A weakening of those emotional activities which permanently form the mainsprings of volition… The result of this part of the morbid process is emotional dullness, failure of mental activities, loss of mastery over volition, of endeavor, and of ability for independent action. The essence of personality is thereby destroyed, the best and most precious part of its being… torn from her. (p. 74)
Taking a cue from Kraepelin's1
description of negative symptoms and aiming to reduce the heterogeneity of schizophrenia, Carpenter and colleagues2
proposed the deficit syndrome, a symptom complex characterized by primary and enduring negative symptoms caused by a specific disease process that is separable from the genetic and neurobiological factors that contribute to nondeficit schizophrenia. Since the first description of the deficit syndrome in the 1980s, over 300 studies have examined its clinical and neurobiological correlates.3
Research has shown that deficit patients, as compared with nondeficit patients, have poorer premorbid functioning,4
more severe neurocognitive impairment,5
worse functional outcome,6
and substantially lower rates of remission and recovery.7
Yet, despite a worse prognosis, deficit patients experience less overall negative affect,8
have a lower risk for suicide,9
and abuse substances less than nondeficit patients.10
Whereas neurobiological research has identified anomalies associated with the deficit syndrome in the areas of eye tracking,11
these findings have not translated into improved treatments. In fact, the poor prognosis of deficit patients may be due, in large part, to their poor response to both psychotropic medications15
and psychosocial interventions such as social skills training.16
In sum, the literature suggests that the deficit syndrome has its own specific biological basis but no effective treatment.
Within the relatively large number of studies of the deficit syndrome,3,4
there have been investigations of psychological processes such as self-reported stress17
and emotion labeling18
; however, none of the studies has reported on psychological variables such as dysfunctional attitudes, negative expectancies (regarding future pleasure, future success, etc.) and self-esteem. In contrast, an emerging body of research has indicated that these psychological variables are associated with negative symptoms. A conceptualization of negative symptoms has been proposed according to which these newly identified psychological factors, including beliefs and expectations, contribute to the maintenance of negative symptoms and disability in schizophrenia.19
For example, defeatist beliefs about performance (eg, If you cannot do something well, there is little point in doing it at all) have been found to mediate the relationship between neurocognitive impairment and both negative symptoms and functional outcome.20
Similarly, asocial beliefs (eg, I prefer hobbies and leisure activities that do not involve other people) predicted both concurrent and future asocial behavior better than neurocognitive or emotion recognition tasks.19,21
Negative expectancies regarding satisfaction were also shown to be associated with negative symptoms: these patients experienced more pleasure than they anticipated.22
Consistent with Kraepelin's aforementioned emphasis on the importance of loss of volition in schizophrenia, Granholm and colleagues23
have demonstrated that patients with negative symptoms do not show the normal pupillary response to performance tasks, a physiological marker of performance effort. Further, they have demonstrated that defeatist attitudes contribute significantly to this diminished pupillary response in negative symptom patients,24
thus establishing the crucial link between defeatist attitudes and deficient behavior in this group.
In view of the findings showing the association of negative attitudes and expectancies with negative symptoms in general, we considered it useful to determine whether these psychological factors play a role in the deficit syndrome, which is composed of negative symptoms that are both enduring (lasting more than 1 year) and primary (not secondary to positive symptoms, depression, or medication side-effects). Specifically, it would be of considerable interest to determine whether deficit syndrome patients also endorse dysfunctional beliefs, attitudes, and negative expectancies. Given that previous research on these patients has focused upon clinical, neurobiological, and neurocognitive factors to the relative neglect of psychological factors, the principal aim of the present study was to redress the lack of investigation of dysfunctional beliefs and attitudes in the deficit syndrome literature. Accordingly, deficit syndrome patients were compared with nondeficit patients with negative symptoms on a variety of psychological measures, including negative beliefs, expectations, and self-esteem, as well as measures of symptoms, functioning, and neurocognition. Based upon the literature on negative symptoms, we hypothesized that (1) the deficit group would endorse defeatist beliefs regarding performance to a greater extent than the nondeficit group, (2) the deficit group would endorse asocial beliefs to a greater extent than the nondeficit group, and (3) the deficit group would have lower expectations of future enjoyment than the nondeficit group. Support for these hypotheses may lead to a more complete understanding of the deficit syndrome and inform psychosocial treatments for this treatment-resistant population.
We included measures of symptoms and neurocognition in order to replicate the findings in the deficit syndrome literature and thereby establish the validity of our means of identifying deficit patients. Accordingly, we also predicted that the deficit group would show more severe negative symptoms, less anxiety and depression, greater neurocognitive impairment, and worse emotion recognition than the nondeficit group.5,6,8
Additionally, we predicted that given an expected lower score on a depression measure, the deficit group would show higher self-esteem than the nondeficit group. In view of the presumed lower anxiety scores, we also predicted that the deficit group would score lower on a measure related to concern about negative evaluations than the nondeficit group.