The Longitudinal Pathway to the Negative Syndrome in Schizophrenia

A number of studies have proposed the relationship of familial incidents, gene mutations, early neuro-motor difficulties, behavioral problems in school, and psychosocial difficulties in school, relativity low performance on academic and psychological tests, and dysfunctional attitudes prior to the development of schizophrenia. These various predictive findings can be collated to provide a hypothetical picture of the longitudinal pathway to the negative symptoms (negative syndrome) in schizophrenia. More specifically, we suggest that these factors conspire to produce a negative self-image leading to the eventual development of the negative syndrome in schizophrenia.

We postulate that the early neuro-motor difficulties demonstrated by Walker et al. (1994) in her study using collected home video tapes in the first two years of life and similar behavioral abnormalities across the lifespan (Manschreck, 1986; Johnstone et al., 1990; Walker, Savoie, & Davis, 1994 ; Weiser, Knobler, Noy, &Kaplan, 2002) lead to a self-image of being different and in many cases inferior and incompetent in relation to others. This difference is manifested in behaviors of social awkwardness, high-strung sensitivity to stress, social isolation and loneliness which have been documented using ratings by school teachers in a comprehensive population study (John, Mednick, and Schulsinger, 1982; Mednick, Parnas & Schulsinger, 1987). We suggest that the beliefs of social incompetence lead to task aversion, lack of effort and poor test performance. The defeatist attitudes driving this behavior have been described by our group in high-risk individuals (Perivoliotis et al, 2009). Additionally, poor social relations during teenage years predicted schizophrenia in a Swedish army study (Malmberg et al., 1998) and also in an Israeli Army Study (Davidson et al., 1999). Moreover, we have found a correlation between negative social attitudes and the presence of the negative syndrome (Grant & Beck, 2010).While we have previously demonstrated that poor performance can be attributed to attitudinal and motivational factors (Beck et al., 2018), we further illuminate a prior pathway to the instatement of these defeatist and asocial attitudes which begins long before the onset of schizophrenia. The proposed pathway is as follows:

Predisposition as a result of genetics, perinatal complications, intrauterine problems leading to Neuro-motor difficulties leading to Impact on behavior (social, cognitive etc.)leading to Social awkwardness, high-strung characteristic, etc. leading to Social rejection leading toAsocial attitudes/ withdrawal +defeatists attitudes leading toLow motivation and effort leading to Task aversion.

Further examination should be given to the pathway described above. It is also apparent that future research needs to document the early occurrence of dysfunctional attitudes in children and adolescents. Including a Defeatist Attitude Scale and Social Avoidance Scale in future population studies would be quite streamlined to implement. Additionally, interventions that aim to decrease the deep-rooted feelings of difference and inferiority and instead focus on building a sense of efficacy, empowerment, and shared interests with family and peers may lessen the cognitive and social gap that affects the self-image of children and adolescents at high risk of schizophrenia. Finally, later prognosis interventions targeting the negative performance and social attitudes (as demonstrated by the efficacy of Recovery Oriented Cognitive Therapy) (Grant et al., 2011) can have a salutary effect on the negative symptoms.



1.Beck, A. T., Himelstein, R., Bredemeier, K., Silverstein, S. M., & Grant, P. M. (2018). What Accounts for Poor Functioning in People with Schizophrenia: A Re-evaluation of the Contributions of Neurocognitive vs. Attitudinal and Motivational Factors. Psychological Medicine. 0, 1-10

2.Davidson, M., Reichenberg, A., Rabinowitz, J., Weiser, M., Kaplan ,Z., & Mark, M. (1999). Behavioral and intellectual markers for schizophrenia in apparently healthy male adolescents .Am. J. Psychiatry156(13) 28–35

3.Grant, P. M. & Beck, A. T. (2010). Asocial beliefs as predictors of asocial behavior in schizophrenia. Psychiatry Research, 177, 65-70.

4.Grant, P., Huh, G. A., Perivoliotis, D., Stolar, N. M., & Beck,A. T. (2011). A Randomized Trial to Evaluate the Efficacy of Cognitive Therapy for Low Functioning Patients with Schizophrenia. Archives of General Psychiatry, EPub.

5.John,R., Mednick, S.A., &Schulsinger,F. ( 1982) Teacher Reports as a Predictor of Schizophrenia and Borderline Schizophrenia: A Bayesian Decision Analysis. Journal of Abnormal Psychology 91(6),399-413

6.Johnstone, E.C., Macmillan, J.F., Frith, C.D., Benn, D.K. & Crow,T.J.(1990) Further investigation of the predictors of outcome following first schizophrenic episodes. British Journal of Psychiatry, 157:182-189,

7.Malmberg, A., Lewis, G., David, A., & Allebeck, P. (1998). Premorbid adjustment and personality in people with schizophrenia.Br. J. Psychiatry.1(72):308–13

8.Manschreck, T . (1986) Motor abnormalities in schizophrenia. In: Nasrallah, H., and Weinberger, D.R., (eds.) Handbook of Schizophrenia: The Neurology of Schizophrenia. Vol. 1. New York, NY: Elsevier, pp. 65-96.

9.Mednick, S. A., Parnas, J., & Schulsinger, F. (1987). The Copenhagen High-RiskProject, 1962-86. Schizophrenia Bulletin, 13(3), 485-495.

10.Perivoliotis, D., Morrison, A.P., Grant, P.M., & Beck, A.T. (2009). Negative performance beliefs and negative symptoms in individuals at ultra-high risk of psychosis: A preliminary study. Psychopathology,42, 375–379.

11.Walker,E.F., Savoie,T.,& Davis,D. Neuromotor Precursors of Schizophrenia (1994) Schizophrenia Bulletin 20(3), 441-451

12.Weiser, M., Knobler, H. Y., Noy, S. and Kaplan, Z. (2002), Clinical characteristics of adolescents later hospitalized for schizophrenia. Am. J. Med. Genet., 114: 949–955. doi:10.1002/ajmg.10647