2.  Negative symptoms represent absence or diminution of normal
intellectual function and expression . Krapelin considered it loss of
functioning while bleuler emphasized it qualitative loss of
organization . Hughling Jackson believed that negative symptom
represented pure loss of function while positive symptoms
represented exaggeration of normal function . They are subtler
and difficult to diagnose.
 Later Crow said positive symptoms found in type 1 schizophrenia
and negative symptoms are found in type 2 schizophrenia and
associated with insidious onset , poor premorbid adjustment , a
poor response to treatment , impaired cognition and structural
brain abnormalities.
 Can be primary or secondary
 Primary negative symptom comprise a core feature intrinsic to
schizophrenia itself.
 Secondary negative symptoms are attributable to or temporally
related to the effect of such factors as unrelieved positive
symptoms , adverse effects of antipsychotic drugs or social
isolation imposed by schizophrenia. They often subside with
resolution of causative factor.

3.  Carpenter et al. (1988) divided primary negative symptoms into
nonenduring and enduring (deficit) subtypes suggesting they
should be present for 12 months to be classified as deficit
symptoms. Möller et al. (1994) suggested that 6 months was more
pragmatic .Kirkpatrick et al. (1989) further specified deficit
symptoms into the deficit syndrome
 Persistent negative symptoms are those which have been present
for > 6 months and when they are enduring and not secondary to
any other cause they constitute deficit syndrome.
 Deficit syndrome is characterized by ---
 a. at least 2 of following 6 negative symptom must be present
 1. restricted affect 2. diminished emotional range 3. poverty of
speech 4. curbing of interest 5. diminished sense of purpose 6.
diminished social drive
 b. above symptoms have been present for preceding 12 month and
always were present during period of clinical stability
 c. negative symptoms are primary i.e. not secondary to factors
other than disease process like -
 1.anxiety 2. drug effect 3. suspiciousness 4. mental retardation 5.
depression.
 d. patient meets DSM criteria for schizophrenia

5.  Poor communication – reduced capacity to initiate
or respond to speech , meager or impoverished
content of speech .
 Psychomotor retardation – slow or restricted
physical movements.
 It has been seen that patients with negative
symptoms are more likely to have been born in
winter (opler et al 1984), to have poor premorbid
cognitive and social adjustment ( opler et al 1984)
,to respond inadequately to neuroleptics (brier et al
, johnston et al 1987), to have family history of
schizophrenia ( kay, opler , fiszbein 1986), to show
morphological brain abnormalities ( andreasen et
al 1982 , weinberger et al 1980).

7.  Weinberger (1987) proposed dysregulation of
dopamine system . Putative hypofunction of
prefrontal dopamine system could provide a
possible neurobiologic mechanism for negative
symptom and increased subcortical dopamine
activity might account for positive symptom and
movement disorder. The combination of positive
and negative symptom common in schizophrenia
could result from reduced prefrontal dopamine
function , leading to relative hyperactivity of
subcortical dopamine , which would normally be
modulated by prefrontal system .

10.  A. SELF RATING INSTRUMENTS –
 1. Subjective experience of deficits in
schizophrenia(SEDS, Liddle and Barnes , 1988) –
consists of 21 items arranged in 6 groups namely
abnormal thinking and concentration , disturbance
of affect , impaired will and decreased energy
, disturbance of perception , intolerance of stress &
disturbance of voluntary movements.
 2. Subjective deficit syndrome scale ( SDSS, Bitter
et al 1989 , Jaeger et al 1990 ) -
based of experimental subscale of subclinical
symptom
scale. Based exclusively on self report.

11.  B . Observer rated instruments –
 1. Brief psychiatric rating scale ( BPRS , overall and graham
1962) – 7 point scale based on 16 or 18 items depending on
version
 2. Krawiecka – Manchester scale ( KMS , krawiecka et al 1977 )
– 5 point 8 item scale. Four items namely incoherence or
irrelevance of speech , poverty of speech or muteness, flattened
or incongruous affect and psychomotor retardation are based
on patient’s response to questions. Four other items depression
, anxiety , delusion and hallucination based on rater’s
observation.
 3. Scale for assessment of negative scale ( SANS ) – it is
enlargement of affective flattening scale ( andreasen ,1979).it is
6 point scale based on 30 items from five symptom complexes –
alogia , affective flattening , avolition – apathy , anhedonia -
asociality , attention al impairment.
 4. Positive and negative syndrome scale ( PANSS , kay 1987 ) –
it consist of 30 items scale 18 adapted from BPRS and 12 from
psychopathology rating schedule rated on 7 point scale.

12.  5. Negative symptom rating scale ( NSRS
, iager ,1985 ) - 7 point scale based on 10 items
divided into 4 subscales two including two
items and 3 including 3 items . a. thought
process through speech , judgment b. cognition
through memory , attention and orientation. c.
volition through grooming , motivation and
motion d. affect and relatedness through
emotional response and expressive relatedness.
 6. other scales – the schedule for deficit
syndrome ( carpenter et al , 1988) , lewin-fog-
melzer scale ( 1983) , pearlson scale (1984)
, emotional blunting scale , wing scale
(1961), pogue – giele – harrow scale (1984)

13.  Treatment begins with assessing factor that can cause secondary negative
symptom . Treatment of secondary negative symptom will be treating their
cause like antipsychotic for positive symptoms , antidepressant for depression
, anxiolytic for anxiety , antiparkinsonian or antipsychotic dose reduction for
extrapyramidal side effects. If they don’t resolve by such treatment than they
are primary negative symptom . For primary negative symptom 2nd
generation antipsychotics in low dose are prescribed.
 Low-dose amisulpride should be currently considered first-line treatment for
patients with primary negative symptoms.
 Aripiprazole and olanzapine should be considered second-line treatments.
 Clozapine is not recommended for patients with primary, enduring negative
symptoms.
 Trials with NMDA agonists, mirtazepine and SSRIs are promising but need
more investigation.
 Mirtazepine, fluoxetine, fluvoxamine or paroxetine should be trialed as
adjunctive medication in patients resistant to amisulpride and/or
aripiprazole/olanzapine.
 Psychological interventions should be incorporated into the treatment
package.
 In one RCT mirtazapine augmentation of risperidone was found to reduce
negative symptom. In another study fluvoxamine has not been found effective
. In another study once weekly dosing of D-cycloserin has been found to
improve negative symptoms. Repeated transcranial magnetic stimulation has
also been found to reduce severity of negative symptoms.

14.  1. Positive and negative syndromes in schizophrenia: assessment and
research:By Stanley R. Kay
 2. Negative schizophrenic symptoms: pathophysiology and clinical
implications :By John F. Greden, Rajiv Tandon
 3. CTP
 4. OTP
 5. Negative symptoms: the ‘pathology’ of motivation and goal-directed
behaviour :Richard G. Brown and Graham Pluck ; Trends Neurosci. (2000)
23, 412–417
 6. Clinical evaluation of negative symptoms in schizophrenia : Hans-
Ju¨rgen Mo¨ller ; European Psychiatry 22 (2007) 380e386
 7. Schizophrenia Research 95 (2007) 151–157
 8. The deficit syndrome in schizophrenia: implications for the treatment
of negative symptoms ; European Psychiatry 19 (2004) 21–26
 9. Drug treatment of the negative symptoms of schizophrenia : David J.
King ; European Neuropsychopharmacology 8 (1998) 33–42
 Pharmacological treatment of primary negative symptoms in
schizophrenia: A systematic review ; Schizophrenia Research 88 (2006) 5–
25