Although this patient does not currently experience positive symptoms of schizophrenia (eg, delusions, hallucinations, disorganized speech and behavior), he suffers from significant negative symptoms (eg, alogia, flat affect, amotivation, social withdrawal). Negative symptoms cause significant functional impairment and poor quality of life, affecting independent living skills, social functioning, and occupational performance and attainment.
Antipsychotic medication is effective in treating positive symptoms, as in this patient, but does not significantly improve negative symptoms. Earlier hopes that second-generation antipsychotics would be more effective than first-generation antipsychotics in treating negative symptoms have not been realized. Perceived benefits of newer antipsychotics in treating negative symptoms are believed to result from fewer extrapyramidal side effects (ie, decreased incidence of drug-induced parkinsonism) rather than true efficacy in treating core negative symptoms. Switching to a second-generation (atypical) antipsychotic (Choice E) is unlikely to significantly improve this patient's negative symptoms and could result in recurrence of his positive psychotic symptoms, which are currently well controlled.
Psychosocial intervention, specifically social skills training, is an effective augmentation strategy to target negative symptoms. Social skills training consists of behavioral techniques to improve the patient's social skills and apply them to specific problems and activities, such as initiating and maintaining conversations and negotiating interpersonal situations. Other psychosocial interventions that may be helpful for this patient include supported employment that serves a therapeutic role.