a community-based sample would be welcomed. In addition, anticipatory and consummatory pleasure was assessed with a German version of the TEPS. Although we translated and back translated it according to the guidelines for the adaptations of foreign language instruments (Schmitt and Eid, 2007), only the original English version has been validated so far. In combination with the fact that the constructs of anticipatory pleasure (pleasure experienced in anticipation of future events) and BAS (drive, fun seeking and reward responsiveness) are not easy to distinguish the precise formulations of the items is relevant and further validation of the TEPS is warranted. Furthermore, in the present study only selfreport measures were used to assess negative symptoms, pleasure and motivation. Subjective reporting may not be precise and it may be biased by social desirability. Future studies might include additional measures (interviews, experimental designs, and physiological measures) to investigate those constructs. Finally, to extend the scope of the conclusions, replication of the study in a sample of patients is needed. Clinical Implications: Negative symptoms are of immense relevance for social and occupational functioning and quality of life in patients with schizophrenia (Norman et al., 2000; Milev et al., 2005). Currently available medical and psycho-social interventions to reduce negative symptoms appear to have only modest impact (Stahl and Buckley, 2007; Turkington and Morrison, 2012). Therefore effective treatment is highly necessary. If reduced BAS motivation is related to an anticipatory pleasure deficit, one would not expect behavioral activation alone to be an effective way of treating negative symptoms. Rather, treatments for negative symptoms might need to focus on increasing patients' ability to anticipate positive feelings. Interventions targeting anticipatory pleasure (e.g., anticipatory pleasure skills training by Favrod et al. (2010)) could be employed to activate the approach motivational system in schizophrenia. In conclusion, there seems to be a close association between negative symptoms, the ability to anticipate pleasure and approach motivation that is evident even in healthy persons. This knowledge may be useful for deriving new psychological treatment approaches for negative symptoms.
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Role of funding sources Funding sources had no role in study design or in the collection, analysis and interpretation of data; or in the writing of this report.
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Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Anticipatory pleasure and approach motivation in schizophrenia-like negative symptoms Maike Engel n, Anja Fritzsche, Tania M. Lincoln University of Hamburg, Department of Clinical Psychology and Psychotherapy, Von-Melle-Park 5, 20146 Hamburg, Germany
art ic l e i nf o
a b s t r a c t
Article history: Received 26 December 2012 Received in revised form 7 May 2013 Accepted 12 July 2013
Previous research of negative symptoms in schizophrenia has emphasized an anticipatory pleasure deficit, yet the relationship of this deficit to patients' motivation in everyday life is poorly understood. This study tested the link between anticipatory pleasure and two broad motivational systems that are said to regulate the intensity of approach and avoidance behavior, the Behavioral Inhibition system (BIS) and the Behavioral Activation System (BAS). It was hypothesized that high vulnerability for negative symptoms would be associated with low reward responsiveness and that this association will be mediated by the amount of anticipated pleasure. Students (n ¼171) with varying vulnerability for negative symptoms (assessed by the Community Assessment of Psychic Experiences) completed questionnaires regarding (a) anticipatory and consummatory pleasure, and (b) responsiveness to threat and reward. As hypothesized, anticipatory pleasure correlated significantly negatively with subclinical negative symptoms (r¼ 0.21) and significantly positively with BAS (r¼ 0.55). Furthermore, evidence for a partial mediation effect was found. The findings support the notion of a close association between negative symptoms, the ability to anticipate pleasure and approach motivation that is evident even in healthy persons. It is suggested that the behavioral deficits immanent to negative symptoms reflect difficulties in the ability to translate emotions into motivation. & 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Subclinical negative symptoms Anticipatory pleasure Approach motivation
1. Introduction Anhedonia, defined as diminished ability to experience positive emotions (Germans and Kring, 2000) is central in patients with negative symptoms of schizophrenia (Horan et al., 2006; Mäkinen et al., 2008). It impairs patients' engagement in everyday activities and strongly affects quality of life (Rector et al., 2005; Mäkinen et al., 2008). According to Meehl (1962) anhedonia is a possible indicator of a genetic vulnerability to schizophrenia. In support of this assumption, anhedonia has been found to be elevated in unaffected relatives of patients with schizophrenia (Kendler et al., 1996; Laurent et al., 2000) and in healthy participants exhibiting clinical characteristics similar to those seen in individuals with schizophrenia spectrum disorders (Blanchard et al., 2011). Those findings imply a continuity of negative symptoms in the population and healthy individuals seem to vary in their vulnerability for anhedonia. Thus, studying anhedonia at a subclinical level may help to identify mechanisms that are involved in transition from a healthy state to negative symptoms.
n
Corresponding author. Tel.: +49 40 42838 9240. E-mail addresses: [email protected] (M. Engel), [email protected] (A. Fritzsche), [email protected] (T.M. Lincoln). 0165-1781/$ - see front matter & 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2013.07.025
One important aspect of anhedonia is the differentiation between its consummatory and anticipatory components (Klein, 1984; Gard et al., 2006). Consummatory pleasure is the ability to actually experience pleasure in response to a pleasurable stimulus in the moment it occurs, whereas anticipatory pleasure refers to the experience of pleasure while anticipating future events (Kring and Caponigro, 2010). Several studies based on self-report measures and experience sampling methods have shown that anticipatory (but not consummatory) deficits are associated with anhedonia in schizophrenia (Horan et al., 2006; Gard et al., 2007; Favrod et al., 2009; Chan et al., 2010). In those studies, patients with schizophrenia reported less anticipated pleasure than controls but comparable levels of positive emotion when they were actually experiencing pleasurable activities. Strauss and Gold (2012) concluded that anhedonia should no longer be defined as diminished capacity for pleasure, but rather reflects beliefs of low pleasure or elevated negative emotions. As in healthy persons, experience of emotion in schizophrenia is hypothesized to be closely linked to motivational systems (Kring and Caponigro, 2010). Based on Gray's (1970) neurobiological model there are two motivational systems that regulate the intensity of approach and avoidance behavior and are associated with specific emotions. The Behavioral Inhibition or Avoid System (BIS) is related to punishment avoidance and the Behavioral Activation or Approach System (BAS) is related to drive, fun seeking and reward responsiveness (Carver and White, 1994). Whereas BIS is said to inhibit behavior
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towards positive stimuli and to be sensitive to aversive stimuli associated with feelings such as frustration and anxiety, BAS is said to activate behavior towards positive stimuli associated with feelings such as hope and happiness (Gray, 1990). People have been found to differ in their motivation to avoid negative (potential punishing) or attend to positive (potential rewarding) stimuli (e.g., Carver and White, 1994; Derryberry and Reed, 1994; Heimpel et al., 2006). Moreover, it has been suggested that imbalances between BIS and BAS underlie affective vulnerability to psychopathological symptoms (Johnson et al., 2003; Becerra, 2010). In schizophrenia, BIS but not BAS was found to be positively associated with overall negative symptoms (Scholten et al., 2006; Depp et al., 2011). With regard to anhedonia, Gard et al. (2006, 2007) found BAS but not BIS to be positively associated with anticipatory but not consummatory pleasure in schizophrenia. Similarly, Germans and Kring (2000) found anticipatory as well as consummatory pleasure to be positively associated with BAS but not BIS in a healthy sample with varying levels of anhedonia. Thus, it seems that BIS may be linked to overall negative symptoms whereas BAS may be uniquely related to anhedonia, possibly to its anticipatory component. Furthermore, because evidence suggests that patients with negative symptoms have difficulties to initiate goal-directed behavior (Gold et al., 2008) and motivational deficits in schizophrenia reflect problems in the ability to translate positive experiences into action (Heerey and Gold, 2007), the association between negative symptoms and BAS may be mediated by pleasure anticipation. The goal of the present study was to examine the association between subclinical negative symptoms, anticipatory/consummatory pleasure and BIS/BAS motivation as well as to test if there is an interaction effect of subclinical negative symptoms and anticipatory pleasure on trait approach motivation (BAS). We studied a sample of healthy participants with varying vulnerability to negative symptoms. This approach appears justified by the fact that subclinical negative symptoms have been used as low-level criterion in high-risk studies (Yung et al., 2003; Lencz et al., 2004; Piskulic et al., 2012) and by the continuity not only of negative symptoms in general (Blanchard et al., 1998; Piskulic et al., 2012) but also of associated anhedonia (Blanchard et al., 2011; Piskulic et al., 2012). We hypothesized that (1) anticipatory, but not consummatory pleasure will be negatively related to subclinical negative symptoms, (2) BAS will be uniquely positively related to anticipatory pleasure, whereas (3) BIS will be positively related to overall subclinical negative symptoms and, (4) the association between subclinical negative symptoms and BAS will be mediated by the ability to experience anticipatory pleasure. 2. Method 2.1. Participants and procedure The sample consisted of 171 healthy psychology students from the University of Hamburg who participated for partial fulfillment of a curriculum requirement. All participants were 18 years or older. Exclusion criteria for all participants were a present or past mental disorder as assessed with two questions (i.e. “Do you have had or have a mental health problem?” and “What kind of mental health problem do you have had or have?”) before the assessment started. After written informed consent was obtained, participants completed a questionnaire battery that was part of a larger project.
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the negative and depression dimensions of the CAPE were used. The 14 items assessing vulnerability for negative symptoms are based on instruments often used in clinical studies (Stefanis et al., 2002): the Schedule Assessing Negative Symptoms (SANS; Andreasen, 1989) and the Subjective Experience of Negative Symptoms (SENS; Selten et al., 1993). Participants were asked to report the frequency of their negative symptoms on four-point Likert scales from (1) never to (4) nearly always (e.g. “Do you ever feel that you are lacking in energy?” and “Do you ever feel that you have no interest to be with other people?”) with higher scores reflecting more vulnerability towards negative symptoms. The eight items that assessed vulnerability for depressive symptoms were used as control variables in the present study. Validation studies of the CAPE within large healthy samples have found high correlations between CAPE scores and schizotypy scales as well as observer-rated symptoms (Konings et al., 2006). Participants with schizophrenia obtained higher mean scores in the negative dimension of the CAPE than healthy controls (Hanssen et al., 2003; Moritz and Laroi, 2008). The internal consistency (Cronbach's alpha ¼0.89 for the negative subscale) and discriminative validity of the German version of the CAPE is good (Woodward et al., 2008). The ability to experience anticipatory and consummatory pleasure was assessed by the Temporal Experience of Pleasure Scale (TEPS; Gard et al., 2006). The TEPS is a self-report questionnaire that comprises 10 items measuring trait anticipatory pleasure (e.g. “I look forward to a lot of things in my life.”) and eight items measuring trait consummatory pleasure (e.g. “I enjoy taking a deep breath of fresh air when I walk outside.”). Scores of anticipatory pleasure reflect the amount of pleasure experienced in anticipation of a positive stimulus, whereas scores of consummatory pleasure reflect the amount of in-the-moment pleasure in response to a stimulus. The English version of the TEPS has good internal consistency (Cronbach's alpha 40.79; Gard et al., 2006) and test-retest reliability (r¼ 0.81, po0.001; Gard et al., 2006). For the purpose of this study the TEPS was translated and back translated into German by an English native speaker. In this study, the Cronbach's alpha was 0.69 for the anticipatory pleasure subscale, 0.68 for the consummatory pleasure subscale and 0.78 for the total scale. Item-total correlation testing and examination of the scree plot revealed a two-factor solution consistent with the two-factor model proposed by Gard et al. (2006). The BIS and BAS motivation was measured using the short form of the Action Regulating Emotion Systems Scale (ARES-K; Hartig and Moosbrugger, 2003). This questionnaire is based on Carver and White's (1994) self-rating instrument that assesses the general tendency to be motivated by positive or negative emotional outcomes. The ARES-K comprises 10 BIS items and 10 BAS items. Each item has four response options ranging from one (strongly agree) to four (strongly disagree). The BIS subscale assesses “anxiety” (e.g. “Criticism makes me experience fear and nervousness.”) and “frustration” (e.g. “I feel worried when I think I have done poorly at something.”) whereas the BAS subscale measures “drive” (e.g. “If I see a chance to get something, I feel energized.”) and “gratification” (e.g. “Achieving a desired goal makes me very happy.”). Higher BIS scores are associated with more anxiety and frustration, whereas higher BAS scores are associated with more positive affect and engagement in approach behavior. The ARES-K shows excellent psychometric properties and a factorial structure consistent with Gray's neurobiological model of BIS and BAS (Hartig and Moosbrugger, 2003).
2.3. Strategy of data-analysis Correlation coefficients (Pearson) and one-tailed tests of significance were computed to assess the strength of the associations between the CAPE negative symptom subscale, the TEPS and the ARES-K subscales. Furthermore, we computed partial correlations to test whether partialing out the CAPE depression subscale and gender in the correlations reduces them to non-significance. To test whether the association between subclinical negative symptoms and BAS is mediated by anticipatory pleasure, we conducted a hierarchical multiple regression analysis and the Sobel test (Preacher and Hayes, 2004). BAS was the dependent variable (DV), the CAPE negative symptom score was the independent variable (IV) and the TEPS anticipatory score was the mediator. In a first step, the IV must be significantly associated with the DV. In the second step, the IV must be significantly associated with the potential mediating variable. In the third step, the mediator must be significantly associated with the DV. The final step is to show that the strength of the association between the IV and the DV significantly decreases when the mediator is added to the model (Muller et al., 2005). All analyses were carried out using SPSS version 20.
3. Results 2.2. Measures
3.1. Sample characteristics Vulnerability for negative symptoms of schizophrenia was measured with the Community Assessment of Psychic Experiences (CAPE; Stefanis et al., 2002). The CAPE is a 42-item self-report instrument developed to rate lifetime psychotic experiences in the general population. It includes items assessing low-grade psychotic, negative and depressive symptom experiences. This 3-factor structure has been demonstrated by Stefanis et al. (2002). For the purpose of this study only
The mean age of the sample was 24.49 (S.D. ¼5.58) and 66% were female. The TEPS and ARES-K subscales were normally distributed. Kolmogorov–Smirnov tests showed only a slightly significant deviation from a normal distribution for the CAPE
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negative symptom scale (p 40.04). The mean CAPE score for the negative symptoms subscale was 1.76 (S.D. ¼ 0.38). The mean scores for the TEPS anticipatory and consummatory pleasure subscales were 4.45 (S.D. ¼0.65) and 4.74 (S.D. ¼0.66) respectively. In the ARES-K, participants mean scores were 2.45 (S.D. ¼0.65) for the BIS and 3.46 (S.D. ¼ 0.39) for the BAS subscale. 3.2. Test of hypotheses 1 thorough 3 All correlations are displayed in Table 1. In support of the hypothesis that anticipatory, but not consummatory pleasure will be negatively related to subclinical negative symptoms (hypothesis 1), we found that the TEPS-anticipatory (p¼0.01), but not the TEPSconsummatory subscale (p¼0.88) was significantly negatively correlated with the CAPE negative symptom subscale. In regard to hypothesis 2, stating that BAS will be uniquely positively related to anticipatory pleasure, we found the BAS subscale to be significantly and positively related to the TEPS-anticipatory (p¼0.00) as well as to the TEPS-consummatory subscale (p¼ 0.00). No significant correlation was found between the BIS subscale and the TEPS-anticipatory (p¼0.87) and TEPS-consummatory (p¼ 0.48) subscale. In support of the hypothesis that BIS will be positively related to overall subclinical negative symptoms (hypothesis 3) there was a significant positive relationship between the BIS subscale and the CAPE negative symptom subscale (p¼ 0.00). Furthermore, an exploratory data analysis indicated a significant negative relationship between the BAS subscale and the CAPE negative symptom subscale (p¼0.00).
Table 1 Correlations between the CAPE negative symptom subscale, TEPS and BIS/BAS subscales.
1. CAPE negative 2. TEPS-anticipatory 3. TEPS-consummatory 4. BIS 5. BAS
1
2
3
– –0.21nn –0.01 0.42nn –0.40nn
– 0.39nn –0.01 0.55nn
– –0.05 0.32nn
4
5
The CAPE depression subscale was significantly associated with the CAPE negative symptom subscale (r ¼0.71, p ¼0.00), the BIS (r ¼0.53, p ¼0.00) and the BAS subscale (r ¼ 0.31, p¼ 0.00), and the TEPS anticipatory subscale (r ¼ 0.15, p ¼0.00). It was not associated with the TEPS consummatory subscale (r¼0.05, p¼0.51). When the CAPE depression subscale was partialed out of the correlations between the CAPE negative symptom subscale, the TEPSanticipatory and the ARES-K subscales, we found the CAPE negative symptom subscale to remain significantly and negatively associated with the TEPS-anticipatory subscale (r¼ 0.163, p¼0.05) and the BAS subscale (r¼ 0.27, p¼0.00). The correlation between the CAPE negative symptom subscale and the BIS subscale (r¼ 0.06, p¼0.43) however, was reduced to non-significance. We found no significant effect of gender on any of the correlations. 3.4. Mediating effect of anticipatory pleasure As can be seen in Table 2, the preconditions of the multiple regression analyses were fulfilled: the CAPE negative symptom score (IV) was significantly associated with the BAS score (DV) and with the TEPS anticipatory score (mediator), and the TEPS anticipatory score was significantly associated with the BAS score. In the multiple regression of the CAPE negative symptom score and the TEPS anticipatory score the direct effect of the CAPE negative symptom score on the BAS score was slightly reduced by entering the TEPS anticipatory score into the model. Furthermore, the Sobel test statistic was significant (Z¼ 2.61, p o0.01), supporting an indirect effect of subclinical negative symptoms on BAS via anticipatory pleasure. After including gender as a covariate in each equation, we found no effect of gender on the mediation effect. The mediation effect is depicted in Fig. 1. Mediator: TEPS-ant -0.25
– –0.25nn
0.29
–
Note: CAPE negative¼ Community Assessment of Psychic Experience, negative symptom subscale; TEPS¼ Temporal Experience of Pleasure Scale, anticipatory and consummatory pleasure subscale; BIS ¼ Behavioral Inhibition Scale; and BAS¼ Behavioral Activation Scale. nn
3.3. Additional analyses
p o0.01.
IV: CAPE negative
DV: BAS
-0.29 (-0.22)
Fig. 1. BAS partially mediates the relationship between the CAPE negative symptom subscale and the TEPS anticipatory pleasure subscale.
Table 2 Regression models to test the mediating hypothesis. Predictor Step 1 CAPE negative Step 2 CAPE negative Step 3 TEPS-ant Step 4 CAPE negative TEPS-ant
B
SE
βa
t
Criterion 2
–0.40 –0.21 0.55 –0.30 0.48
0.05 0.09 0.04 0.05 0.04
–0.29 –0.25 0.33 –0.22 0.29
–4.93nn –2.76n 8.52nn –4.86nn 7.80nn
R ¼ 0.16, F(1,170)¼ 32.44
nn
BAS R2 ¼ 0.04, F(1,170)¼ 7.63n TEPS-ant R2 ¼ 0.30, F(1,170)¼71.47nn BAS R2 ¼ 0.38, F(1,170)¼52.34nn BAS BAS
Note: BAS¼ Behavioral Activation Scale; CAPE negative ¼ Community Assessment of Psychic Experiences, negative symptom subscale; and TEPS-ant¼ Temporal Experience of Pleasure, anticipatory subscale. a n
We report standard β coefficients (ranging between 0 and 1) for better representation of the strength of the relationship between variables. po 0.05. p o0.01.
nn
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4. Discussion This study examined possible associations between vulnerability for negative symptoms, anticipatory pleasure and motivational tendencies. The mean TEPS and BIS/BAS scores were similar to those found in other studies within healthy populations (Hartig and Moosbrugger, 2003; Gard et al., 2006). The mean CAPE score for the negative symptoms subscale was at the higher end and comparable with previous published mean scores for non-clinical samples (Konings et al., 2006; Moritz and Laroi, 2008). Moreover, the distribution of the present CAPE negative data overlapped with the distribution of CAPE negative mean scores found for schizophrenia samples (Moritz and Laroi, 2008). The finding that anticipatory pleasure, but not consummatory pleasure was significantly negatively correlated with subclinical negative symptoms corroborates previous research demonstrating a selfreported anticipatory (but not consummatory) deficit in schizophrenia (Gard et al., 2007; Chan et al., 2010; Favrod et al., 2010). Thus, even healthy individuals who are prone to negative symptoms report a diminished ability to anticipate pleasure. Future longitudinal studies may clarify whether difficulties in anticipating emotions can be conceptualized as a vulnerability factor for negative symptoms of schizophrenia. However, the construct of anticipatory pleasure has recently been questioned by Strauss and Gold (2012) who pointed out that anticipatory pleasure might be more adequately characterized as set of appraisals of past events or beliefs related to the future than as a trait-like diminished ability to anticipate pleasure. They also suggest that anhedonia reflects, at least in part, elevated negative emotions. Further work is needed therefore to determine whether the TEPS measures anticipatory pleasure, a reduced capacity to remember pleasurable events, negative beliefs concerning the future or elevated negative affect. Also, given the fact that the BIS scale particularly taps into negative feelings, it might be still difficult to distinguish low pleasure beliefs resulting from negative experiences from behavioral inhibition. Furthermore, and consistent with the findings of Gard et al. (2006, 2007), we found that anticipatory pleasure and trait approach motivation (BAS) were related in our sample. However, BAS was also significantly and positively correlated with consummatory pleasure. This was not predicted but is in line with the research on anhedonia in healthy participants (Germans and Kring, 2000). In a recent study, Buck and Lysaker (2013) examined the stability of anticipatory and consummatory pleasure in schizophrenia over a 6-month interval. They found consummatory pleasure to be less stable than anticipatory pleasure, which implies consummatory pleasure to be a state, rather than a trait characteristic in schizophrenia. Our finding that consummatory pleasure was significantly positively associated with BAS, which was not evident in studies with schizophrenia patients (Gard et al., 2006, 2007), might implicate a distinct association between the trait BAS and the state of consummatory pleasure. It can be speculated that consummatory pleasure as a state characteristic is more closely related to BAS in healthy individuals than in patients with schizophrenia. Thus, future studies and longitudinal designs are needed to explore these questions. Consistent with our hypothesis, there was a significant positive relationship between BIS and the CAPE negative symptom subscale, indicating that participants with more vulnerability to negative symptoms reported an increased tendency to avoid negative consequences. This is in line with the previous research that found avoidance to be related to negative symptoms using similar instruments (Scholten et al., 2006; Depp et al., 2011). However, when we controlled for CAPE depression symptoms, the positive association between BIS and the vulnerability to negative symptoms was reduced to nonsignificant. This could be due to a strong overlap between negative and depressive symptoms as
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suggested in earlier research (Müller, 2002; Häfner et al., 2005). Possibly, the overlap between negative and depressive symptoms is attenuated within a subclinical sample as was used in this study. Although not hypothesized, we found that participants who were more vulnerable to negative symptoms had lower BAS scores. This association remained significant even when the CAPE depression subscale was controlled for. The results of the present study do not allow us to draw conclusions about causality, but may offer assumptions regarding vulnerability for negative symptoms. The finding that anticipatory pleasure partially mediates motivational approach tendencies may indicate that tendencies to attend to positive stimuli and experience positive feelings (BAS) seem to be reduced in the presence of a diminished ability to anticipate pleasure. This would be in line with findings suggesting that motivational deficits in schizophrenia reflect difficulties in the ability to translate emotions into motivation (Heerey and Gold, 2007). Relatedly, Buck and Lysaker (2013) found that an anticipatory pleasure deficit predicted poorer interpersonal relationships. It therefore seems reasonable to assume that difficulties to anticipate pleasure that might emerge in social activities will result in diminished approach behavior (e.g., social withdrawal) possibly reflecting a mediation effect that is similar to the one we found. However, it needs noting that Buck and Lysaker (2013) did not find a significant correlation between an anticipatory pleasure deficit and negative symptoms. Some limitations of the present study need to be mentioned: one limitation is that the sample was restricted to a university population, which might have caused reduced variance of subclinical negative symptoms. Therefore, a replication in a community-based sample would be welcomed. In addition, anticipatory and consummatory pleasure was assessed with a German version of the TEPS. Although we translated and back translated it according to the guidelines for the adaptations of foreign language instruments (Schmitt and Eid, 2007), only the original English version has been validated so far. In combination with the fact that the constructs of anticipatory pleasure (pleasure experienced in anticipation of future events) and BAS (drive, fun seeking and reward responsiveness) are not easy to distinguish the precise formulations of the items is relevant and further validation of the TEPS is warranted. Furthermore, in the present study only selfreport measures were used to assess negative symptoms, pleasure and motivation. Subjective reporting may not be precise and it may be biased by social desirability. Future studies might include additional measures (interviews, experimental designs, and physiological measures) to investigate those constructs. Finally, to extend the scope of the conclusions, replication of the study in a sample of patients is needed. Clinical Implications: Negative symptoms are of immense relevance for social and occupational functioning and quality of life in patients with schizophrenia (Norman et al., 2000; Milev et al., 2005). Currently available medical and psycho-social interventions to reduce negative symptoms appear to have only modest impact (Stahl and Buckley, 2007; Turkington and Morrison, 2012). Therefore effective treatment is highly necessary. If reduced BAS motivation is related to an anticipatory pleasure deficit, one would not expect behavioral activation alone to be an effective way of treating negative symptoms. Rather, treatments for negative symptoms might need to focus on increasing patients' ability to anticipate positive feelings. Interventions targeting anticipatory pleasure (e.g., anticipatory pleasure skills training by Favrod et al. (2010)) could be employed to activate the approach motivational system in schizophrenia. In conclusion, there seems to be a close association between negative symptoms, the ability to anticipate pleasure and approach motivation that is evident even in healthy persons. This knowledge may be useful for deriving new psychological treatment approaches for negative symptoms.
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Role of funding sources Funding sources had no role in study design or in the collection, analysis and interpretation of data; or in the writing of this report.
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