Negative Symptoms of Schizophrenia—Beyond Hallucinations

When most people think about schizophrenia, they think about hallucinations or delusions—voices that aren’t there or beliefs that don’t align with reality. These symptoms are often grouped under the term "positive symptoms" of schizophrenia and are typically what brings someone into treatment and leads to diagnosis.

But for many individuals, positive symptoms are not the beginning of the illness.

Long before hallucinations or delusions appear, more subtle and often misunderstood symptoms can emerge early on. These are known as negative symptoms, and they frequently shape long-term functioning far more than psychosis itself.

What Are Negative Symptoms?

Negative symptoms are a reduction or loss of normal emotional and motivational functioning. They are not simply reactions to illness, personality traits, or side effects of medication—they are a core component of schizophrenia itself.

Negative symptoms that specifically affect motivation and emotional expression may include:

• Trouble finding motivation to finish tasks or household chores
• Avoiding other people or preferring to be alone
• Difficulty experiencing pleasure or feeling happy
• Trouble speaking or producing very little speech
• Reduced emotional expression, such as not smiling or using facial expressions

These symptoms are often misinterpreted as depression, apathy, or a lack of effort. In reality, they reflect changes in brain systems involved in motivation, reward, and emotional expression. These symptoms can often continue to present even when positive symptoms such as hallucinations and/or delusions are well controlled or absent with antipsychotics.

How Common Are Negative Symptoms?

Negative symptoms are a core and common part of schizophrenia.

Research suggests that nearly 9 out of 10 people experience at least one negative symptom at the time of a first psychotic episode. Even after treatment, an estimated 35–70% continue to experience persistent negative symptoms, despite improvement in hallucinations or delusions.

These symptoms are strongly linked to reduced independence, social withdrawal, and difficulty sustaining work, relationships, and meaningful daily roles.

Why Negative Symptoms Are So Often Missed

Negative symptoms tend to develop gradually and quietly. Unlike hallucinations and delusions, they do not typically trigger urgent clinical attention. They are frequently attributed to stress, personality, medication effects, or “not trying hard enough.”

Because of this, negative symptoms are often overlooked. Healthcare professionals can play a key role in recognizing these symptoms over time, but family members and loved ones are also essential partners in care. Those closest to the individual may notice changes in motivation, emotions, or social engagement long before they are raised in a clinical setting.

Advocacy from both clinicians and families helps ensure these symptoms are recognized rather than dismissed or misunderstood.

Asking the Right Questions Matters

A comprehensive approach to managing schizophrenia involves actively asking about negative symptoms, not just monitoring for hallucinations and delusions.

Negative symptoms are best uncovered through thoughtful, open-ended conversations. Clinicians—and when appropriate, caregivers—can help identify these symptoms by asking questions such as:

• What kind of mood are you in most days?
• How do you spend a typical day?
• What do you do for fun or enjoyment?
• Have you had a chance to meet up with people outside of your family recently?
• Would you like to have a job or be doing something different during the day?

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These questions help clarify whether reduced activity or social engagement reflects limited opportunity—or a greater difficulty with motivation, pleasure, or emotional expression. Input from caregivers can be especially valuable, as they often observe gradual changes that may not be obvious during brief clinical visits.

How are Negative Symptoms Treated?

Despite how common negative symptoms are and their impact on daily functioning, most antipsychotic medications have a limited effect on negative symptoms.

At this time, there are no FDA-approved medications specifically indicated for negative symptoms of schizophrenia, and guideline recommendations for managing negative symptoms remain limited. While some medications—such as cariprazine, olanzapine/samidrophan, and xanomeline–trospium chloride—have shown signals of improvement in negative symptoms in clinical trials, treatment effects can be modest and variable, and can take a long time to improve.

As a result, negative symptoms remain one of the most significant unmet needs in schizophrenia care.

Until more targeted treatments are available, management of negative symptoms typically involves:

• Medication such as antipsychotics to address overall symptom burden
• Psychotherapy focused on engagement, goal setting, and behavioral activation
• Psychosocial interventions that support structure, routine, and social connection

While these approaches may help some individuals, many continue to experience persistent negative symptoms even when considered clinically “stable.”

A New Direction: Targeting Negative Symptoms With Digital Therapy

Because medications alone have had limited success, researchers have begun exploring non-pharmacologic, regulated approaches designed specifically to address negative symptoms.

One such approach is CT-155, an investigational prescription digital therapeutic that is being explored as a treatment for negative symptoms of schizophrenia for adults. CT-155 is not a medication. It is software delivered through a smartphone application and is intended to be used alongside standard antipsychotic treatment, not as a replacement.

CT-155 is designed to help adult individuals living with schizophrenia:

• Increase motivation
• Reduce avoidance behaviors
• Re-engage in meaningful daily activities

In the CONVOKE study, CT-155 met its primary endpoint, demonstrating statistically significant reductions in negative symptoms over 15 weeks of use compared with a non therapeutic "sham" app that is designed to simulate a placebo group. Engagement levels were high, and the intervention was generally well tolerated, with a low rate of adverse effects.

If approved, CT-155 could become one of the first regulated interventions developed to target experiential negative symptoms of schizophrenia in adults, addressing a long-standing gap in care. It also may be able to provide a cost effective and accessible way to deliver treatment. While still investigational, this approach represents an important shift toward treating aspects of schizophrenia that most directly affect daily life and functioning.

For many people living with schizophrenia, negative symptoms—not hallucinations—are what limit recovery. A person may no longer experience psychosis, yet still struggle to initiate daily activities, connect with others, or participate in work or school.

Recognizing negative symptoms as a core feature of schizophrenia—and ensuring there is active assessment and steps to address symptoms—matters for patients and families.

Emerging investigational approaches such as CT-155 highlight a growing recognition that recovery must focus not only on symptom reduction, but also on motivation, engagement, and quality of life.

Schizophrenia is more than hallucinations. Addressing negative symptoms is essential if recovery is to mean more than symptom control.