A Two-Factor Model Better Explains Heterogeneity in Negative Symptoms: Evidence from the Positive and Negative Syndrome Scale

Dimensional characteristics of persistent negative symptoms in schizophrenia and their relationships with schizotypy in first-degree relatives

PURPOSE OF THE ARTICLE

Schizophrenia with persistent negative symptoms (PNS) may have different characteristics regarding negative symptom dimensions and heritability patterns. This study aimed to investigate the dimensional characteristics of PNS and their relationships with schizotypal features in first-degree relatives (FDRs).

MATERIALS AND METHODS

The study included 142 patients, 142 FDRs, and 71 healthy controls (HC). Patients were evaluated with the Positive and Negative Symptom Scale (PANSS), Brief Negative Symptom Scale (BNSS), Calgary Depression Scale for Schizophrenia (CDSS), and Simpson-Angus Scale (SAS). Schizotypy Personality Questionnaire was applied to FDR and HC groups. Clinical symptoms were compared between primary-PNS, secondary-PNS, and non-PNS groups. In addition, schizotypy scores were compared between FDRs and HCs. Then, the relationship between the symptoms of the patients in the PNS group and the schizotypy scores of their relatives was evaluated by multiple regression analysis.

RESULTS

All negative symptom dimension scores were similar in primary-PNS and secondary-PNS and lowest in non-PNS. PNS-FDR had higher in all schizotypy scores than non-PNS-FDR and HC, except for lack of close friends and social anxiety. In the PNS group, positive symptom severity and PANSS experiential deficit scores significantly predicted positive and negative schizotypy scores in relatives. Negative schizotypy was associated with asociality.

CONCLUSIONS

The PNS is likely a subtype in which the genetic basis of negative symptoms is stronger and is associated with genetic abnormalities shared by positive and negative schizotypy dimensions in relatives. Family-based genetic studies will be beneficial in enlightening the genetic etiology of PNS.

Negative symptoms and sex differences in first episode schizophrenia: What's their role in the functional outcome? A longitudinal study

INTRODUCTION

Negative symptoms (NS) include asociality, avolition, anhedonia, alogia, and blunted affect and are linked to poor prognosis. It has been suggested that they reflect two different factors: diminished expression (EXP) (blunted affect and alogia) and amotivation/pleasure (MAP) (anhedonia, avolition, asociality). The aim of this article was to examine potential sex differences among first-episode schizophrenia (FES) patients and analyze sex-related predictors of two NS symptoms factors (EXP and MAP) and functional outcome.

MATERIAL AND METHODS

Two hundred and twenty-three FES (71 females and 152 males) were included and evaluated at baseline, six-months and one-year. Repeated measures ANOVA was used to examine the effects of time and sex on NS and a multiple linear regression backward elimination was performed to predict NS factors (MAP-EXP) and functioning.

RESULTS

Females showed fewer NS (p=0.031; Cohen's d=-0.312), especially those related to EXP (p=0.024; Cohen's d=-0.326) rather than MAP (p=0.086), than males. In both male and female group, worse premorbid adjustment and higher depressive symptoms made a significant contribution to the presence of higher deficits in EXP at one-year follow-up, while positive and depressive symptoms predicted alterations in MAP. Finally, in females, lower deficits in MAP and better premorbid adjustment predicted better functioning at one-year follow-up (R2=0.494; p<0.001), while only higher deficits in MAP predicted worse functioning in males (R2=0.088; p=0.012).

CONCLUSIONS

Slightly sex differences have been found in this study. Our results lead us to consider that early interventions of NS, especially those focusing on motivation and pleasure symptoms, could improve functional outcomes.

A transdiagnostic approach to negative symptoms: exploring factor structure and negative symptoms in bipolar disorders

Background

Negative symptoms are increasingly recognized as transdiagnostic phenomena, linked to reduced quality of life and functioning, and often caused or worsened by amendable external factors such as depression, social deprivation, side-effects of antipsychotics or substance use. The structure of negative symptoms fits into two dimensions: diminished expression and apathy. These may differ in association with external factors that influence their severity and may thus require different treatment approaches. The dimensions are comprehensively established in non-affective psychotic disorders but are understudied in bipolar disorders.

Methods

We conducted exploratory and confirmatory factor analyses in a sample of 584 individuals with bipolar disorder to assess the latent factor structure of negative symptoms as measured by the Positive and Negative Syndrome Scale (PANSS), and performed correlational analyses and multiple hierarchical regression analyses to investigate links between the two dimensions of negative symptoms and clinical and sociodemographic correlates.

Results

The latent factor structure of negative symptoms fits into two dimensions, i.e., diminished expression and apathy. A diagnosis of bipolar type I or a history of psychotic episodes predicted more severe levels of diminished expression. Depressive symptoms were associated with more severe negative symptoms across dimensions, yet 26.3% of euthymic individuals still displayed at least one mild or more severe negative symptom (PANSS score ≥ 3).

Discussion

The two-dimensional structure of negative symptoms seen in non-affective psychotic disorders reproduces in bipolar disorders indicating similarities in their phenomenology. Diminished expression was associated with a history of psychotic episodes and a diagnosis of BD-I, which may infer closer connections to psychosis liability. We found significantly less severe negative symptoms in euthymic than depressed participants. Nevertheless, more than a quarter of the euthymic individuals had at least one mild negative symptom, demonstrating some degree of persistence beyond depressed states.

Negative symptoms in drug-naive patients with a first-episode psychosis (FEP)

INTRODUCTION

Negative symptoms are nuclear features of schizophrenia that may be present from the onset of the disease. In recent years, it has been described 2 subdomains of negative symptoms: experiential and expressive deficits. The aim of the study is to examine the relationship between negative symptoms and demographic and clinical variables in patients with first-episode psychosis. Also, to explore whether there are differences in the association among these variables and negative symptoms when divided into both subdomains.

MATERIAL AND METHODS

A cross-sectional study was performed in 160 patients (52 females and 108 males) with a diagnosis of a first episode psychosis. A questionnaire was administered to collect demographic and clinical variables.

RESULTS

A backward stepwise linear regressions analysis was performed in order to observe potential associations between demographic and clinical variables and the presence of negative symptoms. All three models are predicted by worse PSP score, a higher CDSS, a higher disorganized factor score and a lower excited factor score. A longer duration of untreated psychosis (DUP) is associated to a higher score in the experiential deficit subdomain only.

CONCLUSIONS

Our work highlights some clinical and phenomenological differences between experiential and expressive deficits. We think that taking into account both subdomains in future studies may lead to more accurate clinical assessment and interventions.

The trajectory of two negative symptom dimensions in first-episode psychosis and the role of cannabis use: A 10-year follow-up study

OBJECTIVE

To investigate the trajectories of diminished expression and apathy over 10 years. Further, to explore the effects of baseline- and persistent cannabis use on the development of diminished expression and apathy during follow-up, while controlling other potential sources and predictors of secondary negative symptoms.

METHODS

351 participants with a first episode of non-affective psychosis were examined at baseline and invited to follow-up at one year and 10 years. The trajectories of diminished expression and apathy were investigated using linear mixed models. Subsequently, cannabis use and other potential predictors and sources of secondary negative symptoms were added to the model to investigate the respective impact on their trajectories.

RESULTS

The severity of both diminished expression and apathy decreased during the follow-up period after the first episode of psychosis, with the most improvement observed from baseline to 1-year follow-up. Cannabis use at baseline was associated with a long-lasting higher symptom load for diminished expression, but not apathy. Introducing persistent cannabis use to the model further strengthened the association with diminished expression.

CONCLUSION

Both cannabis use at baseline and persistent cannabis use after a first episode of psychosis were associated with more severe symptoms of diminished expression. Our results imply a causal relationship between cannabis use and diminished expression and suggest that measures to reduce cannabis use both before and after psychosis onset may reduce expressive negative symptoms.

The relationship between negative symptoms, social cognition, and social functioning in patients with first episode psychosis

INTRODUCTION

Social functioning is severely affected in psychotic disorders. Negative symptoms and social cognition seem to play an important role in social functioning, although the preponderance and relationship between these three domains is not clear. In this study, we sought to assess the interrelation between social cognition, social functioning, and the expressiveness and experiential factors of negative symptoms in first-episode psychosis (FEP).

SAMPLE AND METHODS

216 patients, participants in a multicentre study (AGES-CM), comprised our study sample. The WHO Disability Assessment Schedule (WHODAS 2.0) was used to assess functioning, whereas the Positive and Negative Schizophrenia Syndrome Scale (PANSS) was used to measure the severity of negative symptoms, and the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) was applied to assess the emotional processing component of social cognition. Network analyses were conducted with the aim of analysing the patterns of relationships between social cognition, social functioning, and the expressiveness and experiential factors of negative symptoms.

RESULTS

Our findings suggest that there is a direct relationship between social cognition and social functioning (weight = -.077), but also an indirect connection between them, mediated by the experiential (but not the expressiveness) factor of negative symptoms (weight = 0.300).

DISCUSSION

The importance of the affectation of subdomains of social cognition, as well as the role of negative symptoms, specifically the experiential factor, in the functioning of patients with FEP seems to be relevant. The inclusion of these factors in prevention and treatment programs would thus allow us to reduce their impact on the social functioning of these patients.

Identifying clinical and psychological correlates of persistent negative symptoms in early-onset psychotic disorders

Persistent negative symptoms (PNS) contribute to impairment in psychosis. The characteristics of PNS seen in youth remained under-investigated. We aimed to demonstrate clinical, treatment-related, and psychosocial characteristics of PNS in early-onset schizophrenia-spectrum disorders (EOSD). 132 patients with EOSD were assessed with Positive and Negative Symptom Scale, Brief Negative Symptom Scale, Calgary Depression Scale for Schizophrenia, and Simpson-Angus Scale. Parenting skills and resilience were evaluated using Parental Attitude Research Instrument and Child and Youth Resilience Measure-12. Longer duration of untreated psychosis (DUP) and prodromal phase were found in primary and secondary PNS groups, compared to the non-PNS group. The primary PNS group was characterized by earlier age-onset, lower smoking rates, and more common clozapine use. Resilience and egalitarian/democratic parenting were negatively correlated with symptoms related to motivation/pleasure and blunted expression. More blunted expression-related symptoms and longer DUP in the first episode significantly predicted primary/secondary PNS at follow-up. Using the data from total negative symptom scores and DUP, Receiver Operating Characteristic analyses significantly differentiated primary/secondary PNS groups from the non-PNS counterparts. PNS associated with blunted expression and low motivation/pleasure in the first episode could persist into clinical follow-up. Effective pharmacological treatment and psychosocial interventions are needed in youth.

The trajectories and correlates of two negative symptom subdomains in first-episode schizophrenia

BACKGROUND

Recent studies suggest a two-factor structure for negative symptoms as assessed by the Positive and Negative Syndrome Scale (PANSS) in schizophrenia, namely experiential and expressive subdomains. Little is known about their clinical correlates and treatment trajectories.

OBJECTIVES

We sought to replicate the two factor-analysis derived subdomains for PANSS negative symptoms in schizophrenia and to assess their independent demographic, premorbid and treatment-related characteristics.

METHODS

This was a longitudinal study of 106 minimally treated participants with a first episode of a schizophrenia spectrum disorder who received treatment with flupenthixol decanoate 2-weekly injections over two years. Factor analysis was used to characterize the PANSS negative symptom subdomains and linear mixed-effect models for continuous repeated measures were constructed to assess the temporal relations between the negative symptom subdomains and premorbid and treatment related variables.

RESULTS

Factor analysis confirmed a two-factor solution for experiential and expressive subdomains of negative symptoms, although they were strongly correlated. The treatment response trajectories for the two subdomains did not differ significantly, and neither subdomain was significantly associated with our premorbid variables. We found significant main effects for disorganised symptoms and extrapyramidal symptoms on the expressive subdomain, and for disorganised symptoms and depressive symptoms on the experiential subdomain. Post-hoc testing indicated that reductions in HDL-cholesterol levels were associated with less improvement in both expressive and experiential subdomain scores.

CONCLUSION

The two negative symptom subdomains are closely related, have similar premorbid correlates and respond similarly to antipsychotic treatment. Depression affects the experiential subdomain, whereas extrapyramidal symptoms affect the expressive subdomain.

Examining Potential Barriers to mHealth Implementation and Engagement in Schizophrenia: Phone Ownership and Symptom Severity

Objective

Implementation of mobile health (mhealth) interventions remains limited among those with schizophrenia. This study examined several logistical barriers to the implementation of mHealth interventions, particularly text message interventions, for people with schizophrenia.

Methods

This study examined the feasibility of leveraging personal mobile phones to deliver mHealth interventions by using data from a pilot randomized controlled trial (RCT) of a text message intervention delivered on personal mobile phones to 56 people with schizophrenia with motivation reductions.

Results

Among those screened for the RCT (n =100), 91% had a mobile phone. For randomized participants (n = 56), 82.1% had a smartphone, with almost all (93.5%) having an Android processing system. Most randomized participants had unlimited text messages (96.4%) or voice calls (76.8%) with their mobile service plan, with 32.1% having unlimited data each month. At baseline, most used text messages (85.2%) and the internet (59.3%), while fewer participants used mobile applications (35.2%) at least once a week. Finally, there were no significant associations between engagement in the text message intervention and participant demographics, symptoms (positive, mood, negative), neurocognition, or mobile phone or plan characteristics or changes made during the 8 week intervention.

Conclusions

Even those with schizophrenia with perceived symptom barriers to mHealth engagement (i.e., motivation reductions) may have access to mobile phones and plans and familiarity with mobile features to engage meaningfully with a text message intervention. These results help to support future implementations of text message interventions, which may enhance the provision of care for those with schizophrenia.

Measuring Emotional Awareness in Patients With Schizophrenia and Schizoaffective Disorders

The ability to mentalize (i.e., to form representations of mental states and processes of oneself and others) is often impaired in people with schizophrenia spectrum disorders. Emotional awareness (EA) represents one aspect of affective mentalizing and can be assessed with the Levels of Emotional Awareness Scale (LEAS), but findings regarding individuals with schizophrenia spectrum disorders are inconsistent. The present study aimed at examining the usability and convergent validity of the LEAS in a sample of N = 130 stabilized outpatients with schizophrenia or schizoaffective disorders. An adequacy rating was added to the conventional LEAS rating to account for distortions of content due to, for example, delusional thinking. Scores of the patient group were compared with those of a matched healthy control sample. Correlation with symptom clusters, a self-report measure of EA, a measure of synthetic metacognition (MAS-A-G), and an expert rating capturing EA from the psychodynamic perspective of psychic structure (OPD-LSIA) were examined. Regarding self-related emotional awareness, patients did not score lower than controls neither in terms of conventional LEAS nor in terms of adequacy. Regarding other-related emotional awareness, however, patients showed a reduced level of adequacy compared to controls whereas no such difference was found for conventional LEAS scores. Higher conventional LEAS scores were associated with fewer negative symptoms, and higher structural integration of self-perceptions measured by the OPD-LSIA. Higher adequacy of responses correlated with fewer symptoms of disorganization as well as excitement, higher scores of self-reflection on the MAS-A-G as well as self- and object-perception and internal and external communication as measured by the subscales of the OPD-LSIA. Findings suggest that the LEAS might not be sensitive enough to detect differences between mildly symptomatic patients with schizophrenia or schizoaffective disorders and healthy controls. However, LEAS ratings are still suitable to track intraindividual changes in EA over time. Observing the adequacy of patients’ responses when using the LEAS may be a promising way to increase diagnostical utility and to identify patterns of formal and content-related alterations of mentalizing in this patient group. Methodological indications for future studies are discussed.

Negative symptom dimensions in first episode psychosis: Is there a difference between schizophrenia and non-schizophrenia spectrum disorders?

AIM

Identifying discrete dimensions that underline negative symptoms in First Episode Psychosis (FEP) could improve the understanding and the treatment of such invalidating symptomatology. The aim of this study is to examine the negative symptom structure in FEP individuals and to compare the resulting factor configurations between FEP subjects with and without Schizophrenia Spectrum Disorders (SSD vs non-SSD).

METHODS

One hundred and seventy participants (88 SSD and 82 non-SSD), aged 13-35 years, completed the Comprehensive Assessment of At-Risk Mental States (CAARMS) and the Positive and Negative Syndrome Scale (PANSS). A principal component analysis was then performed to investigate PANSS negative symptom structure in both non-SSD and SSD groups.

RESULTS

Whereas in the SSD sample a 3-factor model solution (i.e., "Socio-Emotional Disengagement", "Motor/Thought Poverty", and "Avolition/Apathy" dimensions) was identified, a 2-factor model solution (with a mixed alogia/avolition domain in addition to a mixed socio-emotional disengagement/expressive deficits dimension) appeared more appropriate in the non-SSD group.

CONCLUSIONS

Our results show a relevant difference in the negative symptom factor structure between SSD and non-SSD individuals. In particular, a different specificity and significance of negative symptom models in FEP populations with diagnoses other than schizophrenia (compared to those with SSD) must be realistically considered. Notably, a "Motor/Thought Poverty" domain, which specifically includes alogia and motor retardation separately from the other PANSS negative items, appears to specifically characterize FEP young patients with the schizophrenia spectrum.

Elucidating negative symptoms in the daily life of individuals in the early stages of psychosis

BACKGROUND

It remains poorly understood how negative symptoms are experienced in the daily lives of individuals in the early stages of psychosis. We aimed to investigate whether altered affective experience, anhedonia, social anhedonia, and asociality were more pronounced in individuals with an at-risk mental state for psychosis (ARMS) and individuals with first-episode psychosis (FEP) than in controls.

METHODS

We used the experience sampling methodology (ESM) to assess negative symptoms, as they occurred in the daily life of 51 individuals with FEP and 46 ARMS, compared with 53 controls.

RESULTS

Multilevel linear regression analyses showed no overall evidence for a blunting of affective experience. There was some evidence for anhedonia in FEP but not in ARMS, as shown by a smaller increase of positive affect (BΔat-risk v. FEP = 0.08, p = 0.006) as the pleasantness of activities increased. Against our expectations, no evidence was found for greater social anhedonia in any group. FEP were more often alone (57%) than ARMS (38%) and controls (35%) but appraisals of the social situation did not point to asociality.

CONCLUSIONS

Overall, altered affective experience, anhedonia, social anhedonia and asociality seem to play less of a role in the daily life of individuals in the early stages of psychosis than previously assumed. With the experience of affect and pleasure in daily life being largely intact, changing social situations and appraisals thereof should be further investigated to prevent development or deterioration of negative symptoms.

Negative symptom configuration in patients with first episode affective psychosis: findings from the 1-year follow-up of the "Parma Early Psychosis" program

Background and aim:

Evidence on discrete dimensions underlining negative symptoms in First Episode Affective Psychosis (FEAP) may be useful for their treatment strategy, but is still relatively scarce. Aim of this study was to examine the negative symptom configuration in patients with FEAP using both exploratory and confirmatory factor analysis methods on the Positive And Negative Syndrome Scale (PANSS).

Methods:

Seventy-eight participants, aged 13-35 years, completed the PANSS within the “Parma Early Psychosis” (Pr-EP) program, a specialized protocol of early detection and intervention in psychosis implemented since January 2013 in all public adolescent and adult mental health services of the Parma Department of Mental Health (Northern Italy).

Results:

A 3-factor model (i.e. “Alogia”, “Social Withdrawal” and “Motor/Affective Expression Poverty” domains) was identified. As an alternative, a 2-factor solution previously proposed in patients with first episode schizophrenia (always within the Pr-EP program) also showed good fit indices in our FEAP sample.

Conclusions:

Our results suggest the crucial importance of identifying discrete negative symptom domains already at the onset of affective psychosis in order to implement specific early intervention strategies aiming to improve prognosis and long-term outcomes also in this young FEAP help-seeking population.

EPA guidance on assessment of negative symptoms in schizophrenia

Background

During the last decades, a renewed interest for negative symptoms (NS) was brought about by the increased awareness that they interfere severely with real-life functioning, particularly when they are primary and persistent.

Methods

In this guidance paper, we provide a systematic review of the evidence and elaborate several recommendations for the conceptualization and assessment of NS in clinical trials and practice.

Results

Expert consensus and systematic reviews have provided guidance for the optimal assessment of primary and persistent negative symptoms; second-generation rating scales, which provide a better assessment of the experiential domains, are available; however, NS are still poorly assessed both in research and clinical settings.

This European Psychiatric Association (EPA) guidance recommends the use of persistent negative symptoms (PNS) construct in the context of clinical trials and highlights the need for further efforts to make the definition of PNS consistent across studies in order to exclude as much as possible secondary negative symptoms. We also encourage clinicians to use second-generation scales, at least to complement first-generation ones.

The EPA guidance further recommends the evidence-based exclusion of several items included in first-generation scales from any NS summary or factor score to improve NS measurement in research and clinical settings. Self-rated instruments are suggested to further complement observer-rated scales in NS assessment.

Several recommendations are provided for the identification of secondary negative symptoms in clinical settings.

Conclusions

The dissemination of this guidance paper may promote the development of national guidelines on negative symptom assessment and ultimately improve the care of people with schizophrenia.

What is the Best Latent Structure of Negative Symptoms in Schizophrenia? A Systematic Review

Background

Determining the best latent structure of negative symptoms in schizophrenia could benefit assessment tools, neurobiological research, and targeted interventions. However, no review systematically evaluated studies that assessed and validated latent models of negative symptoms.

Objective

To identify and evaluate existing latent structure models in the literature of negative symptoms and to determine the best model.

Method

Systematic search of MEDLINE, EMBASE, and Scopus on July 19, 2020, for confirmatory factor analysis models of negative symptoms in patients with schizophrenia. The available evidence was assessed through 2 sets of criteria: (1) study design quality—based on negative symptoms assessment and modeling strategy and (2) psychometric quality and model fit—based on fit indices and factor definition quality.

Results

In total, 22 studies (n = 17 086) from 9 countries were included. Studies differed greatly regarding symptom scales, setting, and sample size (range = 86–6889). Dimensional models included 2–6 factors (median = 4). Twelve studies evaluated competing models and adopted appropriate instruments to assess the latent structure of negative symptoms. The 5-factor and hierarchical models outperformed unitary, 2-factor, and 3-factor models on all direct comparisons, and most of the analyses derived from the Brief Negative Symptom Scale. Considering the quality criteria proposed, 5-factor and hierarchical models achieved excellent fit in just one study.

Conclusions

Our review points out that the 5-factor and hierarchical models represent the best latent structure of negative symptoms, but the immaturity of the relevant current literature may affect the robustness of this conclusion. Future studies should address current limitations regarding psychometric properties and also address biological and clinical validity to refine available models.

Negative Symptom Domains Are Associated With Verbal Learning in Adolescents With Early Onset Psychosis

Background: Early-onset psychosis (EOP) is among the leading causes of disease burden in adolescents. Negative symptoms and cognitive deficits predicts poorer functional outcome. A better understanding of the association between negative symptoms and cognitive impairment may inform theories on underlying mechanisms and elucidate targets for development of new treatments. Two domains of negative symptoms have been described in adult patients with schizophrenia: apathy and diminished expression, however, the factorial structure of negative symptoms has not been investigated in EOP. We aimed to explore the factorial structure of negative symptoms and investigate associations between cognitive performance and negative symptom domains in adolescents with EOP. We hypothesized that (1) two negative symptom factors would be identifiable, and that (2) diminished expression would be more strongly associated with cognitive performance, similar to adult psychosis patients. Methods: Adolescent patients with non-affective EOP (n = 169) were included from three cohorts: Youth-TOP, Norway (n = 45), Early-Onset Study, Norway (n = 27) and Adolescent Schizophrenia Study, Mexico (n = 97). An exploratory factor analysis was performed to investigate the underlying structure of negative symptoms (measured with the Positive and Negative Syndrome Scale (PANSS)). Factor-models were further assessed using confirmatory factor analyses. Associations between negative symptom domains and six cognitive domains were assessed using multiple linear regression models controlling for age, sex and cohort. The neurocognitive domains from the MATRICS Consensus Cognitive Battery included: speed of processing, attention, working memory, verbal learning, visual learning, and reasoning and problem solving. Results: The exploratory factor analysis of PANSS negative symptoms suggested retaining only a single factor, but a forced two factor solution corroborated previously described factors of apathy and diminished expression in adult-onset schizophrenia. Results from confirmatory factor analysis indicated a better fit for the two-factor model than for the one-factor model. For both negative symptom domains, negative symptom scores were inversely associated with verbal learning scores. Conclusion: The results support the presence of two domains of negative symptoms in EOP; apathy and diminished expression. Future studies on negative symptoms in EOP should examine putative differential effects of these symptom domains. For both domains, negative symptom scores were significantly inversely associated with verbal learning.

Negative symptom configuration within and outside schizophrenia spectrum disorders: results from the "Parma Early Psychosis" program

The identification of discrete dimensions underlining negative symptoms in First Episode Psychosis (FEP) may be useful in the treatment strategy for such severe symptomatology. Aim of this research was to investigate the negative symptom configuration in FEP patients and to compare the emerging factor solutions between individuals with and without Schizophrenia Spectrum Disorders (non-SSD vs SSD). Two-hundred-seventy-four participants (144 non-SSD and 130 SSD), aged 13-35 years, completed the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning (GAF). Confirmatory and exploratory factor analyses were then performed to examine PANSS negative symptom configuration in both SSD and non-SSD samples. In SSD, a 3-factor model solution (i.e. "Experiential Deficits", "Volition/Empathy Deficits" and "Motor/Affective Expression Deficits" domains) was identified. A different 2-factor configuration (with "Social/Communicative Withdrawal" and "Motor/Affective/Motivational Deficits" dimensions) was more appropriate in non-SSD. In conclusion, our results show differences in negative symptom factor models between non-SSD and SSD. Thus, a different specificity and significance of negative symptom solutions in FEP populations with diagnoses other than schizophrenia (compared to those with SSD) must be realistically considered.

Efficacy of psychological treatments for patients with schizophrenia and relevant negative symptoms: A meta-analysis

Background

Recent meta-analyses on the efficacy of psychological treatments for the negative symptoms of schizophrenia included mostly trials that had not specifically targeted negative symptoms. To gauge the efficacy of such treatments in the target patient population – namely people with schizophrenia who experience negative symptoms – we conducted a meta-analysis of controlled trials that had established an inclusion criterion for relevant negative symptom severity.

Method

We conducted a systematic literature search and calculated random-effects meta-analyses for controlled post-treatment effects and for pre-post changes within treatment arms. Separate analyses were conducted for different therapeutic approaches. Our primary outcome was reduction in negative symptoms; secondary outcomes were amotivation, reduced expression, and functioning.

Results

Twelve studies matched our inclusion criteria, testing Cognitive Behavioral Therapy (CBT) vs. treatment-as-usual (k = 6), Cognitive Remediation (CR) vs. treatment-as-usual (k = 2), CBT vs. CR (k = 2), and Body-oriented Psychotherapy (BPT) vs. supportive group counseling and vs. Pilates (k = 1 each). Accordingly, meta-analyses were performed for CBT vs. treatment-as-usual, CR vs. treatment-as-usual, and CBT vs. CR. CBT and CR both outperformed treatment-as-usual in reducing negative symptoms (CBT: Hedges’ g = -0.46; CR: g = -0.59). There was no difference between CBT and CR (g = 0.12). Significant pre-post changes were found for CBT, CR, and to a lesser extent for treatment-as-usual, but not for BPT.

Conclusion

Although effects for some approaches are promising, more high-quality trials testing psychological treatments for negative symptoms in their target population are needed to place treatment recommendations on a sufficiently firm foundation.

Deconstructing Negative Symptoms in Individuals at Clinical High-Risk for Psychosis: Evidence for Volitional and Diminished Emotionality Subgroups That Predict Clinical Presentation and Functional Outcome

Negative symptoms are characteristic of schizophrenia and closely linked to numerous outcomes. A body of work has sought to identify homogenous negative symptom subgroups-a strategy that can promote mechanistic understanding and precision medicine. However, our knowledge of negative symptom subgroups among individuals at clinical high-risk (CHR) for psychosis is limited. Here, we investigated distinct negative symptom profiles in a large CHR sample (N = 244) using a cluster analysis approach. Subgroups were compared on external validators that are (1) commonly observed in the schizophrenia literature and/or (2) may be particularly relevant for CHR individuals, informing early prevention and prediction. We observed 4 distinct negative symptom subgroups, including individuals with (1) lower symptom severity, (2) deficits in emotion, (3) impairments in volition, and (4) global elevations. Analyses of external validators suggested a pattern in which individuals with global impairments and volitional deficits exhibited more clinical pathology. Furthermore, the Volition group endorsed more disorganized, anxious, and depressive symptoms and impairments in functioning compared to the Emotion group. These data suggest there are unique negative symptom profiles in CHR individuals, converging with studies in schizophrenia indicating motivational deficits may be central to this symptom dimension. Furthermore, observed differences in CHR relevant external validators may help to inform early identification and treatment efforts.

Cognitive Impairment and Diminished Neural Responses Constitute a Biomarker Signature of Negative Symptoms in Psychosis

The treatment of negative symptoms (NS) in psychosis represents an urgent unmet medical need given the significant functional impairment it contributes to psychosis syndromes. The lack of progress in treating NS is impacted by the lack of known pathophysiology or associated quantitative biomarkers, which could provide tools for research. This current analysis investigated potential associations between NS and an extensive battery of behavioral and brain-based biomarkers in 932 psychosis probands from the B-SNIP database. The current analyses examined associations between PANSS-defined NS and (1) cognition, (2) pro-/anti-saccades, (3) evoked and resting-state electroencephalography (EEG), (4) resting-state fMRI, and (5) tractography. Canonical correlation analyses yielded symptom-biomarker constructs separately for each biomarker modality. Biomarker modalities were integrated using canonical discriminant analysis to summarize the symptom-biomarker relationships into a "biomarker signature" for NS. Finally, distinct biomarker profiles for 2 NS domains ("diminished expression" vs "avolition/apathy") were computed using step-wise linear regression. NS were associated with cognitive impairment, diminished EEG response amplitudes, deviant resting-state activity, and oculomotor abnormalities. While a connection between NS and poor cognition has been established, association to neurophysiology is novel, suggesting directions for future mechanistic studies. Each biomarker modality was related to NS in distinct and complex ways, giving NS a rich, interconnected fingerprint and suggesting that any one biomarker modality may not adequately capture the full spectrum of symptomology.

Intersection of verbal memory and expressivity on cortical contrast and thickness in first episode psychosis

BACKGROUND

Longitudinal studies of first episode of psychosis (FEP) patients are critical to understanding the dynamic clinical factors influencing functional outcomes; negative symptoms and verbal memory (VM) deficits are two such factors that remain a therapeutic challenge. This study uses white-gray matter contrast at the inner edge of the cortex, in addition to cortical thickness, to probe changes in microstructure and their relation with negative symptoms and possible intersections with verbal memory.

METHODS

T1-weighted images and clinical data were collected longitudinally for patients (N = 88) over a two-year period. Cognitive data were also collected at baseline. Relationships between baseline VM (immediate/delayed recall) and rate of change in two negative symptom dimensions, amotivation and expressivity, were assessed at the behavioral level, as well as at the level of brain structure.

RESULTS

VM, particularly immediate recall, was significantly and positively associated with a steeper rate of expressivity symptom decline (r = 0.32, q = 0.012). Significant interaction effects between baseline delayed recall and change in expressivity were uncovered in somatomotor regions bilaterally for both white-gray matter contrast and cortical thickness. Furthermore, interaction effects between immediate recall and change in expressivity on cortical thickness rates were uncovered across higher-order regions of the language processing network.

CONCLUSIONS

This study shows common neural correlates of language-related brain areas underlying expressivity and VM in FEP, suggesting deficits in these domains may be more linked to speech production rather than general cognitive capacity. Together, white-gray matter contrast and cortical thickness may optimally inform clinical investigations aiming to capture peri-cortical microstructural changes.

Negative symptom configuration in first episode Schizophrenia: findings from the "Parma Early Psychosis" program

Purpose: Identifying distinct dimensions of negative symptoms in First Episode Schizophrenia (FES) might result in a better understanding and treatment of this invalidating symptomatology. Aim of this study was to examine negative symptom structure in FES patients using the Positive and Negative Syndrome Scale (PANSS).Materials and Methods: All 147 participants, aged 12-35 years, completed the PANSS and the Global Assessment of Functioning (GAF) scale. A principal component analysis with varimax rotation was performed to investigate PANSS negative symptom structure in the FES total sample.Results: A 2-factor model (i.e. "Expressive Deficits" and "Asociality" dimensions) was identified. Only "Expressive Deficits" domain had a significant negative correlation with baseline GAF score.Conclusions: This bipartite solution seems to be adequate to describe the phenomenological variety of negative symptoms experienced by FES individuals at the point of entry in early intervention services.

The brief negative symptom scale in translation: A review of psychometric properties and beyond

Negative symptoms are a core feature of schizophrenia and associated with social and occupational impairment. To encourage treatment development and address the limitations of existing rating instruments in this area across culture, the Brief Negative Symptoms Scale (BNSS) was developed. The authors reviewed studies published since the BNSS was published in 2010 that examined the psychometric properties of the instrument in translation and compared for consistency, psychometric performance and related features. Eleven published cross-cultural validation studies demonstrated the translated versions of the BNSS have strong psychometric properties, similar to the original English version. The internal consistency ranged from 0.88 to 0.98 and the inter-rater reliability ranged from 0.81 to 0.98 for the total score. The BNSS exhibited good convergent validity with existing measures of similar constructs and function, and good discriminant validity relative to other constructs. Recent research also reported that the BNSS is sensitive to drug effects, with effect sizes comparable to established scales. The results of confirmatory factor analyses revealed that the 5-factor structure of negative symptoms in schizophrenia (blunted affect, anhedonia, avolition, asociality, and alogia) crosses cultures. This psychometric evidence suggests that the BNSS is a valid and reliable instrument for assessing pathological mechanism underlying the negative symptoms of schizophrenia across cultures and can be a useful instrument in global clinical trials.

Deficit Versus Nondeficit Schizophrenia: An MEG-EEG Investigation of Resting State and Source Coherence-Preliminary Data

This study investigated the magneto- and electroencephalography (MEG and EEG, respectively) resting state to identify the deviations closely associated with the deficit syndrome (DS) in schizophrenia patients. Ten subjects in each group (control, DS, and nondeficit schizophrenia [NDS]) were included. Subjects underwent MEG-EEG recordings during a resting state condition. MEG coherence source imaging (CSI) in source space and spectral analysis in sensor space were performed. Significant differences were found between the 2 patient groups: (1) MEG and EEG spectral analysis showed significantly higher power at low frequencies (delta band) at sensor space in DS compared with NDS patients; (2) source analysis revealed larger power in the DS compared with NDS group at low frequencies in the frontal region; (3) NDS patients showed significantly higher MEG signal relative power in beta bands in sensor space compared with DS patients; (4) both DS and NDS patients showed higher EEG absolute power at higher beta band compared to controls; and (5) patients with DS were found to have a significantly higher MEG CSI than controls in the beta frequency band. These data support the observation of increased power in the low-frequency EEG/MEG rhythms associated with the DS. Increased power in the beta rhythms was more associated with the NDS.

Distinct structural brain circuits indicate mood and apathy profiles in bipolar disorder

Bipolar disorder (BD) is a severe manic-depressive illness. Patients with BD have been shown to have gray matter (GM) deficits in prefrontal, frontal, parietal, and temporal regions; however, the relationship between structural effects and clinical profiles has proved elusive when considered on a region by region or voxel by voxel basis. In this study, we applied parallel independent component analysis (pICA) to structural neuroimaging measures and the positive and negative syndrome scale (PANSS) in 110 patients (mean age 34.9 ± 11.65) with bipolar disorder, to examine networks of brain regions that relate to symptom profiles. The pICA revealed two distinct symptom profiles and associated GM concentration alteration circuits. The first PANSS pICA profile mainly involved anxiety, depression and guilty feelings, reflecting mood symptoms. Reduced GM concentration in right temporal regions predicted worse mood symptoms in this profile. The second PANSS pICA profile generally covered blunted affect, emotional withdrawal, passive/apathetic social withdrawal, depression and active social avoidance, exhibiting a withdrawal or apathy dominating component. Lower GM concentration in bilateral parietal and frontal regions showed worse symptom severity in this profile. In summary, a pICA decomposition suggested BD patients showed distinct mood and apathy profiles differing from the original PANSS subscales, relating to distinct brain structural networks.

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Structural relationships with symptoms in bipolar disorder are complex.

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A parallel ICA analysis of PANSS questions and structural images finds two correlated profiles.

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The first pair links mood symptoms with right temporal regions.

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The second pair highlights social withdrawal and apathy symptoms linked to bilateral frontal and parietal regions.

A large European, multicenter, multinational validation study of the Brief Negative Symptom Scale

Negative symptoms represent an unmet need of treatment in schizophrenia. Although a consensus exists on negative symptom construct, and second generation assessment instruments reflecting the consensus are available, studies still rely upon old assessment instruments, that do not reflect recent conceptualizations and might limit progress in the search for effective treatments. This is often the case in the European context, where one of the challenges encountered in designing large studies is the availability of validated instruments in the many languages of the continent. To address this challenge and promote sound research on negative symptoms in Europe, the ECNP Schizophrenia Network coordinated a large multicenter, multinational validation study of the Brief Negative Symptom Scale (BNSS). Clinically-stable subjects with schizophrenia (SCZ, N = 249) were recruited from 10 European Countries. Apart from BNSS, subjects were administered the Positive and Negative Syndrome Scale (PANSS) and standardized instruments for depression, extrapyramidal symptoms and psychosocial functioning. Results showed an excellent internal consistency, convergent and discriminant validity of BNSS and replicated a 5 factor-model. A larger number of subjects with predominant negative symptoms, i.e. the target population for clinical trials, was identified by using the BNSS compared to the PANSS. Regression analysis showed that BNSS-avolition, a key negative symptom poorly assessed by PANSS, explained 23.9% of psychosocial functioning, while no combination of the PANSS core negative symptoms showed the same impact on functioning. The study demonstrated that BNSS has substantial advantages with respect to PANSS for the identification of the avolition domain and subjects with predominant negative symptoms.

Differential improvement of negative-symptom subfactors after cognitive remediation in low-functioning individuals with schizophrenia

Background

Negative symptoms and cognitive deficits have a substantial predictive value for functional deficits and recovery in schizophrenia. However, the relationship between negative symptoms and cognitive abnormalities is unclear possibly due to the heterogeneity of negative symptoms. This study used the model of expressive and experiential negative symptoms subfactors to decrease this heterogeneity. It examined these subfactors and cognition before and after treatment with computerized cognitive remediation training (CRT) in chronically-hospitalized individuals with psychosis and predominant negative symptoms.

Methods

Seventy-eight adult participants with a DSM-IV-TR diagnosis of schizophrenia or schizoaffective disorder were enrolled in a 12-week CRT program. Assessments of demographic and illness variables, baseline and endpoint assessments of psychopathology (Positive and Negative Syndrome Scale) and cognition (MATRICS Consensus Cognitive Battery - MCCB) were conducted.

Results

The baseline expressive negative subfactor was associated with Processing Speed (r = −0.352, p ≤ 0.001) and Reasoning/Problem Solving (r = −0.338, p ≤ 0.001). Following CRT, there was a significant decrease in the experiential negative subfactor (p < 0.01) but not of the expressive negative subfactor. Change in MCCB domains after CRT accounted for 51.1% and 50.2% of the variance of change in expressive and experiential negative subfactor scores, respectively. For both subfactors, Visual Learning was a significant predictor of change (p < 0.05).

Conclusion

Our findings suggest that CRT has benefits for negative symptoms in very low-functioning patients and that this change may be in part mediated by change in cognitive functions after CRT.

Metacognition moderates the relationship between self-reported and clinician-rated motivation in schizophrenia

Introduction

Prior work has found varied relationships between self-reported and clinician-rated motivation measures in schizophrenia, suggesting that moderators might impact the strength of this relationship. This current study sought to identify whether metacognition – the ability to form complex representations about oneself, others, and the world – moderates the relationship between self-reported and clinician-rated motivation measures. We also explored whether clinical insight and neurocognition moderated this relationship.

Methods

Fifty-six participants with a schizophrenia-spectrum disorder completed the Motivation and Pleasure Self-Report Scale and the clinician-rated motivation index from the Heinrichs-Carpenter Quality of Life Scale.

Results

Metacognition significantly moderated the relationship; self-reported and clinician-rated motivation were positively and significantly correlated only when metacognition was relatively high. Neither clinical insight nor neurocognition moderated the relationship.

Discussion

Metacognition appears to be a key variable impacting the strength of the relationship between self-reported and clinician-rated motivation measures and may help to partly explain the varied relationships observed in prior work. Using a metacognitive framework to guide assessment interviews and targeting metacognition in psychosocial treatments may help to improve the synchrony between self-perceptions and clinician ratings of motivation.

Clarifying the overlap between motivation and negative symptom measures in schizophrenia research: A meta-analysis

Motivation and negative symptom research has recently been hampered by a series of inconsistent findings, leading to calls for a greater consensus on the type of measures used across studies. To inform this issue, we conducted a meta-analysis that quantified the association between motivation measures (self-report, performance-based) and clinician-rated negative symptom measures as well as a series of moderator analyses to develop a greater understanding of the measurement factors impacting this relationship. Forty-seven eligible studies with people with schizophrenia-spectrum disorders were included. Using a random-effects meta-analytic model, a small but significant overall effect size emerged between motivation and clinician-rated negative symptoms (r = -0.18). Several significant moderators were identified, including the generation of negative symptom measures such that there was a significantly stronger relationship between motivation and second-generation (r = -0.38) than first-generation negative symptom measures (r = -0.17). Further, the type of performance-based measure used moderated the relationship, with effort discounting tasks most strongly related to negative symptoms (r = -0.44). The domain of motivation assessed (intrinsic, extrinsic, amotivation) also moderated the relationship. These findings help to identify sources of inconsistencies observed in prior studies and point to both second-generation and effort discounting tasks as the most promising types of measures, particularly for those interested in validating motivation measures or assessing the effectiveness of motivation treatments. Although additional research is needed, our results suggest that using these measures may help to reduce inconsistencies across studies and move the field forward.

Evoked Potentials Investigations of Deficit Versus Nondeficit Schizophrenia: EEG-MEG Preliminary Data

Heterogeneity of schizophrenia is a major obstacle toward understanding the disorder. One likely subtype is the deficit syndrome (DS) where patients suffer from predominantly negative symptoms. This study investigated the evoked responses and the evoked magnetic fields to identify the neurophysiological deviations associated with the DS. Ten subjects were recruited for each group (Control, DS, and Nondeficit schizophrenia [NDS]). Subjects underwent magnetoencephalography (MEG) and electroencephalography (EEG) testing while listening to an oddball paradigm to generate the P300 as well as a paired click paradigm to generate the mid-latency auditory-evoked responses (MLAER) in a sensory gating paradigm. MEG-coherence source imaging (CSI) during P300 task revealed a significantly higher average coherence value in DS than NDS subjects in the gamma band (30-80 Hz), when listening to standard stimuli but only NDS subjects had a higher average coherence level in the gamma band than controls when listening to the novel sounds. P50, N100, and P3a ERP amplitudes (EEG analysis) were significantly decreased in NDS compared with DS subjects. The data suggest that the deviations in the 2 patient groups are qualitatively different. Deviances in NDS patients suggest difficulty in both early (as in the gating paradigm), as well as later top-down processes (P300 paradigm). The main deviation in the DS group was an exaggerated responsiveness to ongoing irrelevant stimuli detected by EEG whereas NDS subjects had an exaggerated response to novelty.

Cognition, social cognition, and Self-assessment in schizophrenia: prediction of different elements of everyday functional outcomes

A growing body of research has shown that two domains of cognition, neurocognition and social cognition, predict different domains of real-world outcomes in people with schizophrenia. Social cognition has been shown to predict social outcomes but not non-social outcomes (e.g. living independently), and neurocognition provides minimal prediction of social outcomes (e.g. interpersonal relationships). The differing predictive value of neurocognition and social cognition has led to an exploration of potential factors that interact with cognition to influence everyday outcomes. Functional skills, negative symptoms, and self-assessment have shown particularly promising relationships with cognitive ability. Several consensus studies have pinpointed valid performance-based assessments. High-contact informant ratings have additionally been shown to be highly accurate. The emerging understanding of divergent patterns of predicting outcomes and reliable assessments present an opportunity to improve treatment targets and real-world outcomes for individuals with schizophrenia. In particular, a recently defined component of metacognition has shown particular promise. Introspective accuracy (IA) addresses how well individuals evaluate their own abilities. Emerging research has found that IA of neurocognitive ability better predicts everyday functional deficits than scores on performance-based measures of neurocognitive skills and has found that IA of social cognition accounts unique variance in real world disability above social cognitive abilities. Intriguingly, IA of neurocognition appears to preferentially predict non-social outcomes while IA of social cognition predicts social outcomes.

Positive and negative symptoms in schizophrenia: A longitudinal analysis using latent variable structural equation modelling

BACKGROUND

Recent network models of schizophrenia propose it is the consequence of mutual interaction between its symptoms. While cross-sectional associations between negative and positive symptoms are consistent with this idea, they may merely reflect their involvement in the diagnostic process. Longitudinal analyses however may allow the identification of possible causal relationships. The European Schizophrenia Cohort (EuroSC) provides data suitable for this purpose.

METHODS

EuroSC includes 1208 patients randomly sampled from outpatient services in France, Germany and the UK. Initial measures were repeated after 12 and 24 months. Latent variable structural equation modelling was used to investigate the direction of effect between positive and negative symptoms assessed with the Positive and Negative Syndrome Scale, controlling for the effects of depressed mood and antipsychotic medication.

RESULTS

The structural model provided acceptable overall fit [χ² (953) = 2444.32, P < 0.001; CFI = 0.909; RMSEA = 0.046 (90% CI: 0.043, 0.048); SRMR = 0.052]. Both positive and negative symptoms were persistent, and strongly auto-correlated. There were also persistent cross-sectional associations between positive and negative symptoms. While the path from latent positive to negative symptoms from T1 to T2 approached conventional levels of statistical significance (P = 0.051), that from T2 to T3 did not (P = 0.546). Pathways in the reverse direction were uniformly non-significant.

CONCLUSIONS

There was no evidence that negative symptoms predict later positive symptoms. The prediction of negative symptoms by positive symptoms was ambiguous. We discuss implications for conceptualization of schizophrenic processes.

Impaired introspective accuracy in schizophrenia: an independent predictor of functional outcomes

INTRODUCTION

Individuals with schizophrenia present across a spectrum of symptomatology. Disability remains a debilitating reality across varying disease presentations and remains pervasive despite psychiatric medications. Cognition (neuro/social cognition) and negative symptoms have emerged as the strongest predictors of real-world disability, but account for <50% of the variance in outcomes.

METHODS

Our attempts to determine what accounts for the remaining 50% of variance has shown that poor introspective accuracy (IA) may be the most potent predictor of functional outcomes 25% of individuals with schizophrenia. We define IA as the adequacy of self-assessments of ability, skills, performance, or decisions. We suggest that IA is a progression of metacognition and can extend beyond cognition to include misestimation of prior and likely future performance in social or other adaptively relevant situations.

RESULTS

Additionally, IA is bidirectional and self-orientated. Emerging research has found that IA of neurocognitive ability better predicts everyday functional deficits than scores on performance-based measures or neurocognitive skills and has found that IA of social cognition accounts unique variance in real-world disability above social cognitive performance.

DISCUSSION

We argue that impaired IA, affecting 25-50% of patients with schizophrenia, in the absence or minimal presence of other impairments might be the most powerful predictor of functional outcomes.

Social anhedonia and asociality in psychosis revisited. An experience sampling study

The DSM-5 appended the conceptualization of asociality in psychotic disorders as the manifestation of diminished interest in social interactions, but it also admitted that it might merely be the result of limited opportunities for social interactions. In an effort to investigate this apparent dichotomy, we used experience sampling data from 149 patients with psychotic disorder and 143 controls, and divided their social interactions into those occurring in the context of work and other structured activities that patients have limited access to, and those occurring in the context of unstructured activities such as visits and conversations that both groups can choose relatively more freely. Patients spent significantly smaller proportion of their time in structured social context, but matched the controls in the time spent in unstructured social contexts, and endorsed intact hedonic experience of both social contexts. Moreover, employment and living situation, in addition to the severity of symptoms of avolition, predicted the proportion of time patients spent in structured and unstructured social contexts, supporting the notion that both lifestyle as well as disease-specific factors contribute to real-life social behavior in psychosis.

Which levels of cognitive impairments and negative symptoms are related to functional deficits in schizophrenia?

BACKGROUND

Negative symptoms and cognitive impairments predict difficulties in aspects of everyday functioning in schizophrenia, with little research to date attempting to determine if there are threshold levels of impairment required to predict the severity of functional deficits.

METHODS

People diagnosed with chronic schizophrenia (n = 821) were assessed with the MCCB and PANSS, and rated by high contact informants with SLOF. Negative symptoms of reduced emotional experience were specifically targeted for analysis because of their previously identified relationships with social outcomes. We identified patients with moderate negative symptoms (at least one PANSS item ≥4) versus less severe symptoms (PANSS items ≤3) and divided patients on the basis of a single latent-trait global cognition score (neuropsychologically normal vs neuropsychologically impaired; performance at or below 1.0 SD from the normative population mean, T = 40), then examined correlations between cognition, negative symptoms and everyday functioning in the groups with lower and higher negative symptoms and those with/without cognitive impairment.

RESULTS

Even low levels of negative symptoms were correlated with ratings of social functioning. Cognitive performance in the neuropsychologically normal range, in contrast, was not correlated with any aspects of everyday functioning while more impaired performance predicted greater functional impairments.

CONCLUSIONS

Even minimal symptoms may be a target for clinical attention in the domains of negative symptoms, consistent with previous findings regarding social deficits in populations with modest negative symptoms (e.g., schizotypal personality disorder). Cognitive rehabilitation treatments might not improve social functioning if even low levels of negative symptoms (social amotivation) are present.

The specific social costs of expressive negative symptoms in schizophrenia: reduced smiling predicts interactional outcome

OBJECTIVE

We tested whether people with schizophrenia and prominent expressive negative symptoms (ENS) show reduced facial expressions in face-to-face social interactions and whether this expressive reduction explains negative social evaluations of these persons.

METHOD

We compared participants with schizophrenia with high ENS (n = 18) with participants with schizophrenia with low ENS (n = 30) and with healthy controls (n = 39). Participants engaged in an affiliative role-play that was coded for the frequency of positive and negative facial expression and rated for social performance skills and willingness for future interactions with the respective role-play partner.

RESULTS

Participants with schizophrenia with high ENS showed significantly fewer positive facial expressions than those with low ENS and controls and were also rated significantly lower on social performance skills and willingness for future interactions. Participants with schizophrenia with low ENS did not differ from controls on these measures. The group difference in willingness for future interactions was significantly and independently mediated by the reduced positive facial expressions and social performance skills.

CONCLUSION

Reduced facial expressiveness in schizophrenia is specifically related to ENS and has negative social consequences. These findings highlight the need to develop aetiological models and targeted interventions for ENS and its social consequences.

Efficacy of high-frequency repetitive transcranial magnetic stimulation on PANSS factors in schizophrenia with predominant negative symptoms - Results from an exploratory re-analysis

Repetitive transcranial magnetic stimulation (rTMS) applied to the left frontal lobe is discussed to be a promising add-on treatment for negative symptoms in schizophrenia. The Positive and Negative Syndrome Scale (PANSS) has been used as outcome parameter in several previous rTMS trials, but studies focusing on PANSS factor analyses are lacking. For this purpose, we used the available PANSS data of the 'rTMS for the Treatment of Negative Symptoms in Schizophrenia' (RESIS) trial to calculate different literature-based PANSS factors and to re-evaluate the impact of rTMS on negative symptoms in this trial. In an exploratory re-analysis of published data from the RESIS study (Wobrock et al. 2015), we tested the impact of rTMS applied to the left dorsolateral prefrontal cortex on two PANSS factors for negative symptoms in psychotic disorders as well as on a PANSS five-factor consensus model intending to show that active rTMS treatment improves PANSS negative symptom subscores. In accordance to the original analysis, all PANSS factors showed an improvement over time in the active and, to a considerable extent, also in the sham rTMS group. However, comparing the data before and directly after the rTMS intervention, the PANSS excitement factor improved in the active rTMS group significantly more than in the sham group, but this finding did not persist if follow-up data were taken into account. These additional analyses extend the previously reported RESIS trial results showing unspecific improvements in the PANSS positive subscale in the active rTMS group. Our PANSS factor-based approach to investigate the impact of prefrontal rTMS on different negative symptom domains confirmed no overall beneficial effect of the active compared to sham rTMS.

Negative Symptom Dimensions of the Positive and Negative Syndrome Scale Across Geographical Regions: Implications for Social, Linguistic, and Cultural Consistency

Objective: Recognizing the discrete dimensions that underlie negative symptoms in schizophrenia and how these dimensions are understood across localities might result in better understanding and treatment of these symptoms. To this end, the objectives of this study were to 1) identify the Positive and Negative Syndrome Scale negative symptom dimensions of expressive deficits and experiential deficits and 2) analyze performance on these dimensions over 15 geographical regions to determine whether the items defining them manifest similar reliability across these regions. Design: Data were obtained for the baseline Positive and Negative Syndrome Scale visits of 6,889 subjects across 15 geographical regions. Using confirmatory factor analysis, we examined whether a two-factor negative symptom structure that is found in schizophrenia (experiential deficits and expressive deficits) would be replicated in our sample, and using differential item functioning, we tested the degree to which specific items from each negative symptom subfactor performed across geographical regions in comparison with the United States. Results: The two-factor negative symptom solution was replicated in this sample. Most geographical regions showed moderate-to-large differential item functioning for Positive and Negative Syndrome Scale expressive deficit items, especially N3 Poor Rapport, as compared with Positive and Negative Syndrome Scale experiential deficit items, showing that these items might be interpreted or scored differently in different regions. Across countries, except for India, the differential item functioning values did not favor raters in the United States. Conclusion: These results suggest that the Positive and Negative Syndrome Scale negative symptom factor can be better represented by a two-factor model than by a single-factor model. Additionally, the results show significant differences in responses to items representing the Positive and Negative Syndrome Scale expressive factors, but not the experiential factors, across regions. This could be due to a lack of equivalence between the original and translated versions, cultural differences with the interpretation of items, dissimilarities in rater training, or diversity in the understanding of scoring anchors. Knowing which items are challenging for raters across regions can help to guide Positive and Negative Syndrome Scale training and improve the results of international clinical trials aimed at negative symptoms.

Using the Positive and Negative Syndrome Scale (PANSS) to Define Different Domains of Negative Symptoms: Prediction of Everyday Functioning by Impairments in Emotional Expression and Emotional Experience

Background: Reduced emotional experience and expression are two domains of negative symptoms. The authors assessed these two domains of negative symptoms using previously developed Positive and Negative Syndrome Scale (PANSS) factors. Using an existing dataset, the authors predicted three different elements of everyday functioning (social, vocational, and everyday activities) with these two factors, as well as with performance on measures of functional capacity. Methods: A large (n=630) sample of people with schizophrenia was used as the data source of this study. Using regression analyses, the authors predicted the three different aspects of everyday functioning, first with just the two Positive and Negative Syndrome Scale factors and then with a global negative symptom factor. Finally, we added neurocognitive performance and functional capacity as predictors. Results: The Positive and Negative Syndrome Scale reduced emotional experience factor accounted for 21 percent of the variance in everyday social functioning, while reduced emotional expression accounted for no variance. The total Positive and Negative Syndrome Scale negative symptom factor accounted for less variance (19%) than the reduced experience factor alone. The Positive and Negative Syndrome Scale expression factor accounted for, at most, one percent of the variance in any of the functional outcomes, with or without the addition of other predictors. Implications: Reduced emotional experience measured with the Positive and Negative Syndrome Scale, often referred to as "avolition and anhedonia," specifically predicted impairments in social outcomes. Further, reduced experience predicted social impairments better than emotional expression or the total Positive and Negative Syndrome Scale negative symptom factor. In this cross-sectional study, reduced emotional experience was specifically related with social outcomes, accounting for essentially no variance in work or everyday activities, and being the sole meaningful predictor of impairment in social outcomes.

Motivational and Behavioral Activation as an Adjunct to Psychiatric Rehabilitation for Mild to Moderate Negative Symptoms in Individuals with Schizophrenia: A Proof-of-Concept Pilot Study

Few psychosocial approaches address the negative symptoms of schizophrenia, which shares common features with depression and anxiety. Behavioral activation (BA) is effective for addressing depression and anxiety in adults with various mental disorders. Motivational interviewing (MI) has been successfully applied to address ambivalence or lack of motivation toward treatment. Motivational and behavioral activation (mBA) has been developed by incorporating the core principles from BA and MI with recent findings on the negative symptoms of schizophrenia. In this study, we aimed to examine the feasibility and preliminary efficacy of mBA in a non-randomized controlled pilot study that included individuals with schizophrenia with mild to moderate negative symptoms receiving psychiatric rehabilitation. A total of 73 individuals with schizophrenia were recruited. Forty-seven of the participants who met the study inclusion and exclusion criteria were assigned to either an mBA + usual psychiatric rehabilitation group (mBA) or a usual psychiatric rehabilitation only group (treatment as usual, TAU). Administering mBA to individuals with schizophrenia with mild to moderate negative symptoms was feasible in a community mental health setting. Relative to TAU, mBA was associated with large effects in reducing negative symptoms measured using the Positive and Negative Syndrome Scale (PANSS) and the Brief Negative Symptom Scale (BNSS). However, after considering PANSS cognitive deficits and marital status as covariates due to significant differences in their baseline levels, the treatment effects on the BNSS were partially observed. In addition, participants in the mBA group showed improved verbal learning and memory compared with those in the TAU group. In individuals with schizophrenia receiving the usual forms of psychiatric rehabilitation in a community mental health setting, mBA appears to offer a promising adjunctive approach for addressing mild to moderate negative symptoms. Further investigations are needed to replicate the current findings in a randomized controlled trial.

Deficits in attentional processing of fearful facial expressions in schizophrenic patients

Impaired attentional processing of negative facial expressions is prominent in schizophrenia and has been shown to be associated with patients’ social dysfunctions. However, little is known about when and which specific attention deficits influence social functions. Given the dynamic feature of attention, it is necessary to investigate the attention deficits in negative emotional processing unfolding in time. The current study used event-related potentials (ERPs) to investigate the temporal dynamics of attention deficits in emotion perception and their potential relationship with emotional/social impairments in neuroleptic naive schizophrenic patients. Two specific attention deficits were identified and were found to be associated with emotional/social impairments. More specifically, the deficit in orienting attention (evidenced with the reduced P1 amplitude) was correlated with expressive deficits, while the deficit in executive control of attention (evidenced with the reduced P3 amplitude) was correlated with avolition/asociality. Together, these findings may provide novel insights into the core pathophysiological processes and offer objective biomarkers for specific emotional/social impairments in schizophrenia. It is also hoped that this study helps to bridge the gap between basic cognitive deficits and relative high-level social dysfunctions in schizophrenic patients.