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28. Negative Symptoms
Keywords
Negative symptomsEugen BleulerDeficit syndromeAlogiaBlunted affectAnhedoniaAvolitionAsocialityAssessmentPrimary negative symptomsPersistent negative symptomsSecondary negative symptomsTreatmentsCariprazineEssential Concepts
Negative symptoms are a core feature of schizophrenia; they have diagnostic and prognostic significance.
Negative symptoms comprise two main clusters: diminished emotional expression and diminished motivation.
Among the five consensus negative symptom domains (alogia, blunted affect, anhedonia, avolition, asociality), “failure of the will” (avolition) might be particularly pernicious with regard to function.
Avoid and treat secondary negative symptoms, particularly depression.
Educate family members about negative symptoms to reduce undue pressure on the patient.
“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) [1]
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. Older psychiatrists used the idea of a failure of the will to describe these deficiencies. Missing are also the facial expressions and body language that we take for granted when we engage with somebody in dialogue. Patients themselves can perceive the lackluster quality of their inner experiences which can be a painful insight.
Five consensus negative symptom domainsa
Alogia | Lack of words (poverty of speech or poverty of content to speech) |
Blunted affectb | Lack of affectivity (expression of emotions) |
Anhedonia | Lack of capacity for pleasure |
Avolitionc | Lack of volition (“will”) and motivation |
Asociality | Lack of social drive |
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. Among the negative symptoms, amotivation (i.e., avolition or lack of will) might be primus inter pares, particularly with regard to outcome [6]. “Will” is what keeps us going, and there is simply no substitute for it if it is missing. A concept related to amotivation is apathy [7]. Depending on the clinical sample, most patients will have some degree of negative symptoms.
Schizophrenia subtypes with prominent negative symptoms
Deficit schizophreniaa | Patients with prominent negative symptoms that are enduring and primary. Might be a separate disease within the schizophrenias (with different risk factors suggesting different etiology). Depending on the chronicity of the patient sample, up to 30% will have the deficit syndrome |
Simple schizophreniab | Patients who never experience clear-cut positive symptoms but drift slowly into a withdrawn, empty mental state of essentially negative symptoms |
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. I will add, however, that the distinction between negative and cognitive symptoms is less clear-cut than consensus definitions of the terms imply. Saying little in the interview (i.e., showing poverty of speech or alogia on mental status exam) and a poor performance on the verbal fluency test correlate; the former is considered a negative symptom, the latter a cognitive impairment [11]. Even motivated people will fail and eventually give up on pursuing their goals if they lack executive function. Social stress due to poor processing speed can lead young people to withdraw from social life in order to avoid stressful situations and their own perceived ineptitude. As these examples show, negative symptoms can sometimes be understood as a reaction to cognitive deficits and even have a psychologically protective effect. A closer look at a core negative symptom domain, anhedonia (inability to experience pleasure), offers another example of the complexity of the negative symptom constructs and the interplay with cognition. Many patients with anhedonia appear to have deficits in anticipatory pleasure (i.e., they do not derive pleasure from imagining and planning pleasurable activities like visiting the new burger place on the weekend – a cognitive task) but not in consummatory pleasure (i.e., they enjoy a burger in front of them just like you and me) [12]. Anticipatory pleasure is a critical component for a life lived fully. Think about the good feelings that planning for a vacation engenders in you (often more than the trip itself, with its stressful plane rides and the vagaries of travel, including returning with diarrhea). Current work attempts to further delineate anhedonia biotypes, moving away from a monolithic anhedonia concept [13].
Clinical Assessment
Subtle negative symptoms might not be obvious to the observer, but patients who can express their inner experiences will note that they have changed: things are harder; more mental effort is necessary to achieve the same results; previously enjoyable things are no longer exciting; and they do not feel close to other people. In more severe cases, negative symptoms can be observed, and patients will appear blunted, disengaged from the world, and unable to participate in life beyond a very narrow area of their immediate concern (Bleuler’s observation of autism). Little is said either literally because patients are monosyllabic or because not much information is conveyed (alogia). Nonverbal communication is impaired as well. The patient uses gestures sparingly; he speaks with a monotone voice, and he does not emphasize speech with his hands; and he does not look at you and shows little facial expression (blunted affect). Goal setting is reduced (including, e.g., the simple goal of getting up and taking a shower); patients fail projects because they do not persist (avolition). They stop doing things they used to enjoy (anhedonia), and they no longer derive pleasure from social contacts which become infrequent (asociality). Parents can often identify these personality changes in their sons or daughters. A child that used to be outgoing, laugh easily, and be socially active has become homebound, quiet, and disinterested in the future.
Key Point
Factor analysis suggests that the negative symptoms can be combined into two clusters or dimensions: blunted affect and alogia form a diminished emotional expressivity cluster; avolition, anhedonia, and asociality form a diminished motivation cluster [14]. This distinction is somewhat helpful clinically (you can assess the emotional expressivity cluster in the office visit whereas the motivation cluster requires collateral information) but not for treatment planning; there you need to look at individual domains to identify the best treatment target [15].
“Have you noticed a change in your emotions?” (blunted affect)
“What are your plans for this week?” (avolition)
“What gets you excited?” (anhedonia)
“When is the last time you did something with a friend?” (avolition)
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