Schizophrenia is a serious mental illness (SMI) that affects how a person thinks, feels and behaves. While the disease affects about 1.1% of Americans, the burden on those living with schizophrenia, and their friends and family, can be substantial. The symptoms most commonly associated with schizophrenia are the ones that tend to be the most visible, including hallucinations, delusions or disorganized behavior. These are known as positive symptoms as they are experiences or behaviors added to a person’s reality. Positive symptoms are important to identify and treat, and they often draw urgent clinical attention because they can be disruptive and destabilizing.
However, schizophrenia does not always present in the way people may expect and the signs that are easiest to observe are only part of a complex set of symptoms. The more insidious indicators of disease are often the cognitive dysfunction and negative symptoms that are not as readily observed. Cognitive dysfunction can affect several areas of thinking, including attention, working memory, verbal learning and memory, executive functioning, planning, abstraction and processing speed. And negative symptoms are behaviors that are or become absent when the disease takes root. For example, a person may lose motivation, withdraw socially, show reduced emotional expression, speak less, initiate fewer activities or struggle to experience pleasure.
While schizophrenia is known to impact men and women at similar rates, there are differences in how the disease may present. The average age of onset for schizophrenia is typically between the late teens and early 30s, but males tend to develop signs earlier than females. In fact, 90% of those diagnosed with schizophrenia by age 30 are men. Men may also experience more negative symptoms. This Men’s Mental Health Month, it is worth taking a closer look at how schizophrenia may show up in men and how their diagnosis and treatment journey is unique.
When negative symptoms are mistaken for personality
Oftentimes, the way negative symptoms specifically first present in men will play a pivotal role in how their journey progresses. This presentation may impact which changes actually are recognized as symptoms of schizophrenia, whether a person receives an accurate and/or timely diagnosis, whether treatment begins early and what treatment options are considered.
For clinicians, families and care partners, the challenge is that changes in behavior may not immediately look like symptoms of a mental health condition at all. Given the average age of symptom onset, these changes may appear at a time when young men are already navigating life transitions, including leaving home, starting college, entering the military or workforce, etc. These changes can be stressful and dysregulating in their own right, and early indicators may get easily explained away as normal signs of adjustment.
As a result, a young man who withdraws from his friends may be seen as isolating by choice. A student whose academic performance drops may be told he is not applying himself. A person who struggles to get out of bed, return calls, attend appointments or participate in family life may be described as lazy, indifferent or difficult. Those assumptions can be deeply harmful when the underlying issue is an emerging SMI.
When negative symptoms are misunderstood, people can end up being blamed for the very symptoms they need help addressing. A man who is withdrawing socially may be told he needs to try harder, when what he may really need is a careful assessment, appropriate treatment and a support system that recognizes what is happening. Someone with reduced emotional expression may be seen as indifferent, when the illness may be making it harder for him to show what he feels.
Schizophrenia is difficult to diagnose accurately. In one large study of more than 26,000 patients with schizophrenia, nearly 14,000 of which were men, 56.7% had received another diagnosis before being correctly diagnosed with schizophrenia. This emphasizes that diagnosis requires careful, ongoing assessment.
The presence of negative symptoms can add another layer of complexity because some of these can resemble depression or other mental health conditions. Withdrawal, low motivation, and diminished activity can point clinicians in more than one direction. However, when those changes occur alongside other concerns, such as shifts in academic performance, social grouping, perception or thought organization, clinicians have to be willing to keep looking rather than settling too quickly on the most obvious explanation.
The same is true once treatment begins. In a busy psychiatric setting, there can be a temptation to focus on the signs that are most visible and disruptive. If hallucinations, delusions or agitation improve, the person may become calmer, quieter and less “on the radar” for acute response. But that is not good enough. Treatment has to look beyond what other people can see–a person also needs to be able to participate in school or work, maintain relationships, keep up with basic routines and stay connected to care. For many patients, staying connected to care over time is one of the most practical and important aspects of the treatment plan.
When it comes to taking medication as prescribed, the very symptomatology of schizophrenia can make this especially difficult. Negative symptoms may make it harder to initiate tasks, keep appointments or follow through with a daily routine (such as taking daily oral medications). And even positive symptoms, such as delusions, can make a person living with schizophrenia distrustful of medication or believe that they don’t need treatment at all. Treatment planning has to account for this reality.
For some people living with schizophrenia, long-acting injectable (LAI) medications may be worth discussing, especially if taking a pill every day has been difficult or if the goal is to maintain steadier treatment over time. One example is ARISTADA® (aripiprazole lauroxil), an LAI medication used to treat schizophrenia in adults and administered by a healthcare professional. LAIs are not the right fit for every patient, and they should always be considered in the context of an individualized treatment plan. But for some people, they may reduce the daily burden of remembering medication and make it easier to stay engaged to care.
That kind of consistency matters because schizophrenia treatment is not only about what happens during a crisis–it is about helping a person stay connected to care long enough to build stability, address negative and cognitive symptoms, and return to the routines and relationships that support long-term wellness.
Why Men’s Health Month should include SMI
June is both Men’s Health Month and Men’s Mental Health Awareness Month, which is a valuable reminder that men’s overall health must include mental health. Healthcare providers do a reasonable job reminding men to think about the physical aspects of their health, including blood pressure, cholesterol, cancer screenings, exercise and sleep. However, we are less consistent when it comes to SMI. Like physical health, SMI can change the course of a person’s life if diagnosis is missed or the disease is un- or undertreated–mental health is health and should be approached with the same rigor and importance as physical health.
For men living with schizophrenia, that point is especially important. The earliest signs may not look like what families expect psychiatric illness to look like. They may look like withdrawal, flat affect, lack of motivation or a young man simply withdrawing from the life he used to participate in. Stigma can make those behaviors even easier to misunderstand. Schizophrenia is a medical illness–one characterized by physiologic changes in the brain and the rest of the body; it is not a personal failing, character flaw or lack of effort. They literally have. That framing is especially important when discussing negative symptoms because they are often misread through the lens of personality, discipline or effort.
This perspective can be particularly harmful for men, who are already less likely to seek mental health support because of stigma, cultural expectations and the belief that asking for help is a sign of weakness. The influence of stigma can make it harder for men to talk openly about changes in mood, thinking or functioning, and it can make families less likely to recognize symptoms as signs that something clinically meaningful may be happening.
This is why care has to be individualized and comprehensive, including medication when appropriate, psychosocial support, family education and practical strategies that help a person stay connected to treatment over time. Negative symptoms deserve attention because they often determine whether someone can actually participate meaningfully in their life, not just whether the most visible symptoms are under control.
This Men’s Mental Health Month is a moment to think about how we each contribute to creating an environment where mental health is seen as part of whole health and where men feel safe talking about mental health and asking for help when they need it.
This article was written for WHN by Dr. Ray Kotwicki, MD, MPH, DFAPA, who is the Chief Medical Officer at Hightop Health.
Dr. Kotwicki trained as a Department of Energy Fellow and was a Medical Scholar at the University of Wisconsin Medical School. He completed post-graduate training at Harvard Medical School, the Boston University School of Medicine, and Emory University, where he earned a Master in Public Health degree in Health Policy and Management. He remains a full professor on the adjunctive faculty at both the Emory University School of Medicine as well as the Rollins School of Public Health. Kotwicki has presented more than 425 invited lectures, symposia, and seminars to thousands of attendees. He is recognized as a trusted national expert and renowned speaker on current issues in psychiatry, mental health, professionalism, and wellness.
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