Deconstructing negative symptoms of schizophrenia: Avolition-apathy and diminished expression clusters predict clinical presentation and functional outcome

Gregory P. Strauss, William P. Horan, Brian Kirkpatrick, Bernard A. Fischer, William R. Keller, Pinar Miski, Robert W. Buchanan, Michael F. Green, William T. Carpenter

Research output: Contribution to journalArticlepeer-review

314 Scopus citations


Background: Previous studies indicate that negative symptoms reflect a separable domain of pathology from other symptoms of schizophrenia. However, it is currently unclear whether negative symptoms themselves are multi-faceted, and whether sub-groups of patients who display unique negative symptom profiles can be identified. Methods: A data-driven approach was used to examine the heterogeneity of negative symptom presentations in two samples: Study 1 included 199 individuals with schizophrenia assessed with a standard measure of negative symptoms and Study 2 included 169 individuals meeting criteria for deficit schizophrenia (i.e., primary and enduring negative symptoms) assessed with a specialized measure of deficit symptoms. Cluster analysis was used to determine whether different groups of patients with distinct negative symptoms profiles could be identified. Results: Across both studies, we found evidence for two distinctive negative symptom sub-groups: one group with predominantly Avolition-Apathy (AA) symptoms and another with a predominantly Diminished Expression (DE) profile. Follow-up discriminant function analyses confirmed the validity of these groups. AA and DE negative symptom sub-groups significantly differed on clinically relevant external validators, including measures of functional outcome, premorbid adjustment, clinical course, disorganized symptoms, social cognition, sex, and ethnicity. Conclusions: These results suggest that distinct subgroups of patients with elevated AA or DE can be identified within the broader diagnosis of schizophrenia and that these subgroups show clinically meaningful differences in presentation. Additionally, AA tends to be associated with poorer outcomes than DE, suggesting that it may be a more severe aspect of psychopathology.

Original languageEnglish
Pages (from-to)783-790
Number of pages8
JournalJournal of Psychiatric Research
Issue number6
StatePublished - Jun 2013
Externally publishedYes

Bibliographical note

Funding Information:
The current studies were supported in part by NIH Grants: MH043292 (M.F. Green PI) and P30MH068580 (W.T. Carpenter PI). Study sponsors had no role in study design, data collection, analysis and interpretation; the writing of the report; and in the decision to submit the paper for publication.


  • Apathy
  • Avolition
  • Blunted affect
  • Emotion
  • Negative symptoms
  • Schizophrenia


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