Abstract
The negative symptoms of schizophrenia include volitional (motivational) impairment manifesting as avolition, anhedonia, social withdrawal, and emotional disorders such as alogia and affective flattening. Negative symptoms worsen patients' quality of life and functioning. From the diagnostic point of view, it is important to differentiate between primary negative symptoms, which are regarded as an integral dimension of schizophrenia, and secondary negative symptoms occurring as a result of positive symptoms, comorbid depression, side effects of antipsychotics, substance abuse, or social isolation. If secondary negative symptoms overlap with primary negative symptoms, it can create a false clinical impression of worsening deficit symptoms and disease progression, which leads to the choice of incorrect therapeutic strategy with excessive dopamine blocker loading. Different longitudinal trajectories of primary and secondary negative symptoms in different schizophrenia stages are proposed as an important additional discriminating factor. This review and position paper focuses primarily on clinical aspects of negative symptoms in schizophrenia, their definition, phenomenology, factor structure, and classification. It covers the historical and modern concepts of the paradigm of positive and negative symptoms in schizophrenia, as well as a detailed comparison of the assessment tools and psychometric tests used for the evaluation of negative symptoms.
Highlights
Negative symptoms are a core component of the schizophrenia syndrome
In a multicenter retrospective study (n = 1,452), the majority of the patients (57.6%) diagnosed with schizophrenia spectrum disorders had at least one or more negative symptoms, while primary negative symptoms were reported in 12.9% of the patients; in another study (n = 7,678), 41% of the patients had at least two negative symptoms [3]
Negative symptoms lead to a significant burden and deterioration of the quality of life in patients with schizophrenia
Summary
Negative symptoms are a core component of the schizophrenia syndrome. Negative symptoms can be primary symptoms, which are intrinsic to the underlying pathophysiology of schizophrenia, or secondary symptoms that are related to psychiatric or medical comorbidities, adverse effects of treatment, or environmental factors. Negative schizophrenia was characterized by the presence of cognitive and negative symptoms in the premorbid period, low level of education, gradual or latent onset of the disease, predominant negative symptoms (emotional blunting, poor speech, anhedonia, attention deficit, lack of motivation, and volitional impulses), chronic or malignant course, social and working disadaptation, poor performance on cognitive tests, and different structural changes in the brain including signs of cerebral atrophy. The consensus had been reached regarding the inclusion of the following five major factors in the concept of negative symptoms [37]: 1) anhedonia—inability to feel pleasure; 2) avolition (apathy)—lack of energy and initiative, loss of interest for usual activity; 3) social withdrawal—disturbed social activity and avoidance of interpersonal contacts; 4) alogia—negative cognitive disorder, narrowing of speech range, and poverty of content of speech; 5) emotional (affective) flattening or blunting, reduced emotional response to stimuli This five-factor model of negative symptoms in schizophrenia has recently been confirmed with independent network analysis [38]. Secondary negative symptoms overlap with primary negative symptoms, and this can create a false clinical impression of worsening deficit symptoms and disease progression, which frequently leads to the choice of incorrect therapeutic strategy and, namely, the intensification of antipsychotic dopamineblocking treatment
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