Early Psychosis Intervention: A Culturally Adaptive Clinical Guide

28. Handling Patients with Negative Symptoms

28 Handling Patients with Negative Symptoms Wing-chung Chang and Cindy Pui-yu Chiu Manifestations of Negative Symptoms People suffering from first-episode psychosis are often bewildered by the extraordinary experiences evolving around them, being helplessly entwined by events, which often bring turmoil into their lives. Positive psychotic symptoms may be readily understood by patients and caregivers as symptoms of an illness, whereas negative symptoms (including blunted affect, poverty of speech, avolition , apathy, and lack of social drive) are usually less easily accepted as part of the pathological process. Case Vignette 1 “He was a bright boy, being described by teachers to be inquisitive and helpful. He was always busy with sports and extracurricular activities [mother takes out a photo from her purse showing the patient in a wide grin with his parents in front of a cake]. Now he barely does any talking and is rather impatient with us. He spends hours in his room and seems to prefer solitude. In the past he was rather picky with his clothing but now he wears the same old jacket every day. He eats a lot but hardly notices what he is eating. There is little which interests him.” (Mother of Sam, 23 years old) When positive symptoms subside with treatment, some patients may be left with a residual state or deficit state where negative symptoms predominate. 312 Wing-chung Chang and Cindy Pui-yu Chiu In fact, negative symptoms have long been regarded as a core feature of schizophrenia (Bleuler, 1950; Kirkpatrick et al., 2006; Kraepelin, Barclay, & Robertson, 1919). Unlike positive symptoms, negative symptoms remain an unmet therapeutic need, and are associated with poor functional outcomes (Harvey et al., 2006; Ventura et al., 2009) and limited responses to pharmacotherapy (Murphy et al., 2006). Negative symptoms in the mild form may limit the patients’ personal effectiveness as they go back to work or study. They would be less enthusiastic , look detached, and may have problems in communicating or mixing with others. They may no longer find enjoyment in their work and some may feel frustrated about the changes. Those with more prominent negative symptoms may have problems with self-care or lack motivation to return to work, leading to deterioration in functional status. In any case, an individual’s recovery process is affected adversely and such diminished self-efficacy further decreases one’s self-esteem. Caregivers who witness such changes may show concern. They may render the patients responsible for such changes, interpreting such behaviours as sloth or laziness. Some caregivers may react by being permissive and overprotective while others may set strict standards and criticize or act with hostility. This scenario of high expressed emotions is undesirable with consequent escalated conflicts within the family and increased risk of psychotic relapse. What Contributes to Negative Symptoms? Certain subtypes of schizophrenia, particularly simple schizophrenia, have pronounced negative symptoms. Numerous studies examining relationship of duration of untreated psychosis (DUP) and psychopathology in firstepisode psychosis showed that prolonged DUP was associated with more severe negative symptoms at both initial presentation and follow-up (Malla et al., 2002; Marshall et al., 2005; Melle et al., 2004; Perkins et al., 2005). Several previous reports also demonstrate that patients with long DUP may have a higher likelihood of developing persistent negative symptoms (Chang et al., 2011; Chang et al., 2012; Edwards et al., 2002; Malla et al., 2005). It should, however, be noted that some investigators have suggested that it was duration of untreated illness (DUI) rather than DUP that was related to worse outcome on negative symptoms (Harris et al., 2005; Jeppesen et al., 2008). Poor premorbid adjustment, male sex, schizophrenia diagnosis and psychotic illness of Handling Patients with Negative Symptoms 313 neuro­ developmental origin have also been found to be related to more prominent negative symptoms (Chang et al., 2011a; Chang et al., 2011b; MacBeth & Gumley, 2008; Murray et al., 1992; Roy et al., 2001). Differential Diagnosis of Negative Symptoms Negative symptoms can be conceptualized and classified as primary versus secondary symptoms. Differentiating primary from secondary negative symptoms is of utmost clinical significance as the apparent negative symptoms can be much improved if secondary sources are correctly identified and properly treated. Concerning the source of secondary negative symptoms, persecutory delusions and heightened suspiciousness with consequent social avoidance and preoccupation may mimic negative symptoms. Depression, another differential diagnosis, should show other depressive features alongside lack of interest and motivation such as biological symptoms and...