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 emotional distancing.
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 that works.
October 2006 Update