Schizophrenia

There are different types of schizophrenia, each with their own typical symptoms. These are the most common types:

• Paranoid schizophrenia: The main symptoms are delusions, hallucinations (typically hearing voices), and the feeling of being watched and controlled by others. This is the most common type and usually starts between the ages of 25 and 35.
• Residual schizophrenia: This describes the chronic symptoms that are usually seen after an acute psychotic phase. People are then very passive, lack drive, and seem gloomy. They have little interest in activities or seeing other people. Their facial expressions and speech seem to lack emotion. They may also have trouble concentrating or remembering things.
• Disorganized (hebephrenic) schizophrenia: This type is characterized by emotion-related symptoms, often with moods that may not fit the situation and don't change much, inappropriate behavior and disorganized thoughts. It usually starts between the ages of 15 and 25.
• Catatonic schizophrenia: This type is less common. The main symptoms involve abnormal movements – like an urge to move about with no particular purpose, freezing or grimacing (pulling a face). It also typically starts between the ages of 15 and 25.

There are often signs that an acute psychosis phase is approaching, long before it actually starts. In the weeks or months leading up to it, the person and those close to them can usually tell that something is changing. Before the acute psychosis symptoms strike, people are often restless and tense, have sleep problems, difficulty concentrating, and memory problems. They sometimes already have mild hallucinations or the feeling that they're being watched or controlled by others.

The exact causes of schizophrenia are not yet known. Various factors probably play a role and affect each other. Some people have a higher risk of schizophrenia because of their genes – especially if a parent, brother or sister already has schizophrenia. About 12% of children who have a parent with schizophrenia later develop the disease themselves.

Other factors that increase the risk of psychosis include changes in the brain, sleep problems, drug abuse (for instance, using cannabis or amphetamines), traumatic experiences, psychological stress and developmental disorders in the womb or childhood.

Psychosis often occurs during times of major life changes, like separations, moves, or at the start of your career.

An estimated 0.5% of people are diagnosed with schizophrenia at some point in their lives. It is a little more common in men than in women.

Statistically speaking, people of low socioeconomic status and single people are more likely to develop schizophrenia. But loneliness and loss of social status can also be a result of having the disease.

The first acute phase of schizophrenia usually occurs between the ages of 15 and 35. In the years leading up to it, people often have an increasing number of symptoms without a diagnosis. These include restlessness, feeling down, moodiness, anxiety, loss of self-confidence and trouble concentrating. Many people suddenly have problems in school or at university, neglect their appearance, and withdraw from friends and family.

On average, men have their first episode a few years earlier than women do. The reason for this difference between the sexes isn't clear. It is very rare for schizophrenia to start in childhood.

About one quarter of those affected have only one single episode. About 60 out of 100 have a relapse within two years of their first episode. Acute psychosis can last for weeks or months. It often takes a while before you can have a normal daily routine again. In about one quarter of people with schizophrenia, the symptoms never completely go away, but slowly get worse and then stay over the long term. They often have very severe symptoms that are difficult to treat.

Experiencing psychosis often leaves its mark on you, even if the symptoms have long gone. Schizophrenia can make you feel insecure and reduce your self-confidence. But some people can get along fine and live a normal life again after a psychotic episode.

Others need a lot of help because the disease continuously limits what they can do. Many people have particular trouble managing their daily life alone and getting a job. They have difficulty finding friends, tend to have conflicts with others, and often avoid contact with the outside world. It is more common for them to drop out of school or university, be unemployed, move down the social ladder due to low-paid jobs, or retire early. The diagnosis "schizophrenia" often comes with a stigma too.

People with schizophrenia die about 15 years earlier than the average person. Especially those who often have relapses are more likely to die younger. There are many reasons for this reduced life expectancy. For example, they are more likely to suffer from addiction and use more alcohol, nicotine and drugs. They also have more infections, heart disease and diabetes, and are less likely to see a doctor. These physical illnesses may be lifestyle-related or side effects of medications to treat psychosis symptoms. Good treatment increases the life expectancy of people with schizophrenia.

About 5% of affected people take their own lives. This is more common in young men during their first acute phase of psychosis and in people who have had severe symptoms for a very long time. The risk is particularly high during an untreated acute psychotic episode and the time immediately after leaving hospital.

Schizophrenia is only diagnosed if the typical symptoms have lasted for at least one month. Symptoms like delusions and hearing voices all the time are more important for the diagnosis. Things like disorganized speech, aimlessly moving about a lot, or other hallucinations (other than hearing voices) are less typical of schizophrenia.

To find out whether it's schizophrenia, the doctor will talk to the person and their loved ones, and also observe the person's behavior. Physical and neurological examinations, as well as scans, may be done too – mainly to rule out other causes of the symptoms. Other possible causes include conditions of the nervous system and alcohol or drug abuse.

It is not always easy to tell the difference between signs of schizophrenia and “normal” behavior or plausible reactions to certain experiences. In teenagers, it can be difficult to tell apart schizophrenic symptoms from severe developmental problems. Certain symptoms can also be caused by drug abuse or other diseases like depression or anxiety. So it's very important to have a thorough examination by psychiatrists and psychotherapists.

Treatment should be mostly based on the needs of the affected person. But it's often not possible to fully involve someone who is going through their first acute psychotic episode. It is easier to plan continued treatment together when the acute symptoms have improved. The earlier and more effectively the symptoms are treated, the greater the chances of a better course of the disease.

The treatment and support options include:

• Support from family, friends, acquaintances and colleagues: They can give you emotional support, help in everyday life, and provide a stable social environment.
• Medication: Antipsychotic medications can make acute symptoms go away and prevent relapses in the long term. They are effective, but may have unpleasant side effects.
• Talking therapy: This can improve the symptoms and help you to cope with the condition. Common approaches include cognitive behavioral therapy (CBT) and family therapy. Talking therapy can be helpful in all phases of schizophrenia, even during acute psychosis.
• Psycho-education: Here, people with schizophrenia and their loved ones learn all about the signs of the disease, the treatment options, and how best to manage things. It also gives them an opportunity to talk with other affected people.
• Social skills training: Various approaches can help people to get along better with others when they return to daily life – for instance, in social situations or at work – and allow them to be as independent as possible. This can sometimes reduce the symptoms, too.

The treatment can take place in an outpatient or inpatient setting. During acute phases, it often takes place at a psychiatric hospital. People often don’t understand that they are going through psychosis and may refuse to have treatment. Then they might be taken to a psychiatric hospital against their will. But this is only legally allowed if someone is a danger to themselves or others – for example, because of suicidal thoughts or very aggressive behavior – and there’s no other way to protect them.

It is possible to make a written joint treatment plan together with doctors, where you determine things like how acute psychosis should be managed. This includes which medications to use, any other forms of support you want, and how to deal with necessary forced measures. It can also be helpful to create a living will and appoint a health care proxy to determine who can make decisions for you when you can't yourself.

Please note: The following information includes links to German websites that might be useful for people living in Germany.

The “Telefonseelsorge” crisis hotline offers support for acute problems and can advise you on where to find further help. Various other organizations also offer support and advice.

The German Federal Chamber of Psychotherapists (Bundespsychotherapeutenkammer) has a database that you can use to find a therapist anywhere in Germany. The appointment-making service of the Association of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung) can help you get an appointment with a specialist or psychotherapist.

When people are ill or need medical advice, they usually go to see their family doctor first. You can read about how to find the right doctor in our topic "Health care in Germany" – and our list of questions can help you to prepare for your appointment.