What are negative symptoms?
Classical teaching distinguishes between primary and secondary negative symptoms. The primary ones are said to “belong to the disorder itself”, as if they somehow arise from the brain. The secondary ones are said to stem from other causes, such as side effects of medication, depression, anxiety, demotivation, overstimulation or even the hopelessness of a life full of stigma and loneliness.
Does that distinction between primary and secondary sound logical? Perhaps. But in practice this distinction can hardly be made, or in fact simply cannot be made at all.
The problem with ‘primary’
Because what exactly is a primary negative symptom? How do you know whether someone has lost motivation “of their own accord”, or because the side effects of their pills leave them exhausted? Or because they have been shut out of work, school and friendships? Because they have come to feel worthless after years of struggling with a stigmatising diagnostic label and a course of treatment in which their ‘deficit’ was stressed again and again?
The answer is: you do not know. And you cannot know. There is no brain scan or test that shows without fail: this is primary! Or: this is secondary! In fact the whole idea that negative symptoms come ‘from within’, without context, is already suspect. Because people always function in a context: relational, social, psychological.
Antipsychotics: what dampens, dampens everything
What we do know is that antipsychotics often dampen exactly what gives you motivation: your desire, your hunger, your initiative, your longing for contact or meaning. Yes, they are designed to dampen agitation and psychosis. But what if they also dampen your capacity to feel pleasure?
People regularly say that they feel “flat”, “indifferent”, “no longer themselves” on this medication. They do want to do something, but no longer feel anything about things. And without emotional reward, who has any motivation left?
This is a core problem, not a side issue. And it is exactly why it is so important that every client is helped to find the lowest possible effective dose. Not the standard dose. Not what “is usually given”. But what really helps, while giving up as little feeling, initiative and zest for life as possible.
Depression, stigma, demotivation: all ‘secondary’?
And then there are the “secondary” influences: depression, anxiety, trauma, shame, chronic stress, isolation, poverty, racism, queerphobia, rejection. All of them things that can undermine motivation and that are often not addressed in a classical psychiatric course of treatment.
So it is time to acknowledge that the idea of negative symptoms as something that sits primarily in people does not match reality. We need to regard all negative symptoms as the result of something, whether that is medication, depression, surroundings, lack of support or a lack of hope.
What does help?
What do people with psychosis need? Social prescribing. A plan instead of a pill. An invitation instead of a label. Helping someone to take part in something again. Something creative, something social, something meaningful. Think of recovery colleges, self-management groups, peer support, sport, art, gardening, cooking together, making music, dancing, building hope.
Because motivation only blossoms when you have something to gain. And something to mean to others.
So let us stop straining to tell primary from secondary negative symptoms. Let us acknowledge that in principle everything is secondary, in the sense that it arises from circumstances, context and treatment. And above all let us listen to what people themselves say they miss, long for and need. That is what positive psychiatry looks like.
Prof. dr. Jim van Os, Chair Division Neuroscience, Utrecht University Medical Centre. Jim works at the interface of ‘hard’ brain science, health services research, art and subjective experiences of people with ‘lived experience’ in mental healthcare.
Jim has been appearing on the Thomson-Reuter Web of Science list of ‘most influential scientific minds of our time’ since 2014. In 2014 he published his book ‘Beyond DSM-5‘, and in 2016 the book ‘Good Mental Health Care’. In 2026 he published 'Wat psychisch lijden is'.
Want to read more?
Blogs by Jim van Os can be read here
Did you know that PsychosisNet regularly posts new content?
Online tests
Compare antidepressants tool
Compare antipsychotics tool
Podcasts
Books
