Understanding Schizophrenia

SIGNS, SYMPTOMS, CAUSES, AND EFFECTS

Schizophrenia: Signs, Symptoms, Causes & Treatment

Schizophrenia is a challenging disorder that makes it difficult to distinguish between what is real and unreal, think clearly, manage emotions, and relate to others. These obstacles can get in the way of your ability to function normally and take care of yourself. But that doesn't mean there isn't hope.

The truth is, schizophrenia can be successfully managed. The first step is identifying the signs and symptoms. The second step is seeking help without delay. The third is sticking with treatment. With the right treatment and support from family, friends, and health professionals, a person with schizophrenia can lead a happy, fulfilling life.

What is schizophrenia?

One Man’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.

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 significantloss 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.

Most cases of schizophrenia appear in the late teens or early adulthood. For men, the average age of onset is 25. For women, typical onset is around the age of 30. 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.

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 schizophrenia warning signs

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.

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. 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 patients. 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

The negative symptoms of schizophrenia refer to the absence of normal behaviors found in healthy individuals. Important negative symptoms of schizophrenia include:

Flattened or blunted affect: Lack of emotional expression, including a flat voice, lack of eye contact, and blank or restricted facial expressions.
Avolition: Lack of interest or enthusiasm; no ability to pursue goal-driven activities.
Catatonia: Apparent unawareness of the environment, near total absence of motion and speech, aimless body movements and bizarre postures, lack of self-care.
Alogia: Difficulties with speech, inability to carry a conversation, short and sometimes disconnected replies to questions, lessening of fluency.

“Positive” Symptoms of Schizophrenia

In contrast to the negative symptoms of schizophrenia, which refer to normal behaviors that are absent, positive symptoms refer to abnormal behaviors that are present. Delusions, hallucinations, disorganized speech, and disorganized behavior are all positive symptoms of schizophrenia.

Types of schizophrenia

There are three major subtypes of schizophrenia, each classified by their most prominent symptom:paranoid schizophrenia, disorganized schizophrenia, and catatonic schizophrenia.

Signs and symptoms of paranoid schizophrenia

The defining feature of paranoid schizophrenia is absurd or suspicious ideas and beliefs. These ideas typically revolve around a coherent, organized theme or “story” that remains consistent over time. Delusions of persecution are the most frequent theme, however delusions of grandeur are also common.

People with paranoid schizophrenia show a history of increasing paranoia and difficulties in their relationships. They tend to function better than individuals with other schizophrenic subtypes. In contrast, their thinking and behavior is less disordered and their long-term prognosis is better.

Signs and symptoms of disorganized schizophrenia

Disorganized schizophrenia generally appears at an earlier age than other types of schizophrenia. Its onset is gradual, rather than abrupt, with the person gradually retreating into his or her fantasies. The distinguishing characteristics of this subtype are disorganized speech, disorganized behavior, and blunted or inappropriate emotions. People with disorganized schizophrenia also have trouble taking care of themselves, and may be unable to perform simple tasks such as bathing or feeding themselves.

The symptoms of disorganized schizophrenia include:

Impaired communication skills
Incomprehensible or illogical speech
Emotional indifference
Inappropriate reactions (e.g. laughing at a funeral)
Infantile behavior (baby talk, giggling)
Peculiar facial expressions and mannerisms

People with disorganized schizophrenia sometimes suffer from hallucinations and delusions, but unlike the paranoid subtype, their fantasies aren’t consistent or organized.

Signs and symptoms of catatonic schizophrenia

The hallmark of catanoic schizophrenia is a disturbance in movement: either a decrease in motor activity, reflecting a stuporous state, or an increase in motor activity, reflecting an excited state.

Stuporous motor signs — The stuporous state reflects a dramatic reduction in activity. The person often ceases all voluntary movement and speech, and may be extremely resistant to any change in his or her position, even to the point of holding an awkward, uncomfortable position for hours.
Excited motor signs — Sometimes, people with catatonic schizophrenia pass suddenly from a state of stupor to a state of extreme excitement. During this frenzied episode, they may shout, talk rapidly, pace back and forth, or act out in violence—either toward themselves or others.

People with catatonic schizophrenia can be highly suggestible. They may automatically obey commands, imitate the actions of others, or mimic what others say.

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

Brain chemical imbalances

There is evidence that chemical imbalances in certain neurotransmitters, proteins, and amino acids play a role in causing schizophrenia.

Dopamine — Dopamine is the primary brain chemical implicated in schizophrenia. The dopamine hypothesis suggests that an excess of dopamine in the brain contributes to schizophrenia.
Glutamate — Glutamate is another important neurotransmitter implicated in schizophrenia. Studies show an underactivity of glutamate in schizophrenic patients. This supports the dopamine hypothesis, since dopamine receptors inhibit the release of glutamate.

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 significantly 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 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 – Schizophrenics frequently develop problems with alcohol or drugs, 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.

Helping a Schizophrenic Person
Coping with Symptoms, Supporting Treatment, and Finding Services

Schizophrenia Treatment
Diagnosis, Treatments, Medication, and Therapy

Signs and symptoms of schizophrenia

Schizophrenia – Provides a comprehensive overview discussing causes, symptoms, diagnosis, treatment and current research on schizophrenia. (National Institute of Mental Health)

Schizophrenia FAQs – Offers answers to frequently asked questions about schizophrenia, including what the signs and symptoms look like, what causes it, and how it’s treated. (Continuing Medical Education)

Schizophrenia in Children – Describes symptoms in children, which may be different from those in adults. (American Academy of Child and Adolescent Psychiatry)

Early warning signs of schizophrenia

The First Signs of Schizophrenia – Read through personal stories, offered by both people with schizophrenia and their loved ones, describing the early signs and symptoms they observed. (Schizophrenia.com)

Schizophrenia: First Warning Signs – Provides a list of early warning signs and symptoms of schizophrenia, compiled by individuals who have a family member with the disorder. (World Fellowship for Schizophrenia and Allied Disorders)

Types of schizophrenia

Paranoid Schizophrenia – Learn about the most common subtype of schizophrenia, including typical signs and symptoms such as paranoid delusions. (Mayo Clinic)

Catatonic Schizophrenia – Overview of the signs and symptoms of catatonic schizophrenia, as well as its causes and effects. (Mayo Clinic)

Disorganized Schizophrenia – Guide to disorganized schizophrenia’s signs and symptoms, such as disorganized thinking, disorganized behavior, and flat affect. (Mayo Clinic)

Causes of schizophrenia

Possible Causes of Schizophrenia – Reviews the possible causes of schizophrenia, including biological, psychological, and social factors. (Schizophrenia Fellowship of NSW)

What Causes Schizophrenia? – Covers the combination of causes involved in schizophrenia, including genes, brain chemistry, and brain structure. (National Institute of Mental Health)

Effects of schizophrenia

New Factors Identified for Predicting Violence in Schizophrenia – Learn what factors increase the odds that a person with schizophrenia will become violent. (National Institute of Mental Health)

Melinda Smith, M.A. and Robert Segal, M.A. contributed to this article. Last reviewed: April 2010.