CLINICAL HANDBOOK OF SCHIZOPHRENIA

88 I. CORE SCIENCE AND BACKGROUND INFORMATIONtening. It is important to distinguish this from the affective blunting that may be seen indepressed patients.• Alogia (poverty of speech) is manifested by brief, laconic, empty replies. There isan absence of ability to carry out engaging meaningful conversation. Alogia may reflect amore primary inability to form completely and then articulate thoughts, and must be differentiatedfrom unwillingness to speak, which is often seen as part of a severe positivesymptomatology.• Avolition is characterized by an inability to initiate and persist in goal-directed activities.The person may sit for long periods of time and show little interest in participatingin work or social activities.Several additional negative symptoms have been identified. These include anhedonia(reduction in capacity to experience pleasure), asociality (reduction of interest in otherpeople), and inattentiveness (difficulty in maintaining focused or engaged).Although negative symptoms are common, they must be judiciously differentiatedfrom a variety of other clinical features, including depressed mood, isolative behaviorseen in paranoid individuals, or apathy, which is often seen in older persons withdementias, frontal lobe disorders, or parkinsonian features. In older persons who alreadycarry a diagnosis of schizophrenia, this clinical distinction becomes critically important.Certain antipsychotic medications often produce extrapyramidal side effects, such asbradykinesia or akinesia, which may mimic affective flattening. The distinction betweentrue negative symptoms and medication side effects often depends on clinical judgmentand detailed evaluation by the clinician.It is prudent to approach a clinical estimation of negative symptoms with discretion,and a person’s overall functioning and broader clinical and social picture must be assessedas well. Ideally, negative symptoms are diagnosed only after observation over aprolonged period of time.Other Associated Clinical FeaturesDSM-IV-TR lists multiple symptoms that are present in schizophrenia and that may bestrongly associated with certain subtypes:• Dysphoric mood may take the form of depression, anxiety, or anger. Sleep patternsare often disturbed.• Various cognitive dysfunctions such as poor concentration, disorientation, or impairedmemory may be present acutely, but some deficits may persist.• Depersonalization, derealization, and somatic concerns may occur and sometimesreach delusional proportions.• Suicide risk remains higher than that in the general population over the whole lifespan,and is often elevated immediately after an acute psychotic episode.• Many studies have reported that subgroups of individuals diagnosed with schizophreniahave a higher incidence of assaultive and violent behavior.• There are high rates of comorbidity with substance-related disorders and withanxiety disorders, such as obsessive–compulsive and panic disorders.INTERNATIONAL CLASSIFICATION OF DISEASESThe first version of the ICD appeared in 1900, and was designed to establish comparablenomenclature among different countries. In 1946, it was entrusted to the newly estab-