Relational. Interest in social activities and relationships is reduced (asociality). Even enjoyable and recreational activities are neglected. Interpersonal relations may be of little interest. Friendships become rare and shallow, with little sharing of intimacy. Contacts with family are neglected. Sexual interest declines. As symptoms progress, patients become increasingly isolated.
Primary and secondary symptoms
Negative symptoms are an intrinsic component of schizophrenic psychopathology, and they can also be caused by secondary factors (Table).6,7 Distinguishing between primary and secondary causes of negative symptoms can help you select appropriate treatment in specific clinical situations.
Primary symptoms. From a longitudinal perspective, the three major components of primary negative symptoms are:
- premorbid negative symptoms (present prior to psychosis onset and associated with poor premorbid functioning)
- psychotic-phase, nonenduring negative symptoms that fluctuate with positive symptoms around periods of psychotic exacerbation
- deteriorative negative symptoms that intensify following each psychotic exacerbation and reflect a decline from premorbid levels of functioning.
Though little can be done to treat the premorbid component, psychotic-phase negative symptoms improve along with positive symptoms (although more slowly).8,9 Therefore, the best strategy for managing negative symptoms is to treat positive symptoms more effectively. Although there is no specific treatment for deteriorative negative symptoms, the severity of this component appears to be related to the “toxicity of psychosis” and can be reduced by early, effective antipsychotic treatment.10,11
Secondary negative symptoms occur in association with (and presumably are caused by) factors such as depression, extrapyramidal symptoms (EPS), and environmental deprivation. Secondary negative symptoms usually respond to treatment of the underlying cause.
Assessment
Symptom severity. Assessing the severity of a patient’s negative symptoms on an ongoing basis is a most important first step towards optimal treatment:
- Our objective is to improve patients’ function and quality of life, and negative symptoms compromise both of these more than any other factor.
- Ongoing assessment can track whether prescribed treatments are improving or worsening a patient’s symptoms.
Tools to assess the severity of negative symptoms include the Brief Psychiatric Rating Scale (BPRS) and Positive and Negative Symptom Scale (PANSS).12 The Scale for the Assessment of Negative Symptoms (SANS)13 measures them exclusively, and others such as the Schedule for the Deficit Syndrome (SDS)14 attempt to classify them into subgroups.
Discussing these instruments is beyond the scope of this article, but they differ greatly in their approach to assessing negative symptoms. Instead of using cumbersome assessment instruments, however, we recommend that you focus on two to four of a patient’s “target” symptoms or behaviors and note their severity on an ongoing basis.
Contributing factors. Determining the overall contribution of different factors to a patient’s negative symptoms allows us to target treatments. Sorting out these relative factors can be difficult, however. For example:
- In a patient on antipsychotic treatment who is experiencing psychotic symptoms (eg, persecutory delusions), depressive symptoms, and prominent negative symptoms, the clinician can only guess whether the negative symptoms are primary or secondary.
- In a patient who is socially withdrawn and delusional, withdrawal may be secondary to delusions or may represent a primary negative symptom.
- In a patient on typical antipsychotics, a flat affect may be caused by antipsychotic-induced EPS or it may be a primary negative symptom.
- A disorganized patient with schizophrenia and depression is often unable to convey his or her feelings coherently, so that negative symptoms secondary to affective disturbance may often be mistaken as primary.
Even in research settings, the distinction between primary and secondary symptoms is quite unreliable; nevertheless, it is of great clinical importance. Two strategies may be helpful:
- Consider whether symptoms are specific to the presumed etiology, such as guilt and sadness in depression or cogwheeling and tremor in EPS.
- Treat empirically, and monitor whether negative symptoms improve. If they improve with antidepressant treatment, for example, then depression was the presumable cause. If they improve with anticholinergics, they were presumably secondary to EPS.
Treatment
Negative symptoms are generally viewed as treatment-resistant, but evidence suggests that they do respond to pharmacologic and social interventions (Box). Most responsive to treatment are negative symptoms that occur in association with positive symptoms (psychotic-phase) and secondary negative symptoms caused by neuroleptic medication, depression, or lack of stimulation.
The most effective treatment for secondary symptoms is to target the underlying cause. Neuroleptic-induced akinesia may respond to anticholinergic agents, reduction in antipsychotic dose, or a change in antipsychotic. Using one of the newer-generation antipsychotics (clozapine, risperidone, olanzapine, quetiapine, or ziprasidone) may prevent EPS.
PSYCHOSOCIAL TREATMENTS FOR SCHIZOPHRENIA
Apsychosocial approach to schizophrenia builds on relationships between the patient and others and may involve social skills training, vocational rehabilitation, and psychotherapy. Activity-oriented therapies appear to be significantly more effective than verbal therapies.
Goals of psychosocial therapy:
- set realistic expectations for the patient
- stay active in treatment in the face of a protracted illness
- create a benign and supportive environment for the patient and caregivers.
Social skills training, designed to help the patient correctly perceive and respond to social situations, is the most widely studied and applied psychosocial intervention. The training is similar to that used in educational settings but focuses on remedying social rather than academic deficits. In schizophrenia, skills training programs address living skills, communication, conflict resolution, vocational skills, etc.
In early studies of social skills training, patients and their families described enhanced social adjustment, and hospitalization rates improved. More recent studies have confirmed improved social adjustment and relapse rates but suggest that overall symptom improvement is modest.
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