Schizophrenia’s symptoms are often categorized into two types: negative and positive. The term “negative” is used to refer to the absence of typical healthy features, like motivation, interest, and expression. Negative schizophrenia symptoms are the most common first sign of schizophrenia, and usually emerge during the prodromal (i.e., initial) phase of the condition.
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What Is Schizophrenia?
Schizophrenia is a psychotic disorder in which an individual experiences a constellation of positive, negative and cognitive symptoms. While positive symptoms (e.g. hallucinations and delusions) are what usually spur an individual to seek and/or receive help (as they can be more intrusive and disrupting), negative symptoms can be just as debilitating and are quite common. In fact, 90% of individuals experiencing their first psychotic episode report at least one negative symptom.1
Unlike positive symptoms, which tend to wax and wane during the course of the disease (i.e., prodromal, progressive and residual phases), negative symptoms typically persist and may worsen over time–even if positive symptoms improve.2 The more severe the negative symptom, the greater the impact it has on job and school performance, household integration, social functioning, and overall daily functioning.
What Are Negative Symptoms in Schizophrenia?
Negative symptoms of schizophrenia reflect impairments in one’s emotional and social abilities, and may overlap with cognitive symptoms as well. They can be classified as being either primary or secondary.
Primary negative symptoms stem from the pathophysiology underlying schizophrenia. Moreover, they do not tend to improve with antipsychotic medication. Alternatively, secondary negative symptoms result from other factors, such as positive symptoms (e.g., withdrawal from social interaction after an intrusive hallucination); other psychiatric conditions (e.g., anxiety, depression, PTSD, OCD, substance misuse); medication side effects, environmental conditions (e.g., hospitalization); social deprivation; or other medical conditions (e.g., dementia).
Negative symptoms in schizophrenia can be grouped into two main categories:
- Deficits of expression: blunted affect and alogia; tend to be more noticeable by others during routine interactions.
- Deficits of motivation and interest: Avolition, asociality and anhedonia; reflect a lack of desire to engage in various activities and may go unnoticed for longer depending on the individual’s normal level of sociality.
Common Negative Symptoms of Schizophrenia
Deficits of expression, motivation, and interest can manifest in the form of different behaviors and degrees depending on the severity of the illness. Many of these symptoms may overlap with other diagnoses and personality traits, though a skilled professional can help discern if schizophrenia is the root cause.
The most common negative symptoms of schizophrenia include:
Anhedonia
Anhedonia refers to a reduced ability to experience pleasure from things that most typical people would find enjoyable. When this refers to an inability to enjoy activities, people, or things in the present (e.g., eating ice cream, playing a game), it is referred to as consummatory anhedonia.
When anhedonia prevents people from looking forward to future pleasurable experiences, sometimes related to an inability to recall past pleasurable activities, it is called anticipatory anhedonia. Anticipatory anhedonia is more common in schizophrenia than consummatory anhedonia.3 When individuals have little desire to engage in leisure activities or hobbies, this can also lead to a vicious cycle of alienation from peers, inactivity, and subsequent anhedonia.
Blunted Affect & Flat Affect
Blunted affect is a particularly common negative symptom of schizophrenia and refers to reduced emotional expression in one’s face (e.g., smile/frown, furrowed brow), body (e.g., gestures), or voice (e.g., intonation). Flat affect is an extreme case of blunted affect, characterized by the complete absence of emotional expression. An individual with affective deficits may speak in a monotone voice or not make eye contact when speaking to others.
Alogia
Alogia, also referred to as “poverty of speech,” is a reduction in verbal expression, particularly the number of words spoken. Questions may receive one or two word responses, briefer than what a typical person would use for reply. Words will often be monosyllabic and simple in content.
Alogia differs from aphasia (inability to produce or comprehend words due to neurological dysfunction) in that, within the context of schizophrenia, diminished speech seems more related to a lack of motivation to speak rather than an inability to form words. Alogia may present together with blunted affect.
Avolition
Avolition deficits, also referred to as decreased drive, apathy, or amotivation, refer to reduced motivation and initiation of activity, be it in contexts of work, socializing, or recreation. Common examples of this deficit include a failure to pay bills, not showing up to school or work, avoiding self-care, neglecting hygiene (e.g., brushing hair and teeth), and neglecting chores (e.g., tidiness, laundry, etc.). Consequences of ignoring such tasks may result in a downward spiral of dysfunction and stress.
Asociality
Asociality is a reduced interest in social interaction. While a lack of socialization may not be significant for typical individuals, when an individual with schizophrenia retreats from social activities, it can lead to secondary problems. These include increased paranoia, cognitive decline, and a worsening of depression and other negative symptoms.
Catatonia
Catatonia is a symptom cluster that can consist of both positive and negative features, and therefore deserves mention here, despite not generally regarded as a purely negative symptom. Negative catatonic features include stupor (motor immobility), mutism (little to no verbal response to prompts), and negativism (no response to instructions or other prompts). A state of stillness might suddenly give way to a state of excited agitation. The fluctuation of negative features with positive features (such as catalepsy, posturing, mannerism, agitation, mimicking) renders catatonia–a curious condition that is still not fully understood, but can make those suffering from schizophrenia the target of ridicule or even fear from others.
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Examples of Negative Symptoms in Schizophrenia
Negative symptoms of schizophrenia may manifest uniquely and with varying saliency depending on one’s environment, treatment, and pathophysiology. However, there are some common behaviors that may be exhibited. While some of these symptoms are also seen with other disorders, such as depression, a skilled professional will be able to determine if they are being caused by schizophrenia.
Common examples of negative symptoms in schizophrenia include:
- Shaving only part of one’s face (avolition)
- Not showering, changing clothes, or brushing teeth for weeks (avolition)
- Speaking in a monotone voice (blunted affect)
- Remaining in fetal position for hours while awake (catatonia)
- Showing no excitement for the visit of a friend or being given a gift (blunted affect)
- Decreased sense of purpose (avolition)
- Withdrawal from social gatherings (asociality)
- Reduced communication by phone, text, or other routine method (asociality)
- Lack of expression (flat affect)
- Giving a one-word reply, like “ok,” in a monotone voice, in response to any question, even it’s discordant with one’s actual wishes (alogia)
What Causes Schizophrenia?
The precise mechanisms underlying the etiology and development of schizophrenia are not fully understood; current theories combine multiple components. Neurophysiological dysfunction (due to genetics or environmental factors) can produce cognitive and emotional deficits that exacerbate vulnerability to both schizophrenia symptoms, as well as maladaptive behaviors (e.g., drug use) that can lead to earlier onset of the illness.
Possible causes of schizophrenia include:
- Genetic factors: While genes do seem to play a role, a single gene has not been identified as the main cause; rather, many different genetic mutations have been implicated.
- Brain structure: Negative symptoms, especially those involving the experience of pleasure and motivation, likely stem from dysfunction within the prefrontal cortex and limbic system of the brain and/or problems in the white matter pathways connecting them.
- Neurotransmitters: When the negative symptoms of schizophrenia are secondary to psychotic symptoms, antipsychotic medications that target dopamine circuits may help improve the symptoms. However, when negative symptoms are primary, antipsychotics do not seem to work well. This suggests the involvement of other neurotransmitters, like serotonin, glutamate, and acetylcholine since antipsychotic medication has less impact on these brain chemicals.4
- Hormones: Deficits in oxytocin, which is colloquially known as the “love hormone”, may underlie asociality in schizophrenia.
- Psychological & environmental factors: Extreme or toxic stress can lead to the development of schizophrenia, particularly when the stress involves sexual or physical abuse, trauma, social disadvantage, urbanicity, migration, and separation from loved ones.
- Infection: Research suggests that prenatal exposure to certain viral or parasitic infections increases the risk of developing schizophrenia later on.4 Some researchers have even suggested a possible link between prenatal exposure to COVID-19 and schizophrenia, as coronaviruses have been shown to be neuroinvasive.5
- Autoimmune diseases & inflammation: Along with microglia activation and a pro-inflammatory diet, increased cytokines are thought to lead to neuroinflammation, a potential cause or correlation of schizophrenia symptoms.6
- Substance & alcohol use: Persons at risk for or diagnosed with schizophrenia experience poorer outcomes, increased hospitalization, and exacerbation of symptoms when using alcohol or other substances.
How Is Schizophrenia Diagnosed?
Schizophrenia is most often diagnosed in the period from late adolescence to early adulthood (late-20s) with the emergence of psychosis. Negative and cognitive symptoms can manifest earlier in childhood, but they may not be as salient or easily linked with schizophrenia.
The prodromal phase of schizophrenia is usually followed by an acute psychotic episode that often draws attention to the disorder. The acute psychotic episode then typically gives way to a progressive phase of illness, during which time positive symptoms may come and go, and negative and cognitive symptoms gradually worsen.
The DSM-5 criteria for diagnosing schizophrenia include:
- The presence of at least two symptoms of schizophrenia must be present, with at least one being a positive symptom.
- Negative symptoms can be among the symptoms to meet criteria, as long as a positive symptom is present.
- Key symptoms must last for a period of at least one month, with the condition’s effects also lasting for at least six.
- Social or occupational dysfunction must be present.
How Are Negative Symptoms Treated?
Until recently, the negative symptoms of schizophrenia have received much less attention in research and treatment development. Consequently, treatment for negative symptoms has lagged, and currently there are no “magic pills” to alleviate these symptoms, as there are with positive symptoms.
Negative symptoms are not as responsive to medication and remain a challenge to treat. However, recent developments in drug therapies, combined with greater attention being given to these symptoms, offer hope for future treatment. Another welcome development is the enhanced focus on the early detection of negative and cognitive symptoms; hopefully this will lead to earlier treatment for most people.
Medications
Antipsychotic medication has been the main pharmaceutical of choice in treating schizophrenia. Nevertheless, primary negative symptoms are not as responsive, and may be better treated with drugs that modulate other neurotransmitters, hormones, and inflammation.
Medications sometimes used to treat negative symptoms of schizophrenia include:
- Typical Antipsychotics: First-generation or typical antipsychotics work by reducing dopamine levels. Secondary negative symptoms that result from the presence of positive symptoms (e.g., hallucinations) are responsive to this class of drugs, while primary negative symptoms are not.
- Atypical Antipsychotics: Second-generation or atypical antipsychotics work differently, modulating both serotonin and dopamine. Though primary negative symptoms tend not to improve with most atypical antipsychotics, a recent study showed improvement with Cariprazine.7
- Antidepressants & Anti-anxiety Medications: Other medications commonly used for depression and anxiety may also be used to treat specific negative symptoms of schizophrenia; however, efficacy has been mixed. Atypical antidepressants have shown promise in treating negative symptoms, though it remains unclear whether primary or secondary symptoms are improved.
Therapy
While secondary negative symptoms may be responsive to medication, primary negative symptoms tend to be more difficult to treat pharmaceutically. Thus, other forms of treatment, like psychotherapy, will likely be necessary.
Negative symptoms often involve withdrawing from or difficulty with social interaction, so attendance and participation in therapy may be poor. In some cases, the very symptom that the therapy is trying to treat–such as lack of interest and motivation–is what prevents an individual from attending therapy.
Therapy options for positive symptoms of schizophrenia include:
- Behavior therapy (BT): offers patients concrete rewards for behavior successes, like achieving hygiene goals.
- Cognitive behavioral therapy (CBT): can help individuals address their hallucinations and delusions. If negative symptoms are secondary to psychotic symptoms, this line of treatment could be helpful.
- Family therapy: teaches family members how to create a supportive and positive environment that reduces and possibly prevents some schizophrenic symptoms.
- Social Skills Training (SST): can be particularly useful, especially in conjunction with psychotherapy and medication, to help an individual develop skills that are often deficient in schizophrenia. This may involve individual and group work.10
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How to Cope With Negative Symptoms
Schizophrenia symptoms can be challenging for both the individual and family, and coping strategies can be integral for all parties involved. Even if medication is the first line of treatment, compliance can be a big problem; having a solid support system and strategy is imperative to a positive long-term outcome.
Some negative symptoms are more responsive to coping strategies than others. A study exploring the efficacy of different coping strategies found apathy to be the most responsive, while anhedonia and alogia also show modest improvement.11
Here are some ways to cope with negative symptoms:
- Seek family support: Having family members attend doctor and therapy appointments can make a big difference in treatment outcomes, as a person with schizophrenia may be unaware of certain symptoms or the degree to which they interfere with daily functioning. Family members can provide additional information that may be key in determining treatment and support. Moreover, coping strategies work best when relatives are involved, educated about the illness, and equipped with coping strategies themselves.11
- Practice stress management: Avoiding stressful situations is not always possible, but being able to recognize stress and practice relaxation techniques can help reduce any negative impacts.
- Stay social: The best way to break a cycle of social withdrawal is to maintain many healthy relationships and stay social. Social skills training for schizophrenia, including workbooks, can help in this area.
- Practice self-care: Engaging in activities that one finds enjoyable and stimulating holds considerable therapeutic value. Even if one is not looking forward to an activity, they stand to benefit by pushing themselves to engage–especially in the effort to combat anhedonia.
- Build structure: Routine is often the hidden factor behind the success of many individuals adapting to schizophrenia, especially in the face of negative symptoms. Keeping regular sleep and wake times not only maintains schedule consistency, but getting proper levels of sleep can prevent the return of many symptoms. However, it is important to note that getting too much sleep can be just as detrimental as too little sleep.
- Maintain hygiene: Maintaining good hygiene and dressing properly is important to avoid other complicating health issues, and encourage positive social interactions. Routines may increase the likelihood that negative symptoms don’t get in the way of daily functioning.
- Pay attention to nutrition and diet: There is some research backing the fact that foods with anti-inflammatory properties can be helpful in reducing some symptoms and medication side effects.6
- Avoid drugs and alcohol: The same brain structures that are implicated in schizophrenia also play a role in drug use and addiction.12
- Plan ahead: Secondary negative symptoms may come and go with acute psychotic episodes. During stable periods, individuals with schizophrenia would be wise to ask trusted members of their support system to reach out to their treatment team (e.g., their physician, therapist, psychiatrist, or case worker) if they start to notice them withdrawing or experiencing other negative symptoms.
- Smart device apps: While nothing replaces face-to-face, in-person support, a variety of useful mental health apps are available to help maintain routines, activity, emotional awareness, and a sense of overall well-being. Smart devices are also a great way to check in with friends and family if seeing them in person is not an option.
How to Support a Loved One With Schizophrenia
Depending on the severity and manifestation of a person’s diagnosis, support may take different forms; but, there are some ways relatives and friends can help a loved one cope with their negative symptoms.
Here are some ways that you can support someone diagnosed with schizophrenia:
- Acceptance: Negative symptoms may be perceived as someone being “moody” or “lazy.” Realizing that these symptoms reflect actual neurobiological deficits is the first step in helping a person by removing the pressure they may feel to “pretend” they are well.
- Encourage without pressure: It’s natural to want to encourage struggling friends and loved ones to pursue social activities; but, it’s important to avoid being pushy, as this can cause undue stress and exacerbate one’s symptoms. Start with activities at home like playing cards, talking over coffee, or even watching a show together. If the individual seems open to going out, suggest activities that won’t be socially overwhelming for that person. If you find them resistant in any way, let them be and try again another time.
- Don’t give up: It can be frustrating trying to motivate someone to engage in tasks or activities, and you may get turned down often. Patience and persistence can make a huge difference.12
- Start small: Maintaining motivation or interest can seem overwhelming for someone experiencing negative symptoms. Here it can be helpful to break tasks down into smaller sub-tasks that are more manageable.
- Communicate clearly: Cognitive symptoms often accompany negative symptoms in schizophrenia. To help individuals, use short, simple sentences and give them long durations to respond.
- Ask for clarity: Individuals with schizophrenia often have difficulties with communication. If the person is not making sense, try to be patient and ask for clarity.
- Positive reinforcement: Cognitive deficits may prevent individuals with schizophrenia from being aware of their successes. Provide positive feedback often.
- Self-care: In addition to encouraging someone with schizophrenia to take part in enjoyable activities, it is imperative that those supporting them engage in self-care as well to recharge, refresh, and de-stress. Caring for others can present many challenges, and taking time out for oneself is integral to staying healthy and strong.
- Join a support group: Schizophrenia presents a number of unique challenges to family members. A support group can provide a safe, validating environment for family members, and also a forum to learn tips and strategies. Moreover, knowledge is power, and it has been shown that when family members take the time to educate themselves about schizophrenia, the individual tends to be more successful in overcoming symptoms.11
Final Thoughts
While positive and secondary negative symptoms tend to come and go and are somewhat treatable with medication, primary negative symptoms persist and tend to worsen over time if left untreated. Early intervention, as well as maintaining social connectedness, is key to slowing the progression of the disease. Psychotherapy, social skills training, and support groups for you and your family can all help with managing schizophrenia symptoms.
Additional Resources
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