Brave strange brain: Mr B.

Mr B comes to the consultation with this glazed look of barely being there, as if there is a thick glass sheltering him from reality. And that is probably what he hopes for, because his reality is not a pleasing one.
Mr B has the monotone, almost robotic tone you often recognize in people suffering from the same affections, the great and frightening potpourri we call psychotic disorders. He says a few words, but has learned not to say more than that: people don’t believe him.
Mr B has come from Russia many years ago, but it is impossible to know what he has lived there, his past is a shut door – maybe even for himself.
Mr B suffers from paranoid schizophrenia.

He lives in a small studio apartment, in an institution, but they have started to complain. Not that he is aggressive. As it is often the case with people suffering from psychosis, he is more likely to be the victim of an abuse than the perpetrator of one. He is afraid of people, so he avoids contact with them. He would never hurt one.
But he is convinced that he has once seen a cryptic message in a newspaper concerning him, that could help him understand exactly why the KGB – or some other spy organization, it is never really clear and it is shifting, the only certainty remaining is that someone is after him. So he is persuaded to have seen one time, months ago, in a newspaper in a language he doesn’t speak, a clue about why he is being persecuted. And therefore, he keeps every newspaper he comes across.
His small studio is filled with them. There are piles in the shower, so he cannot shower anymore. There are piles on the kitchen table and on the oven, so he has stopped cooking – he never cooked much anyway: he doesn’t trust  the food you can buy that hasn’t been sealed: you never know if it might not have been poisoned. He eats raw eggs, because who could put a poison in an egg without breaking its’ shell?
He doesn’t go out a lot: too many spies, too many people, and in any case, he has to sort through those papers. At the rate he is going, it will probably take him years – and he keeps collecting them.
He lives in a constant state of anxiety and hyper-awareness.
Despite all this, he is still capable of a coherent speech. He is capable of making decisions for himself, like the decision that he doesn’t want more medication. He is on a very low dose of antipsychotic drugs, that clearly aren’t enough to help even taper the paranoid delusions he experiences, but he is not in acute danger – that is, as long as he still manages to eat and shower outside – he has a right to choose, and he is capable of organizing his days.
The last time I saw him in a consultation, we were discussing his anxiety – of course he doesn’t call it that, or very rarely, it is very difficult for him to express emotions, and I had just begun the classic trick of summarizing everything he had told me that made him anxious or uncomfortable and then linking them with the “we have different possibilities to help you, one of them being – but that is your choice – medication”, when some of the security service personnel for the supermarket just next door passed in front of the window in my office, and one of them took a picture of the tree (?) just outside.
That was the undoing, as Mr B. jumped from his seat and said “do you see, they are always after me”. And, as delusions go, you can try – and even if I know this, I sometimes can’t help the reflex of indeed trying, to put those into question: “Do you really think they were taking pictures of you, rather than the tree?” But it is no help. Everything he lives is interpreted in the sense of his delusions, and they are, by definition, impervious to criticism. So we were, once again, stuck, and had to start building a difficulty earned trust again, so that he might still come back to the consultation after this, and not be even more isolated.
Afterwards, I was fuming against weird coincidences of people stopping by my windows just when I am with a paranoid patient (what was on that tree, seriously, it is the most boring view you could imagine – ok that may be because I’ve stared at it everyday), and joking with my colleagues about the fact that I could well be developing delusions of persecution myself, or that M B was right, because, as you’ll notice when working in a hospital for long enough, there is nothing you won’t joke about, sometimes it is how you survive through the day. But mostly I was struck once again by how much suffering it must cause, to live in this world of paranoia. We tend to forget it slightly I think, when facing psychotic patients more than people suffering from depression or anxiety disorders, because the former are often – but not always – not as well able to express their emotions, so we sometimes assume it doesn’t distress them as much as if a “normal” (for that is how our brain simplifies it) person had to endure it. The truth is, we don’t know. What is certain is that an emotion does not need to be expressed – or even conscious – to be present. And there is the absolute necessity, then, to always assume that this kind of reality, Mr B’s, is constant suffering on a scale I can probably not imagine.
Anyway, this is not a lecture about schizophrenia – there would be a lot more to say, and I am far from an expert – and indeed what I feel the most important generality about schizophrenia, is , once again, that there are very few generalities you can make – I was just thinking about the number of people who live with a delusional disorder of some sort, and how fascinating it is that our brain may fabricate complex tales of persecution and mould reality around it, rather than the opposite.
I suppose you could say it has something to do with the general human impulse of always searching for a sense, a link, our refusal to see things as random, but rather seek the connection. I marvel at how relative the concept of reality, of rationality is. But mostly, I know that, even if I cannot know what exactly Mr B or indeed anyone whose discourse is so disintegrated and delusional is feeling, I can always try harder to understand, and to see the fellow human behind the paranoid schizophrenic. That, in the end, is what is real.
Daalbhat2 227

A picture that has nothing to do with the article – or is it maybe a illustration of the relativity of the concept of the reality of trees?? – kidding, I’m not that much of a pedantic bore – it is just an interesting picture of a tree that has eaten a Nepalese temple, you’ve earned it after reading this till the end!


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