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How to Spot 5 Early Signs of Schizophrenia

Early intervention has a profound effect on prognosis.

Key points

  • Schizophrenia presents early warning signs for months or years that aren't as obvious as hallucinations and delusions of the active phase.
  • Affect changes, isolation, suspiciousness, emergence of unusual thinking, and detachment usually preclude florid psychosis.
  • Noticing these precursors can lead to specialized early intervention of first-episode psychosis. This often has a profound effect on prognosis.
Source: Beatriz/Pexels

Imagine someone sitting on a park bench carrying on a discussion to thin air about encoded messages in the license plates of passing cars.

This is probably the type of image that comes to mind for many when they think "schizophrenia," perhaps the most known of the psychosis conditions. And it's not wrong. Candid responses to hallucinations and florid paranoia/delusions are indeed telltale. However, there is a much more expansive set of symptoms, some more subtle than others, especially at the outset when a first episode is taking hold. Recognizing the onset could save someone from a life of torment, or at least considerably reduce suffering.

Importance of Early Detection

While early detection may not completely erase someone's propensity for experiencing future episode onset (Seidman, 2017), preventing florid episodes can reduce "kindling effects." Kindling effects in psychiatry are like the kindling of fires; a smaller fire is initiated to encourage a more intense one. In schizophrenia, this would mean that previous episodes set the stage for successive ones being longer and more intense, and the sufferer eventually doesn't return to premorbid functioning during remission.

Despite the existence of kindling, the phenomenon doesn't appear to occur in all sufferers, as reviewed by Emsley et al. (2013). Regardless, given the pervasiveness of the illness at any level, whether it's keeping someone higher functioning during an episode and/or saving them from future deterioration, early detection is essential.

Thankfully, "first-episode psychosis" programs have increasingly taken hold in mental health care. Establishments such as the Center for Early Detection, Assessment, and Response to Risk (CEDAR) in the Boston area have worked as preemptive strikes against this perhaps most devastatingly pervasive of psychiatric conditions. In fact, researchers (e.g., Kane et al., 2015; Oluwoye et al., 2020; Kline et al., 2022) have consistently discovered a significant increase in long-term treatment cooperation and improved quality of life in psychosis sufferers who received early detection and intervention in such programs.

The Nature of Schizophrenia Development

It is interesting to note that rarely do people with schizophrenia have a family history of the disease (e.g., Seidman, 2017; APA, 2022). Symptoms usually begin for males in their late teens or early 20s, while females initiate signs in the mid-20s to early 30s. Exceptions do occur, with a small percentage of onset in earlier childhood and older adulthood. Further, there is rarely a rapid/acute onset of florid symptoms like hallucinations, delusions, and disorganized or catatonic behavior.

Any instant presentation of such symptomatology is likely indicative of an underlying medical complication, as written about in "Tips for Diagnostic Accuracy: Assessing for Medical Etiology." Usually, there is a precursor period, referred to as the "prodromal phase," when signs begin to arise, but the person is not acutely ill with a psychotic episode whereby they are guided by hallucinations, grossly disorganized, catatonic, etc. This prodromal period can last for months or years before a florid episode occurs.

I once worked with someone whose prodrome lasted throughout their 20s. They willingly sought therapy for "anxiety" about six months before their fragmented paranoia slipped into well-formed delusions and grossly-disorganized behavior. Unfortunately, as discussed by Kanahara (2013), like many psychosis sufferers whose illness develops very slowly, this patient's prognosis proved poor, even with comprehensive intervention.

5 Warning Signs of Budding Psychosis

1. Reduced or odd expressions. Alteration of facial expression, or affect, is a common symptom of schizophrenia. This is most commonly a reduction of the normal range of expressions, referred to as flattened or blunt affect. Unlike the flat affect in depression, there isn't necessarily a sadness or package of other depression symptoms associated with it.

Still others come to exhibit a peculiar affect. They may develop a constant slight grin or smirk, no matter the subject, or perhaps take to a slight grimacing appearance as if injured, though they're not in physical pain. Along with this change in expression, they may also begin to seem less articulate, and show a reduced use of voice intonation and gestures while talking.

2. Isolation. A reduced capacity to relate to others is a major component of schizophrenia, and begins within the prodromal phase. Insidious or fairly abrupt preference to isolate is a common occurrence in the prodromal phase. Patients have told me they developed a feeling of vulnerability, though not really paranoid, that made them feel sticking to themselves was best. Others have mentioned starting to feel like an outcast as a strange internal experience was taking shape and realizing they weren't like others.

Priscilla du Prees/Unsplash
Source: Priscilla du Prees/Unsplash

3. Suspiciousness/unusual thinking. While not yet paranoid in a fully delusional sense, individuals with budding psychosis often develop a suspiciousness of events going on around them or of others. Sometimes, it may be that they seemingly randomly unfold an interest in a topic or ability, like clairvoyance, and uncharacteristically speak of sensing events about to transpire.

It's not unusual, in the prodromal phase, that the individual "has it together enough to know they don't have it together." They can realize the thought is intrusive and not logical, but it nonetheless ebbs and flows, often for weeks or months, and they can't shake it.

I once worked with an inmate, Jerry (name disguised), for example, who, though not religious, exhibited a random curiosity about the second coming of Christ. After some weeks, Jerry confessed he couldn't help but wonder if Christ would embody a mortal as a conduit to Earth, and transform that mortal into Himself. One day, he seemingly mused, "It could happen to me," but his tone simultaneously conveyed a sense of questioning his reality. Jerry had been looking away as he spoke, then turned to me and concernedly asked, "Do you think that's possible?" A short time later, he was actively hallucinating and grossly paranoid about others knowing he was Christ, and how he could become a target.

4. Detachment. In the early phases of psychosis, people may describe a feeling of detachment. It is not a triggered dissociation like in PTSD flashbacks, but rather more of a feeling of depersonalization or derealization. This may or may not be evident to others, though the person may have an air of "something not being right" about their demeanor, perhaps seeming "spacey."

5. Appearing distracted. Further, the person may seem to pay attention to something we aren't aware of (i.e., hallucinations). Early on, these tend to be very fragmented experiences that distract the person, causing them to look away briefly in wonderment, for example, or stare off as if trying to perceive something they're not sure of. Perhaps they uncharacteristically start asking if someone called them, or "Did you hear that, too?"

If someone is displaying the above items, it deserves thorough evaluation, especially if more than one occur together and the person has other risk factors. These include:

  • Family history of the disease.
  • Their gestation was largely in the winter (e.g., Tochigi, 2004; APA, 2022).
  • History of regular use of potent cannabis (e.g., Hall, 2015; Quattrone et al., 2020; Hjorthøj et al., 2021).
  • History of being prescribed stimulants as in ADHD treatment (e.g., Pallanti & Salerno, 2015; Björkenstam, 2020).

Disclaimer: The material provided in this post is for informational purposes only and not intended to diagnose, treat, or prevent any illness in readers or people they know. The information should not replace personalized care from an individual's provider or formal supervision if you’re a practitioner or student.

To find a therapist, please visit the Psychology Today Therapy Directory.

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American Psychiatric Association, (2022). Diagnostic and statistical manual of mental disorders (5th ed, text revision.)

Björkenstam, E., Pierce, M., Björkenstam, C., Dalman, C., & Kosidou, K. (2020).
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Hjorthøj C., Posselt, C.M., & Nordentoft, M. (2021). Development over time of the population-attributable risk fraction for cannabis use disorder in schizophrenia in Denmark. JAMA Psychiatry, 78(9), 1013–1019. doi:10.1001/jamapsychiatry.2021.1471

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Kline, E. et al., (2021). “Real-world” first-episode psychosis care in Massachusetts: Lessons learned from a pilot implementation of harmonized data collection. Early Intervention in Psychiatry,

Oluwoye, O. et al., (2019). Preliminary evaluation of Washington state’s early intervention program for first-episode psychosis. Psychiatric Services,

Pallanti, S. & Salerno, L. (2015). Raising attention to attention deficit hyperactivity disorder in schizophrenia. World Journal of Psychiatry, 5(1),47-55. doi: 10.5498/wjp.v5.i1.47. PMID: 25815254; PMCID: PMC4369549.

Quattrone, D., et al., (2021). Daily use of high-potency cannabis is associated with more positive symptoms in first-episode psychosis patients: The EU-GEI case–control study. Psychological Medicine, 51 (8), 1329-1337. doi:10.1017/S0033291720000082

Seidman, L.J. (2017, April 12). From high risk state to first episode psychosis: Scientific and clinical developments. Early Psychosis Professional Educational Event. University of Massachusetts Medical School, Worcester, MA.

Tochigi, M., Okazaki, Y., Kato, N., & Sasaki, T. (2004). What causes seasonality of birth in schizophrenia? Neuroscience Research, 48 (1), 1-11.

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