Losing contact with reality

I shall now consider some clinical cases in which patients experienced loss of contact with reality – in some cases completely, in others partially. For some, the loss was short-lived while for others they were never able to completely retrieve their state of health. First I will describe the exterior course of events and then I will carry out a psychiatric analysis and diagnosis (pp. 20–24). A mental rape

For six months Angela, a single 33-year-old woman, had been manager of a boutique that was part of an international chain of shops. With her staff she had made intensive preparations for that season’s sales programme. With only a day’s warning, her area manager turned up. Without giving reasons, he complained about her lack of social competence – something that was manifestly unjust according to both Angela and her colleagues. Prior to this visit, there had been no criticism.

Two days later, Angela was called to head office. She was given her notice there and then without any explanation. The boss, a man younger than Angela, was unyielding. Angela was unwilling to lose her dignity and tried to keep her feelings under control. Constraining herself, Angela signed an agreement whereby she was to receive compensation of six months’ pay. She confided to friends who persuaded her not to sue the company in order that her reputation should not be undermined within the industry as this might make it harder for her to find employment.

Angela was given a few days to settle her successor into her job. It had already been agreed that she should. She felt ‘anaesthetised’ but did as she was required with great effort. At night she cried a great deal and talked to her friends on the telephone. Some days later, after a meeting with a lawyer, she began to experience vague death threats from people that she passed on the street. She felt she was being pursued and saw people spying on her from cars. Suddenly everything came clear to her – she felt that her life was being threatened by an international conspiracy. She fled to her parents’ home. There her sense of security was further undermined when she heard people speaking in code about her during the weather report. Her parents tried to show her the absurdity of such a fantasy but without success. A few days later, while her panic about being threatened slowly grew, she sought help at an acute psychiatric department. There she was diagnosed as acutely psychotic, placed in an acute ward and treated with antipsychotic medication.

However, the doctor who saw her the following day considered her to be able to function outside the hospital, in spite of her psychosis, with the proviso that she should return to the hospital for frequent visits. The antipsychotic medication was replaced with something to help her to sleep. Angela’s persecutory ideas lessened after some weeks and she could now see that her relations and friends had encouraged her to separate her real illness from the ‘pursuer’ who had actually been after her. During the working through of the crisis a more pronounced sensitivity, feelings of pain and concern over the future emerged. Angela continued for several years in psychotherapy and eventually found employment in a new job where she fared well.

She spoke about her experiences of being dismissed in terms of a mental rape.

On the loss of the good childhood

Beth became acutely ill with auditory hallucinations, fantasies of saving the world and pronounced agitation. She was 30 years old, lived with a partner and worked in a state-operated factory. A year and a half earlier her grandmother had died and a half-brother had succumbed to schizophrenia. These events had caused Beth to become depressed and to seek psychotherapy. On several occasions she considered suicide but restrained herself, primarily because she felt that her sick brother needed her. Several months before she was hospitalised she had sought acute psychiatric help for panic-anxiety attacks and a couple of weeks later she had fantasies that she had been sent to redeem the world by the UN. She heard God’s voice and the voice of a famous rock star who cried: ‘Persevere Beth!’ which supported her in her mission. The situation was accentuated by a trip abroad. The houses in the city that she visited seemed to her to be somehow like houses from a film set, with the signposts put up to deceive her. She fled her fellow travellers and the city. As a result of her confused behaviour, the police stepped in and sent her home by air ambulance.

Beth was ‘put on section’ (detained under the mental health law) and given antipsychotic medication, but without success. On one occasion she set fire to her mattress on her ward. A couple of weeks later she was encouraged to join a project for first-time psychotic patients. Yet she still felt as if she was being plotted against and refused her medication. Nonetheless, she showed signs of being able to do some mental work without medication and she was transferred to a special crisis centre. Even so, Beth defended herself furiously against any attempt to critically discuss her feelings.

Beth explained that her dead grandmother, who had been in the Salvation Army, represented something positive and good in her childhood. She had lived with her grandmother between the ages of five and eight on the advice of the social services in order to protect her against negligent treatment at home. She had been living with her single mother who because of her work and her all-consuming love life had been unable to cope with her daughter. Beth described how ‘Frequently, in the mornings there was a new man to whom I was to say hello’, and who quickly disappeared from the picture. She also described how ‘hopelessly in love’ she was with her mother and how she tried, without success, to have her love reciprocated during these years. With her grandmother she felt she was noticed and listened to for the first time.

However, Beth’s mother remarried and took her daughter back and gave her several half-siblings. She did well at school and at work but ‘nothing seemed to interest me’. When her grandmother died it was as if ‘the world had lost its contents’ and she became ever more depressed with a strong sense of her life being meaningless. ‘Life was just empty.’

Six months after being admitted, Beth’s psychotic experiences had lessened to a large extent. In her talks she was encouraged to explore what it was that gave reality to her fantasies. The therapist was careful not to appear omniscient. Little by little Beth explored and began to understand her earlier experiences with her mother and understood her sorrow at the loss of her grandmother. Now she encountered a new and important change. During a visit to a convent she met a Catholic nun who reminded her of her grandmother. After this, Beth was able to give up her delusions for good.

In a follow-up discussion four years later Beth was feeling well and was deeply involved with her work. She had had a child with her partner and was experiencing great joy in motherhood. Beth commented on her period of psychosis as having been the most difficult time in her life but she was not sorry that she had undergone it. In many ways she now experienced a greater sensitivity about life than before. She explained that her feelings had more depth and were more intense now: ‘It is strange that I have had to have a psychotic episode in order to break through that emotional shell which I had built up over the years.’

Telepathy, thought control and voices in the wind

Carina was 22 years old and attending a private art school when she was first admitted to hospital. She had believed for some time that people on the street were talking about her and even thought that people were making secret television films of her through her neighbour’s window. When she watched television she noticed that if she thought about something specific the announcer would alter the channel and Carina believed she could control the announcer with her thoughts. Those who were making the films now began to send her messages by telepathic means. These messages tormented her and claimed that she was a dirty person with perverse thoughts. Eventually they went far enough to send her compulsive thoughts about her having intercourse with dogs. These fantasies felt totally foreign to her character and therefore she felt violently insulted by them. She wondered how many people around her knew about these slanders. Carina withdrew more and more from her friends. She did not join in with school parties but worked in her studio, workdays and holidays alike. When her friends and her mother tried to encourage her to go out, she mostly responded with anger. Nobody had realised just how serious her problems were until she called home from the hospital.

One night when Carina overheard how many people up in the attic were talking about her and criticising her paintings, she went to the police for help. She wanted to identify those who plagued her and those who left her alone. Instead of concerning themselves with her problem the police referred her to the psychiatric clinic where she agreed to be admitted.

It emerged that Carina was an only child. Her parents had divorced when she was 5 years old. During her childhood she had lived with her mother. Her father, who was an academic, had remarried and her contact with him had worsened on the birth of a new child which meant that there was now no place for Carina in his home. Several members of the father’s family had been treated for psychiatric illnesses. There had been a period when she was 16 years old when she had become dejected and had spent time pondering the existence of God. She had stopped school but with support from a child psychiatrist had been able to resume after a short while. Carina had always found it easy to make friends, who admired her artistic talent. Teachers too had given her support and she had done well at school on the whole. Apart from a short love affair, which petered out, she had never had a serious boyfriend, although she was considered attractive.

At the clinic Carina was able to feel a certain sympathy for her pursuers. This feeling disappeared quickly once she heard voices that mocked her and forced her to carry out certain meaningless rituals and movements of her body. She dared not take medication and was transferred to a ward where she was compelled to have muscular injections and antipsychotic medication. Disturbing side effects ensued in the form of painful eye movements and an inner sense of unease and restlessness. Although these symptoms could have been relieved she refused to take medication. She was given injections that had a long-term effect. After a couple of months it was possible for Carina to be discharged. Her movements and thinking were slowed down but the voices had disappeared. She did not have the energy to paint and instead took part in the hospital’s therapy. The post-hospital care took place in a psychiatric clinic. She refused point-blank to continue with her medication and was slowly able to resume her painting.

Some years later, during preparations for a students’ exhibition, she became ill again with delusions and hallucinations. This time her hospitalisation lasted longer. Carina was now able to try out newer antipsychotic medication administered in tablet form and for a considerably longer period than previously. On this occasion she experienced considerable benefits from the medication and was able, yet again, to return to her art.

On developmental regression

David had always been something of an eccentric at school. He had difficulties with sport and was considered to be awkward. His parents worked in a religious community and were open and sociable. His younger siblings found life easier and David was seen as the ‘problem child’ at home. During puberty he became attached for a while to a small-time criminal gang where hashish was smoked. This was quickly discovered and at the same time David was apprehended for raiding department stores at night. His parents reacted promptly and began to give more time to encouraging other interests in David. He was a pleasant-looking boy and easily likeable. His performance at school was average. At the age of 17 he complained that he could not sleep and his parents found him sitting up at night, sweating with anxiety, on several occasions. He didn’t know why he should, but began to wonder whether he was homosexual. He had heard people in town, in queues and on buses, saying that he was but could not remember exactly whom. He was referred to his GP who examined him in full without any positive findings and prescribed something to help him sleep. It was put down to being due to the pressures of schoolwork and a late puberty. It was assumed that he would grow out of it.

David finished school when he was given the chance to start employment at a print works as an errand boy. To begin with his state of mind improved. David seemed happy although his boss complained more and more frequently about his slowness. He did his errand work punctiliously but would sometimes find himself standing by the wayside ‘not thinking about anything in particular’. At home there was concern when David began to take less care over his appearance whereas before he had been most particular over his hygiene and about the way he dressed. He smelt of sweat and his parents and siblings had to nag him to wash his hair and change his clothes. David’s behaviour changed gradually. He dragged out his mealtimes and could find himself sitting sometimes for as long as half an hour with food in his mouth without swallowing. His father had particular difficulty in tolerating his temperament and the family centred more and more on David’s behaviour. They didn’t know whether it was a declaration of defiance or a sign of illness. There were no definite indications pointing to ‘disturbed thinking’. However he would sit and laugh to himself. When asked what it might be about he would reply with a secretive smile or would say that it was nothing in particular.

When he was 19 years old his parents again sought help and this time he was referred to a psychiatric clinic. It was not necessary to admit him to inpatient care. The family had a series of counselling sessions at home and David worked well with the help of his parents. A thorough medical and psychological investigation did not produce any definite findings. David agreed to try antipsychotic medication in the hope that it might help him. Eventually it was possible to offer him a placement with other young people who had difficulty with their psychological functioning in communal accommodation. He maintained a relationship with a couple of his old friends and started to attend a specially adapted training. Little by little the family were able to reassure themselves that David’s life had become meaningful and that he could get on.

Arteriosclerosis and confusion at night

Elizabeth was a 69-year-old widow. Her husband had died four years earlier and her two children lived some distance away. She had always been active in the church and dedicated to work in the community and in the sewing club. In recent years she had had several minor strokes which had little lasting effect save for a weakness in her right leg and a certain loss of memory.

In deteriorating winter conditions Elizabeth slipped on the road and broke her leg. Although there were no complications she was admitted to the surgical ward for safety’s sake. On the first night she was frightened and wanted to go home. The night staff managed to persuade her to stay. Around 2 am she found her way to the wastepaper basket where she tried to urinate. When a fellow patient called the night nurse they found Elizabeth in a state of complete confusion. She thought she was at home and imagined that her husband had just gone out. When they tried to help her back to bed she became furious and began to swear. Elizabeth calmed down and slowly became aware that she was in hospital when the nurse turned the light on in her room and brought her a cup of coffee with sugar. After a little she was able to allow herself to lie down and sleep.

The next day Elizabeth had only a vague recollection of the night before. She was quite lucid and her old self again. Elizabeth was soon transferred into a long-term care hospice. Here they gave her a night-light and she had photographs of her husband and children on her bedside table. In this way, she was able to orientate herself whenever she became confused at night. Added to this, she could often be tempted to join in for coffee and a chat. Some years later, Elizabeth had a fatal stroke.

On the other side of ‘the doors of perception'

The author of this book was a young medical student in the 1950s. During my course in pharmacology I came across a book by Aldous Huxley (1954), The Doors of Perception. It was about the Mexican Indian drug mescaline that was described by Huxley as able, in the most delightful way, to deepen experiences and which was, incidentally, safe and free of addictive property.

After a successful examination in pharmacology I asked my professor if he would like to join me in some research by giving me mescaline. He agreed and one Sunday a couple of weeks later at the professor’s country home, I was allowed, together with a fellow student whom I had brought along, 0.4g of pink mescaline crystals in a little water. The ensuing events were recorded. During the first three hours nothing happened and we began to wonder if the dose had been too small. Coffee was served. When I looked into the coffee dregs I suddenly saw how the colour changed. At the same time the coffee cup turned into a deep well. When my companion shut the door the noise released a clutch of small red snakes which slithered swiftly towards the edge of the cup and down into the well where they mingled with the coffee dregs, and became a confusion of red and blue balls of colour, spreading and bursting, and were replaced by more balls of fire. Every subsequent sound resulted in fascinating new explosions of colour of varying types and form.

It was clear that there had been an effect. However, I was barely able to communicate my experiences. I was convinced that the other two wanted to experiment on me and exploit my vulnerable position. I asked them to leave me for a while. When they returned I was sitting, huddled up and paralysed. I experienced – for the first time in my adult life – a powerful anxiety that only let up when I sat stiff and still and returned whenever I tried to relax. As this was happening, I lost the sense of the passing of time. An overwhelming feeling of timelessness had taken hold. However, if a wisp of cigarette smoke began to flutter in a draught of air, then time could ‘start up’ for a short while.

I experienced a growing anxiety which increased until in the end it became unendurable. It felt as though I had to give in to it to argue with the professor. I began to rag him and insisted that he had flirted with the prettiest girls on the course and that he had used his position to seduce them. I tried even further to humiliate him and ended up by calling him an immigrant and a dirty old man. The anxiety, which compelled me to throw aggressive vulgarities at a person whom I actually appreciated very much, lessened but returned with renewed strength.

The professor’s comments, which struck me as very significant, were that I might find myself troubled by my behaviour later on, but that I did not need to worry for he had been in psychoanalysis and had managed to deal with worse.

Eventually the effects wore off and after about eight hours everything returned to normal for me, even though I assured myself that I would never try mescaline again. I remember my experiences very clearly. Some months later I found myself reading another book by Aldous Huxley. This time it was Heaven and Hell published in 1956. Huxley had continued with his experiments and was now in a position to announce that mescaline was by no means an innocent joyride. It could also be a potent force for anxiety.

I came to find psychoanalysis myself later on and was able to discover a deeper understanding for my sudden attacks against my admired professor. The mescaline had loosened my inner censor and for some hours carried into the open things which I was later to meet up with and work through during a long psychoanalysis.