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April
12
Saturday
2025
2025 04 12

Schizophrenia part III



Schizophrenia – An In-Depth Overview

Triggering Factors and Symptom Development

Onset

Schizophrenia typically begins in late teens to early 20s. Sometimes the onset is sudden, but often the first psychotic episode is preceded by a prodromal phase with more diffuse signs. During the prodromal period (which can last for months or up to a year), the individual may experience a gradual decline in functioning: increasing social withdrawal, difficulties in school or work, emotional flattening, odd beliefs, and perceptual disturbances that are not yet fully developed hallucinations. Those close to the person may notice that they are "becoming someone else"—withdrawing from friends, neglecting hygiene, expressing bizarre ideas or suspiciousness. These early symptoms are often nonspecific and may be mistaken for depression or typical adolescent issues. The prodromal phase is usually only recognized in hindsight, after full-blown schizophrenia has developed.

Triggering Factors

A first psychotic episode can be triggered by stressors that accelerate the underlying disease process. Common triggering factors include acute life events such as the loss of a close relationship, relocation, or severe failures affecting self-esteem. Often, there is a combination of stressors. Sleep deprivation can also act as a trigger—sometimes onset occurs during a period of severe sleep disturbance or sleep-wake cycle disruption (e.g., intensive studying, a new romantic relationship, etc.). Substance use, particularly cannabis or amphetamines, is a known trigger and is present in a significant proportion of newly diagnosed cases. In the acute phase of schizophrenia, drug use, stress, or sleep loss often contribute to the psychotic break. However, it is important to remember that the illness often has been "brewing under the surface" in a subclinical form beforehand—the triggering event rarely acts alone but rather interacts with an elevated baseline vulnerability.

Symptoms of Schizophrenia

When schizophrenia fully manifests, the patient exhibits a range of characteristic symptoms. In psychiatry, symptoms are often divided into three main categories:

Positive Symptoms

This refers to experiences that are added to normal mental function. These include hallucinations—most often auditory, such as voices that comment or discuss the person in the third person. Visual and tactile hallucinations can also occur but are less common. Delusions are also part of this category: the patient may have fixed, unshakable beliefs not shared by others, such as being followed by an organization, thoughts being controlled by outside forces, or grandiose beliefs about having a special mission. Disorganized speech and behavior is another positive symptom—thought processes may become fragmented, leading to incoherent and erratic speech, and behavior may become bizarre or unstructured (e.g., odd clothing, stereotyped movements). Catatonic symptoms (abnormal motor behavior) are rarer but can include rigidity, immobility, or peculiar facial expressions and body postures. Positive symptoms are often the most dramatic and recognizable and usually lead to hospitalization.

Negative Symptoms

These refer to the loss or absence of normal functions. Common negative symptoms include social withdrawal, lack of initiative and motivation (avolition), emotional flatness (reduced facial expressions and vocal tone), and poverty of speech (alogia). The person may appear apathetic, indifferent, and isolated. Often, there is noticeable passivity—the patient may spend most of the day lying in bed or sitting at home without engaging in activities. Negative symptoms are particularly prominent after the first acute psychotic episode has resolved; many patients then develop a long-term blunting of emotional life and engagement. Negative symptoms are harder to treat than positive ones and contribute significantly to functional impairment in schizophrenia. It's important to note that these are not due to attitude or laziness—they result from underlying brain changes that impair the person’s capacity for motivation and emotional energy.

Cognitive Symptoms

Cognitive impairments have long been underestimated but are now recognized as a core component of schizophrenia. These include deficits in attention, working memory (the ability to hold information briefly), executive functions (planning, flexibility), and processing speed. Many patients also have impaired insight into their illness (anosognosia), which makes treatment cooperation difficult. Cognitive symptoms may manifest as difficulty understanding complex information, focusing on tasks, or adapting to changes in the environment. Impaired social cognition (mentalizing) makes it hard to interpret others’ intentions—some patients misread neutral communication as threatening or draw incorrect conclusions in social situations. Cognitive deficits often appear early in the disease course and persist between acute episodes. They are strongly linked to prognosis: studies show that cognitive dysfunction (more than the severity of hallucinations or delusions) best predicts the ability to work and function socially in the long term.

In clinical practice, diagnostic criteria (e.g., DSM-5 or ICD-10) require at least two of the main symptom types (positive/cognitive) to be present over an extended period. The diagnosis also requires a significantly reduced level of functioning for at least six months. These symptoms can vary in intensity over time.

Course of the Illness

Schizophrenia can follow highly variable courses in different individuals. Some have an acute onset with a brief, dramatic psychotic episode; others experience a gradual onset over years. Often, the disease follows a pattern of recurring episodes: periods of severe symptoms (acute phase) followed by calmer, stable phases with partial recovery. During stable periods, many can live relatively independently with proper support, although some symptoms (especially negative and cognitive) tend to persist to some extent. Unfortunately, many experience relapses, especially if they stop taking medication or new stressors arise. With each relapse, there is a risk of further decline in functioning. Early detection and treatment are therefore crucial—a short duration of untreated psychosis (DUP) at first onset is associated with better long-term outcomes. A small proportion (~10–15%) experience a single episode and recover almost fully—these cases may be considered full remission or even functional recovery. However, for most, schizophrenia becomes a long-term (often lifelong) condition with alternating periods of improvement and worsening. About 20–30% of patients experience relatively stable improvement over time with treatment, while another large group retains milder symptoms but can adapt, and about one-quarter have a chronic course with significant persistent symptoms and disability. Prognosis has somewhat improved compared to the past due to better treatments and social support, but schizophrenia is still considered one of the most serious mental illnesses.