On Perceptions

Delusions and hallucinations have been something that always puzzled me.

A delusion can be defined as “a fixed false belief that is resistant to reasoning with actual facts”, whereas a hallucination can be defined as “a distortion in a person’s perception of reality”.

For the past two weeks, I’ve been encountering patients who have delusions and hallucinations. For delusions, the puzzling thing is that I don’t understand how any person can have such conviction in their beliefs about something, that almost anyone can see is absurd. But then again, I guess with psychiatric illnesses, such distortion of realities is something that those unwell experience. It’s something that I’ve never experienced before, so I don’t know what it’s like to have such absurdly false beliefs.

The other day for instance, one of the patients (let’s call him Mr A) was seen shadow boxing in the courtyard. When asked about his actions, Mr A explained that he was practicing boxing, because he believed (a delusion) that a “fat man” will be coming in a helicopter to have a fight with him, and if the “fat man” loses, he’ll take Mr A’s spot in the hospital, while Mr A himself can take the helicopter to escape from the hospital.

In dealing with such patients, my consultant gave me a very important word of advice; rather than dismissing or directly challenging such delusions, we should neither accept or dismiss their delusions, but ask them about it. It was explained to me, that the patient lives in a reality completely different to the treating doctor, and any pertubation of such reality by challenging or dismissing it, could possibly lead the patient to close themĀ  self off, or destroy the rapport already built. In a way, it reminds me of a physics principle known as the “observer effect” which asserts that in trying to measure an event or outcome, the measurement itself has the potential to disrupt such an event or outcome.

What the patient believed seemed like absolute reality to him, enough for him to do some shadow boxing in preparation for the supposed “fat man” fight. I pondered about Mr A’s reaction to the non-event of the “fat man” turning up for a fight. Would Mr A think to himself that maybe his belief was wrong? Would Mr A continue to have further delusions that would feed into his primary belief, (for instance, the “fat man” was training as well, so would come in a few days time)? I suspect that it’s more likely the latter option that Mr A would continue the line of thinking for.

I don’t live in Mr A’s reality, so his belief seems absurd to me. He would probably contend that I’m absurd to point out that these are delusions, and that he is unwell with a psychiatric illness, for indeed his illness has probably affected his insight into his illness.

In a way however, I think I have my own delusions at times. There have been times I thought that I would make a fatal error in judgement, and that the medical governing bodies will come and deregister my medical registration. Well, it’s not as much a delusion, as it is probably negative thinking, and a lack of self esteem and confidence on my part.

What I’ve learned from patient’s like Mr A, is that to me and other doctors and health professionals, a psychiatric patient’s delusions are completely absurd. But to them and their reality, they live in a different reality where it makes sense to them, just as much as it makes sense for us to believe that the sun would come up the very next morning after night time.

On many levels, psychiatry in a way is like the movie Shutter Island (if you haven’t seen it, I recommend watching it). Reality can seem to be so engrained to a patient, that they seem to have a distorted reality in which everything to them makes sense and seems normal, whereas to other people, it is highly abnormal.