Negative symptoms are the major contributor to low function levels and debilitation in most patients with schizophrenia. Poorly motivated patients cannot function adequately at school or work. Relationships with family and friends decay in the face of unresponsive affect and inattention to social cues. Personal interests yield to the dampening influences of anhedonia, apathy, and inattention.
Yet because active psychosis is the most common cause of hospital admission, a primary goal of treatment—and sometimes the only objective of pharmacologic treatment—is to eliminate or reduce positive symptoms. And although controlling positive symptoms is remarkably effective in reducing hospitalizations, patients’ functional capacity improves only minimally as psychosis abates. Even with optimal antipsychotic treatment, negative symptoms tend to persist.
For psychiatrists, the three major challenges of schizophrenia’s negative symptoms are their modest therapeutic response, pervasiveness, and diminution of patients’ quality of life. To help you manage negative symptoms, we suggest the following approach to their assessment and treatment.
Importance of negative symptoms
Schizophrenia is a heterogeneous disorder characterized by positive, negative, cognitive, and mood symptoms. The relative severity of these four pathologic domains varies from case to case and within the same individual over time. Though related, these domains have distinct underlying mechanisms and are differentially related to functional capacity and quality of life. They also show different patterns of response to treatment. Whereas positive symptoms refer to new psychological experiences outside the range of normal (e.g., delusions, hallucinations, suspiciousness, disorganized thinking), negative symptoms represent loss of normal function.
Negative symptoms include blunting of affect, poverty of speech and thought, apathy, anhedonia, reduced social drive, loss of motivation, lack of social interest, and inattention to social or cognitive input. These symptoms have devastating consequences on patients’ lives, and only modest progress has been made in treating them effectively.
From negative to positive. Early investigators1,2 considered negative symptoms to represent the fundamental defect of schizophrenia. Over the years, however, the importance of negative symptoms was progressively downplayed. Positive symptoms were increasingly emphasized because:
- positive symptoms have a more dramatic and easily recognized presentation
- negative symptoms are more difficult to reliably define and document
- antipsychotics, which revolutionized schizophrenia treatment, produce their most dramatic improvement in positive symptoms.
Renewed interest. The almost universal presence and relative persistence of negative symptoms, and the fact that they represent the most debilitating and refractory aspect of schizophrenic psychopathology, make them difficult to ignore. Consequently, interest in negative symptoms resurged in the 1980s-90s, with intense efforts to better understand them and treat them more effectively.3-5
Table
SCHIZOPHRENIA’S NEGATIVE SYMPTOMS: PRIMARY AND SECONDARY COMPONENTS
| Primary Associated with positive symptoms Deficit or primary enduring symptoms (premorbid and deteriorative) |
| Secondary Associated with extrapyramidal symptoms, depression, or environmental deprivation |
| Source: Adapted from DeQuardo JR, Tandon R. J Psychiatr Res 1998;32 (3-4):229-42. |
Negative symptoms are now better (but still incompletely) understood, and their treatment has improved but is still inadequate. Because intense effort yielded only modest success, researchers and clinicians have again begun to pay less attention to negative symptoms and shifted their focus to cognition in schizophrenia. Negative symptoms remain relevant, however, because they constitute the main barrier to a better quality of life for patients with schizophrenia.
Assessment for negative symptoms
The four major clinical subgroups of negative symptoms are affective, communicative, conational, and relational.
Affective. Blunted affect—including deficits in facial expression, eye contact, gestures, and voice pattern—is perhaps the most conspicuous negative symptom. In mild form, gestures may seem artificial or mechanical, and the voice is stilted or lacks normal inflection. Patients with severe blunted affect may appear devoid of facial expression or communicative gestures. They may sit impassively with little spontaneous movement, speak in a monotone, and gaze blankly in no particular direction.
Even when conversation becomes emotional, the patient’s affect does not adjust appropriately to reflect his or her feelings. Nor does the patient display even a basic level of understanding or responsiveness that typically characterize casual human interactions. The ability to experience pleasure (anhedonia) and sense of caring (apathy) are also reduced.
Communicative. The patient’s speech may be reduced in quantity (poverty of speech) and information (poverty of content of speech). In mild forms of impoverished speech (alogia), the patient makes brief, unelaborated statements; in the more severe form, the patient can be virtually mute. Whatever speech is present tends to be vague and overly generalized. Periods of silence may occur, either before the patient answers a question (increased latency) or in the midst of a response (blocking).
Conational. The patient may show a lack of drive or goal-directed behavior (avolition). Personal grooming may be poor. Physical activity may be limited. Patients typically have great difficulty following a work schedule or hospital ward routine. They fail to initiate activities, participate grudgingly, and require frequent direction and encouragement.
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