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Section 19
Symptoms of Schizophrenia

Question 19 | Test | Table of Contents

Aspects of the negative syndrome, such as anhedonia, apathy, low motivation, and emotional withdrawal, are not specific to schizophrenia and have been found to be even more prevalent among inpatients with depression than in hospitalized patients with schizophrenia. The negative symptoms of schizophrenia have been shown to share many features with depression, and a recent study demonstrated that the cognitive deficits commonly associated with negative symptoms were primarily accounted for by the presence of depression in those with chronic schizophrenia. Notwithstanding the putative overlap between negative symptoms and depression, they remain distinct symptom domains that can be distinguished reliably. Other negative symptoms, such as affective flattening and alogia, have been conceptualized in terms of deficit states. Recent experimental research on affective flattening suggests that the problem may lie in expressing emotions rather than in a deficit in the ability to feel, while alogia may reflect difficulty in finding the right words rather than representing a dearth of communication skills. In summary, it may be that some negative symptoms reflect cognitive, emotional, and behavioral dysfunction rather than stable deficits. These may be amenable to change with strategies similar to those that have effectively harnessed motivation and social and emotional reengagement. Many patients with prominent negative symptoms experience other individuals (that is, family, friends, and health professionals) as demanding more from them in terms of activity and engagement then they are capable of giving. This may be especially pernicious for some patients who, prior to becoming ill, also held excessively high expectations for themselves, inconsequence of which they now see themselves as failing to live up to both their own and others' expectations. In a recent study (unpublished), higher scores on a measure of dysfunctional attitudes and beliefs regarding performance and achievement (that is, the Dysfunctional Attitude Scale-Perfectionism Dimension) were associated with a greater number and severity of negative symptoms. These scores were unrelated to the presence or severity of positive symptoms. Repeated unmet demands may further impact on perceived self-efficacy and fuel the cycle of hopelessness. The first step for the therapist is to reduce this pressure.

Cognitive Therapy of Negative Symptoms
Prior to implementing change, the cognitive therapist aims to complete a thorough functional analysis of the patient's behavior. How are they spending their time? What do they take pleasure in? What helps create feelings of mastery? What would they like to do more of but currently find difficult to do? What do they not like to do? What do people in their lives want them to do more often? Identifying barriers to engagement should include an assessment of comorbid depression and anxiety disorders. The prevalence of severe depression at the time of relapse has been estimated at 20% to 50%, and more than two-thirds of schizophrenia patients will experience a depressive episode at some time. Further, many patients are withdrawn and apathetic because of fears associated with the spectrum of anxiety conditions, including (but not limited to) anticipated panic attacks and other unmanageable somatic experiences, feelings of helplessness, and negative evaluation. Similarly, symptoms of anhedonia, apathy, and withdrawal may be the consequence of strategic avoidances to prevent the onset of distressing positive symptoms and their feared consequences (for example, readmission). Another potential barrier to engagement may be the problem of overmedication or medication side effects.

The cognitive approach to treating negative symptoms follows from the cognitive and behavioral strategies previously described in the treatment of depression. It includes behavioral self-monitoring, activity scheduling, mastery and pleasure ratings, graded task assignments, and assertiveness-training methods. Cognitive strategies include eliciting the patient's reasons for inactivity and testing these beliefs directly with behavioral experiments; direct attempts either to stimulate new interests or to reactivate previously held interests; and identifying, testing, and changing self-critical automatic thoughts concerning performance.

Dimensional levels of depression and anxiety may be addressed within the context of treating negative symptoms. For the significant number of patients who are experiencing bona fide depressive and anxiety disorders, however, more complete and standard cognitive therapy interventions can be provided.
- Rector, Neil A.; Beck, Aaron T; Cognitive Therapy For Schizophrenia: From Conceptualization to Intervention; Canadian Journal of Psychiatry; Feb2002, Vol. 47 Issue 1

Personal Reflection Exercise #5
The preceding section contained information about cognitive focus in negative symptoms of schizophrenia. Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Assessment of Noninvasive Brain Stimulation Interventions for Negative Symptoms of Schizophrenia: A Systematic Review and Network Meta-analysis

Tseng, P. T., Zeng, B. S., Hung, C. M., Liang, C. S., Stubbs, B., Carvalho, A. F., Brunoni, A. R., Su, K. P., Tu, Y. K., Wu, Y. C., Chen, T. Y., Li, D. J., Lin, P. Y., Hsu, C. W., Chen, Y. W., Suen, M. W., Satogami, K., Takahashi, S., Wu, C. K., Yang, W. C., … Li, C. T. (2022). Assessment of Noninvasive Brain Stimulation Interventions for Negative Symptoms of Schizophrenia: A Systematic Review and Network Meta-analysis. JAMA psychiatry, 79(8), 770–779. https://doi.org/10.1001/jamapsychiatry.2022.1513


Peer-Reviewed Journal Article References:
Hallford, D. J., Farrell, H., & Lynch, E. (2020). Increasing anticipated and anticipatory pleasure through episodic thinking. Emotion. Advance online publication.

Kamath, V., Crawford, J., DuBois, S., Nucifora, F. C., Jr., Nestadt, G., Sawa, A., & Schretlen, D. (2019). Contributions of olfactory and neuropsychological assessment to the diagnosis of first-episode schizophrenia. Neuropsychology, 33(2), 203–211.

Lampropoulos, D., Troïan, J., D'Amico, C., Bentata, L., & Apostolidis, T. (2018). Evidence for the influence of social dominance orientation and intergroup relations on the stigma of schizophrenia. European Journal of Health Psychology, 25(4), 133–139.

Lecomte, T., Potvin, S., Samson, C., Francoeur, A., Hache-Labelle, C., Gagné, S., Boucher, J., Bouchard, M., & Mueser, K. T. (2019). Predicting and preventing symptom onset and relapse in schizophrenia—A metareview of current empirical evidence. Journal of Abnormal Psychology, 128(8), 840–854.

QUESTION 19
What are five aspects of the cognitive approach to treating negative symptoms? To select and enter your answer go to Test.

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