The mental state of a shooter who killed two and injured 13 in Toronto is the subject of intense speculation following his family's statement that said the suspect struggled with psychosis and depression his entire life.
The family of Faisal Hussain, 29, said the interventions of professionals, medications and therapy were unable to treat him.
"While we did our best to seek help for him throughout his life of struggle and pain, we could never imagine that this would be his devastating and destructive end," said the statement.
Hussain was found dead of a fatal gunshot wound after he went on a shooting rampage in Toronto's Greektown area Sunday night, reportedly shooting into restaurants at victims.
While psychosis is a common medical condition, it's less understood and talked about compared to depression or anxiety. About three out of every 100 Canadians will experience an episode of psychosis in their lifetime. We spoke to Dr. Suzanne Fillion, a clinical psychologist and university associate professor, and Dr. David Gratzer, a psychiatrist with the Centre for Addiction and Mental Health in Toronto, to get a better understanding of psychosis.
Can you explain what psychosis is and how it presents in or affects someone?
Fillion: Psychosis is a condition that reflects a disturbance in brain functioning. The condition can radically alter a person's thoughts, speech beliefs, perceptions and behaviour.
One might experience some loss of contact with reality, characterized by changes in their way of thinking and and/or behaving, which can be very disorienting and distressing.
A person with psychosis will have difficulty concentrating, often accompanied by a depressed mood. Suspicious thoughts and withdrawal are common, as are delusions (false beliefs), hallucinations and paranoia.
They might feel like their thoughts have sped up or slowed down. They might feel preoccupied with unusual ideas, like that others can manipulate their thoughts or are out to get them.
Gratzer: Psychosis isn't a disease, it's a cluster of symptoms with a variety of experiences. So as an example, someone might get a prescription for very strong painkillers and actually [experience] psychotic symptoms. But it's also true that people can become psychotic with mental illnesses likeschizophrenia or schizoaffective disorder.
According to the Schizophrenia Society of Canada, schizophrenia is a serious mental illness that affects 300,000 Canadians. Can you explain the difference between schizophrenia and psychosis?
Fillion: Schizophrenia is a brain disease. Symptoms are believed to be caused by a biochemical imbalance. Onset typically occurs between late teens and mid-thirties.
Psychosis is a criteria of schizophrenia, but can also occur as a result of a medical condition or drug use, stress or an illness (i.e. brain injury, brain tumour, depression, bipolar, thyroid disorder). Schizophrenia also includes other symptoms like diminished emotional expression, not speaking very much, and decreased motivation. Schizophrenia affects one per cent of the Canadian population.
Gratzer: I think probably one of the most common experiences these days is that people use substances that cause psychotic symptoms, like very strong marijuana, as an example. Basically, psychosis can be a common symptom of schizophrenia.
What causes psychosis?
Fillion: Precise causes remains unknown. Biology seems to be an important contributor (neurotransmitters, genetics, brain changes). Stress and drugs can also contribute. Abnormalities in key brain functions seem to indicate that the brain is the biological region responsible for symptoms. It would seem that symptoms are produced by a functional abnormality in neurotransmitters. Thalamus, limbic system and other areas of the brain seem to be affected.
How is psychosis diagnosed?
Fillion: Thorough assessment by a family physician and a mental health professional such as a psychologist or a psychiatrist. You need to rule out other medical disorders, therefore physical exam and tests (that could include MRI and CT scan) are important. A health professional also needs to take several factors into account: changes in behaviour, appearance, emotions and thoughts, delusions and hallucinations, verify for potential for suicide and violence, family history.
What are the early indicators of psychosis?
Fillion: There are early warning signs, but sometimes psychosis emerges gradually over time so symptoms might be dismissed or ignored initially. When someone's performance at work or their behaviour at school changes, most people, including those experiencing it, often don't understand what's going on. Parents will often wonder if their kids are on drugs.
Indicators could include reduced concentration and drive, depression, anxiety, mood swings, sleep disturbances, deterioration at work and school, deterioration in personal hygiene, irrational or fearful responses, language change (some words don't make sense), a feeling of being watched, excesses in certain activities, delusions. They will often withdraw from others, wanting to be alone.
After the early onset of symptoms related to psychosis, how quickly do other conditions potentially develop?
Gratzer: It depends on what the underlying illnesses are. There might be an early indicator if somebody takes very strong pain medications and they get psychotic symptoms. They may be feeling pain, then they take a few Percocet because that's what the doctor prescribed them and suddenly they're just not feeling great and the start getting irrational thoughts, which could be an indication of schizophrenia.
Sometimes, it shows up very suddenly that somebody might have some paranoid ideas for a couple of days, and then it goes away.
We speak quite broadly of psychosis, obviously informed by the [recent] news, but we need to be a little bit careful about it. It's a little bit like when we talk about shortness of breath. Shortness of breath may be because somebody has asthma and it's a very hazy day, so they might have difficulty breathing and shortness of breath. But someone could have also run up two flights of stairs to get to a meeting and they're out of breath. Episodes of psychosis might not always be an indication of an ongoing condition.
A link is often made between mental health and violent incidents — is there, in fact, a link?
Fillion: Psychosis, although it may involve rage, is not synonymous to rage. People that suffer from a psychotic brain are often paranoid and fearful and seem to want to protect themselves, to push pain away, to stop the hurt.
Gratzer: A lot of us have watched the movie "Psycho," and so we're lead to believe that if someone has psychosis, they're violent. Let's bring things back to reality, because life is a lot less interesting than Hollywood movies. The vast majority of people with serious mental illness are not violent, don't harbour any major anger or resentment and don't pose a danger to others.
However, if someone does have underlying mental health conditions and if they're untreated and/or they don't have access to care, psychosis could lead to acts of violence. But again, that's the minority.
We need to help people understand that it's not actually mental health issues that will always lead to something like this. The prevalence of somebody with schizophrenia, psychosis and health issues and the the likelihood of acting out violently is low. Studies show that, actually, people with mental illness are much more likely to be a victim of violence than to be a perpetrator of violence.
The suspect's family has indicated that the interventions of professionals, medications and therapy were unable to treat him. Are there inadequate services and treatment for those facing these challenges?
Gratzer: I do not have a diagnosis, I have no idea what was involved in his care before. What I can say is that the vast majority of people with mental illness can get care and can get better.
Fillion: This issue is access to services. I have heard stories upon stories of families not having the support from the system, even after knocking on several doors. It's a complex maze out there. Intense care is required, including medication with follow-ups, support and monitoring, family support, vocational and recreational support, therapy and education. Integrated services, such as Assertive Community Treatment Teams (ACTT) are rendering good results. These include direct treatment, rehabilitation and support services. These are gems within our complex system that remains disconnected.
How can friends and family assist someone who might be facing challenging mental health issues?
Fillion: You can assist someone you think or has indicated that they are suffering from mental health conditions by helping them arrange to see a health professional and by providing non-judgemental support. Asking them what they think they need and listening to them when they reach out to you.
Anti-depressants and psychological treatments like cognitive behavioural therapy are standard treatments for depression. But add the layer of psychotic symptoms and more is needed, potentially requiring anti-psychotics.
If you live in Ontario, 211 is a free helpline that connects you to community and social services in your area 24 hours a day, 365 days a year, in over 150 languages. And more information can be obtained from the Schizophrenia Society of Canada, the Canadian Mental Health Association and ConnexOntario.
Gratzer: If you do have a family friend who is going through something like this or dealing with it, use your common sense. If you think you've got a friend or family member who seems to be different recently, they seem more withdrawn than they were before, talk to them. Perhaps things that interested them historically aren't interesting to them anymore or they just look very stressed out. So again, why not begin a conversation on the topic? There is help available, there is hope.
Further resources: How to support a family member or friend with mental health needs; Mental Health Canada; depression in adults; depression; Canadian Psychological Association; Gerstein Centre; schizophrenia and delusions
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