How They Evolved Over Time

It is a complex and often misunderstood mental health disorder. Symptoms can include hallucinations, delusions, disorganized thinking, and cognitive impairment, which can significantly affect daily life. Although symptoms typically appear in early adulthood, men may experience symptoms earlier than women.

People often misunderstand schizophrenia, leading to the stigmatization of individuals with the condition as “dangerous.” While some symptoms, such as hallucination, may cause a person to become hostile, many individuals living with schizophrenia are nonviolent.

Clinicians categorize symptoms of schizophrenia into three primary groups. Note that the terms “positive” and “negative” symptoms in schizophrenia don’t imply “good” or “bad.” Instead, they describe different types of symptoms:

• Positive symptoms: Hallucinations, delusions, disorganized speech, and unpredictable behavior.
• Negative symptoms: Social withdrawal, lack of motivation, reduced speech, and emotional flattening.
• Cognitive symptoms: Impaired memory, attention difficulties, and difficulty with executive functioning, such as planning and decision making.

To receive a diagnosis of schizophrenia, a person must experience at least two of the following symptoms for 6 months. Their severity must be enough that it affects their work performance, their ability to care for themself, or their relationships with others:

• catatonic or disorganized behavior
• delusions
• hallucinations
• disorganized speech
• negative symptoms such as alogia, flat affect, or avolition

Historical records suggest that symptoms resembling schizophrenia were first documented centuries ago. Ancient Egyptian texts mention conditions involving altered perceptions and behavior, while Greek physician Hippocrates theorized mental disorders arise from imbalances in bodily humors.

During the Middle Ages, people often labeled individuals with schizophrenia-like symptoms as “possessed,” resulting in harsh treatments or exorcisms. The 18th-century French physician Philip Pinel was a pioneer in advocating for more humane treatment of people with mental health issues, laying the groundwork for modern psychiatric care.

Swiss psychiatrist Eugen Bleuler began using the term “schizophrenia” in 1908 to replace earlier classifications such as “dementia praecox,” which essentially meant “premature dementia.”

Elliot Hong, professor of psychiatry and director of the Houston Psychosis Research Center at UTHealth Houston, explained the major difference between how the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, text revision (DSM-5-TR) categorizes schizophrenia today versus how the condition was historically classified. Hong said that schizophrenia is no longer treated as a “reaction” related to how the mind works but as a condition caused by the brain’s biology.

“The initial DSM criteria was bold enough to have made the attempt to include an etiological inference of the symptoms experienced by patients with schizophrenia by referring to psychotic symptoms in schizophrenia as ‘functional’ and as a ‘reaction’.

“As research has continued to discover neurobiological associations with this illness, later DSM versions have retreated from describing the illness by such biased and likely incorrect definitions,” he stated. However, he noted that “we still lack a good understanding of the underlying neurobiological pathways to schizophrenia.”

In the early 20th century, experimental and often inhumane treatments were employed to manage schizophrenia. These included:

• Insulin coma therapy (1920s to 1950s): Inducing a coma using high doses of insulin in an attempt to “reset” the brain.
• Metrazol shock therapy (1930s to 1940s): Utilizing Metrazol, a chemical that caused violent convulsions, which was later abandoned due to its extreme side effects.

Another kind of treatment, electroconvulsive therapy (ECT), was in use during this period. It debuted as a means to elicit seizures in people experiencing psychiatric difficulties. Due to its safety and effectiveness, experts continue to use it today to help treat schizophrenia symptoms.

Clinicians diagnose schizophrenia today based on clinical assessments, symptom history, and standardized criteria from the DSM-5-TR. Neuroimaging and genetic research have provided deeper insights into what might biologically cause schizophrenia.

Still, no single test can definitively diagnose the disorder. Scientists have not always agreed, and still largely do not agree, on whether brain development issues (how the brain forms early in life) or degeneration (brain changes that happen over time) causes schizophrenia.

Hong noted that while we still do not fully understand what causes the condition, revelations have recently occurred: “Large studies affirm the worldwide observation that schizophrenia is strongly associated with premature medical disease and death, especially due to cardiovascular and other related diseases. This raises the question about whether schizophrenia is a brain-only disorder or a disorder involving other systems.”

The treatment of schizophrenia has evolved considerably over time. Modern approaches include:

Antipsychotic drugs, first introduced in the 1950s with chlorpromazine (Thorazine), revolutionized treatment by targeting dopamine regulation. Hong explains early antipsychotics had a significant effect on individuals, their families, and society, as many people with schizophrenia lived in public or private psychiatric hospitals before chlorpromazine.

He noted: “While antipsychotics did not cure the illness for most patients, they significantly reduced the psychosis symptom severity such that many no longer needed to stay in these hospitals or only needed to stay for a short period, resulting in a substantial reduction in the size of psychiatric hospitals, and many even closed their doors.”

• First-generation (typical) antipsychotics: Medications such as haloperidol and chlorpromazine help manage hallucinations and delusions but often cause motor side effects.
• Second-generation (atypical) antipsychotics: Medications like clozapine, risperidone, and olanzapine offer improved symptom management with fewer side effects.

• Cognitive behavioral therapy (CBT): A type of talk therapy that helps people recognize and cope with hallucinations and delusions.
• Social skills training: Behavioral therapy to help improve interpersonal functioning and communication.
• Assertive community treatment (ACT): A community-based approach that offers in-home care and support services for individuals with severe schizophrenia.

• Neuromodulation: These techniques deliver electrical pulses to the brain, either through a helmet during transcranial magnetic stimulation (TMS) or implanted electrodes, such as during deep brain stimulation (DBS). Research on these therapies is still ongoing.
• Personalized medicine: Advances in genetic research aim to tailor medications to individual genetic risks and markers instead of using a trial-and-error approach when selecting medications to manage schizophrenia.

The “recovery movement” for schizophrenia shifted the approach to treatment, emphasizing helping people lead more meaningful lives by finding work, returning to school, or living independently.

Advocacy groups played a big role in pushing for this more hopeful, person-centered model, advocating for better access to treatment, community support, and reducing the stigma associated with the disorder. However, while some people benefit, many still experience symptoms or disabilities.

Hong cautioned: “The recovery model is a very positive development for patients and families, and some patients have benefited from the effort to regain employment, return to school, and live a more productive life. But many patients remained disabled or chronically symptomatic.

“Until we have a way (perhaps by developing more effective medications, therapies, neuromodulation, etc.) to help every patient truly recover, we need to be very cautious about overselling ‘recovery’ while we are still unable to help many of our patients recover.”

Despite medical progress, the stigma associated with schizophrenia remains a significant barrier to care. Misconceptions portray individuals with the condition as dangerous or incapable of leading productive lives, contributing to social isolation and discrimination.

The “deinstitutionalization” era, beginning in the mid-1950s, saw “reductions in size or closings of many large, older psychiatric institutions that housed people for extended periods, or even life, which may have helped the field to shed the ‘asylum’ image of psychiatric hospitals,” explained Hong. It also gave rise to the opportunity to rebuild modern psychiatric hospitals that focus on patient care, empowerment, and reducing the stigma of mental illness.

Despite the progress, Hong said there is still a long way to go: “Until we develop a clear understanding of what causes schizophrenia and have medications or other means to cure it, the stigma will likely continue, although it could evolve into different forms.

“Stigma for mental illnesses still runs deep and wide, particularly for schizophrenia. Stigma and fear are rooted in ignorance — fundamentally, our ignorance of its cause and the lack of ways to effectively help most individuals with the condition recover from it.”

Schizophrenia treatment has evolved from archaic and often cruel practices to evidence-based medical and psychosocial interventions.

While modern treatments provide substantial relief, ongoing research into genetics, neurobiology, and innovative therapies offer hope for even more effective care in the future. Reducing stigma and improving access to mental health resources remain essential in ensuring a better quality of life for those living with schizophrenia.