Cognitive behavioral therapy, or CBT, is one of the most studied therapeutic models in the treatment of schizophrenia. CBT can help people with superficial affect recognize how their emotionless response is not what is needed in a particular situation. Schizophrenia is often a chronic, debilitating disease characterized by heterogeneous constellations of positive and negative symptoms. The aim of this review was to provide information that may be useful to clinicians treating patients with negative symptoms of schizophrenia. Negative symptoms are an essential component of schizophrenia, accounting for much of the long-term disability and poor functional outcomes in patients with the disease. The term negative symptoms describes a reduction or absence of normal behaviors and functions related to motivation and interest or verbal/emotional expression. The negative symptom domain consists of five key constructs: blunt affect, alogy (reduced number of words spoken), avolition (reduced intentional activity due to decreased motivation), asociality, and anhedonia (reduced experience of pleasure). Negative symptoms are common in schizophrenia; Up to 60% of patients may have clinically relevant significant negative symptoms that require treatment. Negative symptoms can occur at any time during the course of the disease, although they are reported as the most common first symptom of schizophrenia. Negative symptoms may be primary symptoms inherent in the underlying pathophysiology of schizophrenia, or secondary symptoms related to psychiatric or medical comorbidities, side effects of treatment, or environmental factors. While secondary negative symptoms may improve following treatment aimed at improving symptoms in other areas (i.e., positive symptoms, depressive symptoms, or extrapyramidal symptoms), primary negative symptoms generally do not respond well to currently available antipsychotic therapy with dopamine D2 antagonists or partial D2 agonists.

Because some patients may lack understanding of the presence of negative symptoms, this is usually not the reason patients seek clinical care, and clinicians need to be very vigilant about their presence. Negative symptoms clearly represent an unmet medical need in schizophrenia, and new effective treatments are urgently needed. The symptoms of schizophrenia are generally divided into three categories: positive, negative, and cognitive. The National Institute of Mental Illness (NIMH) publishes the following on the three categories of symptoms: Flat affect is a characteristic symptom of schizophrenia, although it can also affect people with other conditions. It is a lack of emotion characterized by an apathetic, immutable facial expression and little to no change in the strength, tone, or pitch of the voice. Divergent estimates of the validity of subscales measuring blunt effect are presented in Table 5. The clinically assessed and self-rated NSAID expression subscale was minimally correlated with BPRS-P (0.13 and 0.14, respectively). The CAINS expression subscale and the SANS Blunted Affect subscale were minimally correlated with the CDSS (0.15 and 0.12, respectively).

However, the CAINS SR expression subscale had a slightly stronger correlation (by 0.31) with CDSS compared to the clinical expression subscale. Since affect is a flexible and fluid expression of inner feelings, many situational and important stressors can influence the condition. Some people may notice a change in affect due to something minor like excessive fatigue, while others may be affected by major concerns such as serious medical or mental health issues. It can be difficult to distinguish between primary negative symptoms (intrinsic to the underlying pathophysiology of schizophrenia) and secondary negative symptoms (related to other factors). Secondary symptoms that may respond to treatment occur in association with positive symptoms, affective symptoms, medication side effects, environmental deprivation, or other factors related to treatment or disease (Figure 1).7 For example, negative symptoms could be a side effect of primary positive symptoms in a patient who socially withdraws from paranoia or paranoia; or decreased expression could be a coping strategy in a patient unable to process overwhelming external stimuli associated with psychotic episodes in schizophrenia. Clinically relevant negative symptoms of schizophrenia that occur in the majority of patients should be detected, evaluated and treated as well as possible to achieve better patient outcomes. Because negative symptoms are often not recognized by clinicians and evidence-based treatments are limited, negative symptoms are closely linked to poor patient function, poorer quality of life, and reduced productivity than positive symptoms that can be better managed with available treatment options. Targeting negative symptoms for drug development has produced positive results for some drugs as monotherapy in a limited number of recently well-designed clinical trials, but to date, effective treatment of negative symptoms remains an unmet medical need in schizophrenia. Therefore, D3 antagonists and partial agonists may offer benefits in case of negative or cognitive symptoms. Additional information on schizophrenia is available from the following sources: The above factors may make it difficult to assess blunt affect. The work of Abrams and Taylor and their development of the scale for emotional blunting (SEB) in the late 1970s was an early indicator that blunt affect could be reliably assessed [14]. Since then, several new tools have been developed to assess negative symptoms with subscales that measure blunt affect.

In this context, this article focuses on blunt affect and its clinical evaluation. Our goal is to provide researchers and clinicians with a systematic overview of different attenuated effects assessment tools by allowing a comparison of the type, characteristics, administration and psychometric properties of these instruments. Distinguishing between flat, blunt and restricted affects can be complicated and somewhat subjective. To better categorize the symptom, mental health professionals will assess all facets affected by the altered effects and find the appropriate label. Like other psychological symptoms, affect can change easily, so a person may have blunt affect today and broad affect tomorrow. Tracking and documenting changes over time will help maintain a complete clinical picture. Medications that can be used include antipsychotics (in the case of schizophrenia or psychosis), antidepressants or mood stabilizers (in the case of mood disorders or related problems), and a specific drug approved by the U.S. Food and Drug Administration to treat pseudobulbar effects (a combination of dextromethorphan and quinidine). Often, an inappropriate affect is a symptom of another disorder rather than a syndrome itself, so an assessment is made for mental disorders that could also be a possible cause. The severity of the problem would also be assessed to determine where it falls in the range from mild to severe. Flat affect is more common in men than in women and is often present in the early stages of schizophrenia.

It is generally accepted that negative symptoms include 5 key concepts,61 which can be classified into 2 independent factors (Figure 3).2,62,63 In examining what we now know as schizophrenia in 1909, Stransky referred to “intrapsychic ataxia” as a condition that involves a disturbance between thought and affect.