Centre intégré universitaire de santé et de services sociaux de l’Ouest-de-l’Île-de-Montréal
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Ask the expert

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 They'll be more withdrawn.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

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

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

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.

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