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 withdrawal.

Psychosocial treatment

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 distancing.

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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