Slipping into psychosis: living in the prodrome (part 1, originally 5 January 2011)

(I am republishing ‘legacy content’ from our PLOS Neuroanthropology weblog, which has been taken down, along with many of the other founding PLOS Blogs. Some of these, I am putting up because I teach with them. If you have any requests, don’t hesitate to email me at: greg.downey @ mq (dot) edu (dot) au. I suspect many of the links in this piece will be broken, but I will endeavour to try to slowly rebuild this content. I originally published this on 5 January 2011. Part 2 is here: Delusions, odd and common: Living in the prodrome, part 2 (originally 10 January 2011).

How might it feel to sense your own sanity eroding? Would you realize it? How might you sift the phantoms from physical reality, daydream from delusion, the irrefutable from the implausible? Or, as author Rachel Aviv puts it,

When does a strong idea take on a pathological flavor? How does a metaphysical crisis morph into a medical one? At what point does our interpretation of the world become so fixed that it no longer matters “what almost everyone else believes” [part of the definition of ‘delusion’ in the DSM]? Even William James admitted that he struggled to distinguish a schizophrenic break from a mystical experience. (Aviv 2010: 37)

Aviv wrote in the December issue of Harper’s MagazineWhich way madness lies: Can psychosis be prevented? (UPDATED: The original is now locked, but you can download a pdf of the story here. Thanks, Deidre!)  As Aviv told me in an email, the story arose, in part, out of following young patients at clinics who might be in the prodrome to psychosis, the early stages of experiencing intermittent breaks from shared reality that might lead up to schizophrenia.  Based on interviews with patients and clinicians, Aviv explores how both seek to cope with the warning signs that someone may be sliding toward a definitive break, or ‘conversion’ as it is termed in psychiatry, bolstering the individual’s sense of self and reality against corrosion.

The piece is a powerful, troubling, and thought-provoking read.  Aviv explains:

It is impossible to predict the precise moment when a person has embarked on a path toward madness, since there is no quantifiable point at which healthy thoughts become insane. It is only in retrospect that the prelude to psychosis can be diagnosed with certainty.  (36)

What I particularly appreciate about Aviv’s account is that she writes extensively about the nature of the delusions themselves, about the flow of delusional ideas, their relation to the collapse of a clear sense of self, and the challenges facing an individual who begins to feel the implausible welling up in everyday reality.  She writes that much of psychiatry has tried to get around the specificities of the delusions — Who’s putting thoughts in your head?  How are you being watched?  What sort of ghosts or angels or aliens are following you?

Patients and some clinicians alike have a vested interest in discrediting the content of delusions, dismissing the ideas as errant chemicals or glitches in brain function.  But as Aviv so clearly demonstrates, the specificities of the delusions are both what the patients struggle with daily and the source of the leverage that some of them find to fight off further drift into idiosyncratic worlds.  The delusions matter, both because patients search in them for signs of their truth or unreality, but also because the details of the delusion, not just the fact of having them, arise from our shared reality.

Continue reading