Schizophrenia

What it's like

The three kinds of symptom, the quiet signs that often come first, and what it isn't.

Positive symptoms: experiences added

• Voices: Hearing things that aren't there is the most common hallucination. The voices are often rude, critical or abusive, though some people find them friendly.
• Other hallucinations: Seeing, smelling, tasting or feeling things that aren't there.
• Delusions: Unusual beliefs held with complete conviction, such as being followed, watched or poisoned.
• Confused thinking: Thoughts that feel misty or hazy, trouble keeping track of a conversation, and speech that comes out jumbled.

Negative and cognitive symptoms: things lost

• Withdrawing: Avoiding people, including friends.
• Flat: Feeling emotionally disconnected and flat.
• Self-care: Washing, eating and looking after yourself slipping.
• Thinking: Trouble with attention, concentration and memory.

The quiet signs often come first

Withdrawal and changes in sleep can begin months or years before a first episode, often in the teenage years, and are easy to mistake for an ordinary phase of adolescence or for laziness. Other warning signs: suspicious or paranoid ideas, trouble thinking clearly, confused speech and a sudden drop in grades or work.

• Myth: Schizophrenia means a split personality. In fact: People with schizophrenia don't have a split personality. What's disrupted is the sense of what's real: what you perceive and what you believe.
• Myth: People with schizophrenia are dangerous. In fact: It doesn't usually make people violent, and most people who have psychotic episodes are no danger to others. Treatment lowers what risk there is.
• Myth: You never get better. In fact: Many people recover, though symptoms can return, and recovery is now seen as a realistic possibility.
• Myth: Cannabis is harmless here. In fact: Daily cannabis use was linked to about three times the odds of a psychotic disorder, and daily high-potency cannabis to nearly five times.

What's happening in the brain

Dopamine running high, voices built from the brain's own speech machinery, and a planner that struggles. The model lights each one as you read.

Dopamine, running high

In brain scans of hundreds of patients, the striatum makes and releases markedly more dopamine than usual: the largest chemical difference found in schizophrenia. Every antipsychotic works by blocking dopamine's effects, though the drugs block its receptors rather than that excess at its source.

Where voices come from

Scanned while hearing voices, people's brains were most active in Broca's area, which produces speech, in the temporal gyri that perceive it, in the insula, and in the hippocampus and the memory areas around it — the areas that produce and hear real speech, and remember words.

The planner, struggling

During tasks that take planning, working memory and self-control, the dorsolateral prefrontal cortex, the anterior cingulate and part of the thalamus work less than in other people. The cognitive symptoms — trouble with attention, concentration and memory — are part of the illness too.

Small differences in structure

Comparing over 2,000 people with schizophrenia with over 2,500 without, the hippocampus was smaller on average, more than any other structure below the cortex, along with the amygdala and thalamus, while the fluid-filled ventricles were larger. These are small differences between group averages, and the two groups overlap heavily.

Why it happens

Mostly genes, with a push from the environment.

• ~80% heritability: In twin studies, heritability was 81%.
• 1 in 100 people develop it: As many as one person in a hundred may experience schizophrenia.
• ~5× the odds, with daily strong cannabis: Daily use of cannabis with 10% THC or more.

No one cause has been found. Risk is higher when a close family member has it; on top of genes, cannabis use in youth, social hardship or trauma (especially in childhood), problems in brain development around birth, and growing up in a city all add to it. Stressful events and drugs can then trigger an episode in someone vulnerable.

Of these, cannabis is the one a person can change. Across 11 European sites, an estimated 12% of first episodes of psychosis would have been prevented without high-potency cannabis: 30% in London and 50% in Amsterdam.

What helps

Medication to calm the symptoms and prevent relapse, and therapy and support to rebuild a life.

• Antipsychotic medication (Usually the first treatment; it blocks the effect of dopamine.): Anxiety can ease within hours, but voices and delusions take days or weeks. Staying on one cut relapse within a year from 64% to 27%, and hospital readmission from 26% to 10%.
• Clozapine (For schizophrenia that hasn't responded to other antipsychotics.): In people for whom other drugs hadn't worked, 30% improved on clozapine against 4% on an older drug.
• Early, team-based care (Medication, family education, therapy, and help back into school or work, together.): For a first episode it improved quality of life, symptoms and getting back to work or school more than usual care, and most for people treated sooner.
• Talking and family therapy (CBT, family therapy, arts therapies.): CBT can help a person recognise delusional thinking and not act on it; family therapy covers the illness, practical problems and crisis plans; arts therapies can ease negative symptoms in some people.
• Stopping medication suddenly (Without talking to the care team.): Symptoms can come back. Most people take an antipsychotic for 1–2 years after a first episode, longer if it returns.

Side effects are real, and worth raising

Antipsychotics can cause drowsiness, weight gain and lower sex drive, and older ones shaking and muscle spasms; cholesterol, blood sugar and blood pressure may need checking. If one doesn't help after several weeks, or the side effects are too much, another can be tried.

Day to day

• Keep taking medication even when well.
• Keep regular sleep, food and exercise, and avoid alcohol and drugs, which can trigger psychosis.
• Have a physical check-up every year. On average, people with schizophrenia live about 15 years less.
• Write a crisis plan while well: your early warning signs, what to do, and who to call.

Supporting someone

What to say when someone hears voices or holds a belief you can't share.

• Instead of "That's not real. You're imagining it.", try "I can't hear it, but I can see it's really upsetting you. What's it saying?". Delusions are held with complete conviction, so arguing rarely changes them. The fear is real even when the threat isn't, and that's where you can help.
• Instead of "Pull yourself together.", try "This isn't your fault. Can we call your care team together?". Blame and being told to pull yourself together don't help; support and encouraging treatment do.
• Instead of "You've been fine for months — you don't need those pills anymore.", try "You've been doing really well. Let's ask the doctor before changing anything.". Stopping antipsychotics without the care team can bring symptoms back.

Watch for a relapse coming

• Sleeping badly, eating less, more anxious.
• Growing suspicious, worrying about people's motives.
• Hearing quiet voices, finding it hard to concentrate.

Look after yourself too: supporting someone through psychosis is hard, and carers' support services exist for exactly this.

When to get help

Act early: the sooner treatment starts, the better.

See a doctor if someone…

• Has become suspicious or paranoid, or is withdrawing from everyone.
• Is hearing or seeing things others don't.
• Has stopped looking after themselves, or their grades or work have suddenly dropped.
• Is speaking in a confused way, or can't think clearly.

When it's an emergency

About 1 in 20 people with schizophrenia die by suicide, most often near the start of the illness. Warning signs include talking about death, giving possessions away, self-harm, or a sudden lift in mood. If you're worried, ask directly: asking about suicide doesn't put the idea there. If someone is in danger, stay with them, remove anything they could hurt themselves with, and get help now.

Put it into practice

Five real situations. Choose what you'd do, and see why.

• Your friend tells you, frightened, that the neighbours have put cameras in his walls and are poisoning his water. What's most likely to help right now? Take the fear seriously without agreeing it's true, and help him get to a doctor. Delusions are held with complete conviction, and early treatment often means better recovery.
• A classmate says schizophrenia means having two personalities. Is that right? No — it's a disrupted sense of what's real, not split personalities. People with schizophrenia don't have a split personality; psychosis is a loss of contact with reality.
• Your brother, 17, has been smoking strong weed every day. He's become withdrawn and says people are talking about him. What does the research say? Daily high-potency cannabis is linked to nearly five times the odds of psychosis, and these are warning signs worth a doctor's visit. Daily use of strong cannabis carried an odds ratio of 4.8; withdrawal and paranoid ideas are warning signs of psychosis.
• Someone hearing voices is scanned in an MRI while the voices are speaking. What lights up? The brain's own speech areas: Broca's area and the temporal gyri that perceive speech. Activity during voices was highest in Broca's area, the temporal gyri, the insula and the hippocampus.
• Your cousin has been well on an antipsychotic for eight months and wants to stop because she gained weight. What's the best advice? Talk to her care team: the weight gain is a real side effect, another drug may suit her better, and stopping alone risks relapse. Another antipsychotic can be tried, and stopping without the care team can bring symptoms back. Off medication, relapse in a year was 64% against 27% on it.