In schizophrenia, perception, thinking, drive and the sense of self are altered at times. People affected may, for example, hear voices that no one else hears, or be firmly convinced of something that others cannot follow. Between episodes of illness, many are largely free of symptoms.¹,²
The most stubborn misunderstanding first. Schizophrenia is not a “split personality” and has nothing to do with the very rare dissociative identity disorder. Historically, “schizo” referred to a split between thinking, feeling and perceiving — not to a second person.
The second cliché arises because the very rare cases involving violence are reported at length, while the many unremarkable courses never make the news. In fact, the overwhelming majority of people affected are not dangerous to others. The reverse is more relevant: people with schizophrenia are more often victims of violence and exclusion themselves — and they are put at risk by the illness, among other things through a raised risk of suicide and a shortened life expectancy.¹,³ This is not sugar-coating: fear of the diagnosis and of how others will react is a main reason why people seek help late — and late help worsens the outlook.
2. Positive, negative and cognitive symptoms
“Positive” and “negative” do not mean good and bad: positive symptoms are added to a person's experience and show up mainly in acute phases; negative symptoms are things that fall away, and they often start creeping in beforehand.
Loss of drive, social withdrawal, blunted affect (little emotional expression), poverty of speech
Response to antipsychotics
Usually good
Poorer; here psychotherapy, occupational therapy and sociotherapy contribute more
Common misreading
“He's losing it”, “it's deliberate”
“She's lazy”, “he just won't” — or it is taken for depression
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The last row has the greatest consequences: from the outside, negative symptoms look like idleness or lack of drive. But they are signs of illness — and in the long run they often determine more than delusions or voices do how well someone copes with school, work and relationships.¹ On top of that comes a third, often overlooked group: concentration problems, forgetfulness and slower thinking. And not every psychosis is schizophrenia — delusions also occur in severe depression, in bipolar disorder or as an effect of medication.
3. Course: the prodromal phase and why time matters
Before the first acute phase, many people go through an early stage (prodromal phase) that can last months to years:
Withdrawal and a drop in performance: friendships fade away, and school or training suddenly starts going worse.
Sleep and sensitivity to stimuli:sleep disorders are one of the most common early signs; noises and crowds feel too loud, and inner restlessness sets in as well.
These signs are non-specific — they occur just as much during puberty and in many other conditions. No reason to panic, but a reason to seek medical advice if they persist for weeks.
The duration of untreated psychosis is a prognostic factor. The longer a first episode goes untreated, the less favourable, on average, the course of symptoms and social participation turn out to be.¹ Getting things checked early is the most effective lever. Where to turn: your GP practice, psychiatric outpatient clinics attached to hospitals (Institutsambulanzen) and early detection centres.
4. Causes: the vulnerability-stress model
The established explanation is the vulnerability-stress model: an innate vulnerability, and one acquired over the course of life, meets with stress. Only when both come together and an individual threshold is exceeded can a psychosis develop.¹,²
Genetic predisposition: a higher risk if close relatives have the illness. What is inherited is a susceptibility, not an illness — most people with affected relatives never develop it.
Early development and stress: complications in pregnancy and birth, violence, neglect, discrimination.
Neurobiology and substances: changes in signal transmission in the dopamine system — this is where the medicines act. In people with a predisposition, cannabis and stimulants can trigger a psychosis or bring it forward.
Cannabis: the facts, without a lecture. In most people, cannabis does not cause schizophrenia. With a predisposition — particularly with an early start, high doses and a high THC content — the risk rises measurably, and in people who already have the illness, cannabis use is one of the strongest drivers of relapse.²
For relatives: The idea that the “wrong” upbringing causes schizophrenia is considered outdated — no one has triggered this illness through mistakes in parenting. What is well established: a calm, low-criticism way of dealing with each other lowers the likelihood of relapse.
5. Diagnosis: how it is made
There is no test that proves schizophrenia. The diagnosis comes from conversations, observation over a sufficiently long period and ruling out other causes — it is rarely certain at the first contact.⁴
History and examination: symptoms, previous illnesses, substance use, family history — plus a structured assessment of thinking, perception, sense of self, drive and suicidal thoughts, ideally including the perspective of relatives.
Ruling out other causes: a blood count, inflammatory markers, liver, kidney and thyroid values, a drug screen and, depending on the situation, MRI and EEG (see Understanding blood values). Medicines count too: high-dose cortisone, certain Parkinson's medicines and withdrawal states can trigger psychotic states — see Medication side effects.
Bring your symptoms with dates, all your medicines and your questions to the first appointment — see Prepare for a doctor's appointment.
6. Treatment: the three pillars
According to the guideline, treatment rests on three pillars that belong together. Medication alone falls short, and psychotherapy alone is not enough in acute phases. Which combination fits is decided by the treating practice together with you — ideally in a way that openly weighs benefits against side effects.¹
Pillar 1Antipsychotics
Acute phase and afterwards
In the acute phase the aim is to dampen delusions, hallucinations and tension; treatment usually starts with a single drug. After that, the medication is continued for longer to prevent relapse.
Pillars 2 and 3Psychotherapy, sociotherapy and occupational therapy
Cognitive behavioural therapy and psychoeducation
Expressly recommended — not to argue the delusion away, but to help with handling distressing beliefs and voices. Psychoeducation for patients and relatives lowers the relapse rate.
Structure, participation, exercise
Occupational therapy steps in where negative symptoms slow down everyday life; sociotherapy helps with applications, housing and getting back into work — often more important for quality of life than fine-tuning the dose.
7. Antipsychotics: classes, depot and stopping
Antipsychotics (formerly called neuroleptics) act on signal transmission in the brain, above all in the dopamine system. This explains their effect on positive symptoms as well as some of their side effects. First-generation drugs act strongly on delusions and hallucinations, but more often cause movement disorders: stiffness, a Parkinson's-like tremor, distressing restlessness (akathisia) and, with long-term use, persistent involuntary movements. Second-generation drugs trigger movement disorders less often, but more often cause metabolic problems such as weight gain and unfavourable blood lipid and blood sugar levels; they include quetiapine, olanzapine, risperidone and aripiprazole, among others. The differences lie mainly in the side-effect profile. If two drugs given at an adequate dose do not work well enough, the guideline provides for clozapine — effective, but requiring close blood count monitoring.¹
How a drug is chosen. Less by “strength”, more by fit: which side effects would be the most distressing, is there already diabetes or a lipid metabolism disorder, and how well were medicines tolerated in the past? The decision is made at the treating practice.
Depot injections
Depot antipsychotics are injected into a muscle anywhere from every two weeks to every few months: slow release, no daily tablets, more even drug levels. That resolves the situation that sets off many relapses — the tablet that, after a good week, seems “not really necessary any more”. To be honest about it: the dose is harder to adjust, which is why a drug is usually tried as a tablet first.
Stopping: the most common cause of relapse
Relapses are talked about as if they came out of nowhere. But at the start there is often an understandable chain of events: things are going well. The side effects are a nuisance. The diagnosis feels wrong, because nothing seems to be the matter any more. The tablet is taken less often, then not at all. Weeks later, things tip over.
Never stop antipsychotics on your own. Stopping abruptly can trigger discontinuation symptoms such as restlessness, sleeplessness, nausea and movement disorders — and it raises the risk of relapse considerably. What makes it particularly treacherous: the relapse often comes only after weeks to months. Wanting to stop is legitimate — but it needs to be discussed and supported, with a slow reduction. How a planned taper works is explained in Stopping medications.
An unintentional stop counts too: forgotten doses, an empty pack on holiday, a prescription that slips through the cracks. Anything that makes taking your medication easier is therefore relapse prevention — fixed times, a weekly pill organiser, a depot, reminders, a travel supply. More in How to take medications.
No relapse just because a pack ran out
Fixed reminders and a complete intake history — free.
Side effects are the second most common reason for stopping treatment — yet there is almost always a middle ground between “putting up with it” and “giving up”.
Drink more and step up dental care, take it in the evening; take care when driving. Raise sexual dysfunction actively — a switch is often possible
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A simple trick: note down side effects with the date. “I feel somehow unwell” becomes “since the switch I can't sit still in the evenings” — and a decision can be made from that. The basics: Medication side effects.
Get it checked by a doctor immediately. High fever with muscle stiffness, confusion and circulatory instability can point to neuroleptic malignant syndrome — a rare but life-threatening emergency. Fever or a severe sore throat while taking clozapine also needs to be checked immediately.
9. Taking physical health seriously
People with schizophrenia have a markedly shortened life expectancy. The main reason is not the psychoses but cardiovascular and metabolic diseases.¹,³ Side effects, more frequent smoking, little exercise and physical healthcare that often falls short once there is a psychiatric diagnosis all contribute to this. Physical health deserves to be treated just as consistently as mental health.
Weight and waist circumference: record them before treatment starts and check them closely at first.
Blood sugar, blood lipids, blood pressure:Diabetes develops more often with some antipsychotics, a lipid metabolism disorder causes no symptoms at all, and high blood pressure is very treatable — provided it is measured.
Relapses usually announce themselves — often with the same signs as last time. Writing them down makes it possible to act before insight into the illness fades. Typical signs: needing less sleep and nights spent awake (often the first signal), withdrawal, irritability, mistrust, heightened perception — and “forgotten” doses or postponed depot appointments.
My personal early warning signs — plus what my relatives notice first.
What helps me: prioritise sleep, reduce stimuli, no substances — and who I contact: practice, outpatient clinic, a trusted person, with phone numbers.
My medication with doses, and what I would want if admitted to hospital (treatment agreement, advance directive if applicable).
If there is an acute risk to yourself or others: get help immediately. If you are having thoughts of taking your own life, or if someone is endangering themselves or others, call 112 (emergency number in Germany) or go to the nearest psychiatric hospital — even at night and at weekends. TelefonSeelsorge (German crisis helpline) on 0800 111 0 111 and 0800 111 0 222 can be reached round the clock, free of charge and anonymously. Outside surgery hours, the out-of-hours medical service can help on 116 117. These numbers belong in every crisis plan.
11. Everyday life and relatives
Structure beats motivation — fixed times and a few reliable appointments stabilise more than good intentions. Returning to training or work usually happens in stages; phased return to work and specialist integration services (Integrationsfachdienste) exist for exactly this.
Put alcohol and cannabis on hold, record intake and sleep — substances raise the risk of relapse, and a deterioration shows up earlier in your sleep than in your mood.
For relatives: You are the most important stabilising factor — and the most likely to run into exhaustion. Three things help: calm rather than confrontation when it comes to delusional content; taking your own strain seriously and making use of relatives' groups; writing a crisis plan together early on. Before every appointment: note down the most important questions and the most troublesome side effect, and bring the medication list — see Prepare for a doctor's appointment.
Record early warning signs and side effects
Your history with dates — the basis for your next conversation at the practice.
No, that is the most common misunderstanding. Schizophrenia means that perception, thinking and the sense of self are altered at times — not that several personalities exist within one person. Dissociative identity disorder is a different, very rare condition.
The overwhelming majority are not dangerous to others. The rare cases involving violence shape the public image because they are the only ones that get reported. The reverse is more relevant: people affected are more often victims of violence themselves and are put at risk by the illness.
Not necessarily. How long depends on whether it was the first episode or whether there have already been relapses. After a first episode, longer continuation is usually recommended; after that, a reduction can be considered — together with the treating practice.
Stopping on your own is the most common cause of relapse. It can trigger discontinuation symptoms such as restlessness, sleeplessness and nausea, and the relapse often comes only weeks later. If you want to stop, raise it — a supervised reduction is a legitimate option.
Not in most people. With a corresponding predisposition, however, cannabis can trigger a psychosis or bring it forward, especially with an early start, high doses and a high THC content. In people who already have the illness, cannabis use is one of the strongest drivers of relapse.
Because life expectancy in schizophrenia is shortened mainly by cardiovascular and metabolic diseases, not by the psychoses. Weight, blood sugar, blood lipids and blood pressure can change for a long time without causing symptoms — which is why regular checks are an effective building block.
German S3 guideline on schizophrenia (DGPPN, the German Association for Psychiatry, Psychotherapy and Psychosomatics; AWMF reg. no. 038-009) — German source. awmf.org
Gesundheitsinformation.de, German Institute for Quality and Efficiency in Health Care (IQWiG): Schizophrenia. Accessed 2026 — German source. gesundheitsinformation.de
gesund.bund.de, the national health portal of the German Federal Ministry of Health: Schizophrenia. Accessed 2026 — German source. gesund.bund.de
Medical disclaimer: This article is for general information and does not replace medical advice, diagnosis or treatment. Antipsychotics must never be stopped, or have their dose changed, on your own — that is the most common cause of relapse. If you have thoughts of suicide, if there is an acute risk to yourself or others, or if you have a high fever with muscle stiffness, call 112 straight away; TelefonSeelsorge (German crisis helpline) can be reached round the clock on 0800 111 0 111. The choice of medicine and its dose are always set by the treating practice. Last updated: September 2026.
