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The Relationships Among Cognition, Motivation, and Emotion in Schizophrenia:How Much and How Little We Know

Deanna M. Barch 1,2

2Washington University, Psychology Department, Box 1125,One Brookings Drive, St. Louis, MO 63130

This article summarizes a workshop discussion focused onthe current state of our understanding of the ways in whichcognitive dysfunction in schizophrenia is related to, inu-enced by, or even leads to disturbances in areas such as

emotion, motivation, and stress, as well as areas in needof further research. A major emphasis in the workshop dis-cussion was the critical importance of motivation and itspotential inuence on cognitive function and learning inschizophrenia. As such, the members of the workshop sug-gested a number of questions regarding motivation thatneed further research, including (1) the denition and mea-surement of different components of motivation; (2) the re-lationship between intrinsic motivation and incentive driveand hedonic processing; (3) the integrity of motivationalprocesses, incentive drive, and hedonic processing in schizo-phrenia; (4) the inuence of cognitive decits on motiva-tional disturbances in schizophrenia; (5) the inuence of antipsychotic medication on incentive drive and hedonicprocessing in schizophrenia; and (6) the relationshipsamong cognitive function, stress, and the processing of aversive stimuli.

Key words: Cognition/schizophrenia/emotion/motivation

Introduction

Thefocusof theMeasurement andTreatment Research toImprove Cognition in Schizophrenia (MATRICS; New

Approaches to Cognition Conference, Sept. 9-10, 2004,Maryland) process has been on understanding the natureand breadth of cognitive dysfunction in schizophrenia inorder to facilitate the development of treatments that willhopefully ameliorate this debilitating aspect of schizo-phrenia. In doing so, the work conducted as part of MATRICS has drawn from the large body of research

focused on understanding the neural bases of specific cog-nitive functions in both animal and human models, aswellasthe researchon thenatureandneurobiologyofcognitivedysfunction in individuals withschizophrenia. Thegoal of the workshop reported upon in this articlewas to begin todiscuss the ways in which cognitive dysfunction in schizo-phrenia is related to, influencedby,or even leads to distur-bances in areas such as emotion, motivation, and stress.Any individual who has worked extensively with people

who have schizophrenia knows that, although cognitivedysfunction is prominent, these individuals can also dis-play a host of emotional and motivational deficits. Thesedeficits can include blunted affect or inappropriate affect,lack of achievement motivation, social withdrawal, andreports of reduced ability to experience pleasure. His-torically, work on cognitive and emotional/affectivefunctioninschizophreniahastendedtoproceedinparallel,with researchers focused on either 1 domain or the other.However, more recent work has begun to explore thecritical interactions between emotion and cognition inschizophrenia, 16 work that helped to inform the contentand suggestions of the workshop members.

If one were to identify the strongest theme runningthrough the discussion in this workshop, it would bethe emphasis on the importance of understanding the in-tegrity of motivational processes in schizophrenia. One of the reasons for the emphasis is the possibility or concernthat some aspects of cognitive dysfunction in schizophre-nia might be secondary either to a general lack of moti-vation that spans all aspects of an individuals life or tomore specific motivational deficits associated with intrin-sic motivation to do well on abstract cognitive tasks. Inother words, studies of cognition function in healthy indi-viduals often rely on the assumption that people are mo-tivated in some way to do well on the cognitive task,either because of some intrinsic drive to do well or be-cause of the external reinforcement provided by praiseor even money. However, such assumptions may not nec-essarily hold true for individuals with schizophrenia, if the illness itself may impair either intrinsic motivationaldrives or responsivity to extrinsic reinforcers (a topic thatwill be returned to below). If so, then it could be that poorperformance on cognitive tasks reflects a lack of engage-ment or motivation to do well rather than an inherent

1To whom correspondence should be addressed; tel: 314-935-8729, fax: 314-935-8790, e-mail: [email protected].

Schizophrenia Bulletin vol. 31 no. 4 pp. 875881, 2005doi:10.1093/schbul/sbi040Advance Access publication on August 3, 2005

The Author 2005. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.For permissions, please email: [email protected].

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difficulty with the cognitive process tapped by the task.Consistent with this hypothesis, several studies haveshown that performance on cognitive tasks such as theWisconsin Card Sorting Task, the Span of Apprehension,and facial affect perception can be improved via the useof monetary incentives. 79 However, numerous otherstudies have not shown that monetary reinforcement sig-nificantly improves cognitive task performance amongpatients with schizophrenia, 1012 and even those studiesshowing improvements due to monetary reinforcementdo not necessarily show a complete amelioration of cog-nitive dysfunction. Thus, the role that motivation playsin impaired cognitive task performance in schizophreniais still unclear. Further, even if additional researchshould unequivocally demonstrate that some propor-tion of cognitive impairment in schizophrenia is dueto motivational factors, we would need to understandhow this might interact with the influence of cognitionon social and occupational function in this illness. It is

intuitively easy to understand how a lack of motiva-tion could lead to poor performance on experimentalcognitive tasks in a laboratory setting that may have noinherent salience or relationship to life function. How-ever, it is somewhat less intuitive to explain how moti-vational issues could influence a relationship betweencognitive function and social/occupational function.One possibility is that motivational deficits are a thirdvariable factor that leads to a spurious relationship be-tween cognitive and life function, without there beinga direct causal relationship between the 2. In otherwords, motivational deficits among individuals withschizophrenia may lead to poor performance on cogni-tive tasks in the laboratory and to a failure to engage inor perform life functions necessary to live and work in-dependently.

A second reason for the emphasis on understandingmotivation among the workshop members is the waythat learning may be influenced by motivation or rein-forcement in schizophrenia. Individuals presumablylearn from errors made either during cognitive task per-formance or in real-life situations because of intrinsicmotivations to do well or because they are motivatedto obtain some more concrete reinforcer contingentupon successful performance. As such, motivational def-icits could lead individuals with schizophrenia to respondto errors differently or to fail to learn from feedback,problems that could lead to significant impairment inboth the laboratory and real-life function. 13 In fact, thereis research to suggest that individuals with schizophreniashow impaired behavioral (e.g., post-error or conflict-slowing) or neurophysiological responses to errors, 1422

though there are also a number of other studies suggest-ing intact error processing in schizophrenia. 17, 20 Again,more work is clearly needed to understand the influenceof motivational factors on learning in schizophrenia,both in the laboratory and in real-life settings.

Basic Research on Motivation

In order to better understand motivational function inschizophrenia, the workshop members identified a num-ber of unanswered questions that need to be addressedand areas in which further research is needed. A first major question is how to define what we mean by motiva-

tion and how to distinguish it from other relatedconstructs such as effort. There is a long history of re-search on various aspects of motivation in both psychol-ogy and behavioral neuroscience, emphasizing theimportance of motivational factors as a source of vari-ability in behavior, as a reason why behavior can appearflexible and adaptable in different situations, and as a rea-son why putatively species-specific behavior can be mod-ified. Much of the research on motivation in thebehavioral neuroscience literature has focused on theconcept of homeostatic drives or the idea that organismsmay be driven to maintain a stable internal state in regard

to variables such as thirst, hunger, or other injectivebehaviors (for a review, see 23 ). This view of motivationfocuses on the fact that a deficit or error signal in suchsystems (e.g., lack of water, hunger, low blood glucose,etc.) triggers behaviors designed to return the systemto a set point or stable state (though for a discussionof alternative settling point views, see 23 ). Related discus-sions of the construct of motivation also often involvediscussion of the properties of motivation. For example,it has been suggested that motivation involves both ap-petitive and consummatory phases, with the appetitivephase referring to the signal that indicates the potentialavailability of a desired stimulus as well as the meansor instrumental behaviors used to move toward the goal.

Conceptualizations of motivation that rely on homeo-static mechanisms have powerful explanatory force inmany domains. However, many researchers have arguedthat other types of mechanisms that do not rely on ex-plicit error signals are needed to explain the full rangeof motivated behaviors seen in animals and humans.Animals and humans may be motivated to seek stimulithat are reinforcing in some sense, even if these stimulido not necessarily serve to remediate some internal deficitstate. This view of motivation focuses on the appetitiveapproach or the incentive drive concepts of motivation. 23

In many ways, such views of motivation may be easier toapply to understanding motivation influences on cogni-tive function and social function than homeostatic views.Some of the drives that govern our daily behaviors relateto basic needs such as food and water. However, many of the domains in which we think that motivation is impor-tant are those that are much more abstract and removedfrom basic needs, such as achievement motivations, inter-personal needs, or desires.

The function of appetitive or incentive motivation sys-tems hasreceived much attention in theanimal behavioralliterature, and some aspects of the ways these systems

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work in animals have been relatively well worked out(though this is an active and evolving area of research).For example, work by Schultz and Berridge as well asothers has highlighted the important role that the dopa-mine system plays in approach-related behaviors. 2324

Schultzs work has demonstrated that the dopamine sys-tem is involved in predicting rewards associated with up-coming stimuli. More specifically, Schultzs work hasshown that dopamine bursts from unpredicted rewardshelp the system learn about temporally preceding cuesthat maypredict those rewards, particularly if appropriateactions are taken in response to the cues. Over time, thedopamine response occurs at the earliest predictive cue,instead of at the reward itself. Further, animals exhibita phasic depression in the dopamine response when a pre-dicted reward does not occur, which can serve as an indi-cator that inappropriate actions have been taken or thereward contingencies have changed. Such results are con-sistent with computational theories of reinforcement

learning that postulate that organisms modulate their be-haviorin response toerrorsof rewardprediction that serveas learning or teaching cues. 2526

On a related note, Berridge has suggested that the do-pamine system is specifically involved in wanting (work-ing toward desirable goals) as compared to liking(hedonic responses to obtained goals). 23 Thus, in Ber-ridges framework, deficits in dopamine function mightlead to disturbance in incentive drives or approach be-havior that would lead to the obtainment of a rewardingstimulus, even if the hedonic response to that stimulus isintact. Further, the work on incentive motivation pro-vides a way to understand how motivating propertiescan be transferred from primary reinforcers such asfood and water to more abstract reinforcers that predictthese primary motivators. Specifically, this work suggeststhat in addition to an association being learned betweenthe cue and a reinforcer, a motivational transformationoccurs in which the predictive cue (the conditioned stim-ulus) takes on at least some of the motivation propertiesof the unconditioned stimulus. 2729 The critical role of dopamine in incentive motivation is particularly relevantto understanding motivation deficits in schizophrenia,given long-standing hypotheses regarding the role of do-paminergic disturbances in the pathophysiology of schizophrenia.

Despite the wealth of research on animals, there areseveral areas in which much more basic work is neededto understand how these systems operate even in healthyhumans, let alone how they may be impaired among indi-viduals with schizophrenia. First, much of the work inanimals has used stimuli that are primary reinforcers,such as food, water, and juice. Recent work suggeststhat these systems may operate similarly in humansresponding to the same types of reinforcers or evenmore abstract monetary reinforcers. 3033 However, theways in which systems that have developed to predict pri-

mary reinforcers become adapted to predict or modulatebehaviors related to secondary reinforcers in humans isnot yet clear. As described above, incentive motivationtheories provide mechanisms by which a predictive cuecan take on the motivation properties of an intrinsicallyrewarding stimulus. However, it is not clear over whattemporal distance such associative chains can work. Infact, it is not at all clear whether the same systems thatrespond to the prediction of reward in terms of primaryreinforcers, or even money, play a role in governing in-centive motivation in humans related to very abstractgoals such as achievement, safety, or interpersonal relat-edness. Further, very little is known about the neural orpsychological mechanisms that give rise to what is oftenreferred to as intrinsic motivation, defined here as thepositive feelings associated with an activity or action inthe absence of any tangible reward, or actions that aretaken for their own sake that do not require external sup-ports or reinforcements to be initiated or sustained. 34 In

addition, relatively little is known about the role that thisincentive system may play in learning-related behaviorson the types of cognitive tasks studied in the laboratoryor in learning related behaviors necessary for successfulsocial, occupational, and educational function. Many of these questions are being actively pursued in the basic sci-ence literature on motivation and approach/withdrawalbehavior. Nonetheless, these questions 35 are highlightedhere to emphasize that an understanding of the basicmechanisms will help us to understand how these mech-anisms may go awry in disorders such as schizophrenia.

It is also important to note that there is a very rich basicbehavioral science literature on motivation that also hasmuch to offer in our attempts to understand the interre-lationship between motivation and cognitive function inschizophrenia. 3640 This work comes out of a differenttradition than the animal studies on motivation, andsome theories are less clearly tied to specific neural sys-tems. However, the work coming from this tradition islikely to be highly informative regarding the ways inwhich expectations about outcomes influence the choicesand decisions that individuals with schizophrenia makeregarding potentially affectively laden outcomes, aswell as the types of individual difference variables thatmay be important to consider in understanding motiva-tional function in schizophrenia.

Motivation in Schizophrenia

Even if we fully understand the neural and psychologicalmechanisms that support all types of motivational andincentive drives in healthy humans, the workshop mem-bers suggested that much remains to be learned aboutthe function of these systems in individuals who haveschizophrenia. At the most basic level, much morework is needed on responses to reward and punishment

Relationships Among Cognition, Motivation, and Emotion in Schizophrenia

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in schizophrenia, in both behavioral and neurophysiolog-ical terms. As noted above, many theories postulate a rolefor dopamine either in mediating responses to rewardsthemselves or in learning to predict rewards or learnfrom error feedback. If some aspect of the dopamine sys-tem is dysfunctional in schizophrenia, then there is goodreason to believe that responses to rewards and/or errorfeedback are disturbed in this illness. As alluded to above,there are data to suggest abnormal responses to errors inschizophrenia, both behaviorally and neurophysiologi-cally. However, the source of such deficits is not clear;nor are many aspects of basic reward or appetitive driveprocessing in schizophrenia. Many different types of ab-normalities could influence such deficits in reward or er-ror processing, and different mechanisms may point todifferent directions for treatment. For example, it isnot clear whether individuals with schizophrenia have in-tact responses to basic or primary reinforcers such asfood, water, or smells, in terms of either behavior or brain

function. Anhedonia, or the inability to experience plea-sure, has long been considered a key symptom of schizo-phrenia. 41 One might think of anhedonia as evidence fora reduced response to rewarding or pleasurable stimuli.However, the assessment of anhedonia symptoms is oftendone based on clinical interview or responses to question-naires, which may or may not reflect how individuals re-spond when presented with specific stimuli. Many studieshave examined self-reports of either valence or arousal tostimuli such as words, pictures, films, or faces, many of which suggest relatively intact pleasure responses. 4246

Fewer studies have examined responses to stimuli thatmight be more analogous to primary reinforcers (e.g.,smells, sucrose), and these studies have evidence forboth impaired 47 and intact responses. 48 Further, mostof these studies have relied just on self-reports of respond-ing, and more research is needed that examines other re-sponse channels, such as functional brain activation orperipheral physiology.

Second, it is not clear whether responses to secondaryreinforcers than can also serve to predict primary rewards(i.e., money) are intact in schizophrenia. As with a num-ber of other areas, there is conflicting evidence in thisregard, with at least 1 study suggesting intact responsesto monetary rewards and punishment in a gamblingtask 49 and another showing impaired performance. 50Again, should further research indicate a reliability def-icit in responding to monetary rewards, numerous differ-ent factors could lead to such a deficit, including (1)deficits in the link between monetary reinforcers andmore primary reinforcers, (2) deficits in detecting the oc-currence of reward in relationship to the behavioral pre-dictors, and (3) deficits in the ability to use previousexperiences to guide future responding. At an evenmore complicated level, we know almost nothing abouteven more abstract aspects of motivation in schizophre-nia, such as the development of intrinsic motivation.

Measurement Issues

In addition to work focused on understanding the basicmechanisms of motivation, reward processing, and incen-tive drives, in both healthy individuals and individualswith schizophrenia, the workshop members felt thatmore work is also needed on measurement issues. If mo-

tivational factors have a critical influence on cognition inschizophrenia, then it would be important to have reli-able, valid, and practical measures of motivation. Onecan measure motivation behaviorally, in the sense of ex-amining when an organism works toward some puta-tively desirable goals (i.e., lever pushing in rats, speedof responding in humans). However, such an approachto measuring motivation could be time consuming andpotentially confounded by cognitive deficits themselves.There are questionnaire-based approaches available formeasuring constructs such as (1) behavioral activationand behavioral inhibition, which assess individual differ-ences in reactivity to reward and threat cues; 51 (2) promo-tion (drive toward obtaining positive outcomes andavoiding the absence of such positive outcomes) and pre-vention (drive toward avoiding negative outcomes); 52

and (3) intrinsic versus extrinsic motivation, such asthe Motivational Trait Questionnaire. 53 However, weneed more information on the ability of these measuresto predict behavioral outcomes of interest in schizophre-nia, and their validity in individuals with schizophreniaremains to be demonstrated. A subpoint to this focuson measurement issues is the suggestion that we needto develop or use what was termed more ecologicallyvalid tests of cognition. More specifically, the tasks

that we use in the laboratory tend to be very cold tasksthat use stimuli that have no particular personal saliencefor the individual or motivational relevance. We may in-crease our ability to predict life function from cognitiveperformance by creating tasks that use stimuli that moreclearly tap into the kinds of salient information that peo-ple have to manipulate in their everyday lives. There isa growing body of work on the use of such tasks inthe social cognitive neuroscience literature, 5456 andschizophrenia researchers may wish to adapt such para-digms for work in clinical populations.

Cognitive Inuences on Motivation

The workshop members also suggested that it is impor-tant to examine the possibility of a different type of re-lationship between cognition and motivation, namely,the possibility that cognitive deficits in schizophreniacould be contributing to motivational deficits in schizo-phrenia, as well as or instead of motivational deficitsleading to the appearance of cognitive deficits. As an ex-ample, 1 important component in appetitive drives to-ward potentially rewarding stimuli could be the abilityto represent and/or maintain cognitive representations

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of either the stimuli themselves or the reward value of these stimuli. Tomarken and Keener 57 have put fortha similar argument in trying to explain the functionalimportance of frontal asymmetries in understandingvulnerability to depression. Numerous studies havedemonstrated that individuals with schizophrenia havedeficits in working memory or the ability to activelymaintain information over time. 58 In addition, manystudies have associated altered dorsolateral prefrontalcortex activity (a region important for the active mainte-nance of information) with working memory impair-ments in schizophrenia. 59,60 It is possible that deficitsin the ability to actively maintain information in workingmemory in schizophrenia, potentially related to alteredprefrontal function, may lead to deficits in ability torepresent goal- or reward-related information. If motiva-tion depends in part on the ability to actively representand maintain information about anticipated rewards,then deficits in the ability to maintain such representa-

tions could contribute to motivational or anticipatorypleasure deficits. Such a hypothesis is consistent with re-cent work on the neural systems supporting emotionalregulation. 59

Potential Medication Inuences

Another major theme in the discussion of this workshopis that more research is needed to understand the poten-tial negative effects that treatments for schizophreniamay have on motivation, incentive drive, and responsesto rewards. As noted above, many theories posit a centralrole for the dopamine system in these functions. All of themedications used as primary treatments for schizophre-nia have an influence on the dopamine system, with manyof them serving to block 1 or more dopamine-receptortypes. As such, it is possible that the medications usedto ameliorate some symptoms of schizophrenia may ac-tually be contributing to motivational disturbances orreductions in responses to pleasurable stimuli. It seemsunlikely that all components of reduced motivation oreven anhedonic symptoms in schizophrenia can be attrib-uted to medications, as the clinical literature containsreports of such symptoms in this illness long before med-ications were available to treat schizophrenia. 6061 None-theless, it may be that antipsychotic medications areexacerbating preexisting disturbances in motivation orother aspects of incentive drive or hedonic processing.

Stress and Other Aspects of Emotional Processing

The majority of this article has been focused on addi-tional research needed to understand the relationshipsamong motivation, incentive drives, and cognitive func-tion in schizophrenia. However, the workshop membersalso highlighted the need for further research on otherrelated domains, such as the relationship between stress

and cognitive function in schizophrenia, as well as otheraspects of emotional processing, such as the processing of aversive stimuli. In regard to stress, additional research isneeded to understand the degree to which responses toeither acute or chronic stressors are intact versus im-paired in schizophrenia, as the current literature providesmixed and somewhat sparse data. In addition, the work-shop members suggested that more research is needed todetermine the degree to which cognitive function inschizophrenia is modulated by stress, as assessed by ei-ther objective stress measurements or perceived or subjec-tive stress measurements. As with the discussion of motivation, it will also be important to determine theways in which cognitive deficits among individualswith schizophrenia may also alter responses to stress.

Summary

In summary, the results of this workshop discussion pro-

vide suggestions for several areas in need of further at-tention and research, in regard to both basic andclinical science. First, we suggested that more work isneeded to understand the psychological and neuralmechanisms that support motivation drives for goalsor stimuli that are not necessarily primary reinforcersand to understand the mechanisms that support intrinsicmotivational processes. Second, we suggested that muchmore work needs to be devoted to understanding thefunction of a range of incentive, motivation, and hedonicprocesses in schizophrenia. Third, we suggested that ad-ditional attention is needed to measurement issues, sothat we can utilize tools that will allow for reliable, valid,and practical assessments of motivation as well as eco-logically valid assessments of cognitive function. Fourth,we suggested that more research is needed on the ways inwhich pharmacological treatments for schizophreniamay be interacting with or even contributing to deficitsin motivation or other aspects of incentive or hedonicprocessing. Last, we suggested that similar research isneeded to understand the potential influences of relatedconstructs such as stress or the processing of aversivestimuli.

Acknowledgments

I would like to thank the co-leader of this workshop,Bruce Cuthbert, and the reporter, Sharon Engle, as wellas the other participants, whose wisdom, knowledge,and advice were invaluable: Steve Taylor, KevinOchsner, Liz Phelps, David Penn, Kim Vanover, DannyMathalon, and Steve Silverstein.

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