Signs of schizophrenia and early psychosis

Schizophrenia is a serious mental illness that changes how a person thinks, feels and acts. A person may seem to lose touch with what is real. This can be frightening for the person and for the family around them.^1,2 The signs can be hard to spot, because they often start slowly and look like other things, such as stress, depression or just "a phase."

This page explains the three groups of symptoms, the early warning signs that often come first, what a first episode of psychosis looks like, and when to get help. Early care leads to better recovery, so knowing the signs matters.^2,3

What is psychosis, and how is it different from schizophrenia?

Psychosis is a group of symptoms, not a disease on its own. A person with psychosis has trouble telling what is real from what is not.² It can come from schizophrenia, bipolar disorder or severe depression. It can also come from lack of sleep, some medicines, and alcohol or drug use. In later life it can come with illnesses of the brain such as Parkinson's disease or Alzheimer's disease.²

Schizophrenia is one condition that includes psychosis. About 1 in 300 people worldwide live with it. It usually begins in the late teens or twenties and tends to start earlier in men than in women.⁴ To learn more, see the overview of schizophrenia and psychosis.

The three groups of symptoms

Doctors often sort symptoms into three groups. A person may have some, all or only a few. Symptoms can also come and go.

Psychotic (positive) symptoms

These are called "positive" because they are things added to a person's normal experience. They do not mean "good."³

• Hallucinations are seeing, hearing, smelling, tasting or feeling things that are not there. Hearing voices is the most common. They feel completely real to the person. Some people hear voices for a long time before anyone notices.^1,3
• Delusions are strong beliefs that are not true and do not change, even when shown clear facts. A person may believe others are trying to harm them, or that a TV show or radio program holds a special message just for them.^1,3
• Disorganized thinking and speech means thoughts that jump around or do not connect. A person may stop in the middle of a sentence, switch topics, or make up words that have no meaning.¹
• Some people also feel that an outside force controls their thoughts or actions. Some have agitation, odd body movements or strange postures.⁴

Negative symptoms

These are called "negative" because something is taken away or turned down. They are easy to miss, and family members often read them as laziness or a bad attitude. They are not.^1,3

• Trouble planning or finishing everyday tasks, such as grocery shopping
• Less interest and less enjoyment in daily life
• A flat, quiet voice and little change in facial expression
• Pulling away from people, or awkward contact
• Very low energy and long stretches of doing nothing

Negative symptoms can look like depression. A doctor can help tell the two apart.^1,3 Rarely, a person may stop moving or speaking for a time. This is called catatonia and needs medical care.^1,3

Cognitive symptoms

"Cognitive" means thinking skills. People with schizophrenia may have trouble with:¹

• Paying attention and staying focused
• Using new information right after learning it (working memory)
• Taking in information to make decisions

These problems are not about intelligence. They can still make work, school and daily tasks hard. How well a person thinks is one of the best clues to how well they manage day to day, so this group of symptoms matters a lot.¹

Early warning signs (the prodrome)

Before the first full episode, many people go through a stretch of slow change. Doctors call this the prodrome. It can last months or even years. The changes are usually vague at first.^1,3

Signs that families and friends often notice include:^2,3

• Pulling away from friends and spending much more time alone
• Suspicion, unease around others or odd new ideas
• Trouble thinking clearly or following a conversation
• A sudden drop in grades or job performance
• Sleep changes, such as trouble falling asleep or sleeping much less
• Less care for hygiene and appearance
• Flat feelings, or strong feelings that do not fit the moment
• Irritability, anxiety or low motivation

Many teens and young adults have some of these signs and never develop schizophrenia. A large review followed about 9,200 people judged to be at "clinical high risk" for psychosis. About 1 in 4 developed psychosis within 3 years. That means about 3 in 4 did not.⁷ Having a parent or sibling with schizophrenia raises the chance more than sixfold, but most people with an affected relative never develop it.³

The key is to watch, and to ask for a checkup if changes grow stronger or do not go away.² Learn more on causes and risk factors.

First-episode psychosis

The first time a person has full psychotic symptoms is called a first episode. It often begins in the late teens to mid-20s, but it can happen at any age.² Men tend to be diagnosed in late adolescence to the early twenties, and women in the early twenties to early thirties. Diagnosis is uncommon before age 12 or after age 40.^3,6

Untreated psychosis often goes on for more than a year before treatment starts. Shorter delays are linked to better recovery.² Some people who get treatment early never have another episode. Others have symptoms return but still live full and productive lives.²

Teams called coordinated specialty care programs are built for first-episode psychosis. They combine medicine, talk therapy, family support, and help with work or school. The American Psychiatric Association recommends this type of care for a first episode.⁹ You can read more in therapy and recovery.

How doctors decide it is schizophrenia

There is no single test. A doctor listens to the person's story, talks with family when the person agrees, and rules out other causes, such as medicines, drug use or a medical illness. In general, a person needs at least two core symptoms for a good part of one month, and problems with daily life lasting at least 6 months.³ The full steps are on the page about getting diagnosed.

Psychosis in older adults

Schizophrenia usually starts when people are young. A first psychotic episode after about age 40 is not typical, and it deserves a full medical checkup.³ Seeing things or having false beliefs for the first time in later life can come from dementia, delirium (sudden confusion from an illness or medicine), Parkinson's disease or Lewy body disease, or side effects of a medicine.² Read more in psychosis and schizophrenia in later life and hallucinations, delusions and paranoia in dementia.

Myths and facts

What to read next

• Schizophrenia and psychosis overview
• Causes and risk factors
• Getting diagnosed and related conditions
• Antipsychotic medicines
• Therapy and recovery
• Helping a family member with psychosis
• Psychosis and schizophrenia in later life
• Signs of mania, hypomania and bipolar depression, because mania can also cause psychosis

When to get help

See a doctor soon if you or someone you love shows several of the early warning signs above and they last more than a couple of weeks or get stronger. A primary care doctor is a good first step. They can check for other causes and refer you to a mental health professional.¹ You can also use our mental health check-in and read about finding help.

To find early psychosis programs near you, use the Early Serious Mental Illness Treatment Locator from SAMHSA, or FindTreatment.gov.¹⁰ The NAMI HelpLine (1-800-950-6264, weekdays) can also point you to support.³

Our guide for a family member in a mental health crisis explains what to expect. Making a safety plan while things are calm can help.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.