Characters with schizophrenia on TV and in movies are often depicted as violent, and news reports highlight unusual cases of people acting on violent delusions.
But the vast majority of people with schizophrenia will never do that, says UNC Health psychiatrist Fred Jarskog, MD. “People with schizophrenia are more likely to be the victims of violence than the aggressors.”
The small proportion of people with schizophrenia who are physically aggressive often haven’t been diagnosed and treated, or they’ve stopped treatment. But stigma can make seeking treatment difficult.
“It’s a diagnosis that carries a lot of baggage,” Dr. Jarskog says. “What’s not well understood is that medical treatment, especially in the early stages of the illness, is really quite good. It’s not curable, but most people will experience remission. There’s a good long-term prognosis, even if it’s tough in the beginning.”
Symptoms of Schizophrenia
Schizophrenia affects more than 3 million people in the U.S., though that’s believed to be a low estimate. Men are typically diagnosed in their late teens or early 20s and women in their 20s to early 30s.
While the exact cause is unknown, genetics, brain chemistry and environmental factors all play a role, and a family history of the disease is the main risk factor.
Symptoms of schizophrenia are typically described as “positive” or “negative,” but here, that doesn’t mean good or bad. Rather, a positive symptom denotes something that’s extra or additional compared to someone without the disorder. For schizophrenia, the positive symptoms include hallucinations, delusions, paranoia and disorganization of thought or behavior.
“With hallucinations, hearing voices is most common, but it could be disturbances in the other perceptions—visual, touch, smell, taste,” Dr. Jarskog says. “With voices, you may have the sense that someone is talking inside your head, or you think you’re hearing something outside your head.”
Delusions are false beliefs, and paranoia is the unreasonable fear or suspicion of others. These symptoms can take many forms; it may look like someone worried that the government is spying on them or that a person in power has placed a spell on them. You likely will not be able to convince a person that these beliefs are false, no matter how much you talk to them.
While everyone loses their train of thought from time to time, Dr. Jarskog says the disorganization is often more extreme in schizophrenia.
“Thoughts get discombobulated, to the point that it’s difficult to understand or follow what a person is saying,” he says. “The disorganization can also result in strange and bizarre behavior, and when taken together with other symptoms, like delusions or paranoia, their ideas and actions don’t make sense.”
The main negative symptoms of schizophrenia, meaning that a person with schizophrenia lacks them, include a lack of initiative or motivation, social withdrawal, and a flat affect—they don’t show the emotion you’d expect for the situation.
When a person is exhibiting one or more of the positive symptoms to the point that they lose touch with reality, that’s psychosis, and it sometimes requires hospitalization. Psychosis can be frightening to experience or witness, and that’s usually when a person who is developing schizophrenia is identified, Dr. Jarskog says. It’s quite common to experience many life setbacks on the way to a diagnosis, such as being fired from a job, dropping out of school, and losing housing and connections to friends and family.
To be formally diagnosed with schizophrenia, you must exhibit two or more types of symptoms, one of which must be delusions, hallucinations or disorganization, for six months, together with difficulty functioning in daily life. But you don’t have to wait six months to seek help. Treatment can begin before the diagnosis is finalized.
Too often, by the time a person shows up for treatment, there may be other factors that make diagnosis difficult. If you also have mood symptoms that look like depression or bipolar disorder, you may be diagnosed with schizoaffective disorder, which is marked by symptoms of both schizophrenia and mood disorders. This diagnosis might change if mood symptoms improve after treatment.
Substance use can make it more complicated, too.
“Hallucinogens, cocaine and marijuana can lead to psychosis, and people might focus on the idea that these symptoms are just the drugs,” Dr. Jarskog says. “You have to treat both, but focusing on the substances can make it harder for some people to engage in comprehensive treatment for schizophrenia.”
Treatment for Schizophrenia
Medications called antipsychotics are the primary treatment for schizophrenia. These medications work by blocking certain dopamine receptors in your brain, and there are several dozen that doctors may consider.
While the medications are quite effective at resolving the positive symptoms of psychosis, the side effects are often difficult. Some of the newer medications have fewer side effects than the older ones, and you can work with your doctor to find something that is effective and tolerable.
“The antipsychotics can be sedating, some of them to the point that people sleep much longer than intended,” Dr. Jarskog says. “They can also cause weight gain and increase appetite, and sometimes it can be quite dramatic. There can be neurological side effects that can mimic Parkinson’s disease, because you’re blocking a dopamine receptor’s ability to function.”
Those side effects can include slowness in movement, tremors, restlessness and flat affect (which you may have already had as an underlying symptom). Long-term use of antipsychotics can cause tardive dyskinesia, or involuntary muscle movements. These movements can become permanent with ongoing treatment.
“The medications can feel like they add insult to injury. You have to deal with the symptoms of the illness and on top of that the symptoms of long-term treatment, and both are stigmatizing,” Dr. Jarskog says.
If one medication isn’t working, you may be able to try another, but unfortunately, many people just stop taking their medication.
“When people drop out of treatment because they don’t like the medication, the illness is harder to treat the next time symptoms come back,” Dr. Jarskog says. “That’s why it’s very important to have a comprehensive approach to treatment that includes psychotherapy and supporting the person where they are.”
Living with Schizophrenia
It is daunting to receive a diagnosis of schizophrenia and be told you need to be on an antipsychotic for the rest of your life, which is why the therapy and support systems are so important.
“Because of the seriousness of this illness, you can’t pretend you don’t have it,” Dr. Jarskog says. “Dropping out of treatment just makes it worse. You have to stay engaged with treatment and work with your team.”
It’s helpful for the person with the diagnosis and the people in their lives to learn more about schizophrenia, particularly if they’ve only seen portrayals in media. With more information, many people learn that they can still achieve their life goals.
“Occupational therapy and vocational rehabilitation can be very helpful at getting people back to whatever they were doing before—work, school or other activities,” Dr. Jarskog says. “Schizophrenia can cause people to fall off the normal developmental trajectory, and it’s so much harder to reintegrate into society or to interact with people without that support.”
About a third of people with schizophrenia develop what’s known as treatment-resistant schizophrenia, meaning that at least two antipsychotic medications have failed to curb symptoms. Some of these cases are due to severity, but they also include people who frequently stopped and restarted medications. In these cases, a medication called clozapine is often recommended.
“The stigma of this illness can make it seem like your life is over, but people should have faith and work with their provider to stay on a treatment,” Dr. Jarskog says. “It is possible to succeed. People are often able to achieve things they value in life and to feel good about themselves.”
If you’re concerned about your mental health, talk to your doctor. If you need a doctor, find one near you.