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Schizophrenia ˌskit-sə-ˈfrē-nē-ə

by S. Charles Schulz, MD

Schizophrenia is a mental disorder characterized by loss of contact with reality (psychosis), hallucinations (usually, hearing voices), firmly held false beliefs (delusions), abnormal thinking and behavior, reduced expression of emotions, diminished motivation, and problems in daily functioning, including work, social relationships, and self-care.

  • Schizophrenia is probably caused by hereditary 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 symptoms after they do tests to rule out other possible causes.

  • How well people do depends largely on whether they take the prescribed drugs as directed.

  • Treatment involves antipsychotic drugs, training programs and community support activities, and psychotherapy.

Schizophrenia is a major health problem throughout the world. The disorder typically strikes young people at the very time they are establishing their independence and can result in lifelong disability and stigma. In terms of personal and economic costs, schizophrenia has been described as among the worst disorders afflicting humankind.

Schizophrenia is a significant cause of disability worldwide. It affects about 1% of the population. Schizophrenia affects men and women equally. In the United States, schizophrenia accounts for about 1 of every 5 Social Security disability days and 2.5% of all health care expenditures. Schizophrenia is more common than Alzheimer disease and multiple sclerosis.

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 and slightly later for women. Onset during childhood or early adolescence is uncommon (see Childhood Schizophrenia). Onset is also uncommon late in life.

Deterioration in social functioning can lead to substance abuse, 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.

Did You Know...

  • Schizophrenia is more common than Alzheimer disease and multiple sclerosis.

  • Various disorders, including thyroid disorders, brain tumors, seizure disorders, and other mental health disorders, can cause symptoms similar to those of schizophrenia.

Causes

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 changes in the brain), not one caused by poor parenting or a mentally unhealthy environment.

People who have a parent or sibling with schizophrenia have about a 10% risk of developing the disorder, compared with a 1% risk among the general population. An identical twin whose co-twin has schizophrenia has about a 50% risk of developing schizophrenia. These statistics suggest that heredity is involved.

Other causes may include problems that occurred before, during, or after birth, such as influenza in the mother during the 2nd trimester of pregnancy, oxygen deprivation at birth, a low birth weight, and incompatibility of the mother’s and infant’s blood type.

Symptoms

The onset of schizophrenia may be sudden, over a period of days or weeks, or slow and insidious, over a period of years. Although the severity and types of symptoms vary among different people with schizophrenia, the symptoms are usually sufficiently severe as to interfere with the ability to work, interact with people, and care for oneself.

In some people with schizophrenia, mental function declines, leading to an impaired ability to pay attention, think in the abstract, and solve problems. The severity of mental 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. Drug use, including use of marijuana, may trigger or worsen symptoms as well.

Categories

Overall, the symptoms of schizophrenia fall into four major categories:

  • Positive symptoms

  • Negative symptoms

  • Disorganization

  • Cognitive impairment

People may have symptoms from one, two, or all categories.

Positive symptoms involve an excess or 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.

Negative symptoms involve a decrease in or loss of normal 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 one or two 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 ones.

  • Asociality refers to a lack of interest in relationships with other people. These negative symptoms are often associated with a general loss of motivation, sense of purpose, and goals.

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.

  • 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, display purposeless and unstimulated motor activity.

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, and decision making may be impossible.


Suicide

About 5 to 6% of people with schizophrenia commit suicide, about 20% attempt it, and many more have significant thoughts of suicide. Suicide is the major cause of premature death among people with schizophrenia and is one of the main reasons why schizophrenia reduces average life span by 10 years. Risk may be especially high for young men with schizophrenia and substance abuse. 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.


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 (eg, an authority, a celebrity, their spouse). People who are more likely to engage in significant violence include those who abuse drugs or alcohol, those with delusions that they are being persecuted, those whose hallucinations command them to commit violent acts, and those who do not take their prescribed drugs. 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

No definitive 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 two or more characteristic symptoms (delusions, hallucinations, disorganized speech, disorganized behavior, negative symptoms) persist for at least 6 months and cause significant deterioration in work, school, or social functioning. Information from family members, friends, or teachers is often important in establishing when the disorder began.

Laboratory tests are often done to rule out substance abuse 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, and side effects of drugs. Testing for drug abuse 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. Although people with schizophrenia have brain abnormalities that may be seen on CT or MRI, the abnormalities are not specific enough to help in diagnosing schizophrenia.

Did You Know...

  • About 5 to 6% of people with schizophrenia commit suicide.

Prognosis

The sooner treatment is started, the better the outcome.

For people with schizophrenia, the prognosis depends largely on adherence to drug treatment. Without drug treatment, 70 to 80% of people have another episode within the first year after diagnosis. Drugs taken continuously can reduce this percentage to about 30% and can lessen the severity of symptoms significantly in most people. After discharge from a hospital, people who do not take prescribed drugs are very likely to be readmitted within the year. Taking drugs as directed dramatically reduces the likelihood of being readmitted.

Despite the proven benefit of drug therapy, half of people with schizophrenia do not take their prescribed drugs. Some do not recognize their illness and resist taking drugs. Others stop taking their drugs because of unpleasant side effects. Memory problems, disorganization, or simply a lack of money prevents others from taking their drugs.

Adherence is most likely to improve when specific barriers are addressed. If side effects of drugs are a major problem, a change to a different drug 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.

Over longer periods, the prognosis varies. In general, one third of people achieve significant and lasting improvement, one third achieve some improvement with intermittent relapses and residual disabilities, and one third experience severe and permanent incapacity.

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

  • Presence of positive symptoms (such as delusions and hallucinations) rather than negative symptoms (such as reduced expression of emotions)

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 negative rather than positive symptoms

Treatment

Generally, treatment 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

Antipsychotic drugs, rehabilitation and community support activities, and psychotherapy are the major components of treatment.

Antipsychotic drugs

Drugs 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 drugs substantially reduces the probability of future episodes. However, antipsychotic drugs have significant side effects, which can include drowsiness, muscle stiffness, tremors, weight gain, and restlessness.

Antipsychotic drugs may also cause tardive dyskinesia, an involuntary movement disorder most often characterized by puckering of the lips and tongue or writhing of the arms or legs. Tardive dyskinesia may not go away even after the drug is stopped. For tardive dyskinesia that persists, there is no effective treatment.

A rare but potentially fatal side effect of antipsychotic drugs is neuroleptic malignant syndrome. It is characterized by muscle rigidity, fever, high blood pressure, and changes in mental function (such as confusion and lethargy).

Some newer antipsychotic drugs, termed second-generation antipsychotic drugs, have fewer side effects. The risk of tardive dyskinesia is significantly lower than with the conventional antipsychotics. However, some of these drugs seem to cause significant weight gain. Some also increase the risk of the metabolic syndrome (see Metabolic Syndrome). In this syndrome, fat accumulates in the abdomen, blood levels of triglycerides (a fat) are elevated, levels of high density cholesterol (HDL, the “good” cholesterol) are low, and blood pressure is high. Also, insulin is less effective (called insulin resistance ), increasing the risk of type 2 diabetes. These drugs may relieve positive symptoms (such as hallucinations), negative symptoms (such as lack of emotion), and cognitive impairment (such as reduced mental functioning and attention span). However, doctors are not sure whether they relieve symptoms to a greater extent than the older antipsychotic drugs.

Clozapine, the first of the second-generation antipsychotic drugs, is effective in up to half of people who do not respond to other antipsychotic drugs. However, clozapine can have serious side effects, such as seizures or potentially fatal suppression of bone marrow activity (which includes making blood cells). Thus, it is usually used only for people who have not responded to other antipsychotic drugs. People who take clozapine must have their white blood cell count measured weekly, at least for the first 6 months, so that clozapine can be stopped at the first indication that the number of white blood cells is decreasing.

Antipsychotic Drugs

Drug

Some Side Effects

Comments

Older antipsychotic drugs

Chlorpromazine

Fluphenazine

Haloperidol

Loxapine

Mesoridazine

Molindone

Perphenazine

Pimozide

Thioridazine

Thiothixene

Trifluoperazine

Dry mouth

Blurred vision

Seizures

Increased heart rate and decreased blood pressure

Constipation

Sudden but often reversible tremor and muscle stiffness that may progress to rigidity

Involuntary movements of the face and arms (tardive dyskinesia)

Muscle rigidity, fever, high blood pressure, and changes in mental function (neuroleptic malignant syndrome)

Side effects are much more likely in older people and in people with impaired balance or serious medical disorders.

Long-acting injectable forms of haloperidol and fluphenazine are available.

Eye examination and electrocardiography (ECG) are recommended while people are taking thioridazine.

Newer antipsychotic drugs

Aripiprazole

Asenapine

Clozapine

Iloperidone

Lurasidone

Olanzapine

Paliperidone

Quetiapine

Risperidone

Ziprasidone

Drowsiness and weight gain (most common), which can be substantial

Possibly an increased risk of accumulation of fat in the abdomen, abnormal cholesterol levels in the blood, high blood pressure, and resistance to the effects of insulin (metabolic syndrome)

Newer antipsychotic drugs are less likely to cause tremor, muscle stiffness, involuntary movements (including tardive dyskinesia), and neuroleptic malignant syndrome, but these effects may occur.

A long-acting injectable form is available for aripiprazole, olanzapine, and risperidone.

Clozapine is used much less often because it can cause bone marrow suppression, a reduced white blood cell count, and seizures. However, it is often effective in people who are not responsive to other drugs.

Clozapine and olanzapine are most likely to cause weight gain, and aripiprazole is the least likely.

Ziprasidone does not cause weight gain but may lead to abnormalities on an electrocardiogram.

Aripiprazole and ziprasidone are less likely to cause metabolic syndrome.


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 drugs 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 they lack the skills necessary to live in the community. They usually require full-time care in a safe and supportive setting.


Psychotherapy

Generally, psychotherapy does not lessen the symptoms of schizophrenia. However, psychotherapy can be helpful by establishing a collaborative relationship between people, their family members, and doctor. That way people may learn to understand and manage their disorder, to take antipsychotic drugs 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. Psychotherapy reduces the severity of symptoms in some people and helps prevent relapse in others.


Resources In This Article

Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • FANAPT
  • LATUDA
  • ABILIFY
  • ADASUVE
  • No US brand name
  • ORAP
  • NAVANE
  • INVEGA
  • No US brand names
  • HALDOL
  • GEODON
  • RISPERDAL
  • CLOZARIL
  • SEROQUEL
  • ZYPREXA