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Aspects of the negative syndrome, such as anhedonia, apathy, low motivation, and emotional withdrawal, are not specific to schizophrenia and have been found to be even more prevalent among inpatients with depression than in hospitalized patients with schizophrenia. The negative symptoms of schizophrenia have been shown to share many features with depression, and a recent study demonstrated that the cognitive deficits commonly associated with negative symptoms were primarily accounted for by the presence of depression in those with chronic schizophrenia. Notwithstanding the putative overlap between negative symptoms and depression, they remain distinct symptom domains that can be distinguished reliably. Other negative symptoms, such as affective flattening and alogia, have been conceptualized in terms of deficit states. Recent experimental research on affective flattening suggests that the problem may lie in expressing emotions rather than in a deficit in the ability to feel, while alogia may reflect difficulty in finding the right words rather than representing a dearth of communication skills. In summary, it may be that some negative symptoms reflect cognitive, emotional, and behavioral dysfunction rather than stable deficits. These may be amenable to change with strategies similar to those that have effectively harnessed motivation and social and emotional reengagement. Many patients with prominent negative symptoms experience other individuals (that is, family, friends, and health professionals) as demanding more from them in terms of activity and engagement then they are capable of giving. This may be especially pernicious for some patients who, prior to becoming ill, also held excessively high expectations for themselves, inconsequence of which they now see themselves as failing to live up to both their own and others' expectations. In a recent study (unpublished), higher scores on a measure of dysfunctional attitudes and beliefs regarding performance and achievement (that is, the Dysfunctional Attitude Scale-Perfectionism Dimension) were associated with a greater number and severity of negative symptoms. These scores were unrelated to the presence or severity of positive symptoms. Repeated unmet demands may further impact on perceived self-efficacy and fuel the cycle of hopelessness. The first step for the therapist is to reduce this pressure.
Cognitive Therapy of Negative Symptoms
The cognitive approach to treating negative symptoms follows from the cognitive and behavioral strategies previously described in the treatment of depression. It includes behavioral self-monitoring, activity scheduling, mastery and pleasure ratings, graded task assignments, and assertiveness-training methods. Cognitive strategies include eliciting the patient's reasons for inactivity and testing these beliefs directly with behavioral experiments; direct attempts either to stimulate new interests or to reactivate previously held interests; and identifying, testing, and changing self-critical automatic thoughts concerning performance.
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