It’s all delusional anyway

I am a psychiatric PA.  A lot of people get confused by that title.  I am a physician assistant specialized in psychiatry.  I do the same job as a psychiatrist for much less money, and I’d like to think with a little more style!  I diagnose and treat mental illness, primarily with medication.  I have been doing this for 6 years and for half of that time I have worked with the severely, persistently, mentally-ill population.   Most of my patients have schizophrenia, bipolar disorder, substance abuse or some combination of all three.  When I tell people this, I usually get some kind of response like, “I don’t know how you do that. That seems like a really hard group to work with.”  And it is in some ways.  My patients are often dirty and smelly.  They are often high on something or coming down from something or waking up from something.  They struggle with basic tasks.  They get angry easily.  They don’t answer my questions in straight-forward ways.  Sometimes they are violent or threatening.  Sometimes they lie.  And sometimes they are honest. 

One such patient suffers from schizophrenia.  He is usually stoic with limited eye contact when he sits down in my office, but after only a moment he will start to intensely muse about Father Time and the universe and people and places that, I’m pretty sure only exist in his mind.  I’m trying to find out how he is sleeping and whether he is thinking about suicide.  I’m thinking, “Yeah, ok, Father Time… but let’s talk about the important things.” 

And he is probably thinking, “Yeah, ok, sleep…but let’s talk about the important things!” My interviews often feel like a struggle to obtain the information I want without completely dismissing, what to me is complete gibberish, but what to my patient is his pressing reality.  I’ve learned that patients get used to this dance too.  And like me, sometimes it’s frustrating but usually we just roll with it and do our best to play our parts. 

This particular meeting was different.  He started off with a bizarre statement (not so unusual), “Did you know I have AIDS but it doesn’t register?  I have it in my spirit.” 

I think, “Okay, this is how it’s going to go.”  So I look at the report that he completed in the lobby.  It’s called a Common Ground report and it gives the patient a Likert scale to rate various symptoms.  Sometimes psychiatric patients (and really all patients) have a hard time relating their symptoms to their healthcare provider so this is meant to ease the process.  He marked that he was not doing so well at fulfilling responsibilities so I ask him about it. 

“I have trouble remembering to go on walks, wash my plate and the table cloth, and flush the toilet because I spend a lot of time nervous and confused.” The honesty of this statement strikes me.  He continues, “It’s confusing that I know how to understand what I’m going through and still be able to take the pain that I’m going through.”

Heart wrenching. 

This man stabbed himself in the arm a while back in response to some delusional belief.  It became infected but no one noticed and his arm eventually had to be amputated due to the infection.  “Is the pain physical or emotional?” I asked. 

“Emotional,” he replied.

I saw his pain in that moment.  He is living in two worlds, maybe more.  For a moment, he visited me in my reality, but there is pain there so he quickly wandered back into the land of “Mother Nature”, “Father Time” and “alternate universes.” 

This is a dramatic example—and, speaking from the front lines, mental illness is real—but we all get to choose our reality.  Life happens in the mind.  Ultimately, our experiences hold the meaning that we assign to them.  So be intentional with your narrative, friends.  You get to decide if it is a tragedy or the hero’s journey.  You choose the delusion and make it your reality…choose wisely.