Schizophrenia: what is it, symptoms, testing

Schizophrenia can be a debilitating condition, making it difficult to function with your normal daily activities. The disease can also be distressing for loved ones who may not know how to help. Luckily, treatment is available to manage your symptoms, and support groups exist to help involve family members in your care. 

Only about 0.6–1.9% of the population has schizophrenia, but the public health impact is immense (Hany, 2020). Direct costs for health and social care and high unemployment rates make schizophrenia a significant concern for patients, family members, and society (Owen, 2016). 

Despite stereotypical portrayals in movies, people with schizophrenia are not often violent and do not have a “split-personality” disorder. Schizophrenia can result in a wide range of symptoms, and not all people present the same way. Here’s what you should know about this condition and what treatment options are available. 

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Schizophrenia is a serious mental illness involving a disconnect from reality. It’s a chronic condition that can cycle through periods of hallucinations, delusions, and disorganized speech (SAMHSA, 2016). Patients with schizophrenia often struggle to function at work or school and have difficulties with social situations and relationships (Patel, 2014).

Schizophrenia is typically diagnosed early in adulthood. Men tend to have an earlier onset, experiencing their first psychotic episode in their early 20s. Women are commonly diagnosed in their late 20s or early 30s. People will often show signs of social withdrawal years before their first episode, although some people have no warning signs (Patel, 2014). 

Symptoms of schizophrenia are divided into three main categories: positive symptoms, negative symptoms, and cognitive impairments. Let’s take a look at each of these and see how they might present: 

Positive symptoms

Positive symptoms (also known as psychotic symptoms) involve losing touch with reality. These symptoms tend to come and go during periods of relapse and remission, but some people experience them chronically (Owen, 2016). Positive, in this case, doesn’t mean “good,” but rather, the addition of specific symptoms, including hallucinations, delusions, and disorganized thinking (Picchioni, 2007):

• Hallucinations are when you perceive something that is not there. Hallucinations can affect any of the five senses (sight, sound, smell, taste, or touch). Most often, though, they occur as auditory hallucinations, such as hearing voices. 

• Delusions are firmly held, false beliefs, despite evidence proving otherwise. Delusions may cause you to feel that there is a threat or conspiracy against you. You may believe that someone or something is controlling your thoughts or actions. Other common delusions involve feeling an inflated sense of importance or believing you possess special powers. 

• Disorganized thinking results in speech that does not make sense or is hard to follow. 

Negative symptoms

While positive symptoms are the addition of certain behaviors or thoughts, negative symptoms are the absence of certain parts of normal functioning. Negative symptoms are often chronic and can involve (Patel, 2014; Picchioni, 2007):

• Decreased emotional expression 

• Inability to find pleasure in normal daily activities 

• Lack of motivation or initiative 

• Neglecting to take care of yourself

• Social withdrawal 

• Speaking slowly or not at all 

Cognitive impairment symptoms

Cognitive impairment, like negative symptoms, tends to be chronic. People may experience problems with attention, memory, following conversations, planning, and making decisions (Bowie, 2006). 

People with schizophrenia often have substance use problems involving alcohol, tobacco, or illicit drugs. Other mental health disorders, such as anxiety, depression, or obsessive-compulsive disorder (OCD), can happen alongside schizophrenia and often make symptoms worse (Patel, 2014).

Unfortunately, people with schizophrenia often lack awareness of their illness and may not believe they are sick (Patel, 2014). This makes sticking to medications and other treatments a challenge. 

The exact cause of schizophrenia is unknown. Researchers believe it may be due to an imbalance of certain neurotransmitters or chemicals, in the brain, including dopamine. The way the brain develops, and changes in the brain structure, may also be involved (Hany, 2020).

Risks for schizophrenia include both genetic and environmental factors. Family history plays a significant role. The chance of developing schizophrenia is 10% if a first-degree relative also has the condition. The risk jumps to 40% if both parents are affected (Hany, 2020). Babies born to mothers who experienced certain complications during pregnancy, including some infections, are at increased risk (Patel, 2014). 

A healthcare provider makes a diagnosis of schizophrenia based on symptoms. There is no diagnostic test, such as a blood test, to determine if you have schizophrenia. A psychiatrist or other mental health professional will perform an evaluation that examines your history and mental state (Owen, 2016).

The DSM-5—a manual created by the American Psychiatric Association—requires the following for a diagnosis of schizophrenia (Patel, 2014):

• Two or more of the following symptoms must be present for a significant portion of one month. One of the symptoms must be delusions, hallucinations, or disorganized speech:

  • Delusions

  • Hallucinations

  • Disorganized speech 

  • Grossly disorganized or catatonic behavior (i.e., acting inappropriately or childlike, not moving, not talking) 

  • Negative symptoms (i.e., decreased emotional expression, lack of motivation) 

• The person must also have trouble with social relationships, self-care, or functioning at work for at least six months. 

• Other conditions that can cause psychosis must be ruled out. 

Your healthcare provider will perform blood work and scans (such as an MRI or CT scan) to test for other conditions that might be causing your symptoms. These include mental health conditions, such as bipolar disorder or depressive disorder with psychosis, medical conditions like syphilis or brain tumors, or substance abuse disorders (Hany, 2020; SAMHSA, 2016).  

Antipsychotics are a vital part of schizophrenia treatment. These medications treat the positive symptoms of schizophrenia and should be started as soon as possible. Unfortunately, they don’t treat some of the negative symptoms or cognitive dysfunctions that occur (Stępnicki, 2018). Participating in psychotherapy (talk therapy) and psychosocial programs can help manage these symptoms. 

The acute or immediate phase of treatment involves returning the person to their baseline function, decreasing hostility, and normalizing eating and sleeping habits (Patel, 2014). Treatment during the maintenance phase aims to prevent a recurrence, maximize functioning, and improve quality of life (APA, 2021).  

Most patients require lifelong treatment for schizophrenia. Both medication and psychotherapy, along with the support of loved ones, can help you keep your symptoms under control (Patel, 2014).  

Medication therapy 

Antipsychotic medications are essential for treating schizophrenia. These medications work, in part, by affecting dopamine in the brain. Antipsychotics help treat the positive symptoms of schizophrenia, such as hallucinations and delusions (Patel, 2014). 

Antipsychotic medications are divided into two groups: 

• First-generation (or typical) antipsychotics (FGA): Examples include fluphenazine, haloperidol (brand name Haldol), and perphenazine. 

• Second-generation (or atypical) antipsychotics (SGA): Examples include aripiprazole (brand name Abilify), brexpiprazole (brand name Rexulti), and lurasidone (brand name Latuda). 

FGAs and SGAs differ primarily based on their side effects. FGAs cause more movement disorders, including restlessness, involuntary muscle contractions, tremor, and stiffness. Tardive dyskinesia, a potentially permanent movement disorder that leads to jerky movements of the face and body, can also occur. SGAs cause more metabolic effects, such as weight gain, increased cholesterol, and an increased risk of developing diabetes. SGAs are generally preferred over FGAs since the movement side effects of FGAs can be particularly bothersome (Patel, 2014). 

Several other side effects may occur. Some antipsychotics are more likely to cause certain side effects than others. You and your healthcare professional will work together to select your best treatment option. Antipsychotics may cause (Hany, 2020; Patel, 2014):

• Allergic reactions

• Blurred vision 

• Constipation 

• Decreased white blood cells

• Difficulty regulating body temperature 

• Difficulty urinating 

• Dizziness, especially when standing from a seated position 

• Dry mouth 

• Effects on the heart 

• Glaucoma and other eye problems

• Increased risk of seizures 

• Liver problems 

• Low blood pressure

• Rapid heart rate 

• Sensitivity to the sun, increasing your chance of sunburn

• Sexual dysfunction 

• Tiredness (very common)

Clozapine (brand name Clozaril) is an SGA that helps treat resistant cases of schizophrenia. It is reserved for tough-to-treat cases since it can cause several serious side effects. These include lowering white blood cell levels and increasing your risk of infection. For this reason, people taking clozapine require routine monitoring and blood work (Novartis, 2014). 

Treatment-resistant schizophrenia can occur when your symptoms persist despite having tried several different antipsychotics. For these cases, your healthcare provider may recommend adding electroconvulsive therapy or a mood-stabilizing medication (such as lamotrigine) to your antipsychotic regimen (Hany, 2020). 

When you have schizophrenia, it can be hard to remember to take your medication each day. Sometimes the disease itself can make you feel like you don’t need treatment. Fortunately, several antipsychotics are available in long-acting injectable form. These only need to be administered every 2–12 weeks, depending on the product (Patel, 2014).

Psychosocial therapy 

Psychosocial therapies use various methods to help prevent relapse and control symptoms. They work particularly well for negative and cognitive symptoms and help the person regain the skills needed for daily activities, social interactions, and school or work. Psychosocial therapies can include cognitive behavioral therapy, family interventions and education, and social skills training (Chien, 2013). 

Family involvement and education can provide significant benefits. Studies have shown that treatment involving a family support system helps reduce hospitalizations and improve social functioning. Family members can also help monitor the person for symptoms and report any adverse reactions to medications (Patel, 2014).

Schizophrenia can be a challenging condition, not only for the person going through it, but also for their loved ones. Beginning treatment promptly and continuing treatment consistently is essential. Family members or friends can help recognize changes in their loved one’s behavior to encourage them to seek care. 

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Current version

June 04, 2021

Written by

Christina Varvatsis, PharmD

Fact checked by

Steve Silvestro, MD

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About the medical reviewer

Steve Silvestro, MD, Ro

Dr. Steve Silvestro is a board-certified pediatrician and Associate Director, Clinical Content & Education at Ro.