2007年12月14日星期五

When Delusions Aren't So Delusional

Occasionally, I work with our psychiatry consultation service. When physicians throughout our hospital need help evaluating and caring for patients with psychiatric symptoms, we're the team they call.
These patients may be confused, depressed, agitated, or manic. Some have longstanding psychiatric disorders and others have new, temporary symptoms. Sometimes our contribution is simply to confirm that someone does not have a psychiatric disorder.
One recent morning, I was called to see a male patient because his medical team thought he might have schizophrenia or bipolar disorder. He was an older gentleman with serious medical problems, but was quite exuberant and talkative.
He excitedly described an extraordinary and unbelievable network of international intrigue linking major historical events over the past few decades. He outlined endless details of deception, cover-ups, covert operations, and conspiracies at the highest levels. It seemed to his doctors that he must have been delusional.
Was he psychotic in firmly believing all of these outrageous and impossible claims? Not at all. A delusion is a fixed, false belief. Nothing I could say would ever dissuade him from his view of reality. To be delusional, the beliefs must be idiosyncratic - that is, unique to that person. Yet all of this gentleman's claims are shared by many like-minded people who connect through the Internet.
He's part of a subculture that thrives on distrust and conspiracy theory. Although his wild beliefs and convictions may be entirely wrong, he is neither delusional nor psychotic. There was no reason to suspect a psychiatric disorder like schizophrenia or bipolar disorder.
But did this man's unusual behavior fit the criteria for another mental disorder? As we talked, he clearly expressed paranoid thoughts. For instance, he assumed that the FBI or Secret Service had sent me to evaluate him. Did he suffer from a paranoid personality disorder?
He did meet the requirements for a diagnosis of general personality disorder; that is, he had "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture." That may include "ways of perceiving and interpreting self, other people, and events." But to have a personality disorder, the personality pattern must also lead to significant distress or impairment. That part wasn't true for this man.
It is true that this patient has a paranoid personality style, which means that he tends to view situations suspiciously and anticipates being exploited. However, these are enduring personality characteristics, not traits that developed suddenly. And they do not represent a diagnosis. In fact, many highly successful people have this type of personality style.
I concluded that this patient had no psychiatric diagnosis, although he did express unusual and seemingly unbelievable beliefs. But so do a lot of people.

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