REVIEW

CURRENT
OPINION Categorizing and assessing negative symptoms
Paola Bucci and Silvana Galderisi

Purpose of review
To provide a review on studies published in the last year relevant to the categorization and assessment of
negative symptoms.
Recent findings
Recent research supported the validity of the ‘deficit/non-deficit schizophrenia’ categorization. Few studies
confirmed the validity of the category ‘persistent negative symptoms’, whereas no recent study explored the
validity of the category ‘predominant negative symptoms’. The two-factor structure of the negative
dimension is supported by studies reporting different correlates for the two subdomains: diminished
expression and avolition/apathy. The need to further split avolition/apathy in two distinct components, that
is anhedonia and amotivation, is confirmed in recent papers. Additional approaches to the assessment of
negative symptoms have been proposed, including the self-assessment of negative symptoms, and the
evaluation of negative symptoms in daily life and their assessment by means of computerized analyses.
Summary
Negative symptoms represent an unmet need in the care of schizophrenia, as they are associated to poor
response to available treatments and to poor functional outcome. Their accurate categorization and
assessment represent a major challenge for research on neurobiological substrates and new treatment
strategies.
Keywords
assessment, categorization, measurement, persistent negative symptoms, Schizophrenia

INTRODUCTION as positive symptoms, extrapyramidal side effects,

Negative symptoms are a core clinical dimension of
schizophrenia described since the early 19th century
[1,2]. They represent an unmet need in the care of
the disorder, as they are associated to poor response
to available treatments and to poor functional out-
come [3–8].
The accurate categorization of these symptoms,
together with a valid and reliable assessment,
represent major challenges for advancing the field.
In fact, negative symptoms are a heterogeneous
psychopathological dimension, in which different
constructs, possibly with different neurobiological
substrates, are included. Table 1 summarizes main
current approaches to their categorization. In each
category an effort is made to focus on primary
negative symptoms by minimizing the presence of
secondary negative symptoms, as nowadays the
importance of the distinction between primary
negative symptoms (etiologically related to the core
pathophysiology of schizophrenia; persisting in
spite of changes in positive symptoms, depression,
or extrapyramidal symptoms; not improving signifi-
cantly with any of the available treatments) and
secondary ones (because of identifiable causes, such
depression or isolation) is largely acknowledged.
However, the thresholds for possible causes of sec-
ondary negative symptoms differ among the three
categories and therefore different amounts of sec-
ondary negative symptoms are likely to be present in
the studied populations. The three categories also
differ in terms of longitudinal observation; con-
sequently, whereas deficit schizophrenia and per-
sistent negative symptoms (PNS) are enduring, and
therefore likely to be resistant to available treat-
ments, for the predominant negative symptoms this
characteristic is not required.
Deficit schizophrenia is based on the criteria
proposed by Carpenter et al. [13]. It has also been
proposed as a separate disorder with respect to non-
deficit schizophrenia (NDS) [14]. Its validity has
Department of Psychiatry, University of Campania ‘L. Vanvitelli’, Naples,
Italy
Correspondence to Prof. Silvana Galderisi, Department of Psychiatry,
Largo Madonna delle Grazie, 80138 Naples, Italy. Tel: +39 081 566
6504; fax: +39 081 566 6523; e-mail: silvana.galderisi@gmail.co
Curr Opin Psychiatry 2017, 30:201–208
DOI:10.1097/YCO.0000000000000322

0951-7367 Copyright ß 2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-psychiatry.com

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Schizophrenia and related disorders
KEY POINTS
 The individuation of valid tools and strategies to
categorize and assess negative symptoms is crucial for
research on neurobiological substrates and new
treatment strategies in schizophrenia.
 New-generation rating scales allow the identification of
two main subdomains characterized by different
correlates and probably by different pathophysiological
mechanisms: diminished expression and avolition/apathy.
 Recent findings suggest the need to further characterize
the avolition/apathy domain in two distinct
components: anhedonia and amotivation.
 Alternative approaches such as self-assessment,
ecological momentary assessment, and computerized
evaluation of negative symptoms were recently
proposed to integrate information obtained with the
standard observer-rater tools.
repeatedly been confirmed [15–20]. In spite of its
heuristic value and proven validity, the deficit
schizophrenia/NDS categorization has some draw-
backs. In fact, it requires the use of a specific assess-
ment instrument, the schedule for the deficit
syndrome (SDS) [21], examiners trained in the
use of the instrument and longitudinal clinical
observation, not always feasible, especially in first
episode patients.
The category ‘predominant negative symptoms’
is adopted mostly in clinical trials, as requested by
Table 1. Current approaches to the categorization of negative symptoms
Severity of negative symptoms
Deficit schizophrenia At least moderate for at least two
symptoms
Predominant At least moderate for at least three
negative symptoms symptoms or at least moderately
severe for at least two symptoms [9];
PANSS negative subscale score
greater than the PANSS positive
subscale score [10]; any score on
PANSS negative subscale but at least
6 points greater than the PANSS
positive subscale score [11]; PANSS
Negative subscale score of at least 21
and at least 1 point greater than the
PANSS positive subscale score [12]
Persistent At least moderate for at least three
negative symptoms symptoms or at least moderately
severe for at least two symptoms
PANSS, positive and negative syndrome scale.
202 www.co-psychiatry.com
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
regulatory agencies, in order to evaluate the efficacy
of drugs for treating negative symptoms. It does not
require either a longitudinal observation or the use
of a specific assessment instrument, and the positive
and negative symptom scale (PANSS) [22] is used in
the majority of studies. Negative symptoms should
be more severe than positive ones, but no consensus
has been achieved on the severity of either symptom
dimension. To minimize the presence of secondary
negative symptoms, a threshold is required but
not defined.
PNS can be assessed by means of most validated
psychopathological rating scales and require less
longitudinal observation than the diagnosis of def-
icit schizophrenia. Threshold for their identification
are less well defined, and therefore data relevant to
their prevalence are highly heterogeneous [5].
A large consensus was recently reached on the
inclusion of 5 constructs in the negative symptom
dimension: blunted affect, alogia, anhedonia, aso-
ciality, and avolition [23–26]. It also led to the
exclusion of constructs previously included in nega-
tive symptoms but now considered as relevant to
other schizophrenia dimensions (e.g. difficulty in
abstract and stereotyped thinking or inattentive-
ness). Another important innovation in the categ-
orization of negative symptoms is represented by
the two-factor structure. Several studies based on
factor analysis have shown that the five constructs
listed above can be grouped in two domains: dimin-
ished expression (including blunted affect and
alogia) and avolition/apathy (including avolition,
Persistence of negative
Severity of other symptoms symptoms
Not specified. Positive, depressive and At least 12 months,
anxiety symptoms must be excluded as including periods of
causes of the negative ones clinical stability
Positive PANSS subscale score less than Not specified
19, depressive and extrapyramidal
symptoms lower than a defined
threshold on validated rating scale [9];
not specified [10–12]
Positive, depressive, and extrapyramidal At least 6 months (repeated
symptoms lower than a defined assessments every 3–6
threshold on an accepted and months are
validated rating scale recommended)
Volume 30  Number 3  May 2017
 Categorizing and assessing negative symptoms Bucci and Galderisi
asociality, and anhedonia). The two domains seem
to be associated to different neurobiological abnor-
malities and psychosocial outcome [27].
The above-described progress in conceptualizing
and categorizing negative symptoms has stimulated
the design of two new rating scales, the brief negative
symptom scale (BNSS) [28] and the clinical assess-
ment interview for negative symptoms (CAINS) [29].
With respect to traditional instruments, the new
scales do not include symptoms previously con-
sidered as part of the negative dimension but now
clearly identified as aspects of other dimensions, such
as the cognitive or depressive one [26,30,31]. They
also provide a separate assessment of the consumma-
tory anhedonia (reduced experience of pleasure
derived from ongoing enjoyable activities) and
anticipatory anhedonia (reduced ability to anticipate
future pleasure). In fact, the former one seems to be
relatively intact in schizophrenia, whereas the latter
one seems to be impaired [32–34]. However, discrep-
ant data have also been reported [35].
We will review papers published in English from
November 1, 2015, to present, listed in PubMed, and
relevant to the categorization and assessment of
negative symptoms.
NOVEL FINDINGS ON NEGATIVE
SYMPTOM CATEGORIZATION
The validity of the deficit schizophrenia/NDS categ-
orization, carried out by means of the SDS, has been
confirmed by several recent papers, which reported
different neurobiological correlates [36–40], social
cognition impairment [41] and severity of premorbid
functioning [42] in patients with deficit schizo-
phrenia versus NDS. Less convergent data were
reported by the few studies in which the categoriz-
ation was based on a proxy for the deficit syndrome
(PDS). In particular, deficit schizophrenia defined
with the PDS proposed by Kirkpatrick et al. [43] (based
on the sum of the scores of the anxiety, guilt feelings,
depressive mood, and hostility items, subtracted
from the score for blunted affect), in one study was
stable for 2 years and related to specific neurostruc-
tural markers [44], and in another showed poor
stability over 12 years [45]. By using a PDS based
on severity of symptoms from the PANSS and quality
of life scale (QLS) [46], on symptom persistence over
time and assessment of possible sources of secondary
negative symptoms, Fervaha et al. [47] found a greater
cognitive impairment in deficit schizophrenia versus
NDS, but no group difference when comparing deficit
schizophrenia patients to those with non enduring or
primary negative symptoms.
The validity of the PNS category has been con-
firmed in few recent studies, by the identification of
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different neurobiological correlates [48,49], as well
as worse neurocognitive performance and premor-
bid functioning [50] in patients with PNS than in
non-PNS ones. One study reported poor stability of
PNS over time [45].
Although the predominant negative symptom
category was used in several clinical trials [51–55],
no recent study explored its validity and no con-
sensus was achieved to reduce the heterogeneity in
the definitions.
The two-factor structure of the negative dimen-
sion is supported by recent studies reporting differ-
ent correlates for the two subdomains: a stronger
association of poor social functioning with avoli-
tion/apathy than with diminished expression [56–
58], and a stronger association of cognitive impair-
ment with diminished expression than with avoli-
tion/apathy [59,60].
Two recent studies investigating the psychomet-
ric characteristics of the PANSS [59,60] confirmed the
two-factor structure of the negative dimension
reported in previous studies [61,62]. However, these
studies included items no more considered as specific
to the negative dimension, such as motor retardation
and active social withdrawal. Moreover, a close cor-
relation between the two factors was observed in one
of the two studies [60], suggesting that the PANSS has
a less differentiated factor structure due to a less
extensive evaluation of negative symptoms with
respect to the new-generation scales.
In addition to data supporting the two-factor
structure, findings suggesting the need to further
investigate individual constructs of negative symp-
toms have also been reported [63]. In particular,
different neurobiological correlates have been found
for two constructs included in the same factor avoli-
tion/apathy, i.e. for anhedonia and avolition [64,65].
Among instruments assessing specific aspects of
anhedonia, the structure of the revised social anhe-
donia scale was analyzed (RSAS) [66,67]. Two differ-
ent factors were identified (social apathy and social
withdrawal) that enabled the discrimination of
social anhedonia from social anxiety [68].
Only a few studies in the covered time interval
investigated differences between anticipatory and
consummatory anhedonia and their respective neu-
robiological substrates, reporting heterogeneous
findings [69–72]; however, recent reviews and one
recent meta-analysis addressed critical aspects of this
topic [73–75].
NOVEL TOOLS FOR THE ASSESSMENT
OF NEGATIVE SYMPTOMS
A new self-rating instrument assessing negative
symptoms, the self-evaluation of negative symptom
www.co-psychiatry.com 203
Schizophrenia and related disorders
&&
(SNS) [76 ], has recently been developed. It includes
20 items grouped in five subdomains according to
the consensus statement on negative symptoms
[24], and takes about 5 minutes to be completed.
The SNS allows the identification of the two factors
‘diminished expression’ and ‘avolition/apathy’. It
shows a good discriminating validity, indicated
by the absence of correlations with measures of
extrapyramidal symptoms, positive symptoms,
and insight. Its diminished expression factor is
not correlated with depression scores, whereas its
avolition factor is correlated to the total score of the
calgary depression scale for schizophrenia; the
authors speculate that this may be because of an
increase of avolition secondary to depression or to a
greater tendency to feel depressed in patients with
higher awareness in their deficit to experience
emotions. The SNS total score correlates with the total
score of the scale for the assessment of negative symp-
toms (SANS) [77] global evaluations and of the clini-
cian global impression on the severity of negative
symptoms,suggestingthatself-assessment ofnegative
symptoms is consistent with the one based on
observer-ratings. However, the SNS score for dimin-
ished emotional range did not correlate with the
corresponding SANS score, suggesting that blunted
affect rated by an observer and the subjective experi-
ence of diminished emotional range represent two
distinct aspects of negative symptoms. Furthermore,
so far no study assessed the degree of convergence
between the SNS and the new-generation rating scales.
The brief evaluation of psychosis symptom
domains (BE-PSD) [78] is a newly developed rating
scale assessing negative symptoms as part of a global
psychopathological assessment. The aim of the
authors was to develop an instrument suitable for
both research and routine clinical settings, over-
coming identified limitations of existing rating
scales for psychosis. The BE-PSD assesses the same
psychopathological domains investigated by other
global scales for psychotic symptoms, but in a much
shorter time, while providing a detailed description
of anchor points for each severity score of each
symptom, which is often missing in other rating
scales developed to briefly assess schizophrenia
symptoms. In line with previous factor analytic
studies of negative symptoms, the negative symp-
tom dimension assessed by the BE-PSD includes two
factors: avolition and diminished expression; the
latter is scored based on the behavior observed
during the interview and its impact on behavior
of the observed during the interview.
The authors reported excellent interrater
reliability, as well as good convergent and discrim-
inant validity as expressed by significant correlations
with the corresponding PANSS psychopathological
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domains and by low correlation coefficients with the
remaining PANSS domains, respectively. No study
investigated the BE-PSD sensitivity to changes.
&&
Moran et al. [79 ] investigated the validity of
the ecological momentary assessment (EMA) as an
additional method for assessing negative symptoms,
aimed at addressing some critical points of the
currently used tools. The authors recognize the
major advancement in the assessment of negative
symptoms represented by BNSS and CAINS;
however, they hypothesize that the information
obtained by these rating scales may not completely
reflect patients’ experience of negative symptoms in
their daily lives, because of possible biases, such as
the difficulty to recall events and feelings experi-
enced in the time period investigated during the
interview, or the unfamiliar setting in which the
interview takes place. The EMA questionnaire was
administered via smartphone during 7 days, four
times per day, to patients with schizophrenia who
were asked, each time, to indicate their current
activity, as well as the activities during the previous
and the upcoming 2–3 h. For each reported activity,
patients had to describe the level of motivation and
pleasure. The authors report convergent validity
between EMA and validated clinician-rated (CAINS)
as well as self-report (motivation and pleasure scale-
self report) measures of negative symptoms, indi-
cating that EMA seems to measure similar con-
structs. They also found that this relationship was
moderated by working memory and hypothesized
that a deficit in this cognitive domain reduces the
relationship between symptoms assessed by clini-
cian-rated instruments and those assessed by patient
during the daily life. As concluded by the authors,
the addition of the EMA assessment may help
removing the confounding effect of working mem-
ory deficits and eventually of other cognitive defi-
cits not assessed in their study. In its current version
the EMA does not allow the assessment of the
diminished expression subdomain; however, the
authors hypothesize the possibility to develop, in
future research, methods to explore this domain
during daily life, by means of mobile technology
enabling the assessment of mobility, the use of
audio recordings and measurement of psychophy-
siological indices, such as heart rate.
A recent study explored the feasibility of an
&
objective assessment of negative symptoms [80 ].
The authors analyzed audio-recordings by means
of computerized acoustic analytic technologies, in
order to assess decreased/increased vocal production
(i.e. alogia and pressured speech, respectively) and
intonation emphasis (i.e. blunted affect or affective
liability) to rate negative symptoms and explore
their different severity in different contexts.
Volume 30  Number 3  May 2017
 Categorizing and assessing negative symptoms Bucci and Galderisi
In the light of recent finding of the literature
reporting association of prodromal negative symp-
toms with heightened probability to develop
psychosis in high-risk individuals [81,82], the devel-
opment and validation of tools for the assessment of
attenuated negative symptoms in adolescents
represents a further challenge in the research on
psychosis conversion. In two recent studies, the
adolescent version of the anticipatory and consum-
matory interpersonal pleasure scale (ACIPS-A) was
found to be a valid measure to assess anticipatory
and consummatory anhedonia in nonclinical ado-
lescents [83,84].
RECENT FINDINGS ON THE NEW
GENERATION RATING SCALES FOR
NEGATIVE SYMPTOMS
Few studies have recently been published on the
psychometric characteristics of the new-generation
rating scales.
&
Strauss and Gold [85 ] compared BNSS and
CAINS. They found a good consistency between
the two scales (as well as between them and first
generation rating scales) for blunted affect and alogia,
included in the subdomain ‘diminished expression’.
Instead, for the ‘avolition/apathy’ subdomain, the
convergence between BNSS and CAINS was lower,
especially for the items measuring anhedonia, prob-
ably because of differences in the criteria used to
assess the moment experience of pleasure (intensity
and frequency or only frequency, respectively)
and anticipated pleasure (intensity or frequency,
respectively), as well as in the number and type of
explored pleasurable activities, suggesting the possib-
ility that the two scales assess different aspects
of anhedonia.
Bischof et al. [86] found that BNSS anhedonia has
a greater convergence with the self-reported temporal
experience of pleasure scale (TEPS) [32], as compared
to anhedonia measured by first-generation scales;
however, they found no correlation between BNSS
anticipatory and consummatory anhedonia sub-
scales and the corresponding TEPS subscales and
concluded that BNSS is able to assess the subjective
experience of anhedonia, but not to discriminate
between anticipatory and consummatory anhedo-
nia. In another study, psychometric properties of
BNSS were confirmed in patients with schizophrenia
as good/excellent and were assessed for the first time
in patients with bipolar disorders [87], in which also
resulted good/excellent, suggesting that BNSS is a
promising tool in the assessment of negative symp-
toms also in the latter population.
A very recent paper investigated the correspond-
ence between self- and observer-rating assessment of
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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
motivation and pleasure in both healthy controls
and patients with schizophrenia or schizoaffective
&
disorder [88 ]. In line with previous studies [89,90],
the paper reports comparability between self-rating
and observer-rating for the new-generation rating
scales, and supports the notion that patients are
able to perceive their negative symptoms [91–93].
Healthy controls showed a greater tendency to over-
rate their negative symptoms than patients, which
were more likely to underrate their negative symp-
toms with respect to healthy controls. Possible expla-
nations hypothesized for these findings include a bias
of the observer in rating less severe negative symp-
toms in healthy controls than in patients, or a
tendency of patients to underestimate their negative
symptoms, as well as the fact that CAINS, used for
observer-ratings, is designed for clinical population
and therefore the anchor points are not suitable for
healthy controls.
CONCLUSION
Progress in the definition and categorization of nega-
tive symptoms has been made in recent times. The
validity of the deficit schizophrenia/NDS categoriz-
ation has been confirmed. Future research should
focus on refinement and validation of the alternative
approaches proposed to categorize negative symp-
toms, namely the identification of PNS and predom-
inant negative symptoms. The distinction between
primary and negative symptoms remains a critical
point in the assessment of the negative dimension.
No new tool was developed and no study was con-
ducted on previously developed tools.
Recent papers on the new-generation rating
scales confirm the two-factor structure of the nega-
tive dimension; some findings, however, suggest the
need to further investigate also individual constructs.
Alternative approaches developed to enrich the
observer-rating assessment and to address some of
its limitations are represented by the evaluation of
negative symptoms in daily life and by the devel-
opment of objective/computerized measures and
self-rated assessments providing information on
patients’ own perception of negative symptoms.
The latter one requires further investigation to
clarify whether both negative factors are reliably
self-reported.
Finally, in the light of recent findings of the
literature reporting association of prodromal nega-
tive symptoms with heightened probability to
develop psychosis in high-risk individuals [81,82],
the development and validation of tools specifically
designed to assess attenuated negative symptoms
in adolescents might probably contribute to
advance research on psychosis conversion. Among
www.co-psychiatry.com 205
Schizophrenia and related disorders
questionnaires and interviews developed so far
to assess prodromal symptoms [94–96], none is
specifically designed to assess the negative dimen-
sion by addressing the above-reported critical issues
related to assessment and categorization of negative
symptoms.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
S.G. received honoraria, advisory board or consulting fees
from the following companies: Amgen Dompé, Angelini-
Acraf, Astra Zeneca, Bristol-Myers Squibb, Eli-Lilly,
Gedeon-Richter, Hoffman-La Roche, Innova-Pharma,
Janssen Pharmaceuticals, Lundbeck, Otsuka, and Pierre
Fabre. P.B. has no conflicts of interest.
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