British Journal of Psychiatry (1989), 155 (suppl.
7), 49-52
The Scale for the Assessment of Negative Symptoms (SANS):
Conceptual and Theoretical Foundations
NANCY C. ANDREASEN
The Scale for the Assessment of Negative Symptoms
(SANS) was the first instrument developed in order to
provide for comprehensive assessment of negative
symptoms in schizophrenia (Andreasen, 1982, 1983).
It consists of five scales that evaluate five different
aspects of negative symptoms: alogia, affective blunting,
avolition-apathy, anhedonia-asociality, and attentional
impairment. Each of these negative symptoms can be
rated globally, but in addition detailed observations are
made in order to achieve the global rating. It is
complemented by a Scale for the Assessment of Positive
Symptoms (SAPS), which permits detailed evaluation
and global ratings of hallucinations, delusions, positive
formal thought disorder and bizarre behaviour
(Andreasen, 1984). Taken together, the two scales
provide a comprehensive set of rating scales in order
to measure the symptoms of schizophrenia and to assess
their change over time.
Development of the SANS
The decision to develop the SANS grew out of a
longstanding interest in phenomenology and many years
of direct clinical experience in diagnosing and treating
patients suffering from schizophrenia who were admitted
to the in-patient service at The University of Iowa
Psychiatric Hospital. Repeated close contact with such
patients cannot help but lead to a 'Bleulerian' belief that
delusions and hallucinations, although easier to define
reliably, are not the most important, characteristic, or
crippling symptoms of schizophrenia. Yet Bleulerian
symptoms have tended to be neglected by phenomen-
ologists and nosologists because of a belief that they
were too imprecise.
An initial foray was made on the most important of
the Bleulerian symptoms, thought disorder. A scale to
assess thought disorder was developed using the
empirical assumption that thought is usually inferred
from speech, that speech can be observed directly, and
that abnormalities in language, speech and
communication can be defined precisely through careful
attention to grammar, word choice, and links between
sentences and clauses. The Scale for the Assessment of
Thought, Language, and Communication (TLC) yielded
highly reliable definitions, demonstrated that thought
disorder was not pathognomonic of schizophrenia, and
that it fell into two broad groups of subtypes. One group,
negative formal thought disorder, was characterised
49
primarily by poverty of speech and poverty of content
of speech, while the other, positive formal thought
disorder, was characterised by derailments, tangenti-
ality, incoherence and distractible speech. We also
observed that negative thought disorder, when present,
tended to persist over time and to predict a poor
prognosis. Unlike positive thought disorder, it was not
common in mania. These findings were confirmed by
two independent replications involving several hundred
patients and controls over the course of several years
(Andreasen, 1979b, c; Andreasen & Grove, 1986).
A second foray was made on another major Bleulerian
symptom, affective blunting, through the development
of an affect rating scale (Andreasen, 1979a). This study
also indicated that affect could be defined reliably using
an objective empirical approach, that abnormalities in
affect were not specific to schizophrenia either, and yet
that affective blunting in schizophrenia could be
validated physiologically by measuring voice
characteristics such as frequency and amplitude
(Andreasen et al, 1981).
These studies confirmed that two major negative
symptoms, negative thought disorder and affective
blunting, could indeed be defined reliably and that they
had a variety of important clinical correlates. Both these
negative symptoms, while important, did not provide
a complete coverage of the psychopathology frequently
observed in patients with schizophrenia. Consequently,
a scale was developed to provide a comprehensive
coverage of all negative symptoms, adding avolition,
anhedonia, and attentional impairment to the two already
developed.
Basic assumptions
The SANS is informed by a series of basic assumptions.
First, while the concept of pathognomonic symptoms
is psychologically appealing, it has no basis in reality.
One simply cannot identify symptoms that occur only
in schizophrenia and not in any other illness. Just as
manics and psychotic depressives are likely to have
delusions and hallucinations, so too depressives are
likely to have some negative symptoms such as alogia
or affective blunting. An attempt to define any
psychopathological symptom so that it is specific to a
single diagnosis is likely to lead to convoluted
intellectual contortions or the wearing of blinkers.
Therefore, the SANS and SAPS were both developed
50 CONCEPT AND THEORY OF SANS
in order to define and describe reliably a wide range
of symptoms. They could then be used to observe the
frequency of these signs and symptoms in a variety of
diagnostic categories or differences in change over time.
A second basic assumption is that reliability is best
achieved through the use of objective observational
items. For example, affective blunting is not defined
by examining the patient's internal psychological state.
Instead, it is assessed through observation of a series
of external behaviours, such as mobility of facial
expression, response to a stimulus such as being smiled
at, quality of eye contact, use of expressive gestures,
etc. As is discussed in more detail below, the
fundamental soundness of this strategy has been
confirmed through the repeated achievement of
reliability in a wide range of cultural settings.
A third assumption is that rating scales must build on
cross-sectional evaluation. They must be based on
phenomena that one can observe clinically at a specified
point in time, which may be an hour, a day, a week,
or the past month. The particular cross-sectional window
will depend on the specific goal or purpose of a study.
Studies that attempt to build toward the development
of diagnostic criteria may use a maximally large window
(e.g. one month), while those attempting to observe
change over time (as in treatment studies) may select
a smaller window. The repeated use of rating scales over
time can be used to build longitudinal definitions through
repeated measurements and the observation of change.
Rating scales cannot identify 'enduring' symptoms
reliably during a single evaluation, and to attempt to
do so retrospectively is risky. Consequently, if one
wishes to identify enduring negative symptoms, one
must do so empirically through prospective longitudinal
assessments.
Fourth, ideally symptoms should be defined in such
a way that their underlying neural mechanisms could
be identified. All the various signs and symptoms of
schizophrenia must ultimately reflect neural activity in
the brain, and understanding the presence or absence
of symptoms in terms of such neural mechanisms is one
major long-term goal of phenomenological research.
Since we do not yet know or understand these neural
events, however, the best strategy is to maintain a
comprehensive and flexible data base, and also an open
mind.
Fifth, ideally rating scales should not sacrifice
comprehensive coverage for simplicity, nor should they
use premature foreclosure concerning the
interrelationships between signs and symptoms. While
it is tempting to use a scale that only involves one or
two items and can be completed in two or three minutes,
this is likely to be penny wise and pound foolish if one
wishes to understand either the neural mechanisms or
the longitudinal evolution of symptoms over time.
Detailed comprehensive coverage that stays close to
direct clinical data is the best strategy. While factor
analytic techniques can be used to reduce data sets (and
this may be useful for statistical purposes), nevertheless
the basic data that are reduced statistically should be
maintained intact and re-examined periodically. It could
be argued, for example, that since negative symptoms
tend to be highly intercorrelated, only one need be rated
in order to save time. Yet factor analytic studies tend
to be notoriously unstable (i.e. dependent upon the
population sampled). Thus, if only one negative
symptom were rated based on the reasoning that negative
symptoms are highly intercorrelated, not only might one
have invalid data, but one might fail to observe (for
example) that avolition responds to treatment in some
particular patients while affective blunting does not.
Sixth, ideally rating scales designed to assess
psychopathology should be sensitive to change, since
one major use is to evaluate whether various signs and
symptoms respond to treatment. The identification of
'enduring' or 'core' or 'primary' symptoms is best
achieved through repeated assessments, not through
developing rating scales likely to be insensitive to
change. Clinicians and investigators must also recognise
that negative symptoms may be 'enduring' in some
patients and 'changing' in others; thus the whole issue
of stability and prognostic significance must be studied
empirically and prospectively.
Reliability
The original components of the SANS, the TLC and
the Affect Rating Scale, were subjected to careful
scrutiny as to their reliability and were found to be highly
reliable (Andreasen, 1979a, b, c). After the SANS itself
was completed, similar reliability studies were done and
supported the reliability of the entire scale (Andreasen,
1982).
Reliability studies at The University of Iowa were
quickly followed by reliability studies in a variety of
international settings. The SANS clearly fulfilled an
important clinical and research need, for it has now been
translated into Japanese, Spanish, Italian, French,
German, Dutch, and Korean. Reliability data have been
reported in studies in Japan, Spain, and Italy (Humbert
et al, 1986; Moscarelli et al, 1987; Ohta et al, 1984).
The reliability for the global ratings of the five major
negative symptoms is summarised in Table I. As this
table indicates, the reliability is consistently high in a
variety of cultural settings. These results indicate the
soundness of the basic strategy of using observational
rather than subjective evaluations. Ideally, cross-national
studies would now be appropriate. These have not as
yet been conducted, however.
 ANDREASEN
TABLE I
Reliability of negative symptoms (kappa coefficient)
Global rating USA Japan Italy Spain
Alogia 0.696 0.628 0.694 0.945
Affective flattening 0.877 0.721 0.688 0.844
Avolition apathy 0.763 0.749 0.747 0.860
Anhedonia asociality 0.731 0.725 0.728 0.769
Attentional impairment 0.749 0.788 0.659 0.892
It is, of course, well recognised that good reliability
cannot usually be achieved without adequate training,
even when observational items are stressed. A
comprehensive set of training materials has been
developed for the SANS, involving videotapes and case
vignettes. These have been widely used in order to
ensure that the SANS is being consistently used within
the US, and additional investigators from many other
countries have also received training in the SANS at
Iowa. Our experience in such training indicates that high
cross-national reliability is likely if such studies were
to be conducted, since investigators from other cultures
learn to calibrate against our standards quite rapidly.
Internal validation
Rating scales and diagnostic criteria can be validated
both internally and externally. Internal validators include
the evaluation of correlational relationships and cluster
analytic techniques. External validators involve the
capacity of a symptom scale or diagnostic criterion sets
to predict some useful outcome measure, such as
response to treatment, familial aggregation, outcome,
or structural or chemical brain abnormalities. External
validators are complex to apply and outside the range
of this paper.
From the time of its development, the SANS was
subjected to careful scrutiny in order to determine its
internal validity (Andreasen, 1982). The evaluation of
internal validity stressed the study of intercorrelations
between the items used to make the global ratings and
between the global ratings themselves. These
assessments were done using Cronbach' s alpha.
Cronbach's alpha is a mean of the split half reliabilities
for a group of items. The higher the alpha, the greater
the internal consistency.
We have evaluated the SANS using Cronbach' s alpha
in two separate replication studies involving more than
150 patients suffering from schizophrenia. The results
of these studies are surprisingly consistent. Further,
similar studies have also been done in Spain, Italy, and
Japan.
Consistently, these studies have shown that the
individual items used to make the global ratings are
51
TABLE II
Internal consistency of negative symptoms based on
Cronbach's alpha
Symptom Reliability rating
Alogia 0.628
Affective flattening 0.834
Avolition apathy 0.743
Anhedonia asociality 0.744
Attentional impairment 0.750
All global ratings 0.855
highly intercorrelated with one another. These suggest
that the individual items do tend to measure a single
construct. In addition, the global ratings are also
correlated with one another. While these results support
the validity of the SANS, they also provide an additonal
interesting application. The intercorrelations can be
examined in order to identify whether any individual
items are relatively weak measures of a particular
negative symptom. Again, the results of these studies
have been surprisingly consistent. They indicate that
inappropriate affect tends to be relatively uncorrelated
with other indicators of affective blunting and with
negative symptoms as a whole (alpha = 0.28 and 0.30,
respectively; alpha for other indicators of affective
blunting ranges from 0.71 to 0.84). Blocking may also
be a relatively weak measure of alogia (alpha = 0.38);
this alpha could, however, be due to the relatively low
frequency of blocking in our samples. This relative
infrequency of blocking has been observed in most
studies using the SANS.
Coefficient alpha for the five global ratings, based
on our most recent study of 110 schizophrenic patients,
is summarised in Table II.
Summary: Strengths of the SANS
The SANS has a number of strengths that make it a
useful rating scale for the assessment of negative
symptoms. Its psychometric properties have been
repeatedly and carefully evaluated, both within the
centre where it was originally developed and in a number
of other centres throughout the world. The results of
these evaluations are remarkably consistent and indicate
that the SANS is both reliable and internally cohesive.
It is at present widely used in a variety of international
settings and thus has become a relatively standard scale
for measuring negative symptoms. It has comprehensive
coverage and yet, once investigators are familiar with
it, it can be completed relatively quickly and efficiently.
It can be applied to a variety of time windows and can
be used to map the evolution of symptoms over time
and their response to treatment in clinical drug trials.
52 CONCEPT AND THEORY OF SANS
Acknowledgements
This research was supported in part by NIMH grants MH31593 and
MH40856; a Scottish Rite Schizophrenia Research Grant; The Nellie
Ball Trust Research Fund, Iowa State Bank & Trust Company, Trustee;
a Research SCientist Award, MHOO625; and Grant RR59 from the
General Clinical Research Centers Program, Division of Research
Resources, NIH.
References
ANDREASEN, N.C. (1979a) Affective flattening and the criteria for
schizophrenia. American Journal of Psychiatry, 1366,944-947.
___ (1979b) The clinical assessment of thought, language, and
communication: I. The definition of terms and assessment of their
reliability. Archives of General Psychiatry, 36, 1315-1320.
___ (1979c) The clinical assessment of thought, language, and
communication: II. Diagnostic significance. Archives of General
Psychiatry, 36, 1325-1330.
___ (1982) Negative symptoms in schizophrenia: definition and
reliability. Archives of General Psychiatry, 39, 784-788.
___ (1983) The Scale for the Assessment of Negative Symptoms
(SANS). Iowa City, Iowa: The University of Iowa.
Nancy C. Andreasen, MD, PhD, Department of Psychiatry, University of Iowa College of Medicine, Iowa, USA
___ (1984) The Scale for the Assessment of Positive Symptoms
(SAPS). Iowa City, Iowa: The University of Iowa.
___, ALPERT, M. & MARTZ, J. (1981) Acoustic analysis: an
objective measure of affective flattening. Archives of General
Psychiatry, 38, 281-285.
_ _ & GROVE, W.M. (1986) Thought, language, and
communication in schizophrenia: diagnostic and prognostic
significance. Schizophrenia Bulletin, 12, 348-359.
___ & OLSEN, S.A. Negative vs, positive schizophrenia: definition
and validation. Archives of General Psychiatry, 39, 789-794.
BERRIOS, G.E. (1985) Positive and negative symptoms and Jackson:
a conceptual history. Archives of General Psychiatry, 42, 95-97.
HUMBERT, M., SALVADOR, L., SEGUI, J., et al (1986) Estudio
interfiabilidad version espanola evaluacion de sintomas positivos
y negativos. Revista Departmento Psiquiatria Facultad de
Medicina., University of Barcelona, 13, 28-36.
MOSCARELLI, M., MAFFEI, C., & CESANO, B.M. (1987) An
international perspective on the assessment of positive and negative
symptoms in schizophrenia. American Journal of Psychiatry, 144,
1595-1598.
OHTA, T., OKAZAKI, Y. & ANZAI, N. (1984) Reliability of the Japanese
version of The Scale for the Assessment of Negative Symptoms
(SANS). Japanese Journal of Psychiatry. 13, 999-1010.