Negative symptoms in schizophrenia

Lucie de Blois, Managing Editor
Canadian Journal of Psychiatry
Editorial Office, Suite 204
294 Albert Street
Ottawa, ontario KIP 6E6

Dear Madam:

In their report on negative symptoms in chronic non­ schizophrenic patients (Can J Psychiatry, Vol 34, Nov 1989). Drs. De Bosset and Shaul demonstrate that negative symptoms are not specific to schizophrenia. We would like to comment on the clinical importance of this fact. In our work with chronic psychotic patients in day treatment and outpatient clinic settings, we also observe “secondary” negative symptoms in patients who experience parkinsonian side effects of antipsychotic medications. If these “secondary” negative symptoms are not recognised as medication side effects, this may blur the clinical picture sufficiently that such patients are misdiagnosed as suffering from chronic schizophrenia.

We have seen several patients who were misdiagnosed as schizophrenic following an initial psychotic break. We should not forget the power of the written word (or the uncertainty of our diagnostic schemes). Our experlence has been that once a diagnosis is written in a chart it is regarded as truth, regardless of the reality. When the clinician then senses a “praecox feeling” from the patient and fails to recognise that this may be due to the medication, there is an added reluctance to reconsider the diagnosis. Such patients can then be committed to a life-time of incorrect medical management which exposes them to unnecessary risks, such as Tardive Dyskinesia.

The wisdom of a thorough chart review and reassessment should not be forgotten. With all our patients, we reduce the antipsychotic slowly in an attempt to determine the minimum therapeutic dose. One of the many benefits of this approach is that this also reduces the “secondary” negative symptoms and can permit the underlying pathology to become more clearly visible. This has allowed us to rediagnose some patients who have carried the label of schizophrenia for many years. It is particularly gratifying when affective symptoms emerge or a chart review leads us to change the diagnosis and treatments such as lithium carbonate, antidepressants or carbamazepine result in more appropriate and better control of the illness.