Negative symptoms matter a lot

Picture illustrating negative symptoms.

Negative symptoms.
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Negative symptoms matter a lot.

By David Joel Miller, MS, Licensed Therapist & Counselor.

What’s the difference between negative symptoms and positive symptoms?

The terms negative symptoms and positive symptoms have a different meaning in mental health when applied to symptoms than in other contexts. Positive doesn’t mean good, and sometimes negative isn’t bad in this circumstance.

Positive symptoms are things someone experiences that we don’t expect other “normal” people to have. Experiencing hallucinations (all seven different kinds), delusions, or paranoia would all qualify as positive symptoms.

When someone starts hearing and seeing things others don’t, most people immediately think of schizophrenia. That’s not the only mental health diagnosis that involves hallucinations. But there are so many other possible causes of hallucinations, such as drugs, perception, or even religious experiences, that the presence of hallucinations alone does not always lead to a diagnosis in these cases.

Why negative symptoms matter.

Negative symptoms are identified when people begin to lose the skills they previously had. Those losses, or declining abilities, are more important for diagnosing some mental illnesses than any positive symptoms.

There are a lot more negative symptoms that a psychiatrist might consider that most people initially would recognize. Here’s a list of negative symptoms, most of which are prominent in schizophrenia and related psychotic disorders. The symptoms often come on gradually and may be hard to recognize until they have become severe.

A decrease in emotional expression.

There can be a lot of reasons why someone might become withdrawn and exhibit a narrow or decreasing range of emotional expression. Therapists and counselors would try to rule out things such as depression, anxiety, a reaction to trauma, or even a sudden change in environment. But if this declining emotional expression is prolonged or becomes more pervasive, it would be a good reason for referral to a psychiatrist. Here are some of the prominent signs of decreases in emotional expression.

Poor eye contact.

We must be careful with this symptom, particularly in young children or people with a history of being shy or introverted. Children may do this often, and anyone can develop poor eye contact in an anxiety-provoking situation. But if someone was previously outgoing but gradually withdraws within themselves and stops making good eye contact, especially with people they know, this needs further investigation.

Decreased emotional expression on the face.

The decrease in emotional expression that is seen in schizophrenia and other serious mental illnesses can sometimes be dramatic. In technical terms, it is sometimes described as a “flat affect.” Affect is the way that someone expresses their feelings or emotions. For example, when someone tells you that they are happy, but you can’t tell it from their face or behavior, think flat affect.

Speaking in a monotone.

When someone who previously had a range of intonations starts talking in a monotone, it’s reason for concern. We expect characteristic changes to happen to the patterns of speech when someone is happy, angry, or sad. When you can’t tell what someone is feeling from the way they are speaking, it warrants further investigation.

No longer using gestures to communicate.

A lot of human communication is nonverbal. However, even very reserved people still show some movement of hands, head, and face. If someone gradually gives up the use of gestures and you have no idea why, it warrants a referral to a mental health professional, probably both a therapist and a psychiatrist.

Avolition or low motivation.

Loss of interest in doing things that used to be pleasurable is a characteristic of depression. But when someone stops initiating all kinds of purposeful activities and begins to sit passively, it’s cause for concern. If you know they’re mad, or a child is pouting because they have been told no, that’s not what we are talking about here. The gradual onset of avolition, where the person you care about seems to be retreating into their shell, is a negative symptom that needs attention.

Loss of interest in work or social activities.

Some people lose interest in a hobby or give up an activity they used to enjoy. But when someone loses all interest in going to work or in children going to school and they previously had exhibited an interest in these activities, that’s a cause for concern. Of course, giving up one activity doesn’t constitute a pattern. But if someone gradually loses interest in all kinds of activities they used to participate in, it’s worth checking out.

Alogia – the loss of speech.

Another concerning negative symptom is a decline in speech output, using fewer words, responding less frequently, and having less content to the things they’re saying. Like the other negative symptoms I’ve suggested here, a mental health professional will first want to rule out common causes. If someone’s depressed, angry, or anxious, and that’s the cause of their not speaking, then we treat those conditions. But if they seem to be losing the desire and the ability to speak, that’s very concerning.

Anhedonia – when pleasure stops being pleasant.

Lots of pleasure is a characteristic of Depression. But except for the most severe forms of depression, most depressed people will still seek out pleasure. As a negative symptom of psychosis, pleasure-seeking behavior declines or disappears altogether.


Not wanting to socialize can be a symptom of several mental health conditions. But the asociality we see in schizophrenia and related disorders is much more pervasive. It’s not simple anxiety or a reluctance to meet new people. It’s also stopping social contact with family and friends and preferring to be by yourself. This goes far beyond simply being an introvert.

What should you do if someone has these negative symptoms?

One or two of these symptoms, particularly in a mild form, might simply be someone’s personality or the experiences they’re undergoing right now. But if you see multiple negative symptoms or they are becoming more severe over time, this isn’t something to ignore. A screening by a mental health counselor or therapist might be helpful.

In young children, it’s even harder to be sure if these are really negative symptoms or if they are normal behavior for a child that age. I worry about the times when people, parents, teachers, and even medical doctors, adopt a let’s wait and see attitude. An early referral to a psychiatrist can alter the entire trajectory of a serious psychiatric illness.

So if you or someone in your family seems to be exhibiting negative symptoms, try to get an appointment with a therapist and a psychiatrist. For children, I suggest looking for a psychiatrist who specializes in working with children. I know they are hard to find and harder yet to get an appointment with. Still, it’s better to make that appointment now, even if it turns out it’s not a serious psychiatric illness, rather than wait until the symptoms are severe and the condition is harder to treat.

I hope you find this blog post helpful. I wrote it in response to a comment a reader left which made me realize I had not talked about negative symptoms in the past. If you have other suggestions for posts or questions for me, please leave a comment or use the contact me form.

Does David Joel Miller see clients for counseling and coaching?

Yes, I do. I can see private pay clients if they live in California, where I am licensed. If you’re interested in information about that, please email me or use the contact me form.

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