What are the Negative Symptoms of Schizophrenia and Other Mental Illnesses?
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What are the Negative Symptoms of Schizophrenia and Other Mental Illnesses?

From a clinical perspective, “negative” isn’t what you think

When we study schizophrenia, my students often confuse the negative and positive symptoms of the illness. That’s something that’s easy to do; we’re so used to using the word “negative” in the vernacular, we may automatically think of it as meaning “bad.” That’s not its clinical meaning though.

From a clinical perspective, negative means “absent” or “lacking.” There’s no connotation of desirability or value. That’s why being HIV-negative is not a bad thing.

When considering whether symptoms are negative or positive, it might be useful to relate them to negative and positive numbers. Positive numbers are above the baseline of zero; negative numbers are below it. Being under the baseline doesn’t mean that negative numbers are bad (unless you’re looking at them in your checking account). It only means they are less than zero.

In the same way, negative symptoms are less than normal. Normal behaviors, moods, cognitions, and attitudes in mental health provide a baseline just as zero provides a baseline in math. Anything above the line of normality is a positive symptom; anything below it is negative.

Positive symptoms of schizophrenia

When we study arithmetic, we learn about the positive or “counting” numbers first because they seem less abstract to most of us. Similarly, it’s the positive symptoms — the hallucinations and delusions — that first come to mind when we think about schizophrenia.

How can we call such dreadful symptoms positive? Remember, we’re using the term in the clinical sense, not in its everyday meaning. Hallucinations aren’t “good” but they are present over the baseline of normality. People who hallucinate are seeing more than people normally see. They’re hearing more than people normally hear.

Delusions are less sensory than hallucinations, but they still have that “above the baseline” quality. People who experience delusions make more out of a situation than reality would suggest. They may hear the same voice on the radio that people normally hear, the baseline, but may believe they have also picked up on a secret message aimed directly at them.

That’s not good. But it’s positive.

Negative symptoms of schizophrenia

Most negative symptoms begin with the prefix “a,” meaning “not” or “without.” Here’s a list of some common ones that follow that a-first guideline.

Apathy — without pathos or passion. You may have seen people who have schizophrenia preaching on the streets or wildly waving their arms around. That is a stereotypical image of the illness, and while sometimes accurate, it doesn’t capture the range of emotion that marks the disorder.

It’s just as likely that someone with schizophrenia will lack the normal passion for life than that they will experience an abundance of it. They’ll be below the line.

They may sit in a corner for hours without engaging with the world. They may lack interest in pursuing normal activities and relationships. They may be devoid of passion, apathetic. That’s a common negative symptom of schizophrenia.

Asociality — not social. Apathy toward relationships in particular is known as asociality. We often characterize people who are asocial as being antisocial but that is a misuse of the term.

Just as the prefix “a” means “not,” the prefix “anti” means “against.” People who are truly antisocial in the clinical sense may be at ease with social life but they act out against it. They are destructive.

Ted Bundy, the quintessential lady killer in both senses of the word, is a good example of an antisocial person. In contrast, a person with schizophrenia who sticks to herself and avoids crowds is exhibiting asociality, a negative symptom of the illness.

Avolition — without volition or determination. Schizophrenia can crush the ability to formulate goals and pursue them. As a result, it has a huge impact on life achievements.

It can be difficult for people who have schizophrenia to finish school, find a job, raise a family, or volunteer. The initiative to pursue these goals is lacking or less than normal. Avolition is therefore a negative symptom.

Alogia — not logical; alternatively, a reference to poverty of speech (not wordy). The word “alogia” descends from the Greek “logos,” which can be used to refer to both reason and speech. The two are intricately related; we can best guess what people are thinking based on what they say. Someone with schizophrenia may answer our questions with monosyllables or not at all, giving us the impression that there isn’t much going on “up there.”

We may think of alogia as a problem with the mental processing of language. These disruptions to language processing are just as often seen in positive symptoms. They may be present as overproductive, tangential speech or as the “word salad” of utterances that don’t stick together well enough to form an expression of thought.

But alogia as a negative symptom refers to the poverty of speech in either its amount or its content. Every question may be answered with a single word, for example, or speech may be so vague as to be meaningless.

In any case, a conversation with someone who is experiencing alogia, whether due to depression, dementia, or schizophrenia, gives the impression that little rational thought is going into the words. Not much substance is being conveyed. Since speech characterized by alogia results in less than the exchange of ideas we expect from normal conversations, it is a negative symptom.

Anhedonia — not hedonic. People with schizophrenia often lack a normal ability to feel happy or content. Just imagine what it must be like to hear frightening voices, to believe others are out to get you, to lack the desire to form relationships and the initiative to pursue meaningful goals. It’s no wonder that schizophrenia is highly comorbid with depressive disorders or that the suicide rate for the illness is so high.

A life that oscillates between too much and not enough is not a happy life. And since the passionless life is less than the norm of one that is reasonably satisfying, anhedonia is a negative symptom.

Anosognosia — without awareness of the disease. People who have schizophrenia rarely understand that they have the disorder. They don’t believe they are having hallucinations; they believe a voice is really speaking to them. They don’t think they are delusional; they think the government is really spying on them.

At our baseline of normal, we aren’t without our problems, but we know when something is wrong with us, and we can put it into words. We may say, “I’m too sensitive,” or “I have social anxiety,” or “I have a phobia of snakes,” or “I have trouble trusting other people.”

People with schizophrenia rarely have that self-awareness, and its lack impedes their ability to seek care and follow a treatment plan. After all, why go to the doctor if there is nothing wrong with you? Why would you take a pill you’re given if people are trying to poison you?

Anosognosia marks many mental illnesses but none so much as schizophrenia. Clinicians distinguish anosognosia from the denial that so often accompanies substance use disorders because the latter can be diminished through experience. Insight into the effects of addiction can and do occur.

But while denial can be broken through, anosognosia is the product of a broken brain. As such, it’s more impervious to change. Efforts to convince someone with schizophrenia that the voices they are hearing are not real are unlikely to have an effect. No matter how solid the arguments against delusional ideas, insight into problems is less available to a person with schizophrenia than it is to other people. Anosognosia is therefore a negative symptom.

And now for those that don’t start with an “A”

We can’t always count on the prefix “a” to alert us to negative symptoms. But we can still think in terms of above or below the line of average or normal to determine which adjective fits.

Diminished emotional expression

You may sometimes hear this referred to as “flat affect” meaning the face is an expressionless mask. But diminished emotional expression can be a full-body symptom.

Just think of all the ways we convey emotion. We lean in and maintain eye contact when we listen. We gesture and emote when we speak.

That is, we do unless we have schizophrenia or another mental illness, such as depression, that subdues our spirit and cuts us off from life. Since the expression of emotions is normal at baseline, its diminishment is a negative symptom.

Catatonia

Catatonia refers to an unnatural decrease in responsiveness to the environment. It is (usually) a negative symptom of schizophrenia and of other mental and physical disorders. It can also occur on its own unrelated to other conditions.

My first experience of catatonia occurred in my internship at a detention center. The mental health department was called by a deputy to assess an inmate who was lying motionless on the floor of his cell. His eyes stared unblinkingly at the ceiling.

Several of us responded, including my supervisor who took the man’s arm, held it above his head, and let go. The arm fell with a soft thud on the man’s face.

“Waxy flexibility,” my supervisor labeled this phenomenon for the interns. “And a case of true catatonia. When people are faking, they won’t let their arm hit them in the face like that.”

Today, I question the ethics of such an assessment, but it made an impression on me that has lasted for decades — the motionless man, the flaccid arm muscles, the unseeing eyes, the lack of responsiveness to our voices and touch. Catatonia often takes this form.

The DSM lumps catatonia into a general category called “Grossly Disorganized or Abnormal Motor Behavior (Including Catatonia).” This symptom is frequently seen in all psychotic disorders including schizophrenia.

But just as in problems with language processing, abnormal motor behavior may be a positive or a negative symptom. It can present as overactivity of movement such as the wild waving of arms referred to above.

However, the inmate lying motionless on the floor of his cell was engaged in motor behavior that was less than normal. As such, his catatonia was a negative symptom.

Symptom set for schizophrenia

These are the symptoms of schizophrenia as they are listed in the fifth edition of the DSM. See if you can identify each one as positive or negative.

Hallucinations Delusions Disorganized speech (e.g., frequent derailment or incoherence). Grossly disorganized or catatonic behavior. Negative symptoms (i.e., diminished emotional expression or avolition).

I hope you said that the first 2 are positive. They always refer to symptoms that are over the baseline of normal.

The disorganized speech referred to in criterion 3 is also. Speech that is disorganized may be incomprehensible. It may be circumferential, going around and around in circles without ever getting to the point. There may be a flight of ideas, where speech bounces from one topic to another that may be only tangentially related to the one that preceded it if it is related at all.

Number 4, grossly disorganized or catatonic behavior could be either positive or negative, right? And the 5th criterion, negative symptoms, I hope you knew the answer to that one. And if you can give me some examples, congratulations! You passed the class.
['K M Brown']
['Mental Health', 'Negative Symptoms', 'Schizophrenia', 'Positive Symptoms', 'Psychology']