Several studies have reported an unfavorable impact of schizophrenia negative symptoms on patients’ functional outcome. Both direct and indirect relationships have been found between this psychopathological domain and patients’ functioning in real-life, and evidence that negative symptoms mediate the impact of other variables (i.e., neurocognition or functional capacity) on real-life functioning has also been provided.

However, limitations of previous studies might prevent solid conclusions and generalizability. In particular, largely used scales for the assessment of negative symptoms have been criticized for the inclusion of items assessing neurocognition and for their focus on behavioral aspects, as opposed to internal experience, which may lead to artefactual associations with functional outcome measures; moreover, negative symptoms have generally been regarded as a unitary construct, while the most recent literature suggests that these symptoms are heterogeneous and include at least two factors, ‘avolition” and ‘poor emotional expression” (PEE).

Recent studies by our group and by the Italian Network for Research on Psychoses examined the hypothesis that avolition and PEE might be underpinned by different pathophysiological substrates and show different relationships to functional outcome.

Avolition showed a higher predictive value of functional outcome than PEE. The latter had a modest contribution to functional capacity, which was not independent of cognitive dysfunction.

Efforts aimed to improve our understanding of the pathophysiology of avolition represent a priority of research in schizophrenia, and the implementation of treatments targeting motivation is likely to be an important tool to enable people with schizophrenia to achieve a meaningful life.