EPA guidance on assessment of negative symptoms in schizophrenia
EPA · 2021 · Europe
Source and licence
- Authors
- S Galderisi, A Mucci, S Dollfus et al.
- Title
- EPA guidance on assessment of negative symptoms in schizophrenia
- Journal
- European Psychiatry, 2021
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC8080207
Licence statement of the original publication
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
Open the original publication →Full text on Europe PMC
Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Conceptualization
- Avolition: a reduction in the initiation and persistence of goal-directed activities due to a lack of motivation.
- Anhedonia: a reduction in the experience of pleasure during the activity (consummatory anhedonia) and for future anticipated activities (anticipatory anhedonia).
- Asociality: a reduction in social interactions due to a reduced drive to form and maintain relationships with others.
- Blunted affect: a reduction in the expression of emotion in terms of facial and vocal expression, as well as body gestures.
- Alogia: a reduction in quantity of words spoken and amount of spontaneous elaboration.
Persistent, predominant, and prominent negative symptoms
- Recommendation 1(based on studies included in Table e1)
- The persistent negative symptom construct should be used in the context of clinical trials. EPA recommends the use of established cutoff scores on validated rating scales for clinically significant depression, moderate positive symptoms, and absence of parkinsonism.Grade: B
Factor structures of negative symptom domains
- Recommendation 2(based on studies included in Table e2)
- Based on the available evidence, any summary score or subscale score of the negative dimension should use only core negative symptoms, consistently loading on the negative symptom factor: i.e., for the PANSS, the items “Blunted affect” (N1), “Emotional withdrawal” (N2), “Poor rapport” (N3), “Passive/apathetic social withdrawal” (N4), and “Lack of spontaneity and flow of conversation” (N6); for the SANS the subscales “Affective Flattening or Blunting” (items 1–5, and 7), “Alogia” (items 9, 11–12), “Avolition-Apathy” (items 14–16), “Anhedonia-Asociality” (items 18–21); for the BPRS items “Blunted affect” (item 16) and “Emotional withdrawal” (item 17).Grade: B
Scale for the Assessment of Negative Symptoms
- Recommendation 3(based on studies included in Tables e2 and e5)
- Due to the limits of PANSS negative subscale and SANS according to the present conceptualization of negative symptoms, these scales should be complemented with a second-generation scale in clinical trials.Grade: B
The Negative Symptom Assessment Scale
- Recommendation 4(based on studies included in Table e5)
- Due to the limits of NSA-16 according to the present conceptualization of negative symptoms, this scale should be complemented with a second-generation scale.Grade: B
The Clinical Assessment Interview for Negative Symptoms
- Recommendation 5(based on studies included in Tables e3 and e5)
- Due to their good psychometric properties and coverage of the five domains of negative symptoms, BNSS or CAINS should be used for the assessment of negative symptoms. In clinical trials, they should be used to complement first-generation scales.Grade: B
The Self-evaluation of Negative Symptoms
- Self-assessments can be used to complement observer-ratings. SNS (exploring five domains) and MAP-SR (exploring three domains) can be used for self-assessment of negative symptoms.Grade: C
Scales focused on one dimension of negative symptoms
- Recommendation 7(based on studies included in Table e6)
- The Apathy Evaluation Scale (AES) could be regarded as a useful tool for the assessment of apathy in schizophrenia.Grade: D
Recommendations
- Recommendation 8(based on studies included in Table e8)
- Patients presenting with negative symptoms can be repeatedly assessed over time to identify possible sources of secondary negative symptoms that might be amenable to treatment.Grade: C
- To identify secondary negative symptoms, it can be useful to verify if their severity is modified by changes of antipsychotic drug or dose, or psychotic exacerbation or depressive symptoms over time.Grade: C
- To identify depression as a cause of secondary negative symptoms in subjects with schizophrenia, the Calgary Depression rating Scale should be used to investigate patient’s internal experience of depressed mood and depressive ideation, such as hopelessness and guilt.Grade: B
- The presence of expressive deficits can be more characteristic of subjects with negative symptoms than of those with depression.Grade: C
- Patient’s internal experience of motivation to engage in goal-directed behavior and social interaction in the presence of lack of initiative and social withdrawal could be considered to exclude anxiety or psychotic symptoms as sources of the observed behaviors.Grade: D
- In the presence of negative symptoms and concomitant moderate to severe positive symptoms, remission of positive symptoms could be pursued before classifying negative symptoms as primary.Grade: D
- In subjects with negative symptoms treated with antipsychotics, a standard clinical examination to assess the presence of extrapyramidal signs, which are not in overlap with negative symptoms (e.g., tremor or rigidity), could be carried out to exclude drug-induced parkinsonism.Grade: D
Abstract
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.
Contents of the original publication
The section headings of the original.
- Introduction
- Methodology
- Systematic literature search
- Inclusion criteria
- Exclusion criteria
- Conceptualization
- Classification of negative symptoms
- Factor structures of negative symptom domains
- The burden of negative symptoms in schizophrenia
- Assessment of Negative Symptoms
- Assessment instruments
- Assessment of negative symptoms in first-episode psychosis patients
- Assessment of negative symptoms in clinical high-risk individuals
- Differentiating primary and secondary negative symptoms in the clinical practice
- Discussion
- Conclusions
- Financial Support
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