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Schizophrenia is among the top 10 disabling conditions worldwide for young adults.1,2 In the United States, the cost of treatment and loss in productivity associated with schizophrenia are estimated to be as high as $60 billion annually.3-5 More than three quarters of this amount is associated with loss in productivity.1 Patients with schizophrenia struggle with many functional impairments, including performance of independent living skills, social functioning, and occupational/educational performance and attainment.6 Most patients require some public assistance for support, and only 10% to 20% of patients are able to sustain full- or part-time competitive employment.7-9 Improving functional outcomes for these individuals is a significant mental health priority.
Research suggests that the negative symptoms of schizophrenia, including problems with motivation, social withdrawal, diminished affective responsiveness, speech, and movement, contribute more to poor functional outcomes and quality of life for individuals with schizophrenia than do positive symptoms.10-16 Moreover, caregivers of patients with negative symptoms report high levels of burden.17 Negative symptoms tend to persist longer than positive symptoms and are more difficult to treat.15,18 Research suggests that improvements in negative symptoms are associated with a variety of improved functional outcomes including independent living skills, social functioning, and role functioning.19 Targeting negative symptoms in the treatment of schizophrenia may have significant functional benefits. Treatment of negative symptoms has been identified as a vital unmet clinical need for many persons with schizophrenia.15,18
Current antipsychotic treatments primarily address the positive symptoms of the disorder.15,18,20 In brief medication visits, physicians typically assess issues related to delusions, hallucinations, disorganized and aggressive behavior, and hostility. These are common symptoms that may cause individuals to be hospitalized, go to emergency departments, seek out crisis services, or come to the attention of the criminal justice system. Physicians may not be aware of the extent of negative symptoms, may not know how to assess these symptoms, may be unclear about the impact of treatments on negative symptoms, and may be unfamiliar with treatment strategies that may favorably impact negative symptoms. In this article, we describe the nature of negative symptoms, some of the etiological factors that contribute to a negative symptom presentation, and ways of addressing negative symptoms.
What are negative symptoms?
Negative symptoms represent a reduction of emotional responsiveness, motivation, socialization, speech, and movement. Primary negative symptoms are etiologically related to the core pathophysiology of schizophrenia whereas secondary negative symptoms are derivative of other symptoms of schizophrenia, other disease processes, medications, or environment.15,21 For example, antipsychotic medications can produce akinesia or blunted affect. Depression can cause anhedonia, lack of motivation, and social withdrawal. Lack of stimulation in impoverished institutional environments can lead to complacency and problems with motivation and initiation. Negative symptoms can also be the result of psychotic processes.15,21 For example, social withdrawal can be caused by paranoia or by immersion in the psychotic process to the exclusion of real-life relationships. Primary and enduring negative symptoms are often referred to as the "deficit syndrome."22 Individuals with the deficit syndrome have been found to have greater cognitive deficits and poorer outcomes than patients who do not have this syndrome.22
The face of negative symptoms
The brief narrative presents a description of a typical day of a patient with schizophrenia. As will be apparent, the patient demonstrates several classic negative symptoms, including blunted emotional responsiveness. "Jesse" produces very little speech and needs to be repeatedly prompted by the interviewer. He spends his days without much physical activity, mostly watching television. He has no friends and is visited by his father once a week. His interests are restricted to watching television and smoking. While he states that he likes basketball, he does not play or watch basketball. Emotional responsiveness was blunted in the interview even with attempts to elicit it. Interviews with family members revealed that Jesse has exhibited these behaviors for many years. When asked, Jesse states that he wants to get a job, but he has done nothing to find a job in more than a decade.
Individuals like Jesse are often seen for brief medication visits. Because there are no obvious positive symptoms and no problems with acting out or hostility, few changes in medication may be initiated. There may be little questioning on the part of the treating physician to determine the quality of Jesse's life or manner in which he spends his time. Some of the reluctance to get into such issues has to do with the limited time public-sector physicians may be able to spend with each patient. In most clinicians' minds, patients with pressing needs, such as suicidal or aggressive behaviors or severe symptom exacerbations, need more immediate attention. Moreover, the symptoms embodied in the negative syndrome may not be considered an important domain for treatment by either the physician or the patient. Note that Jesse does not identify anything about his life as a "chief complaint." His family seems to accept these symptoms, and for the most part, society has not targeted them as an unmet health care need. There may also be a perception among physicians that little can be done for negative symptoms even if they are identified.
How to assess negative symptoms
Individuals with schizophrenia are often unaware of the extent of their negative symptoms.23 They frequently do not spontaneously report negative symptoms as problems and are less concerned about them than their relatives may be.17 Family members may complain of a lack of an emotional connection with their son or daughter and state that the individual is not involved in life, but they do not aggressively seek treatment for these symptoms. Physicians or physician extenders will usually not get information about negative symptoms unless they have time to observe and to ask about specific behaviors. Furthermore, if symptoms are identified, there are no generally recognized approaches to treatment or well-established clinical assessment tools to measure treatment progress or failure.