Schizophrenia

The most misunderstood diagnosis in medicine. It does not mean a split personality, and most people with it are far more likely to be harmed than to harm anybody.

What it is

A diagnosis given when psychosis has persisted, with a combination of hallucinations, delusions, disorganised thinking and what clinicians call negative symptoms: loss of motivation, flattened emotion, and withdrawal.

Two myths do most of the damage. It is not a split or multiple personality, which is a different thing entirely. And the association with violence is largely false: people with schizophrenia are several times more likely to be the victims of violence than the perpetrators, and far more likely to harm themselves.

The negative symptoms are usually what limits life, and they are the least treated. Antipsychotic medication works reasonably well on hallucinations and delusions and much less well on the loss of drive, which is the part families find hardest to distinguish from laziness or depression.

Physical health is where people die early. Life expectancy is fifteen to twenty years shorter than average, almost entirely from heart disease, diabetes, smoking and cancers that were found late, not from the psychiatric illness. That gap is the single most important fact in this entry.

Long duration of untreated psychosis predicts worse outcome, which is why Early Intervention in Psychosis services exist and why getting to them quickly matters.

Signs you might notice

Hearing voices, or seeing, smelling or feeling things others do not.

Fixed beliefs that are not shared by others and not shifted by evidence, often about being watched, followed or controlled.

Speech that is hard to follow, jumping between unconnected ideas.

Withdrawal, loss of motivation, self-neglect, and flattened emotional expression.

Before all of this, often a slow period of months of dropping out, changing sleep and losing interest, which is generally recognised only in hindsight.

Urgent: talk of suicide, plans to act on a belief that puts them at risk, refusing food or drink, or not sleeping for days.

Also urgent, and easily missed: a high temperature with muscle rigidity and confusion in somebody on antipsychotics. See serotonin syndrome and NMS.

How it can affect day-to-day life

Stigma changes what people are offered, not just how they feel. Physical symptoms get attributed to the mental illness, and chest pain, breathlessness or weight loss get investigated less thoroughly. Diagnostic overshadowing is the term, and being aware of it is half the defence.

Antipsychotics cause substantial weight gain, sedation and metabolic change. Stopping them is the commonest cause of relapse, and the reasons people stop are usually the side effects nobody asked about. Asking directly is more use than urging adherence.

Movement side effects, including restlessness and tardive dyskinesia, can be permanent and should be monitored rather than discovered.

Clozapine works when other treatments have not, and it requires regular blood tests. Missed monitoring, not the drug, is usually what ends it.

Many people recover substantially, work, have relationships and live independently. The picture families are given at diagnosis is often bleaker than the evidence supports.

Supporting someone well

Get to an Early Intervention in Psychosis service fast if this is a first episode. In England they accept self-referral in many areas.

Do not argue with a delusion and do not agree with it. Respond to the feeling, which is usually fear, and stay with the person.

Insist on the annual physical health check: weight, blood pressure, glucose, lipids, smoking and cancer screening. It exists precisely because this group dies early, and it is frequently not done.

Ask what the side effects are actually like, and ask for a medication review rather than a lecture on compliance.

Ask for a crisis plan and an advance statement written while the person is well, saying what helps, what does not, and who to call.

Ask for a carer's assessment. Families in this situation are often carrying a great deal with nothing formal in place.

Keep the person connected to work, study or something structured. Losing the day is what makes everything else harder.

Where to get help

A GP practice, the community mental health team, or an Early Intervention in Psychosis service for a first episode.

The local crisis team or NHS 111, option 2 in England, for a mental health crisis.

Rethink Mental Illness have the best written guides for families, including on the Mental Health Act.

Mind for general information and local services.

Samaritans on 116 123, any time.