Schizophrenia

What is schizophrenia?

Schizophrenia is a relatively uncommon, severe mental health problem in which people often become disconnected from the world around them, and their perception of reality becomes warped.

Schizophrenia is experienced in episodes, so rather than someone experiencing symptoms at a steady level of severity, there are times when it appears to be in remission. This is why it is so important, if you know someone with this diagnosis, that you are aware of the signs of schizophrenia, as this might mean they are about to experience an episode.

Schizophrenia does not mean someone has a ‘split personality,’ as it is commonly misunderstood.

Types of schizophrenia

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, is used by clinicians to diagnose various mental health conditions.

The latest version of this manual, the DSM-5, removed previously accepted subtypes of schizophrenia, which grouped symptoms under different names. This was largely due to disagreement among clinicians about these subtypes and overlaps in symptoms. However, they can still be helpful for understanding schizophrenia. ^[1]

These subtypes included:

Paranoid schizophrenia

Paranoid schizophrenia is yhe most commonly diagnosed subtype, as many individuals with schizophrenia experience delusions that make them worried, for example, that they are being watched or are under scrutiny from certain people or the state.

People with this subtype of schizophrenia also experience hallucinations in which they have sensory experiences that others around them are not having. For example, seeing images or hearing voices. Hallucinations can affect any or all of the five senses.

Disorganized schizophrenia

This subtype, also known as hebephrenic schizophrenia, is characterized by erratic behavior and often irresponsible actions, for example, putting themselves in danger when crossing roads.

People with disorganized schizophrenia often struggle with talking, and the pattern of their thoughts is jumbled. It can seem like someone experiencing symptoms of this subtype is in their own world, for example, laughing at jokes that others aren’t aware of.

Residual schizophrenia

Mental health professionals can only diagnose this subtype once someone has already been experiencing schizophrenia for some time.

Residual schizophrenia is characterized by what is called ‘negative symptoms’ - essentially the loss or impairment of someone’s social functioning. For example, you might feel withdrawn and disconnected from others or lose the motivation to do things you usually enjoy or would find easy to start.

Catatonic schizophrenia

This subtype is relatively uncommon as a distinct set of symptoms. People with catatonic schizophrenia struggle with movement and talking. For example, they might be unable to move or get out of bed for days or talk at all while also being very active and restless at other times.

Undifferentiated schizophrenia

If someone experienced multiple symptoms from different subtypes, or only one symptom within a subtype, like hallucinations without delusions, they would have be classified as experiencing ‘undifferentiated schizophrenia.’ ^[2]

Signs and symptoms of schizophrenia

The symptoms of schizophrenia are highly varied, which is why the diagnosis has been a subject of so much debate in the medical community. The number of episodes of symptoms that people with schizophrenia have also varies.

Changes to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders mean that someone must experience at least two of the following symptoms to qualify for a diagnosis of schizophrenia.

Symptoms are grouped as follows:

Positive symptoms

This group of symptoms is things that people with schizophrenia experience that others don’t – the use of the word 'positive means’ they are in addition to most people’s reality.

They contribute to the person’s warped perception of the world and are a clear sign that someone is experiencing schizophrenia. For example, they might say unusual things as part of a delusion or seem to be experiencing things others aren’t as part of a hallucination.

Hallucinations

People with schizophrenia often have sensory experiences that others around them are not experiencing.

This might mean seeing things, like an apparition of a historical figure, or a distortion of what others can see, like insects crawling up a wall that isn’t there. It could also mean hearing things, like voices telling the person to do things or that they are worthless.

While seeing and hearing things that aren’t there is very common for people with schizophrenia, hallucinations can be multi-sensory experiences, meaning people taste, smell, or physically feel things as part of them. This can be incredibly distressing for the person as these experiences feel very real to them.

Delusions

People with schizophrenia may believe things that others would say are untrue or overly exaggerated.

A delusion might be that the person believes they have superhuman powers, like being able to fly or cure people of illnesses. It might also look like paranoia. For example, a delusion that the government has placed the person under surveillance.

Some of these beliefs are called ‘delusions of grandeur’ because they imply the person believes themselves to be God-like when experiencing this symptom.

Negative symptoms

This group of symptoms is to do with someone’s social functioning and limited engagement with the world.

A common negative symptom is becoming extremely withdrawn, avoiding people, including family and friends, and retreating into your own world. Another is to lose motivation or interest in the things you would usually want to do and find enjoyable, such as a hobby.

People experiencing these symptoms as part of schizophrenia often feel detached from their own emotions, so they find it hard to be aware of what is happening.

Cognitive symptoms

This is the newest group of symptoms attributed to schizophrenia and is concerned with how the person is processing things and behaving.

A person experiencing cognitive symptoms might have very disordered thinking, jumping from one thing to the next without any connection. This is often experienced alongside jumbled speech, sometimes called ‘word salad.’ For example, using words together because they sound similar rather than have a common meaning.

Cognitive symptoms also include unusual physical behavior. Examples include fidgeting a lot or in an agitated way, contorting their body, and unusual behavioral traits like playing pranks on people and refusing to follow instructions or look after themselves.

Any of these symptoms can be experienced early on in someone’s schizophrenia, so it is important to be aware of the signs that someone is struggling.

Be aware that if someone starts to withdraw, say unusual things, have sensory experiences that aren’t connected to reality, or become disordered in their thinking and speaking, then they might be about to experience a schizophrenic episode.

Causes of schizophrenia

The causes of schizophrenia are unknown, but there is a large amount of ongoing research to understand why some people develop this mental health disorder.

Genetics

There is some evidence to suggest that schizophrenia runs in families, with people more likely to develop it if relatives have the diagnosis.

Environment and experiences

Other studies show that certain experiences can trigger the onset of schizophrenia symptoms. For example, using narcotics, particularly when young, or going through a very stressful or traumatic situation like an abusive relationship.

Some research has focused on how people’s experiences in the womb or early childhood impact the development of schizophrenia, such as exposure to toxins or traumatic births. ^[3]

There is also increasing interest in experiences of racial trauma and how living in the inner city can increase someone’s likelihood of being diagnosed with schizophrenia.

Biology

Research on schizophrenia focuses on the role of neurotransmitters in the brain, particularly dopamine and glutamate, which behave differently in those with the condition.

There is also evidence that people with schizophrenia have different brain structures and that their nervous systems respond to stimuli differently from others.

It is still unclear the extent to which all of these things interact – whether those genetically predisposed to schizophrenia or experience unusual neurotransmitter behavior in the brain respond differently to environmental factors compared to those without a family link to the diagnosis.

Diagnosing schizophrenia

If you or a friend or family member thinks you have schizophrenia, you should see a doctor as soon as possible. Your healthcare provider doctor will use the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), along with asking questions and conducting tests, to determine if schizophrenia is the right diagnosis.

Questions your doctor will ask

As well as asking about your symptoms, how long you have experienced them and how severe they are, your doctor might also ask about your medical history. It will be important for them to determine if you are experiencing an episode and whether this is the first time something like this has happened.

They might also ask about your family’s medical history because of the genetic link for some people with schizophrenia.

Tests your doctor will carry out

Your doctor will also carry out a series of tests to help them rule out other diagnoses or causes of your symptoms, such as bipolar disorder or depression, or the effect of taking narcotics. This could include a CT test and an MRI scan.

Qualifying criteria for diagnosis

According to the DSM-5, to qualify for a schizophrenia diagnosis, you need to have experienced at least two of these symptoms for at least a month:

• Hallucinations
• Delusions
• Disorganized speech

As well as these symptoms, DSM-5 states that you need to show that you are not functioning at your usual level with your work, close relationships, or self-care. ^[4]

Prevention of schizophrenia

It is not possible to prevent schizophrenia, but the earlier you and those around you recognize the signs that you might have it, the more effective treatment can be. This is also true once you have a diagnosis, as early recognition of the signs that you are about to have an episode can help you manage it well.

Most of the research about diagnosing the disorder early has focused on which groups of people are most at risk of schizophrenia and why.

Treatment for schizophrenia

There is no cure for schizophrenia, and people with this diagnosis often must undergo treatment for their whole lives. However, with the proper treatment, people with schizophrenia can live full lives, while ongoing research means new and safer treatments are becoming available.

Schizophrenia treatment aims to minimize symptoms, prevent severe episodes, and help the person to live well in their community. ^[5]

Medication

Most people with schizophrenia will need to take medication to manage their symptoms and to be able to engage with other forms of therapy. The group of medications prescribed for schizophrenia is antipsychotics, which are prescription medicines that sometimes produce side effects such as weight gain, heart disease, or diabetes.

Older antipsychotic medicines that are still prescribed include (brand names in brackets):

• Haloperidol (Haldol)
• Fluphenazine (Prolixin)
• Chlorpromazine (Thorazine)

Newer medicines include:

• Aripiprazole (Abilify)
• Clozapine (Clozaril)
• Olanzapine (Zyprexa)
• Risperidone (Risperdal)

People will often have to take more than one medication to manage their symptoms, so it is important to manage the different dosages and how they interact with your doctor. However, clozapine, often used to manage suicidal behaviors in people with schizophrenia, is not typically taken alongside other drugs.

Therapy

People with schizophrenia often respond well to therapy, especially if they also take antipsychotics to manage their symptoms. Most people with this diagnosis will work with a psychiatrist to help them manage their medication and symptoms.

Psychosocial therapy can help people with schizophrenia to engage with the world and people around them and to integrate into their community. This therapy might also be used as rehabilitation, for example, following a stay in the hospital.

Family therapy is very effective for people with schizophrenia as family members are often best placed to spot the signs the person is about to experience an episode and encourage them to stick to their treatment plan.

Other support

People with schizophrenia might also be assigned a support worker who helps them with practical, everyday tasks, like keeping their house clean and tidy, grocery shopping, looking after themselves, and attending appointments.

Hospital stays

Sometimes people with schizophrenia will experience severe episodes that require hospitalization. These hospitalizations can be voluntary, for example, if someone’s family works with them to acknowledge this level of treatment is needed. However, if the person is resistant to hospitalization, they might be detained for treatment – laws around this vary from state to state.

During a hospital stay, treatment aims to stabilize the person and minimize any risk they pose to themselves. This includes making sure they take their medication and, in some cases, increasing the dose during their time in the hospital to ease their symptoms.

They might also participate in therapy, including in groups with other patients with schizophrenia. The key aim of any hospital stay is to ensure the person is safe and can look after themselves when they leave. Your hospital should work with you and your family on a discharge plan and aftercare.

Self-care for schizophrenia

One of the most important elements of self-care if you have schizophrenia is recognizing the signs that you are becoming more unwell. This varies from person to person but might include withdrawing from those around you, struggling to concentrate on things you usually find easy, or not looking after yourself by not eating or washing enough.

As far as possible, try to avoid things you know can trigger an episode, like excessive consumption of drugs or alcohol or arguments with people you are close to. Instead, engage in things you enjoy and find relaxing. That could be something creative, like playing or listening to music or getting outside into nature.

If you hear voices, joining a support group with people who also experience this symptom can help to make it feel less overwhelming and find ways to manage it. ^[6]

Another key element of self-care with schizophrenia is to seek help if you are struggling. That includes practical things like paying bills on time, eating well, and things to do with your diagnosis, like staying on top of your medication routine.

Consider agreeing with a trusted person that you can let them know if you think you are becoming unwell so that they make decisions on your behalf if you are too unwell to make choices about your treatment.

Helping someone with schizophrenia

Schizophrenia is a complex diagnosis, so try to learn as much about it as possible and set realistic expectations about how the person you support will manage. Joining a group with other people supporting someone with schizophrenia can help with this.

If you are close to someone with schizophrenia, your support can be one of the most effective types of treatment for this diagnosis. Evidence shows that therapy that involves people’s families is effective at helping those with schizophrenia to engage with society and reduces the likelihood of them being re-admitted to the hospital. ^[5]

People with schizophrenia often lack awareness about their illness, so friends and family need to stay alert to the signs that they might be becoming more unwell and seek help.

Because of this lack of awareness and struggle with self-care, people with schizophrenia are also statistically likely to struggle to stick to their treatment plan, particularly concerning medication. Again, the role of friends and family in helping them to do this is crucial. ^[7]

People with schizophrenia often need practical support and might even need to live in supported accommodation. A support worker should help with this, but friends and family also have a role to play.

As it is common for people with schizophrenia to relapse and experience severe episodes, agree to a crisis plan with them if this happens. This should include calling 911 if the person poses a threat to themselves or anyone else. It is important to remember that people with schizophrenia are usually more of a danger to themselves than to other people.

FAQs about schizophrenia

What is the outlook for people with schizophrenia?

With the right treatment, the outlook for people with schizophrenia can be positive. With support, you can carry on with day-to-day activities like working and shopping and live a full life.

It is important to note that many people with schizophrenia also experience physical health problems, like weight gain or diabetes, often because of their medication. This is why it is important to have regular check-ups with your doctor to examine your physical health.

Despite much innovation in the treatment of schizophrenia, people with this diagnosis still have a shorter life expectancy of around 10-25 years compared to the rest of the population. As well as the accompanying physical conditions, which can also be exacerbated by the higher risk of homelessness among people with the schizophrenia, it can also be due to the fact that people with schizophrenia are at high risk of suicide. ^[8]

How common is schizophrenia?

Schizophrenia is relatively uncommon, affecting about 1 in every 100 people in the U.S. There is no evidence to suggest it affects men or women more. Still, men tend to experience symptoms earlier in life.

It is quite common for people to begin to develop the symptoms of schizophrenia during adolescence or into their early 20s. ^[9]

Schizophrenia vs. Psychosis – What is the difference?

Hallucinations and delusions, common symptoms of schizophrenia, are called psychosis. Psychosis is not a mental health disorder - it is a group of psychotic symptoms - and it can be experienced and treated separately from schizophrenia.

Common behaviors as part of psychosis, or a psychotic episode, are disordered talking and thinking or anything that shows the person has lost touch with reality. Some people experience psychosis as part of another mental illness, such as bipolar disorder.