Schizophrenia: understanding it

Doctors sometimes call these “positive” experiences. Positive does not mean good. It means something has been added that most people don’t experience, such as hearing a voice when no one is there.

These experiences tend to be strongest during an episode. You can read about each one in the “Experiences, described kindly” section below.

These are sometimes called “negative” experiences, because something is reduced. A person may find it hard to start things, enjoy things, keep up friendships or show emotion on their face or in their voice.

They are often mistaken for laziness, rudeness or depression. They are none of these. They are part of the condition, and they can be some of the hardest parts to live with.

Many people notice changes in attention, memory and decision-making. It might be harder to follow a conversation, learn something new or remember an appointment.

NIMH notes that a person’s thinking skills are one of the best predictors of how they manage day to day. That’s why therapies that build these skills matter so much.

The NHS is clear: people with schizophrenia do not have a split personality. The old mix-up comes from the word itself, but the “split” was never about being two people.

Having separate identity states is a different experience linked to dissociation. If that’s what you want to understand, see the Dissociation guide.

NIMH says most people with schizophrenia are not violent. In fact, people with schizophrenia are more likely than people without it to be harmed by others.

The NHS adds that most people who have psychotic episodes are not a danger to others. Risk is highest when the illness is untreated or mixed with alcohol or drug misuse, which is one more reason early care matters.

WHO reports that at least one in three people with schizophrenia will be able to fully recover. The NHS says many people recover, though some have times when experiences return.

Recovery doesn’t always mean every experience is gone. For many people it means a life with purpose, relationships, work or study, and tools to handle hard days.

Old theories blamed families, especially mothers. Modern research points instead to a mix of genes, brain development and life stresses. No single thing, and no single person, causes it.

Families are not the cause, but they can be a huge part of recovery. Family programmes help everyone cope and can lower the chance of relapse.

Low energy, little interest and trouble starting tasks are recognised parts of schizophrenia. The NHS notes they are often mistaken for laziness or rudeness, which can strain relationships.

Pressure and criticism usually make things harder. Small, kind steps and encouragement work better.

NIMH says effective treatment can help people stay in school, keep jobs, live independently and keep relationships.

Supported employment programmes help people find and keep jobs that match their strengths. Read more in the Living well with schizophrenia guide.

Hallucinations are when someone sees, hears, smells, tastes or feels something that doesn’t exist outside their mind. Hearing voices is the most common kind.

Brain-scan research shows changes in the brain’s speech areas when people hear voices. The NHS describes it as if the brain mistakes thoughts for real voices. So the experience is real, even if no one else can hear it.

Some voices are friendly. More often they are critical, rude or bossy. They might comment on what the person is doing, talk to them directly or seem to come from one place, like the TV.

Doctors call these delusions: beliefs held with complete certainty even when there is clear evidence against them. They can start suddenly or build up over weeks or months.

They might include

• Feeling watched, followed or plotted against
• Believing the TV, radio or posts carry messages meant just for them
• Feeling that thoughts are being put in, taken out or controlled
• Finding special meaning in ordinary things, like the colour of passing cars

Sometimes a belief grows to explain a hallucination. If a voice describes everything you do, it makes sense to wonder whether someone is watching. The belief is a way of making sense of something frightening.

People may find it hard to keep track of thoughts and conversations. Ideas can drift from one to the next, and reading an article or following a TV show can become hard.

Some people describe their thoughts as “misty” or “hazy”. Speech can become jumbled, which makes conversation hard for everyone.

A person may lose interest in things they loved, stop looking after themselves, or seem emotionless. These experiences can appear months or even years before a first episode.

Inside, the person may still feel a lot. It can be more that the “engine” for starting things and showing feelings is running low.

Arts therapies, skills training and gentle routines can help. NICE recommends considering arts therapies especially for these experiences.

In rare cases, a person may stop moving or talking for a period of time. This is called catatonia and needs prompt medical care.

The Psychosis & schizophrenia guide has a full section on catatonia awareness.

Many different genes each add a small amount of risk. No single gene causes schizophrenia by itself.

Twin studies show genes matter but aren’t everything. If one identical twin develops schizophrenia, the other has about a 1 in 2 chance. For non-identical twins it’s about 1 in 8, compared with about 1 in 100 in the general population.

NAMI says having a parent or sibling with schizophrenia makes it more than 6 times as likely. But most people with a close relative who has it will never develop it themselves.

People with schizophrenia may be more likely to have subtle differences in some brain areas and the connections between them. Some of these may begin before birth.

Complications around pregnancy and birth, and exposure to viruses or poor nutrition before birth, have been linked to a higher risk.

Brain chemical messengers, such as dopamine and glutamate, also seem to be involved. These differences are not seen in everyone, and research is ongoing.

Stressful events, like losing someone, losing a job or home, or abuse, don’t cause schizophrenia on their own. But they can trigger it in someone who is already vulnerable.

NIMH lists poverty and stressful or dangerous surroundings among the environmental factors researchers study. Cleveland Clinic adds childhood trauma and social isolation.

WHO says heavy cannabis use is linked to a higher risk. The NHS adds that teens and young adults who use cannabis regularly are more likely to develop schizophrenia later, and the risk may be higher with stronger forms.

NAMI notes that the younger a person is and the more often they use, the greater the risk. Drugs like cocaine, LSD and amphetamines can also raise the risk or bring on a relapse.

When the mood side looks like depression, a person may feel sad, empty or worthless alongside experiences like voices or unusual beliefs.

The “Depression: understanding it” guide explains low mood in depth, and the When to get help section below covers what to do if things feel hopeless.

When the mood side looks like mania, a person may feel euphoric, have racing thoughts and take more risks.

NAMI notes early mania can feel good, so the person may not want help. Watching for less sleep and fast talking can help spot it early. The “Bipolar: understanding it” guide covers highs and lows in more detail.

Therapies like CBT for psychosis, supported employment, peer support, family involvement and steady routines are all part of care. For any treatment decisions, consult with your clinical provider.

Everyday supports

• A regular sleep and wake time
• Knowing your stress triggers, like holidays or conflict
• Cutting back on alcohol and drugs
• Staying connected with people who steady you

NAMI says awareness can change: a person may see their illness clearly at one time and not at another. This back-and-forth is typical of anosognosia, not a sign of stubbornness.

Early studies found about 30% of people with schizophrenia had a “severe” lack of awareness of their diagnosis. Many more have some degree of it.

Because their perception feels accurate, the person may conclude that loved ones are lying or mistaken. If family keeps insisting, the person may get frustrated or angry, or start avoiding them.

NAMI suggests focusing on helping the person feel safe and supported, rather than trying to convince them. Trust is the bridge to care.

NAMI notes that lack of insight often leads people to avoid treatment, and raises the risk of homelessness or arrest. Understanding it helps families respond with patience instead of blame.

Planning ahead while someone is well, such as a crisis plan or an advance directive, can make a big difference later.

Casual words like “schizo” or calling something “so schizophrenic” turn a health condition into an insult. Person-first language, like “a person living with schizophrenia”, keeps the person in view.

Gently correcting a friend or family member is one of the simplest anti-stigma actions there is.

People living with schizophrenia sometimes start to believe the stereotypes about themselves, and lose hope or stop reaching out. This is understandable, and it isn’t the truth about you.

Peer support, sharing your story when you feel ready, and connecting with others who understand can all loosen self-stigma’s grip.

NAMI reports Black and Latino people are more likely to be misdiagnosed with psychotic conditions, due to things like provider bias and limited access to culturally responsive care.

Working with a provider who understands your culture and values can lead to a more accurate picture and better care. The Culture & mental health guide explores this further.

Try

• “I’m here. You’re not alone.”
• “That sounds really frightening.”
• “I don’t hear it, but I believe it’s real for you.”
• “What would help right now?”

NIMH reminds us that beliefs and hallucinations feel very real to the person. Be respectful, supportive and kind, without accepting dangerous behaviour.

Avoid

• “Pull yourself together.”
• “That’s crazy” or “you’re paranoid”
• Arguing about whether voices are real
• Talking about them as if they aren’t there

NAMI suggests calmly saying you see things differently, rather than telling the person their experience isn’t real.

Ideas

• Offer a ride to appointments
• Help write down questions for the care team
• Notice events that tend to set off symptoms
• Encourage small goals and celebrate them
• Share relaxed time that isn’t about the illness

Family education programmes help families manage their own distress and build coping skills, NIMH says. The NHS adds that carers can ask the care team about their own needs.