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Ask the expert
Development and process

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

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

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

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

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

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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