Schizophrenia is a multidimensional psychiatric disorder that extends well beyond psychosis alone. In this edition of Additional Advances, Christoph U. Correll, MD, Clinical Professor of Psychiatry and Molecular Medicine at the Zucker School of Medicine at Hofstra/Northwell and Chair of Child and Adolescent Psychiatry at Charité University in Berlin, discusses the evolving understanding of positive, negative, and cognitive symptoms of schizophrenia, as well as the importance of multidisciplinary education and shared decision making in optimizing outcomes.

Understanding the Core Symptom Dimensions

Dr. Correll emphasizes that schizophrenia is “a complex illness that has different dimensions,” commonly categorized as positive, negative, and cognitive symptoms. Distinguishing among these domains is critical because each has distinct functional implications and treatment strategies.

Positive symptoms refer to an excess or distortion of normal function. “Positive doesn’t mean it’s a good thing. It means a surplus. It’s too much,” Dr. Correll explains. These include delusions— “faulty beliefs that can’t be reasoned about”—hallucinations, disorganized thought, and abnormal behavior. Positive symptoms are often the most visible and disruptive, driving hospitalization and acute intervention. As Dr. Correll notes, “These positive symptoms are very much at the forefront of what we treat, currently” largely with dopamine-blocking agents”.

Negative symptoms, by contrast, represent an absence of normal function. Dr. Correll describes them as the “five A’s”: anhedonia, amotivation, asociality (active and passive), alogia, and affective flattening. Experiential symptoms such as anhedonia and amotivation often have the greatest impact on real-world functioning, while expressive symptoms such as alogia and flat affect can impact interpersonal communication. Importantly, even when positive symptoms are controlled, negative symptoms frequently persist and are “very much associated with poorer functioning.”

Cognitive impairment, although not included in formal DSM diagnostic criteria—is highly prevalent and clinically meaningful. Dr. Correll states that cognitive dysfunction is present in approximately 80% of patients with schizophrenia and may make schizophrenia “the most pan-cognitively disabling disease.” Domains affected include attention, verbal and visual memory, executive functioning, processing speed, and social cognition. These deficits significantly limit independence, employment, and social reintegration.

Understanding these distinctions provides targeted opportunities for intervention. While antipsychotics primarily address positive symptoms, clinicians can mitigate negative and cognitive symptoms through side-effect management, depression treatment, cognitive remediation therapies, aerobic exercise, and psychosocial interventions. Future treatments are hoped to selectively address negative and cognitive symptoms.

Anosognosia and Adherence

In addition to the traditional symptom triad, Dr. Correll highlights a fourth critical dimension: anosognosia, or impaired awareness of illness. He refers to this as the “sixth A” and describes it as “a neural network problem.” Rather than simple denial, anosognosia reflects a neurobiological deficit in illness awareness, which contributes significantly to nonadherence.

Patients with partial or full anosognosia “are harder to treat and don’t respond as well; they have more negative symptoms and more cognitive disability.” For clinicians, this necessitates a shift in communication strategy. Dr. Correll cautions against confrontational “disease talk”—for example, telling a patient, “You have schizophrenia. You need to take this medication.” Instead, he advocates for symptom-focused dialogue, addressing symptoms that the patient also feels interfered with their stated goals. This approach turns this into a discussion that is grounded in motivational interviewing and shared decision making.

Rather than debating diagnosis, clinicians should connect treatment to patient-defined goals. He illustrates this approach by reframing the conversation around concrete consequences—relationship strain, hospitalization, legal involvement—and asking, “Do you want this not to happen again?” This method shifts the focus from diagnostic labels to functional recovery, helping patients better understand the treatment plan, in turn increasing patient adherence.

The Role of the Multidisciplinary Team

Effective schizophrenia care requires coordinated, team-based management. Dr. Correll notes that physicians and advanced practice providers often have limited time, whereas therapists, psychologists, nurses, and social workers spend more face-to-face time with patients and can detect subtle functional impairments or emerging symptoms and engage in psychoeducation and the assessment of adherence as well as reasons that may interfere with adherence.

“The patient doesn’t exist in isolation,” he emphasizes. Educating family members and caregivers is equally essential, particularly in recognizing negative symptoms or cognitive dysfunction or decline that may not be immediately apparent in brief clinical encounters. Multidisciplinary teams can implement psychosocial interventions, reinforce adherence strategies, monitor subjective and objective functional burden, and communicate concerns back to prescribers.

Treatment planning should be driven by both symptom severity and functional interference. “Understanding where the patient is in terms of severity and treatment needs in these areas and how these symptoms then interfere with either subjective wellbeing and/or functionality basically drives the treatment plan,” Dr. Correll explains.

The Importance of Lifelong Learning

Given the evolving landscape of psychopharmacology and neuroscience, ongoing education remains essential. Dr. Correll encourages clinicians to pursue “lifelong learning,” combining literature review, expert interviews, roundtables, online content, and in-person meetings. Peer interaction is equally valuable, allowing clinicians to tap into collective expertise and refine best practices in complex cases.

Key Takeaways

Schizophrenia has multiple symptom domains: Positive, negative, and cognitive symptoms require distinct assessment and management strategies.
Positive symptoms drive acute care, but negative and cognitive symptoms are major determinants of long-term functional impairment.
Cognitive dysfunction affects up to 80% of patients and may be the most globally disabling aspect of schizophrenia.
Anosognosia (“lack of illness awareness”) is a neurobiological contributor to nonadherence and requires symptom-focused, motivational interviewing approaches rather than diagnostic confrontation.
Multidisciplinary collaboration is essential: Therapists, nurses, psychologists, and family members play key roles in monitoring functional burden and reinforcing adherence.
Shared decision approach improves adherence: “You only get adherence when patients buy into the treatment plan.”
Ongoing education is critical in a rapidly evolving psychiatric landscape.

About Dr. Correll

Christoph U. Correll, MD, is a Clinical Professor of Psychiatry and Molecular Medicine at Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in New York. He is also a Professor and Chair of the Department of Child and Adolescent Psychiatry at Charité – University Medicine in Berlin, Germany. Dr. Correll’s research focuses on early identification and treatment of children and adults with severe mental illness, including schizophrenia and other psychotic disorders. With more than 1,100 published articles that have been cites more than 110,000 times, he is in the top 1% of cited scientists in psychiatry.

Additional Advances in Addressing Positive, Negative, and Cognitive Symptoms of Schizophrenia With Christoph U. Correll, MD