Physicians and therapists tend to think of schizophrenia as a spectrum of disorders. The spectrum also includes schizoaffective disorder, schizophreniform disorder, and other chronic psychotic illnesses, each of which requires professional evaluation. Even though much progress has been made toward a better understanding of schizophrenia, researchers acknowledge that in many respects the disease remains a black box. About one in 100 American adults has schizophrenia.

“It’s not one disease; it’s probably many different diseases,” says Yale Medicine psychiatrist Vinod Srihari, MD, who directs the Specialized Treatment Early in Psychosis (STEP) program. Early, intensive treatment may lead to better outcomes for patients over time. With the right care, Dr. Srihari says, most patients with schizophrenia are able to manage their symptoms and live productive lives.

Symptoms and signs of schizophrenia usually fit into the following categories:

• Reality Distortion. A hallmark of schizophrenia is when a person has trouble distinguishing reality from disordered perception or thinking. People with schizophrenia might hear sounds or voices when no one is talking, or they might see things that don’t exist. They also might hold on to beliefs that aren’t true, such as a conviction that someone is trying to harm them.
• Disorganization. People might display a lack of connection among thoughts, feelings, and behavior. These symptoms might be revealed through: abruptly changed subjects during a conversation; rapid, disorganized speech that reflects disorganized thinking; or inappropriate emotional expression.
• Deficit Symptoms. A person with schizophrenia may lack energy and motivation to participate in activities previously found pleasurable. Social withdrawal is a common early feature of the illness.
• Cognitive Dysfunction. People with schizophrenia may have trouble with paying attention or with processing speed and memory. They may have difficulty keeping different ideas in their head at the same time and can find decision making to be difficult.
• Emotional Dysregulation. Illnesses such as schizophrenia can adversely impact processes that regulate mood and result in symptoms of depression or mania.

Numerous factors have been associated with increased risk for schizophrenia. These include, but are not limited to, paternal age, complications during pregnancy and childbirth, and substance use disorders.

People with schizophrenia sometimes have a family history of the disorder, but many cases occur in people with no affected relatives. One hypothesis suggests that the condition can develop after a loss of too many neural synapses during adolescent brain development. Synapses are connections between neurons. 

As children become teenagers and then young adults, the immune system removes many synapses to streamline brain activity. Specific genes tell the immune system what to prune, and some people who develop schizophrenia appear to have abnormal versions of these genes.

Symptoms of schizophrenia typically first appear in the late teens or 20s. Evaluation for schizophrenia typically begins with a long conversation about a person’s history and current symptoms. A psychiatrist or psychologist will inquire about a patient's professional and social life. The provider may request permission to speak with family members or friends to get a more complete picture of how symptoms have emerged.

Physical, neurological, and laboratory testing can help rule out other conditions that may mimic schizophrenia, such as epilepsy or brain injury. Other psychiatric conditions, such as bipolar disorder, should also be ruled out to confirm a schizophrenia diagnosis.

For people with schizophrenia, intervention early in the course of the disease can improve their ability to make a long-term recovery. Certain medications can make hallucinations and delusions less severe or disappear completely. Therapy can teach coping skills for symptoms that persist. 

Education services, peer support, and education and assistance for family members can also improve the patient’s life. People with schizophrenia often need ongoing treatment throughout their lives. Fortunately, “for most individuals, recovery is the rule,” Dr. Srihari says.

Yale Medicine has pioneered early interventions for schizophrenia. The PRIME Psychosis Prodrome Research Clinic has established approaches to diagnosing individuals who may be at high risk for developing schizophrenia and tested ways to prevent onset of the illness. The goal of the Specialized Treatment Early in Psychosis (STEP) Program at the department of psychiatry is to improve access to care for people living with the condition and deliver a comprehensive package of treatments to reduce its impact on daily living.