Otherwise, The Patient Was Normal

He was a new patient to a community clinic.  They warned me to be careful with this 48 year old, thinking he was “really crazy, schizophrenic or something.”  The social worker had tried to do the intake and told me he was confusing, “not your average bear.” Strangely enough, most of my female staff already had told me they were attracted to him; an unusual state of affairs.

I was struck first by his clothes and demeanor.  A little like Michael Douglas as Gordon Gekko.

This is not usually what new patients look like, schizophrenic or not, when they come in. No wonder the front desk staff already had a crush on him (“sigh!”).  We didn’t get men in designer suits in these parts.

Also the “Chief complaint,” the answer when I ask the patient what is the worst thing going on in your life that you want me to fix yesterday, is not usually “a financial conglomerate has ruined my family in the east and I had to escape to California to start to plot how to save them.  I need your help.”

The story was worthy of any really good novelist or scriptwriter and had all taken place within the last year or two.  His father, a research scientist retired from the faculty of an Ivy League school had developed powerful secrets that were relevant to future developments in chemical warfare and had thus come to the interest of a European branch of organized crime, because of his European origins. He had tried to patent and exploit his findings but had been blocked financially by this European cartel which had a grasp on his family. He had tried to help his family but they had “pushed” him out; his only hope was that he could establish himself on the west coast and “fight” through the local organized crime division of the FBI.  He had a leather valise with him, and allowed me to copy some papers he thought were proof of his story, and which clearly were not.

He was not suicidal or homicidal or in any way psychotic, other than the above story. He did say that he had spent some time in a famous Ivy League hospital to deal with the stress wrought upon him by the situation described above. I secured a release and got a trusted assistant to call them; luckily it was early in the day, so maybe they could respond quickly by faxing a discharge summary.  I was already pretty sure of the diagnosis, but I wanted some corroboration because it would be hard to get people to believe me on this one.

They call it “delusional disorder,” confirmed by the east coast Ivy League hospital.  He was happy to sign releases, seeing me as an ally. I also checked with the FBI.  Now just for the record they are fine ladies and gentlemen, and have often helped me when releases have been signed, and probably would if there were not, always giving me enough information to get me where I need to go to protect the patient. Sometimes the differential diagnosis for what sounds like a delusion is the truth.  I have taken care of patients in the Witness Protection Program, and the FBI has told me that.  They have declined to tell me things that would put myself in jeopardy, and as far as I can tell, they have always been correct in that regard.  In this case, they told me that the gentleman’s story had been checked in detail with is family and “relevant authorities” on the east coast and I could rest assured that they had found no substance to the story. God bless them, that FBI and their state offices and their romanticization on television. For me they have never been anything but good guys, and I welcome the chance to say so.

Back to the realities of delusional disorder. It is rare enough that there is not a lot of help in the literature, where I do not remember having seen any articles with more than 50% efficacy of medications.  I tried to give him one of the newer anti-psychotics. After all, he had been hospitalized out East for “nerves,” so I could reasonably try to help him. I was careful not to tell him I knew every word he was telling me was false.  It was, or else his own family would not have exiled him to the West Coast.  I could not stop him from “working” with the FBI, who to their credit told me sometimes they end up just reassuring people like him and this is part of their job. I tried to get him to relax.   I tried to get him to work with a cognitive behavioral therapist (usually the only kind you can get in county mental health) to work on “reality testing,” that has been shown to help but at the very least, he needed some kind of support in life.  We could find him a place to live, but he did not feel comfortable with the “schizophrenics off the street” and would not talk to the them, he promised me in advance. He agreed to try the medicine, although I wondered if he really would. He agreed to come back and see me, because I told him I would try and help him “find some peace” from this thing. I saw him once before leaving the institution; he said he had found some relaxation from the medication but still had work to do; I wished him well.

I remembered having a preceptor back in residency who was fascinated by delusional disorders.  Why would the human brain go “haywire” in this particular way, in a later stage of development, compared to most of the “major mental illnesses” we see; and in this particular way, with no hallucinations, but rather with beliefs.  Beliefs that are strong, that can destroy careers or lives, but that do not have the “alternative reality” flavor of other “psychotic” type disorders.

In residency I saw a highly respected businessman who was productive for a Forbes 500 type company.  He believed something about foreign pilots smuggling in illegal birth control pills and slipping them to certain populations to control the presence of certain genes in America.  My preceptor and I simply worked on convincing him that telling his employer about this was a bad idea.  We got him a very good therapist and basically kept him from doing things like contacting Federal agencies with a steady (if to him, fairly depressing) diet of reality therapy.  It worked for at least 18 months known to me.

In my own Midwest private practice, we had a 51 year old woman who was convinced her 64 year old husband was cheating on her.  She declined to take medications; of course, I had to tell her they had only a 50/50 chance of changing what she thought. She said any record of having taken medications would mess up her career as a professional educator at the college and graduate school level, and she may have been right about that.  So I had to use psychotherapy alone.  I saw her several times both alone and with her husband.  We worked primarily on reality testing; they looked in each other’s eyes, she took his hand. As I recall, he had some kind of urology problems, likely prostate. He did something few men would ever do, and for which I applauded him with all my heart, and praised him to her. He produced a certificate from his urologist that affirmed, beyond a shadow of a doubt, that he was completely impotent.  He could not be cheating on her in any way any of us could figure out. She understood intellectually what was going on, we worked on the “feeling,” and the last time I saw them, they were still together and making it work.

I remember a long time ago reading somewhere in the professional literature about a man who thought he was Christ. A psychiatrist told him to just “not tell anybody” and he did well for quite a long time, but ultimately decompensated somehow, I think it was under general anesthesia for some kind of a procedure.

So in situations like this, with uncommon diagnoses, where medication (and also, I expect, natural substances) are no more than a crapshoot, you do what you can with creativity and psychotherapy, and yes, the FBI when you need them, and maybe, just maybe, it is possible to hold a life together.