Positive vs. Negative Symptoms

   (from 1887)

   "Positive" symptoms in the context of schizophrenia mean thought disorder, hallucinations and delusions, "negative" mean such symptoms as social withdrawal and flattening of affect. The use of the terms in psychiatry goes back to British neurologist John Hughlings Jackson (1835–1911), who applied "positive" and "negative" (already available in the medical literature) first to such neurological affections as epilepsy, then to mental illness. Jackson explained in the Journal of Mental Science in 1887 that, "The levels of evolution vary in the different kinds of insanity. . . . Disease, in the strict sense of pathological process, produces the negative physical change dissolution only, answering to negative affection of consciousness; disease is not the cause of positive mental symptoms. He who is studying the physical conditions of positive mental symptoms in any case of insanity is dealing with evolution" (Selected Writings, II, p. 78). Although Jackson expressed himself obscurely, this does mark the beginning of an important distinction. At a meeting of the British Medical Association in Leeds in 1889, Jackson clarified this polarity: "All the positive mental symptoms in . . . insanities occur during activities of healthy nervous arrangements remaining in the maimed highest centres; they are . . . parts of the insane man’s mentation . . . signs of his lowered consciousness; his illusions, as we call them, are his perceptions, and his mental symptoms altogether are lower homologues of his normal mentation." "Negative lesions," by contrast, involved paralysis and loss of consciousness. Jackson explained his theory more amply in an article in the Medical Press and Circular in 1894, accompanied by a diagram showing successive dissolution of function from highest levels of "cerebral centres" to lowest. This schema of successive downward dissolution in the central nervous system was later highly influential in French psychiatry.

   "Basic vs. accessory" (1911). When Bleuler (see Schizophrenia: Emergence: Bleuler [1911]) distinguished between "basic" symptoms of schizophrenia such as thought disorder and "accessory" symptoms such as hallucinations and delusions, he had something different in mind from Jackson, and indeed Bleuler seemed unacquainted with Jackson’s views. Bleuler did use the expressions positive and negative but only in the specific sense of "positive" and "negative" thoughts.* Yet, his "basic" symptoms of thought disorder might be considered negative symptoms and his accessory ones of hallucinations, et cetera, might be seen as positive.

   Positive vs. negative revived (1974). Making specific reference to Jackson’s earlier use, John S. Strauss (1932–) at the University of Rochester (and collaborators at the National Institute of Mental Health), in an article in Schizophrenia Bulletin in 1974, revived the concepts of "positive" and "negative" symptoms in schizophrenia. This use was reinforced by researcher Nancy Andreasen (1938–), who developed a scale for measuring negative symptoms in the disease. In 1982, Andreasen wrote in the Archives of General Psychiatry, "Although Hughlings Jackson’s conceptual model of brain function may not apply precisely . . . his distinction between positive and negative symptoms is very useful for descriptive phenomenology" (p. 785).

   Type I vs. Type II syndromes of schizophrenia (1980). Timothy J. Crow suggested in 1980 in the British Medical Journal that schizophrenia was really two different diseases. Type I schizophrenia, marked by so-called positive symptoms such as hallucinations, delusions, and thought disorder, was the acute form of the disease and was caused by abnormalities in the transmission of dopamine. Type II schizophrenia, characterized by such "negative" symptoms as flat affect, poverty of speech, and loss of drive, was the chronic form, or "defect" state, and was probably unrelated to dopamine. The hypothesis stimulated a good deal of research, although it was not ultimately accepted.

   * See Bleuler’s article on "schizophrenic negativism" in the Psychiatrisch-Neurologische Wochenschrift, 1910, p. 184.