The negative symptoms of schizophrenia refer to an absence of normal functions. This may include (but is not limited to); blunted affect, which is a scarcity of facial expressions of emotion, reduced frequency and range of gestures and voice modulation, and restricted eye contact; alogia (poverty of speech); asociality (reduced social interaction); avolition (reduced motivation and often poor hygiene) and anhedonia, which is reduced experience of pleasure, often manifesting as scarcity of recreation, inability to experience closeness, and reduced interest in sexual activity.

Psychosocial therapies may provide a clinical adjunct to pharmacological therapy, and include cognitive behavioural therapy (CBT), hallucination focused integrative treatment, acceptance and commitment therapy, experience focused counselling, family intervention, metacognitive training, mindfulness, social skills training, and supportive therapy.

What is the evidence for psychosocial treatments for negative symptoms?

Moderate to high quality evidence shows a small to medium-sized benefit of CBT for greater improvement in negative symptoms than treatment as usual. Moderate quality evidence finds skills training, occupational therapy, music therapy, and exercise also provided small to medium-sized benefits for negative symptoms when compared to treatment as usual. The factors associated with the most benefit were skill enhancement, behavioural activation, social engagement and neurocognitive factors.

February 2022

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Defeatist performance beliefs are over-generalised negative thoughts about one’s ability to successfully perform goal-directed behaviour. This prevents the initiation of and engagement in social and employment opportunities and therefore is considered a possible contributing factor to negative symptoms and poor functional outcomes.

Neurocognitive deficits in memory and attention for example may contribute to unsuccessful goal attainment, which over time can give rise to dysfunctional attitudes, including defeatist performance beliefs. These dysfunctional attitudes, in turn, may lead to a decrease in motivation for future goal-related activities, which may contribute to functional outcome deficits. Reduction in goal-directed behaviour reinforces further disengagement with the social world.

What is the evidence for defeatist performance beliefs?

High quality evidence suggests significant but small relationships between increased defeatist performance beliefs and worse negative symptoms and functional outcomes (e.g. general functioning, quality of life, life skills).

March 2022

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Negative symptoms are referring to an absence of normal functions. This may include (but is not limited to) blunted affect, which is a scarcity of facial expressions of emotion, reduced frequency and range of gestures and voice modulation, and restricted eye contact; alogia (poverty of speech); asociality (reduced social interaction); avolition (reduced motivation and often poor hygiene) and anhedonia, which is reduced experience of pleasure.

What is the evidence on medications for negative symptoms?

Moderate to high quality evidence finds medium-sized effects of greater improvement in negative symptoms with clozapine, zotepine, amisulpride, olanzapine, perphenazine, and asenapine compared to placebo. There were small improvements over placebo with risperidone, paliperidone, sertindole, chlorpromazine, ziprasidone, aripiprazole, cariprazine, quetiapine, lurasidone, haloperidol, brexpiprazole, and iloperidone. There were no significant differences between placebo and flupentixol or zuclopenthixol.

Moderate quality evidence finds some benefit for improving negative symptoms from second-generation, but not first-generation antipsychotics compared to placebo. Moderate to low quality evidence finds some benefit of antipsychotics plus psychological interventions compared to antipsychotics alone. For individual antipsychotics, amisulpride provided more benefit than placebo; cariprazine, olanzapine and quetiapine provided more benefit than risperidone; olanzapine provided more benefit than haloperidol. Fluphenazine-treated patients received more antiparkinson medication than those on amisulpride or risperidone, risperidone-treated patients received more antiparkinson medication than those on quetiapine, and risperidone produced more extra-pyramidal symptoms than olanzapine.

For other agents, moderate quality evidence finds a small benefit for negative symptoms with adjunctive antidepressants, particularly SNRIs and SSRIs, and with adjunctive glutamatergic agents. Antidepressants were associated with more abdominal pain, constipation, dizziness, and dry mouth than placebo. Moderate to high quality evidence finds a medium-sized improvement in negative symptoms with anti-dementia medications compared to placebo, particularly galantamine, rivastigmine and memantine. There were no differences in adverse events between anti-dementia medications and placebo. Moderate to low quality evidence finds there may also be benefits of other adjunctive agents including aspirin, atomoxetine, celecoxib, cerebrolysin, amotidine, folate, granisetron, insulin, latrepirdine, mazindol, mianserin, mirtazapine, methotrimeprazine, oxytocin, pramipexole, reboxetine, selegiline, sildenafil, sodium benzoate, tropisetron, viloxazine, and vitamin B12.

February 2022

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Negative symptoms of schizophrenia refer to an absence of normal functions. These include a scarcity of facial expressions of emotion, reduced frequency and range of gestures and voice modulation, restricted eye contact, poverty of speech (alogia), reduced social interaction, reduced motivation (avolition), poor hygiene, and reduced experience of pleasure (anhedonia) which is often manifested as scarcity of recreation, inability to experience closeness, and reduced interest in any sexual activity. Deficit schizophrenia is a subtype of schizophrenia with persisting negative symptoms that is described by specifically defined assessments used primarily in research.

What is the evidence for negative symptoms?

Moderate to low quality evidence indicates negative symptoms occur in 50-90% of people with first-episode psychosis. This estimate decreases to 35-70% with treatment, but 20-40% of first-episode patients have persisting negative symptoms. There were more severe negative symptoms in patients with a family history of psychosis than in patients without a family history of psychosis.

Moderate to high quality evidence shows people with chronic schizophrenia report more anhedonia, and less consummatory and anticipatory pleasure than controls. There were small to medium-sized associations between more overall negative symptoms and more episodic memory deficits, more depression symptoms, less insight, and less motivation.

Moderate to high quality evidence finds deficit syndrome is apparent in around one-third of people with chronic schizophrenia. Deficit syndrome is associated with greater severity of negative and disorganised symptoms and less severity of mood symptoms. Deficit schizophrenia is more likely to occur in males than in females.

Moderate quality evidence finds large effects of longer pauses and less spoken time in people with schizophrenia compared to controls. There were medium-sized effects of lower speech rate and less pitch variability. No differences were found for pitch, intensity variability, duration of utterance and number of pauses. Significant associations were found between more negative symptoms and less pitch variability, greater flat affect, less time spoken, more alogia, and more duration of pauses.

Moderate to high quality evidence found no differences in negative symptoms between people with schizophrenia and current cannabis and/or nicotine use and people with schizophrenia with no cannabis and/or nicotine use. However, there was a small to medium-sized effect of less severe negative symptoms in people with schizophrenia who recently abstained from cannabis use.

March 2022

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Schizophrenia is characterised by positive, negative and disorganised symptoms. Positive symptoms refer to experiences additional to what would be considered normal experience, such as hallucinations and delusions. Negative symptoms include blunted affect, impoverished thinking, alogia, asociality, avolition, and anhedonia. Alogia is often manifested as poverty of speech, asociality involves reduced social interaction, avolition refers to poor hygiene and reduced motivation, while anhedonia is defined as an inability to experience pleasure. Disorganised symptoms involve bizarre behaviour and disorganised thought and speech. Cognitive deficits are also a core feature of schizophrenia. These deficits may be present in chronic patients, as well as prior to onset of the disorder and during its early and acute stages. Cognitive deficits may be associated with specific symptoms as well as functional impairment.

What is the evidence for cognitive functioning relating to symptom dimensions?

Moderate to high quality evidence shows more severe overall symptoms are associated with poor prospective memory, insight, executive functioning, facial perception, facial emotion recognition, emotion processing and perception, social perception, and Theory of Mind.

More severe positive symptoms are associated with poorer insight, attention/vigilance, reasoning, problem solving, non-emotional recognition, self-recognition, psychomotor speed, executive functioning, Theory of Mind, verbal list learning and digit span performance. More severe negative symptoms are associated with poorer language fluency, IQ, attention, memory, learning, speed of processing, reasoning, executive functioning, insight, social cognition, and olfaction. More severe disorganised symptoms are associated with poorer IQ, attention, executive functioning, speed of processing, reasoning/problem solving, and memory, but not verbal working memory. Thought disorder was associated with poorer semantic priming and verbal fluency.

March 2022

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Schizophreniform disorder is a part of the schizophrenia spectrum of disorders and has sometimes been used as a provisional diagnosis while waiting to see if symptoms improve by six months or progress, resulting in a diagnosis of schizophrenia. DSM-5 requires at least one of the following symptoms is present for a significant portion of the time during a one-month period, but for less than six months: delusions, hallucinations or disorganised speech. Disorganised behaviour or negative symptoms may also be present. There can be no manic, depressive or mixed manic-depressive episodes, and any mood disturbance must have been present for  minority of the time. The symptoms cannot be due to the effects of a substance or due to a medical or neurological disorder.

What is the evidence for schizophreniform disorder?

Moderate to high quality evidence suggests the rate of a schizophrenia diagnosis following a diagnosis of schizophreniform disorder is around 65% by about four years. The rate of first-episode psychosis patients retaining a diagnosis of schizophreniform disorder over time is around 29%.

February 2022

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