A young woman in a dusty-rose hijab and her mother sitting together at a clinic desk, talking calmly with a friendly female doctor holding a notepad

Skizofrenia (Schizophrenia): Tanda Awal, Punca & Rawatan

Skizofrenia (schizophrenia) is a long-term mental illness that affects how a person thinks, feels and behaves. It can cause hallucinations (hearing or seeing things that are not there), delusions (strongly held beliefs that are not true), muddled thinking, and withdrawal from friends and daily life. It is usually first diagnosed between the ages of 16 and 30; in women it often starts a few years later than in men, with a second rise around menopause. The cause is a mix of genes and environment, and heavy cannabis use raises the risk. Antipsychotic medicine, talking therapy and family support work, and at least 1 in 3 people recover fully. Early treatment gives the best results. Schizophrenia is not a split personality, and most people with it are not violent.

Need help now? If you or someone you know is thinking about suicide, may harm themselves or others, or is in danger, call 999 or go to the nearest emergency department.

You can also talk to someone: Talian HEAL 15555 (Ministry of Health mental health line) or Befrienders KL +603-7627 2929 (24 hours).

Ringkasan: Skizofrenia (Schizophrenia)

  • Skizofrenia ialah penyakit mental jangka panjang yang menjejaskan cara seseorang berfikir, merasa dan berkelakuan. Ia bukan personaliti berpecah.
  • Tanda utama: halusinasi (dengar suara atau nampak benda yang tiada), delusi (kepercayaan yang tidak benar), fikiran bercelaru, dan menarik diri daripada orang lain.
  • Tanda awal sering datang perlahan: kurang tidur, susah fokus, tidak jaga kebersihan diri dan mengasingkan diri.
  • Pada wanita, ia biasanya bermula 3 hingga 4 tahun lebih lewat berbanding lelaki, dan risiko naik sedikit lagi sekitar menopaus.
  • Rawatan: ubat antipsikotik, terapi bercakap (CBT), sokongan keluarga dan pemulihan. Jangan berhenti makan ubat secara tiba-tiba.
  • Merancang kehamilan? Jumpa doktor sekurang-kurangnya 3 bulan sebelum mencuba, dan jangan berhenti ubat secara tiba-tiba jika didapati hamil.
  • Bantuan: klinik kesihatan, Mentari, Talian HEAL 15555, atau 999 jika ada bahaya.

Sumber: NHS; WHO; MedlinePlus; Garis Panduan Amalan Klinikal (CPG) Kementerian Kesihatan Malaysia 2021; RCPsych.

Apa itu skizofrenia?

Schizophrenia (skizofrenia in Malay) is a long-term mental health condition. Doctors describe it as a type of psychosis, which means the person may not always be able to tell their own thoughts and ideas apart from reality (NHS). It changes how a person thinks, feels and behaves, and people with it may seem to have lost touch with reality, which is distressing for them and for their family (NIMH).

About 1 in 300 people worldwide, or 27 million, live with schizophrenia, rising to about 1 in 206 adults aged 20 and over (WHO). People are usually first diagnosed between the ages of 16 and 30, after a first episode of psychosis (NIMH). Many people have episodes when symptoms are severe, followed by periods with few or no symptoms (NHS).

Two common misunderstandings are worth clearing up at the start. People with schizophrenia do not have a split personality, and the condition does not usually cause someone to be violent (NHS). Schizophrenia is also very treatable: the WHO says at least 1 in 3 people achieve complete remission of their symptoms.

In this guide we use “a person with schizophrenia” rather than labels, because the illness is something a person has, not who they are.

Tanda awal dan gejala skizofrenia

Early warning signs. Schizophrenia often develops slowly. Changes in behaviour can appear months or even years before the first hallucinations or delusions; doctors call this the prodromal period (NHS). Early signs include (NHS; MedlinePlus):

  • pulling away from friends and family, and spending more time alone;
  • losing interest in study, work or activities the person used to enjoy;
  • not looking after themselves, such as no longer caring about hygiene;
  • trouble sleeping, or sleeping at unusual times;
  • trouble concentrating, and feeling irritable or tense;
  • odd or eccentric behaviour, and finding it hard to communicate (Malaysian CPG).

Because these changes often start in the teenage years, they can be mistaken for a “phase” (NHS). They can also have other causes, such as depression, so a doctor’s assessment is needed.

Main symptoms. Doctors group the symptoms of schizophrenia into these types:

Type What it means Examples
Hallucinations (halusinasi) Seeing, hearing, smelling, tasting or feeling things that do not exist outside the mind. They feel completely real to the person (NHS) Hearing voices is the most common. Voices may comment on what the person is doing, give instructions or seem to come from the television (NHS)
Delusions (delusi) Strongly held beliefs that are not based on reality (NHS) Believing you are being followed, watched, plotted against or poisoned, often by family or friends, or that the TV is sending you secret messages (NHS)
Muddled thinking and speech Trouble keeping track of thoughts and conversations (NHS) Jumping between ideas, jumbled speech, feeling that thoughts are being put into or taken out of your mind (NHS; WHO)
Negative symptoms A loss of things a person used to do or feel (NHS) Withdrawing from others, flat emotions, little speech, losing interest and pleasure, neglecting self-care (NHS; WHO)
Thinking difficulties Problems with cognitive skills (WHO) Poor memory, attention and problem-solving (WHO)

Negative symptoms are easy to misread. Family members may see them as laziness or rudeness, which can cause conflict at home (NHS), but they are part of the illness. People with schizophrenia may also have anxiety, depression and suicidal thoughts (MedlinePlus); see our guide to kemurungan (depression).

Skizofrenia pada wanita

Schizophrenia affects women and men, but there are some differences that matter for women:

  • It often starts later. On average, women become unwell 3 to 4 years later than men, and there is a second, smaller peak of onset around menopause (Häfner 1997). Hormones such as oestrogen are thought to play a part (Häfner 1997). So symptoms that start for the first time in a woman’s 40s or 50s should not be dismissed; see our guide to menopaus.
  • Treatment may start later. In Malaysia’s National Mental Health Registry report for 2003 to 2005, people went untreated for an average of 28.7 months after psychosis began, and the delay was longer among women (Malaysian CPG). This delay is one of the few things affecting the outlook that better services can change (Malaysian CPG).
  • Medicines can affect hormones. Some antipsychotics raise the hormone prolactin. This can cause irregular or missed periods, milky discharge from the breasts, a lower sex drive and difficulty getting pregnant (Haddad 2004). In older studies of women taking older antipsychotics, about 45% had irregular or absent periods (Haddad 2004). Other antipsychotics rarely raise prolactin, so tell your doctor about these changes (Haddad 2004; RCPsych).
  • Pregnancy and the weeks after birth need planning, because the risk of becoming unwell again is highest in the first days after giving birth (Malaysian CPG). See the pregnancy section below.

Women are also often the main carers when a parent, husband or child has schizophrenia. Looking after a family member can be exhausting, and carers need support too; see the section for families below.

Punca dan faktor risiko

The exact cause of schizophrenia is unknown. Research suggests a combination of physical, genetic, psychological and environmental factors makes some people more likely to develop it, and that a stressful event can then trigger the first episode (NHS; WHO).

Factor What the evidence says
Genes It runs in families, but no single gene causes it. If one identical twin has schizophrenia, the other has about a 1 in 2 chance; for non-identical twins it is about 1 in 8, compared with about 1 in 100 in the general population (NHS)
Brain development and chemistry Subtle differences in brain structure and in chemical messengers such as dopamine have been found, and medicines that lower dopamine activity can ease symptoms (NHS)
Pregnancy and birth complications Low birth weight, premature birth and lack of oxygen at birth are more common in people who later develop schizophrenia (NHS). Infections during pregnancy may also play a part (Malaysian CPG)
Cannabis (ganja) and other drugs Heavy cannabis use is linked to a higher risk (WHO). In a European study, daily cannabis use was linked to about 3 times higher odds of psychosis, and daily use of strong cannabis to nearly 5 times (Di Forti 2019). Psychosis caused by cannabis, hallucinogens or amphetamines (such as syabu) raises the risk of later developing schizophrenia (Malaysian CPG)
Stressful life events Bereavement, losing a job or home, divorce, the end of a relationship, or physical, sexual or emotional abuse do not cause schizophrenia, but can trigger it in someone already vulnerable (NHS)
Other factors Living in a big city, an older father, and infections of the brain in childhood are linked to a higher risk (Malaysian CPG)

Having these genes or risk factors does not mean a person will definitely develop schizophrenia, and it is not known why some people develop symptoms while others do not (NHS). Using drugs can also cause a relapse or stop symptoms from improving in people who already have the illness (NHS).

How schizophrenia is diagnosed

There is no single test for schizophrenia. It is diagnosed by a psychiatrist after an assessment (NHS; MedlinePlus). The doctor will usually talk with the person and their family about (MedlinePlus):

  • what the symptoms are and how long they have lasted;
  • how daily life, study or work has changed;
  • family history of mental illness;
  • alcohol and drug use, and any other medical conditions.

Blood tests and brain scans such as a CT or MRI are not used to diagnose schizophrenia, but may be done to rule out other conditions with similar symptoms (MedlinePlus). Drug use can cause psychosis or a similar illness (NHS), and in the weeks after childbirth a sudden psychosis may be postpartum psychosis, which is a medical emergency.

The person may not believe they are ill and may refuse to see a doctor (NHS). If you are worried about a family member, you can speak to the doctor at a klinik kesihatan yourself first to ask how to help.

Rawatan skizofrenia

Schizophrenia is usually treated with a combination of medicine and talking therapy, tailored to each person (NHS). Treatment works best when it starts early.

Antipsychotic medicines

Antipsychotics are the most effective treatment for schizophrenia (MedlinePlus). They can reduce anxiety or agitation within a few hours, but may take several days or weeks to reduce hallucinations and delusions (NHS). Most people take medicine for 1 to 2 years after the first episode, and for longer if the illness comes back (NHS). Antipsychotics registered in Malaysia include (Malaysian CPG):

Group Examples (generic names) Notes
Older (first-generation) chlorpromazine, flupenthixol, fluphenazine, haloperidol, perphenazine, sulpiride, trifluoperazine, zuclopenthixol More likely to cause shaking, stiffness and muscle spasms (NHS)
Newer (second-generation) amisulpride, aripiprazole, asenapine, brexpiprazole, cariprazine, clozapine, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone Some are more likely to cause weight gain (NHS)
Long-acting injections fluphenazine, flupenthixol and zuclopenthixol decanoate; risperidone; paliperidone; aripiprazole Given every 1 to 4 weeks, so there is no daily tablet to remember (NHS; Malaysian CPG)

The choice should be made together with your psychiatrist, weighing benefits and side effects (NHS). Common side effects include (NHS; MedlinePlus):

  • sleepiness, dizziness, blurred vision, constipation and a dry mouth;
  • restlessness, shaking or slowed movements;
  • weight gain, higher cholesterol and changes in blood sugar, which need regular checks; see our guides to kencing manis (diabetes) and kolesterol tinggi;
  • lower sex drive, and in women irregular periods or breast discharge from raised prolactin (NHS; Haddad 2004);
  • with long-term use, a movement problem called tardive dyskinesia, with repeated movements the person cannot control; tell your doctor straight away if you notice this (MedlinePlus).

Many side effects can be managed (MedlinePlus); there may be another antipsychotic you can switch to, or an extra medicine to ease the side effect (NHS). Do not stop your medicine without talking to your doctor, because symptoms often come back (NHS). Tell your doctor or pharmacist before taking supplements, herbal products or over-the-counter medicines, as some can interfere with antipsychotics (NHS).

Clozapine. If symptoms have not improved enough after trying two different antipsychotics, each for at least 6 weeks at a proper dose, doctors call this treatment-resistant schizophrenia. It affects up to 23% of people, and clozapine should be offered (Malaysian CPG). Clozapine needs a full blood count every week for the first 18 weeks and then every month, to check for a rare but serious drop in white blood cells (Malaysian CPG; RCPsych).

Talking therapies and rehabilitation

  • Cognitive behavioural therapy (CBT): helps people cope with hallucinations and delusions and avoid acting on distressing thoughts. It works best alongside medicine (NHS).
  • Family therapy and psychoeducation: helps the whole family understand the illness, solve practical problems and plan for a crisis (NHS). Malaysia has run family psychoeducation programmes for many years (Malaysian CPG).
  • Arts therapy: may ease negative symptoms in some people (NHS).
  • Supported employment: people with severe mental illness were about 3 times more likely to find work with supported employment than with other job programmes (Malaysian CPG).
  • Exercise: exercise therapy improved symptoms, mood and fitness in studies (Malaysian CPG).

During a severe episode, a stay in hospital may be needed to keep the person safe (MedlinePlus).

Skizofrenia, kehamilan dan menyusu

Pregnancy does not protect against mental illness, and women with a psychotic illness have a higher risk of becoming unwell during pregnancy or after birth (RCPsych). With good planning, babies of mothers taking antipsychotics usually do as well as other babies once factors such as smoking are taken into account (RCPsych).

Stage What to know
Before pregnancy Get pre-pregnancy care at a klinik kesihatan or O&G clinic at least 3 months before trying, so your treatment can be adjusted while you are well. Take folic acid 5 mg a day before conception and for the first 3 months (Malaysian CPG). Some antipsychotics raise prolactin and can make it harder to conceive; ask for a prolactin test if you are having trouble (RCPsych). See also our guide to cara cepat hamil.
If you find out you are pregnant Talk to your psychiatrist or doctor as soon as possible, but do not stop your antipsychotic suddenly: stopping makes it quite likely you will become unwell again (RCPsych). Guidelines prefer continuing the lowest effective dose of a single antipsychotic, and not switching if you are stable (Malaysian CPG).
Safety for the baby About 3 in 100 babies are born with a birth defect even without any medicine. Studies of more than 10,000 women have not found an overall increase with antipsychotics (RCPsych). One large study found a small increase with risperidone, from about 3 to 4 in 100, which needs more research (Huybrechts 2016; RCPsych). Long-acting injections are best avoided during pregnancy (Malaysian CPG).
Extra checks Antipsychotics can increase weight gain and diabetes, so your blood sugar is checked more often (RCPsych). Some newborns have short-lived crying, jitteriness, sleepiness or feeding difficulty if medicine is taken late in pregnancy; this usually settles within hours or days (Malaysian CPG).
After birth The risk of relapse is highest in the first 9 days after giving birth (Malaysian CPG). If you stopped medicine during pregnancy, restarting within 24 hours of birth can lower the risk of postpartum psychosis (RCPsych). Arrange extra help so you can sleep.
Breastfeeding All antipsychotics pass into breast milk, mostly in small amounts; levels are lowest with olanzapine and quetiapine. Aripiprazole can reduce milk supply. Do not breastfeed while taking clozapine (RCPsych; Malaysian CPG). Avoid sharing a bed with your baby if your medicine makes you sleepy (RCPsych).

Whatever you decide about breastfeeding, choose what keeps you well. A partner or family member can help with night feeds so you get enough sleep, which helps prevent relapse (RCPsych).

Panduan untuk keluarga dan penjaga

Families play a huge part in recovery. These steps can help (NHS; MedlinePlus):

  1. Learn about the illness together with the person, and ask the clinic about family psychoeducation.
  2. Know the early warning signs of a relapse, such as poor sleep, loss of appetite, feeling anxious, suspicious or fearful, hearing quiet voices now and then, or trouble concentrating (NHS). Act early: an episode can sometimes be prevented with medicine and extra support (NHS).
  3. Make a crisis plan with the care team: who to call, which hospital to go to, and the person’s wishes about treatment (NHS).
  4. Support medicine and appointments without nagging, and help report side effects to the doctor.
  5. Listen without arguing. Hallucinations feel very real to the person (NHS). Acknowledge how they feel, and gently encourage them to talk to their care team.
  6. Encourage them to avoid alcohol and drugs, which can trigger psychosis, worsen symptoms and react badly with antipsychotics (NHS).
  7. Look after yourself. Caring is hard work. Talk to someone, take breaks and ask other relatives to share the load.

Faith, traditional healing and medical care. In a study in north-east Peninsular Malaysia, the most common first step for Malay patients with psychosis was a traditional or alternative healer, and 61.7% had consulted a bomoh or homeopath (Razali 2008). In another Malaysian study, caregivers said that limited knowledge about schizophrenia and stigma both made it harder to seek professional help (Wong 2019). Malaysia’s guidelines describe care for schizophrenia as biological, psychological, social and spiritual (Malaysian CPG). Prayer and religious support can be a comfort, but they should go alongside medical treatment, not delay it.

Mitos dan fakta tentang skizofrenia

Stigma about schizophrenia is common in Malaysia. Mental health professionals here have described labelling, rejection, exclusion and job discrimination, often from family, friends and workplaces (Hanafiah 2015). In one Malaysian hospital study, 83.5% of people with schizophrenia said they had felt stigma (Malaysian CPG).

Myth Fact
“Schizophrenia means a split personality.” It does not. Schizophrenia affects thinking and perception of reality, not a split into different personalities (NHS).
“People with schizophrenia are dangerous.” Schizophrenia does not usually cause someone to be violent (NHS), and most people who have psychotic episodes are not a danger to others (NHS). People with schizophrenia often face stigma, discrimination and violations of their rights (WHO).
“They are just lazy.” Withdrawal and lack of motivation are negative symptoms of the illness, not laziness (NHS).
“Nobody recovers.” At least 1 in 3 people achieve complete remission (WHO), and most people make a recovery, even if symptoms sometimes return (NHS).
“It is someone’s fault.” Experts believe it comes from a combination of genetic and environmental factors (NHS; WHO). Stressful events can trigger it in someone already vulnerable but do not cause it on their own (NHS).

How we talk matters. Saying “a person with schizophrenia” instead of a label, and avoiding words like gila, makes it easier for people to seek help early.

Jaga kesihatan fizikal

People with schizophrenia die on average about 9 years earlier than the general population, often from heart disease, metabolic problems such as diabetes, and infections (WHO). Much of this can be prevented:

  • Have a check-up at least once a year, including weight, blood pressure and blood tests (NHS). Weight and blood tests are checked more often in the first year of a new antipsychotic (Malaysian CPG).
  • Eat well and stay active. A balanced diet and regular exercise lower the risk of heart disease and diabetes (NHS).
  • Stop smoking. In a Malaysian hospital, 38.1% of people with schizophrenia were dependent on smoking, compared with 21.3% of all Malaysian adults who used tobacco (Malaysian CPG). Stopping smoking improves mental health too (NHS). Tell your doctor before stopping or restarting, because smoking changes how much medicine you need (NHS).
  • Keep a regular sleep pattern and try to limit stress (NHS); see our guide to susah tidur (insomnia).

Di mana dapatkan bantuan di Malaysia

Most health facilities in Malaysia, including klinik kesihatan and district hospitals, provide mental health services and can refer you to a psychiatrist (Malaysian CPG). Places to start:

  • Klinik kesihatan or a GP: for a first assessment and referral.
  • Mentari community mental health centres: you can walk in for an assessment if you have symptoms of mental illness (Malaysian CPG).
  • Psychiatric clinics at government and private hospitals.
  • Talian HEAL 15555: the Ministry of Health mental health support line, open daily including public holidays from 8am to midnight.
  • Befrienders Kuala Lumpur, +603-7627 2929: free, confidential emotional support, 24 hours a day.
  • Talian Kasih 15999 (or WhatsApp 019-261 5999): a 24-hour government helpline that includes counselling.

Contact a doctor if someone hears voices telling them to hurt themselves or others, sees or hears things that are not there, feels scared or overwhelmed, or feels unable to care for themselves (MedlinePlus). Call 999 or go to the emergency department if they are thinking about hurting themselves or others, and do not leave a person alone if they have attempted suicide (MedlinePlus). The lifetime risk of suicide in schizophrenia is about 5% (Malaysian CPG), so take any talk of suicide seriously.

Frequently asked questions (FAQ)

Apa itu skizofrenia (what is schizophrenia)?

Schizophrenia is a long-term mental illness that changes how a person thinks, feels and behaves. Doctors describe it as a type of psychosis, which means the person may not always be able to tell their own thoughts and ideas apart from reality (NHS). It affects about 1 in 300 people worldwide (WHO). It is not a split personality, and with treatment many people recover or live well.

Apakah tanda awal skizofrenia (what are the early signs of schizophrenia)?

Early signs often appear slowly, months or even years before hallucinations or delusions. They include pulling away from friends and family, losing interest in everyday activities, not looking after personal hygiene, trouble sleeping, trouble concentrating, and feeling irritable or tense (NHS; MedlinePlus). In teenagers these changes are easy to mistake for a phase (NHS). See a doctor early if they are new and getting worse.

Skizofrenia boleh sembuh ke (can schizophrenia be cured)?

There is no single cure, but it is very treatable. The WHO says at least 1 in 3 people with schizophrenia achieve complete remission of symptoms, and the NHS says most people make a recovery, although many have times when symptoms return (relapses). Taking medicine as prescribed, talking therapy, family support and early treatment of warning signs all lower the chance of relapse.

Apa punca skizofrenia (what causes schizophrenia)?

There is no single cause. Experts think it comes from a mix of genes and environment (NHS; WHO). It tends to run in families, and complications at birth, heavy cannabis use and stressful life events such as bereavement or abuse can raise the risk or trigger the first episode in someone who is already vulnerable (NHS). Stressful events can trigger it but do not cause it on their own (NHS).

Skizofrenia pada wanita berbeza ke (is schizophrenia different in women)?

In women it usually starts a few years later than in men, on average 3 to 4 years later, and there is a second, smaller rise around menopause (Häfner 1997; WHO). Some medicines for schizophrenia can raise the hormone prolactin, which may cause irregular or missed periods, milky discharge from the breasts or trouble getting pregnant (Haddad 2004). Tell your doctor about these changes, as there are options.

Ubat skizofrenia kena makan seumur hidup ke (do I need medicine for life)?

Not always. Most people take an antipsychotic for 1 to 2 years after their first episode, and for longer if the illness comes back (NHS). Many people need long-term treatment, because symptoms are very likely to return if medicine is stopped (MedlinePlus). Never stop suddenly on your own. Talk to your psychiatrist about the dose, side effects and long-acting injections if taking tablets every day is hard.

Boleh mengandung kalau ada skizofrenia (can I get pregnant if I have schizophrenia)?

Yes. Malaysian guidelines advise pre-pregnancy care at least 3 months before trying, folic acid 5 mg a day before conception and in the first 3 months, and staying on the lowest effective dose of a single antipsychotic if you need it to stay well (Malaysian CPG). Large studies have not found an overall increase in birth defects with antipsychotics, and babies usually do as well as other babies once factors such as smoking are taken into account (RCPsych; Huybrechts 2016). Do not stop your medicine suddenly if you find out you are pregnant.

Boleh menyusu badan bila makan ubat antipsikotik (can I breastfeed on antipsychotics)?

Usually yes. All antipsychotics pass into breast milk, but mostly in small amounts, and the levels are lowest with olanzapine and quetiapine (RCPsych). Mothers taking clozapine are advised not to breastfeed (Malaysian CPG; RCPsych). Do not share a bed with your baby if your medicine makes you sleepy (RCPsych). Discuss the choice with your psychiatrist; looking after your own mental health is good for your baby too.

Bagaimana keluarga boleh membantu (how can family help)?

Learn about the illness, help the person keep their appointments and medicine, and learn their early warning signs, such as poor sleep, suspiciousness or hearing quiet voices (NHS). Ask about family psychoeducation or family therapy at the clinic; in Malaysia, family programmes have run for many years (Malaysian CPG). Hallucinations feel very real to the person (NHS), so listen to how they feel rather than arguing about them, and look after your own wellbeing too.

Di mana dapatkan rawatan skizofrenia di Malaysia (where can I get help in Malaysia)?

Start at a klinik kesihatan or a GP. You can also walk in to a Mentari community mental health centre for an assessment, or go to the psychiatric clinic of a government hospital (Malaysian CPG). For emotional support, call Talian HEAL 15555 (8am to midnight) or Befrienders KL +603-7627 2929 (24 hours). If someone is in danger or talks about suicide, call 999 or go to the nearest emergency department.

Disclaimer

This article is for general information only and is not a substitute for advice, diagnosis or treatment from a doctor or mental health professional. Do not start, stop or change any medicine without talking to your doctor, especially if you are pregnant, planning a pregnancy or breastfeeding. If you are in crisis, call 999 or Talian HEAL 15555.

References

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