Effects of environmental deprivation on negative symptoms of schizophrenia: a nationwide survey in Japan's psychiatric hospitals

Conceptualization and characterization of "primary" and "secondary" cognitive impairment in schizophrenia

Cognitive impairment represents one of the core features of schizophrenia, involves both neurocognition and social cognition domains, and has a significant negative impact on real-world functioning. The present review provides a framework for the conceptualization and characterization of "primary" and "secondary" cognitive impairment in schizophrenia. In this conceptualization, primary cognitive impairment can be defined as a consequence of the neurobiological alterations that underlie psychopathological manifestations of the disorder, while secondary cognitive impairment can be defined as the results of a source issue that has a negative impact on cognitive performance. Sources of secondary cognitive impairment are frequent in people with schizophrenia and include several different factors, such as positive and negative symptoms, depressive symptoms, autistic symptoms, pharmacotherapy, substance abuse, metabolic syndrome, social deprivation, and sleep disorders. It can be hypothesized that secondary cognitive impairment may be improved by effectively resolving the source issue, while primary cognitive impairment may benefit from dedicated treatment. Further research is required to confirm this hypothesis, to better characterize the distinction between primary and secondary cognitive impairment in a clinical and in a neurobiological perspective, and to evaluate the impact of systematically assessing and treating secondary cognitive impairment.

Environmental factors contributing to negative symptoms in youth at clinical high risk for psychosis and outpatients with schizophrenia

BACKGROUND

A bioecosystem theory was recently proposed positing that negative symptoms of schizophrenia (SZ) are influenced by environmental factors. These environmental processes reflect sources of resource deprivation that manifest across multiple systems that impact individuals directly through microsystems and indirectly through the exosystem and macrosystem. As an initial test of this theory, the current study examined whether self-reported environmental resource deprivation was associated with anhedonia, avolition, and asociality.

METHOD

Two samples were collected: (1) outpatients with schizophrenia or schizoaffective disorder (SZ: n = 38) and matched psychiatrically heathy controls (CN: n = 31); (2) youth at clinical high risk for psychosis (CHR: n = 34) and matched CN (n = 30). Measures of negative symptoms and environmental factors influencing the frequency of recreational, goal-directed, and social activities were collected.

RESULTS

Negative symptoms were associated with environmental deprivation factors in the microsystem (number of social and activity settings) and exosystem (economy, mass media, politics/laws, neighborhood crime). These associations did not appear due to depression and were greater among those with SZ than CHR.

CONCLUSIONS

These findings provide preliminary support for the bioecosystem theory and highlight an under-recognized role for environmental factors underlying negative symptoms across phases of psychotic illness. Environmental systems-focused treatment approaches may offer a novel means of treating negative symptoms, which could be promising when coupled with person-level pharmacological and psychosocial treatments.

Environmental resource reductions predict greater severity of negative symptoms in schizophrenia

No pharmacological or psychosocial interventions effectively treat negative symptoms in schizophrenia (SZ), despite the identification of biological and psychological mechanistic targets. Limited treatment progress may result from failure to account for non-person-level environmental factors that present barriers to performing recreational, social, and goal-directed activities. The bioecosystem model of negative symptoms proposes that four interactive ecosystems (i.e. microsystem, mesosystem, exosystem, and macrosystem) influence person-level factors (e.g., dysfunctional beliefs, glutamate, cortico-striatal functioning) to initiate and maintain negative symptoms. The current study tested this hypothesis by examining whether indirect environmental factors (e.g., access to resources for performing activities in the built environment) were associated with dysfunctional beliefs (defeatist performance, asocial, anhedonic) and negative symptoms (anhedonia, avolition, asociality). Self-reports of indirect environmental factors (i.e., the built environment), dysfunctional beliefs, and negative symptoms were collected from 31 individuals with SZ and 29 matched healthy controls. Mediation analyses were conducted with dysfunctional beliefs as the predictor, indirect environmental factors as mediator, and negative symptoms as the outcome. Individuals with SZ reported reduced access to environmental resources for performing recreational, goal-directed, and social activities; these reductions were associated with greater negative symptom severity. Mediation analyses indicated that the effect of dysfunctional beliefs on negative symptoms was mediated by participants' satisfaction with resources for performing activities in their environment. These findings suggest that psychosocial treatments could be augmented to not only target dysfunctional beliefs, but also environmental processes that lead these beliefs to emerge and contribute to negative symptoms.

The efficacy of homestyle rehabilitation on negative symptoms in chronic schizophrenia: A randomized controlled trial

Objective

Schizophrenia is a debilitating mental disorder with a high disability rate that is characterized by negative symptoms such as apathy, hyperactivity, and anhedonia that can make daily life challenging and impair social functioning. In this study, we aim to investigate the effectiveness of homestyle rehabilitation in mitigating these negative symptoms and associated factors.

Methods

A randomized controlled trial was conducted to compare the efficacy of hospital rehabilitation and homestyle rehabilitation for negative symptoms in 100 individuals diagnosed with schizophrenia. The participants were divided randomly into two groups, each persisting for 3 months. The primary outcome measures were the Scale for Assessment of Negative Symptoms (SANS) and Global Assessment of Functioning (GAF). The secondary outcome measures included the Positive Symptom Assessment Scale (SAPS), Calgary Schizophrenia Depression Scale (CDSS), Simpson-Angus Scale (SAS), and Abnormal Involuntary Movement Scale (AIMS). The trial aimed to compare the effectiveness of the two rehabilitation methods.

Results

Homestyle rehabilitation for negative symptoms was found to be more effective than hospital rehabilitation, according to the changes in SANS (T = 2.07, p = 0.04). Further analysis using multiple regression indicated that improvements in depressive symptoms (T = 6.88, p < 0.001) and involuntary motor symptoms (T = 2.75, p = 0.007) were associated with a reduction in negative symptoms.

Conclusion

Homestyle rehabilitation may have greater potential than hospital rehabilitation in improving negative symptoms, making it an effective rehabilitation model. Further research is necessary to investigate factors such as depressive symptoms and involuntary motor symptoms, which may be associated with the improvement of negative symptoms. Additionally, more attention should be given to addressing secondary negative symptoms in rehabilitation interventions.

Discrepancies between ideal and actual affect in schizophrenia: Implications for understanding negative symptoms

Anhedonia is a core symptom of schizophrenia (SZ). However, psychological mechanisms underlying anhedonia are unclear, making it difficult to develop personalized psychosocial treatments. The current study explored the novel hypothesis that anhedonia is driven by discrepancies between ideal and actual affect (i.e., how positive or negative someone wants to feel compared to how they do feel), which impact the frequency of recreational, goal-directed, and social behaviors. Participants included 32 outpatients with SZ and 29 healthy controls (CN) who completed the Affect Valuation Index and measures of negative symptom severity. Results indicated that individuals with SZ displayed greater positive and negative emotion discrepancy scores than CN, suggesting that they strongly desire to feel more positive and less negative in the future than they actually do. Additionally, greater ideal relative to actual positive and negative affect was associated with greater severity of anhedonia, avolition, and asociality. The discrepancy between ideal and actual affective states may be demotivating, leading individuals with SZ to develop dysfunctional beliefs after repeated experiences of failing to achieve their desired emotional goal state. These findings suggest that ideal affect may be a novel psychological mechanism underlying negative symptoms that could be targeted in psychosocial treatments.

Primary and Secondary Negative Symptoms in Schizophrenia

The negative symptoms of schizophrenia include volitional (motivational) impairment manifesting as avolition, anhedonia, social withdrawal, and emotional disorders such as alogia and affective flattening. Negative symptoms worsen patients' quality of life and functioning. From the diagnostic point of view, it is important to differentiate between primary negative symptoms, which are regarded as an integral dimension of schizophrenia, and secondary negative symptoms occurring as a result of positive symptoms, comorbid depression, side effects of antipsychotics, substance abuse, or social isolation. If secondary negative symptoms overlap with primary negative symptoms, it can create a false clinical impression of worsening deficit symptoms and disease progression, which leads to the choice of incorrect therapeutic strategy with excessive dopamine blocker loading. Different longitudinal trajectories of primary and secondary negative symptoms in different schizophrenia stages are proposed as an important additional discriminating factor. This review and position paper focuses primarily on clinical aspects of negative symptoms in schizophrenia, their definition, phenomenology, factor structure, and classification. It covers the historical and modern concepts of the paradigm of positive and negative symptoms in schizophrenia, as well as a detailed comparison of the assessment tools and psychometric tests used for the evaluation of negative symptoms.

The impact of the COVID-19 pandemic on negative symptoms in individuals at clinical high-risk for psychosis and outpatients with chronic schizophrenia

Negative symptoms are core features of schizophrenia-spectrum disorders that are frequently observed across all phases of illness. By their nature, COVID-19 social isolation, physical distancing, and health precautions induce behavioural aspects of negative symptoms. However, it is unclear whether these prevention measures also lead to increases in experiential negative symptoms, whether such effects are equivalent across individual negative symptom domains, and if exacerbations occur equivalently across phases of illness. The current study compared negative symptom severity scores obtained during the pandemic to pre-pandemic assessments in two samples: (1) outpatients with chronic schizophrenia (SZ: n = 32) and matched healthy controls (CN: n = 31) and (2) individuals at clinical high risk for psychosis (CHR: n = 25) and matched CN (n = 30). Pre-pandemic ratings of negative symptoms were clinically elevated in SZ and CHR groups, which did not differ from each other in severity. In SZ, ratings obtained during the pandemic were significantly higher than pre-pandemic ratings for all 5 domains (alogia, blunted affect, anhedonia, avolition, and asociality) and item-level analyses indicated that exacerbations occurred on both experiential and behavioral symptoms of anhedonia, avolition, and asociality. In contrast, CHR only exhibited increases in anhedonia and avolition items during the pandemic compared to pre-ratings. Findings suggest that negative symptoms should be a critical treatment target during and after the pandemic in the schizophrenia spectrum given that they are worsening and critically related to risk for conversion, functional outcome, and recovery.

Mechanisms Underlying Motivational Dysfunction in Schizophrenia

Negative symptoms are a debilitating feature of schizophrenia which are often resistant to pharmacological intervention. The mechanisms underlying them remain poorly understood, and diagnostic methods rely on phenotyping through validated questionnaires. Deeper endo-phenotyping is likely to be necessary in order to improve current understanding. In the last decade, valuable behavioural insights have been gained through the use of effort-based decision making (EBDM) tasks. These have highlighted impairments in reward-related processing in schizophrenia, particularly associated with negative symptom severity. Neuroimaging investigations have related these changes to dysfunction within specific brain networks including the ventral striatum (VS) and frontal brain regions. Here, we review the behavioural and neural evidence associated with negative symptoms, shedding light on potential underlying mechanisms and future therapeutic possibilities. Findings in the literature suggest that schizophrenia is characterised by impaired reward based learning and action selection, despite preserved hedonic responses. Associations between amotivation and reward-processing deficits have not always been clear, and may be mediated by factors including cognitive dysfunction or dysfunctional or self-defeatist beliefs. Successful endo-phenotyping of negative symptoms as a function of objective behavioural and neural measurements is crucial in advancing our understanding of this complex syndrome. Additionally, transdiagnostic research–leveraging findings from other brain disorders, including neurological ones–can shed valuable light on the possible common origins of motivation disorders across diseases and has important implications for future treatment development.

A Bioecosystem Theory of Negative Symptoms in Schizophrenia

Objective: Negative symptoms are a core feature of schizophrenia that has been linked to numerous poor clinical outcomes. Although person-level mechanisms have been identified for negative symptoms, psychosocial and pharmacological treatments targeting these mechanisms have been ineffective. The current theoretical paper proposes that limited treatment progress may result in part from a failure to identify and target environmental processes that cause and maintain negative symptoms. Methods: A novel theoretical model is outlined, called the bioecosystem theory of negative symptoms, that offers a conceptual framework for studying interactions among environmental systems and person-related biological and psychosocial factors. Results: Relying on Bronfenbrenner's developmental theory as an organizing framework, four interactive environmental systems are proposed to be critical for the genesis and maintenance of negative symptoms: (1) Microsystem: the immediate environment; (2) Mesosystem: the interactions among microsystems; (3) Exosystem: indirect environments that influence the individual through the microsystems; (4) Macrosystem: socio-cultural factors. The environmental factors within these systems are proposed to function as a network and have dynamic within-system interactions, as well as cross-system interactions that change over time and across phases of illness. Conclusions: Environmental contributions to negative symptoms have received minimal empirical attention, despite their potential to explain variance in negative symptom severity. The bioecosystem model of negative symptoms introduced here offers a novel conceptual framework for exploring environmental contributions to negative symptoms and their interaction with person-level biological and psychological factors. This theory may facilitate new avenues for identifying environmental treatment targets and novel systems-level interventions.

Evidence for two distinct domains of negative symptoms: Confirming the factorial structure of the CAINS

Negative symptoms are an important predictor of course of illness as well as social and occupational functioning. Clinically effective interventions are scarce. For negative symptoms to become a reliable primary endpoint in treatment studies, clear operationalization and construct validation is needed. Recent factor analyses mostly find two main factors for negative symptoms: diminished expression und amotivation/anhedonia. The Clinical Assessment Interview for Negative Symptoms (CAINS) consists of the subscales "motivation and pleasure" and "expression". We assessed three samples of subjects with schizophrenia (n = 105) for different aspects of the scale's reliability and validity. A confirmatory factor analysis (CFA) of the CAINS confirmed its two-factorial structure. The subscales had distinct correlational profiles: "Motivation and pleasure" was strongly associated with functional outcome and depression and further with neurocognition, positive symptoms and social cognition. "Expression" seems independent of sources of secondary negative symptoms and neurocognition. We found good internal consistency and interrater agreement. Test-retest reliability (two-week interval) was moderate for the CAINS and its "expression" subscale and low for the "motivation and pleasure" subscale. Our findings indicate that the CAINS differentiates reliably between the two main domains of negative symptoms with some questions remaining concerning the validity of the "motivation and pleasure" subscale.

Predictors of negative symptoms in the chronic phase of schizophrenia: A cross-sectional study

This study was designed to investigate the relationship between negative symptoms and key indicators for long-term hospital stays among inpatients with schizophrenia. A further aim was to elucidate the clinical determinants of negative symptoms. The following were used as index factors: age, duration of illness, duration of hospitalization, age at onset, years of education, smoking status, body mass index, concentrations of serum triglycerides, total cholesterol, uric acid, QTc interval duration from electrocardiography, dose equivalents of antipsychotic and anticholinergic agents, neurocognitive function, drug-induced extrapyramidal symptoms, involuntary movements, and psychiatric symptoms. Spearman's rank correlation coefficients were calculated and regression analyses were performed to examine associations between these factors and negative symptoms. Positive symptoms correlated positively with negative symptoms as rated on the Brief Psychiatric Rating Scale. Age at onset correlated negatively with negative symptoms. Multiple regression analysis showed that dose equivalents of atypical antipsychotics and positive symptoms predicted negative symptoms. Increasing our understanding of these predictors as key indicators of the severity of negative symptoms may aid in the reconsideration of therapeutic programs for chronic schizophrenia.

Amendment of traditional assessment measures for the negative symptoms of schizophrenia

Schizophrenia research based on traditional assessment measures for negative symptoms appears to be, to some extent, unreliable. The limitations of the Positive and Negative Syndrome Scale (PANSS) and the Scale for the Assessment of Negative Symptoms (SANS) have been extensively acknowledged and should be taken into account. The aim of this study is to show how the PANSS and the SANS conflate negative symptoms and cognition and to offer alternatives for the limitations found.

METHODS

A sample of 117 participants with schizophrenia from two independent studies was retrospectively investigated. Linear regression models were computed to explore the effect of negative symptoms and illness duration as predictors of cognitive performance.

RESULTS

For the PANSS, the item "abstract thinking" accounted for the association between negative symptoms and cognition. For the SANS, the "attention" subscale predicted the performance in verbal memory, but illness duration emerged as a stronger predictor than negative symptoms for outcomes of processing speed, verbal and working memory.

CONCLUSION

Utilizing alternative models to the traditional PANSS and SANS formats, and accounting for illness duration, provide more precise evidence on the relationship between negative symptoms and cognition. Since these measures are still extensively utilized, we recommend adopting more rigorous approaches to avoid misleading results.

Using Functional Analysis as a Framework to Guide Individualized Treatment for Negative Symptoms

Although numerous interventions are available for negative symptoms, outcomes have been unsatisfactory with pharmacological and psychological interventions producing changes of only limited clinical significance. Here, we argue that because negative symptoms occur as a complex syndrome caused and maintained by numerous factors that vary between individuals they are unlikely to be treated effectively by the present "one size fits all" approaches. Instead, a well-founded selection of those interventions relevant to each individual is needed to optimize both the efficiency and the efficacy of existing approaches. The concept of functional analysis (FA) can be used to structure existing knowledge so that it can guide individualized treatment planning. FA is based on stimulus-response learning mechanisms taking into account the characteristics of the organism that contribute to the responses, their consequences and the contingency with which consequences are tied to the response. FA can thus be flexibly applied to the level of individual patients to understand the factors causing and maintaining negative symptoms and derive suitable interventions. In this article we will briefly introduce the concept of FA and demonstrate-exemplarily-how known psychological and biological correlates of negative symptoms can be incorporated into its framework. We then outline the framework's implications for individual assessment and treatment. Following the logic of FA, we argue that a detailed assessment is needed to identify the key factors causing or maintaining negative symptoms for each individual patient. Interventions can then be selected according to their likelihood of changing these key factors and need to take interactions between different factors into account. Supplementary case vignettes exemplify the usefulness of functional analysis for individual treatment planning. Finally, we discuss and point to avenues for future research guided by this model.

Secondary negative symptoms - A review of mechanisms, assessment and treatment

Negative symptoms in schizophrenia may be classified as primary or secondary. Primary negative symptoms are thought to be intrinsic to schizophrenia, while secondary negative symptoms are caused by positive symptoms, depression, medication side-effects, social deprivation or substance abuse. Most of the research on secondary negative symptoms has aimed at ruling them out in order to isolate primary negative symptoms. However, secondary negative symptoms are common and can have a major impact on patient-relevant outcomes. Therefore, the assessment and treatment of secondary negative symptoms are clinically relevant. Furthermore, understanding the mechanisms underlying secondary negative symptoms can contribute to an integrated model of negative symptoms. In this review we provide an overview of concepts, evidence, assessment and treatment for the major causes of secondary negative symptoms. We also summarize neuroimaging research relevant to secondary negative symptoms. We emphasize the relevance of recent developments in psychopathological assessment of negative symptoms, such as the distinction between amotivation and diminished expression, which have only rarely been applied in research on secondary negative symptoms.

Jung's views on causes and treatments of schizophrenia in light of current trends in cognitive neuroscience and psychotherapy research II: psychological research and treatment

Jung was the first to emphasize the importance of psychological factors in the aetiology and treatment of schizophrenia. Despite this, and other seminal contributions, his work on schizophrenia is almost completely ignored or forgotten today. This paper, a follow-up to one on Jung's theories of aetiology and symptom formation in schizophrenia (Journal of Analytical Psychology, 59, 1) reviews Jung's views on psychological approaches to research on, and treatment of, the disorder. Five themes are covered: 1) experimental psychopathology; 2) attentional disturbance; 3) psychological treatment; 4) the relationship between the environment (including the psychiatric hospital) and symptom expression; and 5) heterogeneity and the schizophrenia spectrum. Review of these areas reveal that Jung's ideas about the kind of research that can elucidate psychological mechanisms in schizophrenia, and the importance of psychotherapy for people with this condition, are very much in line with contemporary paradigms. Moreover, further exploration of several points of convergence could lead to advances in both of these fields, as well as within analytical psychology.

Predictors of quality of life in inpatients with schizophrenia

Shortening hospital stays has become a key focus in psychiatric care in recent years. However, patients with schizophrenia account for about 60% of inpatients in psychiatry departments in Japan. This study was designed to investigate the relationship between quality of life (QOL) and key indicators for long-term hospital stays among schizophrenia inpatients. A further aim was to elucidate the clinical determinants of QOL among long-stay inpatients. The study sample consisted of 217 inpatients with schizophrenia. Age, duration of illness, duration of hospitalization, years of education, body mass index, neurocognitive function, drug-induced extrapyramidal symptoms, involuntary movements, psychiatric symptoms, and dose equivalents of antipsychotics and anticholinergic agents were used as index factors. Pearson linear correlation and regression analyses were performed to examine the associations between QOL and the above-mentioned factors. Negative symptoms, psychological discomfort, and resistance as rated on the Brief Psychiatric Rating Scale (BPRS) were correlated with all subscale scores of the Japanese version of the Schizophrenia Quality of Life Scale (JSQLS). Stepwise regression showed that negative symptoms, psychological discomfort, and resistance predicted the dysfunction of psycho-social activity score and the dysfunction of motivation and energy score on the JSQLS. This study shows that active treatment for negative symptoms, psychological discomfort, and resistance should be recommended to improve QOL among inpatients with schizophrenia.

Association between feasibility of discharge, clinical state, and patient attitude among inpatients with schizophrenia in Japan

AIM

There have been some studies on the feasibility of discharging mentally ill inpatients from mental hospitals. The purpose of the present study was to investigate how a psychiatrist judges whether an inpatient can be discharged.

METHODS

A survey regarding such judgments on discharge was conducted involving 549 inpatients with schizophrenia with a hospital stay of > or =1 year. Relationships between psychiatrist judgments on discharge and the Brief Psychiatric Rating Scale (BPRS), Scales for the Assessment of Negative Symptoms (SANS), Global Assessment Scale (GAS), patient attitude to discharge, and other variables were investigated. A similar analysis was conducted regarding patient attitudes toward discharge.

RESULTS

After controlling for potential confounding factors using multiple logistic regression, the judgments showed significant relationships with BPRS-P, SANS, GAS, and age. Patient attitudes showed significant relationships with the length of the current hospital stay, SANS, and psychiatrists' judgments.

CONCLUSION

A psychiatrist's judgment regarding discharge is a comprehensive decision that takes into account psychiatric symptoms, social functioning, and age. Such a judgment could also affect a patient's own attitude toward discharge.