Negative Symptoms

“Dementia Praecox consists of a series of clinical states which have as their common characteristic a peculiar destruction of the internal connections of the psychic personality with the most marked damage of the emotional life and volition.”

—Emil Kraepelin, from the 8th edition of his textbook (1913)

In this chapter, we look at a nonpsychotic symptom cluster: negative symptoms. Negative symptoms are characterized by a loss or diminution of function: something is missing that you expect to be there. Missing is the independent drive, the curiosity about the world, and the boundless energy that we expect from young people. Missing are also the facial expressions and body language that we take for granted when we engage somebody in dialogue. Patients themselves can perceive the lackluster quality of their inner experiences. Both Emil Kraepelin (see epigraph) and Eugen Bleuler (recall that two of his four As of schizophrenia are autism and affectivity) recognized the centrality of these symptoms to the experience of schizophrenia. In 1980, Timothy Crow made a very influential distinction between type I (mainly positive symptoms) and type II (mainly negative symptoms, with poor response to antipsychotics) and schizophrenia. A modern conceptualization of negative symptoms includes five broad symptom domains, listed in Table 26.1.

As a less modifiable aspect of the schizophrenia syndrome, negative symptoms are more the essence of schizophrenia
than positive symptoms, which can be seen as accessory (albeit key in defining psychotic disorders). It is rather obvious to any clinician that negative symptoms, unless mild, are profoundly impairing. “Will” is what keeps us going, and there is simply no substitute for it if it is missing.

TABLE 26.1. Negative Symptom Domains^a

Alogia	Lack of words (poverty of speech or poverty of content of speech)
Blunted affect	Lack of affectivity (perception, experience, expression of emotions)
Anhedonia	Lack of capacity for pleasure
Avolition	Lack of volition (“will”) and motivation
Asociality	Lack of social drive
^aTerms based on National Institute of Mental Health-supported consensus conference (Kirkpatrick et al., 2006).

The centrality of negative symptoms is now acknowledged and officially recognized in the DSM-IV as a core feature of schizophrenia, and two clinical subtypes of schizophrenia in which negative symptoms are the predominant feature have been described (Table 26.2). Negative symptoms can be a major factor in poor community functioning: imagine a person devoid of drive or capacity to experience reward and the clinical problems this poses with regard to rehabilitation, interpersonal functioning, or work. Clinically, the negative symptom domain,
rather than the cognitive domain, often seems to be the critical factor that determines community outcomes.

TABLE 26.2. Schizophrenia Subtypes with Negative Symptoms

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