The Phases Of Schizophrenia: Symptoms And Treatment Options

Those unfamiliar with schizophrenia might assume that its symptoms remain unchanged without treatment or progressively worsen over time. However, clinicians treating individuals with schizophrenia often observe a cyclical pattern in which psychotic symptoms increase and decline in distinct phases. The characteristic course of this mental health disorder can shape its diagnosis and treatment.

The initial phase of schizophrenia usually involves shifts in mood and behavior that may be hard to distinguish from other conditions. As the individual shifts into the second phase, their positive or psychotic symptoms, such as hallucinations, delusions, and disorganized thinking, tend to become more pronounced. The third phase can involve a combination of positive and negative symptoms. Some people, though not all, may eventually relapse and enter a new active episode — a pattern that can recur many times if left untreated. However, schizophrenia can often be effectively managed with a combination of doctor-prescribed medication and therapy.

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The lifelong course of schizophrenia

According to the American Psychiatric Association, schizophrenia is a chronic disorder with no permanent cure. However, this doesn’t mean that the symptoms will be unchanged throughout a person’s lifespan. 

Unlike some other disorders strongly linked to genetics and neurological development, schizophrenia is usually not apparent during childhood. Research suggests that the typical age of onset is around 21 to 25 for males and 25 to 30 for females. 

The type and severity of symptoms related to this mental illness may vary throughout a person’s life. Many individuals experience repeated shifts between periods of relative lucidity and periods of intensely disordered cognition, perception, and behavior.  

Symptoms of schizophrenia: Cognitive, negative, and psychotic symptoms

Researchers and mental health professionals may classify the symptoms of schizophrenia into three distinct categories:

1. Positive or “active” symptoms:  Also referred to as “psychotic” symptoms, this category generally includes delusions, hallucinations, and disordered thinking, speech, and behavior. Positive symptoms can also include catatonia, a pattern of suppressed or repetitive motor activity. Positive symptoms are often the most noticeable signs of schizophrenia, sometimes involving highly atypical actions. 
2. Negative or “passive” symptoms: Symptoms in this category usually involve the absence, diminishment, or impairment of typical mental and behavioral function. Common negative symptoms can include a lack of emotional responsiveness, limited speech, lack of motivation or interest in everyday activities, and decreased ability to experience enjoyment and pleasure.
3. Cognitive impairment: Many people with schizophrenia also exhibit decreased proficiency at certain types of cognitive tasks. Compared to healthy individuals, they may have slower reaction times, greater difficulty maintaining focused attention, less working memory capacity, and more challenges with decision-making and behavioral control.

These categories of symptoms may vary in severity throughout the different phases of schizophrenia.

Phase 1 of schizophrenia: The prodromal phase

Estimates suggest that in around 75% of cases, the onset of schizophrenia is preceded by a preliminary period in which the individual may display noticeable changes in behavior, mood, and thinking, but doesn’t yet meet the criteria for a clinical diagnosis. 

The boundaries of this early stage can be hard to clearly define, but research suggests the average duration may be around 21 months. Individuals may show psychotic symptoms below the clinical threshold for as long as one year before the emergence of active schizophrenia. Cognitive and mood-related symptoms may present much earlier. 

Prodromal phase symptoms

Negative symptoms, such as apathy, blunted emotional responses, and social withdrawal, tend to emerge earlier than positive ones. These early symptoms may be harder to identify as signs of schizophrenia, since similar changes can also be observed in conditions like depression or anxiety disorders. Life-course analyses show that the misdiagnosis of schizophrenia can be common in the early stages.

Phase 2: The active phase, when symptoms of psychosis are more pronounced

Sometimes referred to as the “acute phase,” this period is usually when the positive symptoms of schizophrenia become more pronounced, frequent, and debilitating. A person in this state may no longer be able to distinguish between hallucinatory perceptions and reality, and they may fail to recognize when their beliefs or thoughts are unusual. Their behavior may become significantly more erratic and at odds with social norms. 

Because positive symptoms are required for a clinical schizophrenia diagnosis, the condition is most often identified during the acute stage. The diagnosis of schizophrenia normally requires the presence of active symptoms for at least one month. However, within the course of their lifetime, a person with this condition may experience periods of days, weeks, or, in rare cases, multiple months in the active stage.

Active symptoms

Types of symptoms seen in active-stage schizophrenia may include the following:

• Vivid hallucinations: The person may clearly perceive things that aren’t there. The most common form tends to be auditory hallucinations, which can involve commentary on an individual’s behavior or commands to do things. Visual hallucinations can also be fairly common, and some people may also hallucinate tactile sensations, smells, or tastes.
• Persistent delusions: The person may be convinced of unusual ideas that don’t correspond to reality. Delusions of persecution and control can be common. Examples may include the belief that extraterrestrials disguised as humans are conspiring to ruin the person’s life or that their actions are being controlled by machinery implanted by government agents. 
• Highly disorganized speech and behavior: The person may perform actions that are hard to understand and seem to be directed toward a purpose that does not correspond to reality. Communicating with them can be difficult because their speech may not follow a logical train of thought.
• Catatonia: Some people with schizophrenia may exhibit a disruption of motor function known as catatonia. This can involve a pronounced lack of intentional movement in which the individual sits still for long periods and remains in any position into which they’re moved. They may also repeat gestures or mimic the speech or actions of others.

Phase 3: The residual phase of schizophrenia

Following an active phase of schizophrenia, an individual’s positive symptoms will typically become less severe, but most will still display one or more persistent negative symptoms. These can continue to pose difficulties for the person’s daily function and quality of life. 

This stage is sometimes referred to as the “recovery phase,” especially when it follows the successful treatment of positive symptoms like delusions and hallucinations using antipsychotic medications. This may be misleading, though, because entering a residual stage does not necessarily predict long-term recovery. 

Many people with schizophrenia relapse after several months or years, returning to the active stage. Some estimates suggest that roughly 82% of individuals may relapse within the first five years following treatment. More frequent relapse can be associated with less desirable social, financial, and physical health outcomes.

Residual symptoms

Symptoms in the residual phase are often similar to those in the schizophrenia prodrome. The most common tend to include limited emotional expression, cognitive impairment, and social isolation. 

Some features of the active stage may persist in the residual stage, though usually at a decreased intensity. For example, a person might continue to experience occasional faint hallucinations. However, during the residual stage, they may be better able to distinguish between real and unreal perceptions than during active episodes.

Therapy can make living with schizophrenia more manageable

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Treatment in different phases of schizophrenia

Appropriate treatment for schizophrenia may vary considerably depending on the stage. If the prodromal stage is recognized in time, early treatment with psychotherapeutic methods like cognitive-behavioral therapy may prevent the transition into active psychosis. Researchers are also exploring possible medication targets, such as neuronal glutamate receptors or the oxidative stress response.

Once someone with schizophrenia enters the active stage, treatment with antipsychotic medication may be necessary to relieve positive symptoms like delusions and hallucinations. Many clinical practice guidelines recommend the use of long-lasting injectable medicines when possible. This can reduce the chance that an individual relapses due to forgetting or declining to take a prescription. Always consult your doctor regarding medication options. The information in this article is not a replacement for medical advice.

Seeking regular mental health support in the residual stage

During the residual phase, it may be helpful for people with schizophrenia to meet regularly with mental health professionals who may be able to offer assistance in managing symptoms like depression or difficulty with social function. Regular interaction with a clinician can also make it more likely that someone will spot symptoms indicating the risk of relapse.

Online therapy may be a useful option for people with schizophrenia whose symptoms or life circumstances make it challenging to attend in-person appointments. It’s often easier to maintain a regular therapy schedule when you can meet remotely. However, online therapy may be most suitable for individuals in the prodromal or residual phases, as those in the active phase of schizophrenia may require in-person care. 

Some clinical evidence indicates that internet-based treatment can be useful in managing schizophrenia. In one trial reported in the journal Schizophrenia Research, an online cognitive-behavioral therapy program often reduced depression and relieved positive symptoms in people with this disorder.