The negative symptoms of schizophrenia
Hallucinations and delusions are the most vivid and conspicuous symptoms
of schizophrenia. But the psychotic or “positive” symptoms — exaggerations
and distortions of normal perception and thinking — are not necessarily
the most important or characteristic ones. Another set of symptoms
is much more pervasive and persistent and has a much greater effect
on a patient’s quality of life.
These “negative” symptoms are so called because they are
an absence as much as a presence: inexpressive faces, blank looks, monotone
and monosyllabic speech, few gestures, seeming lack of interest in the
world and other people, inability to feel pleasure or act spontaneously.
About 25% of patients with schizophrenia have a condition called the
deficit syndrome, defined by severe and persistent negative symptoms.
Positive symptoms make treatment seem more urgent, and they can often
be effectively treated with antipsychotic drugs. But negative symptoms
are the main reason patients with schizophrenia cannot live independently,
hold jobs, establish personal relationships, and manage everyday social
situations. These symptoms are also the ones that trouble them most.
Surveys find that their chief concerns are difficulty in concentrating,
thinking, socializing, and enjoying life. It is important to distinguish
between lack of expression and lack of feeling, between lack of will
and lack of activity. When questioned, patients with schizophrenia often
express a full range of feelings and desires. The difference between
what they may feel and what they show has to be taken into account in
interpreting their facial expressions, speech, and social behavior.
Some newer antipsychotic medicines, such as Clozaril, Zyprexa and Risperdal
are thought to show some benefit for negative symptoms, but research
has shown that other therapies can be beneficial.
The cognitive connection
Negative symptoms are closely related to the thinking deficiencies that
are attracting increasing attention from schizophrenia researchers. Patients
with schizophrenia perform poorly on tests of mental fluency and flexibility,
and the capacity to sustain attention and shift its focus when necessary.
Studies suggest that these cognitive limitations affect real-world functioning
and the outcome of the illness even more than negative symptoms do.
But cognitive failings are “negative” symptoms, too. It’s
not always easy to tell the difference between a person who chooses not
to talk and one who is unable to find words, or between a deficit in
motivation and a deficit in social competence. The border between negative
and cognitive symptoms blurs. The absences could be negative symptoms,
cognitive limitations, or the result of anxious social and emotional
Meanwhile, the best we can do for negative symptoms is to provide education,
psychotherapy, behavioral training, and help with employment, housing,
and family relations. Supportive therapy offers reassurance, morale building,
companionship, commonsense advice, and sometimes help with practical
problems. Family therapy helps patients with schizophrenia and their
families avoid both angry confrontations and equally harmful emotional
In behavioral therapy, patients with schizophrenia improve their social
skills and put structure in their lives. Through social skills training,
they may learn how to make requests, express feelings, and adjust their
voices and facial expressions.
Cognitive therapy draws attention to the interplay between cognitive
and negative symptoms, using questioning and reasoning exercises to clarify
confusion and overcome self-defeating thoughts. Cognitive therapy may
also counteract the fear of exposing limitations that makes some people
with schizophrenia withdrawn and apathetic.
A form of cognitive therapy designed specifically for schizophrenia
is called cognitive rehabilitation, remediation, or enhancement. It is
based on the assumption that people with schizophrenia become isolated
and withdrawn because others are put off by their apparent inability
to express or understand feelings and desires. Patients are taught how
to safely communicate their own needs and show that they understand the
needs of others.
As research links subtle signs and symptoms of illness to a person’s
underlying genetic makeup, we will likely better understand the range
of schizophrenic disorders. And that will make it easier to develop specific
treatments, along with better ways for clinicians and patients to choose
a treatment that works.
July 2006 update
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