lesser-known symptoms of schizophreniaWhen people think of schizophrenia, they often think of hallucinations and delusions. And these are debilitating for many people with the illness. Imagine that you can’t trust your own mind to tell you what’s real and what isn’t.

One of Devon MacDermott’s clients asked her to think of an image and then to imagine that the knowledge that she’d conjured the image herself was erased. Which would leave MacDermott to question: Is the thought really my own or a symptom of schizophrenia?

“In that moment I realized that it must be terrifying and extraordinarily frustrating to be in the mind of someone with schizophrenia,” said MacDermott, Ph.D, a psychologist in private practice in New York City, who has worked extensively with people with schizophrenia in inpatient settings.

But there are other, less recognized symptoms of schizophrenia that can be just as problematic as hallucinations and delusions — or even more so.

For Rebecca Chamaa, who pens the Psych Central blog Life with Schizophrenia, lack of motivation is especially disruptive. Chamaa lacks the motivation to socialize. She can easily go weeks without seeing anyone but her husband of 18 years. “If you met me at a party, you’d think ‘she’s just like everyone else.’ But for me to actually want to go to that party is a big deal.”

Chamaa also believes the sinking motivation hampers her productivity. Even though she writes articles, blog posts and essays for various websites and attends a writing program at UCLA, Chamaa has noticed that her motivation is diminishing as she gets older.

Lack of motivation is classified as a “negative symptom” of schizophrenia. (Hallucinations and delusions are considered “positive symptoms.”) Negative symptoms are an absence or reduction of characteristics that are present in well-functioning people who don’t have schizophrenia, said Dawn I. Velligan, Ph.D, professor and co-director of the Division of Schizophrenia and Related Disorders at the Department of Psychiatry, UT Health Science Center at San Antonio.

Negative symptoms affect about 30 to 50 percent of people with schizophrenia, she said. These “lead individuals to spend a lot of idle time.” For instance, a person might be able to cook and clean, but they don’t initiate or start these activities.

People with schizophrenia have a hard time getting out of bed, working, fostering relationships and pursuing hobbies, MacDermott said. “Life can feel much heavier and effortful when your motivation and energy are zapped. It leads people to be less likely to engage in their lives.”

People with schizophrenia also are much less expressive with their emotions (another negative symptom). They might be feeling joy or sadness but they look like they aren’t feeling anything, MacDermott said. Our ability to express our emotions is vital to connecting with others. When that’s reduced, “it can severely impact someone’s ability to obtain support and empathy. It means that people with schizophrenia are much more likely to feel alone in their experiences.”

It can become a vicious cycle. According to Velligan, a person might have a blank facial expression and little emotion. They also might have little to talk about because they aren’t engaging that much in life. This can make others uncomfortable, which can lead to rejection, which “causes people with negative symptoms to initiate even less.”

Chamaa, author of Pills, Poetry and Prose, also struggles with anxiety. As she wrote in this post on her personal blog:

I have episodes of anxiety that make it impossible for me to do anything besides trying to relieve the anxiety. It is a catch-22 because the more I focus on relieving the anxiety, the more anxious I become. Anxiety ruins many events for me. At a writer’s conference, I will almost always be overcome with anxiety and have to leave to be by myself and try to diminish the symptoms. When I see friends, and I am socializing, I often have a panic attack and need to go home quickly. Being around people in general can easily trigger a wave of anxiety. I take medication for this, but this symptom is probably the one that keeps me from leading a “normal” life.

Chamaa’s paranoia around standing up for herself is especially hard. As she writes in the same post:

Constantly being fearful when you are just trying to be treated decently and fairly in this world is difficult to live with. Believing that people are going to punish you for disagreeing with them is a terrible way to live. We all need to feel some form of safety and comfort and trust in order to be healthy and happy. Those things are disrupted for me by schizophrenia.

About 95 percent of individuals with schizophrenia have cognitive impairments, which means difficulty paying attention, processing information quickly, remembering and planning, Velligan said. Because of these symptoms, people forget to perform important tasks at work and at home (like paying their bills). Not being able to plan also affects a person’s ability to complete tasks, along with identifying problems and finding solutions, Velligan said.

In fact, research has found that cognitive symptoms predict people’s social and occupational functioning, more so than hallucinations and delusions, said Melissa Fisher, Ph.D, a research psychologist and director of assessments in the Vinogradov Research Laboratory at the San Francisco VA Medical Center, and a senior statistician in the Department of Psychiatry at the University of California at San Francisco.

For instance, she cited this study by Lin et al. The authors found that both cognitive symptoms and negative symptoms in individuals at risk for psychosis were the strongest predictors of poor outcome.

Cognitive symptoms (and negative symptoms) also don’t respond to medication. (Medications do improve positive symptoms, which is critical.) This is why researchers are exploring interventions such as cognitive training, which seems to bolster the benefits of psychosocial treatments and occupational programs.

Fisher cited this study by McGurk et al. According to the researchers, findings revealed that: “Over 2-3 years, patients in the supported employment with cognitive training program were more likely to work, held more jobs, worked more weeks, worked more hours, and earned more wages than patients in the program offering supported employment alone.”

Schizophrenia is highly heterogeneous, Fisher said. “Any given patient may exhibit just a few, or several, or most of the symptoms over time.” Whatever combination of symptoms a person experiences, it still disrupts their everyday life. However, with treatment and support, people with schizophrenia can and do lead fulfilling, productive lives. That might be the least well-known fact of all.

Unmotivated woman photo available from Shutterstock