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For Henry Cockburn, the onset of schizophrenia felt like pure common sense.
It was February 2002, and the 20-year-old art student had strayed from the University of Brighton to satisfy his desire for a life of magic outside the city. He also wanted to take a 70-mile journey (about 113 kilometers) barefoot back to his childhood home in Canterbury.
About 15 miles (24 kilometers) into his walk, he heard planes in the distance, and told CNN he believed “that somehow an evil force knew I had left.” Cockburn knew with absolute certainty that he was being followed.
The solution, he believed, was to dive into the frigid tidal waters of the Newhaven Estuary and swim away from the malevolent presence. Fishermen found him and rescued him just before he blacked out from hypothermia.
After being revived in a general hospital, he was transferred to a psychiatric hospital, where doctors diagnosed him with schizophrenia. The institution was the first of several where he would spend the next eight years.
Schizophrenia is simultaneously one of the most famous mental illnesses and one of the most misunderstood. Affecting 0.32% of the global population, or around 24 million people, schizophrenia is a chronic brain disorder often marked by psychosis, delusions, hallucinations, lack of motivation, and disorganized thinking and speech, according to the American Psychiatric Association. Cockburn’s case reflects a typical pattern of onset: in early adulthood, a psychological break into false beliefs, hallucinations and paranoia, all of which escalate over time.
“I saw it as more of a spiritual awakening and not paranoid schizophrenia,” Cockburn recalled. “It almost felt like I was on the run, and if you’re part of the system and you take yourself out of the system, the system doesn’t like that.
“I was kind of cross and angry, like, ‘Why can’t people understand me?’” Cockburn added. “I can sort of see their point of view a bit more now.”
Part of the confusion about schizophrenia may originate from the name of the disorder itself. Coined by Swiss psychiatrist Dr. Paul Eugen Bleuler in 1908, “schizophrenia” derives from the Greek words “schizo,” meaning “split,” and “phrene,” or “mind.” To describe the severe social withdrawal of some patients with schizophrenia, Bleuler also devised the term “autism.”
In the early 20th century, Bleuler proposed that the disorder was marked by a “splitting of psychological functions” by which “the personality loses its unity.”
The idea that schizophrenia means a split mind has contributed to a widespread belief in more formal contexts that the condition is like dissociative identity disorder, previously called split or multiple personality disorder, said Dr. Daniel Weinberger, director and CEO of the Lieber Institute for Brain Development. Dissociative identity disorder, caused by trauma, is when two or more distinctive personalities control a person’s behavior, causing gaps in memory when the personalities switch off.
Beyond those misperceptions about its underlying nature, schizophrenia is one of the most heavily stigmatized mental health disorders, said Dr. Deepak D’Souza, Vikram Sodhi ’92 Professor of Psychiatry and director of the Schizophrenia Neuropharmacology Research Group at Yale University.
There’s a widespread stereotype that people with schizophrenia are a threat to others — “the homeless person walking barefoot in the winter screaming at no one in particular (or the) mass murderer compelled by their symptoms to kill strangers,” said Dr. Jeffrey Lieberman, the Lawrence C. Kolb Professor of Psychiatry at Columbia University.
It’s the condition that people “associate with madness and psychosis and lunacy,” said Lieberman, who is the author of “Malady of the Mind: Schizophrenia and the Path to Prevention.” While some of these stereotypes are based in true symptoms that some patients experience, they aren’t reflective of all patients and can prevent a holistic, compassionate view of schizophrenia as a treatable disorder that’s usually more harmful to the patient than to others.
“The way society has dealt with it — from ancient times through medieval times, even until the 21st century — is to ostracize or segregate people with these severe mental disorders,” Lieberman said.
To make matters worse, among people who don’t have schizophrenia, there’s also the popular colloquial use of “schizophrenic” or “schizo” to describe feeling self-contradictory or frazzled by having multiple stressors or responsibilities simultaneously.
Misperceptions and fears about schizophrenia can make it difficult for people to recognize its signs and seek help for themselves or others, experts say. That help is critical since the disorder is associated with co-occurring mental health issues, a lower quality of life and life expectancy, and higher rates of disability, according to the National Institute of Mental Health.
Accordingly, among some experts there is growing interest in changing the name of this chronic brain disorder. Altered perception syndrome, psychosis spectrum syndrome and neuro-emotional integration disorder were the alternatives most supported in a 2021 survey of nearly 1,200 people, including those who had experienced mental illness, family members, clinicians, researchers, government officials and the general public.
When and why schizophrenia sets in
Symptoms of schizophrenia typically begin between the ages of 15 and 25, experts said.
People might have been doing OK or even great in their lives, and then suddenly they have what experts call a “first break” in their capacity to function normally, said Weinberger, also a professor of psychiatry, neurology, neuroscience and genetic medicine at the Johns Hopkins University.
“To me, (schizophrenia) is the most devastating of mental illnesses — because it strikes before a person reaches their potential,” D’Souza said.
Research suggests this disruption may stem from alterations in normal neurodevelopmental processes that happen as adolescents mature — especially since the higher end of the typical age range of onset is when the brain completes maturation, D’Souza said. But for some people, the stage for such changes may be set as early as infancy and require 20 years of brain maturation for the effects to become obvious, Weinberger said.
There are forms of schizophrenia that can begin earlier, but it’s rare, D’Souza said.
Schizophrenia predominantly occurs in males, he added. Still, “there’s an interesting second peak in the rates of schizophrenia that occurs in the early 50s, and that’s predominantly among women,” D’Souza said. “It’s thought to be related to menopause.”
What directly causes schizophrenia isn’t clear, but there are several known risk factors, Weinberger said. Those include brain chemistry and genetics that increase the likelihood that, with enough risk factors accumulated, someone will develop the disorder. Many neuroimaging studies have also shown structural abnormalities in the brains of people with schizophrenia, but nothing consistent enough across patient populations to become signature features of the disorder.
A pregnancy complicated by factors such as preeclampsia, prolonged labor or low birth weight can double a child’s risk, Weinberger said. Stress and trauma can also increase one’s likelihood of schizophrenia.
Taking mind-altering drugs as a teen or young adult is another risk factor, and researchers have increasingly been finding associations between cannabis use and schizophrenia.
That increase may be partly because today, the potency of cannabis varies from five to 20 times what it used to be in the 1970s, D’Souza said. Additionally, “young people are using it at a time when the brain is undergoing a major upheaval.”
When Cockburn was diagnosed after his swimming episode at age 20, he had just quit using marijuana about four days weekly and alcohol two or three days weekly since he was 14 years old, he said. Cockburn doesn’t think drug use caused his schizophrenia, but he had also started behaving unusually — walking barefoot in the winter — before he got sober.
The active chemicals in cannabis mimic natural brain molecules called endocannabinoids, which stimulate cannabinoid receptors — together, these two elements represent the brain’s endocannabinoid system. The system is not there to facilitate getting high, D’Souza said, but to help regulate the levels and activities of neurotransmitters that affect our mood, learning, body temperature and more. It also has a critical role in neurodevelopment, controlling where some neurons migrate to, which ones are removed and whether any are unhealthily disrupted.
“Imagine that this endocannabinoid system is working normally, and then it’s bombarded with THC,” D’Souza said. That’s the compound delta-9-tetrahydrocannabinol, the major active ingredient in cannabis thought to be responsible for the psychoactive effects of use.
Weinberger thinks the cannabis-schizophrenia research is controversial, as cause and effect can’t be inferred from associations, he said.
But the idea isn’t a new one, D’Souza said, citing 19th-century work by French psychiatrist Dr. Jacques Joseph Moreau. Moreau detailed users of hashish experiencing delusions, hallucinations and paranoia — all things now associated with schizophrenia.
There are several categories of schizophrenia symptoms, and they can affect how people feel, think and act.
Delusions, or believing in things that aren’t true or real, and acting on them are common. They can be “extremely unsettling, tormenting and very disabling,” Weinberger said.
Someone with delusions may think the Central Intelligence Agency has infiltrated their phone to spy on them, Weinberger said, and thus remove the phone’s battery. Cockburn said that this past spring, he was reading the C.S. Lewis novel “The Magician’s Nephew” and became fascinated with Aslan the lion’s ability to sing the world of Narnia into creation from a dark void.
“I thought that was how the world began,” Cockburn said. “I read fantasy books and then look for the fantasy within the reality of this world.”
Cockburn also felt that plants and birds could talk to him, and that he could “converse with the spirits,” he added. A conversation with a tree had a big impact on him: “It told me I could rap, and that’s what I started getting into after that happened.”
During some of Cockburn’s escapes from psychiatric hospitals — a habit that led to admission to five or six mental hospitals over those eight years — he would strip naked and explore a forest on a snowy day.
Many people with schizophrenia also have hallucinations, such as talking to someone who isn’t there, Weinberger said. Cockburn sometimes saw snipers outside the window of his hospital room, he said.
Delusions and hallucinations can lead to fear and paranoia, Weinberger said. That paranoia can make patients think others are talking about them, plotting against them, or affecting or reading the thoughts in their own brains — which “makes them very uncomfortable in public settings, because they feel they’re not safe,” he added. “Most individuals with schizophrenia are much more likely to feel that they’re unsafe than they are to make you feel that.”
Hallucinations also commonly take the form of voices that can sometimes start out benign and darken over time, experts said. Many patients often hear multiple voices carrying on a conversation about them.
When voices told Cockburn that “there was no redemption for me,” he recalled, “I would have really bad days where I felt I was being sucked into a godless world, I suppose, and my mood would go down.”
Voices can also command someone to perform actions that are difficult to resist, even when they’re self-destructive, Weinberger said. Probably 5% to 13% of patients die by suicide, and sometimes that’s due to following hallucinated orders to perform lethal actions, Weinberger added.
In neuroimaging studies of patients hearing voices, “areas of the brain that are responsible for language and speech generation are lighting up,” D’Souza explained.
People with schizophrenia can have cognitive deficits such as difficulty creating and following a plan, processing complicated information, or using information to reach appropriate conclusions, Weinberger said. Disorganized speech, unusual movements and a lack of motivation are other common symptoms — as is social isolation, which Cockburn had begun to exhibit before his first hospitalization.
“Schizophrenia is a very disabling problem,” Weinberger said.
Schizophrenia cannot be cured, Lieberman said, but it can be substantially alleviated with a combination of medications and therapies — though accessing multidisciplinary care and getting insurance to cover it remain difficult, even for the health care providers wanting to provide such resources for their patients.
The most effective drugs for patients are antipsychotics, Lieberman said, since those medications manage the elements of psychosis that impair thoughts and perceptions. The cognitive difficulties are harder to treat, Weinberger said.
At the same time, Weinberger added, the greatest treatment obstacle is patients not taking their medications — sometimes due to anosognosia, the unawareness of being ill, which affects 50% to 98% of people with schizophrenia. Other times, nonadherence results from the medicine’s uncomfortable side effects. But now that experts better understand some causal factors of schizophrenia, other drugs currently being studied or developed should be much more effective with fewer side effects, Weinberger said.
Effective therapies include talk therapy, social skills training and cognitive behavioral therapy for psychosis, Weinberger and D’Souza said. With comprehensive treatment, patients can learn to dismiss or respond to urges or voices in healthier ways.
Since Cockburn was discharged from his last hospital in 2011, he has largely accomplished just this, thanks to CBT for psychosis, medications and counseling. Just before his interview with CNN, he had gone on a run. He felt something beyond himself urging him to run further than he usually does, but instead of obeying, he turned around, he said.
“I felt a little bit guilt-ridden for it,” Cockburn said. “But then as I got towards the end of the run, I realized that I wouldn’t have been able to finish it if I hadn’t turned back at that moment. I guess common sense got the better of me.”
Dating is nonexistent for Cockburn, he said, but he has close friends and family and lives with a roommate in England. He’s on government disability benefits, but also sometimes makes a living from his paintings. He still gets panic attacks occasionally, but the comforting stillness of sitting in a dark, cool room helps them pass. Cockburn has also finished his bachelor’s degree and tries to dwell more on the good in life than the bad.
In 2011, he cowrote a memoir with his father, journalist Patrick Cockburn, titled “Henry’s Demons: A Father and Son’s Journey Out of Madness.” The book was shortlisted for a prize by the now-defunct Costa Book Awards and dramatized into a radio play for BBC Radio 4.
“It sounds cheesy, but don’t give up,” Cockburn advises others with schizophrenia and their loved ones. “I always believe that even in your darkest moments, there’s always someone who’s looking out for you somewhere. You’re not alone.”
how to get help
If you or someone you know is struggling with suicidal thoughts or mental health matters, call the 988 Suicide & Crisis Lifeline by dialing 988 to connect with a trained counselor, or visit the 988 Lifeline website.
To learn more about schizophrenia causes, symptoms and treatments, visit Mental Health America.
To find a mental health provider, visit Mental Health America if you’re in the United States or Mind in the United Kingdom. The Schizophrenia and Psychosis Action Alliance has more tips for finding effective treatment.