Written & medically reviewed by Dr. Fazal Ullah, FCPS (Psychiatry) — last reviewed 2026-09-11
Schizophrenia: Symptoms, Early Signs, Causes, Diagnosis and Treatment
Written & medically reviewed by Dr. Fazal Ullah, FCPS (Psychiatry), Consultant Psychiatrist & Assistant Professor of Psychiatry.last reviewed 2026-09-10 Schizophrenia is a serious but treatable psychiatric illness that changes how a person thinks, perceives and relates to the world. It usually begins in the late teens or twenties, often quietly, and is frequently mistaken for stress, laziness, a phase of adolescence or a spiritual problem. In Pakistan, research shows it commonly goes untreated for more than a year before a family reaches a psychiatrist.
That delay matters. The earlier schizophrenia is recognised and properly treated, the better the long-term outlook and with the right care, many people return to their studies, work and family life.
Key points
Schizophrenia affects around 1 in 345 people worldwide, and most often begins between late adolescence and the early thirties. Its symptoms fall into three groups: positive symptoms (hallucinations, delusions), negative symptoms (loss of motivation, emotion and speech) and cognitive symptoms (memory and concentration). There is no blood test or scan for schizophrenia. Diagnosis is made by a psychiatrist through a detailed clinical assessment. Treatment combines antipsychotic medication, family involvement, psychological therapy and regular follow-up. According to the World Health Organization, at least one in three people with schizophrenia recovers fully, and many more achieve long-term stability. Stopping medication is the most common reason the illness returns.
Worried about yourself or a family member? You can book an online psychiatric consultation with Dr. Fazal Ullah from anywhere in Pakistan, in Urdu, English, Pashto, Sindhi, Balochi or Brahui.
What is schizophrenia?
Schizophrenia is a long-term mental illness in which a person experiences psychosis — periods of losing contact with shared reality — along with changes in motivation, emotional expression and thinking ability. In Urdu it is written شیزوفرینیا, and families often describe it in everyday terms: dimagh ka tawazun bigar jana, or simply "hearing voices".
Two misconceptions are worth clearing up at the start.
Schizophrenia does not mean a "split personality". That is a different and far rarer condition. The "split" in the original Greek term referred to a disconnection between thinking, emotion and perception — not to two separate personalities.
Schizophrenia is also not a character weakness, the result of poor upbringing, or something a person can decide to snap out of. It is a medical condition of the brain, and it responds to medical treatment.
How common is schizophrenia?
The World Health Organization estimates that schizophrenia affects about 23 million people worldwide — roughly 1 in 345 people overall, and about 1 in 233 adults. Onset is most common in late adolescence and the twenties, and it tends to begin earlier in men than in women.
Robust national figures for Pakistan are limited. If the global rate applies, several hundred thousand people in the country are living with the condition — most of them young adults at the stage of life when education, careers and marriages are being built.
The problem of delayed treatment in Pakistan
Research from Pakistan consistently shows long delays between the first symptoms and the start of treatment:
A study of patients with schizophrenia at the Aga Khan University in Karachi found an average duration of untreated psychosis of about 64 weeks — well over a year with financial difficulty cited by 29% of families as a reason for delay. A 2023 study of care pathways in Karachi reported clinicians describing delays of one to three years, with stigma, low awareness among families and first visits to faith healers named as major barriers. A 2026 study from Peshawar found that spiritual explanations for symptoms and fear of stigma continue to shape where families first seek help.
Globally, the WHO reports that only 29% of people with psychosis receive specialist mental health care. Longer periods of untreated psychosis are consistently linked with slower and less complete recovery, which is why early recognition is one of the most useful things a family can do.
Early warning signs of schizophrenia
Before the first obvious psychotic episode, many people pass through a period of subtle change lasting weeks, months or occasionally longer. Psychiatrists call this the prodrome. Families usually notice it before the person does. Common early signs include:
Withdrawing from friends and family, or spending long hours alone in a room A marked drop in performance at school, university or work — or dropping out altogether Disturbed sleep, or sleeping at unusual hours Neglecting personal hygiene and appearance Growing suspiciousness — feeling watched, followed or talked about A new preoccupation with unusual ideas that feels out of character for the person Flat or odd emotional reactions, or new irritability Difficulty concentrating, and speech that is harder to follow Starting to use cannabis (charas) or other drugs
None of these signs is specific to schizophrenia. They also occur with depression, anxiety, substance use and ordinary difficulties of adolescence. That is precisely why an assessment by a psychiatrist is valuable: the aim is to tell these possibilities apart early, not to attach a label.
Symptoms of schizophrenia
Psychiatrists group the symptoms of schizophrenia into three categories. Not everyone experiences all of them, and their severity changes over time.
Positive symptoms
"Positive" does not mean good. It means experiences that are added to normal experience.
Hallucinations are perceptions without an external source. The most common is hearing voices — voices that comment on what the person is doing, talk to each other about them, or give commands. Hallucinations can also involve sight, smell, taste or touch.
Delusions are fixed false beliefs that the person holds with complete conviction despite clear evidence to the contrary. Common themes include being persecuted, poisoned or followed; believing that television or strangers are sending personal messages; or holding grandiose beliefs about special powers or identity.
An important point in the Pakistani context: a belief is not a delusion simply because it involves the supernatural. Belief in jadu, nazar or jinn is shared by many people in our culture and is not in itself a sign of illness. A psychiatrist assesses whether a belief is out of keeping with the person's own cultural and religious background, how fixed and idiosyncratic it is, and whether it comes with other symptoms of psychosis. This is one reason an assessment in the person's own language, by a clinician who understands the culture, matters.
Passivity experiences are the sense that one's thoughts, feelings or actions are not one's own — that thoughts are being inserted into or removed from the mind, broadcast to others, or that the body is being controlled by an outside force.
Disorganised thinking and speech may appear as answers that drift off the point, jumps between unconnected ideas, or in severe cases speech that is very difficult to follow.
Disorganised or catatonic behaviour can range from unpredictable or purposeless actions to extreme slowing, unusual postures, or not responding at all.
Negative symptoms
Negative symptoms are the loss of normal functions:
Reduced motivation and difficulty starting or finishing tasks Reduced speech Flattened emotional expression Loss of interest and pleasure Social withdrawal
Negative symptoms are often misread as laziness, disobedience or ingratitude, and they are a major source of conflict at home. In the long term they are frequently more disabling than hallucinations. Recognising them as part of the illness — not a choice — changes how a family responds.
Cognitive symptoms
Many people with schizophrenia have difficulties with attention, memory, planning and problem-solving. These are less visible than voices but often explain why returning to study or work is hard, and they deserve attention in rehabilitation.
Insight
Many people with schizophrenia do not recognise that they are unwell, particularly during an acute episode. This is not stubbornness or denial in the everyday sense; reduced insight is itself part of the illness. Understanding this helps families avoid arguments that go nowhere and focus instead on keeping the person engaged with care.
Is it schizophrenia — or jinn, saya or jadu?
For many families in Pakistan, this is the first question, and it deserves a respectful answer.
Faith and prayer are a source of strength for a great many families, and nothing in psychiatric treatment asks anyone to give them up. The difficulty arises only when spiritual treatment replaces medical assessment rather than accompanying it. Research from both Karachi and Peshawar has found that families frequently consult faith healers first, and that this is one of the factors that delays treatment — often by months or years. During that time the illness continues, and studies, relationships, and sometimes safety, deteriorate.
Some practices used to "drive out" spirits — physical restraint, beating, or depriving a person of food or sleep — cause real physical and psychological harm to someone who is already unwell.
A practical and widely accepted approach is dua bhi, dawa bhi — pray, and seek medical treatment. The two are not in competition.
What causes schizophrenia?
Research has not identified a single cause. Schizophrenia appears to result from an interaction between genetic vulnerability and environmental factors:
Genetics. Having a close relative with schizophrenia increases risk. Even so, most people with an affected relative never develop the illness. Brain development and brain chemistry. Differences in brain development and in dopamine signalling are involved; antipsychotic medicines act on these dopamine systems. Pregnancy and birth complications are associated with a modestly increased risk. Cannabis. Heavy cannabis use, particularly starting in adolescence, is associated with an elevated risk of schizophrenia and can trigger relapse in people who already have it. Stimulant drugs. Methamphetamine (commonly called "ice" or crystal) can cause psychosis directly and can unmask or worsen schizophrenia in vulnerable people. See our page on addiction and dual-diagnosis care. Stress and adversity. Childhood adversity and major life stress are associated with onset and relapse, although they do not cause schizophrenia on their own.
Schizophrenia is not caused by bad parenting, weak faith, or anything the person or their family did wrong.
Schizophrenia, psychosis and related conditions
Psychosis is a state; schizophrenia is one illness that causes it. Psychosis can also be caused by:
Bipolar affective disorder, during severe manic or depressive episodes Severe depression with psychotic features Drug-induced psychosis, particularly from cannabis and stimulants Medical conditions such as infections, thyroid disease, epilepsy, head injury or autoimmune illness Psychosis following childbirth (postpartum psychosis), which is a psychiatric emergency Dementia and delirium in older adults
Related psychotic disorders include brief psychotic disorder, schizophreniform disorder, schizoaffective disorder (where psychotic and mood symptoms occur together) and delusional disorder. Distinguishing between them matters because the treatment and outlook differ.
What happened to "paranoid schizophrenia"?
Many people still search for "paranoid schizophrenia" or other subtypes. The major diagnostic systems — the American Psychiatric Association's DSM-5 and the WHO's ICD-11 — no longer use these subtypes, because they proved unstable over time and did not guide treatment. Psychiatrists now describe the specific pattern and severity of symptoms a person experiences instead.
How is schizophrenia diagnosed?
There is no blood test, brain scan or online quiz that can diagnose schizophrenia. The diagnosis is clinical, made by a psychiatrist on the basis of a careful assessment. A thorough assessment covers:
The history of the illness — when changes began, how they developed, and how they affect daily life A mental state examination — a structured assessment of thoughts, perceptions, mood and cognition carried out through conversation Information from family members, with the patient's consent, since relatives often notice changes the person does not report Substance use, including cannabis, stimulants and alcohol Medical history and current medicines, since some physical conditions and medicines can cause psychotic symptoms Family psychiatric history Risk — to the person themselves and to others Physical investigations where appropriate, such as blood tests to exclude thyroid, metabolic or infective causes, and occasionally brain imaging or an EEG when there are specific clinical indications. These can be arranged at a laboratory or hospital near the patient.
Duration also matters. Under ICD-11, symptoms must be present for at least a month; DSM-5 requires signs of illness for six months, including a month of active symptoms. For this reason, a first episode is often described initially as first-episode psychosis, with the diagnosis refined as the course becomes clearer. A careful psychiatrist does not rush to a lifelong label — nor delay treatment while waiting for certainty.
How is schizophrenia treated?
The goal of treatment is not only to quieten hallucinations. It is recovery: returning to study or work, maintaining relationships, living as independently as possible, and staying well. International guidance — including that of the WHO and the UK's National Institute for Health and Care Excellence (NICE) — recommends combining several approaches.
Antipsychotic medication
Antipsychotic medication is the foundation of treatment. It reduces positive symptoms such as voices and delusions and substantially lowers the risk of relapse.
There are several antipsychotic options, with different side-effect profiles. The choice depends on the person's symptoms, physical health, previous response to treatment and — importantly — their own preferences, because a medicine only works if the person is willing to keep taking it. Medication can be taken as daily tablets or, for some people, as a long-acting injection given every few weeks, which can be very helpful when remembering tablets is difficult or insight fluctuates.
Agitation and sleep often improve first; the full effect on hallucinations and delusions builds over weeks to months.
Antipsychotics can cause side effects, including weight gain, raised blood sugar and cholesterol, sleepiness, muscle stiffness or restlessness, and hormonal effects. For this reason, good care includes regular monitoring of weight, blood pressure, blood glucose and lipids, and sometimes an ECG. Side effects are a reason to review treatment with your psychiatrist not a reason to stop suddenly.
Specific medicines and doses are individual clinical decisions and are not discussed here; they belong in a consultation.
Treatment-resistant schizophrenia
For a significant minority — commonly estimated at around one in four to one in three people — symptoms do not respond adequately to standard antipsychotics. Before reaching this conclusion, a psychiatrist checks whether the medicine was taken regularly at an adequate dose for long enough, whether substance use is interfering, and whether the diagnosis is correct.
Where the illness has not responded to at least two different antipsychotics, NICE guidance recommends clozapine, a medicine that is particularly effective in treatment-resistant schizophrenia. It requires regular blood tests for safety, and it can transform outcomes for people who have been unwell for years.
Psychological therapies Cognitive behavioural therapy for psychosis (CBTp) helps people understand and cope with distressing voices and beliefs. NICE recommends it be offered to people with schizophrenia, delivered one-to-one over at least 16 planned sessions. Family intervention structured work with the family over at least ten sessions — improves communication, reduces stress at home and lowers relapse rates. A randomised trial from Pakistan found that psychoeducation for families reduced the burden of caring. Psychoeducation for both patient and family covers what the illness is, how treatment works, and how to recognise early warning signs. Rehabilitation and physical health
Recovery also involves practical support: rebuilding daily routine, life skills, and supported return to education or employment. Physical health deserves equal attention — the WHO reports that people with schizophrenia die around nine years earlier than the general population, often from heart disease, diabetes and infections. Stopping smoking, staying active, eating well and regular health checks are part of treatment, not optional extras.
Can schizophrenia be cured?
Schizophrenia is usually a long-term condition, but it is very treatable, and the outlook is considerably better than most people assume. According to the WHO, at least one in three people with schizophrenia experiences complete remission of symptoms. Others have episodes separated by long periods of stability, and a smaller group has more persistent symptoms that still improve with the right treatment.
Many people with schizophrenia study, work, marry and raise families. The factors that most improve the outlook are early treatment, continuing treatment once well, family support, and avoiding cannabis and other drugs.
Why does schizophrenia relapse and how can you prevent it?
The single most common reason for relapse is stopping medication. A major meta-analysis published in The Lancet found that, over a year, about 27% of people who continued antipsychotic medication relapsed, compared with about 64% of those who stopped. Other common triggers include cannabis and stimulant use, major stress, disrupted sleep and missed follow-up appointments.
A relapse prevention plan, agreed between the patient, family and psychiatrist, should cover:
Personal early warning signs for many people, the first signs are poor sleep, withdrawal, suspiciousness or the return of faint voices What to do if those signs appear, including contacting the psychiatrist promptly rather than waiting for the next scheduled review Continuing follow-up even when well stable periods are when the most useful planning happens Never stopping medication suddenly any change should be planned with your psychiatrist and monitored closely Guidance for families and carers
Families in Pakistan carry most of the day-to-day care for people with schizophrenia. Some approaches consistently help:
Learn about the illness. Understanding that negative symptoms and poor insight are part of schizophrenia reduces blame and conflict. Don't argue with delusions — but don't agree with them either. Acknowledge the feeling instead: "That sounds frightening. I'm here." Keep the atmosphere at home calm. Research consistently links high levels of criticism and hostility at home with relapse. Warmth and patience are protective. Support treatment without turning it into a battle. Help with routines and reminders, and attend appointments where the patient agrees. Keep medicines stored safely, and know which warning signs mean urgent help is needed. Understand that marriage is not a treatment. It is sometimes suggested that marriage will "settle" someone who is unwell. Major life decisions are best made when the person is stable, with honesty between families and, where helpful, advice from the treating psychiatrist. Look after yourself. Caring for someone with a serious illness is demanding, and carers' own mental health matters. If you are struggling, a consultation for yourself is appropriate too. When is schizophrenia an emergency?
Go to the nearest hospital emergency department or call emergency services (Rescue 1122 where available) if the person:
Talks about, plans, or attempts suicide or self-harm Hears voices telling them to harm themselves or others Makes threats or behaves violently Stops eating or drinking, or becomes unresponsive or frozen in posture Develops high fever, severe muscle stiffness and confusion while taking antipsychotic medication, which can signal a rare but serious medical reaction Is unable to look after their basic needs or safety
Online consultation is not appropriate in these situations. Acute psychosis with risk requires urgent in-person assessment and often hospital admission.
Can schizophrenia be managed through online consultation?
For much of schizophrenia care, yes with clear limits.
Psychiatric assessment depends on a detailed history, a mental state examination and the family's account, all of which transfer well to secure video. Ongoing management reviewing response to treatment, side effects, early warning signs, adherence and physical health monitoring — is particularly well suited to online follow-up.
This matters because long-term follow-up is where many families struggle. When the nearest psychiatrist is a long journey away, appointments are missed, prescriptions lapse, and relapse follows. Online care removes the travel, the waiting room and the fear of being recognised, which makes consistent follow-up far easier to maintain over years.
An initial assessment can often begin online, especially when a family member can join the call. Where in-person assessment, investigations or hospital care are needed at any point, your psychiatrist will say so plainly and help you arrange it. Blood tests and other monitoring can be done at a local laboratory, with results reviewed during your consultation.
Why families across Pakistan choose PsychConnect for schizophrenia care
Schizophrenia care is measured in years, not single appointments. PsychConnect is built around what long-term care actually requires:
Consultant-level care from the first appointment. Every consultation is with Dr. Fazal Ullah, FCPS (Psychiatry), a Consultant Psychiatrist and Assistant Professor of Psychiatry, registered with the Pakistan Medical Commission (PMC 4556-B). Continuity. You are reviewed by a consultant who knows your history essential in an illness where subtle early changes are what predict relapse. Assessment in your own language. Consultations are available in Urdu, English, Pashto, Sindhi, Balochi and Brahui. Subtle changes in thinking and speech are best assessed in a person's first language, and families can describe what they have seen without anything being lost in translation. Family involvement, even across cities. With the patient's consent, relatives in different cities can join the same video consultation. Privacy. No waiting room and no risk of being recognised locally a real consideration where stigma still keeps families from seeking help. Nationwide reach. Patients in every province and territory book on the same terms, including areas where specialist psychiatric care is hard to reach. Evening availability. Consultations run Monday to Saturday, 10:00 AM to 10:00 PM (PKT), so follow-up does not have to compete with work or study. Evidence-based practice. Care follows international guidance from the WHO and NICE, informed by academic work at the Balochistan Institute of Psychiatry and Behavioral Sciences and clinical experience in Pakistan and the Republic of Ireland. Transparent fees and honest limits. Fees are shown before booking, and you will be told directly if your situation needs in-person or hospital care.
Learn more about schizophrenia care at PsychConnect · How online consultation works · Services and fees
Speaking to a psychiatrist
I am Dr. Fazal Ullah, Consultant Psychiatrist and Assistant Professor of Psychiatry, FCPS (Psychiatry) from the College of Physicians and Surgeons Pakistan, and a faculty member at the Balochistan Institute of Psychiatry and Behavioral Sciences. I am registered with the Pakistan Medical Commission (4556-B) and provide online psychiatric consultation to patients throughout Pakistan in Urdu, English, Pashto, Sindhi, Balochi and Brahui.
If you or your family have noticed withdrawal, suspiciousness, unusual beliefs, hearing voices, or a decline in functioning that has no clear explanation, a full psychiatric assessment is worth arranging sooner rather than later. If a diagnosis of schizophrenia is already established and you are finding it difficult to maintain regular follow-up, online review can make long-term care considerably easier to sustain.
Book an online consultation
If you are in crisis or having thoughts of harming yourself, go to your nearest emergency room immediately.
شیزوفرینیا کیا ہے؟ — اردو میں مختصر خلاصہ <div dir="rtl" lang="ur"> <p>شیزوفرینیا ایک سنگین مگر قابلِ علاج ذہنی بیماری ہے جو انسان کی سوچ، احساسات، رویّے اور حقیقت کو سمجھنے کی صلاحیت کو متاثر کرتی ہے۔ یہ عموماً نوجوانی کے آخری برسوں یا بیس سے تیس سال کی عمر کے دوران شروع ہوتی ہے۔</p> <p>اس کی عام علامات میں ایسی آوازیں سننا جو دوسروں کو سنائی نہیں دیتیں، بلاوجہ شک کرنا یا یہ یقین رکھنا کہ کوئی نقصان پہنچانا چاہتا ہے، بے ربط گفتگو، لوگوں سے الگ تھلگ ہو جانا، اور پڑھائی، کام یا صفائی ستھرائی میں دلچسپی ختم ہو جانا شامل ہیں۔</p> <p>یہ کمزور ایمان یا خاندان کی کسی غلطی کا نتیجہ نہیں بلکہ دماغ کی ایک طبی بیماری ہے۔ دعا اور روحانی سکون اپنی جگہ اہم ہیں، لیکن ان کے ساتھ ساتھ طبی علاج بھی ضروری ہے — دعا بھی، دوا بھی۔</p> <p>علاج میں دوا، خاندان کی رہنمائی، نفسیاتی تھراپی اور باقاعدہ فالو اَپ شامل ہیں۔ اپنی مرضی سے دوا چھوڑ دینا بیماری کے دوبارہ لوٹنے کی سب سے عام وجہ ہے۔ بروقت اور مسلسل علاج سے بہت سے مریض پڑھائی، ملازمت اور خاندانی زندگی دوبارہ شروع کر پاتے ہیں۔</p> <p>ڈاکٹر فضل اللہ (ایف سی پی ایس، سائیکاٹری) سے پورے پاکستان میں آن لائن ویڈیو مشورہ اردو، انگریزی، پشتو، سندھی، بلوچی اور براہوی زبان میں کیا جا سکتا ہے۔ اگر مریض خود کو یا کسی اور کو نقصان پہنچانے کی بات کرے تو فوراً قریبی ہسپتال کی ایمرجنسی سے رجوع کریں۔</p> </div>
A: Early signs are often subtle: withdrawing from family and friends, falling performance at studies or work, disturbed sleep, neglect of hygiene, growing suspiciousness and unusual ideas. Hallucinations and delusions usually appear later. Because these signs overlap with depression and drug use, a psychiatric assessment is the way to tell them apart.
A: Schizophrenia is usually a long-term condition, but it is very treatable. According to the WHO, at least one in three people with schizophrenia achieves complete remission, and many others reach long periods of stability. Early treatment, continuing medication, family support and avoiding drugs all improve the outlook.
A: Psychosis is a state of losing touch with reality through hallucinations or delusions. Schizophrenia is one illness that causes psychosis, but psychosis can also result from bipolar disorder, severe depression, drug use or medical conditions. A psychiatrist establishes which cause applies, because the treatment differs.
A: Genes play a substantial role, and having a close relative with schizophrenia raises the risk. But genetics alone do not determine it; most people with an affected relative never develop the illness. Environmental factors such as heavy cannabis use and complications during pregnancy or birth also contribute.
A: No. Antipsychotic medicines are not habit-forming and do not cause the craving or dependence associated with sleeping pills or drugs of abuse. They do have side effects, which is why they are monitored. They should not be stopped suddenly — not because of addiction, but because stopping sharply raises the risk of relapse.
A: Treatment is usually long-term. After a first episode, medication is typically continued for at least one to two years after recovery, and many people benefit from continuing longer. Any decision to reduce or stop treatment should be planned with your psychiatrist, with close monitoring for early warning signs.
A: Yes. Many people with schizophrenia study, work, marry and raise families, particularly when the illness is well treated. Marriage is not a treatment for schizophrenia, however. Major life decisions are best made when the person is stable, with honest discussion between families and, where helpful, advice from the treating psychiatrist.
A: Much of schizophrenia care history, mental state examination, family input, medication review and relapse monitoring works well over secure video, and online follow-up makes long-term care easier to sustain. Acute psychosis involving risk to the person or others, refusal of food, or severe agitation needs urgent in-person hospital care.
A: Schizophrenia ka ilaj (شیزوفرینیا کا علاج) combines antipsychotic medication, family guidance, psychological therapy and regular psychiatric follow-up. It is a medical illness that needs medical treatment; prayer and spiritual support can continue alongside it but should not replace it. PsychConnect consultations are available in Urdu and five other languages.
A: Heavy cannabis use, especially starting in adolescence, is associated with a higher risk of developing schizophrenia, and it can trigger relapse in people who already have the illness. Stimulants such as methamphetamine ("ice") can cause psychosis directly. Stopping substance use is an important part of treatment.
A: Reduced insight is part of the illness, not stubbornness. Stay connected, avoid arguing about the diagnosis, and focus on problems they do acknowledge, such as poor sleep or stress. Family members can consult a psychiatrist themselves for guidance. If there is any risk of harm, go to the nearest emergency department.
To discuss any of this with a qualified psychiatrist, you can book an online consultation with Dr. Fazal Ullah. See conditions treated · More articles