Tell Me All I Need to Know About Schizophrenia

If schizophrenia had a nickname, it would be: Misunderstood. That’s because it’s every shade of complicated. And, to confuse matters more, each of its symptoms appear in at least one other psychiatric disorder.

The easiest way to make sense of it is to say what it’s not. Schizophrenia is not characterized by split or multiple personalities (aka dissociative identity disorder), or the extreme shifts in mood that come with bipolar disorder. And people with schizophrenia aren’t prone to violence—or genius, for that matter, in spite of what you might have seen in the film “A Beautiful Mind.”

“The hallmark symptoms of schizophrenia—hallucinations and delusions, bizarre thoughts and perceptual difficulties—are typically what we think of, but ultimately it’s a brain disorder that involves progressive deterioration in cognitive abilities,” explains Dr. Frank Chen, MD, Chief Medical Officer at Houston Behavioral Healthcare Hospital in Texas. “Unfortunately, it’s an illness that doesn’t get any better, but you can use medications to palliate some of the symptoms and improve quality of life.”

Because schizophrenia is tricky to diagnose, numbers on its prevalence vary, but experts estimate it affects about 2.4 million Americans. The disorder affects more men than women—the ratio is 1.4 to 1—and it strikes men earlier, too. Age of onset for men tends to be in the late teens to early 20s; for women, onset typically occurs in the early 20s to early 30s. Experts believe this has something to do with the pruning of neurons, a process that takes place after birth in babies, which happens later for women than for men.

People with schizophrenia experience what’s called a psychotic break, which is the onset of psychosis: It’s when their mind is overtaken by hallucinations and/or delusions that make it hard to know what’s real and what’s not. But while the word “break” sounds sudden, symptoms of schizophrenia don’t happen in a single traumatic moment. Instead, they are usually gradual and can progress for years, and they can be easy to miss—until they’re impossible to ignore. Here’s how the disorder can manifest.

Also called the “prodromal phase,” early symptoms of schizophrenia are those that happen before a first episode of psychosis and usually during teenage or young adult years. The duration of the prodromal phase can vary, and in some people may last over 2 years. Early symptoms can be difficult to detect because they can mirror the typical behavior of an angsty teenager or young.

“When individuals first experience some of the bizarreness associated with this illness, they kind of look depressed,” says Dr. Chen. “They become much more reclusive. They don't talk as much. A lot of times they're hibernating in their room. Like most teenagers, they don't share their thoughts with their parents. It’s easy to think it’s teenage angst, or that they're just going through a phase.”

According to the National Alliance on Mental Illness, early signs of schizophrenia to look out for include:

• A steep drop in grades or job performance

• Trouble thinking clearly or concentrating

• Suspiciousness or uneasiness with others

• A decline in self-care, like not showering for days

• Spending a lot more time alone than usual

• Strong, inappropriate emotions such as laughing when someone dies or having no feelings at all

Symptoms of schizophrenia are generally put into two categories: positive or negative. But don’t be fooled by the term “positive”; these symptoms aren’t positive in the good sense. “Positive symptoms are experiences which are not generally part of everyday experience,” says Dr. Russell Margolis, M.D., Clinical Director at the Johns Hopkins Schizophrenia Center in Baltimore and professor of psychiatry and behavioral sciences.

In other words, positive symptoms are created or added to a person’s life by the disease. The experience of positive symptoms in schizophrenia designates that break with reality that comes with psychosis. Patients can experience either hallucinations or delusions, or both simultaneously.

Just like positive schizophrenia symptoms are added to someone’s life, negative symptoms are what the disease takes away. “They are the absence of something that's normally present in life, such as goals, interests, and initiative,” says Dr. Margolis. “The person just doesn't want to do things anymore. They may just want to sit around all day; they may not speak very much or have spontaneous ideas. It's like everything is turned down.”

Positive symptoms of schizophrenia include:

• Hallucinations: These are sensory experiences that are not comprehensible to others but feel perfectly real and vivid to the person experiencing them. Roughly 70% of people with schizophrenia will have hallucinations. Auditory hallucinations—hearing voices or sounds that aren’t there—are the most common, affecting more than 83% of patients, followed by visual ones (57%), such as seeing body parts or unidentifiable things. Other, less common types (27%) of hallucinations include tactile or sense-of-touch ones, such as feeling bugs crawling on your body; olfactory or scent-related hallucinations (27%); and gustatory hallucinations (14%), which involve your sense of taste. No matter what the type of hallucination, a person with schizophrenia can’t be talked out of it or convinced that what they’re hearing or experiencing isn’t actually happening.

• Delusions: Defined as false beliefs or beliefs that conflict with reality, people with schizophrenia hold strong to these notions despite plenty of evidence to the contrary. Delusions come in many forms; some of the more common ones include:

  • Delusions of persecution: The belief that someone or something means to do you physical or emotional harm, like believing that your next-door neighbor is entering your home while you are sleeping in order to poison your food or to spy on you.

  • Delusions of grandeur: The belief that you are an important, powerful, or a famous person such as a member of royalty, a deity, or a superhero with special powers such as an ability to know the future.

  • Delusions of reference: The belief that something or someone is referring to you when they are not. For instance, you may believe something you read in the newspaper refers to you or your thoughts, or that an actor talking in a movie is sending you a personal message through the screen.

• Thought insertion: The belief that your thoughts are not your own, rather they were placed there by an outside source.

• Thought broadcasting: The belief that your thoughts are being broadcast so that someone or something can observe or collect them (say, aliens or the government), or that people around you can read your mind.

• Thought Disorder: “This is a disordered way of thinking where it’s difficult for the affected person to keep their thoughts in a linear, organized way,” says Dr. Margolis. “As a result, words and phrases are misused, underused, or overused, and it’s difficult for another person to understand.” For example, a person with thought disorder might respond to a question like “Where are you from?” in a tangential, irrelevant way by explaining they don’t know their ancestral history. Or they might derail off topic with a flight of ideas that are only vaguely associated with the original concept.

• Disorganized Behavior and Speech: This is characterized by trouble with goal-directed behavior, which can not only get in the way of starting and completing a task like making dinner or getting dressed for the day, but it can also impact your ability to work or interact with others. Speech can also be affected: Words may become so jumbled and confused that it’s often described as a “word salad.” Other ways disorganization can manifest:

  • A decline in overall daily functioning

  • Unpredictable or inappropriate emotional responses

  • Lack of impulse control

  • Bizarre behaviors that lack purpose

  • Routine behaviors such as bathing, dressing, or brushing teeth can be severely impaired or lost

The negative symptoms of schizophrenia include:

• Avolition: A total lack of motivation, to the point of not being able to pursue any sort of goal, including seemingly simple things like making or taking a phone call

• Anhedonia: An inability to experience pleasure from social situations or physical activities like eating, touching, or sex

• Social withdrawal: Lack of interest in being with other people

• Difficulty paying attention: Staring off aimlessly while someone is speaking, for example

• Apathy: This might show up as lack of personal hygiene, or a lack of concern for yourself or others.

• Affective flattening: An absence of “affect” or emotional expression, such as unresponsive facial expressions or vocal tones and very little body language or movement

• Alogia: Difficulty speaking, which might mean a significant reduction in the amount of words spoken or in the ability to speak with ease or use detail when communicating

And what about cognitive symptoms of schizophrenia?

There's some overlap between cognitive symptoms and both positive and negative ones, but cognition can be defined more narrowly as the capacity to think through and solve problems, explains Dr. Margolis.

“This is the kind of a thinking you would get on an IQ test, for instance, the ability to generate a certain number of words in a period of time, or the ability to connect one idea to another,” he says.

“Most people with schizophrenia do have some cognitive problems compared to where they were before they became ill.” The way their brain works and processes information can become weaker, and cognitive skills they used to have are harder to perform because their brain isn’t functioning normally.

“Psychosis is symptoms—hallucinations and delusions—that can occur in a number of different entities,” says Dr. Chen. For instance, someone who is on cocaine or methamphetamine can have psychotic symptoms, so can someone at the very extremes of depression or mania. And of course, so can someone with schizophrenia.

The distinction, says Dr. Chen, lies in how long symptoms last. “Substance-induced psychosis is reversible. Once your depression resolves, the psychosis goes away. When you treat the mania, the psychosis goes away and you don’t have to treat it anymore. But in the case of schizophrenia, the psychosis is enduring. And if you stop the medications, the psychosis will invariably come back.”

• Paranoid Schizophrenia: The most common type of schizophrenia characterized by psychosis misaligned with reality. If you are suffering from paranoid schizophrenia, you may be unreasonably paranoid of others, have paranoid delusions that someone is after you and that they are trying to hurt you. Common paranoid delusions include coworkers, spouses, the government, and neighbors plotting to hurt you in some way. You may believe others are out to try to kill you, spy on your, make your life miserable, poison you, or cheat on you. Paranoid schizophrenia has a severe impact on relationships, understandably so, as if you are suffering from this disorder, you believe those that are close to you are trying to hurt you in some way. This may cause you to feel angered and agitated. To cause an even deeper impact on the situation, your paranoid delusions may be accompanied by hallucinations where you hear voices that are insulting you or prompting you to do bad things.

• Schizoaffective Disorder: Schizoaffective disorder is a type of combination disorder that combines symptoms of schizophrenia with a mood disorder – most likely either major depression or bipolar disorder. This type of schizophrenia is chronic and appears in intermittent episodes. Mood (affective) symptoms occur at the same time as the schizophrenic symptoms and the schizophrenic symptoms often stay put after the mood symptoms disperse. Common symptoms of schizoaffective disorder include depression, mania, and classic schizophrenia.

• Brief Psychotic Disorder: This is a short-term occurrence of schizophrenia, where there is a sudden onset of symptoms that only persist for less than one month. The causes of these brief stints of psychoses include an obvious stressor (e.g., death of a loved one, trauma from natural disasters), no apparent stressor (i.e., the symptoms come on due to no obvious reaction to a disturbing event), and postpartum psychoses – occurring in women within 4 weeks of giving birth. During this brief episode of psychosis, you might experience hallucinations, delusions, and cognitive deficits, as present during more general schizophrenia. It is unknown what causes brief psychotic disorder to affect certain individuals, but certain genetic and environment factors have been examined as culprits, including predisposition to develop mood disorders and psychoses within the family history.

• Schizophreniform Disorder: This is another short-form occurrence of full-blown schizophrenia, where the affected individual experiences distorted thinking, emotional reactions, and perceptions of reality. If you are suffering from this disorder, you likely have a very hard time distinguishing between what’s real and what’s imagined. Though the symptoms of schizophreniform disorder and general schizophrenia overlap, the major difference is the length of duration. If you suffer from schizophreniform disorder, you experience psychosis symptoms for six months or less. If they persist longer than this time frame, you are likely to receive a diagnosis of schizophrenia instead.

• Delusional Disorder: As the name suggests, this is a form of psychosis where the main symptom is delusions – the inability to shake untrue beliefs. If you are suffering from this form of psychosis, it is not likely you are making up unbelievable scenarios – most delusions involve someone trying to poison you or harm you in some type of way. In reality, these delusions may be a heightened exaggeration of reality or just false altogether. A distinguishing characteristic of individuals suffering from this condition is that among other things, there is no bizarre behavior – you wouldn’t know someone is suffering from this condition if it weren’t for the delusions.

• Shared Psychotic Disorder: Also known as “folie a deux” (the folly of two), this is a rare form of psychosis where an otherwise healthy individual begins to adopt the psychotic beliefs/delusions of someone suffering from schizophrenia. For example, if you are suffering from schizophrenia and believe monsters are after you and trying to abduct you, if your spouse (otherwise healthy) also starts to believe that monsters are out to get you, your spouse would be considered to suffer from shared psychotic disorder. If you and your partner separate, the delusions resolve.

Experts can’t say exactly what causes schizophrenia, but they’ve been able to identify a number of key risk factors, and they believe it’s likely a combination of more than one that contribute to someone developing the disorder. Here are the factors at the top of the list:

Genetics

Genes appear to be by far the biggest risk factor for schizophrenia. “When you look at the illness overall, somewhere between 60% to 80% of the risk of developing schizophrenia is genetic,” says Dr. Margolis, and the risk will depend on their family history, and whether a diagnosed relative is close or distant.

“If you have a sibling with schizophrenia, you probably have a 10% chance of getting it yourself,” says Dr. Margolis. “If you have a parent with schizophrenia, it's a little bit lower, about a 6% chance. If you have a grandparent, your chances are like 5%. If you have an aunt or uncle with schizophrenia, the chances are 2%.”

These exact numbers are all subject to discussion as experts continue to learn more, says Dr. Margolis, but the takeaway is that your risk rapidly goes down the further removed you are from the relative with schizophrenia. It’s also important to note that there’s not just one gene implicated in schizophrenia.

For instance, one 2014 research consortium funded by the NIMH found 108 genetic regions with variations that were significantly associated with schizophrenia risk, and more have been discovered since. For now, that means genetic tests for schizophrenia remain a dream, not a reality.

Pregnancy Complications

Researchers have found that severe complications during pregnancy—such as extreme malnutrition or asphyxia (oxygen deprivation)—are associated with an increased risk of the child developing schizophrenia later in life. But don’t freak out: “This does not by any means mean that schizophrenia would inevitably result if you have a pregnancy complication, it just increases the risk,” says Dr. Margolis.

There are at least two possible connections, the first being genetics. “You may already have some genetic vulnerability, but then some damage occurs that unmasks the vulnerability,” says Dr. Margolis.

Second, there is the more general biological factor that the brain is developing during pregnancy. “Anything that interferes brain development is likely to increase the risk of schizophrenia,” says Dr. Margolis. “Of course, it's going to increase the risk of all sorts of other things, too.”

Substance Abuse

Abuse of alcohol or any illicit drugs has long been linked with an increased risk of developing schizophrenia, but there’s one drug in particular that has experts especially worried: Cannabis.

One study out of Denmark, for instance, found strong associations between almost any substance abuse and later risk of developing schizophrenia, but marijuana was the clear leading culprit. Here’s a rundown of substance risks associated with schizophrenia development:

• Cannabis: 5.2 times

• Alcohol: 3.4 times

• Hallucinogenic drugs: 1.9 times

• Sedatives: 1.7 times

• Amphetamines: 1.24 times

• Other substances: 2.8 times

“There is pretty striking evidence that marijuana use, especially in younger teens, is associated with increased risk for schizophrenia in a dose-response way: The more the use, the higher the risk,” says Dr. Margolis. Though the exact reason isn’t yet understood, he points to timing and what’s happening in the brain.

“The brain doesn’t reach its full maturity until the late teens-early twenties, and so there are a number of important biologic processes underway,” says Dr. Margolis. “The presumption is that somehow, marijuana is interfering with those processes.”

Older Sperm

Or rather, the sperm of older fathers, to be exact. Children born to middle-aged fathers may be at higher risk for developing a range of mental illnesses, possibly including schizophrenia, some evidence suggests. One study in JAMA Psychiatry found that kids born to fathers age 45 and older had about twice the risk of developing psychosis—a hallmark of schizophrenia—compared with those born to younger dads aged 20 to 24.

“This has been debated for a while, but it appears that there may be an increased risk of new mutations developing,” says Dr. Margolis. “It has to do with constant turnover of sperm, and the older someone is, the more chances there are of mutations occurring.”

This is where things get tricky. Diagnosing schizophrenia can be challenging for a few reasons. “It starts with the fact that there is no one unique feature of schizophrenia—people can have hallucinations and positive and negative symptoms of all types with other psychiatric disorders,” says Dr. Margolis. “So, the first step is to avoid being fooled and ruling out those other disorders.”

Second, there is no specific test for schizophrenia. “There’s no blood or genetic test, or any imaging test—though there's great hope that as functional MRI scans get more sophisticated, we may be able to develop better tools for diagnosis,” says Dr. Margolis. “But for now, it’s a clinical diagnosis.” Part of that process involves making sure there are no other medical factors at play that can manifest like schizophrenia, such as a brain tumor or syphilis.

From there, a classic diagnosis comes from comprehensively evaluating the individual’s psychiatric history, starting from when they were well through to how their symptoms have progressed over time, and performing a detailed mental status examination of the person in the moment. For instance, are they currently experiencing hallucinations, delusions, or disordered thinking? This information is gathered not just from the patient, but also from close family members and friends.

“Some people with schizophrenia are very guarded and suspicious of everything as part of their illness, so they won't reveal what they're thinking,” explains Dr. Margolis. “Or, they can be so thought disordered that they won't be able to communicate what they've experienced or how they behave. That’s why it’s vitally important to obtain information from outside informants.”

The schizophrenia brain looks different than a healthy brain, but it’s not easy to spot on standard neuroimaging tests. A few key markers in schizophrenia:

• Enlarged ventricles: These are fluid-filled cavities in the center of the brain. “This was the first consistent biologic finding that proved that schizophrenia is a brain disease,” says Dr. Margolis. “It’s a sign that they’ve lost brain matter, but there’s so much variability in ventricle size between patients that it’s not helpful diagnostically, at least not yet.” Speaking of lost brain matter…

• Reduced gray matter: There’s a reduction in volume of gray matter, neuronal cell bodies that process information in the brain, particularly in the temporal lobe, which processes memories and associates them with sensations of taste, sound, sight, and touch, as well as the frontal lobe, which is important for cognitive functions and control of voluntary movement or activity.

• Unhealthy levels of biochemicals: Many theories point to either an excess or shortage of neurotransmitters serotonin, glutamate, and dopamine. In the latter case, there’s an overactivity in dopamine signals, which plays a role in reward and desire—leading to the hallucinations and delusions, says Dr. Chen.

• Less active frontal lobes: This section of the brain is involved in future planning and reasoning, memory formation, speech and language production, impulse control, and more—all cognitive skills that are impaired in people with schizophrenia.

As mentioned previously, the occurrence of suicide in schizophrenics is abnormally higher than other mental illness disorders. Such that, an estimated 20% to 40% of individuals suffering from schizophrenia will attempt suicide at some point in their lifetimes. Up to 13% are likely to successfully complete the act, the majority being males. Suicide is a tricky complication of schizophrenia because many suffering from this condition are unaware they have it, making treatment that much more difficult.

Substance abuse is another common complication of schizophrenia. Nicotine addiction is the most common substance abuse among schizophrenics, with schizophrenics being addicted to nicotine three times the rate of the general population.

If you are suffering from schizophrenia, you have an increased propensity to abuse more harder substances in addition to nicotine, including marijuana, alcohol, and cocaine. Certainly compounding the already detrimental impact of substance abuse on one's general health, taking medications to treat schizophrenia while abusing drugs makes the medication less effective, in fact, potentially dangerous. In addition, amphetamines (stimulants) make schizophrenic symptoms considerably worse.

Antipsychotic medications are the gold standard, though they work more effectively for positive symptoms (hallucinations, delusion, thought disorder) than they do for negative or cognitive ones. There are several antipsychotics available, each with their own advantages and disadvantages, making it hard to say which ones are better than the others — it really depends on who’s taking it, says Dr. Margolis.

“In general, the older medicines tend to have a slightly higher rate of neurologic side effects,” he says, referring to so-called first-generation drugs like chlorpromazine and haloperidol. For instance, some patients will develop movement abnormalities that look like Parkinson’s disease, or akathisia, an urgent and unpleasant sense of restlessness. On the other hand, some of the newer, second-generation medications such as olanzapine and clozapine have a greater chance of causing metabolic syndrome—a cluster of symptoms including weight gain, diabetes, and high cholesterol—but not all of them carry this risk.

Another thing to consider with medication is the method of delivery. “Many patients with schizophrenia have a condition called anosognosia, where they don't have awareness of their illness,” says Dr. Chen. “And if they don't think they’re ill, they’re not going to take medications—so they're notorious for being noncompliant.” Newer technologies like long-acting injectable medications or transdermal patches are helpful for these patients to stick with a treatment protocol.

Beyond medication, different types of psychotherapy such as cognitive behavioral therapy can help people with schizophrenia manage their illness on a number of fronts. For one, medications aren’t perfect, and psychotherapy can help teach a person how to ignore or disengage with symptoms that slip through the cracks. It can also aid with common issues like managing strained family relationships, finding and holding down a job, and remembering to take medications and show up for doctors’ appointments.

Another treatment to consider is Electroconvulsive therapy (ECT), which involves stimulating the patient’s brain with small electric currents while they’re under anesthesia. “There's some evidence that very severely ill patients respond well to a combination of clozepine and ECT together,” says Dr. Margolis. “It may be particularly effective in people who have schizophrenia with prominent mood symptoms such as depression or mania.”

Childhood-onset schizophrenia (COS) is a rare and poorly understood illness, affecting only about 1 in 40,000 children. It’s considered COS when diagnosed in kids under 13 years old. Though the symptoms are very similar on paper to those of adult schizophrenia, they can be even more difficult to diagnose in children than adults, because symptoms can be easily mistaken for normal kid-like behavior.

For instance, early warning signs of COS include shyness, introversion, loneliness, depression, and manic-like behavior, all of which could be chalked up to “kids being kids.” And children have wild imaginations (Think: monsters in the closet), which can be used to explain away the possibility of hallucinations or delusions. What’s more, symptoms overlap with those found in other more common childhood disorders such as autism and ADHD, adding to the challenge of accurate diagnosis.

Treatment for COS looks very similar to that for adults—antipsychotic medication combined with psychotherapy, with the addition of academic and social support. Unfortunately, the condition is not likely to go away even with treatment, and instead continues into adulthood. Early diagnosis is key to helping children and their families better prepare to cope with the chronic illness.

National Institute of Mental Health

The lead federal agency for research on mental disorders, you’ll find the latest research, news, and statistics on schizophrenia here, and you can explore the idea of participating in an upcoming clinical trial for finding new and better treatments.

National Alliance on Mental Illness

The nation’s largest grassroots mental health organization, NAMI provides information on understanding different mental health conditions and latest research, as well as resources to find a mental health provider and navigate health insurance. For free information and support, call the NAMI HelpLine at 1-800-950-NAMI (6264), or email info@nami.org.

Schizophrenia Alliance

This self-help group is managed by people who are dealing with schizophrenia or a related disorder firsthand. Here, you’ll find social support and fellowship with a community of people who share your challenges and encourage positivity and being proactive in your recovery.