This article will describe promising non-drug approaches to reducing the feelings of apathy or emotional blunting that can occur with schizophrenia-spectrum illnesses. The approach is based on the deliberate cultivation of positive experience, and it can be highly effective.
The ‘Negative Symptoms’ of Schizophrenia
Many people with schizophrenia struggle with symptoms of apathy, lack of motivation, or diminished ability to feel emotion. Experiences such as these are called negative symptoms, a term reflecting a view of ordinary capacities having been diminished during the illness process.
So-called negative symptoms tend not to respond as well to customary schizophrenia medications. And this is unfortunate because these are symptoms that tend to cause the greatest disruption to life quality.
Physicians should also be aware that antipsychotic medications can produce secondary negative symptoms. Therefore, it is important that these medications not be dosed excessively. During the course of pharmacotherapy, every effort should be made to assure that patients receive the lowest effective dose of medication. Finding the lowest yet effective medication dose is probably the most useful of the pharmacological approaches to minimize negative symptoms.
Deliberate Cultivation of Positive Experience
Probably the best approach to overcoming negative symptoms is the deliberate cultivation of positive experience. Responses can be dramatic. Here are some examples.
A young man with schizophrenia was spending most of his time in the basement of his parents’ house. He did very little down there. He had more of an existence than a life at that point. When he expressed a tiny bit of curiosity about guitars, his parents bought one for him. He played with it, started watching YouTube videos and played a bit more. It started to become a regular thing. Eventually, he decided to get some in-person lessons from a teacher in his city. This required riding the bus to and from the lessons. After several bus rides, he decided to clip his nails and wash and trim his hair – realizing that his previous inattention to grooming made him look different from the other passengers. Thus began a pathway to sustained improvements and a solid passion for music.
A psychiatrist had struggled for many years to help a woman with longstanding schizoaffective disorder. Multiple antipsychotic medications had failed to improve the patient’s symptoms. Long-acting injectable medications were hardly effective. Even clozapine had minimal benefit.
Knowing of an interest in music, an astute case manager encouraged her to sign up for a local song contest. The feedback and support she received made a profound improvement. The patient’s psychiatrist wrote:
“The patient… is now doing the best I’ve ever seen her (in 6 years of knowing her, literally light years different) because of participation in a singing/song-writing contest that she was well-valued in and motivated for. And as the physician I had to step back and say I have done “nothing” for her while her case manager – aware of the patient’s creativity and skills – has done more good than any medication I’ve seen.”
These anecdotes reveal a fundamental truth about healing from mental illness. Even though it may feel difficult or awkward in the beginning, getting in touch with an interest or a talent and building on it can be a powerful catalyst for desired change. It’s always vital to pursue one’s dreams, even if only bit-by-bit. Indeed, gradual but deliberate action – in line with one’s interests, values, goals or purpose – is as important for real happiness as food is for the body.
A Sizeable Effect on Negative Symptoms
They stories also exemplify a strategy called“broaden and build.”Deliberately creating positive emotions, like exploring an interest in music, broadens cognition and behavioral practices. Regularly doing things that bring healthy pleasure (intentionally broadeningone’s positive experiences) will buildthe brain circuits that ultimately support higher-level coping and flourishing mental health, according to this theory.
“The broaden-and-build theory posits that positive emotions broaden an individual’s thoughts and behavioral urges; the accrual over time of these broadened mindsets leads an individual to think and behave in ways that build personal resources, such as mindfulness, purpose in life, and social support” (Johnson et al., 2011)
To test this hypothesis, Johnson and colleagues studied the effect of a secularized version of the Buddhist ‘loving kindness meditation,’ an exercise that involves cultivating one’s attention and focus on kindness toward self and others. Participants practiced this mediation one hour per week for six weeks. It seemed to work well.
Compared to baseline values, there were significant increases of positive emotion frequency and intensity as well as a very significant drop in the severity of negative symptoms and anhedonia. The effect sizes for these latter changes were very large: 1.68 to 1.88. (For reference, the effect size of non-clozapine antipsychotic medications ranges from 0.4 to 0.6, while the effect size of clozapine is about 0.9. So the effect size of this secular meditation practice was very large indeed.)
Weaknesses of this study are its small sample size (n=18) and the lack of a control group. It was designed as a pilot, proof of concept study. It has unfortunately not been repeated.
Nonetheless, it’s in line with clinical experience – and it suggests a possibly large impact from a simple mental exercise. Perhaps one of the more disabling features of this illness might yield to systematically and deliberately cultivating positive emotional experiences, both in the real world, and in the mind.