A 33-year-old woman hears brutal and frightening voices daily but continues her college studies. A middle-aged man, who served in the Navy and has since struggled with substance abuse, spends 10 weeks homeless. And another man lives alone with mental confusion and chaos, yet tends to his garden. He has trouble using clocks to stay on top of medication, so instead uses a mirrored prism to track time. Three very different people, all living with schizophrenia.
For those living with schizophrenia, reality can feel fragmented and unpredictable. Symptoms like delusions and hallucinations can significantly disrupt daily life, impacting the ability to function at work, school and social settings.
Schizophrenia is a severe mental health condition that affects approximately 24 million people worldwide. Although there is no specific cause or cure, early intervention and effective treatment can be crucial in managing symptoms and improving quality of life.
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What Is Schizophrenia?
Schizophrenia is a chronic and complex mental health disorder that impacts how a person feels, thinks and behaves. It involves a variety of different symptoms, including delusions, hallucinations and disorganized speech.
“Onset oftentimes appears as a person who seemed to be doing fine beginning to have more problems — usually in school and social situations — during their teen years,” explains Dr. Roscoe Brady, the vice-chair of Research at the Department of Psychiatry of the Beth Israel Deaconess Medical Center. “And then at some point in the late teen years or early twenties, the individual will start to have noticeable symptoms, like hearing voices or experiencing delusions.”
It’s important to note that presentation can look different in men and women. Men usually experience an earlier onset of schizophrenia, with symptoms emerging in their late teens to early twenties. For women, onset tends to occur slightly later, often in their mid-to-late twenties or even into their thirties. In both men and women, childhood schizophrenia — onset before 13 — is rare but can occur.
Symptoms may also manifest differently in men and women. Mood-related symptoms (depression and mood instability, for example) are more common in women with schizophrenia, while negative symptoms like decreased motivation and social withdrawal are more common in men.
“Men also have a higher incidence of schizophrenia compared to women,” notes Dr. Christian Kohler, professor of psychiatry at the Hospital of the University of Pennsylvania and clinical director of the Neuropsychiatry/Schizophrenia Research Center at the University of Pennsylvania.
Signs and Symptoms
Even as individual schizophrenia cases vary considerably, experts say there are some warning signs that clearly point to the need for a clinical evaluation. Often it is loved ones who may initiate this, when those experiencing the symptoms lack awareness — or aren’t able to understand the significance of the issues they face, or recognize those as symptoms.
“The onset of schizophrenia is highly individual,” Kohler explains. Some people may go through a phase of subtle, non-specific pre-psychotic symptoms — marked by struggles with work, school and social isolation that can last for months or even years. Others, however, may experience a sudden onset, developing full psychosis within days or weeks.
Although schizophrenia presents differently in each individual, symptoms are typically classified into three different categories: positive, negative and cognitive symptoms.
Positive symptoms
“Positive symptoms are usually the most visible symptoms of schizophrenia,” Brady says. These symptoms are described as “positive” as they represent a change, addition or distortion in normal behavior and thoughts. Positive symptoms may include:
— Hallucinations. Hallucinations are perceptual disturbances without any outside stimulus or influence. Hallucinations may be auditory, visual, or somatic. Auditory hallucinations are by far the most common in schizophrenia. Auditory hallucinations involve hearing one or more voices that can be familiar, but are more often unfamiliar to the individual. Voices may be commanding and threatening or positive and friendly. Visual hallucinations may involve seeing floating images or shadows. Somatic hallucinations can include feelings of skin crawling or internal organs moving or changing.
— Delusions. “Delusions are fixed false beliefs that are not real and are not shared by individuals in a person’s surroundings or culture,” Kohler says. Delusions may be persecutory, where an individual believes they are being tracked, followed or conspired against. Delusions may also be grandiose, where an individual believes they possess extraordinary powers. Somatic delusions involve false beliefs centering on the physical body, where an individual believes there is something wrong with their body, externally or internally. Erotomanic delusions involve the false belief that another person is in love with them. Jealous delusions lead individuals to believe their partner or spouse is being unfaithful despite a lack of evidence. The most common type of delusions experienced are persecutory delusions.
— Disorganized thinking and speech. In individuals with schizophrenia, speech and thought may be affected. This can manifest as answers to questions being unrelated or tangentially related to the topic, quick shifts from one topic to another, difficulty holding conversations, jumbled speech, improper use of words or the use of invented words (neologisms).
— Disorganized behavior. Disorganized behavior may involve actions that stray from social norms, such as laughing inappropriately, mumbling to oneself or interrupting others. Disorganized behavior can also look like posturing, aggression and silliness. In its most extreme form, it can manifest as catatonic behavior.
Negative symptoms
Negative symptoms involve a lack of normal functioning.
“Negative symptoms are often more subtle and pervasive than positive symptoms,” Kohler says. While they are not required for a diagnosis of schizophrenia, they are typically present. Negative symptoms include:
— Lack of motivation. Many people with schizophrenia experience a lack of drive that may make starting or completing tasks difficult.
— Lack of enjoyment. Some individuals with schizophrenia display an inability to experience pleasure from previously enjoyable activities (anhedonia) as well as a marked lack of interest in pleasurable activities.
— Emotional blunting. Emotional blunting is marked by difficulty in expressing emotions through gestures or facial expressions.
— Social withdrawal. Another key negative symptom is social withdrawal, which can lead to reduced engagement with others and increased isolation.
— Neglect of personal hygiene. Individuals with schizophrenia may also experience a lack of maintenance of personal hygiene as a negative symptom.
— Decrease in speech. Some people with schizophrenia may speak much less frequently, use fewer words, have trouble finding words or take an extended time to respond in conversation.
Cognitive symptoms
Cognitive symptoms affect an individual’s ability to think and function. The most common cognitive symptoms include:
— Difficulty maintaining attention
— Lack of mental flexibility or rigid thinking
— Difficulty with executive functioning or decision-making
— Trouble with memory formation
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Causes of Schizophrenia
There is no singular cause of schizophrenia, although it is thought that a combination of risk factors may contribute to its development:
— Genetic factors. “Genetics is by far the biggest known risk factor for developing schizophrenia,” Brady says. Studies have shown that schizophrenia is highly heritable, with the National Institutes of Health reporting that the condition is known to be as much as 90% heritable. This means that having a family member with schizophrenia significantly increases your risk of developing it.
— Environmental factors. Various environmental factors have been linked to an increased risk of schizophrenia. Obstetric and maternal conditions — such as maternal malnutrition, infections, oxygen deprivation (hypoxia) during birth, preeclampsia, low birth weight and pregnancy-related bleeding — may contribute to a higher likelihood of developing the disorder. Other environmental factors like traumatic life events and substance use (particularly cannabis use) have also been associated with an increased risk of schizophrenia.
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Diagnosis
Usually people seek help — or their loved ones do so on their behalf — when a person displays troubling positive symptoms or has a psychotic episode.
People experiencing an onset of schizophrenia don’t always seek psychiatric evaluation and care right away. Their early struggles may be noticed in other settings, as early symptoms of schizophrenia may include trouble socializing, falling behind in school or heightened anxiety or depression. In many cases, they may initially be seen by a therapist, school counselor or pediatrician.
During psychotic episodes, individuals may seek emergency care or their loved ones may do so on their behalf.
In the process of getting diagnosed with schizophrenia, other possible causes of symptoms and distress must be eliminated first. This is called a diagnosis of exclusion. That includes eliminating drug use as the primary cause of symptoms, as well as other psychiatric disorders like bipolar disorder or other mood disorders and medical issues, such as an underlying illness that may cause dementia or even a brain tumor. This requires a thorough evaluation, including family medical history (though a person needn’t have a family member with schizophrenia to develop the disorder) and a determination that persistent symptoms are undermining a person’s ability to function.
To do this, a health care provider may conduct physical exams, imaging studies like MRIs to rule out brain injuries or tumors and screenings to rule out the possibility of alcohol or drug use impacting symptoms.
Several different health care providers may be involved in diagnosing schizophrenia, including psychologists, psychiatrists, licensed clinical social workers, nurse practitioners, family practitioners, emergency medicine doctors and various other health care providers.
To ensure a proper diagnosis, sometimes it may be necessary to see multiple clinicians with experience in assessing and treating schizophrenia and other psychotic disorders. Because diagnosing schizophrenia “can be tricky … we have plenty of examples where it’s both underdiagnosed and over-diagnosed,” explains Dr. Russell Margolis, clinical director of the Johns Hopkins Schizophrenia Center and professor of psychiatry and behavioral science at Johns Hopkins School of Medicine. “So we encourage people to get second opinions.”
How does schizophrenia change the brain?
There are some structural changes that can be observed in people who have schizophrenia. For example, people with schizophrenia have enlarged ventricles in the brain, which are small spaces in the brain that hold cerebral spinal fluid. In people with schizophrenia, these ventricles are enlarged and the spaces are bigger. This indicates that some of the brain tissue that is expected to be there has been lost, compressed or shrunk.
Treatment
While there is no cure for schizophrenia, there are a variety of treatments available to help manage symptoms, improve functioning, and enhance quality of life.
“Optimal management for schizophrenia typically involves multiple types of treatment,” Brady says.
Medications
Anti-psychotic medications are a first-line treatment for schizophrenia.
“Antipsychotics are particularly effective for treating positive symptoms,” Brady explains. These medications work by balancing brain chemical activity, specifically operating on dopamine receptors, to reduce positive symptoms. Antipsychotics can dramatically improve quality of life and are best used in combination with other treatment approaches, like therapy and social programs.
Antipsychotics are grouped into two categories: first-generation and second-generation. They differ in their exact mechanism of action, how they affect neurotransmitters and side effects. Second-generation antipsychotics are associated) with a lower risk of neurological side effects like akathisia (uncontrollable movement) and dystonia (uncontrollable and repeated muscle contractions) that affect movement.
First-generation antipsychotics include:
— Haloperidol (Haldol)
— Chlorpromazine (Thorazine)
— Fluphenazine (Prolixin)
— Trifluoperazine (Stelazine)
— Perphenazine (Trilafon)
— Thioridazine (Mellaril)
— Thiothixene (Navane)
— Loxapine (Loxitane or Adasuve)
— Pimozide (Orap)
— Prochlorperazine (Compazine)
Second-generation antipsychotics include:
— Aripiprazole (Abilify)
— Asenapine (Saphris)
— Brexpiprazole (Rexulti)
— Cariprazine (Vraylar)
— Clozapine (Clozaril)
— Iloperidone (Fanapt)
— Lumateperonee (Caplyta)
— Lurasidone (Latuda)
— Olanzapine (Zyprexa)
— Olanzapine and fluoxetine (Symbyax)
— Paliperidone (Invega)
— Paliperidone palmitate (Invega Trinza)
— Quetiapine (Seroquel)
— Risperidone (Risperdal)
— Xanomeline and trospium chloride (Cobenfy)
— Ziprasidone (Geodon)
Antipsychotics can be critical in managing schizophrenia, but they may have side effects that are important to monitor. Adverse effects and risks include dizziness, sedation, movement issues (tremors, stiffness, etc.), movement disorders (dystonia, for example), blurred vision, dry mouth, constipation, high blood sugar, high cholesterol, weight gain, tardive dyskinesia (a chronic movement disorder), constipation and immune disruption.
It’s important to work with a health care professional to find a medication and dose that works best for you.
Therapeutic interventions and social support programs
Apart from medication, therapy to help patients cope with persistent symptoms is also often recommended. Psychosocial interventions can also help with symptom management, support education and employment and improve quality of life for both individuals and their families.
— Psychotherapy. Psychotherapy, or individual therapy, can help people manage schizophrenia symptoms. “Cognitive behavioral therapy for psychosis can be particularly effective,” says Kohler. Therapy may help with developing coping strategies, managing persistent symptoms, addressing negative and cognitive symptoms, and reframing thoughts related to positive symptoms.
— Family therapy and education. Family support involves providing education and emotional support to individuals with schizophrenia and their loved ones. Family support helps families understand schizophrenia and learn how to navigate the diagnosis best and support their loved one. It also provides family members with a space to process their emotions and cope with challenges.
— Supported employment and education. This type of intervention supports people with schizophrenia in pursuing and maintaining education or employment.
— Peer support. Peer support can also be vital in schizophrenia treatment, providing individuals with guidance and support from trained peer counselors who have lived experience with psychosis.
“People with schizophrenia are best treated, as in a number of other serious mental illnesses, with a combination of medical treatments and psychotherapeutic interventions,” Margolis says. “For example, individuals might benefit from therapy where they practice not responding to voices that they hear out loud in a public setting, where they would potentially end up facing stigma or discrimination. And people can learn to challenge their suspicions to say wait a minute … just because there are people talking around me doesn’t mean it’s about me. I don’t have to be concerned about that.”
Inpatient stays
During severe acute episodes of psychosis or periods involving suicidal or violent behavior, inpatient hospitalization may be helpful in medication monitoring, crisis stabilization, assessment and treatment planning.
Given the varied nature of schizophrenia — and what that diagnosis means for different people — it’s not uncommon for treatment to be a matter of trial and error. So it’s important, experts say, to stick with treatments to give them a chance to work, let clinicians know about side effects or other concerns and try alternative treatments when needed.
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Schizophrenia: Symptoms, Causes and Treatment originally appeared on usnews.com
Update 03/28/25: This story was published at an earlier date and has been updated with new information.
