The relationship between experiential deficits of negative symptoms and subjective quality of life in schizophrenia
Introduction
For decades there has been a consensus that improving symptoms alone is not a sufficient treatment outcome in schizophrenia, with improvements in quality of life seen as central to the concept of recovery (Liberman et al., 2002, Priebe, 2007). Lower quality of life has consistently been associated with higher negative symptoms of schizophrenia, rather than positive symptoms (Ho et al., 1998), however the relationship appears complex.
Quality of life is recognised to comprise of objective components such as daily life functioning and external resources, and subjective components such as wellbeing and satisfaction with life (Katschnig, 2000, Lehman et al., 1982, Priebe, 2007). While there evidence of a strong association between negative symptoms and objective quality of life (OQOL) (Ho et al., 1998, Hunter and Barry, 2012, Milev et al., 2005, Whitty et al., 2008), only a weak association between negative symptoms and subjective quality of life (SQOL) has previously been found (Eack and Newhill, 2007, Fitzgerald et al., 2001, Narvaez et al., 2008, Priebe et al., 2011). This may be because SQOL is determined by multiple processes, including the comparison between expectations and aspirations, a comparison with others, and adaptation over time, all of which may result in a less negative appraisal by individuals with chronic schizophrenia (Priebe, 2007). However, it may also be because the relationship has been under-reported due to how negative symptoms have been assessed.
Negative symptoms include expressive deficits such as blunted affect and alogia, and experiential deficits such as asociality, anhedonia and amotivation. There is evidence to to suggest that older scales are associated more with expressive deficits (Horan et al., 2011), which may be attributable to the fact that such tools rely largely on behavioural referents to measure different negative symptoms (Blanchard et al., 2011). One advantage of the newly developed CAINS is that experiential and expressive symptoms are separated into distinct subdomains, with a focus on subjective experiences of negative symptoms in addition to observed and reported behaviours.
With this in mind, this study aimed to re-evaluate the link between negative symptoms and SQOL using data from one of the largest trials to use the CAINS to date (Priebe et al., 2013). We tested the hypothesis that the association between negative symptoms and SQOL will relate exclusvely to experiential deficits, both cross sectionally and over time. We hypothesised that this relationship would remain after controlling for depressive symptoms, which is important given the association between low mood and SQOL (Eack and Newhill, 2007, Priebe et al., 2011). With evidence to suggest that the relationship between SQOL and symptoms may be different between men and women (Röder-Wanner and Priebe, 1998), and between those with a long and short illness duration (Priebe et al., 2000), a comparison between these groups was also considered.
Section snippets
Design
This is a secondary analysis of data from the NESS Study (ICTRN842165587); a randomised controlled trial evaluating the effectiveness of body psychotherapy for schizophrenia. In the study participants were randomised to receive either a 20 session Pilates class or body psychotherapy group. Assessments were conducted at three timepoints; baseline, end of treatment approximately 3 months later, and then six months after treatment end. At each stage the CAINS (Horan et al., 2011), PANSS (Kay et
Results
Participants were mostly men (73.8%), with a mean age of 42.2 years (SD = 10.65) and a long history of illness (mean = 13.6 years, SD = 9.1). At baseline participants reported low depressive symptoms (Calgary mean = 4.70, SD = 4.37), and moderate negative symptoms (PANSS Marder negative mean = 22.1, SD = 4.8). A total of 275 participants completed the baseline assessment, and 255 the final assessment, resulting in a rentention rate of 92.7%. No significant differences were detected between completers and
Main findings
The findings indicate that the relationship between SQOL and negative symptoms relate exclusively to experiential deficits. A significant negative association was detected between SQOL and the CAINS experiential subscale at all three time points assessed. Over time, again only the experiential features of negative symptoms were found to be a significant predictor of SQOL change. No relationship was found between either SQOL and the CAINS expressive subscale, or the PANSS negative subscale in
Role of funding source
The data was collected as part of the NESS study, a trial funded by a grant from the National Institute for Health Research-Health Technology Assessment programme (REF: 08/116/68). The funding source had no role in study design, analysis, interpretation or manuscript submission.
Contributors
Mark Savill was responsible for study design and implementation, data analysis, and prepared the original manuscript. Stefan Priebe provided oversight on all aspects of the study, was the chief investigator of the original study from which the data was obtained, and assisted in preparation of the manuscript. Stavros Orfanos was involved in data collection on the original study, and assisted in study design and manuscript preparation. Ulrich Reininghaus was involved in study design, and
Conflict of interest
None.
Acknowledgement
The authors would like to thank Ciara Banks, Erica Eassom, Josie Davies, Rebecca Stockley and Tabitha Dow for the role in the data collection, in addition to all participants that agreed to take part.
References (34)
- et al.
Internal consistency, temporal stability and neuropsychological correlates of three cognitive components of the Positive and Negative Syndrome Scale (PANSS)
Schizophr. Res.
(1999) - et al.
Anhedonia in schizophrenia: distinctions between anticipatory and consummatory pleasure
Schizophr. Res.
(2007) - et al.
Development and psychometric validation of the Clinical Assessment Interview for Negative Symptoms (CAINS)
Schizophr. Res.
(2011) - et al.
Negative symptoms and psychosocial functioning in schizophrenia: neglected but important targets for treatment
Eur. Psychiatry
(2012) - et al.
Apathy, cognitive deficits and functional impairment in schizophrenia
Schizophr. Res.
(2011) - et al.
Subjective and objective quality of life in schizophrenia
Schizophr. Res.
(2008) - et al.
Association between symptoms and quality of life in patients with schizophrenia: a pooled analysis of changes over time
Schizophr. Res.
(2011) - et al.
Assessing depression in schizophrenia: the Calgary Depression Scale
Br. J. Psychiatry
(1993) - et al.
The structure of negative symptoms within schizophrenia: implications for assessment
Schizophr. Bull.
(2006) - et al.
Toward the next generation of negative symptom assessments: the collaboration to advance negative symptom assessment in schizophrenia
Schizophr. Bull.
(2011)
Determinants of quality of life at first presentation with schizophrenia
Br. J. Psychiatry
Psychiatric symptoms and quality of life in schizophrenia: a meta-analysis
Schizophr. Bull.
Subject and observer-rated quality of life in schizophrenia
Acta Psychiatr. Scand.
Do people with schizophrenia have difficulty anticipating pleasure, engaging in effortful behavior, or both?
J. Abnorm. Psychol.
Apathy but not diminished expression in schizophrenia is associated with discounting of monetary rewards by physical effort
Schizophr. Bull.
Two-year outcome in first-episode schizophrenia: predictive value of symptoms for quality of life
Am. J. Psychiatry
Does anhedonia in schizophrenia reflect faulty memory for subjectively experienced emotions?
J. Abnorm. Psychol.
Cited by (36)
Plasma complement and coagulation proteins as prognostic factors of negative symptoms: An analysis of the NAPLS 2 and 3 studies
2024, Brain, Behavior, and ImmunityEffects of bilateral, bipolar-nonbalanced, frontal transcranial Direct Current Stimulation (tDCS) on negative symptoms and neurocognition in a sample of patients living with schizophrenia: Results of a randomized double-blind sham-controlled trial
2022, Journal of Psychiatric ResearchCitation Excerpt :Schizophrenia is a severe mental disorder (McGrath et al., 2008), presenting with negative, positive, disorganized symptoms and cognitive impairments (APA, 2013), and characterized by reduced life expectancy, poor psychosocial functioning and quality of life, posing high burdens for mental health care systems, patients and relatives (Jauhar et al., 2022). Particularly, with prevalence of 50–90% and 20–40% in first-episode psychosis and in chronic stages respectively (Mäkinen et al., 2008; Carbon and Correll, 2014), negative symptoms (NS) (Millan et al., 2014; Galderisi et al., 2015; Marder and Galderisi, 2017) represent potential determinants of impaired quality of life (Alessandrini et al., 2016; Savill et al., 2016). NS seem to be multidimensionally described (Galderisi et al., 2018b) as two distinct factors (Kirkpatrick et al., 2006): the Expressive Deficit domain (EXP domain, including features of blunted affect and alogia) and the Avolition-Apathy domain (AA domain, including manifestations of anhedonia, asociality and avolition) (Blanchard and Cohen, 2006; Kirkpatrick and Fischer, 2006; Millan et al., 2014; Messinger et al., 2011; Jang et al., 2016; Galderisi et al., 2018a).
Psychometric properties of the BIRT Motivation Questionnaire (BMQ), a self-measure of avolition in individuals with schizophrenia
2022, Journal of Psychiatric ResearchCitation Excerpt :However, more recent work using either confirmatory factor analysis (Strauss et al., 2018) and network analysis (Strauss et al., 2019) revealed that the latent structure of negative symptoms is best conceptualized in relation to five consensus domains, namely blunted affect, alogia, asociality, anhedonia, and avolition (Kirkpatrick et al., 2006). Avolition is often reported as the most distressing and poorest predictor of functional status (Foussias and Remington, 2010), employment (Llerena et al., 2018) and quality of life (Savill et al., 2016). Both family and mental health clinicians often agree that reduced motivation is the patient's most profoundly disabling symptom (Galderisi et al., 2018).
Profiles and trajectories of mental health service utilisation during early intervention in psychosis
2021, Schizophrenia Research“I just don't look forward to anything”. How anticipatory pleasure and negative beliefs contribute to goal-directed activity in patients with negative symptoms of psychosis
2020, Schizophrenia ResearchCitation Excerpt :However, in patients with psychosis and negative symptoms, this adaptive process seems to be disturbed, as they show a reduced initiation and persistence of goal-directed activities (Strauss and Cohen, 2017). Consequently, they report a decreased subjective quality of life (Savill et al., 2016) and are found to spend more time resting, alone and less time in activity than healthy controls in daily life (e.g., Cella et al., 2016). So far, antipsychotic medication shows limited or even adverse effects on negative symptoms (Artaloytia et al., 2006; Zhou et al., 2018) and the enhancement of goal-directed activity remains a major challenge for psychological interventions (Aleman et al., 2017; Velthorst et al., 2015).