Managing Negative Symptoms of Schizophrenia

In recent years, the negative symptoms of schizophrenia, such as affective flattening, lack of volition, and poverty of thought, have received increased and well-deserved attention. Awareness of the major contributions of negative symptoms to disability in schizophrenia and the fact that they do not necessarily respond to treatment in the same way as positive symptoms or to the same forms of treatment has led to a considerable expansion of the literature in the area.

Managing Negative Symptoms of Schizophrenia is a slim volume that attempts to present a thorough view of the phenomenology, neuroscience, and treatment of negative symptoms. Its authors, Ann Mortimer and Sean Spence, are British, on the faculty at the University of Hull and the University of Sheffield, respectively.

The book comprises nine chapters, all with references. The authors begin by discussing the new hope for patients with negative symptoms, ushered in by atypical antipsychotics. They continue with a review of the syndromes seen in schizophrenia, separating the positive syndrome (with a distinction between “reality distortion” and “disorganization”) from the negative syndrome. They see the primary psychopathology of negative symptoms as a failure to respond to stimuli, seen as poverty of ideation and poverty of affect, and consider other negative symptoms, such as loss of self-care, poverty of speech, and loss of motivation, as consequences of these primary symptoms. They are careful to enumerate “pseudonegative” symptoms separately—such entities as medication side effects, untreated positive symptoms, depression, and the effects of an institutional environment.

In chapter 4, the longest and most heavily referenced chapter, the authors review the contributions of neuroscience, including structural and functional imaging, neurochemistry, neuropsychology, and neurophysiology, acknowledging the lack of evidence pointing to one specific pathophysiology. Hypofrontality, lower dopaminergic activity in key pathways, and glutamate dysfunction are all given attention. A brief assessment of the burden of negative symptoms on the patient, family, and society follows.

The sixth chapter examines clinical and rating-scale-based assessment of negative symptoms. Commonly used rating scales, including the Brief Psychiatric Rating Scale, Positive and Negative Syndrome Scale, and Scale for the Assessment of Negative Symptoms, are discussed and included in appendixes. A practical discussion about evaluating and treating causes of “pseudonegative” symptoms is included. The seventh chapter provides a concise review of the effects of atypical antipsychotics. The authors note positive results with clozapine, olanzapine, and risperidone as well as the availability of less evidence recommending quetiapine and ziprasidone. Amisulpride, sulpiride, and zotepine, which are not available in the United States, are discussed, and the authors note that there is good evidence for amisulpride’s effectiveness. Other drugs of interest, including selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, glutamatergic agents, and dopamine agonists are also reviewed.

The eighth chapter discusses social and family approaches, including rehabilitation, social skills training, and support for family caregivers; the authors point out the importance of these approaches even when pharmacological management is optimal. The last chapter, “Co-ordinating the Delivery of Services,” focuses on the need for a team approach in the community, active outreach, and formal supervision. Services specific to the British health system, including extensive involvement of the patient’s general practitioner and certain legal mandates for monitoring, form the core of this chapter. The authors do not mention this specifically, but the approach they advocate seems to resemble the assertive community treatment model in the United States, which has much to recommend it for patients with persistent negative symptoms.

All in all, Managing Negative Symptoms of Schizophrenia is a solid book. It is concise, clearly written, and well referenced. Its length appears to be a compromise—the busy practicing psychiatrist may prefer a briefer review, such as a long journal article, but the academic scholar of negative/deficit schizophrenia might expect a full volume, citing all the literature, rather than the key studies referenced in this book. It is worthy of attention from anyone with a serious interest in schizophrenia, and its brevity means that most of us will actually have time to read it.