The negative symptoms of schizophrenia
Hallucinations and delusions are the most vivid and conspicuous symptoms
of schizophrenia. Many people regard imaginary voices in the head and
bizarre ideas with no basis in reality as the essence of mental illness.
An eruption of these psychotic symptoms — a psychotic break — is
often what brings a person with schizophrenia to treatment for the first
time. But the psychotic or “positive” symptoms 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, monotone and monosyllabic
speech, few gestures, seeming lack of interest in other people, inability
to feel pleasure or act spontaneously. 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 and manage everyday social situations. These
symptoms are also the ones that trouble them most. 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. They may describe
themselves as demoralized, depressed, and anxious. 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.
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,
especially word fluency and the capacity to sustain attention and shift
its focus when necessary.
But cognitive failings are “negative” symptoms, too. It’s
not always easy to tell the difference between a person who chooses not
to talk (alogia) and one who is unable to find words, or between a deficit
in motivation (avolition) 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.
The schizophrenic spectrum
Schizophrenia-like conditions can occur without hallucinations and delusions — that
is, with only negative and cognitive symptoms. One term for these conditions
that has fallen out of fashion is simple schizophrenia. Newer terms,
as listed in the American Psychiatric Association diagnostic manual,
are schizotypal personality and schizoid personality. Both these disorders
involve discomfort with or incapacity for social relations, apparent
indifference to others, and emotional inexpressiveness — classic
schizophrenia symptoms. The range of conditions, from schizoid and schizotypal
personality to the most severe forms of schizophrenia, is called the
schizophrenia spectrum, and it consists mostly of negative symptoms.
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, commonsense advice, and sometimes
help with practical problems. Family therapy helps patients with schizophrenia
and their families avoid both angry confrontations and equally harmful
In behavioral therapy, patients with schizophrenia improve their social
skills and put structure in their lives.
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.
It now looks as though schizophrenia is not one disorder but several,
with genetic roots and brain malfunctions that may be entirely different
or overlapping. Psychotic, negative, and cognitive symptoms could result
from different underlying processes, each with a genetic basis, that
occur separately or together. These processes result in biological traits
or markers that are a new focus for schizophrenia research.
As research links subtle signs and symptoms of illness to a person’s
underlying genetic makeup, we will likely better understand this range
of disorders. And that will make it easier to develop specific treatments,
along with better ways for clinicians and patients to choose a treatment
October 2006 Update
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