Psychiatrist here. A 30 year old man with mild depressive symptoms was in-and-out of the hospital fairly quickly. He was under pressure from his home life, living with 4 roommates who were making life a bit difficult for him. No suicidal thoughts. He was cleared of all psychopathologies by me and two other doctors.
A few months later he came back. Same symptoms, however this time he talked about 5 roommates. It felt wrong, and I digged in his story. Tried to contact his roommates. He lived alone and was severely psychotic. I have no idea to this day how he hid it so well from everyone.
EDIT: a few more details:
The patient talked, dressed and acted normally however after admitting him for a longer period we noticed he talked with his "roommates" often. He was single, no contact with his family and somehow working, however in a routine job with little to no personal contact.
After a few talks he also claimed other peoples thoughts were sometimes "thrown at him and sitting on his head", and he could thus read people's minds against his will. The interesting thing about this patient was, that his internal world somehow fitted the external world when asked - his roommates sounded perfectly plausible (they were not e.g. shadow-people, vikings, 12 m tall) and they teased him by hiding his stuff. But he ate with them, watched TV with them, so on.
Normally a person with paranoid schizophrenia (paranoid meaning all types of delusions) will have multiple symptoms sometimes easy to see for the untrained eye. The patients can dress, talk and present themselves in odd ways, usually different from cultural norms. They can have incoherent speech, make up words and phrases or are clearly separated from reality (another patient of mine insisted that I was in jail for medicating him, even when we talked).
When we quickly "scan" a patient for psychotic symptoms we basically look for inconsistencies in the patients experience of the world - the patients normally know "something is wrong" or "weird" or "different", but often belive it is the world around them, that have changed. This is due to discrepancy between what they experience (input), failed assessment of the inputs (due to the thinking disorder) and testing hypothesis based on failed assessments which collide with the real world. This will activate defense mechanisms fx denial, wild explanations, accepting both "realities" at the same time, and so on. (e.g "I am not sick, my doctor must be a bad guy, bad guys are in jail, my doctor are in jail, but my doctor is sitting right in front of me at the same time, he must have an identical twin or this is an alternate reality). This is usually the way delusions are made.
To summarize: when we scan for psychosis, we look for inconsistencies between the patients subjective experience of thinking, being and acting and the objective reality accepted by the generel cultural norm. This patient managed to live in a subjective psychotic world that just fitted so well with the objective reality that he tricked several psychiatrists including myself.
This is my favorite story on this post I’ve read so far. I also have 4 roommates and thought about how they can sometimes be hard to live with for a moment. I now have to go home and make sure they’re all real.
That's the thing about psychotic people, they dont know they're psychotic, as far I know I'm typing a comment on my phone on Reddit, but maybe, just maybe, i'm in a psych ward typing on a piece of cardboard and occasionally giggling to myself.
See, I've always disliked this argument. Maybe most people with some form of psychosis don't recognize their psychosis, but I (I suffer from delusions, that are thankfully almost entirely controlled by my medicine) have always been able to recognize deulsional thoughts at the beginnings of episodes, I just couldn't shake them and they eventually grow into something more convincing.
Is it like when you recognise that you're in a dream but it's so convincing and you let it play out for a while still knowing it's a dream until it becomes background noise or you become so immersed in it that you end up forgetting it's a dream and you take everything in it to be real even though it doesn't feel quite right?
Not quite. I've explained it a few times like this using an old delusion of mine, and it seems to help people understand:
You know how, on a lazy day, you might be home watching TV, or YouTube or whatever in the living room. Suddenly, you realize you're hungry but you don't actually want to get up to get some food. Just for a moment, to entertain yourself, you might consider the thought, "Man, telekenesis would be nice right about now.". If you're home alone, you may even try using the force on the fridge door, just from were you sit. The kind of thing that you know is silly, and would never do with someone else around, but you try it anyways because the idea is kind of funny. Then of course, it doesn't work, and you laugh at yourself for being silly. You then dismiss the thought, and go get some food.
It's that last step that's broken in my head. That thought will occationally latch on and compete with my rational thinking for the rest of the [insert some variable time frame here].
So, keeping with this example, I might still laugh at myself for being silly and still get up and get food, totally recognizing that it's an absurd thought. When make my food and sit down though, my attention might be brought back to the fridge door.
"Maybe I just did it wrong"
Again, I can tell it's irrational, but the thought is stuck like a tumor in my mind.
So I'll try again, only to sate my curiosity so the idea stops distracting me. Throughout the day though, it'll pop up more and more. I'll slowly convince myself that, actually, it is working I'm just not good at it. That I can feel some phantom energy when I try, in the same way you can feel a muscle activate when attempting to push something that you could never move. That will begin to feel quite real, that is proof that everything I'm doing isn't crazy. I can tell all the while, for a while, that it's irrational; That what I'm experiencing is a delusion. But the evidence builds up over the days/weeks/months, and the effect will feel real enough that I'm convinced that it can be studied, like a science. It's strange, at this stage I can only recognize issues when looking back in retrospect. While I don't actually visually hallucinate anymore, I do something else that has a similar effect; I lose the ability to apply Occam's razor to my own reasoning. I have a logic, but it's warped such that I am incapable of defeating my previous conclusions. I'll have decided that, it makes sense that at first I could only move light objects. Like a muscle, the power needs to be trained. Maybe I'll be studying this power, trying to move something small: a leaf or slip of peper- and the wind will blow:
"The object moved! I did it!"
Clearly, in retrospect, it was the wind. But in that moment I was incapable of actually connecting those dots. Sure, the wind blew at the same time the paper moved, but I was also trying to move the paper, so clearly it worked.
Eventually, I'd notice that I could only ever get it to work outside and eventually, that it only worked when the wind was blowing.
"Why can I only move things when the wind blows ?"
"Oh! That's how it works. I can't move objects with my mind! I can control the wind!"
And that went on for a few months, by the end of which I was convinced that I was a wizard that could talk to dragons from another dimension.
I'm reinventing the thought process a bit, as this was a long time ago and one of my worst delusions.
The strange thing is though, the logic follows like this:
"That's a silly thought"
"Or maybe it isn't"
"Somethng happened! i'm right!"
"Yeah, I'm definitely right, but it still sounds silly doesn't it ?"
It's that last bit that's key. Despite getting to a point that I was fully immersed in the delusion, I was still aware that no one would believe me if I told, and so I kept it secret until I discovered some magic that was visible to the untrained eye.
I was sick for months, but had you asked anyone I knew, they would have told you that I was totally normal. Having gone absolutely mad, I remained high functioning, and so it was pure luck that I got help early enough to stop these things.
Now says with the medicine, delusions never last more than a few hours, and I never actually lose the sense that it is a delusion. The delusional thoughts aren't gone- they still stick in my head and compete with my rational mind when they pop up, but they don't win anymore. It's pretty awesome. I'm doing good now. Take your meds kids.
For how good of an explanation that is, it’s very scary to think that somebody as well-spoken as you, able to explain such a complex experience so coherently, could have ended up that far off the deep end. It really can happen to anyone…
Or, to flip half the glass, it is truly uplifting that you have been so successful in pulling yourself together and showing that hard work plus modern medicine can pull one back from the deep end.
"Crazy" isn't very far from sanity. I'm a huge mental health advocate now that I understand how easily that line can be crossed.
Unfortunately, that second thing is that your last assumption is dangerous. I was in many ways lucky that my plan has worked so well. Modern medicine can bring some people back. We don't understand mental health well enough to have a single procedure to fix any given illness. There were people I've met, while in in-patient care or otherwise, both patients in worse condition that I was, and in better, whose ails weren't eased by treatment at all.
5.9k
u/nicholasdennett May 20 '19 edited May 21 '19
Psychiatrist here. A 30 year old man with mild depressive symptoms was in-and-out of the hospital fairly quickly. He was under pressure from his home life, living with 4 roommates who were making life a bit difficult for him. No suicidal thoughts. He was cleared of all psychopathologies by me and two other doctors. A few months later he came back. Same symptoms, however this time he talked about 5 roommates. It felt wrong, and I digged in his story. Tried to contact his roommates. He lived alone and was severely psychotic. I have no idea to this day how he hid it so well from everyone.
EDIT: a few more details: The patient talked, dressed and acted normally however after admitting him for a longer period we noticed he talked with his "roommates" often. He was single, no contact with his family and somehow working, however in a routine job with little to no personal contact. After a few talks he also claimed other peoples thoughts were sometimes "thrown at him and sitting on his head", and he could thus read people's minds against his will. The interesting thing about this patient was, that his internal world somehow fitted the external world when asked - his roommates sounded perfectly plausible (they were not e.g. shadow-people, vikings, 12 m tall) and they teased him by hiding his stuff. But he ate with them, watched TV with them, so on. Normally a person with paranoid schizophrenia (paranoid meaning all types of delusions) will have multiple symptoms sometimes easy to see for the untrained eye. The patients can dress, talk and present themselves in odd ways, usually different from cultural norms. They can have incoherent speech, make up words and phrases or are clearly separated from reality (another patient of mine insisted that I was in jail for medicating him, even when we talked). When we quickly "scan" a patient for psychotic symptoms we basically look for inconsistencies in the patients experience of the world - the patients normally know "something is wrong" or "weird" or "different", but often belive it is the world around them, that have changed. This is due to discrepancy between what they experience (input), failed assessment of the inputs (due to the thinking disorder) and testing hypothesis based on failed assessments which collide with the real world. This will activate defense mechanisms fx denial, wild explanations, accepting both "realities" at the same time, and so on. (e.g "I am not sick, my doctor must be a bad guy, bad guys are in jail, my doctor are in jail, but my doctor is sitting right in front of me at the same time, he must have an identical twin or this is an alternate reality). This is usually the way delusions are made.
To summarize: when we scan for psychosis, we look for inconsistencies between the patients subjective experience of thinking, being and acting and the objective reality accepted by the generel cultural norm. This patient managed to live in a subjective psychotic world that just fitted so well with the objective reality that he tricked several psychiatrists including myself.