Saturday 9 May 2009


I recently saw a lady who medics asked me to assess on their ward. She'd been brought in breathless but had been checked out and all was well. That's to say, serious things (like a heart attack) had been excluded, no cause for her breathlessness was found, but since it got better she was medically fit for discharge. She'd nociceptive pain that seemed pleuritic to me and was a touch alkalotic for my liking, but by the time I got to see her I couldn't hear anything odd in her lungs, her CXR was clear, haematological and biochemical indices were all normal (but her ABG hadn't been repeated). It could have been anxiety. It probably was. It could be pleuritic pain and consequent suboptimal ventilation and respiratory alkalosis from rapid short shallow breaths blowing off her CO2 but, in truth, I think the medics had it right and she'd been anxious.

What surprised me was that they sought an urgent consultation because as the discharge facilitator said, "She's mad as a sack of rats." Challenging stigma. Ace.

The lady told me, at length, about her voices. She hadn't told anyone about them for 30 years. Last time she mentioned them they locked her up and gave her ECT. Coercive psychiatry that did her no good. She was rightly wary of mental health services after that less than helpful contact.

I don't know why she said to ward staff she wanted to talk with someone about her voices, or why she opened up to me after 30 years of silence, but she'd clearly a desire to narrate her life story and what changes voices had made. They'd told her who to marry. Where to live. Which countries to go to. They'd hidden behind her eyes, spying for Stalin (which was when she piped up about them and had ECT in England as a young woman).

Mostly the voices talked with her about politics, current affairs and gossip. She really enjoyed them, she didn't believe she was ill and certainly didn't either want help or want the voices to go away. They talked to her, constantly. She said, several times, that they were real people who could talk to her psychically and were her friends. Better still, they could make her feel things. One had made her breathless (causing her admission) but mostly they made her feel good things. Every evening she has an overwhleming feeling of warmth, as if held, and is suffused with a feeling of being loved, "as if you look in to your mother's smiling eyes." It sounded beautiful.

She manages everything at home. She's been living like this for ages. Decades.

She has auditory hallucinations talking to her.
She has auditory hallucinations talking about her.
She has mood incongruent delusions of government conspiracies unfolding through presences utilising surveillance and telepathy within her head.
She has made acts, to touch things.
She has made feelings, usually they're positive.
She has made impulses, usually thoughts of travel.
She has thought insertion.
She has thought withdrawl.
She has thought broadcast.
She has had these for decades, she described hearing voices since she was an 11 year old child.
Maybe you like to consider Schneider's First Rank symptoms. Maybe you like Andrew Sims models of throught disorder (a man I met in my training, and even when he explained it to me I still couldn't get it). I tend to favour Nancy Andreasen's definitions of thought disorder. But however you like to assess, formulate and structure things, it's clear she's psychotic.

She had sufficient symptom and signs to attract a diagnosis F20.0 paranoid schizophrenia.

But, she's well. She's had no contact with mental health services for decades, she sees herself as well, she's scared witless of hospitals and psychiatrists (no idea why she spoke to me for an age), she's adamant that she will accept no medication (having had ghastly experiences of it, and since she sees herself as well) and avoids seeing her GP unless she feels she absolutely has to.

What should I have done?


David said...

What should you have done? Leave well alone, of course.

Lovely story. Thanks.

Unknown said...

According to the DSM-IV a diagnosis of schizophrenia requires evidence of significant social or occupational dysfunction. If her psychotic symptoms aren't preventing her from living a normal life, then she probably can't be considered fully schizophrenic. From what you describe, she sound more like a borderline case and forcing her into treatment would do more harm than good. An onset of age 11 seems surprisingly young for a major mental illness. All in all, it sounds like a fascinating case.

Anonymous said...

What should you have done?

Absolutely nothing. If her 'symptoms' are not causing her any distress, and not making her a risk to herself or others, the whose business is it.

RMJ said...

Discharged her.

sw2be said...

The Hearing Voices Network has a lot to say about this sort of thing.
But why the need to pathologise someone who isn't suffering, or in danger of causing any harm? Unwanted- and often unpleasant- treatment would cause likely more distress than leaving her.
Wish her well and leave well alone!

Unknown said...


My support worker always tells me that symptoms only need treating if they negatively impact your life. And used an example almost exactly like this lady.

I guess another way to see it would be if someone told you God talks to them and their faith is a positive thing in their life. You wouldn't think they were "mad", you'd just ascribe it to her personal experiences.

Sure she may not be mentally "normal" (although I firmly believe that normality doesn't in fact exist!),but then are people who see ghosts normal or psychotic, what about those who God talks to, those who believe in aliens etc.

She sounds like a very interesting person.
Thanks for the thought-provoking post


XE said...

I suppose just make arrangements to check in with her periodically and make sure she's still doing okay. Other than that, leave her be I guess.

What did you end up deciding? (If you're allowed to share such information that is!)

Milo said...

I really think that she wanted to talk to someone. It takes courage after going through a traumatic experience (like being forced to go through treatment) to come out and speak to the very same people (i am sorry i don't mean you personally but of the same profession)about how life has been. I don't think that there are many psychiatrists out there (i haven't been able to find any!) who would not be judgmental towards someone who has paranoid schizophrenia and chooses not to take anti-psychotic medication! I am sorry, i wasn't trying to be disrespectful or anything...

Milk and Two Sugars said...

I'm with XE: arrange for follow-up so you're able to provide ongoing care should the need arise. Would that all people in her situation didn't need medical intervention.

nmg20 said...

Did you explain what you thought about the voices to her? My inclination - bearing in mind that I've never done a psychiatry job - would perhaps have been to explain to her that the voices probably qualified her for a diagnosis of schizophrenia, that given her history and current state you didn't feel treatment was needed, but that you'd like to offer her an outpatient appointment should she want one.

I have a nagging feeling there is a downside to what I've suggested, and a worse feeling that I can't pinpoint it. But there we are.

The Shrink said...

Thanks all for commenting. You've collectively stirred my thoughts into a lengthy reply here!

Abysmal Musings, pinkfriction, ifr, Heidi, XE, Milo, M&2S, I agree. Sometimes the best thing to do is do nothing. Meddling would not have been helpful.

rvcanuck, she did have deficits that were sufficient to attract an ICD-10 diagnosis of F20.0 paranoid schizophrenia. I'm not familiar enough with DSMIV now, since it's 2001 since I last used it!

sw2be, indeed! I'm familiar with the Hearing Voices Network and have been to their annual international conferences. They've shaped my thinking a lot.

Nick, I asked her about the idea that the voices could be hallucinations, then later asked her if maybe they weren't of real people, but she was adamant that they were real folk talking to her psychically. I'd not be so bold as to say, "You're wrong!" since it's not be helpful. We're both in agreement she's having these experiences, we can both have different interpretations of that, but it's surely more important that we can then get along and manage care rather than come to blows over formulation. So we talked openly about what she was experiencing and what the impact was and what options she had to choose from, without getting too hung up on diagnosis and formulation. Over time I'd hope to be able to have more frank conversations and bring up the term schizophrenia if that's relevant, but for now it'd be unheloful and it'd servce no purpose.

Can of worms if all patients get a copy of their GP letter though, eh?