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Ask the expert
Psychotic Disorders

Can anybody get schizophrenia at any age?

Yes. There are certain periods and certain predictors that are sort of indicative of risk. The first one is that males tend to be more at-risk than females. In addition, the principal age at which the males are at-risk is between ages 14 and 18. Females tend to be at risk slightly later (i.e., in their early 20s). Nevertheless, a 35-year-old male or female can become schizophrenic but at a much lower risk.

The PEPP program (Prevention and Early Intervention Program for Psychoses) here at the Douglas Institute is trying to identify children at-risk for a psychotic episode as early as they can. Effectively, a representative of the PEPP program goes into the schools, public organizations, or churches, and tries to educate teachers, parents, and other adults. If the conduct of a teenager changes, like for example, if he or she is withdrawing socially in a significant way, this person should be brought in and be evaluated by a trained psychiatrist who would be able to identify the prodromal syndrome of schizophrenia.

-Joseph Rochford, PhD, Mini-Psych School 2009

Yes. Every one of us has plenty of genes that are responsible for this condition, and someone can develop the illness even if no one in the person’s family has schizophrenia or psychosis.
- Ridha Joober, MD, PhD, Mini-Psych School 2012

If you have a family history of psychosis, what can you do to prevent developing it yourself?

Live happily, do what you need to do, engage in life. For now, there are no specific strategies to prevent psychosis. What I would advise is sleep well, don’t use drugs, don’t let yourself get stressed, and take life easily. That is easier said than done. We don’t have any specific approach to prevent psychosis. I think it’s a more of a general approach in terms of a healthy life that will help you very much to avoid an expression of schizophrenia in someone who has a predisposition to it.
-Ridha Joober, MD, PhD, Mini-Psych School 2009

What is the probability of passing schizophrenia to your offspring if your sibling has the disorder?

If your sibling has the schizophrenia, the probability of your children getting the disorder would be 2 to 3 %. To put that number in perspective, 1 % of the general population has schizophrenia. Therefore the risk is increased 2 to 3 times. This is not a big increase in risk, compared with the general population.

That being said, two people with identical genetic risk may or may not develop schizophrenia depending on their exposure to environmental protective factors or stressors. Unfortunately, we still do not know for certain which environmental factors play a role in the development of the disease.
-Ridha Joober, Mini-Psych School 2007

Is it best to confront the patient about his delusions or to play along with him?

Let’s say you are driving in a car with a psychotic patient and he was talking to something that wasn’t there, and, when asked who he was talking to, he at first refused, and then opened up that he was talking to an implanted circuit in his body. Is addressing these issues in public a good thing or should one just let it go?

It depends on the phase of the psychosis. When people are living with psychotic symptoms that are very strongly present, it is very hard to confront them about these symptoms. What is recommended, generally, is to have some engagement with the patient, and, when they’re engaged, they become more confident to talk about it. If they are taking medication and getting help, they may want to talk about their experiences. And then their insight increases bit by bit and we know that, once the symptoms disappear, what most of the people will say is “How come I had these beliefs, how come that happened to me?”

I think that you need to have a position of bienveillance. I always take patients very seriously. Their hallucinations, delusions, etc., are as much their reality as your reality is yours. You need to be compassionate, empathetic, to take the path together down their reality in order to go from that severe situation to a better one in which there is less suffering, less dysfunction, and a better life. I think if you’re going to confront someone with their delusions, it’s not a great idea because you run the risk of becoming very frustrated about not being able to convince them that they’re wrong and that can lead to a whole emotional situation.
-Ridha Joober, MD, PhD, Mini-Psych School 2009

Understanding is key. If someone is having a psychotic episode, it’s very important to remember that this is something that can simply happen in life; it’s best not to antagonize the person and get into an argument. Reality is what people work out for themselves. Present a positive attitude to help; don’t criticize, don’t judge. If you can, consult a mental health professional and help the person seek help. All of these attitudes need to be adopted to help people with psychotic disorders and mental health issues.
- Ridha Joober, MD, PhD, Mini-Psych School 2012

What comes first in psychotic disorders: the brain abnormalities or the clinical manifestations?

There are a number of longitudinal studies in imaging that have been conducted with child-onset schizophrenia, and it’s been shown that there are some cortical developmental abnormalities. So, basically, as the brain develops from the back to the front, it seems that there is less cortical development in children in early-onset schizophrenia than in the control group.

I’m not sure whether there was a study of children who have parents with schizophrenia, but what we do know is that schizophrenia is conceived as a developmental disorder and so there are behavioural abnormalities and probably neurological abnormalities that are manifested much earlier than the clinical manifestations. Looking at home videos of people who have schizophrenia from when they were children, you notice that they already had some abnormalities in their movement or some social abnormalities.

So it wouldn’t surprise me if there are future studies that show that the brain has some developmental abnormality. But again, I think it’s extremely important to understand the fact that all these studies are done on a large number of patients and, in order to come to a clear picture, or to pinpoint the exact abnormalities, we need a huge number of subjects. When we talk about schizophrenia, it’s much more accurate to talk about schizophrenias. And I think that the brain abnormalities will be very, very heterogeneous. Therefore, we have a lot of work on our hands to understand this complex condition.
-Ridha Joober, MD, PhD, Mini-Psych School 2009

Is electric shock therapy still used and, if so, what are the risks associated with it?

It is still used, but rarely for psychotic disorders. However, it tends to be more effective for people with psychotic depression. Very severe depression, which is called melancholia, can be associated with psychotic symptoms. So, if one is very sad, and extremely discouraged, he or she can also have the impression that their body has been transformed, that they have lost everything in life, and they enter into this very negative mode. It’s been shown for a fact that one of the best treatments for these major depressive episodes with melancholia is ECT.

It was discovered in 1936 by an Italian psychiatrist by the name of Seletti and, since then, has been used extensively in different disorders. Its main indication is still major depression with psychotic symptoms. There is also psycho-surgery and lobotomy, which are prohibitive treatments, but still used in psychiatry in very, very selected situations. For example, it’s been shown that some specific brain surgery could be helpful if someone has very severe or obsessive symptoms.

In my practice, I primarily see young people with psychotic disorders, not psychotic depression. I can't remember the last time I used ECT.
-Ridha Joober, MD, PhD, Mini-Psych School 2009

Is it true that antipsychotic drugs can produce Parkinson's disease in the long run?

Not Parkinson's disease, but Parkinson-like symptoms. They can cause tremors or, to a certain extent, rigidity. That is because the drugs used for the treatment of schizophrenia affects the same part of the brain that is involved in Parkinson's disease. If you stop using those drugs, the symptoms can be reversed.
-Judes Poirier, PhD, Mini-Psych School 2006

What are the warning signs of psychotic disorders in a young adolescent?

That's really what our work is all about! There are two very important signs to look for: total withdrawal and a drastic change in sleeping patterns. First of all, most people who develop psychosis will first show changes in behaviour. They'll be more withdrawn. They may be more sullen and irritable. Once they have psychotic symptoms, they probably won't tell anyone. Nobody wants to say they feel strange inside. With regards to their behaviour, we usually ask families to be aware of adolescents who totally withdraw into themselves. They're not only breaking away from their parents (which is part of adolescence and not unusual in itself), they're also breaking away from friends. This is a sign that something is definitely wrong. The other symptom is a change in sleeping patterns. They lie awake all night and sleep during the day. They become very irritable and easily lose their temper. These are signs that a person needs to speak with a professional.
-Ashok Malla, MD, Mini-Psych School 2006

Can schizophrenia be detected in children? And if so, how might the treatment of a schizophrenic child differ from that of an adult?

There is what we call “child onset schizophrenia,” so, as early as six or seven, you can see schizophrenia in children; but it’s extremely rare. Now, the problem is that children have a lot of fantasies, imagination, play, etc. And, therefore, it becomes extremely tricky to make the diagnosis of schizophrenia in childhood. I have seen many children coming to me saying: “I’ve seen this, and I’ve seen that.” But, knowing what psychosis is, I play with them, and, it turns out, in most of the cases, it’s not real psychotic symptoms. I’ve seen people at the age of fifteen, but I haven’t seen anyone at the age of twelve or less having psychotic schizophrenia; it has been seen though, but it’s very rare.

Treatment with Ritalin can actually cause hallucinations because it increases dopamine levels. Schizophrenia, hallucinations and delusions involve excess dopamine. This doesn't mean that Ritalin is a bad medication. But if it's not prescribed properly, it can cause side effects. Its use has to be monitored.

I don’t have any experience treating children with psychotic disorders. From what I have read, I know that they use exactly the same medication but probably at lower doses. What I can say also is that these forms of schizophrenia, when they manifest themselves very early on in life, are very severe forms of schizophrenia. So, most of the time the functioning of these children, or the development of the children, would be quite compromised. I mean imagine the development of a child who presents schizophrenia at the age of six: that’s the period where people are going to school, acquiring social skills, etc. It’s the entire program of a human being that is being deployed and all of a sudden, you have something like that; so the development will be very much compromised. But I confess that I don’t have a lot of experience to talk really clearly about this topic.
-Ridha Joober, MD, PhD, Mini-Psych School 2009

Do we know why some patients don’t gain any insight into their illness, especially in paranoid schizophrenia?

Insight is extremely variable from one patient to the other. Some people have very good insight that they were experiencing a psychotic episode. This is after remission of course; otherwise, if they had had insight during the psychotic episode, they would not be qualified as psychotic. Afterwards, some will not gain insight and keep their original ideas. But, in most of the cases, we see some kind of distancing; the delusions are not so imposing on the mind. “Yes, I’m the queen of England, but that doesn’t matter anymore.” a patient might say. In the beginning, when they have these ideas, these ideas impose so much on their mind that they drive their behaviour.

Why doesn’t medication improve insight in all patients? We are trying to understand that by doing some brain imaging studies. We know, for example, that there are neurological conditions that are associated with complete absence of insight. If you have a frontal parietal stroke, you will not have the insight that you have lost your movement and so on. You look at your hand and it’s not moving, but you don’t see that you have a disease. So insight into conditions and into our body has a neurological basis. And probably some of the patients have more deficits in this area than others. But, as schizophrenias are heterogeneous, we see forms where insight is very poor, and forms where insight is much better.
-Ridha Joober, MD, PhD, Mini-Psych School 2009

If families initiate treatment, why is it so difficult to involve them in an intervention?

I believe that anyone who says you cannot be involved doesn't know what he's doing! When I give a talk, either here or in the United States, this is the most common question I hear. To answer this, we have to address the question of intent. The intent of the clinician is to help the patient get better. The intent of the family is to stay involved and get the best possible help for their family member. If these intentions are clear, why should there be any barriers? Of course, we don't want to discuss things with families that patients tell us are in confidence and are of no relevance. However, if the patient admits to wanting to kill himself, it's everybody's business.

Nothing prevents clinicians from listening to families. If families call, they don't have to discuss the “patient”. If a patient declares that he doesn't want treatment, a clinician can still invite the family to educational workshops. If a crisis happens, it's helpful to have already established a relationship with a clinician because it saves time during the admission process. In one case in Ontario, the reverse happened. A clinician was reprimanded for not keeping the family informed, even though it was against the patient's wishes, because the situation was very serious.
-Ashok Malla, MD, Mini-Psych School 2006

My brother, who suffers from schizophrenia, has gained a lot of weight due to his meds. Any recommendations other than exercise and diet?

I don't really know what to recommend. The only thing I can say is that we are starting a trial and it will be offered to people who have not had previous treatments. It involves a medication, in combination with antipsychotics, that actually reduces weight gain. We hope it will prove useful. The trial began in Israel and we are taking part. If it works, we hope the medication will be available for use in several years. There are signs of hope!
- Ashok Malla, MD,  Mini-Psych School 2006

For a person who suffers from schizophrenia but responds well to treatment, what are the implications in using cannabis and alcohol?

I believe that a moderate amount of alcohol is not a huge problem. One has to see it in context. If a person is doing well and wants to socialize, we can't say “act normal, but don't spend time with your friends when they're drinking”. Moderation is the key word here.

Cannabis is slightly different. We would never advise anyone to smoke cannabis after they've had a psychotic disorder. However, young people still do. We encourage them to have enough confidence in their clinician to tell him/her whenever they engage in such activities. We've seen patients who significantly reduce their substance use and do relatively well. When it comes to people who continue to use large amounts, there's a problem. Also, there's a difference between cannabis and alcohol in terms of its relationship to psychoses. Speed, ecstasy, acid, and cocaine are absolutely forbidden!
-Ashok Malla, MD, Mini-Psych School 2006

Are high dopamine levels the cause of schizophrenia or a consequence?

I think that schizophrenia is much more complex than excess dopamine. Schizophrenia is a brain developmental disorder. The most enduring and most difficult symptoms in schizophrenia are referred to as negative symptoms-a lack of motivation, a lack of planning for the future, and a difficulty of going out with friends and socializing. However, dopamine is mainly associated with psychotic symptoms: delusions and hallucinations. When we reduce dopamine in the brain, the hallucinations and delusions are also reduced and treated.
-Ridha Joober, MD, PhD, Mini-Psych School 2006

Are there any known treatments for residual schizophrenia?

Residual schizophrenia means that the disorder has improved with treatment, but the person still experiences mild symptoms. Most of the time, these are negative symptoms such as a lack of motivation or a lack of planning for the future. These residual symptoms can be treated with psychosocial intervention and by helping the patient to return to his previous activities.
-Ridha Joober, MD, PhD, Mini-Psych School 2006

How can you tell if the medications aren’t working?

I think the first criterion is: Does the person seem a little bit happier? Do they seem to be suffering less? Signs and symptoms don’t give a diagnosis. What gives the diagnosis really is the degree of pain and suffering and impairment of functioning. So, my major criterion for remission is this: Are you happier? Are you going out more? Are you meeting your friends more? Are you back to school? Are you realizing your dreams?

Now, sometimes I see patients taking the medication, still having hallucinations and probably some delusions, but functioning much better, going back to school, doing work, etc. That’s a very important point. We know that better functioning is correlated with fewer symptoms, so we watch symptoms also. We are very satisfied when hallucinations and delusions are less present and people go back to what we call “the normal reality”.
-Ridha Joober, MD, PhD, Mini-Psych School 2009

What are the new forms of psychotherapy for psychotic patients?

It’s a form of what is known as cognitive behavioural therapy or CBT. One of the things about the more recent form of psychotherapy was literally developed on the basis of learning theory. It takes the principle of learning theory and asks: How can we take what we know about the way the people learn and how that learning changes their behaviour and then formulate that in a psychotherapeutic context. What you do in CBT for psychosis is you try and get patients to identify what their triggers are for their hallucinations or their delusions, and then try to teach them different ways of dealing with those delusions. Identifying the triggers is a major advantage.

There is also psychoeducation, which is informing the patient and family what the illness is all about. This does wonders for the whole family. For example, if you tell a parent that the reason why his or her child is locked up in his or her room and does not want to come out is because he or she is experiencing some kind of delusion, they will be less likely to criticize the child and more likely to try and go in and talk to them and support them.

-Joseph Rochford, PhD, 2009

Can people with schizophrenia stop taking medication if they are feeling better?

When people get better, the first they think is often “I will stop the medication. Don’t tell me that this little pill is giving me my sanity because basically I know what I am now, I am completely aware about my reality, and what happened to me is something that is bizarre and it’s in the past, it’s gone.” Unfortunately, when people stop the medication, all that stuff starts coming back for the same reasons that it started in the first place.

I’m not saying that everybody will relapse but most people do. In only 10% of the cases, we will stop the medication and the symptoms won't come back. In this case, we reduce the medication very slowly and watch the symptoms for what we call “early warning signs”: reduced sleep, more anxiety, etc. Every patient has his own early warning signs; we identify them together with the patient, and closely monitor (and self-monitor) for them.
-Ridha Joober, MD, PhD, Mini-Psych School 2009

What effect might MTV have on someone who is psychotic?

We can't protect our young people from being bombarded with multiple images. It's something we're going to have to accept. I hope we can educate the school system. I know that some jurisdictions have done an excellent job of including mental health literacy as part of their education curriculum. That is not a direct answer to your question, but I don't think we have, or ever will have, control over what happens on TV.
-Ashok Malla, MD, Mini-Psych School 2006

Is there hope for people in their 30s and 40s suffering from schizophrenia?

There's hope for everyone. If someone has been ill for a while and isn't satisfied with their current situation, they should feel comfortable asking for a reassessment. New treatments are continually being developed. In the past ten years, we have new medications that are a lot more effective, especially clozapine. There are also variations in people's responses to medication. One person may respond to one medication and not to another. We have no idea why this happens. There may be times when someone is not doing well—not because they're not being treated—but because they're being over treated. Feel free to get a second opinion from an expert in the field if things aren't going well.

Can an individual with psychotic tendencies get better?

Yes. In fact, most of the antipsychotic medications that we have, allow the patient either not to have their delusions or hallucinations, or at least to ignore them. In terms of cure, they will not get rid of the disease necessarily, but allow people to deal with it in a way that is more comforting to them.

-Joseph Rochford, PhD, Mini-Psych 2009

Why is a seriously ill person not forced to take medication, but allowed to "opt out" of medication and live a disastrous life?

As most of you know, our mental health laws across Canada (each province has its own laws, but they are very similar) are not based on medical grounds. Firstly, they're based on individual liberty. Secondly, they're based on whether or not you'll cause harm to somebody else or imminent harm to yourself. Unless those conditions are present, we cannot force people to take medication. Sometimes we feel we have enough evidence to prove that a person will deteriorate, but we may not have enough evidence to convince the judge. It's not entirely a medical decision.

What is Thorazine ?

Thorazine is a brand name of the original Chlorpromazine, a discovery for which P Deniker, H Laborit and J Delay got the Laskar Award of medicine, the most prestigious award in the medical sciences. This is the parent molecule of all antipsychotic medications which helped millions of people to live better lives despite severe mental illness like schizophrenia.

Are nutrition and exercise good complementary treatments for schizophrenia?

When I took my medical training, we were told that these were not real treatments. More recently, however, there has been some evidence that options such as a combination of Omega 3 and Vitamin E might offer "extra protection"—although they're not treatments on their own. There's a trial going on right now in Israel, where patients are taking combinations of Omega 3 and Vitamin E, in addition to regular medication. They may find it will reduce the amount of medication required and offer additional protection to the brain. We'll have to wait for the results and see. As far as nutrition is concerned, in our program, we teach young people how to prepare their food and be diligent about their food choices. As for exercise, it's important, especially since weight gain is such a huge problem. And everyone knows if you want to lift your mood, you should exercise! That's what we teach our patients.

If a gene is detected that is responsible for psychiatric diseases, how can we prevent it from being expressed?

I personally believe that no one particular gene is responsible for schizophrenia. Many, many genes play a role. We do not currently know how many genes are involved. I don't think you can prevent schizophrenia from a genetic point of view, although anything is possible. However, by understanding the genetic basis of schizophrenia, we learn how this disease develops and if there are better ways to intervene in this process.
-Ridha Joober, MD, PhD, Mini-Psych School 2006

My son was diagnosed with schizophrenia, and my daughter, who is expecting a baby, is worried about the baby’s mental health. Are there signs or symptoms that we need to watch out for?

I don’t think that there are any signs or symptoms to follow as a precursor for schizophrenia. First of all, a second degree relative has about a three percent chance of developing schizophrenia. If you compare that to the general population, whose risk is one percent, this is not a tremendous increase. Second, there aren’t really any signs that will tell us with precision that the subject will develop a mental disorder, meaning that the disorder is impossible to predict. Being alarmed and overly scrutinizing the child could have more of a negative impact than anything else.
-Ridha Joober, MD, PhD, Mini-Psych School 2010

Can people living outside of Montreal use the services of PEPP-Montréal?

The reason that we restrict it to Montreal is that the philosophy of the program is to see patients in the community and engage patients wherever we can engage them. For example, if people don’t want to come to the hospital because they feel stigmatized, the case manager can meet them at a local coffee shop and work with them there. We also work very closely with families. And case managers visit families at home if patients don’t want to come to the hospital. In this case, it becomes extremely difficult to go outside of Montreal. These kinds of early intervention programs need to be developed in all regions of Quebec so that everyone can benefit. Anyone who does not live on the Island should still be encouraged to get help as soon as possible through a family doctor or CLSC, and there are other services available even if the PEPP program isn’t available in other areas.
-Ridha Joober, MD, PhD, Mini-Psych School 2012

What are the signs that a person who has suffered from major depression for many years is developing psychosis?

In severe depression, we can indeed see psychotic symptoms. In cases when people have extremely severe depression, they can have psychotic symptoms that are generally congruent with their moods and can include delusions of nihilism, delusions of poverty, delusions of having lost everything, delusions of sometimes having lost their bodies, etc. These symptoms can actually be very severe in the case of severe depression.
- Ridha Joober, MD, PhD, Mini-Psych School 2012

What are the conditions that may prevent someone with a psychotic disorder from recovering or functioning on a daily basis?

Some forms of schizophrenia or psychosis are very severe and require much more intervention and help. About 20% of patients will have this severe form of illness. Clozapine can help a good proportion of these patients, but a small proportion of patients will still have a severe condition. This doesn’t mean that they lead an unhappy life; community-oriented treatment and understanding can help. If the person isn’t suffering, then this at least is very positive. But when the disease starts, people suffer quite a bit, as do their families. Why? Because delusions are like a painful, acute throbbing that make people suffer. People with chronic forms of schizophrenia do not experience the same degree of suffering. So even though people may still experience delusions or hallucinations, they’re still happy. Then it comes down to the values of society and how society can help these people live a happy life that is free from stigma.
- Ridha Joober, MD, PhD, Mini-Psych School 2012

Is it safe to say that schizophrenia is always characterized by psychosis?

Not necessarily. Some patients have schizophrenia but they don’t have psychotic symptoms; they display mostly negative symptoms. Negative symptoms are when people cut themselves off from their friends, they don’t go out or socialize, and they express very little emotion. They don’t have hallucinations or delusions in the classical sense, but they can become stuck in their lives and lose the ability to see other options. So even in the absence of psychotic symptoms, a person can still have a very severe condition.

It should be noted that the label schizophrenia has to be erased, as it has been attached to a lot of stigma. Even the idea of schizophrenia, which is “split mind,” is not a positive way to talk about this disease, which is in fact a very big constellation of disorders. It’s best for people to define their conditions based on their own experiences.
- Ridha Joober, MD, PhD, Mini-Psych School 2012

What are the dangers of high blood serum prolactin levels?

Prolactin is a hormone that promotes lactation in humans. Prolactin is highly controlled by dopamine: when dopamine is active, it inhibits prolactin secretion. Anti-psychotic medication can block dopamine, which means that there isn’t enough dopamine to block the prolactin. Some patients will experience increased prolactin levels, but this does not always translate into symptoms, such as producing milk (although this can occur).

The prolactin level itself is not a condition or a disorder, but if you have symptoms like lactation then you need to do something. There are medications that are less prolactin-promoting, and we have some medications that don’t increase prolactin at all. We even have a neuroleptic called aripiprazole that can at least partially reverse prolactin levels. So there are different strategies to deal with this; however, if you have high prolactin levels without any other symptoms, this is not something to worry about.
- Ridha Joober, MD, PhD, Mini-Psych School 2012

Why does psychosis develop in some drug users?

This is an interesting question because we know that some drugs have the property of increasing the dopamine level in certain brain regions. For example, cocaine, amphetamines, methylphenidate, cannabis, and alcohol all increase the level of dopamine in the mesolimbic system and, therefore, they make people more prone to psychotic experiences. If you don’t have any vulnerability, you can smoke pot or take cocaine in excess and not have psychotic experiences. However, some people are extremely fragile and will have psychotic experiences even with very little doses of cocaine or cannabis. And that’s because these drugs increase the level of dopamine. Even a small increase in the amount of dopamine can bring them into a dangerous region. And that’s the model, I think, for every kind of chemical in the body. If you are suffering from diabetes, your level of insulin is already so high that, if you eat a little bit more pasta, it gets out of control. That’s exactly the same thing. These drugs are very potent dopamine agonists (enhancers) and they will increase your risks of having these psychotic episodes.
-Ridha Joober, MD, PhD, Mini-Psych School 2009

Are there common patterns in delusions, such as conspiracy patterns, etc. and why?

In terms of paranoia, there may be some kind of predisposition to react in a defensive way or paranoid way in stressful situations. In the general population, people don’t have these experiences when they are in familiar places, but then they may become suspicious of behaviour when they are in a completely new setting (i.e., a trip to Africa). The new situation can make the person suddenly become suspicious of the differences, which is a kind of programmed defence reaction. One of these reactions is paranoia, while others are mania, withdrawal and depression. There are different patterns of major programmed behavioural reactions in the face of stress, and since paranoia is one of them, this is probably why it is very common in psychotic disorders.

- Ridha Joober, MD, PhD, Mini-Psych School 2012

Why are delusions always portrayed as negative and never something fun?

It’s true that some people can enjoy their delusions. For example, instead of feeling paranoid, someone who has a delusion of being watched all the time can feel important and this can make the person happy. For quite a few people, these experiences give them a feeling of worth.

It’s very important to ask people with delusions how they feel about the experience and whether it is positive or negative for them. It’s important to point out that it’s not the delusions themselves that are harmful, but rather how they affect the person’s life. For example, if someone has delusions but can still work and is happy, then the person’s condition is not that much of an issue. However, in most cases, the delusions keep someone from having a life and cause the person and the people around them to suffer, which of course then becomes an issue.
- Ridha Joober, MD, PhD, Mini-Psych School 2012

If a traumatic event goes untreated, will this eventually lead to psychosis and/or mental illness?

This is a debated issue. Some research shows that traumatic events are more frequent in the histories of people who develop psychosis. Overall psychological trauma, especially if it is chronic, can lead to psychosis. For example, if people aren’t valued, loved or cherished and are instead criticized and put down all the time, especially during childhood, this will have an impact on development and might increase the risk for psychosis. The research is not very strong in this area, but it is possible. Some studies now indicate that traumatic events could actually increase the risk for psychotic disorders, particularly in the case of sexual trauma and physical trauma.
- Ridha Joober, MD, PhD, Mini-Psych School 2012

Is psychotic autism genetic?

Autism is considered to be highly genetically determined, possibly even more so than psychotic disorders. It is believed that 90% to 95% of autism risk is genetically determined. This field is quite complex, and as more and more research is done in the next 10 or 20 years, we should understand more about the genetics of autism.
- Ridha Joober, MD, PhD, Mini-Psych School 2012

Even though schizophrenia is often considered as a group of illnesses, research suggests that we should separate positive schizophrenia symptoms from negative ones. Is this a good idea?

The medical model is to group people together because they share some commonalities of a disease or increased risk of disease. This model may work in diabetes (high blood sugar, risk of kidney problems, retina problems, etc.). But in psychiatry and psychotic disorders, we find very few people that share the same factors that cause the condition. Although other experts may disagree, I don’t believe that there are strata in this disease; I believe that everyone has his or her own disease or disorder.
- Ridha Joober, MD, PhD, Mini-Psych School 2012

Can creative expression be useful in recovery?

Absolutely. At the Douglas, we offer a lot of creative activities. We have a creative group at PEPP–Montréal, and we invite people to come and participate. One of our participants is a woman with a history of psychosis and who is now doing her master’s degree in art therapy. She did a presentation recently at a theatre in Montreal about her whole experience, and she has also been actively involved in theatre with patients. It’s a very good medium of therapy, and it can help people who like the arts.
- Ridha Joober, MD, PhD, Mini-Psych School 2012

What are the best ways to help a person cope with their symptoms?

I think that medication is a very effective way to help people control the symptoms because, in about 80% of cases, when people take their medication, the symptoms will completely disappear, or they will disappear up to about 90%. Sometimes, there are a bit of symptoms or hallucinations or delusions that remain. Thus, cognitive behaviour therapy is also used because it has been shown to be effective in helping people cope with their symptoms. What is also important is giving people the opportunity to detach themselves from their delusions and to come to understand them as part of a psychotic experience they have gone through rather than as the actual “truth”.
-Ridha Joober, MD, PhD, Mini-Psych School 2009

Do we develop schizophrenia or we are born with it?

We can’t answer that question for sure. About 0.5% to 1% of the population suffers from schizophrenia. However, if one parent has the illness, the odds of a child having the disease are about 10%. Which means 9 out of 10 children won’t inherit the illness, but they will have a vulnerability.

The interesting thing is that in the case of identical twins, if one of them has the illness, the likelihood that the other twin will have the illness is between 40% to 70%. This tells us that it’s not just genes; it’s how the genes are expressed. This is known as the “diathesis” model, in that people have a degree of genetic vulnerability, but this predisposition can be triggered by something else. For some people, it is triggered by something like substance abuse, while for other people the condition can develop without any kind of trigger. But it often takes both together to really lead to the development of the disease. What we know so far is that both environment and genes are a factor.
-Janina Komaroff, Research Assistant, Douglas Institute, Mini-Psych School 2012

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