Screening For Delusions
Every honest and complete psychiatric evaluation includes screening for delusions. A delusion is a strongly held belief that is totally without basis in the factual reality that we all use to live our daily lives. I have taken care of several people, institutionalized and not, who have had such beliefs. Medications known as “antipsychotics” can be very effective on the hallucinations — the hearing voices and seeing things and such — that are the hallmark of a lack of mental “normalcy” as is generally expected and accepted in the community. The same medications may be less effective on these delusions, these beliefs. Sometimes, in a particular kind of delusion, a kind that hits folks somewhere between 18 and 90 (average age 40) where there are no hallucinations, just beliefs. They are less frequent. They are also hard to treat, with antipsychotic medicines working maybe about half the time — in those who can actually be convinced to take them.
Many years ago I cared for a woman government worker in her late forties. She had been diagnosed as having delusional disorder by another psychiatrist, who had suggested a trial of Haldol — then the best antipsychotic drug available. It had taken her very little time to decline the medication trial, for she quickly discovered that she would not be allowed to continue in her job if she took Haldol. She contacted every psychiatrist in town, and said I was the only one willing to try another way. Delusional disorder is a little more common in women than men. The most common sort are erotomanic delusions, often a belief the patient has that some notable person is in love with her. In this case, the woman believed her husband was cheating on her.
After I had interviewed her, I interviewed him. He told me that he loved his wife dearly, never had cheated on her, and certainly never would cheat on her. The first thing I thought we could do would be to try some simple reality testing. He (and I) asked her what could make her believe that he had not been and would not cheat on her. As it happened, he was impotent. To his credit, he provided her with a certificate to this effect, signed by his urologist. She told me she understood what was going on, and what he was saying, and she knew perfectly well what powerful evidence this was, but she simply could not shake her belief. We got him to get amorous in speech while looking into her eyes. The best I can say is that she was pleased with his efforts, and saw he was trying, but she admitted that deep down she could not really shake the belief. After a few creative sessions (which I had carefully researched) they thanked me for my efforts, and continued life with an uneasy truce. I only heard that they were still married and she was still working at that time. At least I had been able to convince her that her belief was probably not an appropriate subject of conversation with either woman-friends or colleagues. Even less frequently, patients have isolated bizarre, even wild beliefs. To have this disorder, they must be functioning totally normally, aside from these unusual beliefs.
Patients like this are few and far between. A respected preceptor who trained me in psychiatry had been personally consulted in one such case. He told me one day that as a special “treat,” he had arranged for me to interview the patient, which would be a once in a lifetime experience, and it was. My preceptor escorted me into his most private office, and introduced me to a highly educated and articulate business executive (in a 3-piece suit), whom he directed to tell me about all the things he believed, and had spoken of, and that he could speak as freely to me as he had to my preceptor. He told me a complex story that made every conspiracy theory I have ever heard pale in comparison. The only part I can reproduce with any accuracy was something about airline pilots flying Mexican birth control pills into the United States. He implicated many sorts of people and the net effect of the story seemed as if he believed some kind of plan for eugenics was taking place currently in these United States. My clever preceptor basically told the patient that this particular set of beliefs was the only thing about him that would make anyone think he was (a word we professionals generally hate to use ) “crazy,” so he should stop talking about it, and he would do just fine. If he felt the need to discuss this, the only “safe” place to do it was (as a patient in) my preceptor’s office. All of this reminds me of the “Three Christs of Ypsilanti.” Sometime in the 1950’s, Milton Rokeach, a psychiatrist at the state hospital in Ypsilanti, Michigan, took three men, each of whom believed he was Jesus Christ, and put them together. It is not too surprising that each quickly decided he was the true Christ and the other two were impostors. The results make for a fascinating case study (which I read for amusement long before I had any thoughts of becoming a psychiatrist). They also show just how tenacious this kind of beliefs can be. I agree with those who say that what Rokeach did, although audacious for the time, was also pretty humane for the time. Rokeach himself came out and said somewhere fairly recently that he was manipulative and “playing God,” and that it was not a particularly good thing to do, to put it mildly. Flash forward to 2016. I am working in a milieu that treats “dual diagnosis,” that is, people who are in the process of detoxifying from alcohol and/or hard drugs. Screening them to make sure they do not have (and probably have not had) hallucinations is fairly simple and direct. It is not hard to check to see if they are comporting themselves in the office as if someone or something is there besides them and me. As for if they have had this in the past, I ask them gently if their senses have ever played tricks on them, making them think they see or hear or feel or even smell something that they find out simply is not there. If they look even a bit bewildered, I assure them that this would not mean that they were “crazy,” simply that they had a problem we needed to take care of. It is a lot harder to tell if they have a set of unusual, idiosyncratic, or even irrational beliefs. If even excellent psychiatrists such as my preceptor can tell a patient to just be quiet about it, then patients and their families might have reached that conclusion, too, especially if everything else in life seems to be “normal.” The clinic where I am gives me a multi-page form to fill out, with boxes to check. I have to check “yes” or “no” for delusions. I want to do this honestly, and earn my keep. I am unaware of any “standard” questions for this — I never really learned a good way to do it. When I was in training, I asked “are there any special personal beliefs that you have that the people around you don’t share?” I would usually get a shaken head, possibly with squints and a frown. Now, it is important to me to ask such a question in as non-prejudicial a way as possible. I have precious little time, and I would like patients to tell me as much as possible in the precious time we have. So now, this is what I generally ask. “How do you think the world is put together? Do you believe in religion, or science or both, or do you think something else runs the world?” Sometimes, at this point, they just look at me, a bit confused. “I would like to know what your personal philosophy of life is, so I can do a better job taking care of you.”
As of the time I am writing this, I not only have not been able to think of a better way to screen for delusions. I also have no other way to get people to tell me what they really believe in. My real personal belief is that nobody, but nobody, should be discriminated against because of what they believe in, whether or not it is an organized religion. My patients are all paid for by insurance, and cover a rather amazing variety of socio-economic strata, from regular folks who work in factories or machine shops or such, to employees of either government or private industry, ranging also to independent professionals who are highly credentialed and sometimes quite distinguished in their fields, or businessmen who run their own companies. In this particular clinic, I am treating patients who are being detoxified from substances of abuse for their underlying psychopathology. Knowing what they think about how the world is put together really does help me figure out how to take care of them. Some patients — probably a majority — simply tell me that they are Christian. Often they will show me they wear a cross around their neck. Sometimes they will cite a denomination of Christianity, telling me they are “Baptist” or “Methodist” or “Episcopal.” At any rate, patients who say this are the easiest to treat. I simply tell them (and this is rigorously true) that I pray daily that Christ can work through a crazy old Jewish lady psychiatrist like me. I usually get a laugh or at least an encouraging smile or nod.
I have said the same thing about Mohammed, and I think I could probably cover pretty much any (organized and institutionalized) world religion with something like this. I am open about who I am and what I am, but I am very careful to validate their pre-existing belief system. I usually go on to tell them that the power they believe in is what will make them well, for I am but an instrument. I usually quote what my grandmother — my Bobie of blessed memory — told me right before I got in a plane to go to medical school in France. “Only God cures people. Doctors just collect all the money.”
Actually, I am pretty sure the first person who said this was George Bernard Shaw, who seems to have spent his entire life running around and making quotes. My Bobie, however, always insisted it was an ancient Jewish proverb. (Of course, she thought everything and everybody was really Jewish.) Me, I think it is one of the more clever things I have been able to come up with. The power of belief is absolutely the most powerful mental force in the world. When people really believe something is going to happen, it generally does. To harness and use the force of belief to make people well is something that has worked for maybe a couple of millenia, so I figure I could do a lot worse than to ride on its coattails.
I love to use Emotional Freedom Technique (EFT) with these patients. Pretty much any infirmity that has an emotional component and is not purely anatomical (which would require surgery or some means to bring about structural change) can be made at least somewhat better by this technique. I have made chronic pains disappear, blood pressure go down to acceptable levels, and numerous other assorted miracles by having patients tap on their own acupuncture meridians and recite aloud appropriate affirmations, including “I can do all things through Christ who strengthens me.”
Jewish patients are special to me, of course. I only rarely have the opportunity to care for patients whose religious background is the same as my own. Not that we seem to be any mentally healthier (or less addicted) than other folks, but rather because we represent a fairly small proportion of the population at large, usually hovering around 1.5 % of the population. (This includes all the regions in which I have served, in the states as well as France.) The tricky thing here is that not only does being Jewish mean different things to different Jews, but there are so many different sects that not everybody even manages to get along with each other. Most Jewish patients I see now are “cultural” or “ethnic” Jews who have not had the rich training in Jewish language, literature, and custom that my folks insisted on for me, and that was for me a serious handle on learning to understand the universe. These people hear me speak a word of “Yiddish” — the Judaeo-German that was (technically speaking) my first language. This is the lower working class language of the Jews of Russia and Eastern Europe. Few people actually speak or understand it, but most get by (like my own beloved husband) on the casual jargon of Yiddish you can pick up from Mad Magazine or parody songs written by Alan Sherman.
If people have any belief at all in the God of our Fathers (Abraham Isaac, and Jacob of Biblical fame), I do exactly the same tapping on acupuncture meridians as I do with the Christians. Mostly everyone who has been to any kind of a Jewish house of worship can recite it with me in Hebrew. It is “Hear Oh Israel, the Lord our God, the Lord is one.” (I actually wear it inscribed in Hebrew on an amulet around my neck.) The miraculous effects of reciting this while tapping on acupuncture meridians are exactly the same as reciting “I can do all things through Christ who strengthens me.” This affirmation of faith is so ingrained in the Jewish psyche that I usually don’t need to add the nice details of Jewish liturgy. I still remember, even when I have treated a few pious Jews who would actually understand them. It is supposed to be recited by a Jew when they believe the hour of death is approaching. My husband will corroborate that I actually shouted it between screams while clinging for dear life to the hand-bar at the front of my car while flying through the air riding the Space Mountain roller coaster at Disneyland. The power of faith, of anything in which someone honestly believes, is immense. I really think it is much more than most people imagine. I am not suggesting it does everything a person needs. Although I make it really clear to people that what I am trying to do is consistent with their strongly held beliefs, I believe that what I do is important, even necessary. If I didn’t make good diagnoses, and choose the right treatments, even recommending surgery when it is necessary, people simply would not get well. They certainly need and deserve to get well. This includes people who have few or no beliefs in anything. I can still use Emotional Freedom Technique and some other somewhat similar techniques can pull out of my bag of tricks. I have, however, learned more than I could have imagined about the American Scene, simply by trying to find out what people believe in. Occasionally, some people with as all pervasive a sense of humor as me, will give me a funny answer. One — exactly one — person told me that the universe was controlled by The Flying Spaghetti Monster (a longstanding internet joke).
Most frequently, I get an answer that is resplendent with — would you believe — guilt.
- “I am a lapsed Catholic.”
- “I was brought up Methodist, and I believe it, but I stopped going to church a long time ago.”
- “I was baptized, but church people make me want to throw up.”
Even, “I am a Jew and I believe in the Jewish God, but I always hated going to Synagogue and I have not been since my Bar Mitzvah.” I found out pretty quickly that to responses like this, it is not particularly helpful to ask people if they believe in God. People with a belief so strong they profess it at the drop of a hat have very strong beliefs. My own response, if a physician ever asked me in a clinical setting, would be something like, “I am quite certain there is a power greater than me. I call it (or him or her) ‘God’ because that is a concept I learned to deal with in a fairly traditional Jewish upbringing.” I sometimes do wish I could enjoy some of the rich traditions of being with groups steeped in the Jewish cultural heritage, but it is not going to happen. Like many people involved with European Judaism around the end of the nineteenth and the beginning of the 20th century, my ancestors believe in the “Heskalah” movement. My paternal grandfather had been a diploma-bearing civil engineer in the old Russia; and in America, a self-trained architect some of whose buildings are as far as I know, still standing in Boston — notably the Union Bank Building. My father of blessed memory was a Harvard University trained musical composer, and so we go on. Some very religious folks, often Christian, are moving in the opposite direction, building and patronizing Christian faith-based institutions. They have every right to do so. Still, I have chosen my attitude and my questions and my responses to try to keep such debates out of my office, and far away from the doctor-patient relationship. I have been criticized for saying that America is NOT a Christian theocracy. Within the last few months, well-meaning patients have tried energetically to convert me to Christianity, even though several hundred years of experience have shown that attempting to convert Jews to Christianity is — a bit more often than not– generally a losing proposition.
In one city in the rural desert of southern California, I suggested to a colleague psychologist that we start a therapeutic group of disenfranchised Mormons. The most distressed one I ever met went through a terrible crying spell in my office — a by-product of her profound depression. She was getting some kind of excommunication from the only church she believed in. She alleged that there was no doubt in her mind that the Mormon church was “the one true church,” but her bishop had given her an assignment to become a caretaker for children. She had never married, had no children of her own, and simply didn’t like kids. She was looking for ways to resolve this within her church, and I was ill-equipped to advise her. I have worked with religious authorities before, and actually offered to talk to her bishop if she would sign a release to permit me to do so. She declined, telling me she was afraid it could make things worse. Sectarianism, parochialism: these things are not my concern. I do wish that the sense of guilt that comes with non-compliance did not distance as many people as it did from the great healing power of religion. The primordial documents of most religions known to me talk of a joy and exultation in the infinite and all-powerful. Somehow, I have always felt that the creation of religious institutions by human beings could go awry when they generated rules and became somehow rigid. If rigid rules are enforced in a punitive manner, these exultatory aspects of religion seem to disappear like the morning mist.
I am touched by how often I get creative, thoughtful answers from patients whom I actually believe to be telling me their interpretations of the absolute nature of the universe. I love the patients, often quite young (I see nobody under 18, and they are usually not generally much over 30) who tell me things like this. “I was brought up religious, but I don’t think religion is the answer to everything, the way my parents did. I’m still trying to figure it out.” Or even the one who told me “I only believe in what I can see with my own two eyes. It seems like these religious folks are always out to get your money or something.” I have heard enough stories of rural preachers “mooching” meals from parishioners when I was in the Midwest to accept this may sometime be the case. I have heard “I know there is something bigger than I am, but I don’t know that it is the same God they talk about in the Bible.” Or even this: “I don’t get the religion thing. I just try to obey the laws and be a good and honest person.” The one that scared me a little was: “All the AA (Alcoholics Anonymous) and NA (Narcotics Anonymous) stuff says that you have to abandon all your problems to a higher power. I am not sure if there is a higher power or not. Can I get sober here, or are you going to throw me out or something?” I alerted her psychotherapist, and we were (mercifully) able to keep this young lady in treatment. There are ways to think things through, and to do what one needs to do in order to preserve life, that can accommodate alternative or minority beliefs. This is a function of my delusion-screening questions which I had not predicted at all. I frequently need to reassure people that questioning the institution of religion is perfectly normal. Sometimes, I even find myself telling them that despite neology and mythology, the founders of America were far from unanimously confirmed Christians, and were people who not only questioned religion, but were people who may have expected it to become obsolete. (My favorite example is Ben Franklin, who never joined a church, but once paid to build a new tower for one to keep the rain from coming in on the congregation.) Once I have managed, sometimes with considerable effort, to actually get past varying world views, I can actually screen for delusions, those false beliefs. Paranoid views are generally the most common. Only a couple of times in my career, I have heard stories about ancient conspiracy theories involving the Illuminati or the Knights Templar or the Freemasons. A few still come up with theories about who is controlling the government, or who killed President Kennedy. Many tell me the world is controlled by moneyed interest or corporations or extremely wealthy folks with hidden assets.
I still remember a young lady I saw in a hospital emergency room in the Midwest, who told me that she and her whole family had been threatened by the Mafia, because someone in her family had testified against them on the east coast. She said her family had started a new life locally as dairy farmers. She gave me the phone number of someone at the local office of the F.B.I., who told me every word she had told me was true, but he could not give me any details, because to do so would put me in danger. I will never forget what my supervisor said when I reported the case to him over the phone. “The differential diagnosis of paranoia includes reality.” I have unearthed a few deeply troubled folks, who thoroughly believed fearsome things, involving God and the Devil and secret codes that could lead to death and destruction. I do not mind that I have unearthed more than I have been looking for, not only because the journey into people’s beliefs is generally a helpful one, but also because I have unearthed people who have needed my help, and I may perhaps have given them some.