When Their Reality Is So Different, How Can We Understand People With Schizophrenia?

Schizophrenia is a long-term mental health condition affecting approximately 1 in 222 adults or 0.45%¹ of the adult population. It is rarer than other types of mental disorders. 

Schizophrenia means “split mind” in Greek: Schizo meaning split, and phrene meaning mind. Swiss psychiatrist Eugen Bleuler² was the first person to use the term in 1908. The name causes some confusion, and it’s not a condition that causes a split personality. 

It can be hard to understand someone’s experiences when their reality is different from yours. In this article, we aim to give you an insight into the mind of someone with schizophrenia. 

What is schizophrenia?

Schizophrenia is a severe, long-term psychotic disorder³ causing a combination of hallucinations, delusions, and incredibly disordered thinking. These symptoms are debilitating, require lifelong treatment, and often disrupt a person’s life and ability to participate socially and nurture deep relationships. 

It typically develops⁴ between 15 and 25 years old, with men often developing symptoms earlier than women. Most men experience symptoms between 16 and 25, and the average age of onset is 18 years old. The incidence in women is markedly higher after 30 years, and the average age of onset is 25.

Schizophrenia rarely starts before age ten or after age 40. 

Approximately 50% of people in psychiatric units have a schizophrenia diagnosis. Only 31.3% of people with psychosis get proper specialist care.

People with schizophrenia are 2 to 3 times more likely to die early than the general population

People with schizophrenia have a life expectancy approximately 20 years⁵ below the general population, and they’re 2-3 times more likely to die early, too. 

But why do people with schizophrenia have a higher mortality rate? A 2012 paper⁶ suggested four explanations:

• Psychological illnesses are common, but doctors diagnose them too late and treat conditions insufficiently

• Antipsychotic medicine may have negative side effects

• People with schizophrenia often have an unhealthy lifestyle (smoking, excess alcohol consumption, poor diet, and lack of exercise)

• The risk of suicide and accidents is high

Experiencing a different reality: Signs and symptoms

Schizophrenia symptoms typically fall into three categories: Positive, negative, and cognitive.

Positive symptoms

In this context, positive means the symptoms are present rather than good. Positive symptoms can also be called “psychosis⁷.” These symptoms refer to abnormal experiences or behaviors that healthy people don’t experience.

These can include hallucinations, delusions, and disorganized thinking. 

Hallucinations

Hallucinations are when you can see, hear, smell, or feel things that other people don’t. You may see things that other people can’t, hear voices, smell things that other people can’t, or feel someone touch you who isn’t there. 

Delusions

Delusions are fixed, false beliefs that don’t make sense in the context of your life. Some delusions include: 

• Thinking you are being followed, whether by secret agents or other people

• Thinking you have special powers

• Believing you have something buried in your brain to monitor your thoughts

• Believing that someone is transplanting their thoughts into your head

• Believing that you are someone important, like Jesus

• The certainty that a huge catastrophe is imminent

Disorganized thinking (speech)

Disorganized speech can make conversations tricky. Someone might ask you a question, but your answer doesn’t make sense, or you never get to the answer. Your thoughts are jumbled, and you get distracted easily, often going off-topic and talking about tangential things.

Sometimes you may try and put together a sentence, but it makes no sense. This is called a “word salad.”

Negative symptoms

Negative symptoms⁸ refer to the decline or loss of behaviors and thoughts that are part of normal functioning. They include difficulty showing emotions, social withdrawal, lack of interest in daily activities, loss of motivation, and difficulty functioning normally. 

Researchers have referred to these negative symptoms as the “five As”: Affective flattening, alogia, anhedonia, asociality, and avolition⁹.

Flat affect

If you have affective flattening, you may have a very limited range of emotions, speak in a monotonous voice, or appear emotionless. You’ll even have very little response to disturbing images or situations. 

Reduced speech

If you have this symptom, you may be speaking much less than usual or not as fluently as before. Doctors also refer to this as alogia. 

Reduced pleasure

This is where you might struggle to find pleasure in things you used to enjoy. While this is a hallmark symptom of depression, it is also one of schizophrenia’s five As: Anhedonia. 

Social withdrawal

If you are socially withdrawn or asocial, you lack interest in making or maintaining relationships, and you may eschew social interaction. 

Lack of initiative

Loss of motivation and initiative is a common symptom of schizophrenia. You may struggle to finish a task or even get started. It’s also called avolition. 

Cognitive symptoms

Cognitive symptoms¹⁰ are the changes in your brain’s processes that you encounter with schizophrenia. They include issues with concentration, memory, and attention. You may struggle to follow conversations as your mind wanders. Another problem you may have is remembering appointments. 

• Difficulty maintaining attention and focusing

• Memory problems

• Trouble using information after you’ve just learned it

• Difficulty making decisions, planning, and structuring activities

• Lack of insight

Schizophrenia tends to happen in episodes

There are three schizophrenic stages: Prodromal, active/acute, and residual/recovery.

Prodromal phase

This is the first phase where your friends and family might notice some strange behavior. You might isolate yourself from people and become very interested in certain topics, like religion, conspiracy theories, or certain public figures. You may also have very little energy, lose interest in hobbies, and start experiencing hallucinations. 

The prodromal phase can last from weeks to years. Some people with schizophrenia never go past this phase, but most move onto the active phase.

Active phase

This phase is sometimes called the acute phase. You’re more likely to experience positive symptoms during the active phase. It can be the most worrying to your friends and family as you start dealing with psychosis symptoms, including suspicion, delusions, disorganized speech, and hallucinations. 

This phase can also appear unexpectedly without a prodromal phase. While it may occur without any notice, most often, you’ll have experienced the prodromal phase symptoms for up to two years before the active phase happens. 

If the active phase is left untreated, it can go on for weeks or even months. 

Residual phase

This phase is also known as the recovery phase. While medical professionals no longer use it in diagnosing schizophrenia, some specialists will still use the term when describing symptoms and phases. Although you may still struggle with illogical thinking, you’re more likely to experience negative symptoms as your intense positive symptoms fade.

Essentially, it mirrors the prodromal phase. 

With effective treatment, most people with schizophrenia recover from their first psychosis episode and may never have another one. Without treatment, you can lapse back into the active phase. Schizophrenia is treatable, and if you get help as soon as you or your loved ones recognize your symptoms, you may never have to experience psychosis again. 

People with schizophrenia are 50 times more likely to attempt suicide than the general population

People with schizophrenia often struggle with other elements of their mental and physical health. They may have anxiety, depression, substance use issues, health problems caused by smoking, and various physical health problems. 

Around 25%¹¹ of people diagnosed with schizophrenia also meet the diagnostic criteria for depression¹². Alcohol abuse¹¹ is rife, with one study¹³ calling it “more the expectation than the exception,” as it can provide temporary relief from symptoms. It’s a central nervous system (CNS) depressant, so it dulls hallucinations and unpleasant feelings.

People with schizophrenia may also experience more euphoria from drinking alcohol than others.  

Many people with schizophrenia also have at least one chronic health condition. One study¹⁴ discovered that 58% of people with schizophrenia had a comorbid physical illness. Not only are they more likely to have a physical illness, but they also experience health problems at a younger age than other people. They often have health-related side effects from antipsychotic medication.

People affected by schizophrenia in the 25-44 age group are five times more likely to have a heart problem than the general population. 

Suicide is one of the main causes of death¹⁵ in people with schizophrenia. They have a 50 times higher risk⁴ of attempting suicide than the general population. In the early stages of illness, severe depression can set in, a huge risk factor for suicide. 

A 2021 cohort study¹⁶ found that people with schizophrenia have a 4.5-fold increased risk of death by suicide. This was highest among the group aged 18-34 years. Suicide is the tenth leading cause of death in the United States. 

Another enormous issue for people with schizophrenia is the prevalence of human rights violations in community settings and mental health institutions. The intense, widespread stigma¹⁷ surrounding people with schizophrenia causes social exclusion, impacting their relationships with everyone, including their families¹⁸. The resulting discrimination¹⁹ can limit their access to education, housing, employment, and even general healthcare. 

Risk factors for schizophrenia

There are a variety of risk factors that interact to increase the chance of developing schizophrenia:

Genetics

Schizophrenia can run in families, but studies²⁰ strongly suggest that many different genes impact the risk of developing schizophrenia. So, just because one family member has the condition doesn’t mean you will develop it. Even if you have an identical twin with schizophrenia, you have less than a 50% chance of developing it.

Over 60%²¹ of people with schizophrenia have no first- or second-degree relatives with the condition.

Brain function and structure

Neuroimaging²² studies have identified differences in brain structure between people with schizophrenia and healthy brains.

In people with schizophrenia:

• The cerebral ventricles are enlarged

• They have an overall loss of neurons²³ in the cerebral cortex

• They may show less activity in the frontal and temporal lobes, impacting language, memory, and attention. 

Environment

Researchers believe that interactions between genetic risk factors and elements of your environment may play a role in developing schizophrenia. 

Environmental factors include stressful surroundings, living in poverty²⁴, and exposure to viruses²⁵ or nutritional deficiencies²⁶ before birth. 

What are the Diagnostic and Statistical Manual (DSM) criteria for schizophrenia?

The American Psychiatric Association (APA)²⁷ publishes the Diagnostic and Statistical Manual of Mental Disorders (DSM). Clinicians and psychiatrists in the United States use the DSM to diagnose psychiatric illnesses. It covers all categories of mental health disorders for adults and children.

The Diagnostic and Statistical Manual, fifth edition (DSM-5), states these clinical features must be present for a schizophrenia diagnosis:

1. Presence of at least two of the following symptoms, with at least one of the psychotic symptoms in the top three here:

• Delusions

• Hallucinations

• Disorganized speech

• Disorganized behavior

• Negative symptoms

2. You must experience the symptoms for at least six months, with the psychotic features present for at least one month.

3. You experience significant work and social functioning difficulties because of your symptoms.

4. Your diagnosing clinician can determine that other conditions or substance use is not causing the symptoms you’re experiencing. 

Treatments: From antipsychotics to support groups

Antipsychotic Medications

Antipsychotics alter certain chemicals in your brain. They primarily affect dopamine, but they can also impact noradrenaline, serotonin, and acetylcholine. These chemicals affect your mood, emotions, and behavior.

Adjusting these chemicals in your brain can suppress or prevent extreme mood swings, hallucinations, delusions, and disordered thinking. 

Typically, you will take antipsychotics daily in either pill or liquid forms. Some antipsychotics are injectable once or twice a month, which can be more convenient than daily doses and easier to remember. Your doctor will start you on a low dose to see if this alleviates your symptoms, increasing as necessary.

This approach prevents side effects like weight gain. 

It can take 2-4 weeks to feel a difference in your symptoms after starting medication and several weeks for full improvement. Antipsychotics don’t always make the symptoms go away completely or forever. Many people with schizophrenia need to take them long-term, even if they feel well.

This prevents symptoms from coming back. 

The recommended approach for determining the best treatment is shared decision-making (SDM) between you and your doctor. 

This conversation combines:

• Your knowledge of your own body and circumstances: Your preferences, goals, values, and life circumstances

• Your doctor’s expertise: Treatment options, benefits, risks, and evidence

Psychosocial Treatments

Psychosocial treatment options for schizophrenia include social skills training, cognitive behavioral therapy (CBT), cognitive remediation therapy (CRT), and social cognition training (SCT), among others.

Social skills training

If you have schizophrenia, you may have profound social and instrumental role functioning²⁸ deficits that severely impact your quality of life. You can do social skills training individually or in groups, with groups providing opportunities to learn by observing and people to practice your skills on. The group support element is vital as well. Research shows that participating in social skills training affects different aspects of recovery and can have broader effects on community functioning. 

Cognitive behavioral therapy (CBT)

CBT addresses your perception of events, which can help regulate emotions. This targets psychotic symptoms, including delusions and hallucinations. More recently, researchers have paid attention to applying the cognitive model of psychosis to negative symptoms. CBT reduces the severity of positive and negative symptoms. It can enhance aspects of community functioning and quality of life.  

Cognitive remediation therapy (CRT)

The approaches of CRT aim to improve your cognitive functioning through stimulating your impaired cognition areas, including your memory. Brain training is usually conducted through computer programs, although you may also use paper worksheets. The training includes brief exercises that tap into vital cognitive processes.

Social cognition training (SCT)

Studies show that SCT²⁹ can help people with schizophrenia improve their social cognitive processes linked to successful social functioning. These processes include: 

• Emotional perception and processing: Recognizing emotions

• Attribution: Deducing the causes of events or behavior

• Social perception and knowledge: Understanding social cues, context, and norms

• Theory of Mind: Understanding and recognizing someone else’s mental state. 

Family Education and Support

Family support is vital for people with schizophrenia. It can be tricky to know how to respond to or support your loved one experiencing the (sometimes frightening) symptoms of schizophrenia. Here are a few ideas to get you started.

Four tips to support your loved ones with schizophrenia

1. Be involved as much as possible

Helping your loved ones keep on top of their medication is a useful way to get involved. Medication adherence is vital in treating schizophrenia and can alleviate its symptoms.

2. Learn how to react

People with schizophrenia truly believe the things they’re hearing and seeing are real, so responding to them with grace is important. Don’t immediately dismiss or challenge their beliefs and tell them they’re wrong. Empathy and validation are important, so use phrases like, “that sounds really scary, I’m sorry you’re hearing these voices,” rather than phrases such as, “that’s not real, don’t worry!” as these are not as helpful.

3. Educate yourself 

This is somewhat related to learning how to react: Educating yourself about schizophrenia is important. It’s a complex condition, so speak to a treatment provider or check out trusted resources for accurate information. Once you understand the condition better, empathy will come more naturally, and you’ll know how to handle different situations and when it’s time to ask for more support. 

4. Look for support groups

Support groups³⁰ can be a great place to share and feel validated in your experiences, whether for yourself or your loved one. 

Schizophrenia is treatable

While schizophrenia isn’t curable, treatment can immensely improve the quality of life in those with schizophrenia. If your loved one has the condition, it can be scary at times, but making sure they get the right help and supporting them along the way is invaluable for their wellbeing.

Educating yourself about schizophrenia is a great way to understand what they’re going through, and it can make you feel more confident in supporting them, too.