Negative symptoms in schizophrenia include affective flattening, alogia, anhedonia, asociality, and avolition. These symptoms can be difficult to recognize and differentiate into primary symptoms that are core to schizophrenia versus secondary symptoms caused by other factors like medication side effects. Over time, positive symptoms tend to diminish whereas negative symptoms become more prominent, especially in the residual phase of schizophrenia. Risk factors for negative symptoms include male gender, genetic factors, and structural brain abnormalities. Various scales are used to assess negative symptoms including the Positive and Negative Syndrome Scale and the Scale for the Assessment of Negative Symptoms. Treatments targeting negative symptoms include cariprazine, olanzapine, amisulpride, and ris

1. Negative Symptoms:
 Negative symptoms area key element of schizophrenia including
symptoms such as ,
o Affect (blunted), refers to a decrease in emotions and expressions.
Patients may appear immobile, lifeless, and have a wooden
expression . They may make little to no eye contact and speak in a
dull monotone voice . Absence of emotions is called flat affect
o Alogia, Patients with schizophrenia often have reduced speech
and may give shortanswers to questions. Many questions may be
required in order to receive sufficiently detailed information from
the patient
o Anhedonia refers to lack of pleasure. Patients suffering from
schizophrenia may not take interest in activities they previously
enjoyed
o Asociality show diminished interest and pleasure in social
interactions, and often neglect activities of daily living (such as
personalhygiene) . Asociality should not be defined in purely
behavioralterms (whether the subjecthas social interactions and
close relationships), butmainly as a reduction in motivation for
social contacts (whether the subjectvalues and desires social
interactions and closesocial bonds)
o Avolition refers to lack of motivation, senseof purpose, or ability
to follow through on plans. For example, the patient may havea
desire or interest to grow a garden but never act on the plan.
 These symptoms may occur with or without positive symptoms and
can,at times,be difficult to recognize as part of the disorder.
 Carpenter and colleagues differentiated it into primary and secondary
negative symptoms.
 Primary negative symptoms areconsidered as the core symptom of
schizophrenia.
 Secondary negative symptoms aredrug-induced
akinesia,chronicity,socialdeprivation,depressivefeatures and psychotic
symptoms.

2.  Deficit syndromepresenceof at least two out of the following six
negative symptoms in patients meeting criteria for schizophrenia: 1.
restricted affect , 2. diminished emotional range , 3. poverty of speech,
4. curbing of interests, 5. diminished senseof purpose, 6.diminished
social drivefor at least 12 months including periods of clinical stability.
The above symptoms areprimary, i.e., not secondary.
 Negative symptoms representan important componentof schizophrenia
and haveconsistently been associated with poor outcome.
Course:
The prodromalperiod and the very early phases of the diseaseare
characterized by negative symptoms . In contrast, early stages and acute
exacerbations aremore characterized by positive symptoms. Over time,
the positivesymptoms diminish due to treatment or due to the natural
courseof the illness and are replaced by more prominent negative
symptoms. Finally, during the residual phaseof the illness, negative
symptoms aremost prevalent.
According to the ICD-10,which classifies schizophrenia into different
subtypes, negativesymptoms prominently occur in hebephrenic, simple,
and residualschizophrenia.
Risk factors:
• male gender—while in general schizophrenia, thereis no differencein
gender
• summer births, compared to a winter birth in general schizophrenia
• serum antibodies to cytomegalovirus
• low serum folate concentration
• higher genetic contribution in negative symptoms than to positive
symptoms
• obstetric complications
• structuralabnormalities, such as
enlarged ventricles
• dysfunctionalbeliefs about performance(increased defeatist
performancebeliefs), acceptance, likelihood of success, and resources,
which reduce motivation

3. PREVALENCE OF NEGATIVESYMPTOMS INPSYCHOSIS:
(Journal-Harvard Review Of Psychiatry)
 In the first stage,adolescents or young adults who presentwith sub-
threshold symptoms or with a combination of genetic risk plus
functional deterioration are considered to be at clinical or Ultra-high risk
of psychosis(UHR).
 The First EpisodePsychosis(FEP) typically occurs between 19 to 26 years
and is characterised by full-blown combinations of positive and negative
symptoms.Later on,a significantproportion of FEP patients will continue
to experience reccurent Multiple Episodes Of Psychosis(MEP),with
positive & negative symptoms,which can persisteven through later life.
 Anhedonia-Neuraldysfuntions within the brain’s reward system-in
particular,the striatum-representa specific factor that could play role in
the increasing rates of anhedonia observed between the FEP and yMEP
stages.On the other hand,somestudies reported hyperactivation of the
striatum in FEP individuals,leading someauthors to hypothesizethat the
reduced activity observed in yMEP samples stem from effectsof long-
term antipsychotics.
 Avolition-UHR individuals showed lower motivation than FEP individuals
according to a study.Thepresenceof avolition may precipitate the
development of other negative symptoms.
 Asociality-Higher levels of anxiety in UHR may apply here to explain the
elevated rates of asociality at the UHR stage.Psychotic symptoms have
lower plasma levels of oxytocin.
 Blunted affect-Dueto beliefs such as “showing my feelings will let others
see my inadequacy” and due to extra pyramidal symptoms on using anti-
psychotics.
 Alogia-Prevalenceof this symptom is due to defeatist beliefs such as” I
will not find the right words to express myself”.Theseare due to the
connectivity alterations in the venteromedial prefrontaland parietal
cortices which has decreased verbalexpression in patients with
psychosis.

4. Assessment of Negative Symptoms:
 The Positive and Negative Syndrome Scale (PANSS) is a medical scale used for
measuring symptom severity of patients with schizophrenia.It has positive scale(7
times),negative scale(7times) andgeneral psychopathology(16times)
 The Scale for the Assessment of Negative Symptoms (SANS) is a rating scale to
measure negative symptoms in schizophrenia.Has 5 Domains.
 The Brief Negative Symptom Scale(BNSS)
 Clinical Assessment Interview for Negative Symptoms(CAINS)
Treatment:
 Cariprazine
 Olanzapine
 Amisulpride
 Risperidone