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Psychosis

Psychosis Is Not Always What It Seems

For clinicians, curiosity is essential.

Key points

  • Psychosis does not always arise because of poor mental health.
  • Writing a prescription does not always sort out a problem and can sometimes worsen it.
  • Listening more closely to a patient can enable a doctor to determine the correct diagnosis.
Source: Photo by Mariana Montrazi on Pexels

I first saw Clem when she was with her mother, a former neighbour of mine, in the supermarket where I was shopping. I was pleased to see my former neighbour and we stopped briefly for a chat, but I was struck by the vacant, glassy-eyed look on her daughter’s face and the stiff way she carried herself. When her mother, who knew I was a therapist, asked if she could give me a call, I assumed my hunch about Clem’s mental health was correct.

I soon learned that Clem had experienced a major psychotic episode six months earlier. Completely out of character, she had behaved in a highly inappropriate manner (details were not divulged) and ended up being sectioned. She was now on high doses of an antidepressant, an antipsychotic, and an anti-epileptic drug used often for extreme anxiety. Normally bright, bubbly, and efficient, she was on extended sick leave from her job as a school bursar.

Despite her flat, expressionless stare, Clem was constantly anxious, her mother said, and the drugs didn’t seem to be doing any good yet. The family was struggling to cope, as she couldn’t bear to be alone, and so her mother, husband, and grown-up son had to arrange their lives completely around her. I offered to see if I could at least help her relax, and Clem came to my home to talk.

In answer to my questions, Clem told me that she had not been under stress; her marriage was happy; she liked her job; and she was enjoying more freedom now that her son lived away from home. So what had precipitated the psychotic episode? I learned that it occurred a few days after she had had a steroid injection for bursitis of the hip.

Corticosteroid-induced psychosis is, I discovered, far from rare, and usually passes within days or, at most, weeks. Yet this knowledge did not seem to inform her psychiatric treatment, nor find its way into her notes. Indeed, Clem, terrified by her incarceration in what to her were frightening surroundings, deteriorated – and so her drug dosages were upped. Harried staff were too busy to listen to her.

As her symptoms of extreme anxiety and restlessness continued even after her return home, it seemed to me likely that these were drug-induced. I was the only person to support Clem in her instinctive knowledge that she needed to get off the drugs. (Her family was far too frightened.) But it took a long time to convince a community psychiatrist to let her withdraw from them gradually, one by one, after which Clem returned completely to her previous, competent self.

So what is the message here? Certainly, psychosis is not always what it seems. But it is more than that. I had a salutary health-service experience decades ago, which I still think back to. I had an appointment with my new GP, who was running exceptionally late. At ten to seven in the evening, the remaining patients were getting riled and vocal and the reception staff increasingly harassed and irritable. When my name was called, I walked into the consulting room expecting to see a weary-looking doctor, and squirming mentally at how trivial my complaint would seem to him, after such a long and taxing afternoon.

An unexpectedly bright and welcoming face looked up as I entered. ‘Good evening,’ said Dr. I. ‘What can I do for you?’ Encouraged, I told him that I had had enough of my acne. At 30, it was still flourishing, not as badly as in my teens and 20s, but I wanted to be done with it.

Dr. I considered me as if I were the most interesting patient he had seen that day. We discussed how acne affected me and what the options were. As the remedies I had tried previously had not been helpful, that left only the heavy-duty variety, the effectiveness of which was counterbalanced by potentially high side effects. Did I think the benefits would be worth it, asked Dr. I? He seemed genuinely interested in my opinion. On reflection, I decided that they were not. I came out of the office empty-handed – and satisfied that I had been helped to come to the right decision.

I think of Dr. I when I hear of cases like Clem’s: how, even at the end of a long day, he treated me as a human being with feelings, deserving of participating in decisions about my health and well-being. It would have been so much more convenient to rush me out with a prescription but, instead, he listened. If that had happened for Clem, perhaps her relationships and career, which had been working fine, would not have been put at risk.

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