Approaching anger in schizophrenia: What an implicit task tells you that self-report does not

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Abstract

Motivational deficits are important determinants of impaired social functioning in schizophrenia, yet we know very little about their precise nature. One influential model of motivation distinguishes between approach and avoidance neurobiological systems that impact the tendency to approach rewarding and avoid threatening stimuli. The current study evaluated approach and avoidance motivational tendencies using both implicit and explicit measures. One-hundred and sixteen individuals with schizophrenia and 73 healthy controls completed the implicit Approach Avoidance Task (AAT) which provides a reaction time-based measure of approach and avoidance tendencies for happy and angry faces, and the Behavioral Inhibition/Behavioral Activation System Scale (BIS/BAS), a self-report measure of approach and avoidance tendencies. The patient sample was re-administered the AAT four weeks later to evaluate re-test reliability. At baseline, patients showed a significant tendency to approach (rather than avoid) angry faces on the AAT. This same pattern was replicated at the follow-up assessment. In contrast, on the BIS/BAS, patients reported significantly elevated BIS scores, reflecting increased avoidance of aversive, anxiety-inducing stimuli. Results suggest a discrepancy between patients' implicit behavioral tendency to approach angry faces and their self-reported avoidance of aversive stimuli.

Introduction

Schizophrenia is associated with diminished engagement in social activities and high levels of social disconnection. Although it is believed that these functional deficits stem largely from disturbances in motivation, our understanding of motivational impairments in schizophrenia is limited. A prominent model of motivation makes a basic distinction between approach and avoidance (Gray, 1987, Gable and Gosnell, 2013, Spielberg et al., 2013). According to this model, behavioral approach relies on a reward system that is sensitive to appetitive stimuli. Behavioral avoidance, in contrast, is sensitive to aversive stimuli and activated by anxiety, novelty, and innate fear stimuli.

A variety of methods have been used to examine approach and avoidance motivation in clinical samples, including both implicit and explicit measures. Implicit measures include reaction time measures of automatic associations that provide a different level of analysis and can show different patterns from those provided via self-report and other explicit methods (Wiers et al., 2007). One example of an implicit measure of social motivation tendency is the Approach Avoidance Task (AAT; Heuer et al., 2007), a well-established measure that uses reaction time to assess approach and avoidance biases. The AAT presents happy and angry faces in two different colors and participants are instructed to push a joystick for one of the colors and pull for the other color as quickly and accurately as possible. Thus, the expressions of the faces are not directly relevant to completing the task. A critical feature of the task is the “zooming” function: When participants push the joystick, the picture shrinks and appears to move away. When the joystick is pulled, the picture becomes larger and appears to move closer. A discrepancy between task instructions (push/pull) and automatic action tendencies of avoiding angry and approaching happy faces results in a slower reaction time.

In studies of healthy samples on the AAT, subjects often do not show implicit biases; they are able to respond to the task demands without interference from emotional quality of the faces, which are task-irrelevant. However, clinical populations often show implicit biases and significantly altered reaction times on the AAT that reflect an inability to ignore emotionally salient features of the stimuli. For example, people with social anxiety tend to show increased avoidance of pictures of faces and crowds (Heuer et al., 2007, Lange et al., 2008, Roelofs et al., 2010) and individuals with spider phobia show an elevated avoidance tendency to pictures of spiders (Rinck and Becker, 2007). Two relatively small studies have used the AAT in schizophrenia, and the results have been mixed. In one study, patients had generally slower reaction times than controls and there was no effect of emotion (Radke et al., 2015). The other study used happy and angry faces with two types of gaze: direct and averted. Patients and controls showed equivalent avoidance of angry faces and approach toward happy faces when the gaze was direct (de la Asuncion et al., 2015). However, patients showed enhanced avoidance of happy faces with averted gaze, compared to controls. In this context, it is noteworthy that studies examining how patients assess interpersonal space with respect to threatening and non-threatening social stimuli have also produced inconsistent findings (Deus and Jokic-Begic, 2006, Ponizovsky et al., 2013, Park et al., 2009). Thus, additional research using the AAT in schizophrenia is needed to clarify implicit motivational tendencies.

Explicit measures, on the other hand, include self-report questionnaires and interviews that directly ask patients about their emotional and social experiences. The Behavioral Inhibition/Behavioral Activation System Scale (BIS/BAS; Carver and White, 1994) is conceptually related to the AAT and assesses self-reported approach and avoidance tendencies. On this scale, psychologically healthy people typically score in the middle range for both BIS and BAS sensitivities (Johnson et al., 2003, Mitchell and Nelson-Gray, 2006). However, extreme scores on either scale are associated with various forms of psychopathology. For example, depression is frequently associated with diminished BAS, mania is associated with elevated BAS, and anxiety disorders including social anxiety, obsessive-compulsive disorder, and generalized anxiety disorder are associated with elevated BIS (Kasch et al., 2002, Mitchell and Nelson-Gray, 2006, Bijttebier et al., 2009). In schizophrenia, a number of studies have consistently found that patients report elevated BIS scores, though no difference in BAS sensitivity (Horan et al., 2006, Scholten et al., 2006, Barch et al., 2008, Strauss et al., 2011). Further, higher BIS scores are associated with poorer clinical functioning (Reddy et al., 2014). Thus, in terms of self-reported motivation, schizophrenia is consistently associated with elevated avoidance tendencies. The clinical characteristics of schizophrenia tend to support this finding, and suggest that results on both explicit and implicit tasks, like the AAT, should reveal tendencies to avoid aversive or arousing stimuli.

The current study examined approach and avoidance motivation using both implicit and explicit measures. While our hypotheses for the explicit BIS/BAS are based on empirical literature, our hypotheses related to the implicit AAT measure are primarily theoretically guided because of the paucity of published studies. The study had three main goals. First, we compared a large sample of schizophrenia outpatients and healthy controls on a social AAT and the BIS/BAS. Previous findings of higher self-reported avoidance tendencies in schizophrenia versus controls led us to predict that patients would show higher BIS scores and an enhanced avoidance tendency for angry faces on the AAT. Second, because of the undeveloped literature on implicit and explicit motivation systems in schizophrenia, we examined whether AAT response tendencies and BIS/BAS scores were associated with clinical symptoms or neurocognitive deficits. Third, given the paucity of psychometric data on the AAT in schizophrenia, we evaluated the test-retest reliability in the patient sample.

Section snippets

Participants

The sample included 116 individuals with schizophrenia and 73 matched healthy controls. Patients were recruited from outpatient clinics at University of California, Los Angeles (UCLA), the Veterans Affairs Greater Los Angeles Healthcare System (GLA), and from local clinics and board and care facilities. Selection criteria for participants with schizophrenia included (1) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnosis of schizophrenia determined with the

Group comparisons on the primary AAT variables

As shown in Fig. 1, there was a main effect of group (F (1158) = 6.5, p = 0.01), a main effect of emotion (F (1158) = 19.8, p < 0.001), and a significant interaction (F (1158) = 3.8, p < 0.05) between group and emotion. Pairwise contrasts indicated that patients showed an approach bias toward angry faces, compared to controls (t (1158) = 3.2, p < 0.001) but there was no group difference for happy faces; controls showed neither approach nor avoidance bias toward either emotion.

Group comparisons on BIS/BAS variables

There were no group differences on

Discussion

This paper evaluated approach and avoidance motivational tendencies using both implicit and explicit measures in a large sample of outpatients with schizophrenia. Contrary to expectations, patients showed an implicit approach bias towards angry faces. Controls showed no bias for angry faces and neither patients nor controls showed an implicit response bias to happy faces. On the explicit measure, patients self-reported overall heightened avoidance tendencies. Thus, the patients demonstrated

Conflict of interest

The authors declare no conflicts of interest.

Role of funding source

This project was funded by a VA MERIT Award to WPH (5I01CX000593) . The funding source had no direct role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

Contributors

WPH and MG initiated and designed the study. LFR and MR analyzed the data. LFR and WPH wrote the first draft of the manuscript. MG, JW, and MR proof-read the manuscript and contributed to the discussion of the manuscript. LFR wrote the manuscript and submitted it with the approval of all co-authors.

Acknowledgements

We gratefully acknowledge all of the individuals who participated in the present study.

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