Negative Symptoms in Schizophrenia

"Negative" does not mean "bad" but...

Woman holding her head
Paula Bronstein/Getty Images

Why are they called negative symptoms?

The negative symptoms include symptoms where there is a decrease or a loss in a mental function compared to normal functioning.  

What are the negative symptoms of schizophrenia?

  1. A decrease in the observed emotional response (clinical term: restricted affect).  Of note, this symptom is diagnosed based on observations about the patient’s behavior – as opposed to a reported subjective lack of emotion. A patient with restricted affect patient might report feeling emotions but they do not show it.
  1. A decrease in the reported emotional response (clinical term: decreased emotional range). The patient feels little if any emotions.
  2. Decreased speech production (clinical term: poverty of speech). There is little spontaneous speech. The patient tends to answer most questions with a monosyllabic “yes” or “no”. At times there is a delay in getting the words out or there are long time gaps separating sentences or even words within a sentence. Speech delays due to the patient paying attention to hallucinated voices or visions or simply being disorganized should be differentiated from poverty of speech.
  3. Decreased interest. Apathy is a common symptom of schizophrenia. The patient appears indifferent, lacking interest for even basic activities (grooming and hygiene). There is a pervasive lack of enthusiasm coupled with a striking lack of concern for both minor and major matters (e.g., what is to eat, how the bills will get paid, what will happen when the family will no longer be around for support).
  1. Decreased sense of purpose. The patient has a difficult time discussing the meaning or value of engaging in activities or projects. It might be difficult to get the patient to articulate short and long term goals and plans.
  2. Decreased desire to socialize (clinical term: decreased social drive). Of course, this could be a consequence of the more generalized lack of interest.  However, some patients show a distinct lack of interest in being social while they might continue to be interested in a variety of other activities. A patient might have his favorite TV shows, which he enjoys and follows, but when asked why he spends all his time by himself he states that he doesn’t care for the company of others. Of note, choosing to isolate due to feeling paranoid or because of voices commanding to stay alone should be differentiated from decreased social drive (conceivably, the patient would choose to spend time with others provided they stop harassing him).

    What causes negative symptoms?

    It is not clear. While some studies reported the deficit schizophrenia run in families, there is no known genetic association for negative symptoms or deficit schizophrenia. Interestingly, while winter birth increases the risk for schizophrenia, people with schizophrenia born in the summer appear to be at higher risk for negative symptoms.

    What is the course and prognosis for negative symptoms?

    The course appears to be more persistent for negative symptoms when compared to positive symptoms. People with deficit schizophrenia have a poorer response to treatment, social and occupational functioning, and overall quality of life than people with non-deficit schizophrenia.

    As negative symptoms indicate deficits in functioning they are also called deficit symptoms. However, deficit schizophrenia is not synonymous with deficit or negative symptoms.

    Often times, patients with schizophrenia might have one negative symptom in addition to the more commonly observed positive symptoms. At times, some of medications prescribed for the treatment of schizophrenia, such as the first generation or typical antipsychotics, can have adverse effects such as decreased interest or decreased emotional response.

    As these symptoms are due to the medications, they are called secondary negative symptoms. Also, negative symptoms might come and go during the course of schizophrenia.

    Deficit schizophrenia is diagnosed when patients have:

    1. At least two out of the six negative symptoms.

    2. The symptoms are persistent – meaning they are present for at least one year and the patient experiences them even during times of clinical stability.

    3. The symptoms are primary. Primary means not due to other causes (see above – secondary negative symptoms).

    Antipsychotics are effective in treating negative symptoms that are secondary to positive symptoms. For example, patients can be socially isolated due to paranoid beliefs or voices commanding them not to leave their home. In such cases, antipsychotics effective against paranoia and auditory hallucinations will also result in improved social affiliation. Unmedicated patients experiencing positive symptoms with secondary negative symptoms should start a neuroleptic; if already treated, the dose might need to be increased or alternatively, if the medication is deemed ineffective, a switch to an alternative medication is recommended.

    While effective against positive symptoms first generation/typical antipsychotics have a number of neurological adverse effects, such as parkinsonism, that can increase secondary negative symptoms. When patients treated with a typical neuroleptics appear withdrawn and slowed down, that could be a side effect of their neuroleptic. If that is the case, the medication dose can be lowered or the medication might need to be changed to a second generation/atypical antipsychotic.

    Depression, with secondary lack of interest and motivation, can be treated with an antidepressant.

    Neither first generation/typical antipsychotics or second generation/atypical antipsychotics improve primary and persistent negative symptoms.

    Psycho-social interventions with a focus on the social disconnection play an important role in the treatment of persistent negative symptoms.

    Supportive therapy provides an opportunity for companionship, where the patient is offered non-judgmental validation, common sense advice, and reassurance.

    Behavioral therapy teaches patients to recognize and engage in behaviors and activities that will improve their quality of life. Social skills training is a specific type of behavioral therapy where the patients are taught how to express feelings and needs, ask questions, and control their voice, body and facial expressions.

    Cognitive therapy aims to train the patient to question and correct patterns of thoughts that result in overwhelming feelings.

    Psycho-education for patients and families is helpful in decreasing stigma and improve opportunities for ongoing social engagement.

    As medications efficacy is limited, it is best to combine medications with psycho-social interventions.

    Further reading:

    Kirkpatrick B, Fenton WS, Carpenter WT, Marder SR. The NIMH-MATRICS consensus statement on negative symptoms. Schizophr Bull. 2006;32(2):214–9. doi:10.1093/schbul/sbj053.

    Kirkpatrick B1, Galderisi S. Deficit schizophrenia: an update. World Psychiatry. 2008 Oct;7(3):143-7

    Kring AM1, Gur RE, Blanchard JJ, Horan WP, Reise SP. The Clinical Assessment Interview for Negative Symptoms (CAINS): final development and validation. Am J Psychiatry. 2013 Feb 1;170(2):165-72

    Continue Reading