The Negative & Cognitive Symptoms in Schizophrenia
A Call for Treatment Options
There is a significant consensus of opinion that individuals with schizophrenia need better treatment options regarding Negative and Cognitive symptoms.
While the atypical neuroleptic medications have been more effective, they are usually more effective at treating the Positive Symptoms of the disorder, such as auditory hallucinations (voices), paranoia and delusions. Even with significant medication doses negative and cognitive symptoms often stubbornly persist.
Studies show that negative and cognitive symptoms have a significant long-term impact on quality of life. Memory functions, decision-making, personal initiative, socialization and self-direction can remain severely affected, inhibiting recovery. For these individuals, the benefits of supportive relationships, productive work, independent living arrangements and exploration of personal interests are often elusive.
What are the Negative Symptoms?
In a nutshell, the negative symptoms of schizophrenia can best be conceptualized as a loss of personality. The word “Negative” is used to describes a “loss” of emotional range and interpersonal function.
Symptoms vary, but many people with schizophrenia experience a decrement in individual initiative, depth of interests, and social fluency. Verbal communication is affected, with poor descriptive power, decreased range of tone, and reduced complexity.
In many with schizophrenia these symptoms inhibit effective socialization. Opportunities for personal growth and development grow scarce as the individual’s personal initiative and pursuit of goals becomes more and more blunted. Apathy and inertia can eventually set in completely, and pursuits that seemed a reason to live are abandoned and forgotten.
What are the Cognitive Symptoms?
Cognitive Symptoms have been found to occur in multiple areas of brain function in people with schizophrenia, and they are often just as devastating as the more overt symptoms of the disorder.
At this point, multiple areas of cognitive dysfunction have been identified for research in schizophrenia. Trouble with short and long-term memory process can make mastery of new information and skills very difficult. Sometimes, despite studying harder than ever, individuals with schizophrenia can barely remember what they have read a few hours before. Fortunately, today we have more to offer patients through off-label medications and nutrients that have been shown to be helpful in research.
Finally, the negative and cognitive symptoms of schizophrenia often overlap in destructive ways. While it may be difficult to develop a new plan or solution due to cognitive difficulties, removing personal motivation and initiative can make simple goals nearly impossible. Cognition may be impaired, but often so are the basic internal drives that create the machinery for motivation and mental stamina. This aspect of the illness can be particularly difficult and painful for family members to cope with.
Regarding Working Memory
Brain functions involved in planning and executing routine functions rely heavily upon Working Memory (WM). WM refers to the immediate, gestalt-level understanding of what is occurring referenced to what has just occurred. WM reminds us of the umbrella we left by the door, even if it has stopped raining when we leave. It nags that the kettle is on, and it keeps us mindful that our appointment is at 3 pm. It helps remind us to put the groceries in the fridge after being interrupted by a call from a friend.
In many ways, WM places a person in time both functionally and experientially and allows executive function to occur with a minimum of hassle.
In schizophrenia however, WM is often adversely affected and adverse fallout occurs in downstream layers of memory processing. On a functional level this can be a daily irritation – important forms are forgotten for the third time, money is once again spent without collecting receipts, or the desires of a moment trump the quieter necessities of the week or month.
There can be a timeless quality to the inner experience of people with significant working memory deficits, where each day is experienced anew and without the referential and comparative processes that mark one’s place in time.
Positive Symptoms generally refer to the hallucinations and delusions so common in schizophrenia. Auditory hallucinations can range from random noise or a single repeated word, to rich conversations between entities that sometimes attempt to control the individual. Delusions can take many forms, but they are generally easily disproven with common sense or fact checking. Examples would include the belief that one is being persecuted, monitored or controlled by outside entities (spies, aliens, parents), mindreading or broadcasting thoughts, predicting the future, or the conviction that a famous person is secretly in love with the individual. Paranoid delusions – that the phone is tapped, that cameras are watching, that emails are being hacked and manipulated – are quite common.
Despite the variety in the presentation of positive symptoms, one thing is clear – everyday logic and reasoning are of little utility while through these symptoms in treatment. The feelings of trueness and authenticity attached to the beliefs are so strong that rational debate is often useless. It is usually best to respectfully circle around these issues when treatment planning.
Positive and Negative Syndrome Scale (PANSS)
A common research tool in schizophrenia is the PANSS, which used to discern different symptom categories and measure treatment effects. Lindenmayer et al (1994 – abstract below) proposed a reorganization of the PANSS and the following categories reflect these changes. These are the specific definitions for negative and cognitive symptoms most frequently used.
Negative Symptoms (PANSS) – Inhibiting Social Integration and Development
1) Blunted Affect or Reduced Emotional Range
- Diminished emotional responsiveness and modulation of feelings.
- Reduced facial expression and communicative gestures.
2) Emotional Withdrawal
- Diminished interest and involvement with life’s events.
- Decreased commitment to previous interests.
3) Poor Rapport or Interpersonal Relatedness
- Lack of empathy and sense of closeness with others.
- Interpersonal distancing and reduced verbal and nonverbal communication.
4) Passive and Apathetic Social Withdrawal
- Diminished social interests and initiative.
- Passive, apathetic approach to life.
5) Lack of Spontaneity and Flow of Conversation
- Reduction in communication due to apathy and lack of interest.
- Poor flow and fluidity in verbal conversation.
6) Stereotyped or Rigid Thought Process
- Decreased spontaneity and flexibility of thinking.
- Rigid, repetitive, or barren thought content.
7) Active social avoidance
- Diminished social involvement due to fear, hostility, or distrust.
Cognitive Symptoms (PANSS) – Inhibiting Memory, Work and Performance
1) Conceptual disorganization
- Disorganized thinking that disrupts goals and problem solving.
- Circumstantial or loose associations, non-sequiturs, and gross illogicality.
2) Difficulty in abstract thinking
- Poor abstract-symbolic thinking and reasoning.
- Concrete or egocentric thinking in problem-solving tasks.
- Lack of awareness of relationship to the surroundings.
- Including person, place, and time.
4) Mannerisms and posturing
- Unnatural movements or posture.
- Awkward, stilted, disorganized appearance.
5) Poor attention
- Poor concentration and distractibility.
- Difficulty in harnessing, sustaining, or shifting focus.
A new five factor model of schizophrenia. Lindenmayer JP, Bernstein-Hyman R, Grochowski S (1994). Psychiatric Quarterly. 65(4): 299-322.
Schizophrenic psychopathology is heterogeneous and multidimensional, Various strategies have been developed over the past several years to assess and measure more accurately discrete domains of psychopathology. One of the more fruitful strategies to investigate more homogenous domains of psychopathology has been the positive-negative syndrome approach. However, this approach is unable to address a number of important issues. Most schizophrenics present a mixed syndrome; the criteria for what constitutes a positive and negative syndrome are variable; distinguishing primary from secondary negative symptoms can be difficult. In order to address some of these problems, we propose the introduction of a five syndrome model based on a reanalysis of factor analytic procedures used on 240 schizophrenics assessed with the Positive and Negative Syndrome Scale (PANSS). We present data on a 5-factor solution which appears to best fit the psychopathological data and which is supported by three independent and comparable factor analyses; negative, positive, excitement, cognitive and depression/anxiety domains of psychopathology give patients their individual mark. Data on internal consistency of the five factors and on initial validation using demographic and clinical variables are presented.