The web of delusion: a clinical vignette

Bill (not his real name) had been seeing a psychotherapist for several months. She told him he was delusional and needed to talk to someone (me) in the Early Psychosis Program. He didn’t like the idea, but eventually agreed. He and I met weekly for two months.

Bill told me that he was the focus of a global conspiracy; that his every move and every word were being monitored. When he left home (which he did rarely) he constantly saw doubles of his family and friends. These ‘people’ were clearly part of the conspiracy and had been placed along his route.

He was willing to talk about the idea that he might be delusional, and he said, when I asked, that he did not see me as part of the conspiracy. Nonetheless, on several occasions he noticed doubles in the hallway leading to my office.

I told him about the salience theory of psychosis. He was interested (he had taken a number of psychology courses). I suggested that he could conduct an experiment. Take a small amount of antipsychotic medication (to help improve his ability to discriminate relevant from irrelevant experiences) and see whether the doubles, and other signs of the conspiracy, were reduced. If so, he could conclude that they were not real.

He was not convinced. He felt the conspiracy was so pervasive and cleaver that they would know that he was taking medication and simply stay out of sight for a while, thus leading him to the false conclusion they weren’t real, and leaving him more open to attack. He also speculated that the conspiracy might be trying to get him to start on medication, which would, in some unknown way, play exactly into their plans for his destruction.

In the end he declined medication. We mutually agreed that our conversations, while quite interesting at times, were not leading to anything useful. We parted on good terms.