The Unreal World

My favorite population to work with is the very chronically mentally ill, especially very psychotic patients. They are frequently misunderstood, isolated and rejected by their families and friends. Their lives can be a very lonely and sad one of lost dreams and little hope for the future. With the emergence of newer antipsychotic medication, there has been more hope for these patients, and their prognoses have been much improved but there is still quite a way to go before we can truly say we have fully controlled these conditions. They are by far the most interesting people to work with and their behaviors, although bizarre to the outside world are not that hard to understand if one understands why they do what they do. Despite this, some of what they say is still fairly comical.

A patient we have been dealing with has refused to accept her diagnosis and will stop her medication after discharge from the hospital invariably. Despite this, she functions and manages to survive until her behavior becomes simply too strange for the neighbors to tolerate and she is dragged in on an involuntary commitment. We repeat the cycle of resuming medication to clear her just enough that she makes some sense and send her home and the whole thing repeats. She is most noted for having what is called disorganized thoughts. She denies hearing voices, although it is clear she does, but her biggest problem is her inability to communicate in a coherent manner. Today she accused me of being a women who she believes has been tormenting her for years, pretends to have many jobs and aliases, the most memorable of which was "Ringbo Money Money Monkey Potato Gun." It took everything within me not to break out in laughter. It is very bad form to laugh at your patient when he/she is not trying to be funny. My contract is in the process of being renewed and I am pretty sure the hospital is not going to be willing to change my name to Dr. Ringbo Money Money Monkey Potato Gun. It will not fit on my ID tag for certain.

Disordered thinking is something that is hard to fully appreciate unless one has actually heard it in person. It is noted by rather nonsensical rambling, often where the patient will jump from one topic to the next in the same sentence and tie unrelated ideas together through words. Sometimes they will talk in rhyme, known as clang associations. They often do not make much sense until you get to know them, but once you do, you start to understand as least some of what they are talking about, usually by knowing what is concerning to them in life. Many people will never encounter this in person as so many psychotic patients tend to isolate and do not socialize often.

Most people have encountered people talking to themselves, though. Not just those that are frustrated and grumbling, those that are carrying on full conversations. Comedians make jokes about pairing them up so they have someone to look like they are conversing with. People cross the street and shelter their children from these people. They are quite misunderstood. Most of the time, these people are totally harmless and would be happy to carry on a conversation with you if you were to approach them. In truth, they are not talking to themselves. They are talking to someone else, or maybe many people, but the outsider just cannot see them. Most of the time they cannot, either. But the voices are very real sounding to them and are very much a part of their reality. Often it is not very fruitful to ask a patient if they are hearing voices because "hearing voices" implies one is hallucinating, and the patient does not view the experience as a hallucination. I have found it useful to ask if they hear the neighbors through the walls, people walking outside of their homes, or in the distance. Often they believe they are reading other people's thoughts. If someone is truly hearing voices (as opposed to those who claim this for personal gain) they believe the voices are real and it is not uncommon for them to talk back to the voices, hence the people who talk to themselves. Some know enough to go in private to have a conversation, so do not. Even those who do not openly talk with their voices are often preoccupied and looking around at other parts of the room when they are being talked with. They cannot tell where the voice is coming from, whether the interviewer, the invisible voices, or another person in the room. So they are looking around to find the source.


It is how a psychotic patient deals with the voices that can sometimes be rather amusing. It is not that we spend out days making fun of our patients but when a patient is standing in the hall talking to the fire extinguisher much of the day, one must admit that this behavior is comical. Some can get into pretty heated arguments with the voices, even threatening violence, yielding knives, etc. Sometimes they just look over and talk to the air. Commonly they whisper to themselves, sometimes mid sentence during a discussion with another person.

Treating for this population has gotten much better than in previous generations, and some have reported near total relief of their symptoms, or at least a dulling enough to be able to return to regular function. It is gratifying to be able to offer options that can actually give these patients the hopes of some degree of normalcy. Most will never be able to get married, have a FT job, raise a family, etc, but the days of being locked away in a run down state hospital for years is long gone. Many people are able to have friends and live independently. It is nice to see that and give people some of the life they lost back.