Mindfulness in schizophrenia: Associations with self-reported motivation, emotion regulation, dysfunctional attitudes, and negative symptoms
Introduction
Based on consensus definition, mindfulness is a metacognitive process with two components: (1) the self-regulation of attention, which involves sustained attention, attention switching, and the inhibition of elaborative processing with (2) an orientation of curiosity, openness, and acceptance towards all aspects of the immediate experience, including thoughts, feelings, and sensations (Bishop et al., 2004). Though specific definitions vary, it is clear that mindfulness is a multifaceted construct that is strongly linked to improved self-regulation through its effects on attentional control, emotion regulation, and self-awareness (Tang et al., 2015).
Scientific interest in mindfulness has steadily increased over the past 30 years, and there has been a surge of published studies since 2011 (over 200 per year). In clinical psychology, mindfulness-based interventions have been developed to treat a wide variety of mental health concerns, from chronic recurrent depression (Segal et al., 2002) to substance use disorders (Bowen et al., 2010) and borderline personality disorder (Linehan, 1993).
Mindfulness-based interventions are also being applied to schizophrenia research. Historically, there was some hesitation about incorporating meditation into treatments for schizophrenia based on a handful of case reports that linked intensive meditation practice with psychosis and mania (e.g., Walsh and Roche, 1979, Yorston, 2001). However, the type of secular meditation that is practiced in mindfulness-based psychotherapy is typically brief (15–45 min) and encourages direct applications of the mindfulness cultivated in meditation to daily life. This style of meditation is very different from the meditation practiced in intensive, religious retreats that are typically offered in remote locations and may also involve fasting and sleep deprivation. In schizophrenia research, some additional modifications to mindfulness-based interventions have been suggested, such as limiting meditation to 10 min, starting sessions with a brief body scan to help ground patients, and offering frequent guidance to limit prolonged periods of silence (Chadwick et al., 2005).
Early clinical trials suggest that mindfulness-based approaches can reduce rehospitalization rates (Bach and Hayes, 2002), improve aspects of neurocognition (Tabak and Granholm, 2014), and enhance clinical improvement (Chadwick et al., 2009, Shawyer et al., 2012, Gaudiano and Herbert, 2006, Davis and Kurzban, 2012) in individuals with schizophrenia. In early psychosis, mindfulness training has also led to improved emotion regulation, anxiety, and depression (Khoury et al., 2013a, Samson and Mallindine, 2014). Interestingly, a handful of studies have now documented that mindfulness-based treatments may improve negative symptoms in schizophrenia (Johnson et al., 2011, Shawyer et al., 2012, White et al., 2011). In fact, an initial meta-analysis concluded that, while mindfulness interventions are moderately effective in improving several aspects of psychotic disorders, the effects on negative symptoms are higher than for positive symptoms (Khoury et al., 2013b). These preliminary results are encouraging, as we still do not have effective treatments for persistent and debilitating negative symptoms, such as avolition, anhedonia, and blunted affect.
While mindfulness is increasingly being applied to schizophrenia, basic behavioral research on mindfulness in this disorder is lacking. For example, it is notable that no studies to our knowledge have compared schizophrenia patients with healthy controls on self-reported mindfulness. In addition, no research has examined the correlates of mindfulness in patients with schizophrenia.
This initial study of mindfulness in schizophrenia had three primary objectives: First, we sought to compare levels of self-reported mindfulness in patients with schizophrenia and healthy controls. Because the core mechanisms of mindfulness (attention, emotion regulation, and self-awareness; Tang et al., 2015) are known to be impaired in schizophrenia, we hypothesized that patients would report lower mindfulness than controls. Second, we examined correlations between mindfulness and two interview-based assessments of negative symptoms in patients. The mindfulness-based treatment effects noted above led us to hypothesize that higher mindfulness would correlate with lower negative symptoms. Third, we assessed relationships between mindfulness and key variables linked to negative symptoms and adaptive functioning in schizophrenia, including self-reported motivational tendencies (behavioral activation and behavioral inhibition), emotion regulation, and dysfunctional attitudes (Blanchard et al., 2011, Grant and Beck, 2009, Henry et al., 2007). We hypothesized that mindfulness would be associated with lower behavioral inhibition, greater behavioral activation, more adaptive emotion regulation (i.e., higher use of reappraisal and lower use of suppression) and less dysfunctional attitudes (including defeatist performance beliefs and need for approval) in patients. For comparison, we additionally examined these correlations in control participants. Finally, exploratory analyses examined correlations among mindfulness and other clinical characteristics in patients, including positive symptoms and neurocognition.
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Participants
Participants included 35 outpatients with schizophrenia and 25 healthy controls. Control participants were recruited through online advertisements. They were administered the Structured Clinical Interview for DSM-IV (SCID) Axis I Disorders (First et al., 1996) and portions of the SCID for Axis II Disorders (First et al., 1994). Controls were excluded if they had a history of schizophrenia, other psychotic disorder, bipolar disorder, recurrent major depressive disorder, substance dependence, or
Demographics
Patients and control participants did not differ on sex, age, race, ethnicity, or parental education (Table 1). There were group differences on personal education; schizophrenia patients had lower education levels compared to controls. In each group, mindfulness was unrelated to all demographic variables.
Group differences in mindfulness
We first conducted an independent samples t-test to compare groups on the FFMQ factor score; control participants endorsed significantly greater FFMQ factor scores compared to patients (Table 2
Discussion
In our study, schizophrenia patients endorsed lower levels of overall mindfulness (FFMQ factor score) than control participants. Group differences were significant for the facets of describing, acting with awareness, and nonjudging and the magnitudes of these effects were medium to large. Among patients, mindfulness showed essentially no relations to demographic or clinical characteristics. Regarding clinical characteristics, we did not find support for our hypothesis that greater mindfulness
Contributors
All authors contributed to the conceptualization of the study. Statistical analyses and writing of the first draft of the manuscript were performed by Dr. Tabak. All authors have approved the final manuscript.
Role of funding source
Funding for the current study was provided by a Veterans Affairs Merit grant (Dr. Horan) and NIMH grant MH095878 (Dr. Green). A postdoctoral fellowship for Dr. Tabak was supported by an NIMH training grant in Cognitive and Affective Dysfunctions in the Psychoses at the University of California, Los Angeles (T32MH09668).
Conflict of interest
Dr. Green reports consulting for AbbVie, DSP, Forum, Mnemosyne (scientific board), and Takeda. He has received research support from Amgen and Forum. The rest of the authors report no biomedical financial interests or potential conflicts of interest.
Acknowledgments
The authors wish to thank Ana Ceci Myers, Courtney Fazli, Julio Iglesias, Aaron McNair, and Aaron Waters for assistance in data collection.
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