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COMBS: Feeling positive about negative symptoms of schizophrenia
Negative symptoms of schizophrenia—such as social withdrawal, avolition, avoidance, lack of spontaneity, anhedonia, poverty of speech, and blunted affect—often persist after successful treatment of positive symptoms, such as hallucinations and delusions.1 Negative symptoms can be debilitating and are associated with poor social and occupational outcomes, as well as cognitive dysfunction. Currently, treatments for negative symptoms are not nearly as effective as treatments for positive symptoms. The mnemonic COMBS can be used to easily recall 3 treatment modalities often used to address negative symptoms.
COgnitive-behavioral therapy
Cognitive-behavioral therapy (CBT) and other psychosocial therapies derived from it, such as social skills training, recovery-oriented cognitive therapy, motivation and enhancement therapy, and cognitive-behavioral social skills training (CBSST), have shown to be effective for treating negative symptoms.2 In a study of 149 patients with schizophrenia, CBSST reduced symptoms of avolition and apathy and improved functioning outcomes.2
Medications
Antipsychotics. Although second-generation antipsychotics (SGAs) were initially promising, accumulating clinical experience and research have shown that these agents have limited efficacy for treating negative symptoms.1 Unlike first-generation antipsychotics, SGAs do not cause affective blunting, and are effective at treating depressive symptoms; however, depressive symptoms can sometimes be difficult to distinguish from negative symptoms. Improvement of depressive symptoms observed with SGA treatment could be mistakenly interpreted as alleviation of negative symptoms; however, clinical trials that focused specifically on treating negative symptoms have found no specific efficacy of SGAs.1
Antidepressants. Although clinical trials and meta-analyses have had mixed results,1 antidepressants appear to be safe add-on treatments with small efficacy for negative symptoms.
Anticonvulsants have long been used as augmentation to antipsychotics for patients with treatment-resistant schizophrenia; however, there is no evidence that these medications can improve negative symptoms.1
Stimulants. There is no strong evidence that stimulants could be an efficacious treatment for negative symptoms.1
Other pharmacologic agents,1 such as acetylcholine-related medications, oxytocin, and medications with a mechanism of action that is related to an inflammatory response and immunologic pathways (ie, minocycline), are being evaluated for treating negative symptoms. Research into the efficacy of glutamate-related agents also appears to be continuing.1
Continue to: Brain Stimulation therapies
Brain Stimulation therapies
Transcranial magnetic stimulation (TMS), transdirect current stimulation (tDCS), vagus nerve stimulation, and deep brain stimulation have been evaluated for treating negative symptoms. A recent meta-analysis of randomized controlled trials comparing the effects of brain stimulation with sham interventions in patients with schizophrenia found that TMS and tDCS that targeted the left dorsolateral prefrontal cortex effectively reduced the severity of negative symptoms.3
The Table1-3 summarizes available treatments for negative symptoms of schizophrenia and their efficacies. Although research investigating the improvement of negative symptoms is currently insufficient, CBT-related therapies and antidepressants appear to be helpful. For more information, see “Treating negative symptoms of schizophrenia” (C
1. Remington G, Foussias G, Fervaha G, et al. Treating negative symptoms in schizophrenia: an update. Curr Treat Options Psychiatry. 2016;3:133-150.
2. Granholm E, Holden J, Worley M. Improvement in negative symptoms and functioning in cognitive-behavioral social skills training for schizophrenia: mediation by defeatist performance attitudes and asocial beliefs. Schizophr Bull. 2018;44(3):653-661.
3. Kennedy NI, Lee WH. Efficacy of non-invasive brain stimulation on the symptom dimensions of schizophrenia: a meta-analysis of randomized controlled trials. Eur Psychiatry. 2018;49:69-77.
Negative symptoms of schizophrenia—such as social withdrawal, avolition, avoidance, lack of spontaneity, anhedonia, poverty of speech, and blunted affect—often persist after successful treatment of positive symptoms, such as hallucinations and delusions.1 Negative symptoms can be debilitating and are associated with poor social and occupational outcomes, as well as cognitive dysfunction. Currently, treatments for negative symptoms are not nearly as effective as treatments for positive symptoms. The mnemonic COMBS can be used to easily recall 3 treatment modalities often used to address negative symptoms.
COgnitive-behavioral therapy
Cognitive-behavioral therapy (CBT) and other psychosocial therapies derived from it, such as social skills training, recovery-oriented cognitive therapy, motivation and enhancement therapy, and cognitive-behavioral social skills training (CBSST), have shown to be effective for treating negative symptoms.2 In a study of 149 patients with schizophrenia, CBSST reduced symptoms of avolition and apathy and improved functioning outcomes.2
Medications
Antipsychotics. Although second-generation antipsychotics (SGAs) were initially promising, accumulating clinical experience and research have shown that these agents have limited efficacy for treating negative symptoms.1 Unlike first-generation antipsychotics, SGAs do not cause affective blunting, and are effective at treating depressive symptoms; however, depressive symptoms can sometimes be difficult to distinguish from negative symptoms. Improvement of depressive symptoms observed with SGA treatment could be mistakenly interpreted as alleviation of negative symptoms; however, clinical trials that focused specifically on treating negative symptoms have found no specific efficacy of SGAs.1
Antidepressants. Although clinical trials and meta-analyses have had mixed results,1 antidepressants appear to be safe add-on treatments with small efficacy for negative symptoms.
Anticonvulsants have long been used as augmentation to antipsychotics for patients with treatment-resistant schizophrenia; however, there is no evidence that these medications can improve negative symptoms.1
Stimulants. There is no strong evidence that stimulants could be an efficacious treatment for negative symptoms.1
Other pharmacologic agents,1 such as acetylcholine-related medications, oxytocin, and medications with a mechanism of action that is related to an inflammatory response and immunologic pathways (ie, minocycline), are being evaluated for treating negative symptoms. Research into the efficacy of glutamate-related agents also appears to be continuing.1
Continue to: Brain Stimulation therapies
Brain Stimulation therapies
Transcranial magnetic stimulation (TMS), transdirect current stimulation (tDCS), vagus nerve stimulation, and deep brain stimulation have been evaluated for treating negative symptoms. A recent meta-analysis of randomized controlled trials comparing the effects of brain stimulation with sham interventions in patients with schizophrenia found that TMS and tDCS that targeted the left dorsolateral prefrontal cortex effectively reduced the severity of negative symptoms.3
The Table1-3 summarizes available treatments for negative symptoms of schizophrenia and their efficacies. Although research investigating the improvement of negative symptoms is currently insufficient, CBT-related therapies and antidepressants appear to be helpful. For more information, see “Treating negative symptoms of schizophrenia” (C
Negative symptoms of schizophrenia—such as social withdrawal, avolition, avoidance, lack of spontaneity, anhedonia, poverty of speech, and blunted affect—often persist after successful treatment of positive symptoms, such as hallucinations and delusions.1 Negative symptoms can be debilitating and are associated with poor social and occupational outcomes, as well as cognitive dysfunction. Currently, treatments for negative symptoms are not nearly as effective as treatments for positive symptoms. The mnemonic COMBS can be used to easily recall 3 treatment modalities often used to address negative symptoms.
COgnitive-behavioral therapy
Cognitive-behavioral therapy (CBT) and other psychosocial therapies derived from it, such as social skills training, recovery-oriented cognitive therapy, motivation and enhancement therapy, and cognitive-behavioral social skills training (CBSST), have shown to be effective for treating negative symptoms.2 In a study of 149 patients with schizophrenia, CBSST reduced symptoms of avolition and apathy and improved functioning outcomes.2
Medications
Antipsychotics. Although second-generation antipsychotics (SGAs) were initially promising, accumulating clinical experience and research have shown that these agents have limited efficacy for treating negative symptoms.1 Unlike first-generation antipsychotics, SGAs do not cause affective blunting, and are effective at treating depressive symptoms; however, depressive symptoms can sometimes be difficult to distinguish from negative symptoms. Improvement of depressive symptoms observed with SGA treatment could be mistakenly interpreted as alleviation of negative symptoms; however, clinical trials that focused specifically on treating negative symptoms have found no specific efficacy of SGAs.1
Antidepressants. Although clinical trials and meta-analyses have had mixed results,1 antidepressants appear to be safe add-on treatments with small efficacy for negative symptoms.
Anticonvulsants have long been used as augmentation to antipsychotics for patients with treatment-resistant schizophrenia; however, there is no evidence that these medications can improve negative symptoms.1
Stimulants. There is no strong evidence that stimulants could be an efficacious treatment for negative symptoms.1
Other pharmacologic agents,1 such as acetylcholine-related medications, oxytocin, and medications with a mechanism of action that is related to an inflammatory response and immunologic pathways (ie, minocycline), are being evaluated for treating negative symptoms. Research into the efficacy of glutamate-related agents also appears to be continuing.1
Continue to: Brain Stimulation therapies
Brain Stimulation therapies
Transcranial magnetic stimulation (TMS), transdirect current stimulation (tDCS), vagus nerve stimulation, and deep brain stimulation have been evaluated for treating negative symptoms. A recent meta-analysis of randomized controlled trials comparing the effects of brain stimulation with sham interventions in patients with schizophrenia found that TMS and tDCS that targeted the left dorsolateral prefrontal cortex effectively reduced the severity of negative symptoms.3
The Table1-3 summarizes available treatments for negative symptoms of schizophrenia and their efficacies. Although research investigating the improvement of negative symptoms is currently insufficient, CBT-related therapies and antidepressants appear to be helpful. For more information, see “Treating negative symptoms of schizophrenia” (C
1. Remington G, Foussias G, Fervaha G, et al. Treating negative symptoms in schizophrenia: an update. Curr Treat Options Psychiatry. 2016;3:133-150.
2. Granholm E, Holden J, Worley M. Improvement in negative symptoms and functioning in cognitive-behavioral social skills training for schizophrenia: mediation by defeatist performance attitudes and asocial beliefs. Schizophr Bull. 2018;44(3):653-661.
3. Kennedy NI, Lee WH. Efficacy of non-invasive brain stimulation on the symptom dimensions of schizophrenia: a meta-analysis of randomized controlled trials. Eur Psychiatry. 2018;49:69-77.
1. Remington G, Foussias G, Fervaha G, et al. Treating negative symptoms in schizophrenia: an update. Curr Treat Options Psychiatry. 2016;3:133-150.
2. Granholm E, Holden J, Worley M. Improvement in negative symptoms and functioning in cognitive-behavioral social skills training for schizophrenia: mediation by defeatist performance attitudes and asocial beliefs. Schizophr Bull. 2018;44(3):653-661.
3. Kennedy NI, Lee WH. Efficacy of non-invasive brain stimulation on the symptom dimensions of schizophrenia: a meta-analysis of randomized controlled trials. Eur Psychiatry. 2018;49:69-77.
8 tests rolled into a mnemonic to detect weakness in suspected conversion disorder
DSM-5 criteria for conversion disorder (or functional neurological symptom disorder) requires findings that are incompatible with recognized neurologic or medical conditions.1 Knowledge of signs specific to conversion disorder may help you diagnose the illness with confidence.
We review signs suggestive of conversion disorder. These can be remembered using the mnemonic How About Finding Some Conversion Weakness [in an otherwise] Strong Guy/Gal? (Table2).
Inconsistencies in motor function can be observed on examination. Signs may be consciously or unconsciously produced. Although most of the tests mentioned have high positive and negative predictive values (noted in the Table2) they have limited sensitivity and specificity,3 and the presence of a positive sign does not exclude the possibility of comorbid disease.
Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Stone J, LaFrance WC Jr, Levenson JL, et al. Issues for DSM- 5: conversion disorder. Am J Psychiatry. 2010;167(6):626-627.
2. Daum C, Hubschmid M, Aybek S. The value of ‘positive’ clinical signs for weakness, sensory and gait disorders in conversion disorder: a systematic and narrative review. J Neurol Neurosurg Psychiatry. 2014;85(2):180-190.
3. Stone J, Carson A, Sharpe M. Functional symptoms and signs in neurology: assessment and diagnosis. J Neurol Neurosurg Psychiatry. 2005;76(suppl 1):i2-i12.
DSM-5 criteria for conversion disorder (or functional neurological symptom disorder) requires findings that are incompatible with recognized neurologic or medical conditions.1 Knowledge of signs specific to conversion disorder may help you diagnose the illness with confidence.
We review signs suggestive of conversion disorder. These can be remembered using the mnemonic How About Finding Some Conversion Weakness [in an otherwise] Strong Guy/Gal? (Table2).
Inconsistencies in motor function can be observed on examination. Signs may be consciously or unconsciously produced. Although most of the tests mentioned have high positive and negative predictive values (noted in the Table2) they have limited sensitivity and specificity,3 and the presence of a positive sign does not exclude the possibility of comorbid disease.
Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
DSM-5 criteria for conversion disorder (or functional neurological symptom disorder) requires findings that are incompatible with recognized neurologic or medical conditions.1 Knowledge of signs specific to conversion disorder may help you diagnose the illness with confidence.
We review signs suggestive of conversion disorder. These can be remembered using the mnemonic How About Finding Some Conversion Weakness [in an otherwise] Strong Guy/Gal? (Table2).
Inconsistencies in motor function can be observed on examination. Signs may be consciously or unconsciously produced. Although most of the tests mentioned have high positive and negative predictive values (noted in the Table2) they have limited sensitivity and specificity,3 and the presence of a positive sign does not exclude the possibility of comorbid disease.
Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Stone J, LaFrance WC Jr, Levenson JL, et al. Issues for DSM- 5: conversion disorder. Am J Psychiatry. 2010;167(6):626-627.
2. Daum C, Hubschmid M, Aybek S. The value of ‘positive’ clinical signs for weakness, sensory and gait disorders in conversion disorder: a systematic and narrative review. J Neurol Neurosurg Psychiatry. 2014;85(2):180-190.
3. Stone J, Carson A, Sharpe M. Functional symptoms and signs in neurology: assessment and diagnosis. J Neurol Neurosurg Psychiatry. 2005;76(suppl 1):i2-i12.
1. Stone J, LaFrance WC Jr, Levenson JL, et al. Issues for DSM- 5: conversion disorder. Am J Psychiatry. 2010;167(6):626-627.
2. Daum C, Hubschmid M, Aybek S. The value of ‘positive’ clinical signs for weakness, sensory and gait disorders in conversion disorder: a systematic and narrative review. J Neurol Neurosurg Psychiatry. 2014;85(2):180-190.
3. Stone J, Carson A, Sharpe M. Functional symptoms and signs in neurology: assessment and diagnosis. J Neurol Neurosurg Psychiatry. 2005;76(suppl 1):i2-i12.