What is schizophrenia?
Most cases of schizophrenia appear in the late teens or early adulthood. However, schizophrenia can appear for the first time in middle age or even later. In rare cases, schizophrenia can even affect young children and adolescents, although the symptoms are slightly different. In general, the earlier schizophrenia develops, the more severe it is. Schizophrenia also tends to be more severe in men than in women.Schizophrenia is a brain disorder that affects the way a person acts, thinks, and sees the world. People with schizophrenia have an altered perception of reality, often a significant loss of contact with reality. They may see or hear things that don’t exist, speak in strange or confusing ways, believe that others are trying to harm them, or feel like they’re being constantly watched. With such a blurred line between the real and the imaginary, schizophrenia makes it difficult—even frightening—to negotiate the activities of daily life. In response, people with schizophrenia may withdraw from the outside world or act out in confusion and fear.
Although schizophrenia is a chronic disorder, there is help available. With support, medication, and therapy, many people with schizophrenia are able to function independently and live satisfying lives. However, the outlook is best when schizophrenia is diagnosed and treated right away. If you spot the signs and symptoms of schizophrenia and seek help without delay, you or your loved one can take advantage of the many treatments available and improve the chances of recovery.
Common misconceptions about schizophrenia
MYTH: Schizophrenia refers to a "split personality" or multiple personalities.
FACT: Multiple personality disorder is a different and much less common disorder than schizophrenia. People with schizophrenia do not have split personalities. Rather, they are “split off” from reality.
MYTH: Schizophrenia is a rare condition.
FACT: Schizophrenia is not rare; the lifetime risk of developing schizophrenia is widely accepted to be around 1 in 100.
MYTH: People with schizophrenia are dangerous.
FACT: Although the delusional thoughts and hallucinations of schizophrenia sometimes lead to violent behavior, most people with schizophrenia are neither violent nor a danger to others.
MYTH: People with schizophrenia can’t be helped.
FACT: While long-term treatment may be required, the outlook for schizophrenia is not hopeless. When treated properly, many people with schizophrenia are able to enjoy life and function within their families and communities.
Early warning signs of schizophrenia
In some people, schizophrenia appears suddenly and without warning. But for most, it comes on slowly, with subtle warning signs and a gradual decline in functioning long before the first severe episode. Many friends and family members of people with schizophrenia report knowing early on that something was wrong with their loved one, they just didn’t know what.
In this early phase, people with schizophrenia often seem eccentric, unmotivated, emotionless, and reclusive. They isolate themselves, start neglecting their appearance, say peculiar things, and show a general indifference to life. They may abandon hobbies and activities, and their performance at work or school deteriorates.
The most common early warning signs of schizophrenia include:
- Social withdrawal
- Hostility or suspiciousness
- Deterioration of personal hygiene
- Flat, expressionless gaze
- Inability to cry or express joy
- Inappropriate laughter or crying
- Depression
- Oversleeping or insomnia
- Odd or irrational statements
- Forgetful; unable to concentrate
- Extreme reaction to criticism
- Strange use of words or way of speaking
While these warning signs can result from a number of problems—not just schizophrenia—they are cause for concern. When out-of-the-ordinary behavior is causing problems in your life or the life of a loved one, seek medical advice. If schizophrenia or another mental problem is the cause, treatment will help.
Daniel’s story
Daniel is 21 years old. Six months ago, he was doing well in college and holding down a part-time job in the stockroom of a local electronics store. But then he began to change, becoming increasingly paranoid and acting out in bizarre ways. First, he became convinced that his professors were “out to get him” since they didn’t appreciate his confusing, off-topic classroom rants. Then he told his roommate that the other students were “in on the conspiracy.” Soon after, he dropped out of school.
From there, things just got worse. Daniel stopped bathing, shaving, and washing his clothes. At work, he became convinced that his boss was watching him through surveillance bugs planted in the store’s television sets. Then he started hearing voices telling him to find the bugs and deactivate them. Things came to a head when he acted on the voices, smashing several TVs and screaming that he wasn’t going to put up with the “illegal spying” any more. His frightened boss called the police, and Daniel was hospitalized.
Signs and symptoms of schizophrenia
There are five types of symptoms characteristic of schizophrenia: delusions, hallucinations, disorganized speech, disorganized behavior, and the so-called “negative” symptoms. However, the signs and symptoms of schizophrenia vary dramatically from person to person, both in pattern and severity. Not every person with schizophrenia will have all symptoms, and the symptoms of schizophrenia may also change over time.
Delusions
A delusion is a firmly-held idea that a person has despite clear and obvious evidence that it isn’t true. Delusions are extremely common in schizophrenia, occurring in more than 90% of those who have the disorder. Often, these delusions involve illogical or bizarre ideas or fantasies. Common schizophrenic delusions include:
- Delusions of persecution – Belief that others, often a vague “they,” are out to get him or her. These persecutory delusions often involve bizarre ideas and plots (e.g. “Martians are trying to poison me with radioactive particles delivered through my tap water”).
- Delusions of reference – A neutral environmental event is believed to have a special and personal meaning. For example, a person with schizophrenia might believe a billboard or a person on TV is sending a message meant specifically for them.
- Delusions of grandeur – Belief that one is a famous or important figure, such as Jesus Christ or Napolean. Alternately, delusions of grandeur may involve the belief that one has unusual powers that no one else has (e.g. the ability to fly).
- Delusions of control – Belief that one’s thoughts or actions are being controlled by outside, alien forces. Common delusions of control include thought broadcasting (“My private thoughts are being transmitted to others”), thought insertion (“Someone is planting thoughts in my head”), and thought withdrawal (“The CIA is robbing me of my thoughts”).
Hallucinations
Hallucinations are sounds or other sensations experienced as real when they exist only in the person's mind. While hallucinations can involve any of the five senses, auditory hallucinations (e.g. hearing voices or some other sound) are most common in schizophrenia. Visual hallucinations are also relatively common. Research suggests that auditory hallucinations occur when people misinterpret their own inner self-talk as coming from an outside source.
Schizophrenic hallucinations are usually meaningful to the person experiencing them. Many times, the voices are those of someone they know. Most commonly, the voices are critical, vulgar, or abusive. Hallucinations also tend to be worse when the person is alone.
Disorganized speech
Fragmented thinking is characteristic of schizophrenia. Externally, it can be observed in the way a person speaks. People with schizophrenia tend to have trouble concentrating and maintaining a train of thought. They may respond to queries with an unrelated answer, start sentences with one topic and end somewhere completely different, speak incoherently, or say illogical things.
Common signs of disorganized speech in schizophrenia include:
- Loose associations – Rapidly shifting from topic to topic, with no connection between one thought and the next.
- Neologisms – Made-up words or phrases that only have meaning to the patient.
- Perseveration – Repetition of words and statements; saying the same thing over and over.
- Clang – Meaningless use of rhyming words (“I said the bread and read the shed and fed Ned at the head").
Disorganized behavior
Schizophrenia disrupts goal-directed activity, causing impairments in a person’s ability to take care of him or herself, work, and interact with others. Disorganized behavior appears as:
- A decline in overall daily functioning
- Unpredictable or inappropriate emotional responses
- Behaviors that appear bizarre and have no purpose
- Lack of inhibition and impulse control
Negative symptoms (absence of normal behaviors)
The so-called “negative” symptoms of schizophrenia refer to the absence of normal behaviors found in healthy individuals. Common negative symptoms of schizophrenia include:
- Lack of emotional expression – Inexpressive face, including a flat voice, lack of eye contact, and blank or restricted facial expressions.
- Lack of interest or enthusiasm – Problems with motivation; lack of self-care.
- Seeming lack of interest in the world – Apparent unawareness of the environment; social withdrawal.
- Speech difficulties and abnormalities – Inability to carry a conversation; short and sometimes disconnected replies to questions; speaking in monotone.
Causes of schizophrenia
The causes of schizophrenia are not fully known. However, it appears that schizophrenia usually results from a complex interaction between genetic and environmental factors.
Genetic causes of schizophrenia
Schizophrenia has a strong hereditary component. Individuals with a first-degree relative (parent or sibling) who has schizophrenia have a 10 percent chance of developing the disorder, as opposed to the 1 percent chance of the general population.
But schizophrenia is only influenced by genetics, not determined by it. While schizophrenia runs in families, about 60% of schizophrenics have no family members with the disorder. Furthermore, individuals who are genetically predisposed to schizophrenia don’t always develop the disease, which shows that biology is not destiny.
Environmental causes of schizophrenia
Twin and adoption studies suggest that inherited genes make a person vulnerable to schizophrenia and then environmental factors act on this vulnerability to trigger the disorder.
As for the environmental factors involved, more and more research is pointing to stress, either during pregnancy or at a later stage of development. High levels of stress are believed to trigger schizophrenia by increasing the body’s production of the hormone cortisol.
Research points to several stress-inducing environmental factors that may be involved in schizophrenia, including:
- Prenatal exposure to a viral infection
- Low oxygen levels during birth (from prolonged labor or premature birth)
- Exposure to a virus during infancy
- Early parental loss or separation
- Physical or sexual abuse in childhood
Abnormal brain structure
In addition to abnormal brain chemistry, abnormalities in brain structure may also play a role in schizophrenia. Enlarged brain ventricles are seen in some schizophrenics, indicating a deficit in the volume of brain tissue. There is also evidence of abnormally low activity in the frontal lobe, the area of the brain responsible for planning, reasoning, and decision-making.
Some studies also suggest that abnormalities in the temporal lobes, hippocampus, and amygdala are connected to schizophrenia’s positive symptoms. But despite the evidence of brain abnormalities, it is highly unlikely that schizophrenia is the result of any one problem in any one region of the brain.
Effects of schizophrenia
When the signs and symptoms of schizophrenia are ignored or improperly treated, the effects can be devastating both to the individual with the disorder and those around him or her. Some of the possible effects of schizophrenia are:
- Relationship problems. Relationships suffer because people with schizophrenia often withdraw and isolate themselves. Paranoia can also cause a person with schizophrenia to be suspicious of friends and family.
- Disruption to normal daily activities. Schizophrenia causes significant disruptions to daily functioning, both because of social difficulties and because everyday tasks become hard, if not impossible to do. A schizophrenic person’s delusions, hallucinations, and disorganized thoughts typically prevent him or her from doing normal things like bathing, eating, or running errands.
- Alcohol and drug abuse. People with schizophrenia frequently develop problems with alcohol ordrugs, which are often used in an attempt to self-medicate, or relieve symptoms. In addition, they may also be heavy smokers, a complicating situation as cigarette smoke can interfere with the effectiveness of medications prescribed for the disorder.
- Increased suicide risk. People with schizophrenia have a high risk of attempting suicide. Any suicidal talk, threats, or gestures should be taken very seriously. People with schizophrenia are especially likely to commit suicide during psychotic episodes, during periods of depression, and in the first six months after they’ve started treatment.
Diagnosing schizophrenia
A diagnosis of schizophrenia is made based on a full psychiatric evaluation, medical history, physical exam, and lab tests.
- Psychiatric evaluation – The doctor or psychiatrist will ask a series of questions about you or your loved one's symptoms, psychiatric history, and family history of mental health problems.
- Medical history and exam – Your doctor will ask about your personal and family health history. He or she will also perform a complete physical examination to check for medical issues that could be causing or contributing to the problem.
- Laboratory tests – While there are no laboratory tests that can diagnose schizophrenia, simple blood and urine tests can rule out other medical causes of symptoms. The doctor may also order brain-imaging studies, such as an MRI or a CT scan, in order to look for brain abnormalities associated with schizophrenia.
Mental health professionals use the following criteria to diagnose schizophrenia:
- The presence of two or more of the following symptoms for at least 30 days:
- Hallucinations
- Delusions
- Disorganized speech
- Disorganized or catatonic behavior
- Negative symptoms (emotional flatness, apathy, lack of speech)
- Significant problems functioning at work or school, relating to other people, and taking care of oneself.
- Continuous signs of schizophrenia for at least 6 months, with active symptoms (hallucinations, delusions, etc.) for at least 1 month.
- No other mental health disorder, medical issue, or substance abuse problem is causing the symptoms.
Conditions that can look like schizophrenia
The medical and psychological conditions the doctor must rule out before diagnosing schizophrenia include:
- Other psychotic disorders – Schizophrenia is a type of psychotic disorder, meaning it involves a significant loss of contact with reality. But there are other psychotic disorders that cause similar symptoms of psychosis, including schizoaffective disorder, schizophreniform disorder, and brief psychotic disorder. Because of the difficulty in differentiating between the psychotic disorders, it may take six months or longer to arrive at a correct diagnosis.
- Substance abuse – Psychotic symptoms can be triggered by many drugs, including alcohol, PCP, heroin, amphetamines, and cocaine. Some over-the-counter and prescription drugs can also trigger psychotic reactions. A toxicology screen can rule out drug-induced psychosis. If substance abuse is involved, the physician will determine whether the drug is the source of the symptoms or merely an aggravating factor.
- Medical conditions – Schizophrenia-like symptoms can also result from certain neurological disorders (such as epilepsy, brain tumors, and encephalitis), endocrine and metabolic disturbances, and autoimmune conditions involving the central nervous system.
- Mood disorders – Schizophrenia often involves changes in mood, including mania and depression. While these mood changes are typically less severe than those seen in bipolar disorder and major depressive disorder, they can make diagnosis tricky. Schizophrenia is particularly difficult to distinguish from bipolar disorder. The positive symptoms of schizophrenia (delusions, hallucinations, and disorganized speech) can look like a manic episode of bipolar disorder, while the negative symptoms of schizophrenia (apathy, social withdrawal, and low energy) can look like a depressive episode.
- Post-traumatic stress disorder (PTSD) – PTSD is an anxiety disorder that can develop after exposure to a traumatic event, such as military combat, an accident, or a violent assault. People with PTSD experience symptoms that are similar to schizophrenia. The images, sounds, and smells of PTSD flashbacks can look like psychotic hallucinations. The PTSD symptoms of emotional numbness and avoidance can look like the negative symptoms of schizophrenia
