Psychosis is not always what it seems

Source: Photo by Mariana Montrazi on Pexels

I first saw Clem when she was with her mother, a former neighbor of mine, in the supermarket where I was shopping. I was glad to see my former neighbor and we stopped briefly to chat, but I was struck by the blank, glassy look on her daughter’s face and the way she held herself. When his mother, who knew I was a therapist, asked if she could call me, I assumed my hunch about Clem’s sanity was correct.

I soon learned that Clem had experienced a major psychotic episode six months earlier. Completely out of character, she had behaved very inappropriately (details were not disclosed) and ended up being severed. She was now taking high doses of an antidepressant, an antipsychotic and an antiepileptic drug often used for extreme anxiety. Normally bright, bubbly and efficient, she was on extended sick leave from her work as a school bursar.

Despite her flat, expressionless gaze, Clem was constantly anxious, her mother said, and the medication still didn’t seem to be doing any good. The family struggled to cope, as she couldn’t stand being alone, and so her mother, husband and adult son had to organize their lives completely around her. I offered to see if I could at least help her relax, and Clem came over to my house to talk.

In response to my questions, Clem told me that she hadn’t been stressed; his marriage was happy; she loved her job; and she enjoyed greater freedom now that her son lived away from home. So what had precipitated the psychotic episode? I found out this happened a few days after she received a steroid injection for hip bursitis.

I have found that corticosteroid-induced psychosis is far from uncommon and usually resolves within days or, at most, weeks. However, this knowledge did not seem to inform his psychiatric treatment, nor to be found in his notes. Indeed, Clem, terrified of her incarceration in what for her was a terrifying environment, deteriorated – and so her drug doses were increased. The rushed staff were too busy to listen to him.

As his symptoms of extreme anxiety and agitation persisted even after he returned home, it seemed likely to me that they were due to drugs. I was the only person supporting Clem in her instinctive knowledge that she needed to stop using drugs. (Her family was far too scared.) But it took a long time to convince a community psychiatrist to let her step down, one by one, after which Clem fully reverted to her competent old self.

So what is the message here? Certainly, psychosis is not always what it seems. But it’s more than that. I had a life-saving experience in health care decades ago that I still look back on. I had an appointment with my new GP, who was exceptionally late. At ten to ten at night, the remaining patients were getting angry and speaking out, and the front desk staff were increasingly harassed and irritable. When my name was called, I walked into the consulting room expecting to see a tired-looking doctor and writhing mentally about how insignificant my complaint would seem to him, after such a long and trying.

A surprisingly bright and welcoming face rose as I entered. “Good evening,” said Dr. I. “What can I do for you?” Encouraged, I told her that I had had enough of my acne. At 30 it was still thriving, not as bad as in my teens and 20s, but I wanted to get it over with.

Dr. I thought of myself as the most interesting patient he had seen that day. We discussed how acne affected me and what options were available to me. Since the remedies I had tried before had not been helpful, only the heavy duty variety remained, the effectiveness of which was outweighed by potentially high side effects. Did I think the benefits were worth it, Dr. I asked, apparently genuinely interested in my opinion. After some thought, I decided they weren’t. I walked out of the office empty-handed – and satisfied that I had been helped to make the right decision.

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

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