When is a delusion not delusional?

[OldPsychDoc]

So we have a 70-some year old lady on the unit--no colateral and not much frontal lobe function. Nice enough, not thoroughly demented, but perseverative as all get out, will NOT stop talking about this and that project, community stuff she's done, celebrities she claims to have known, her friend who's a state senator, and on and on and on....

This morning in report, we're told that pt is telling everyone that "Senator B" is coming to visit between 10 and 11. Everybody is dismissing it, even making fun a little--she'd made the same claim yesterday. At 1030, I walk through the dayroom and see the patient with a casually dressed middle-aged female visitor. Stop by to check on her..."Hi Doctor, this is Senator B!" Sure enough...patient worked on campaigns long ago. It was a treat for me to have a prominent state legislator on my unit to see us in action (hopefully she'll keep us in mind next budget session!), and to see her support and advocate for her friend. But anyhow--you can't just dismiss every "crazy" delusion, can you?

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[Manicsleep]

Where was the family in all of this?

 

[loveoforganic]

 

[whopper]

sometime perhaps 10-20 years from now a lot of the techno-paranoia delusions that are not possible these days will be.

E.g. someone believing they have a microscopic chip implanted in them that is tracking them and giving them messages.

When that happens, how much work will we psychiatrists have to do to figure out if they person is in fact delusional?

I've already had a patient that for real had a device implanted in him and it was giving messages to a "central computer." The device was placed in for medical purposes. Most psychiatrists would've simply blown off this guy as delusional but he in fact did have such a device. It turned out he was delusional but based on other data.

Funny--because that's why he was hospitalized in the first place. Turns out the psychiatrist in the ER did the right thing for the wrong reason. That doctor heard about the device and immediately ordered the guy for hold and hospitalization.

 

[OldPsychDoc]

Where was the family in all of this?

I do not understand your question.
"Family"?
What is this entity of which you speak?

(Seriously--if there was any, the admit probably would never have happened...)

 

[heyjack70]

Martha Mitchell Effect: http://en.wikipedia.org/wiki/Martha_Mitchell_effect


A little uncertainty in psychiatry is what keeps things interesting I think.

 

[kugel]

We had a man come in with all the signs of mania, severely disorganized and he'd done something overtly dangerous. In his pressured speech and demanding manner, he told us that the FBI follows him everywhere he goes because he used to work for the CIA. So the FBI follows him in order to assure that "state secrets" don't fall into the wrong hands. "Because everyone knows the CIA isn't allowed to work inside the US borders."

The next day, two FBI agents showed up, stating, "We know he arrived yesterday. We know you can't confirm or deny if he's here. We've been through this before. Please take him this Consent to Release Information form and ask him to sign so that the hospital can notify us upon discharge. He used to work for the CIA but his mental illness forced his separation, so now we have to keep track of him so that his information doesn't fall into foreign hands." The patient was all too happy to sign, since it confirmed how important he is.

Sometimes there are gangmembers after our patients.
Sometimes they have important connections.
Sometimes they are enormously wealthy.
If the claims are physically possible, I chart them as "probably delusional" or "possible delusions" until we can know for sure.

My primary question is whether I would detain this person even if the claims are verified. If several family members call and state his claims are all true, what would I do? Does he require a locked door today? If the answer is that he is still too dangerous to self/others, or won't utilize food/shelter even if someone provides it for him because of his mental state - then the answer is clear and so is my conscience.

But it sure is fun to ask students, "What do we do if it's all true?"

 

[whopper]

About on the order of at least once every six months, usually a handful of times a year, when in residency, I got someone who fit the Martha Mitchell effect. I didn't know there was a term for it until I was reading about Watergate. I had never seen the term coined in any mental health source of information, but IMHO, it's something that needs to be emphasized.

Where I work now, I pretty much never see this because in a long term facility, a person had to go through multiple layers before they end up there. In the ER and a short term care facility? I got this to the point where IMHO it warrants double checking into anything that could be possible even if it sounds outlandish.

I had some very interesting cases. I had one where we had a Paris Hilton type--who although not famous, did know several rich and famous people. While she was in the hospital, he kept yelling "Do you know who I am? You better not mess with me!!!," while she cited several famous celebrities and powerful people she knew. The ER staff medicated her, she was knocked out, woke up in the psychiatry unit and when the social workers looked into it, everything she said was true.

A problem with that was when I asked staff to look into collateral information, I often got resistance. Of course as an attending, they'd do what I'd say, but as a resident, staff members did not want to spend an extra 5 minutes of work when the odds that the call would reveal a Martha Mitchell effect were low.

 

[st2205]

Has anyone ever seen Bowfinger?

 

[Apollyon]

When I was in the Caribbean, there was a guy in the mental hospital (such as it was) who said that his brother was some government minister. He was. In those banana republics, the guy selling t-shirts and drugs on the beach during the day, and thieving at night, may indeed be the Prime Minister's cousin.

Occam's Razor - you have to consider that the too-fantastic-to-be-true story, at it's most simple, is true. It's just more interesting seeing it in the US, with almost 300 million people (vs 100K on an island).

I also remember a patient in a state hospital back in the 90s when I was an EMT. He says, "I'm Dr. James (whatever). I have a PhD in Economics from the University of Pennsylvania. I have the cure for AIDS and other diseases". He was wearing orange scrubs and rubber gloves, and had a very closely cut haircut, but not actually bald. The case worker said that he indeed had a PhD in Econ from Penn, and had a psychotic break from work one day. The CW said that the guy was, indeed, really intelligent, and was one of his closest friends at work.

(Name and educational institution changed for privacy.)