Schizophrenia is a serious mental illness that affects how a person thinks, feels, and behaves. The onset of schizophrenia typically occurs in late adolescence or early adulthood, with the average age of onset between 18 and 25 years old for men and between 25 and 35 years old for women. However, schizophrenia can develop at any age, even in childhood, though this is rare.
When Does Schizophrenia First Develop?
There are three main phases related to the onset of schizophrenia:
- Prodromal phase – Early warning signs may begin to develop weeks, months or years before psychosis appears. These early symptoms are often mild and tend to come and go. They may include depression, anxiety, irritability, difficulty sleeping, trouble concentrating, and withdrawing from others.
- Active phase – This is when psychotic symptoms like hallucinations, delusions, and disorganized thinking first emerge and become more severe. People often experience a major decline in functioning during this time. The active phase often begins gradually but can have a rapid onset.
- Residual phase – After the worst psychotic symptoms subside, usually with treatment, many people are left with lingering symptoms like lack of motivation, difficulty expressing emotion, and trouble concentrating. Social and work skills often need to be relearned and rebuilt.
Let’s take a closer look at when the active psychotic phase of schizophrenia typically emerges.
Childhood-Onset Schizophrenia
It is very rare for schizophrenia to develop before the age of 12. When it does happen, it is sometimes referred to as childhood-onset or very early-onset schizophrenia. About 1 in 40,000 children will be diagnosed with schizophrenia before age 13. The symptoms and diagnostic criteria are similar to adult schizophrenia, though children are more likely to experience hallucinations and less likely to have delusions.
Adolescent-Onset Schizophrenia
The first psychotic break of schizophrenia typically happens for males between ages 15-25 and for females between ages 15-35, with the average being early to mid 20s. The onset occurs later for females, likely due to the protective effect of estrogen. About 3 in 100 cases of schizophrenia start before age 18. The symptoms and course of adolescent-onset schizophrenia are similar to cases that begin in early adulthood.
Adulthood-Onset Schizophrenia
Schizophrenia striking first in adulthood between the ages of 18-25 is most common for males, accounting for over 50% of cases. For females, the majority of cases (about 75%) have an onset between 25-35 years old. Adult-onset schizophrenia follows the typical pattern of prodromal, active and residual phases outlined above.
Risk Factors for Developing Schizophrenia
While the average age of onset for schizophrenia is clear, it is still not well understood exactly why symptoms emerge when they do. There are several factors believed to play a role in schizophrenia onset:
- Genetics – Having a family history of schizophrenia significantly increases risk. Certain gene variants affect brain development and functioning.
- Environment – Exposure to viruses, malnutrition before birth, psychosocial stressors, substance abuse can all contribute.
- Brain chemistry – Imbalances in dopamine, glutamate and other neurotransmitters are implicated in schizophrenia.
- Neurodevelopmental factors – Problems with brain connections occurring during development may lay the groundwork for later onset of psychosis.
For most people who develop schizophrenia, it is a combination of genetic and environmental factors disrupting normal brain development and biochemistry. These processes unfold over many years until a tipping point is reached when overt symptoms emerge.
Prodromal Phase Symptoms and Duration
The prodromal phase represents a period of deterioration and behavioral changes leading up to the active psychotic break of schizophrenia. On average, the prodromal phase lasts about five years, but can range from a few months to over a decade.
Signs of the prodromal phase include:
- Depression or anxiety
- Suspiciousness or unease around others
- Irritability or angry outbursts
- Increasing isolation from friends and activities
- Difficulty concentrating
- Thought and speech abnormalities
- Sleep disturbances
- Lack of motivation
These early symptoms tend to gradually worsen over time. People often start to have brief psychotic episodes during the prodromal phase as well, which may include temporary hallucinations or delusional beliefs. These warning signs are often not recognized as leading to schizophrenia, delaying diagnosis.
Transition to the Active Phase
There is no clear line demarking exactly when the prodromal phase ends and the active phase begins. In general, the active phase is said to start when overt psychotic symptoms emerge and persist. This includes hallucinations (hearing, seeing or sensing things that aren’t there), delusions (false fixed beliefs), and disorganized thinking and speech.
The transition is gradual in about 60% of cases, with psychotic episodes increasing in frequency and duration over weeks or months. But for around 30% of people, the onset of acute psychosis is sudden, occurring rapidly over a few days or weeks. Stressful or traumatic events often precede an abrupt onset.
Hallmark Symptoms of the Active Phase
The active phase of schizophrenia involves a constellation of characteristic symptoms, including:
- Hallucinations – hearing voices or seeing, smelling or feeling things that are not real. Auditory hallucinations of voices are most common.
- Delusions – fixed false beliefs like being watched, controlled or plotted against that don’t change even when contrary evidence is presented.
- Disorganized thinking and speech – incoherent or illogical thoughts and speech patterns.
- Grossly disorganized behavior – highly erratic or inappropriate behavior and appearance.
- Negative symptoms – apathy, lack of emotion, poor social functioning, loss of interest and motivation.
These psychotic disturbances cause significant disruption to a person’s ability to function in work, social settings and self-care. Without treatment, psychotic episodes tend to recur and intensify over time in cycles. Early intervention and treatment is important for minimizing damage to life functioning.
Duration of Untreated Psychosis
The duration of untreated psychosis (DUP) refers to the time interval between the onset of the active phase symptoms and the start of appropriate treatment, which is usually with antipsychotic medication. On average, DUP lasts about 1-2 years, but can vary from a few weeks to over 10 years in rare cases.
The risks of a longer DUP include:
- Worse short and long-term clinical outcomes
- Poorer response to treatment
- More severe positive and negative symptoms
- Greater functional disability and poorer quality of life
These findings highlight the importance of early detection and intervention soon after psychosis begins to minimize DUP and improve prognosis.
When Does the Residual Phase Start?
With effective treatment, usually meaning antipsychotic medication and psychosocial support, the severe psychotic symptoms of the acute phase will gradually subside over the course of weeks or months. When overt hallucinations and delusions are absent or under better control, this marks the beginning of the residual phase of schizophrenia.
On average, the residual phase starts within six months to a year after starting treatment for the initial psychotic episode. However some people take longer to stabilize, so this phase may take two years or more to begin.
Residual Symptoms
Even when the positive symptoms like hallucinations and delusions resolve, many people are left struggling with lingering residual symptoms that cause ongoing impairment. Common residual symptoms include:
- Lack of energy or motivation
- Emotional flatness or apathy
- Trouble feeling pleasure (anhedonia)
- Difficulty concentrating and completing tasks
- Slowed thinking and reaction time
- Difficulty carrying on conversations
- Poor grooming and hygiene
These negative symptoms tend to have a greater impact on social and occupational functioning during the residual phase. Rehabilitation programs focusing on life skills and social connection can help overcome residual barriers.
Course of Schizophrenia After Onset
After the initial onset of schizophrenia, studies show that the course of the illness can vary considerably between different people:
- 20% experience a single acute episode followed by a complete remission of symptoms
- 60% tend to have a relapsing-remitting pattern, with bouts of acute symptoms followed by periods of recovery
- 20% suffer from chronic unremitting symptoms despite treatment
For the majority of patients, schizophrenia follows an episodic pattern, with exacerbations of acute psychosis followed by more stable periods where only residual symptoms may be present. Maintaining treatment is critically important during the residual phase to prevent relapse. With proper care, many people with schizophrenia can live rewarding lives with manageable symptoms.
Conclusion
In summary, schizophrenia onset typically occurs between the late teens and mid 30s, with an average age of 18-25 in males and 25-35 in females. A lengthy prodromal phase often precedes the active psychotic break, providing opportunities for early intervention. Rapid treatment to minimize duration of untreated psychosis is vital for positive outcomes. Even during the residual phase, ongoing management is needed to prevent new episodes of acute symptoms from emerging.