Understanding the Phases of Schizophrenia

Schizophrenia symptoms often follow 3 main phases. Sometimes, these are called stages. The 3 phases are the prodromal phase, the active phase, and the residual phase.^1-3

The prodromal phase

The prodromal phase is the time between when a person first shows symptoms and their first episode of psychosis. Psychosis refers to when a person starts having problems connecting with reality.^1-3

Not everyone with schizophrenia will have a recognized prodromal phase. The first recognized signs of schizophrenia may be severe and classified as psychosis right away. However, many people experience a slow onset of mild symptoms that worsen over time. This prodromal phase can last for months to years.^2,3

Prodromal phase symptoms

During the prodromal phase, mostly negative symptoms occur. Here, the word “negative” refers to a loss of something that normally would be present. Common negative symptoms of schizophrenia include:^5-8

• Decreased expression of emotions, or being very “flat” in response to emotional things
• Lack of interest in socializing (asociality)
• Decreased or slowed speech (alogia)
• Lack of motivation or excitement (avolition)
• Inability to feel pleasure (anhedonia)
• Decreased attention to personal hygiene or self care

Each person may have a different combination of negative symptoms. The effect these symptoms have on daily life also varies. The number and severity of negative symptoms may help predict how severe a person’s schizophrenia will become. More symptoms or more severe symptoms often lead to worse outcomes over time.²

The active phase

The active phase occurs when a person is experiencing psychosis, or positive symptoms. Here, “positive” means new or additional effects on a person’s thoughts or behaviors. The most common positive symptoms of schizophrenia are:^2,4,7,8

• Hallucinations – Hearing, seeing, or sensing things that are not there.
• Delusions – Firmly believing things that are not true. An example of a delusion is that the government is tracking or spying on them.
• Disorganization – Unusual thoughts, speech, or behavior. A person may speak in strange phrases. Or they may speak in a way that cannot be understood at all. Behaviors may include a lack of impulse control, odd body movements, or inappropriate emotional responses.

Hallucinations and delusions can happen during the prodromal or residual phase as well, but they are typically much less severe.^2,7,8

Treating active phase symptoms

Most schizophrenia treatments are meant to help control psychosis. Antipsychotic drugs are an example of these treatments. But antipsychotic drugs can be used during any phase of schizophrenia, and are typically taken lifelong once diagnosed (as long as they are tolerated).⁹

It is possible to start treatment during the prodromal phase and never experience severe psychosis at all. But it is also possible to have multiple episodes of psychosis even while following a treatment plan. Each person’s experience is different. It is common for episodes of psychosis during the active phase to be treated in a hospital setting.^1-4

The residual phase

As psychosis symptoms start to get better, a person enters the residual phase. This phase is similar to the prodromal phase, but it occurs after psychosis. Most symptoms in the residual phase are negative symptoms. But some delusions or hallucinations may continue. Usually, these symptoms are not as severe as those in the active phase.^1-4

The types of symptoms present in the residual phase often determine how well a person will function day to day. A person may have mild to no schizophrenia symptoms in the residual phase. If this continues for 6 or more months, some experts consider the person to be in remission.^1,4

Residual phase symptoms

Negative or positive symptoms that occur in the residual phase can impact a person’s ability to do regular tasks and activities. Cognitive problems (those that affect thinking) can happen during this time, too. Examples of cognitive symptoms include trouble paying attention, decreased motivation (amotivation), remembering things, and planning tasks.^1,2,4

Treatment with antipsychotic drugs continues in the residual phase to try to improve symptoms. These drugs also help lower the risk of having new active phase episodes. Taking all treatments as they are prescribed and sticking to a plan is the best way to maintain health.^2,4,8

Cycling between phases

Cycles of active phases and residual phases can continue throughout a person’s life. During each residual phase, a person may return to their previous baseline. But it is possible for symptoms during each residual period to get worse over time, too. Your healthcare team will monitor any changes and recommend updates to your treatment plan as needed.^1-4