It was a routine question: "Is there anything else you want to add?"
And in retrospect, Ridwan Tahseen's decision to answer the school counsellor truthfully was nothing less than life-changing. Otherwise, he may have been on a fast track to schizophrenia. Mr. Tahseen's university grades had plummeted so far that the 20-year-old was talking to his counsellor about being suspended. Feeling he had nothing to lose, he blurted out a string of disturbing revelations: He was devastated by a breakup. He had been cutting himself. In crowds, he thought people were staring at him and about to harm him.
"She was shocked," says Mr. Tahseen, pulling up his right sleeve to reveal the wide scar he showed her that day. Faded now, it runs along his inner arm, elbow to wrist.
In a swift chain of events, he was referred to a program at Toronto's Centre for Addiction and Mental Health specializing in monitoring and treating young people with early signs of severe mental illness.
Doctors saw in him hints of schizophrenia. "They said, 'You don't have it. But we have seen symptoms of it,' " Mr. Tahseen, now 22, says in an interview in a CAMH meeting room. He and his doctors have been tackling his early symptoms in the hopes of either preventing schizophrenia from happening or, if it does occur, lessening its severity. Schizophrenia is perhaps the biggest mystery of modern psychiatry. A person with schizophrenia has trouble distinguishing between what is real and what is not.
He may hear voices or experience hallucinations, paranoia, delusions, serious disability and violent impulses.
Three in every 100 people will experience a psychotic episode in their lifetime and one in 100 will have schizophrenia. Often emerging
during the teenage years, many of the signs - a sudden drop in grades, irritability, feeling suspicious and withdrawing from family - happen to look a lot like adolescence in general.
"It's hard to differentiate the beginnings of illness from normal adolescent turmoil but there are differences," says Jean Addington, a psychiatry professor, researcher and the director of the Prevention through Risk Identification, Management and Education program Mr. Tahseen visited.
While there have been advances in treating people immediately after their first psychotic episode, many researchers are looking to detect the risk factors before they erupt. Even successfully treated schizophrenia patients say that getting a handle on their condition earlier could have spared them some of the more serious effects, such as hospitalization.
The PRIME Clinic has been open for nearly a decade, but the field of preventative mental-health care is still in its infancy, so patients often double as research subjects.
Dr. Addington and her colleagues at clinics in Connecticut, North Carolina and Calgary follow patients for years after they first seek help.
By looking back at the particular warning signs in those patients who go on to develop full-blown schizophrenia, the researchers are able to refine their understanding of which "prodromal," or pre-illness, symptoms are the most predictive.
Their most recent research, published in January in the Archives of General Psychiatry, drew on the experiences of 291 patients and identified five reliable early-warning signs. Until recently, the only hard evidence of risk was that one in 10 people with a parent or sibling with schizophrenia would go on to develop it, which, Dr. Addington says, wasn't much use as a preventative measure.
Some of the risk factors are similar to the full-blown characteristics of the illness, such as unusual thought content, suspicion/paranoia, perceptual anomalies, and disorganized communication. Others are not, such as a feeling of grandiosity. Of people with the five symptoms, 20 to 40 per cent go on to experience psychosis within 30 months.
Only a handful of PRIME patients go on to suffer a first episode each year, Dr. Addington says, yet about 200 people visit the centre's first-episode clinic.
"We're just touching the tip of the iceberg. So where are all the others?" she asks. "It may be some of them don't think they have an illness. It may be stigma, or fear of what doctors might confirm. Or they may believe the early symptoms."
Hence the push to increase mental-health literacy among teachers, counsellors and anyone who deals with youth, says Chris Summerville, the interim CEO of the Schizophrenia Society of Canada. Up to 70 per cent of people with schizophrenia recover, he says. "We can enhance that recovery with early discovery."
And that doesn't mean simply prescribing anti-psychotic medication early. Treatment for PRIME patients begins with psychological and social help, and attention for related problems such as depression.
Young patients are strongly advised to steer clear of marijuana, since recent studies have linked heavy pot use with an earlier and more intense onset of schizophrenia.
Those studies may also be a clue that schizophrenia as we know it is on the rise, says neuroscientist James Kennedy, head of the Psychiatric Neurogenetics Section, at CAMH and a professor of psychiatry at the University of Toronto.
"Since marijuana is more widely available in North America over the past 40 years or so, this could be contributing to increased rates of schizophrenia."
For those not detected early, Dr. Kennedy's genetic research aims to minimize the negative side effects of anti-psychotic drugs, such as obesity, diabetes and the involuntary movements known as tardive dyskinesia. A new lab is about to open at CAMH this month to offer this gene-based pharmacological advice to psychiatrists before they prescribe.
There's a good chance that Mr. Tahseen will never receive this analysis. He has stayed in school, now studying international development; he plays soccer regularly, and works part-time. His psychiatrist visits have been scaled back to once monthly and he continues to use sleeping and anti-anxiety medication only occasionally.
Every time a Columbine-style shooting is in the news, though, he sees an alternate path his life could have taken as a result of his budding paranoia. "You don't think about who is innocent. You're so frustrated and sad and angry. At that point, that's what I felt."
David can relate. He was a popular 24-year-old student with good grades when a breakup - in addition to heavy pot use, he believes - triggered a severe first episode in which he was hospitalized after threatening roommates.
David, who declined to be identified, was released to
his parents' home outside
Toronto and months later sought help at CAMH. Diagnosed with schizoaffective disorder - schizophrenia with an added mood disorder element - he began a successful five-year course of anti-psychotic medication and psychosocial therapy.
Still, he wonders what might have happened if he had been flagged early. He did visit his university's health centre before his first episode, describing mood swings and suicidal feelings.
"They prescribed the wrong drugs, without any follow-up, without any referral to a psychiatrist," he says, adding that negative side effects of the drugs, including twitches, only added to his instability. "They had an opportunity early on to get [me]some intervention, to get some help. I was at risk of something."
Compounding the problem, however, is the fact that paranoia itself can deter people from seeking help. Marie Asuncion, 23, had her first episode at 15. Before that she recalls rebuffing a schoolmate who asked her if something was wrong. "Could I have gotten a little bit of support?" Ms. Asuncion asks. "But at the same time, if I told everyone what was wrong I probably would have gotten more sick, because you worry about what people are thinking about you."
Mr. Tahseen has been coached to tweak this kind of thinking. When he worries he's being watched, he tells himself, "Maybe they're not looking at you. Maybe they're looking at the logo on your shirt."
Mr. Tahseen is confident he has dodged schizophrenia, "I feel I'll never end up there."
Risk factors
Signs a teen may be at risk
of developing psychosis:
trouble concentrating
or thinking clearly.
confusion about what is real or imaginary.
hearing voices or seeing things that aren't really there.
feeling suspicious
or paranoid.
disorganized speech, racing or slowed-down thoughts.
irrational ideas of special identity or abilities.
problems with social activities at work or at school.
people who have a family member who has a mental
illness, and who are now
experiencing their own difficulty functioning, are also considered to be at some risk.
Source: CAMH
Resources for treatment
Schizophrenia Society of Canada: http://www.schizophrenia.ca
Canadian Mental Health
Association: http://www.cmha.ca
Centre for Addiction and Mental Health: http://www.camh.net
Prevention through Risk
Identification, Management
and Education Clinic (PRIME): http://www.camh.net/prime_clinic
PRIME clinic, Calgary Health
Region: http://www.thesoonerthebetter.ca and http://www.earlypsychosis.ca