May 13, 2008
CASES
In Delusions of Romance, Genuine Comfort
By ELISSA ELY, M.D.
She was never on time to clinic appointments. Leaving her apartment was not simple when it required pushing aside the furniture she had pushed against the front door the night before, and even the furniture was no protection against the threats she perceived.
She said strange men burrowed into the apartment after dark, right through the door, the chest of drawers and the armchairs. They entered her body, and then they ate her up from the inside.
It took years before she told us this. We might doubt her, but she knew it happened. Numerous expensive antipsychotics made no difference at all.
She smoked heavily, partly from anxiety and partly because, like many chronically institutionalized patients, she had been bribed into placidity with cigarettes years earlier. Before her first psychotic break, she had been a singer. Smoking was not good for her voice, of course, but under these harrowing circumstances, quitting was impossible.
A few days after an appointment at which she had looked even wearier than usual, she collapsed. In the emergency room, her blood sodium was low. The medical resident decided it was from her psychiatric medication; he discontinued some, decreased others and sent her home.
Three months later, while defensively moving furniture, she had a seizure. Back in the hospital, she still had low sodium, but a scan showed diffuse lung cancer, metastatic to bones and brain. Her problem was not a result of psychiatric medications.
She refused to acknowledge her cancer, but she demanded that everything reasonable and unreasonable be done for the illness she insisted did not exist. When she grew too weak from chemotherapy and radiation to live alone — much less move the furniture — she was transferred to a rehabilitation facility. The consultant there stopped all of her medications except for a low dose of a single antipsychotic. In his view, the drugs increased her fatigue from the medical therapies. In our view, he might as well have been treating a raging pneumonia with a vitamin.
Two months before she died, she came to see us. She arrived in a wheelchair, unable to walk from metastatic fractures, wearing a stylish bandanna. She was hard to recognize physically, and almost impossible to recognize mentally. She was rational, brisk and organized. She told us she had decided to stop the chemotherapy and radiation. “It’s cancer; there’s no cure,” she said, as I recall. She was lucid as could be, on almost no medication at all, with not one molecule of paranoia or a single misconception. We were the ones confused. We were astounded.
Then she told us something else astounding. Love had come into her life.
During the last few M.R.I.’s that tracked the progress of her tumors, a radiology technician had given her headphones to pass the time. Jazz began to play, and then each time, in the M.R.I. tube, a famous singer appeared in the dark.
She recognized him immediately. “I can’t tell you who he is,” she said, modestly, “because he’s married.” Still, she couldn’t keep good news to herself. “He was singing love songs to me,” she said, “and I sang them back to him.”
She had a look of demure joy, recalling the married Frank or Dean (she couldn’t tell us who) crooning to her over the M.R.I. machine. Against all spatial reality, they lay together, singing. “It was very nice,” she said. We might doubt her, but she knew it had happened.
She had underestimated us. We would not have dreamed of questioning her. If there is anything fair about psychosis (and there is not), this was the least schizophrenia owed her. Her delusions, unremittingly ugly, had suddenly grown beautiful. In the end, the psychosis was her friend.
Elissa Ely is a psychiatrist in Boston.
She said strange men burrowed into the apartment after dark, right through the door, the chest of drawers and the armchairs. They entered her body, and then they ate her up from the inside.
It took years before she told us this. We might doubt her, but she knew it happened. Numerous expensive antipsychotics made no difference at all.
She smoked heavily, partly from anxiety and partly because, like many chronically institutionalized patients, she had been bribed into placidity with cigarettes years earlier. Before her first psychotic break, she had been a singer. Smoking was not good for her voice, of course, but under these harrowing circumstances, quitting was impossible.
A few days after an appointment at which she had looked even wearier than usual, she collapsed. In the emergency room, her blood sodium was low. The medical resident decided it was from her psychiatric medication; he discontinued some, decreased others and sent her home.
Three months later, while defensively moving furniture, she had a seizure. Back in the hospital, she still had low sodium, but a scan showed diffuse lung cancer, metastatic to bones and brain. Her problem was not a result of psychiatric medications.
She refused to acknowledge her cancer, but she demanded that everything reasonable and unreasonable be done for the illness she insisted did not exist. When she grew too weak from chemotherapy and radiation to live alone — much less move the furniture — she was transferred to a rehabilitation facility. The consultant there stopped all of her medications except for a low dose of a single antipsychotic. In his view, the drugs increased her fatigue from the medical therapies. In our view, he might as well have been treating a raging pneumonia with a vitamin.
Two months before she died, she came to see us. She arrived in a wheelchair, unable to walk from metastatic fractures, wearing a stylish bandanna. She was hard to recognize physically, and almost impossible to recognize mentally. She was rational, brisk and organized. She told us she had decided to stop the chemotherapy and radiation. “It’s cancer; there’s no cure,” she said, as I recall. She was lucid as could be, on almost no medication at all, with not one molecule of paranoia or a single misconception. We were the ones confused. We were astounded.
Then she told us something else astounding. Love had come into her life.
During the last few M.R.I.’s that tracked the progress of her tumors, a radiology technician had given her headphones to pass the time. Jazz began to play, and then each time, in the M.R.I. tube, a famous singer appeared in the dark.
She recognized him immediately. “I can’t tell you who he is,” she said, modestly, “because he’s married.” Still, she couldn’t keep good news to herself. “He was singing love songs to me,” she said, “and I sang them back to him.”
She had a look of demure joy, recalling the married Frank or Dean (she couldn’t tell us who) crooning to her over the M.R.I. machine. Against all spatial reality, they lay together, singing. “It was very nice,” she said. We might doubt her, but she knew it had happened.
She had underestimated us. We would not have dreamed of questioning her. If there is anything fair about psychosis (and there is not), this was the least schizophrenia owed her. Her delusions, unremittingly ugly, had suddenly grown beautiful. In the end, the psychosis was her friend.
Elissa Ely is a psychiatrist in Boston.
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