By Dr David Laing Dawson
I was in my early 30’s when I first met Robert. He was just twenty but had already been hospitalized three times. He had schizophrenia. He became my patient for the next 10 years, and indirectly my patient for 25 years after that. He did well with reasonable doses of anti-psychotic medication, monitored and adjusted over the years, though his paranoia, his ‘ideas of reference’ and his anxiety would resurface in socially stressful moments.
I saw him through group programs into employment, steady employment with good sick benefits and a pension at the end. He kept this job throughout his working life though several times he came close to losing it when his symptoms surfaced at work.
And I saw him through his first dating experience, then engagement and marriage. Their honeymoon ended abruptly when he became paranoid at the luggage carousel upon landing at their destination. They flew back, we talked, I adjusted his medication, the marriage lasted. His new wife came to me for genetic counseling and I told them what we knew. They agreed to have no children, she worked as a primary school teacher, and with two incomes and later an inheritance they did well financially. He always had more savings in the bank than I had.
At the end of those ten years I worked out of town for five years and I did not see him but I knew he regularly attended a nurse at the clinic I left. Over the next 10 years I was psychiatrist-in-chief at the mental hospital where he had once been a patient. His medications were now being looked after by his family doctor but he came to see me occasionally to talk something over.
After those 10 years as medical director of the hospital I left to work clinically part-time and devote the other half of my time to artistic pursuits. This included being co-owner of an art gallery with my wife. Robert started coming to every art opening. He would find me, often tending bar, and fill me in on his struggles and successes, his medication, his work. He wrote poetry he shared with me, and he began to write a book about his life, his illness, his hospitalizations. He was conflicted about this; his wife wanted him to keep it as a private journal but he wanted to share his story to help others. By this time both his father and mother had died but his life with this wife was solid. He gave me copies of each chapter and asked for my advice.
Neither of us were young anymore. I was now in my sixties, Robert in his fifties.
Then one Sunday afternoon at the gallery I received a phone call from Robert. My wife answered and told me it was Robert but “he doesn’t sound right”.
On the phone Robert said he needed to see me. He needed to talk something over. He didn’t have schizophrenia after all. The police really are watching and following him. And for the same thing as years before. The same crime. It was all real. Not a delusion at all. A major mistake had been made. He did not have schizophrenia. Out of character he also suggested we sit down over a beer to discuss this. We talked some more and I learned that his family doctor, after seeing Robert symptom free and well for the past many years had taken him off his Olanzapine. It was not an entirely unreasonable clinical decision for he had put on more weight than is healthy. But the same delusion returned. The same guilt, fear, and belief that the police were after him for once owning, hiding, and then throwing away, a small pile of pornographic magazines that had so troubled him in his late teens.
I asked him how I could help. He asked if I knew the police chief. I assured him I did. He asked if maybe I could influence the Chief, to get his men to stop harassing him. I told him I would certainly do that. I would get the Chief to call off his men. But in return I wanted him to go back on his Olanzapine and come in to see me the next Saturday morning. He promised he would.
When Saturday came he had been back on his medication for 5 days. He looked a little sheepish. He asked if I had spoken with the Chief. I told him I hadn’t gotten around to it. He said, “Thank goodness.”
It cannot be that often that a psychiatrist has the privilege of observing the course of a psychotic illness over 35 years, especially that of a patient who remains symptom free for many of those years. But I write this story as counterpoint to the courageous blog by Erin Hawkes.
A delusion is a delusion. It is not a moment of misunderstanding; it is not a passing thought; it is not an odd experience that we check out with others (“Did you hear that?” “I’d like to see what you think of an idea I have.”); it is not an ‘issue’; it is not an idea or even a conviction up for debate; it is not assailable by either reason or evidence, and it is certainly not a spiritual experience preceding moral growth. And Erin, despite her training in and knowledge of science, and neuroscience at that, when ill is ill, when delusional is delusional, and when in that state she, like all the people who suffer from that illness that I know, seeks evidence to prove the belief, the delusional idea, the hallucinatory experience, and disprove the diagnosis, no matter the illogic of the quest.
And, away from treatment, off treatment, five or thirty-five years later, the delusion that returns is the same.
This latter phenomenon I have always found fascinating. Why the same delusion? Ultimately, I think, this is further prove of the illness being a brain problem. For surely if it were the mind, the open-source software, changing, growing, adapting with every input over those many years of life-experience, a delusion would refresh itself, would become more topical, more age specific. But it doesn’t. Which makes it, to me, more of a hardware problem, an illness for which the only effective treatment is medication. Offered of course within a family inclusive humane care system.