THE INFLUENCE OF NEGATIVE SYMPTOMS ON THE SOCIAL FUNCTION OF PEOPLE WITH SCHIZOPHRENIA IN THE COMMUNITY

The most People with Schizophrenia (PwS) experience a decline in social function caused by various factors. Clinical symptoms of PwS affect the social function of PwS, especially negative symptoms. The purpose of this study is to analyze the effect of negative symptoms on the social function of people with schizophrenia in the community. This is a cross-sectional study. Subjects of the study were people with schizophrenia aged 18-56 years who will follow Community-Based Rehabilitation activities in 10 areas of puskesmas in Yogyakarta Special Region. The study was conducted in February 2017. The social function and negative symptoms of PwS were measured using a validated measuring instrument. Hypothesis test using Anova test. The subjects of the study were obtained by purposive sampling technique of 100 PwS that fulfilled inclusion and exclusion criteria. Subjects with a PSP score of 0-30 (poor: someone who intensively needs care and social support) of 8 people (8%) had negative PANSS score of 28.50 ± 6.78. Subjects with a score of 31-70 (moderate: someone who occasionally needs care and social support) of 57 people (57%) had negative PANSS of 20.65 ± 8.18. Subjects with a score of 71-100 (mild: someone with mild disturbance, but able to perform individual functions) of 35 subjects (35%) had negative PANSS score of 12.49 ± 5.98. PwS which has a negative value of PANSS is greater, has a worse social function. The results showed that the negative symptoms had an effect on the social function of people with schizophrenia which was statistically significant (p <0.05). Negative symptoms affect the social function of PwS. PwS that has a high negative symptom score, has a worse social function.


INTRODUCTION
The decreased function experienced by People with schizophrenia (PwS) is worse when compared with other psychiatric disorder patients. 1People with schizophrenia have decreased almost all aspects of life that cause disability throughout their lives. 2,3,4The decline in social function is a common condition encountered in PwS. 5,6While social function is an important predictor of the quality of life assessment of people with schizophrenia, which is now a major goal in the management of PwS. 7,8chizophrenia management, more recently focused on improving function and quality of life than simply curing symptoms alone.8,9   Studies in six European countries concluded that more than 80% of people with schizophrenia had decreased sedentary social function. 10,11A decreased social function is often experienced by PwS earlier before other symptoms of schizophrenia occur. 11Social function is the quality of interpersonal relationships and one's ability to fulfil roles and expectations defined by society.Social functionality is assessed from various domains of life, including role functions, social relationships, self-care, independent living skills, leisure use, leisure activities, and community integration. 4PwS with low social function is associated with a worse prognosis which, among others, is indicated by the inability to find employment and independent living. 12hile PwS and their families are often more concerned with functional impairment experienced by people with schizophrenia-related to work, education, independence, and socialization skills. 13wS expectations in medicine in addition to symptom improvement, PwS also requires improvement in social functions such as daily activities, social contact and employment opportunities.14 . Heping PwS achieve its life goals including improving its social function is one of the principles of PwS management. 2 Many factors affecting social functioning in PwS include premorbid function, cognitive function, community participation, family condition and treatment, adequate psychotherapy and negative symptoms (Essock et al., 2005 8 ).Social dysfunction is associated with PwS psychopathology and is most associated with negative symptoms.15,16 Negative symptoms refer to the missing or decreased normal mental function.17 Negative symptoms can also be interpreted as missing or diminishing some of the functions that exist in healthy individuals.18 Negative symptoms include decreased social or personal attraction, anhedonia, emotional collecting or mismatch, and decreased symptomatic activity. Pple with schizophrenia often exhibit negative symptoms long before the positive symptoms appear 19 and may persist despite PwS in a stable phase.20 The negative symptoms experienced by ODS affect the function and quality of life of the PwS.5,8 Schizophrenia management is intended to support PwS in developing meaningful life function, although symptoms are still experienced by PwS.20 This study aims to analyze the effect of negative symptoms on social function on PwS participants of community-based rehabilitation activities in Yogyakarta special region.

RESEARCH METHODS
This study is a cross-sectional study of people with schizophrenia in the community.The  Subject is vulnerable group.Recruitment of subjects is performed by the primary health center doctor.Subjects are given information by primary health center doctors that the subject will be contacted by the researcher.If the subject and his family are willing then the subject will get an explanation of the research by the researcher.The researcher explains objectives, volunteerism, research procedures, obligations, benefits, risks, confidentiality, compensation, financing, contact person.Families were given adequate time to reflect on the information, had any questions answered and gave free and voluntary consent then provided written informed consent.
The independent variable is a negative symptom, the dependent variable is the social function of the people with schizophrenia.The investigation was conducted by using the following structural and clinical test procedure: standardized clinical interview; Personal and Social Performance Scale (PSP) and PANSS.A non-standardized questionnaire regarding sociodemographic and clinical characteristic data of people with schizophrenia.
The social function of people with schizophrenia assessed with Personal Social Performance (PSP).PSP measures the score is based on the assessment of a patient's performance in four categories; socially useful activities, personal and social relationships, self-care, disturbing and aggressive behaviour.PSP is a 100item scale, divided into 10 similar intervals.Regarding the total score on the Personal and Social Performance Scale (PSP) that assesses the personal and social functioning and quality of life, the subjects with the score 0-30 (poor: someone who intensively needs care and social support); the score of 31-70 (moderate: someone who occasionally needs care and social support); the score of 71-100 (mild: someone with mild disturbance, but able to perform individual functions).
For the assessment of negative symptoms of patients used the Positive and Negative Symptoms Scale (PANSS).PANSS is an instrument to assess the symptoms of people witg schizophrenia consisting of positive symptoms, negative symptoms and general psychopathology.The negative symptom scale consists of 7 assessed symptoms (N1-N7).There are 7 possible rating points, representing increasing levels of psychopathology severity (1 = absent; 2 = minimal; 3 = mild; 4 = moderate; 5 = moderate-severe; 6 = severe; 7 = extreme).The PANSS is scored by summation of ratings across items, thus the potential ranges are 7-49 for the Negative Scales.
Univariate statistical analysis is used to see the percentage of demographic data and the characteristics of the disorder experienced by the subjects.Bivariate analysis to determine the effect of clinical symptoms with social function using ANOVA test.The data used in anova test is negative PANSS data with numeric scale.Anova test is used to determine the difference of negative PANSS score in three categories of social function.All analyzes were performed using a computer program

RESULTS AND DISCUSSION
A total of 100 people with schizophrenia fulfilling the inclusion and exclusion criteria were selected from 10 puskesmas areas in DIY.Subjects   2 shows that the majority of the subjects had been experienced the intrusion for more than 10 years (55%).Most subjects had schizophrenia in the age range of 20-30 years old (42%).Majority of the subjects didn't have any mental disorder history in their family (72%).Most subjects received a typical and atypical combination antipsychotic (50%).Most of the subjects had been hospitalized more than once (65%).Most of the study subjects (57%) had a PSP score of 31-70 (moderate social function) which means that the subject still occasionally needs care and social support.
The hypothesis test to know the difference between the negative PANSS score on its three social functional groups of people with schizophrenia was analyzed using anova test.Based on the anova test, the value obtained is p = 0.000.Therefore, the value of P <0.05 means the hypothesis is accepted.Negative PANSS scores which showcase the negative symptoms of the subject affects the social function of people with schizophrenia.Based on the descriptive data, it can be seen that the bigger the negative PANSS score is, the worse the social function of people with schizophrenia.
After the Anova test, it continues with the Posc Hoc test to determine the differences in negative PANSS values between the two categories of subjects' social functions.Posc Hoc test that was used is the LSD test.The test was used to analyze the differences in negative PANSS scores between subjects who had a social function score of 0-30 and subjects with a social function score of 31-70 (analysis 1); subjects with a social function score of 31-70 and subjects with a social function score of 71-100 (analysis 2); subjects who have a social function score of 31-70 and subjects that has a social function score of 71-100 (analysis 3).The results of the LSD test analysis are presented in tables 3, 4, and 5.The second LSD test was an analysis to see the differences in negative PANSS scores in people with schizophrenia who had a PSP score of 0-30 (poor social function) with people with schizophrenia who had a PSP score of 71-100 (mild social function).The second LSD test is shown in Table 4, which shows the value of p <0.05.This suggests that there is a significant difference between a negative PANSS score of people with schizophrenia who have poor social function and a PANSS score of people with schizophrenia who have a mild social function.The third LSD test was an analysis to see the differences in negative PANSS scores in people with schizophrenia who had PSP score of 31-70 (moderate social function) with people with schizophrenia who had a PSP score of 71-100 (mild social function).The third LSD test is shown in table 5, which shows the value of p <0.05.This suggests that there is a significant difference between a negative PANSS score of people with schizophrenia who have moderate social function and a PANSS score of people with schizophrenia who have a mild social function.

RESULTS AND DISCUSSION
The social function in this study was assessed using the PSP instrument.The PSP score is divided into 3 groups: the score 0-30 (poor: someone who intensively needs care and social support); the score of 31-70 (moderate: someone who occasionally needs care and social support); the score of 71-100 (mild: someone with mild disturbance, but able to perform individual functions). 21Most of the study subjects (57%) had PSP score of 31-70 which means the subject still occasionally needs care and social support.The same condition is also shown in the previous research which says that the social relation domains are the most affected domains in people with schizophrenia if it's being compared to the normal population. 22he negative symptoms in this study were assessed by PANSS score for negative symptoms which consist of 7 domains: blunted affect, emotional withdrawal, poor rapport, passive/apathetic social withdrawal, difficulty in abstract thinking, lack of spontaneity and flow of conversation, stereotypes thinking (Hunter,  2012).The study subjects had a negative PANSS score of 18.42 + 8.74012.This suggests that the study subjects still have strong negative symptoms.
The results of the test analysis of the effect of negative clinical symptoms as measured by PANSS showed that the negative symptoms had an effect on the social function of people with schizophrenia.The results of this study are consistent with previous studies which concluded that the negative symptoms had an effect on the social function of people with schizophrenia. 4,11,23Another study using PANSS instruments to assess the positive, negative, and generalized psychopathology symptoms of schizophrenia concluded that the negative symptoms had the strongest correlation with the occurrence of social dysfunction in people with schizophrenia when compared with other symptoms of schizophrenia which were positive symptoms and general psychopathology. 5his study shows that negative clinical symptoms have a negative effect on social function.The highest negative mean PANSS score was found in the subjects with PSP score 0-30, whereas the lowest negative PANSS score was found in subjects with a PSP score of 71-100.This means, the higher the score of negative clinical symptoms, the worse the social function of people with schizophrenia.Similar results were also obtained in previous studies which concluded that lower the function in people with schizophrenia, the more severe negative clinical symptoms they had. 20,24egative symptoms refer to the loss or decrease in normal mental function. 17egative symptoms include blunted affect, emotional withdrawal, poor rapport, passive/apathetic social withdrawal, difficulty in abstract thinking, lack of spontaneity and flow of conversation, stereotypes thinking. 20Negative symptoms can also be interpreted as lost or decrease in some functions that exist in healthy people. 18The decreasing normal mental functions which indicated by the presence of these negative symptoms affect the ability of people with schizophrenia in performing the functions of everyday life.People with schizophrenia often show negative symptoms much earlier before the positive symptoms occurrence. 19Negative symptoms can also remain encountered by people with schizophrenia even though they already in a stable phase. 20This suggests that the negative symptoms are related to the chronicle of the disorder, which made an impact on lowering the competence of people with schizophrenia in social interaction. 25,26he negative symptoms experienced by people with schizophrenia are associated with decreased cognitive function and adaptive function. 27ognitive function and adaptive function were needed by people with schizophrenia to do social interaction with the environment.Thus, these negative symptoms interfere with the ability of people with schizophrenia to perform normal functions including functions in social interaction, which make the social function of people with schizophrenia is poor.Improving the negative symptoms in the management of people with schizophrenia is an important factor for improving the function of people with schizophrenia in the community. 20

CONCLUSION
Negative symptoms affect the decreasing social function of people with schizophrenia.Improvement of the negative symptoms becomes an important factor to increase the function of people with schizophrenia in the community.

Table 1 .
Sociodemographic Characteristics of Subject

Table 2 .
Clinical Characteristics of Subject

Table 4 .
The Second LSD test

Table 5 .
The third LSD test