What Schizophrenia Takes Away (And How People Get It Back)
The part of psychotic disorders that isn't talked about
Posted June 16, 2025 | Reviewed by Davia Sills
Schizophrenia is arguably the most complex diagnosis given in psychiatry . While most practitioners are familiar with what are called the "positive" symptoms of schizophrenia, like hearing voices, paranoia , and disorganized speech, this is only a small part of the experience of psychotic disorders. In addition to these louder manifestations, schizophrenia is also associated with negative symptoms.
Negative symptoms can be thought of as what schizophrenia takes away from a person's interactions with the rest of the world. These aspects of the diagnosis can be more subtle, affecting individuals' motivation , social interactions, and experience of emotions. This can look like social withdrawal, a flat facial expression or voice tone, and choosing solitary activities. Negative symptoms can be incredibly insidious, having a greater impact on a person's quality of life and progress toward valued goals than other symptoms (Rabinowitz, 2012).
I spoke with Dr. Ray Kotwicki, a psychiatrist, to better understand these hidden qualities. He is the chief medical officer of Hightop Health and an expert in schizophrenia.
Among the top subjects I discussed with Dr. Kotwicki was this subjective feeling of being behind glass. Many individuals who have experienced psychosis share times of this sense as though we are trying to relate from behind glass. I have found that with intervention, this has dissipated, but I would also acknowledge that it was one of the most difficult parts of what I went through.
Some clinicians also describe this disconnection when meeting with clients with these diagnoses. I have a close friend who describes this sense as a key indicator to assess for psychosis spectrum disorders.
Dr. Kotwicki endorses these as signatures of negative symptoms for many, expressing that "these are potential barriers to be understood."
This can be a big problem.
Dr. Kotwicki expands, "If the negative symptoms prevent you from feeling you have a connection between you and those people you would have in a support system, and those people are turned off by you because you aren't engaging, that is not a great combination for someone's prognosis. Given that having social support and people who expect you to do well are major predictors of recovery,"
The flattened motivation and social withdrawal of negative symptoms can lead to misunderstandings. A person's internal experience can be mistaken for a chosen attitude. In Dr. Kotwicki's words, "It can look like there is a volitional component, but that's just not the case. It's a fundamental part of the illness itself."
What Families Need to Know
Support from family and friends is often key to mental health recovery. Yet, families may find negative symptoms tricky. It can be painful to feel that your loved one is relating in a way that is different from how they always have before.
Dr. Kotwicki shares that families need to know the following: "When someone is experiencing negative symptoms, it does not mean that they are not trying, engaged, or hopeful. It means they have a neurobiology that isn't allowing them to share those things."
Further, negative symptoms do not mean that a person has disappeared. Although negative symptoms can make it harder for someone to communicate, it doesn't mean someone is no longer there or has nothing to say. Dr. Kotwicki explains, "The saddest thing is when family members say my loved one with schizophrenia doesn't care. We are putting all this time, energy, and resources into helping them, and they are not moving forward. That's what you should expect with negative symptoms."
While historically, negative symptoms have been seen as treatment-resistant, new treatments are offering hope.
Transcranial Magnetic Stimulation (TMS)
Transcranial Magnetic Stimulation (TMS) involves using magnetic pulses to spark brain activity. It has been most studied for use in depression and OCD . More recently, negative symptoms have been targeted.
A meta-analysis found that TMS consistently had a positive impact on negative symptoms, even when compared with sham controls (Lorentzen et al., 2022).
In the last few years, a new class of medication has also been explored for use in negative symptoms. This class of schizophrenia medications has a novel mechanism compared to other antipsychotics in that it does not affect the neurotransmitter dopamine , instead targeting muscarinic processes (Kidambi et al., 2023).
With most antipsychotics having the effect of blocking dopamine, a neurotransmitter associated with a sense of reward, in the past, it was assumed that these would not help with negative symptoms. This said, more recent research has found that certain atypical antipsychotics in a long-acting injectable form may also be used (Citrome et al., 2025).
Specialized psychotherapies for psychosis can also be of assistance with negative symptoms. A meta-analysis found that cognitive behavioral therapy (CBT) and cognitive remediation (CR) both led to a decrease in negative symptoms compared with treatment as usual (Riehle et al., 2020).
As we closed, I asked Dr. Kotwicki about the last words, and he gave me a message of hope. He states, "They are doing the best that they can with the way they see the world, the way they feel internally, and their genes . The more understanding there is of the negative symptoms of schizophrenia, I hope that it will allow people to be less judgmental toward people who are experiencing schizophrenia, who are doing the best that they can to be social and move forward."
Citrome, L., Correll, C. U., Cutler, A. J., Dunbar, M., Hoberg, A. R., Hopkinson, C., ... & McDonnell, D. (2025). Aripiprazole Lauroxil: Development and Evidence-Based Review of a Long-Acting Injectable Atypical Antipsychotic for the Treatment of Schizophrenia. Neuropsychiatric Disease and Treatment , 575-596.
Kidambi, N., Elsayed, O. H., & El-Mallakh, R. S. (2023). Xanomeline-trospium and muscarinic involvement in schizophrenia. Neuropsychiatric Disease and Treatment , 1145-1151.
Lorentzen, R., Nguyen, T. D., McGirr, A., Hieronymus, F., & Østergaard, S. D. (2022). The efficacy of transcranial magnetic stimulation (TMS) for negative symptoms in schizophrenia: a systematic review and meta-analysis. Schizophrenia , 8 (1), 35.
Rabinowitz, J., Levine, S. Z., Garibaldi, G., Bugarski-Kirola, D., Berardo, C. G., & Kapur, S. (2012). Negative symptoms have greater impact on functioning than positive symptoms in schizophrenia: analysis of CATIE data. Schizophrenia research , 137 (1-3), 147-150.
Riehle, M., Böhl, M. C., Pillny, M., & Lincoln, T. M. (2020). Efficacy of psychological treatments for patients with schizophrenia and relevant negative symptoms: a meta-analysis. Clinical Psychology in Europe , 2 (3), e2899.
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Jennifer Gerlach, LCSW, is a psychotherapist based in Southern Illinois who specializes in psychosis, mood disorders, and young adult mental health.
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