Overview

Schizophrenia is a severe long-term mental health condition. It causes a range of different psychological symptoms.

Doctors often describe schizophrenia as a type of psychosis. This means the person may not always be able to distinguish their own thoughts and ideas from reality.

Title
Schizophrenia

Types
Symptoms

Schizophrenia changes how a person thinks and behaves.

The condition may develop slowly. The first signs can be hard to identify as they often develop during the teenage years.

Symptoms such as becoming socially withdrawn and unresponsive or changes in sleeping patterns can be mistaken for an adolescent "phase".

People often have episodes of schizophrenia, during which their symptoms are particularly severe, followed by periods where they experience few or no symptoms. This is known as acute schizophrenia.

Positive and negative symptoms

The symptoms of schizophrenia are usually classified into:

  • positive symptoms – any change in behaviour or thoughts, such as hallucinations or delusions
  • negative symptoms – a withdrawal or lack of function that you would not usually expect to see in a healthy person; for example, people with schizophrenia often appear emotionless and flat
Hallucinations

Hallucinations are where someone sees, hears, smells, tastes or feels things that don't exist outside their mind. The most common hallucination is hearing voices.

Hallucinations are very real to the person experiencing them, even though people around them can't hear the voices or experience the sensations.

Research using brain-scanning equipment shows changes in the speech area in the brains of people with schizophrenia when they hear voices. These studies show the experience of hearing voices as a real one, as if the brain mistakes thoughts for real voices.

Some people describe the voices they hear as friendly and pleasant, but more often they're rude, critical, abusive or annoying.

The voices might describe activities taking place, discuss the hearer's thoughts and behaviour, give instructions, or talk directly to the person. Voices may come from different places or one place in particular, such as the television.

Delusions

A delusion is a belief held with complete conviction, even though it's based on a mistaken, strange or unrealistic view. It may affect the way the person behaves. Delusions can begin suddenly, or may develop over weeks or months.

Some people develop a delusional idea to explain a hallucination they're having. For example, if they have heard voices describing their actions, they may have a delusion that someone is monitoring their actions.

Someone experiencing a paranoid delusion may believe they're being harassed or persecuted. They may believe they're being chased, followed, watched, plotted against or poisoned, often by a family member or friend.

Some people who experience delusions find different meanings in everyday events or occurrences.

They may believe people on TV or in newspaper articles are communicating messages to them alone, or that there are hidden messages in the colours of cars passing on the street.

 

Confused thoughts (thought disorder)

 

People experiencing psychosis often have trouble keeping track of their thoughts and conversations.

Some people find it hard to concentrate and will drift from one idea to another. They may have trouble reading newspaper articles or watching a TV programme.

People sometimes describe their thoughts as "misty" or "hazy" when this is happening to them. Thoughts and speech may become jumbled or confused, making conversation difficult and hard for other people to understand.

Changes in behaviour and thoughts

A person's behaviour may become more disorganised and unpredictable, and their appearance or dress may seem unusual to others.

People with schizophrenia may behave inappropriately or become extremely agitated and shout or swear for no reason.

Some people describe their thoughts as being controlled by someone else, that their thoughts aren't their own, or that thoughts have been planted in their mind by someone else.

Another recognised feeling is that thoughts are disappearing, as though someone is removing them from their mind.

Some people feel their body is being taken over and someone else is directing their movements and actions.

Negative symptoms of schizophrenia

The negative symptoms of schizophrenia can often appear several years before somebody experiences their first acute schizophrenic episode.

These initial negative symptoms are often referred to as the prodromal period of schizophrenia.

Symptoms during the prodromal period usually appear gradually and slowly get worse.

They include the person becoming more socially withdrawn and increasingly not caring about his or her appearance and personal hygiene.

It can be difficult to tell whether the symptoms are part of the development of schizophrenia or caused by something else.

Negative symptoms experienced by people living with schizophrenia include:

  • losing interest and motivation in life and activities, including relationships and sex
  • lack of concentration, not wanting to leave the house, and changes in sleeping patterns
  • being less likely to initiate conversations and feeling uncomfortable with people, or feeling there's nothing to say

The negative symptoms of schizophrenia can often lead to relationship problems with friends and family as they can sometimes be mistaken for deliberate laziness or rudeness.

Psychosis

Schizophrenia is often described by doctors as a type of psychosis.

A first acute episode of psychosis can be very difficult to cope with, both for the person who is ill and for their family and friends.

Drastic changes in behaviour may occur, and the person can become upset, anxious, confused, angry or suspicious of those around them.

They may not think they need help, and it can be hard to persuade them to visit a doctor.

Causes

The exact causes of schizophrenia are unknown. Research suggests a combination of physical, genetic, psychological and environmental factors can make a person more likely to develop the condition.

Some people may be prone to schizophrenia, and a stressful or emotional life event might trigger a psychotic episode. However, it's not known why some people develop symptoms while others don't.

Increased risk

Things that increase the chances of schizophrenia developing include:

Genetics

Schizophrenia tends to run in families, but no single gene is thought to be responsible.

It's more likely that different combinations of genes make people more vulnerable to the condition. However, having these genes doesn't necessarily mean you'll develop schizophrenia.

Evidence that the disorder is partly inherited comes from studies of twins. Identical twins share the same genes.

In identical twins, if one twin develops schizophrenia, the other twin has a one in two chance of developing it, too. This is true even if they're raised separately.

In non-identical twins, who have different genetic make-ups, when one twin develops schizophrenia, the other only has a one in seven chance of developing the condition.

While this is higher than in the general population, where the chance is about 1 in 100, it suggests genes aren't the only factor influencing the development of schizophrenia.

Brain development

Studies of people with schizophrenia have shown there are subtle differences in the structure of their brains.

These changes aren't seen in everyone with schizophrenia and can occur in people who don't have a mental illness. But they suggest schizophrenia may partly be a disorder of the brain.

Neurotransmitters

Neurotransmitters are chemicals that carry messages between brain cells.

There's a connection between neurotransmitters and schizophrenia because drugs that alter the levels of neurotransmitters in the brain are known to relieve some of the symptoms of schizophrenia.

Research suggests schizophrenia may be caused by a change in the level of two neurotransmitters: dopamine and serotonin.

Some studies indicate an imbalance between the two may be the basis of the problem. Others have found a change in the body's sensitivity to the neurotransmitters is part of the cause of schizophrenia.

Pregnancy and birth complications

Research has shown people who develop schizophrenia are more likely to have experienced complications before and during their birth, such as:

  • a low birth weight
  • premature labour
  • a lack of oxygen (asphyxia) during birth

It may be that these things have a subtle effect on brain development.

Triggers

Triggers are things that can cause schizophrenia to develop in people who are at risk.

These include:

Stress

The main psychological triggers of schizophrenia are stressful life events, such as:

  • bereavement
  • losing your job or home
  • divorce
  • the end of a relationship
  • physical, sexual or emotional abuse

These kinds of experiences, although stressful, don't cause schizophrenia. However, they can trigger its development in someone already vulnerable to it.

Drug abuse

Drugs don't directly cause schizophrenia, but studies have shown drug misuse increases the risk of developing schizophrenia or a similar illness.

Certain drugs, particularly cannabis, cocaine, LSD or amphetamines, may trigger symptoms of schizophrenia in people who are susceptible.

Using amphetamines or cocaine can lead to psychosis, and can cause a relapse in people recovering from an earlier episode.

Three major studies have shown teenagers under 15 who use cannabis regularly, especially "skunk" and other more potent forms of the drug, are up to four times more likely to develop schizophrenia by the age of 26.

Diagnosis

There's no single test for schizophrenia and the condition is usually diagnosed after assessment by a specialist in mental health.

If you're concerned you may be developing symptoms of schizophrenia, see your GP as soon as possible. The earlier schizophrenia is treated, the better.

Your GP will ask about your symptoms and check they're not the result of other causes, such as recreational drug use.

Community mental health team

If a diagnosis of schizophrenia is suspected, your GP should refer you promptly to your local community mental health team (CMHT).

CMHTs are made up of different mental health professionals who support people with complex mental health conditions.

A member of the CMHT team, usually a psychiatrist or a specialist nurse, will carry out a more detailed assessment of your symptoms. They'll also want to know your personal history and current circumstances.

To make a diagnosis, most mental healthcare professionals use a diagnostic checklist.

Schizophrenia can usually be diagnosed if:

  • you've experienced one or more of the following symptoms most of the time for a month: delusions, hallucinations, hearing voices, incoherent speech, or negative symptoms, such as a flattening of emotions
  • your symptoms have had a significant impact on your ability to work, study or perform daily tasks
  • all other possible causes, such as recreational drug use or bipolar disorder, have been ruled out
Related illnesses

Sometimes it might not be clear whether someone has schizophrenia. If you have other symptoms at the same time, a psychiatrist may have reason to believe you have a related mental illness, such as:

  • bipolar disorder (manic depression) – people with bipolar disorder swing from periods of elevated moods and extremely active, excited behaviour (mania) to periods of deep depression; some people also hear voices or experience other kinds of hallucinations, or may have delusions
  • schizoaffective disorder – this is often described as a form of schizophrenia because its symptoms are similar to schizophrenia and bipolar disorder, but schizoaffective disorder is a mental illness in its own right; it may occur just once in a person's life, or come and go and be triggered by stress

You should also be assessed for post-traumatic stress disorder, depression, anxiety and substance misuse.

Getting help for someone else

As a result of their delusional thought patterns, people with schizophrenia may be reluctant to visit their GP if they believe there's nothing wrong with them.

It's likely someone who has had acute schizophrenic episodes in the past will have been assigned a care co-ordinator. If this is the case, contact the person's care co-ordinator to express your concerns.

If someone is having an acute schizophrenic episode for the first time, it may be necessary for a friend, relative or another loved one to persuade them to visit their GP.

In the case of a rapidly worsening schizophrenic episode, you may need to go to the accident and emergency (A&E) department, where a duty psychiatrist will be available.

If a person who is having an acute schizophrenic episode refuses to seek help, their nearest relative can request that a mental health assessment is carried out. The social services department of your local authority can advise how to do this.

In severe cases, people can be compulsorily detained in hospital for assessment and treatment under the Mental Health Act (2007).

 

After diagnosis

If you or a friend or relative are diagnosed with schizophrenia, you may feel anxious about what will happen. You may be worried about the stigma attached to the condition, or feel frightened and withdrawn.

It's important to remember that a diagnosis can be a positive step towards getting good, straightforward information about the illness and the kinds of treatment and services available.

Treatment

Schizophrenia is usually treated with an individually tailored combination of therapy and medication.

Most people with schizophrenia are treated by community mental health teams (CMHTs).

The goal of the CMHT is to provide day-to-day support and treatment while ensuring you have as much independence as possible.

A CMHT can be made up of and provide access to:

  • social workers
  • community mental health nurses – who have specialist training in mental health conditions
  • occupational therapists
  • pharmacists
  • counsellors and psychotherapists
  • psychologists and psychiatrists – the psychiatrist is usually the senior clinician in the team

After your first episode of schizophrenia, you should initially be referred to an early intervention team.

These specialist teams provide treatment and support, and are usually made up of psychiatrists, psychologists, mental health nurses, social workers and support workers.

Care programme approach (CPA)

People with complex mental health conditions are usually entered into a treatment process known as a care programme approach (CPA). A CPA is essentially a way of ensuring you receive the right treatment for your needs.

There are four stages to a CPA:

  • assessment – your health and social needs are assessed
  • care plan – a care plan is created to meet your health and social needs
  • key worker appointed – a key worker, usually a social worker or nurse, is your first point of contact with other members of the CMHT
  • reviews – your treatment will be regularly reviewed and, if needed, changes to the care plan can be agreed

Not everyone uses the CPA. Some people may be cared for by their GP, while others may be under the care of a specialist.

  1. work together with your healthcare team to develop a care plan. The care plan may involve an advance statement or crisis plan, which can be followed in an emergency.

Your care plan should include a combined healthy eating and physical activity programme and support for giving up smoking, if you smoke.

Your care co-ordinator will be responsible for making sure all members of your healthcare team, including your GP, have a copy of your care plan.

Acute episodes

People who have serious psychotic symptoms as the result of an acute schizophrenic episode may require a more intensive level of care than a CMHT can provide.

These episodes are usually dealt with by antipsychotic medication and special care.

Crisis resolution teams (CRT)

One treatment option is to contact a home treatment or crisis resolution team (CRT). CRTs treat people with serious mental health conditions who are currently experiencing an acute and severe psychiatric crisis.

Without the involvement of the CRT, these people would require treatment in hospital.

The CRT aims to treat people in the least restrictive environment possible, ideally in or near their home. This can be in your own home, in a dedicated crisis residential home or hostel, or in a day care centre.

CRTs are also responsible for planning aftercare once the crisis has passed to prevent a further crisis occurring.

Your care co-ordinator should be able to provide you and your friends or family with contact information in the event of a crisis.

Voluntary and compulsory detention

More serious acute schizophrenic episodes may require admission to a psychiatric ward at a hospital or clinic. You can admit yourself voluntarily to hospital if your psychiatrist agrees it's necessary.

People can also be compulsorily detained at a hospital under the Mental Health Act (2007), but this is rare.

It's only possible for someone to be compulsorily detained at a hospital if they have a severe mental disorder and if detention is necessary:

  • in the interests of the person's own health and safety
  • to protect others

People with schizophrenia who are compulsorily detained may need to be kept in locked wards.

All people being treated in hospital will stay only as long as is absolutely necessary for them to receive appropriate treatment and arrange aftercare.

An independent panel will regularly review your case and progress. Once they feel you're no longer a danger to yourself and others, you'll be discharged from hospital. However, your care team may recommend you remain in hospital voluntarily.

Advance statements

If it's felt there's a significant risk of future acute schizophrenic episodes occurring, you may want to write an advance statement.

An advance statement is a series of written instructions about what you would like your family or friends to do in case you experience another acute schizophrenic episode. You may also want to include contact details for your care co-ordinator.

If you want to make an advance statement, talk to your care co-ordinator, psychiatrist or GP.

Antipsychotics

Antipsychotics are usually recommended as the initial treatment for the symptoms of an acute schizophrenic episode. They work by blocking the effect of the chemical dopamine on the brain.

Antipsychotics can usually reduce feelings of anxiety or aggression within a few hours of use, but may take several days or weeks to reduce other symptoms, such as hallucinations or delusional thoughts.

It's important that your doctor gives you a thorough physical examination before you start taking antipsychotics, and that you work together to find the right one for you.

Antipsychotics can be taken orally as a pill, or be given as an injection known as a depot. Several slow-release antipsychotics are available. These require you to have one injection every two to four weeks.

You may only need antipsychotics until your acute schizophrenic episode has passed.

However, most people take medication for one or two years after their first psychotic episode to prevent further acute schizophrenic episodes occurring, and for longer if the illness is recurrent.

There are two main types of antipsychotics:

  • typical antipsychotics – the first generation of antipsychotics developed in the 1950s
  • atypical antipsychotics – newer-generation antipsychotics developed in the 1990s

The choice of antipsychotic should be made following a discussion between you and your psychiatrist about the likely benefits and side effects.

Both typical and atypical antipsychotics can cause side effects, although not everyone will experience them and the severity will differ from person to person.

The side effects of typical antipsychotics include:

  • shaking
  • trembling
  • muscle twitches
  • muscle spasms

Side effects of both typical and atypical antipsychotics include:

  • drowsiness
  • weight gain, particularly with some atypical antipsychotics
  • blurred vision
  • constipation
  • lack of sex drive
  • dry mouth

Tell your care co-ordinator, psychiatrist or GP if your side effects become severe. There may be an alternative antipsychotic you can take or additional medicines that will help you deal with the side effects.

If you don't benefit from one antipsychotic medication after taking it regularly for several weeks, an alternative can be tried. It's important to work with your treatment team to find the right one for you.

Don't stop taking your antipsychotics without first consulting your care co-ordinator, psychiatrist or GP. If you stop taking them, you could have a relapse of symptoms.

Your medication should be reviewed at least once a year.

Psychological treatment

Psychological treatment can help people with schizophrenia cope with the symptoms of hallucinations or delusions better.

They can also help treat some of the negative symptoms of schizophrenia, such as apathy or a lack of enjoyment.

Psychological treatments for schizophrenia work best when they're combined with antipsychotic medication.

Common psychological treatments include:

  • cognitive behavioural therapy (CBT)
  • family therapy
  • arts therapy
Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) aims to help you identify the thinking patterns that are causing you to have unwanted feelings and behaviour, and learn to replace this thinking with more realistic and useful thoughts.

For example, you may be taught to recognise examples of delusional thinking. You may then receive help and advice about how to avoid acting on these thoughts.

Most people require between 8 and 20 sessions of CBT over the space of 6 to 12 months. CBT sessions usually last for about an hour.

Your GP or care co-ordinator should be able to arrange a referral to a CBT therapist.

Family therapy

Many people with schizophrenia rely on family members for their care and support. While most family members are happy to help, caring for somebody with schizophrenia can place a strain on any family.

Family therapy is a way of helping you and your family cope better with your condition. It involves a series of informal meetings over a period of around six months.

Meetings may include:

  • discussing information about schizophrenia
  • exploring ways of supporting somebody with schizophrenia
  • deciding how to solve practical problems that can be caused by the symptoms of schizophrenia
Arts therapy
Prevention
Complications
Risks
Recovery
Living with

If schizophrenia is well managed, it's possible to reduce the chance of severe relapses.

This can include:

  • recognising the signs of an acute episode
  • taking medication as prescribed
  • talking to others about the condition

There are many charities and support groups offering help and advice on living with schizophrenia. Most people find it comforting talking to others with a similar condition.

Self-help