Negative Symptoms in Schizophrenia

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People with schizophrenia can experience both positive and negative symptoms. This doesn't mean that there are "good" versus "bad" symptoms. Positive symptoms are behaviors that appear in surplus in people with schizophrenia and are typically not found in otherwise healthy individuals. Positive symptoms, which include delusions, hallucinations, disorganized thoughts, and disorganized speech, can cause you or someone you love to lose touch with reality.

Negative schizophrenia refers to the symptoms that are lacking or decreased in people with schizophrenia. As negative symptoms indicate deficits in functioning they are also called deficit symptoms.

Negative symptoms, including lack of emotion, decreased joy or motivation, delayed speech, and difficulty beginning and sustaining activities, can be scary and extremely debilitating. If you or someone you love is struggling with negative symptoms, you may need help in order to complete daily tasks.

Causes

The cause of negative symptoms is not clear. While some studies say these deficits 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.

Types

The first step in managing the negative symptoms of schizophrenia is to understand the different types, which typically have one of four defining features:

  • Affective deficits: lack of facial expression, eye contact, gestures, and variations in voice pattern
  • Communicative deficits: speech lacking in quantity or information
  • Relational deficits: lack of interest in social activities and relationships
  • Conational deficits: severe lack of motivation or initiative to accomplish purposeful tasks (also known as avolition).

Since negative symptoms can include deficits in cognitive, emotional, and socio-abilities, there can be a large number of potential symptoms.

The most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) describes negative symptoms as “restricted emotional expression and avolition,” and includes the following five types.

Blunted Affect

This limits a person's ability to convey his or her emotions, causing diminished facial and emotional expressions. A blunted affect is less severe than flat affect, in which a person has an extremely limited range of emotions; for instance, not even being able to crack a smile or laugh during a time of great joy. People can mistake blunted affect as someone being "cold" or "unfeeling."

Aalogia

Defined in DSM-5 as a "decrease in verbal output or verbal expressiveness," aalogia (also known as "poverty of speech") can make it nearly impossible to communicate your thoughts and carry on a conversation.

People with aalogia may answer a monosyllabic "yes" or "no" when responding to questions and/or experience delays in getting the words out. It should be noted that these speech delays are not the same as those caused by positive symptoms like auditory or visual hallucinations and disorganized thinking.

Asociality

Other terms used to describe asociality are nonsocial, unsocial, social disinterest or a lack of social drive. Asociality causes a lack of involvement in social relationships or increased desire to spend time alone. This is different than a person who isolates him or herself after hearing voices or experiencing feelings of paranoia.

Avolition

Avolition is a form of emotional or behavioral paralysis that can diminish your drive to participate in social activities and meet goals as well as your ability to complete daily tasks. Many people mistake this negative symptom for "laziness" but, in the case of schizophrenia, avolation causes 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). This can even carry over into basic activities like personal hygiene and grooming.

Anhedonia

In Greek, an means "without" and hedone means "pleasure," so in simple terms, anhedonia is a state where you are unable to feel pleasure. For people with schizophrenia, this can mean a lack of enthusiasm for activities, hobbies, passions, and pleasures once enjoyed.

Diagnosing Negative Symptoms

Negative symptoms are not always easy to recognize and can be mistaken for depression as well as other mental illnesses. What's more, they may come and go during the course of schizophrenia.

Often times, people with schizophrenia might have one negative symptom in addition to the more commonly observed positive symptoms.

At times, some of the medications prescribed for the treatment of schizophrenia, such as the first generation or typical antipsychotics, also known as neuroleptics, have adverse effects such as decreased interest or decreased emotional response. Since these symptoms are due to the medications, they are called secondary negative symptoms.

What Is Deficit Schizophrenia?

Deficit schizophrenia, which is not synonymous with deficit symptoms or negative symptoms, is diagnosed when patients have:

  • At least two out of the six negative symptoms
  • The symptoms are persistent, or present for at least one year, and the patient experiences them even during times of clinical stability
  • The symptoms are primary, or not due to other causes like medication or other conditions


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.

Treatment

Treating negative symptoms is tricky due to the very nature of the negative symptoms; someone experiencing a lack of motivation, enthusiasm, or desire to be social, for instance, may be hesitant to seek and stick with treatment.

In addition, the drugs used to treat positive symptoms of schizophrenia can increase secondary negative symptoms and do not work on primary and persistent negative symptoms. This is why effective treatment ideally includes a combination of drugs, therapy, and support.

Antipsychotics

Antipsychotic medications (Haldol (haloperidol) and Thorazine (chlorpromazine), which are the first-line treatment for the positive symptoms of schizophrenia, such as hallucinations and delusions, are not effective in treating negative symptoms, such as lack of emotion, motivation, or interest in social activities.

While effective against positive symptoms, first-generation or typical antipsychotics have a number of neurological adverse effects, such as parkinsonism (when medications cause symptoms similar to Parkinson disease), that can increase secondary negative symptoms.

These drugs, also known as neuroleptics or major tranquilizers, can help treat negative symptoms that are secondary to positive symptoms. For example, people can be socially isolated due to paranoid beliefs or voices commanding them not to leave their home. In such cases, antipsychotics that decrease paranoia and auditory hallucinations (hearing voices or sounds) will improve social affiliation.

Atypical Antipsychotic

If you are still experiencing side effects of antipsychotics, even after your health care provider has adjusted your dose, he or she may switch you to a newer class of medication referred to as second-generation or atypical antipsychotics.

There are many different atypical antipsychotics used to treat schizophrenia, including:

Antidepressant

While it is by no means a cure, combining antipsychotics with antidepressants has been shown more effective than taking antipsychotics alone. Antidepressants work by increasing the availability of one or several of the following neurotransmitters: serotonin (mood, appetite, sleep, memory, social behavior, sexual desire), norepinephrine (alertness and motor function), dopamine (decision-making, motivation, signaling of pleasure and reward). 

Psychosocial Interventions

Psychosocial interventions, including behavioral therapy, support therapy, and family psychoeducation, aim to change a person's behaviors toward a more healthy interaction with society. These therapies can provide people with persistent negative systems as well as their families with tools to identify and cope with deficits in cognitive and emotional functioning and social skills.

Supportive Therapy

Supportive therapy provides an opportunity for companionship, non-judgmental validation, common sense advice, and reassurance from a trained therapist. Often, your therapist will step in on your behalf to facilitate communication with family members as well as authorities like schools and social agencies.

Behavioral Therapy

Behavioral therapy, including social skills training and cognitive-behavioral therapy (CBT), can teach you to recognize and engage in behaviors and activities that will improve the quality of life and day-to-day living. For example, during social skills training you will be taught how to express feelings and needs, ask questions, and control voice, body, and facial expressions. CBT can teach you or someone you love to identify and change the deficits that have a negative influence on behavior and emotions.

Family Psychoeducation

Family support plays a key role in the treatment of negative symptoms. Psychoeducation for patients and families is helpful in decreasing stigma and improving opportunities for ongoing social engagement. It can also offer families effective strategies for communicating and coping with a loved one with schizophrenia.

A Word From Verywell

The negative symptoms of schizophrenia can cause severe disruptions in daily functioning, relationships, work, school, hobbies, and leisure activities. With an appropriate diagnosis, treatment, and support, you or someone you love can find relief from these symptoms and discover ways to cope effectively.

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