Galore International Journal of Health Sciences and Research Vol.4; Issue: 1; Jan.-March 2019 Website: www.gijhsr.com Review Article P-ISSN: 2456-9321 Negative Symptoms- an Update Dr Pavithra P. Rao1, Dr Preethi Rebello2, Dr P. John Mathai3 1Assistant Professor, Department of Psychiatry. Father Muller Medical College, Mangalore, Karnataka, India. 2Senior Resident, Department of Psychiatry, Father Muller Medical College, Mangalore, Karnataka, India. 3Professor. Department of Psychiatry, Jubilee Mission Medical College, East Fort Thrissur. Kerala. India. Corresponding Author: Dr P. John Mathai ABSTRACT INTRODUCTION Negative symptoms (NS) are Negative Symptoms in psychiatry are deficits in abnormal absence of normal behaviour and experience and behavior that are attributed to experience, attributed to the loss of normal loss of functions of brain. Negative symptoms functions of the brain. The NS are defined have been conceptualized as the core aspect of as absence of experience/behaviour that schizophrenia and have been recognized as [1] important ever since the days of Griesinger, should have been present. They are Kraepelin and Bleuler. But over the years the general descriptive terms used for the significance of the negative symptoms was various clinical manifestations of the deleted and emphasis was placed almost diminished capacity for ordinary exclusively on positive symptoms. The return of behavioural functioning (behavioural negative symptoms in schizophrenia was deficits). [2] Though there are differences in inevitable. The five general categories of the language used to refer to NS such as, negative symptoms include avolition, deficits symptoms, defect state symptoms, anhedonia, affective blunting, alogia and type II symptoms, core symptoms, asociality. The subdomains of negative fundamental symptoms, primary symptoms symptoms are experience domain (avolition and and basic symptoms, there are definite anhedonia) and expressivity domain (affective [3-7] blunting and alogia). consensus about its clinical significance. In this review article the authors discuss the The NS are important in the diagnosis, evolution of the concept, the current prognosis as well as in understanding the [4,7] conceptualization, consensus general categories neurobiology of schizophrenia. The NS and subdomains of negative symptoms, the and the cognitive deficits are considered as relationships to symptoms of other domains, the core aspects of schizophrenia. [3-7] In negative symptoms in the different phases of ICD-10 and DSM5 the NS are neither schizophrenia, Primary Enduring Negative necessary nor sufficient for diagnosis of Symptoms (PENS) and Persistent Negative schizophrenia. The primary enduring NS Symptom (PNS), the nonspecific, specific and (PENS) and the persistent NS(PNS) predict new generation scales for assessment. The poor outcome in patients with clinical importance of negative symptoms in terms of diagnosis, prognosis and treatment schizophrenia. The concept of NS options, the impact on comprehension of challenged the then existent frontiers and neurobiology of schizophrenia and the resultant concepts of schizophrenia. This paved way modifications in clinical and etiological models for researchers to develop new models of of schizophrenia are discussed. Further the schizophrenia and new biological and authors briefly discuss negative symptoms in neurological explanations for schizophrenia. other psychiatric disorders. The concept of NS was reintroduced to psychiatry in 1974. [2] Since early 1980’s Keywords: Negative Symptoms, Deficits, Core there has been a rekindled interest in NS of Schizophrenia, Category, Sub-domain. among schizophrenia researchers. [3-7] This renewed interest resulted in the Galore International Journal of Health Sciences and Research (www.gijhsr.com) 162 Vol.4; Issue: 1; January-March 2019 Pavithra P. Rao et.al. Negative Symptoms- an Update development of competing concepts, acceptance of Schneider’s FRS as soon as it assessment methods, biological and was published. First Rank Symptoms neurological models and new treatment consist of exclusively positive symptoms options for schizophrenia. [3,7] and they became so popular that most of the diagnostic criteria for schizophrenia were EVOLUTION OF THE CONCEPT based exclusively on the presence of the Recognizable descriptions of the NS FRS until recently. The reasons for the of schizophrenia can be found as early as neglect of the NS described as core features the mid-1800s, with Griesinger’s by Kraepelin and Bleulermay include the descriptions of an “absence of following; the florid expression and will,” followed by Kraepelin’s description manifestations of the positive symptoms, the of a “weakening of volition” among some dramatic response of positive symptoms to people with schizophrenia. Since Emil dopamine receptor antagonists, the fact that Kraepelin and EugenBleuler consolidated it is easier to define, assess and document the concepts of dementia praecox and positive symptoms compared to the NS and schizophrenia, it has been recognized that the universal popularity of the FRS. In the disorders are heterogeneous. Clinicians addition to the views of Kraepelin and and investigators had struggled to find out Bleuler, the concept of the core symptoms of schizophrenia. NS ‘Institutionalization’(Wing 1970) and were given a more prominent place in the Barton’s Neurosis(Institutional Neurosis) earlier concepts of schizophrenia. Emil were major influences in support of NS. [5-7] Kraepelin in his writings on dementia The return of NS in schizophrenia was praecox described the ‘avolition syndrome’ inevitable because of their universal as characteristic of the disorder. Emotional presence and endurance and the fact that the dullness, loss of inner sympathy, loss of positive symptoms failed to explain chronic interest, loss of motivation, loss of goal state, deterioration, residual phase, disability directed movements and deterioration were and treatment refractoriness. [3] described as core aspects of dementia It is generally held that John praecox. EugenBleuler described emotional Hughlings Jackson introduced the negative deterioration as characteristic of and positive symptom concept to neurology schizophrenia. He recognized that the (1875, 1889). This was done based on his fundamental symptoms (primary symptoms) complex hierarchical organization theory of were more important for diagnosis of the brain. Berrios (1985) in his historical schizophrenia than delusions and review remarks that it was in fact John hallucinations. The primary symptoms Russell Reynolds (1857) who introduced the (4As) have very strong resemblance to the NS to neurology. [8] Reynolds’s concept of current NS. [3,7] Kurt Schneider described NS was not based on any theory as such. It emotional withdrawal and lack of empathy is generally believed that the NS were as characteristic features of schizophrenia. reintroduced to psychiatry by Strauss and But he did not include such symptoms in his Carpenter (1974). HoweverBerrios mentions First Rank Symptoms. that it was De Clerambault (1942) who Both Kraepelin and Bleuler introduced the concept to psychiatry and considered NS as fundamental or core Crow remarks that it was introduced to psychopathology of schizophrenia. But over psychiatry by Snezhenesky(1968). [8] It is the years the significance of the NS was generally accepted that the reintroduction of brought down and emphasis was placed NS and the initial semantic work was done almost exclusively on positive symptoms by Strauss et al (1974), the empirical like delusions, hallucinations, formal research was kicked off by Crow(1980) and thought disorders and catatonic symptoms. the initial codification was completed by This fact is evidenced by the universal Andreasen (1981, 1982). [1-4,9] Mathai and Galore International Journal of Health Sciences and Research (www.gijhsr.com) 163 Vol.4; Issue: 1; January-March 2019 Pavithra P. Rao et.al. Negative Symptoms- an Update Gopinath introduced NS to psychiatric depression or neuroleptic medication are the research in India during 1982-84. [3,6,7,10] ICD-10 NS of schizophrenia. The DSM 5 CURRENT CONCEPTULIZATION includes diminished emotional response and Most of the current investigators have used avolition as characteristic NS of the concept of NS to refer to the reduction schizophrenia.To reduce the differences in or loss of normal functions. The current this area the consensus conference of concept is descriptive, not based on theories experts on NS held in the NIMH in 2005 and does not imply neurobiology or described five general categories of NS. relationship to other symptoms. Hence it They are Avolition, Anhedonia, Affective could be argued that the current concept is Blunting, Asociality and Alogia. [15] more Reynoldian than Jacksonian. The NS Avolition and Anhedonia are the most include signs and symptoms pertaining to common NS. During the conference the two affective, cognitive, volitional and social possible subdomains within the NS were behaviour domains of the higher functions discussed and agreed upon by the experts. of the brain. They indicate the loss of [16] emotional experience, conceptual fluency, Five General Categories of NS the experience of pleasure, volition and Avolition means loss of will or [3] ability for interpersonal relationship. drive. The term may be considered as There is no unanimity on the number, having almost similar meaning to abulia in category and components of NS. The list of neurology. Avolition and apathy