People with schizophrenia often suffer terrifying symptoms such as hearing internal voices not heard by others, or believing that other people are reading their minds, controlling their thoughts, or plotting to harm them. 

These hallucinations and delusions are categorised in the ‘positive’ symptom category, mentioned briefly above. These symptoms may leave them fearful and withdrawn. Their speech and behaviour can be so disorganized that they may be incomprehensible or seem frightening to others. The available treatments can relieve many symptoms, but some people with schizophrenia continue to suffer some symptoms throughout their lives. It has been estimated that no more than one in five individuals recovers completely.

Some may be unwell for a few months only, others may have longer and repeated episodes. For an unfortunate few, the episodes may be severe and continuous. It is now possible to predict within the first two years, which form it will take. Schizophrenia profoundly affects their health, happiness, and social life. They are more likely to be physically ill or commit suicide, and many live in poverty and isolation. Good treatment can go a long way to prevent this.
At times, people with it may find it difficult to plan and do things. They may find it hard to get up and get going.  These symptoms are categorised amongst the ‘negative’ symptoms of the illness. Everything may seem dull and pointless. These symptoms can make it hard for them to do things for themselves and therefore normal functioning in day-to-day life can become extremely difficult. It can look like they are being lazy. But they are not.  All of the above symptoms can be described in terms of abnormal brain chemical activity.

Some people have only one such psychotic episode; others have many episodes during a lifetime, but can lead relatively normal lives during the interim periods. However, the individual with chronic schizophrenia, or a continuous or recurring pattern of illness, often does not fully recover normal functioning and typically requires long-term treatment, generally including medication, to control the symptoms.

Distorted Perceptions of Reality

People with schizophrenia may have perceptions of reality that are strikingly different from the reality seen and shared by others around them. These perceptual changes are also believed to be due to abnormal brain chemical (dopamine) activity in particular brain regions. Living in a world distorted by hallucinations and delusions, individuals with schizophrenia may feel frightened, anxious, and confused.

In part, because of the unusual realities they experience, people with schizophrenia may behave very differently at various times. Sometimes they may seem distant, detached, or preoccupied and may even sit as rigidly as a stone, not moving for hours or uttering a sound. Other times they may move about constantly and be always occupied, appearing wide-awake, vigilant, and alert.

Schizophrenia is expressed in various ways in different people, and it is thought that these differences are related to different genes and environmental experiences of the individual. Symptoms can appear quickly, over a few days, or develop more gradually over a period of weeks, months or even years.  Often, there is a ‘prodromal’ phase before the onset of ‘full-blown’ schizophrenia where the behaviour changes.  These changes may be similar to the negative symptoms of schizophrenia.

We normally feel that we are in control of our thoughts and actions, but schizophrenia interferes with this perceived control. It may feel as though thoughts are being put into the mind or taken out by some outside, uncontrollable force. The body may feel as if it has been taken over, like a puppet or a robot under outside control. At worst, the whole personality seems under the influence of an alien force or spirit. This is a terrifying experience, which the person tries to explain according to education and upbringing. In 'high-tech' societies, invisible influences capable of working over a distance may be put down to radio, television or laser beams, or a computer somehow installed in the brain. In traditional and religious communities, witchcraft, angry spirits, God or the Devil may be held responsible.

Positive symptoms:

These symptoms tend to be the active psychotic symptoms that interfere with the persons reality. They comprise delusions, thought disorder and hallucinations.

Delusions

Delusions are false, usually strange personal beliefs that are not subject to reason or contradictory evidence and are not explained by a person’s usual cultural concepts, and cannot be changed by argument. Delusions may take on different themes, for example, patients suffering from paranoid-type symptoms. About one-third of people with schizophrenia have delusions of persecution, or false and irrational beliefs that they are being cheated, harassed, poisoned, or conspired against. These patients may believe that they, or a member of their family or someone close to them, are the focus of this persecution. In addition, delusions of grandeur, in which a person may believe he or she is a famous or important figure, may occur in schizophrenia. Sometimes the delusions experienced by people with schizophrenia are quite bizarre; for instance, believing that a neighbour is controlling their behavior with magnetic waves; that people on television are directing special messages to them; or that their thoughts are being broadcast aloud to others. On the other hand, delusions may be somewhat awesome - 'I'm God's messenger!' 'I'm the richest person in the world!' 'I'm persecuted by men from Mars!' - or apparently reasonable - 'My husband is unfaithful'. 'Everyone at work is against me'. Persecutory delusions are especially distressing for the family if they are seen as the persecutors. Delusions may come out of the blue or may start as an explanation for hallucinations or the sensation of being taken over.  Often, unless they are uncovered and treatment started early, delusions evolve and become more elaborate over time, gradually encompassing more people, places, things and events, as the person becomes more ill and engrossed in their perception of reality.

Disordered Thinking

Schizophrenia often affects a person’s ability to think logically. Thoughts may come and go rapidly. The person may not be able to concentrate on one thought for very long and may be easily distracted, unable to focus attention.

People with schizophrenia may not be able to sort out what is relevant and what is not relevant to a situation. The person may be unable to connect thoughts into logical sequences, with thoughts becoming disorganized and fragmented. This lack of logical continuity of thought, termed ‘thought disorder’, can make conversation very difficult and may contribute to social isolation. If people cannot make sense of what an individual is saying, they are likely to become uncomfortable and tend to leave that person alone.

Hallucinations and Illusions

The word hallucination, refers to disturbances of perception that cause the person to hear, smell, feel or see something, without there actually being anything there to hear, smell, feel or see. Hallucinations and illusions are common in people suffering from schizophrenia. The voices sound so real that the hearer is convinced that they come from outside, perhaps from hidden microphones, loudspeakers, or the spirit world. Voices are sometimes heard in some other mental illnesses, but in schizophrenia they typically talk about, as well as to, the person. As mentioned, hallucinations can occur in any sensory form whether this is auditory (sound), visual (sight), tactile (touch), gustatory (taste), and olfactory (smell). Hearing ‘voices’ that other people do not hear is the most common type of hallucination in schizophrenia. Voices may describe the patient’s activities, carry on a conversation, warn of impending dangers, or even issue orders to the individual. Illusions, on the other hand, occur when a sensory stimulus is present but is incorrectly perceived and interpreted by the individual.

Speech and behaviour

Sometimes schizophrenia interferes with a person's train of thought, so it may be difficult to follow what they say. Emotions and behaviour may be affected by hallucinations. This may be talking or shouting back at the 'voices', or carrying out the instructions (which may even mean self-harm or suicide). False beliefs may not affect behaviour but persecutory delusions may lead to the person accusing members of their family or strangers and, rarely, to attacks which may be dangerous. When such incidents occur they understandably cause much concern and distress for all involved.
News and entertainment media tend to link mental illness and criminal violence. However, studies indicate that except for those persons with a record of criminal violence before becoming ill, and those with substance abuse or alcohol problems, people with schizophrenia are not especially prone to violence. Most individuals with schizophrenia are not violent; more typically, they are withdrawn and prefer to be left alone. The vast majority of violent crimes are not committed by persons with schizophrenia, and most persons with schizophrenia do not commit violent crimes. Substance abuse significantly raises the rate of violence in people with schizophrenia but also in people who do not have any mental illness. People with paranoid and psychotic symptoms, which can become worse if medications are discontinued, may also be at higher risk for violent behavior. When violence does occur, it is most frequently targeted at family members and friends, and more often takes place at home. The person with schizophrenia is not a ‘split personality’. Schizophrenia is the name given to a set of characteristic symptoms.

Negative symptoms:

These symptoms are often the symptoms that cause the most disability in schizophrenia.
These symptoms negatively affect interest, energy, emotional life and motivation. As a result, the person may not bother to get up or go out, may not maintain hygiene – personal or otherwise, and may never get excited or enthusiastic about anything any more. The person will tend to avoid meeting people, will say little or nothing, and may appear emotionally rather blank. Negative symptoms upset families, who feel that it is a matter of 'won't' rather than 'can't', or as if the person they knew had been replaced by a stranger who just won't do anything. It is important for the family to understand that this is as much a part of this crippling illness as are delusions and hallucinations.

The young person suffering from schizophrenia may become quiet, reserved and can appear emotionally isolated. They seem to lose general interest, drive and motivation and may stop washing regularly or looking after themselves properly. Concentrating on work and other commitments can seem impossible at times.

Typically, the symptoms are severe enough to cause concerns both at home and at school. Positive or negative symptoms alone do not mean that the person is definitely developing schizophrenia. Similar symptoms also happen in other conditions, such as depressive illness or as part of a severe reaction to stress. The nature and sheer complexity of the illness mean that medical attention is a must.

Emotional Expression

People with schizophrenia often appear flat or emotionally withdrawn. This refers to a severe reduction in emotional expressiveness. A person with schizophrenia may not show the signs of normal emotion, perhaps may speak in a monotonous voice, have diminished facial expressions, and appear extremely apathetic. The person may withdraw socially, avoiding contact with others; and when forced to interact, he or she may have nothing to say, possibly reflecting impoverished thought, amongst other things. As motivation and an individual’s ability to experience pleasure can be greatly decreased, this impacts severely on a person’s desire to continue on with day-to-day life.  Unfortunately, rates of suicide are extremely high.  It is estimated that around 1 in 20 of people with schizophrenia complete suicide.  These pervasive problems with emotional expression and motivation and inability to experience pleasure, which may be extremely troubling to family members and friends, are symptoms of schizophrenia, not ‘character flaws’ or ‘personal weaknesses’.

Making A Diagnosis

The first signs of schizophrenia often appear as confusion or significant changes in behaviour and emotions. This makes accurate diagnosis, especially in the early stages, extremely difficult.  Unfortunately, there is no blood test or any other definitive diagnostic test which can confirm schizophrenia.  Therefore, it is left up to the medical professional to determine, based on the available evidence, whether a diagnosis of schizophrenia is appropriate, and the necessary course of action. 

The person and the family may not know what is occurring and it may take some time for symptoms to evolve.  Coping with the symptoms of schizophrenia can be especially difficult for family members who remember how involved or vivacious a person was before they became ill. The sudden onset of severe psychotic (‘positive’) symptoms is referred to as an acute phase of schizophrenia. Psychosis is a common condition in schizophrenia. Psychosis is a state of mental impairment marked by hallucinations, which are disturbances of sensory perception, and/or delusions, which are false yet strongly held personal beliefs that result from an inability to separate real from unreal or perceived experiences (See the Psychotic Disorders brochure on this website). Less obvious symptoms, such as social isolation or withdrawal, or unusual speech, thinking, or behavior, may precede, be seen along with, or follow the psychotic symptoms.

The person may say that they can hear people talking about them, commenting on what they are doing, being insulting or making a running commentary. They may hear these voices when they are alone or in company. They may think they come from the television or radio or from invisible beings. People with schizophrenia at times experience reality differently. They may say that they can pick up other people’s thoughts, or that they can read minds. These experiences may be frightening or exhilarating, unsettling or fascinating. They are almost always extraordinary. They form the basis of beliefs and actions. To the person they are intensely real, often even more so than ordinary events. This makes them hard to differentiate from ‘real’ life itself.

Some other symptoms may be observed rather than reported. Some people may be very quiet and withdrawn. They may do little and say that they lack interest or motivation. Others may speak in a way which is hard to understand. They may use strange words or their sentences may be fragmented.
It is important to rule out other illnesses, as sometimes people suffer severe mental symptoms or even psychosis due to undetected underlying medical conditions. For this reason, a medical history should be taken and a physical examination and laboratory tests should be done to rule out other possible causes of the symptoms before concluding that a person has schizophrenia. In addition, since commonly abused drugs may cause symptoms resembling schizophrenia, blood or urine samples from the person can be tested for the presence of these drugs.

At times, it is difficult to tell one mental disorder from another. For instance, some people with symptoms of schizophrenia exhibit prolonged extremes of elated or depressed mood, and it is important to determine whether such a patient has schizophrenia or actually has bipolar disorder or major depressive disorder. Persons whose symptoms cannot be clearly categorized are sometimes diagnosed as having a ‘schizoaffective disorder’. At times depression and anxiety disorders may be reactions to or coexist with the schizophrenia and need also to be treated.