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Expert Q&A: Schizophrenia

The earliest signs and symptoms come before a diagnosis can be certain. There is now a growing emphasis on identifying young people at high risk for a psychotic disorder and offering treatment and services in advance of a full psychotic experience. At this stage symptoms and signs include problems with personal relationships and school or work performance, experiencing odd phenomena such as hearing a voice or noise but being uncertain if it was really heard, or becoming excessively suspicious. Also, some people may develop a “loner” lifestyle, a sense that something is wrong and that one’s mind is playing tricks, and other things that mark a change in life course. These are not always early schizophrenia symptoms, but it is a good time for clinical assessment and care in hopes of preventing a progression to a full first episode of psychosis.

At first episode of schizophrenia, common symptoms include paranoia, hearing voices or seeing visions, disorganization of thoughts and behaviors, low motivation and reduced experience of pleasure, anxiety, fear, depression, sleep disturbance, social withdrawal and sometimes poor emotional control seen as anger and hostility.

All the signs and symptoms can occur at a mild level in people who are not ill. A diagnosis must look at the severity of the symptoms, their impact on function and resulting distress. It is critical to rule out other possible causes of these symptoms before a diagnosis of schizophrenia.

Substance abuse is a common problem in persons with schizophrenia, including tobacco, marijuana, alcohol and other drugs. Abuse has all the usual health-related problems, but the presence of schizophrenia complicates this issue. Patients may stop their antipsychotic medications if they believe it interferes with the marijuana or alcohol effect. Disorganized thinking and behavior may be made worse. Marijuana increases the risk of schizophrenia in vulnerable young people and may complicate the course of schizophrenia. Impaired cognition is common in schizophrenia and misused drugs adversely affect cognition, such as attention, memory, task orientation and the like. There are many good reasons to avoid substance misuse.

All persons with schizophrenia need drugs some of the time and most will do better with continued use of medication to help control symptoms and prevent relapse. But the drugs are not effective for all aspects of the illness. Cognitive behavioral therapy may help with certain symptoms and supportive psychotherapy can support personal strengths and improve quality of life. Vocational programs increase the chances of successful employment. Family psychoeducation can give patients and family members a better understanding of the disorder and what will be helpful. A relationship with a case worker may help with the problems of daily living and supportive psychotherapy may help. New treatments such as neuromodulation are being developed and drugs with novel mechanisms of action are being tested.

So, yes, drug treatment is important, but many patients will not take medication continuously for long periods and many experience side effects that have to be addressed. An integrated, comprehensive approach works best.

Negative symptoms refer to a decreasing or absence of normal experiences/actions. Examples include reduced speech, low drive and motivation, little experience and expression of normal emotions, reduced pleasure in activities, failure to initiate activities withdrawal from social interaction with indifference to personal relations.

Warning signs include trouble sleeping, increased anxiety, agitation, increasing suspiciousness or hostility, lack of insight into symptoms and an increase in severity of any of the person’s usual symptoms. Here continuity of clinical care is essential to detection and rapid intervention.

William Carpenter Jr., M.D.

William Carpenter Jr., M.D.

Professor of Psychiatry and Pharmacology
University of Maryland School of Medicine
Editor-in-Chief, Schizophrenia Bulletin
Reviewed Oct. 2020

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