- Introduction to Schizophrenia and Related Disorders
- Delusional Disorder
- Brief Psychotic Disorder
- Schizophreniform Disorder
- Schizophrenia
- Schizoaffective Disorder
- Substance- or Medication-Induced Psychotic Disorder
- Psychotic Disorder Due to Another Medical Condition
- Other Schizophrenia Spectrum and Psychotic Disorders
- Antipsychotic Medications
Topic Resources
The cause of schizophrenia is unknown but is thought to be multifactorial, involving both genetic and environmental factors.
People may have a variety of symptoms, ranging from bizarre behavior and rambling, disorganized speech to loss of emotions and little or no speech to inability to concentrate and remember.
Doctors diagnose schizophrenia based on standard psychiatric diagnostic criteria after they do tests to rule out other possible causes of psychosis.
Treatment involves antipsychotic medications, cognitive and social skills training programs, community support activities, psychotherapy, and family education.
How well people do can be influenced by whether they take their medications as prescribed.
Early detection and early treatment improve long-term functioning.
Schizophrenia is a major mental health problem throughout the world. The disorder typically develops in young people at the very time they are establishing their independence and can result in lifelong disability and stigma.
Schizophrenia affects just under 1% of the population worldwide, and it is equally common in men and women.
Determining when schizophrenia begins (onset) is often difficult because unfamiliarity with symptoms may delay medical care for several years. The average age at onset is the early to mid-20s for men, although 40% of males have their first episode before age 20. For women, the average age at onset is during the mid to late 20s, with an additional peak of diagnosis in the 30s. Onset during childhood is rare, but schizophrenia may begin during adolescence or, rarely, late in life.
Deterioration in social functioning can lead to a substance use disorder, poverty, and homelessness. People with untreated schizophrenia may lose contact with their families and friends and often find themselves living on the streets of large cities. The condition can last a lifetime, with poor psychosocial functioning over the long term in most cases.
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Causes of Schizophrenia
What precisely causes schizophrenia is not known, but current research suggests a combination of hereditary and environmental factors. Fundamentally, however, it is a biologic problem involving molecular and functional changes in the brain. It is not thought to be primarily caused by life events although certain external factors, including major life stresses and substance use (especially cannabis), can serve as triggers in a person who is already predisposed to developing schizophrenia.
Factors that make people vulnerable to schizophrenia include the following:
A genetic predisposition
Problems that occurred before, during, or after birth
Viral infections of the brain
Childhood trauma and neglect
Schizophrenia does run in families and seems to be have a genetic component. People who have a parent or sibling with schizophrenia have about 5 to 11 times the risk compared with people without a family history of the disorder. An identical twin whose co-twin has schizophrenia has a 40 to 80% risk of developing schizophrenia.
Various factors have been studied to understand which people are at risk of developing schizophrenia. Strongly associated factors include parental mental illness, particularly if a person's mother had a history of psychosis. Factors related to pregnancy and birth include maternal stress during pregnancy, pregnancy complications, season at time of birth, low birth weight, and birth defects. Other factors include exposure to famine or nutritional deficiencies and certain infections (such as herpes simplex virus type 2).
Symptoms of Schizophrenia
Schizophrenia may begin suddenly, over a period of days or weeks, or slowly and gradually, over a period of years. Although the severity and types of symptoms vary among different people with schizophrenia, the symptoms are usually sufficiently severe to interfere with the ability to work, interact with people, and care for oneself.
However, symptoms are sometimes mild at first. People may simply appear withdrawn, disorganized, or suspicious. Doctors may recognize these symptoms as the beginning of schizophrenia, but sometimes doctors recognize them only in hindsight.
Schizophrenia is characterized by psychotic symptoms, which include delusions, hallucinations, disorganized thinking and speech, and bizarre and inappropriate behavior. Psychotic symptoms involve a loss of contact with reality.
In some people with schizophrenia, mental (cognitive) function declines, sometimes from the very beginning of the disorder. This cognitive impairment leads to difficulty paying attention, thinking in the abstract, and solving problems. The severity of cognitive impairment largely determines overall disability in people with schizophrenia. Many people with schizophrenia are unemployed and have little or no contact with family members or other people.
Symptoms may be triggered or worsened by stressful life events, such as losing a job or ending a romantic relationship. Illicit drug use, including use of cannabis, may trigger or worsen symptoms as well.
Overall, the symptoms of schizophrenia fall into 5 major categories:
Hallucinations
Delusions
Disorganized speech and though
Disorganized movements
Negative symptoms
People may have symptoms from any or all categories, as well as cognitive impairment.
Positive symptoms
Positive symptoms involve a distortion of normal functions. They include the following:
Delusions are false beliefs that usually involve a misinterpretation of perceptions or experiences. Also, people maintain these beliefs despite clear evidence that contradicts them. There are many possible types of delusion. For example, people with schizophrenia may have persecutory delusions, believing that they are being tormented, followed, tricked, or spied on. They may have delusions of reference, believing that passages from books, newspapers, or song lyrics are directed specifically at them. They may have delusions of thought withdrawal or thought insertion, believing that others can read their mind, that their thoughts are being transmitted to others, or that thoughts and impulses are being imposed on them by outside forces. Delusions in schizophrenia may be bizarre or not. Bizarre delusions are clearly implausible and not derived from ordinary life experiences. For example, people may believe that someone removed their internal organs without leaving a scar. Delusions that are not bizarre involve situations that could happen in real life, such as being followed or having a spouse or partner who is unfaithful.
Hallucinations involve hearing, seeing, tasting, or physically feeling things that no one else does. Hallucinations that are heard (auditory hallucinations) are by far the most common. People may hear voices in their head commenting on their behavior, conversing with one another, or making critical and abusive comments.
Disorganization
Disorganization involves thought disorders and bizarre behavior:
Thought disorder refers to disorganized thinking, which becomes apparent when speech is rambling or shifts from one topic to another. Speech may be mildly disorganized or completely incoherent and incomprehensible.
Disorganized (bizarre) behavior may take the form of childlike silliness, agitation, or inappropriate appearance, hygiene, or conduct. Catatonia is an extreme form of bizarre behavior in which people maintain a rigid posture and resist efforts to be moved or, in contrast, move randomly.
Negative symptoms
Negative symptoms involve a decrease in or loss of normal emotional and social functions. They include the following:
Reduced expression of emotions involves showing little or no emotion. The face may appear immobile. People make little or no eye contact. People do not use their hands or head to add emotional emphasis as they speak. Events that would normally make them laugh or cry produce no response.
Poverty of speech refers to a decreased amount of speech. Answers to questions may be terse, perhaps 1 or 2 words, creating the impression of an inner emptiness.
Anhedonia refers to a diminished capacity to experience pleasure. People may take little interest in previous activities and spend more time in purposeless activities.
Asociality refers to a lack of interest in relationships with other people.
Lack of motivation refers to a reduced desire to engage in goal-oriented activities
These negative symptoms are often associated with a general loss of motivation, sense of purpose, and goals.
Cognitive impairment
Cognitive impairment refers to difficulty concentrating, remembering, organizing, planning, and problem solving. Some people are unable to concentrate sufficiently to read, follow the story line of a movie or television show, or follow directions. Others are unable to ignore distractions or remain focused on a task. Consequently, work that involves attention to detail, involvement in complicated procedures, decision making, and understanding of social interactions may be impossible.
Suicide
About 4 to 10% of people with schizophrenia die by suicide, about 35% attempt it, and many more have significant thoughts of suicide. Suicide is the major cause of premature death among young people with schizophrenia and is one of the main reasons why schizophrenia reduces average lifespan by 15 years.
Risk of suicide is increased in young men with schizophrenia, especially if they also have a substance use disorder. Risk is also increased in people who have depressive symptoms or feelings of hopelessness, who are unemployed, or who have just had a psychotic episode or been discharged from the hospital.
Risk of suicide is greatest for people who developed schizophrenia late in life and who were functioning well before it developed. Such people remain able to feel grief and anguish. Thus, they may be more likely to act in despair because they recognize the effects of their disorder. These people are also often the ones with the best prognosis for recovery.
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Violence
Contrary to popular opinion, people with schizophrenia have only a slightly increased risk for violent behavior. Threats of violence and minor aggressive outbursts are far more common than seriously dangerous behavior. A very few severely depressed, isolated, paranoid people attack or murder someone whom they perceive as the single source of their difficulties (for example, an authority, a celebrity, their spouse).
People who are more likely to engage in significant violence include the following:
Those who use alcohol or illicit drugs
Those with delusions that they are being persecuted
Those whose hallucinations command them to commit violent acts
Those who do not take their prescribed medications
However, even taking risk factors into account, doctors find it difficult to accurately predict whether a given person with schizophrenia will commit a violent act.
Diagnosis of Schizophrenia
A doctor’s evaluation, based on standard psychiatric diagnostic criteria
A physical examination and sometimes medical tests to evaluate for physical disorders
No definitive laboratory test exists to diagnose schizophrenia. A doctor makes the diagnosis based on a comprehensive assessment of a person’s history and symptoms.
Schizophrenia is diagnosed when all of the following are present:
Two or more characteristic symptoms (delusions, hallucinations, disorganized speech, disorganized behavior, negative symptoms), with at least one of the symptoms being delusions, hallucinations, or disorganized speech.
These symptoms cause deterioration in work, school, or social functioning from the onset of the illness.
These symptoms of illness are continuous for at least 6 months.
Information from family members, friends, or teachers is often important in establishing when the disorder began.
Laboratory tests are often done to rule out a substance use disorder or an underlying medical, neurologic, or hormonal disorder, that can have features of psychosis. Examples of such disorders include brain tumors, temporal lobe epilepsy, thyroid disorders, autoimmune disorders, Huntington disease, liver disorders, side effects of drugs, and vitamin deficiencies. Testing for substance use disorder is sometimes done.
Imaging tests of the brain, such as computed tomography (CT) or magnetic resonance imaging (MRI), may be done to rule out a brain tumor or another neurological condition. Although people with schizophrenia have brain abnormalities that may be seen on CT or MRI, the abnormalities are rarely specific enough to help in diagnosing schizophrenia.
In addition, doctors try to rule out a number of other mental illnesses that share features with schizophrenia, such as brief psychotic disorder, schizophreniform disorder, schizoaffective disorder, and schizotypal personality disorder.
Treatment of Schizophrenia
Antipsychotic medications
Rehabilitation and community support activities
Psychotherapy
Coordinated specialty care
Generally, treatment of schizophrenia aims
To reduce the severity of psychotic symptoms
To prevent the recurrence of symptomatic episodes and the associated deterioration in functioning
To provide support and thus enable people to function at the highest level possible
Early detection and early treatment have become the guiding principles for managing schizophrenia. The sooner treatment is started, the better the outcome.
Antipsychotic medications, rehabilitation and community support activities, and psychotherapy are the major components of treatment. Teaching family members about the symptoms and treatment of schizophrenia (family psychoeducation) helps provide support for them and helps health care practitioners maintain contact with the person who has schizophrenia.
Coordinated specialty care, which includes resilience training, personal and family therapy, addressing cognitive dysfunction, and supported employment, is an important aspect of psychosocial recovery.
For people with schizophrenia, the prognosis depends largely on taking medications as prescribed. Without medications, 65 to 80% of people have another episode within the first year after diagnosis. Medications taken consistently can reduce this percentage to about 30% and can lessen the severity of symptoms significantly in most people.
Despite the proven benefit of medications, half of people with schizophrenia do not take their prescribed medications. Some do not recognize their illness and resist taking medications. Others stop taking their medications because of unpleasant side effects. Memory problems, disorganization, or simply a lack of money prevents others from taking their medications.
If people are hospitalized for schizophrenia, after discharge from a hospital, those who do not take prescribed medications are very likely to be readmitted within the year. Taking medications as directed dramatically reduces the likelihood of being readmitted.
People are most likely to be consistent about taking their medications when specific barriers are addressed. If side effects of medications are a major problem, a change to a different medication may help. A consistent, trusting relationship with a doctor or other therapist helps some people with schizophrenia to accept their illness more readily and recognize the need for adhering to prescribed treatment.
Antipsychotic medications
Antipsychotic medications can be effective in reducing or eliminating symptoms, such as delusions, hallucinations, and disorganized thinking. After the immediate symptoms have cleared, the continued use of antipsychotic medications substantially reduces the probability of future episodes. However, antipsychotic medications have significant side effects, which can include drowsiness, muscle stiffness, tremors, involuntary movements (for example, tardive dyskinesia), weight gain, and restlessness. Second-generation antipsychotic medications, which are prescribed most often, are less likely to cause muscle stiffness, tremors, and tardive dyskinesia than first-generation antipsychotic medications.
Rehabilitation programs and community support activities
Rehabilitation and support programs, such as on-the-job coaching, are directed at teaching people the skills they need to live in the community, rather than in an institution. These skills enable people with schizophrenia to work, shop, care for themselves, manage a household, and get along with others.
Community support services provide services that enable people with schizophrenia to live as independently as possible. These services include a supervised apartment or group home where a staff member is present to ensure that a person with schizophrenia takes medications as prescribed or to help the person with finances. Or a staff member may visit the person's home periodically.
Hospitalization may be needed during severe relapses, and involuntary hospitalization may be needed if people pose a danger to themselves or others. However, the general goal is to have people live in the community.
A few people with schizophrenia are unable to live independently, either because they have severe, persistent symptoms or because medication therapy has not been effective. They usually require full-time care in a safe and supportive setting.
Support and advocacy groups, such as the National Alliance on Mental Illness, are often helpful to families.
Psychotherapy
Psychotherapy can be helpful to alleviate some symptoms, such as depression and psychosis. It is important to establish a collaborative relationship between people with schizophrenia, their family members, and a doctor. That way, people may learn to understand and manage their disorder, to take antipsychotic medications as prescribed, and to manage stresses that can aggravate the disorder. A good doctor-patient relationship is often a major determinant of whether treatment is successful.
If people with schizophrenia live with their families, they and their family members may be offered psychoeducation. This training provides people and their family members with information about the disorder and about ways to manage it—for example, by teaching them coping skills. This training can help prevent relapses.
Prognosis for Schizophrenia
Over longer periods, the prognosis varies across people, roughly as follows:
About 15 to 25% of people with schizophrenia achieve significant and lasting improvement.
About one-third achieve some improvement with intermittent relapses and residual disabilities.
About 40% experience severe and permanent incapacity.
Only 15 to 25% of all people with schizophrenia are able to function as well as they could before schizophrenia developed.
Factors associated with a better prognosis include the following:
Sudden onset of symptoms
Older age when symptoms start
A good level of skills and accomplishments before becoming ill
Minimal cognitive impairment
Presence of only a few negative symptoms (such as reduced expression of emotions)
A shorter time between the first psychotic episode and treatment
Factors associated with a poor prognosis include the following:
Younger age when symptoms start
Problems functioning in social situations and at work before becoming ill
A family history of schizophrenia
Presence of many negative symptoms
A longer time between the first psychotic episode and treatment
The presence of other psychiatric disorders, particularly obsessive-compulsive disorder
Men have a poorer prognosis than women, though this is not consistent in all studies. Women respond better to treatment with antipsychotic medications.
More Information
The following English-language resources may be useful. Please note that The Manual is not responsible for the content of this resource.
