Dennis,
Thanks so much for your interesting comments. I very much appreciate our shared interest and look forward to learning from, and with, you.
Your comment that ‘imposing our preconceptions’ on sensory data should not imply intentionality to do so certainly makes sense to me. Experientially, I seem to be totally unaware of this process. I wouldn’t have a clue as to how to ‘impose my preconceptions’ even if I wanted to. It just seems to happen naturally. I can talk about it intellectually, but experientially it just seems to roll along on its own; which means that I rarely question the validity of my sensory experiences. In the same way, I suppose, most people who have hallucinations, like hearing voices, assume that their experiences are ‘real’.
Your other comment, about Jill Taylor’s experience during a severe stroke, raises the question (among others) of the process by which a sense of separate ‘self’ is generated. Again, this seems to be something that happens without intention, and on a moment to moment basis I, for one, take the result to be ‘real’ without even thinking about it.
Recently there have been a couple of papers from Dr. Patrick McGorry and his Early Psychosis group in Melbourne, suggesting that a disturbance in this sense of self is an early and core aspect of the development of psychosis. Here is their latest abstract:
A disturbed sense of self in the psychosis prodrome: linking phenomenology and neurobiology. Neurosci Biobehav Rev. 2009 Jun;33(6):807-17. Epub 2009 Jan 20.
Nelson B, Fornito A, Harrison BJ, Yücel M, Sass LA, Yung AR, Thompson A, Wood SJ, Pantelis C, McGorry PD .ORYGEN Youth Health Research Centre, Department of Psychiatry, The University of Melbourne, Victoria, Australia. nelsonb@unimelb.edu.au
Interest in the early phase of psychotic disorders has risen dramatically in recent years. Neurobiological investigations have focused specifically on identifying brain changes associated with the onset of psychosis. The link between these neurobiological findings and the complex phenomenology of the early psychosis period is not well understood. In this article, we re-cast some of these observations, primarily from neuroimaging studies, in the context of phenomenological models of "the self" and disturbance thereof in psychotic illness. Specifically, we argue that disturbance of the basic or minimal self ("ipseity"), as articulated in phenomenological literature, may be associated with abnormalities in midline cortical structures as observed in neuroimaging studies of pre-onset and early psychotic patients. These findings are discussed with regards to current ideas on the neural basis of self-referential mental activity, including the notion of a putative "default-mode" of brain function, and its relation to distinguishing between self- and other-generated stimuli. Further empirical work examining the relationship between neurobiological and phenomenological variables may be of value in identifying risk markers for psychosis onset.
Saturday, June 13, 2009
Sunday, June 7, 2009
On posting comments
It seems that some people are unable to post comments on this blog. If you are in that situation, please feel free to email your comments to me (davidwhitehorn@eastlink.ca) and I will post them for you.
Below are two interesting comments sent to me from Dennis P. I will respond to them in a day or so. Thanks Dennis.
Re: An Optical Illusion and Psychosis (April 21, 2009)
Hello David:
This is a fascinating observation, but I think that we have to be a bit careful in how we interpret it. Saying that we "impose our preconceptions" on the sensory data is cognitively loaded and carries a connotation of intentionality, while the processes at work may not be particularly cognitive at all. Our brains have encountered thousands (millions?) of examples of faces in our experience, including under conditions of degraded sensory input, prior to exposure to the stimulus evoking the illusion. The hollow mask stimulus confronts us with sensory data that are somewhat ambiguous, and most intelligent perceivers (man or machine) would probably default to the interpretation that has been helpful so many times before. I'm reminded of the case of relative motion. When a small object and a large object move relative to each other in the absence of other disambiguating information, the default interpretation is that it is the smaller object which is moving because the perceptual system has encountered that scenario far more often than the alternative. In both the "hollow mask" illusion and relative motion cases, we don't need to postulate that the perceptual system is attempting to "match our past experiences"; rather, the perceptual system uses past experience to provide the most likely interpretation of incoming, impoverished sensory data.
It remains fascinating that schizophrenics may not generally behave this way (at least with regard to the hollow mask illusion), and your point that our past experience influences our present perceptions is well taken. The point I'm trying to make here is that the mechanism through which experience expresses its effect may be much more low-level than the cognitive one that the expression "impose our preconceptions" implies. As I type this, it occurs to me that a low-level account of the hollow mask illusion might speak to the "salience" issue raised in your earlier posts: is the finding with the hollow mask illusion evidence that schizophrenics have an impaired ability to weight the data from the various sources of information (bottom-up, top-down) normally used in perceptual judgements? I hope that this helps. Kind wishes,
DPP
Re: Separating 'this' from 'that' (February 26, 2009)
Hello David:
I wonder how much of this "duality" is a natural consequence of the human gift of language? As soon as we apply the (linguistic) label "chair," everything else becomes "not chair." On the one hand, as you imply, this skill is what makes our interactions with others, and with the world, so workable. On the other hand, the labels create a duality that runs counter to the reality of the interdependence of all things, or "interbeing," to borrow the term from Thich Nhat Hanh. A quite striking case supporting this view is the work of Jill Bolte Taylor (see "My Stroke of Insight"; see also her talk at ted.com), the neuroscientist who suffered a left hemisphere stroke which, among other things, left her temporarily with a severe language impairment. In her book, Taylor describes her perceptions at the time of the accident, which I might in turn describe as "perception stripped of language." In this state, Taylor experienced a loss of boundary between self and other, and something of a dissolution of ego as hard, separate, and permanent; instead, everything, including perceptions, became fluid, with a distinct sense of "flow." This afforded Taylor a quite profound insight. It also rendered her interaction with her world almost unworkable.
Jill Bolte Taylor's retrospective descriptions of her stroke experience use a language (so to speak) that is a little different to that offered by meditation masters trying to teach us about absolute and relative truth. It seemed to me, however, that the descriptions have common themes, and this made me wonder if one of the insights provided by the disciplined meditative practice is to "see" past the language layer that we automatically impose on what would otherwise be more direct perceptions. Perhaps the real gift of being human is the ability to have a heartfelt appreciation of interdependence and impermanence, balanced with a language facility that enables us to communicate effectively with our world.
Thanks for your blog. Kind wishes,
Dennis PP
Below are two interesting comments sent to me from Dennis P. I will respond to them in a day or so. Thanks Dennis.
Re: An Optical Illusion and Psychosis (April 21, 2009)
Hello David:
This is a fascinating observation, but I think that we have to be a bit careful in how we interpret it. Saying that we "impose our preconceptions" on the sensory data is cognitively loaded and carries a connotation of intentionality, while the processes at work may not be particularly cognitive at all. Our brains have encountered thousands (millions?) of examples of faces in our experience, including under conditions of degraded sensory input, prior to exposure to the stimulus evoking the illusion. The hollow mask stimulus confronts us with sensory data that are somewhat ambiguous, and most intelligent perceivers (man or machine) would probably default to the interpretation that has been helpful so many times before. I'm reminded of the case of relative motion. When a small object and a large object move relative to each other in the absence of other disambiguating information, the default interpretation is that it is the smaller object which is moving because the perceptual system has encountered that scenario far more often than the alternative. In both the "hollow mask" illusion and relative motion cases, we don't need to postulate that the perceptual system is attempting to "match our past experiences"; rather, the perceptual system uses past experience to provide the most likely interpretation of incoming, impoverished sensory data.
It remains fascinating that schizophrenics may not generally behave this way (at least with regard to the hollow mask illusion), and your point that our past experience influences our present perceptions is well taken. The point I'm trying to make here is that the mechanism through which experience expresses its effect may be much more low-level than the cognitive one that the expression "impose our preconceptions" implies. As I type this, it occurs to me that a low-level account of the hollow mask illusion might speak to the "salience" issue raised in your earlier posts: is the finding with the hollow mask illusion evidence that schizophrenics have an impaired ability to weight the data from the various sources of information (bottom-up, top-down) normally used in perceptual judgements? I hope that this helps. Kind wishes,
DPP
Re: Separating 'this' from 'that' (February 26, 2009)
Hello David:
I wonder how much of this "duality" is a natural consequence of the human gift of language? As soon as we apply the (linguistic) label "chair," everything else becomes "not chair." On the one hand, as you imply, this skill is what makes our interactions with others, and with the world, so workable. On the other hand, the labels create a duality that runs counter to the reality of the interdependence of all things, or "interbeing," to borrow the term from Thich Nhat Hanh. A quite striking case supporting this view is the work of Jill Bolte Taylor (see "My Stroke of Insight"; see also her talk at ted.com), the neuroscientist who suffered a left hemisphere stroke which, among other things, left her temporarily with a severe language impairment. In her book, Taylor describes her perceptions at the time of the accident, which I might in turn describe as "perception stripped of language." In this state, Taylor experienced a loss of boundary between self and other, and something of a dissolution of ego as hard, separate, and permanent; instead, everything, including perceptions, became fluid, with a distinct sense of "flow." This afforded Taylor a quite profound insight. It also rendered her interaction with her world almost unworkable.
Jill Bolte Taylor's retrospective descriptions of her stroke experience use a language (so to speak) that is a little different to that offered by meditation masters trying to teach us about absolute and relative truth. It seemed to me, however, that the descriptions have common themes, and this made me wonder if one of the insights provided by the disciplined meditative practice is to "see" past the language layer that we automatically impose on what would otherwise be more direct perceptions. Perhaps the real gift of being human is the ability to have a heartfelt appreciation of interdependence and impermanence, balanced with a language facility that enables us to communicate effectively with our world.
Thanks for your blog. Kind wishes,
Dennis PP
Tuesday, April 21, 2009
An Optical Illusion and Psychosis
In an earlier posting we talked about the conclusion that the brain/mind creates our perceptions; an important insight that is accepted in western neuroscience and in eastern contemplative traditions.
Here is the link to the previous posting on this blog:
http://comingbacktoreality.blogspot.com/2009/01/constructing-reality.html
Optical illusions are an entertaining way to literally ‘see’ that what we see is not what is actually there. Instead, we tend to impose our preconceptions on the ‘data’ that has been presented to the brain by the sensory neurons and create perceptions that match our past experiences.
A posting on the website “Wired Science” provides an interesting example of such an optical illusion. The context is that in a recent research study people who had a diagnosis of schizophrenia actually were not able to see a particular optical illusion. They saw the visual object as it actually was while the ‘healthy controls’ experienced an optical illusion that fundamentally misinterpreted the actual visual object.
So, this is an interesting twist; people with psychosis see a visual object as it actually is, while people without psychosis are fooled.
The link to the Wired Science blog is as follows:
http://blog.wired.com/wiredscience/2009/04/schizoillusion.html
The optical illusion is demonstrated with a video that is available within the Wired Science blog.
Here is the link to the previous posting on this blog:
http://comingbacktoreality.blogspot.com/2009/01/constructing-reality.html
Optical illusions are an entertaining way to literally ‘see’ that what we see is not what is actually there. Instead, we tend to impose our preconceptions on the ‘data’ that has been presented to the brain by the sensory neurons and create perceptions that match our past experiences.
A posting on the website “Wired Science” provides an interesting example of such an optical illusion. The context is that in a recent research study people who had a diagnosis of schizophrenia actually were not able to see a particular optical illusion. They saw the visual object as it actually was while the ‘healthy controls’ experienced an optical illusion that fundamentally misinterpreted the actual visual object.
So, this is an interesting twist; people with psychosis see a visual object as it actually is, while people without psychosis are fooled.
The link to the Wired Science blog is as follows:
http://blog.wired.com/wiredscience/2009/04/schizoillusion.html
The optical illusion is demonstrated with a video that is available within the Wired Science blog.
Monday, April 20, 2009
The Dopamine Hypothesis, Version 3
The idea that psychosis involves hyperactivity of dopamine neurons has been generally accepted in psychiatry for nearly fifty years. A new review brings this hypothesis up to date. The authors (Howes and Kapur) incorporate results from a number of new techniques in molecular biology, genetics and brain imaging to define four major points.
Each of the points has interesting implications, some of which have already been mentioned in previous posting on this blog. For example, the first point in the review is that multiple factors, both genetic and environmental, interact, resulting in dopamine dysregulation. This point supports the idea we discussed that each person with psychosis has a unique path of causation and a unique condition. (Click below for the relevant previous posting on this blog).
http://comingbacktoreality.blogspot.com/2009/02/how-does-psychosis-arise-part-2.html
The second point is that the locus of the dopamine dysregulation is presynaptic, involving increased synthesis and tendency to release transmitter. The implication of this point is that current antipsychotic medications (which act postsynaptically) are acting ‘down stream’ from the point of actual dysregulation. Medications that act directly at the site of dysregulation may be preferable.
The third point is that dopamine dysregulation is linked specifically to the dimension ofpositive psychotic symptoms and 'psychosis proneness', regardless ofdiagnosis. This point is consistent with the idea that the current diagnostic system for psychotic disorders should be revised to emphasize symptom dimensions that are viewed as independent, each having its own particular underlying mechanisms. (Click below for the relevant previous posting on this blog).
http://comingbacktoreality.blogspot.com/2009/02/jim-van-os-and-salience-dysregulation.html
The fourth point is that dopamine dysregulation alters the appraisal of stimuli through the process of aberrant salience (stimuli that are not relevance are taken as relevant). This in turn leads to psychosis. This idea is extensively discussed in a previous posting on this blog; click below for that posting.
http://comingbacktoreality.blogspot.com/2009/01/salience-and-psychosis.html
Finally, there is no doubt much more to psychosis than dopamine. Still, the four major points in the updated hypothesis provide a helpful way to clarify issues in understanding psychosis.
Reference: OD Howes and S Kapur; The Dopamine Hypothesis of Schizophrenia:Version III - The Final Common Pathway. Schizophrenia Bulletin, March 2009.
Each of the points has interesting implications, some of which have already been mentioned in previous posting on this blog. For example, the first point in the review is that multiple factors, both genetic and environmental, interact, resulting in dopamine dysregulation. This point supports the idea we discussed that each person with psychosis has a unique path of causation and a unique condition. (Click below for the relevant previous posting on this blog).
http://comingbacktoreality.blogspot.com/2009/02/how-does-psychosis-arise-part-2.html
The second point is that the locus of the dopamine dysregulation is presynaptic, involving increased synthesis and tendency to release transmitter. The implication of this point is that current antipsychotic medications (which act postsynaptically) are acting ‘down stream’ from the point of actual dysregulation. Medications that act directly at the site of dysregulation may be preferable.
The third point is that dopamine dysregulation is linked specifically to the dimension ofpositive psychotic symptoms and 'psychosis proneness', regardless ofdiagnosis. This point is consistent with the idea that the current diagnostic system for psychotic disorders should be revised to emphasize symptom dimensions that are viewed as independent, each having its own particular underlying mechanisms. (Click below for the relevant previous posting on this blog).
http://comingbacktoreality.blogspot.com/2009/02/jim-van-os-and-salience-dysregulation.html
The fourth point is that dopamine dysregulation alters the appraisal of stimuli through the process of aberrant salience (stimuli that are not relevance are taken as relevant). This in turn leads to psychosis. This idea is extensively discussed in a previous posting on this blog; click below for that posting.
http://comingbacktoreality.blogspot.com/2009/01/salience-and-psychosis.html
Finally, there is no doubt much more to psychosis than dopamine. Still, the four major points in the updated hypothesis provide a helpful way to clarify issues in understanding psychosis.
Reference: OD Howes and S Kapur; The Dopamine Hypothesis of Schizophrenia:Version III - The Final Common Pathway. Schizophrenia Bulletin, March 2009.
Thursday, March 19, 2009
Treatment (Part 1)
In the conventional medical model, psychotic symptoms lead to dysfunction and, therefore, deserve treatment; interventions intended to reduce the symptoms and their impact on social function.
The recognized standard for treatment of psychosis in most developed countries of the world consists of antipsychotic medications coupled with support from professionals, family and friends and, in some cases, psychotherapy.
Before delving into the details of treatment it is worth asking whether the recognized standard treatment is always necessary and appropriate. There are two lines of logic that support the idea that the current standard treatment is not always necessary and appropriate.
The first logic is that there are a significant number of people who are, by virtue of their ability to function in society, considered ‘healthy’ (in terms of psychiatric conditions) and yet experience psychosis. The most common situation is a person who has auditory hallucinations. A recent study suggests that 10-15% of the general population report having auditory hallucinations (usually hearing a voice), from time to time. There is even an organized group of such people in the Netherlands who strongly believe the voices they hear are of value to them, and an important part of their life and who they are. These people are not at all interested in ‘treatment’.
The second line of logic comes from clinicians who believe that psychosis, even when it is severe enough to cause considerable social dysfunction, will, for at least some people, resolve or improve without medication if the person is in a supportive therapeutic environment.
Published research in recognized scientific journals examining the therapeutic environment approach for first episode psychosis is rare. One model, called ‘Soteria’ was developed in California in the 1970’s. Outcomes after one year were reported to be the same as for a comparator sample of patients receiving the convention care of the time. Unfortunately both groups had relatively poor outcomes by today’s standards. More recently a group in Berne has used a modified Soteria model, allowing some use of medication. (Soteria references: Carlton et al; Schizophr Bull. 2008 Jan;34(1):181-92. and Ciompi and Hoffman, World Psychiatry. 2004 Oct;3(3):140-6).
More recently a group in Finland tried to minimize use of medication in working with first-episode psychosis patients. They provided an intensive, high quality psychosocial intervention to two groups of patients. One of the groups received antipsychotic medication as usual while the other received the minimum medication consistent with ethical clinical practice. They reported that 40% of the patients in the minimal medication group recovered from the episode without ever taking anti-psychotic medication. (Finland references: Lehtinen et al Eur Psychiatry. 2000 Aug;15(5):312-20 and Bola et al J Nerv Ment Dis. 2006 Oct;194(10):732-9)
The overall lack of research makes it difficult to interpret these isolated findings. It has long been appreciated that there is a very wide range in terms of the inherent severity of conditions involving psychosis. It is not unreasonable to think that some young people experiencing a first episode of psychosis might have a relatively mild condition that could resolve without antipsychotic medication. It is likely, as well, that many people have gone through a psychotic episode and returned to social functionality without ever coming to the attention of the health care system.
There are two practical problems to keep in mind. First, very few, if any clinical services have the resources and expertise to provide intensive, high quality therapeutic environment based support of the kind provided in the Finland study. The second is that, with current knowledge, we cannot determine with sufficient accuracy, at the time of the psychosis emerges, whether an individual has a relatively mild, or relatively severe condition. In a future blog I will talk about some of the research that might help sort that out.
In the meantime, the medical-legal environment in the developed nations (certainly in North America) is such that a psychiatrist who failed to recommend antipsychotic medication to a person with significant psychosis (impacting on their social function) would certainly face malpractice charges.
The recognized standard for treatment of psychosis in most developed countries of the world consists of antipsychotic medications coupled with support from professionals, family and friends and, in some cases, psychotherapy.
Before delving into the details of treatment it is worth asking whether the recognized standard treatment is always necessary and appropriate. There are two lines of logic that support the idea that the current standard treatment is not always necessary and appropriate.
The first logic is that there are a significant number of people who are, by virtue of their ability to function in society, considered ‘healthy’ (in terms of psychiatric conditions) and yet experience psychosis. The most common situation is a person who has auditory hallucinations. A recent study suggests that 10-15% of the general population report having auditory hallucinations (usually hearing a voice), from time to time. There is even an organized group of such people in the Netherlands who strongly believe the voices they hear are of value to them, and an important part of their life and who they are. These people are not at all interested in ‘treatment’.
The second line of logic comes from clinicians who believe that psychosis, even when it is severe enough to cause considerable social dysfunction, will, for at least some people, resolve or improve without medication if the person is in a supportive therapeutic environment.
Published research in recognized scientific journals examining the therapeutic environment approach for first episode psychosis is rare. One model, called ‘Soteria’ was developed in California in the 1970’s. Outcomes after one year were reported to be the same as for a comparator sample of patients receiving the convention care of the time. Unfortunately both groups had relatively poor outcomes by today’s standards. More recently a group in Berne has used a modified Soteria model, allowing some use of medication. (Soteria references: Carlton et al; Schizophr Bull. 2008 Jan;34(1):181-92. and Ciompi and Hoffman, World Psychiatry. 2004 Oct;3(3):140-6).
More recently a group in Finland tried to minimize use of medication in working with first-episode psychosis patients. They provided an intensive, high quality psychosocial intervention to two groups of patients. One of the groups received antipsychotic medication as usual while the other received the minimum medication consistent with ethical clinical practice. They reported that 40% of the patients in the minimal medication group recovered from the episode without ever taking anti-psychotic medication. (Finland references: Lehtinen et al Eur Psychiatry. 2000 Aug;15(5):312-20 and Bola et al J Nerv Ment Dis. 2006 Oct;194(10):732-9)
The overall lack of research makes it difficult to interpret these isolated findings. It has long been appreciated that there is a very wide range in terms of the inherent severity of conditions involving psychosis. It is not unreasonable to think that some young people experiencing a first episode of psychosis might have a relatively mild condition that could resolve without antipsychotic medication. It is likely, as well, that many people have gone through a psychotic episode and returned to social functionality without ever coming to the attention of the health care system.
There are two practical problems to keep in mind. First, very few, if any clinical services have the resources and expertise to provide intensive, high quality therapeutic environment based support of the kind provided in the Finland study. The second is that, with current knowledge, we cannot determine with sufficient accuracy, at the time of the psychosis emerges, whether an individual has a relatively mild, or relatively severe condition. In a future blog I will talk about some of the research that might help sort that out.
In the meantime, the medical-legal environment in the developed nations (certainly in North America) is such that a psychiatrist who failed to recommend antipsychotic medication to a person with significant psychosis (impacting on their social function) would certainly face malpractice charges.
Wednesday, March 11, 2009
What this blog is about (revisited)
After a bit more than two months of creating this blog, it seemed useful to remind myself, and any readers who might wander by, about the purpose of the blog. Below is the very first posting, back in January.
"This blog is about psychosis and particularly psychosis as it is experienced by young people. From a psychiatric point of view the term psychosis refers to “a loss of contact with reality”. In psychiatric practice psychosis manifests in one, or all, of three ways; as hallucinations (‘false’ perceptions), as delusions (‘false’ beliefs) and as disorganization.
My interest in psychosis in young people stems most directly from the ten years (1996-2005) when I was Clinical Nurse Specialist and Coordinator of the Nova Scotia Early Psychosis Program. During that time I had the privilege of getting to know hundreds of young people who were experiencing psychosis, and their parents. As I tried to help these young people and their families understand what they were experiencing and how to deal with it, I found myself drawing upon two sources of information from my own background, the neurosciences and the study and practice of Buddhism.
In this blog I will try to bring together information from those two sources (and any others I can find) with the practicalities of clinical care and recovery to accomplish two objectives. The first is to open a door into the complex world of psychosis in young people. The second is to use the concept of psychosis as a focal point for exploring the nature of human mental experience".
I dont' know to what extent the objectives of the blog have been accomplished; it's certainly an ongoing challenge.
"This blog is about psychosis and particularly psychosis as it is experienced by young people. From a psychiatric point of view the term psychosis refers to “a loss of contact with reality”. In psychiatric practice psychosis manifests in one, or all, of three ways; as hallucinations (‘false’ perceptions), as delusions (‘false’ beliefs) and as disorganization.
My interest in psychosis in young people stems most directly from the ten years (1996-2005) when I was Clinical Nurse Specialist and Coordinator of the Nova Scotia Early Psychosis Program. During that time I had the privilege of getting to know hundreds of young people who were experiencing psychosis, and their parents. As I tried to help these young people and their families understand what they were experiencing and how to deal with it, I found myself drawing upon two sources of information from my own background, the neurosciences and the study and practice of Buddhism.
In this blog I will try to bring together information from those two sources (and any others I can find) with the practicalities of clinical care and recovery to accomplish two objectives. The first is to open a door into the complex world of psychosis in young people. The second is to use the concept of psychosis as a focal point for exploring the nature of human mental experience".
I dont' know to what extent the objectives of the blog have been accomplished; it's certainly an ongoing challenge.
Thursday, March 5, 2009
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.
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.
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