The earliest signs and symptoms come before a diagnosis can be certain. There is a growing emphasis on identifying young people at high risk for a psychotic disorder (a general category that includes disorders such as schizophrenia and schizoaffective disorder), as well as offering treatment and services prior to a formal diagnosis of schizophrenia. At an early or “prodromal” 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. Some people may start to socially withdraw or feel that something is wrong and that their mind is playing tricks. Family members might notice that their loved one seems different in a manner that is difficult to describe. It is important to remember that these symptoms will not always progress to a diagnosis of schizophrenia and could represent a number of other issues. The presence of any of these symptoms represent a good time for clinical assessment and care in hopes of preventing a progression to a full first episode of psychosis.

During a first episode of schizophrenia, common symptoms include paranoia such as feeling that someone is following them or trying to control them, hearing voices or seeing visions. Inappropriate or unusual behavior, impulsive actions, mood swings, and thoughts and speech that are difficult to follow (described as disorganized thoughts) can also be present. Some people may experience other symptoms that look like depression such as low mood, low motivation, reduced experience of pleasure, anxiety, sleep disturbance, and social withdrawal.

It is important to remember that all the signs and symptoms can occur at a mild level in people who do not have schizophrenia or another psychiatric disorder. In order for a diagnosis to be made, the severity of the symptoms and their impact on function and resulting distress must be considered. Additionally, it is critical to rule out other possible causes of these symptoms before a diagnosis of schizophrenia can be made.

Substance use is a common issue in persons with schizophrenia, including cannabis, tobacco, alcohol and other drugs. Substance use comes with many health-related problems, but the presence of schizophrenia can lead to further complications. Patients may stop their medications if they feel it interferes with the perceived desired effect of cannabis or alcohol. Substance use can lead to worsened disorganized thinking and behavior. Cannabis increases the risk of schizophrenia in vulnerable young people and may complicate the course of schizophrenia. Impaired cognition is common in schizophrenia, and substance use can also adversely affect cognition, such as attention, memory, and ability to complete tasks.

All persons with schizophrenia will need medications some of the time, and most will do better with continued use of medication to help control symptoms and prevent relapse. The primary class of medications taken by those with schizophrenia are called antipsychotics, but many other medications such as antidepressants or mood stabilizers may be helpful in addition to antipsychotics. Medications are typically helpful with “positive” symptoms of schizophrenia which include hallucinations, paranoia, and disorganized thoughts and behavior. However, medications may not be effective for all aspects of the illness. Cognitive behavioral therapy may help with certain symptoms, and supportive psychotherapy can build upon personal strengths and improve quality of life. Vocational programs can increase the chances of successful employment. Family psychoeducation may 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 problems of daily living and other aspects of living with schizophrenia. New treatments such as neuromodulation are being developed, and drugs with novel mechanisms of action are being tested.

While treatment with medication is important, 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 in the long term for those with schizophrenia.

Negative symptoms refer to a decrease or absence of typical experiences and actions. Examples include reduced speech, low drive and motivation, decreased experience and expression of typical emotions, reduced pleasure in activities, failure to initiate activities, and withdrawal from social interaction.

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 which could include hallucinations. Ongoing support from loved ones and care with a provider are essential for detection and rapid intervention.