(Greg has given me
permission to tell his story on my blog.)
Greg is one of the
people on my case list. I’ve been seeing him for about two years.
Greg is in his 50’s.
For the last 40 years, he has been experiencing vivid and terrifying visual and
auditory hallucinations. However, he has been under the radar of secondary
mental health services for most of that time. That is, until 2 years ago, when
he stabbed himself and was admitted to a medical ward.
Why did he stab
himself? Because he could no longer tolerate his hallucinations. He would have
spells, sometimes lasting days, sometimes just a few hours, of exceptionally
vivid hallucinations, when he could both hear and see a number of menacing men,
who would threaten to kill him in horrible ways. Most of the time, these
figures would stand outside his window, looking in at him. Sometimes, they insinuate
themselves into his house.
So one day, after a
number of hours of enduring the threats and taunts of these figures, who were
telling him they were going to burn him alive like The Wicker Man, he decided
that the only way of escaping this awful fate was by killing himself. So he
went into the kitchen, inserted a knife into his ribcage, and leaned against
the wall, using his weight to push the knife deep inside.
Fortunately, his wife
found him in time, called an ambulance, and was able to get him to hospital.
But although they were
able to patched Greg up and saved his life, he was still experiencing the
hallucinations, and the ward appropriately asked for a psychiatric assessment.
It nearly unravelled
at that point. This is because Greg had been self medicating with alcohol for
many years. The psychiatrist who assessed him noted his history, diagnosed
alcoholic hallucinosis, and decided that no further involvement was necessary
from mental health services.
When he was
discharged, however, his supportive GP made a referral to the Community Mental
Health Team. I started to look through his records, such as they were. This is
when I found that he had had a brief psychiatric admission 15 years previously.
And unfortunately his history of alcohol use was held against him, and he was
discharged with no follow up.
I discovered that Greg
had actually stopped drinking completely a few months before he stabbed
himself. But there had been no reduction in his experience of hallucinations. So
alcohol abuse could not have been the cause. Speaking to Greg, it became clear
that he had been using alcohol in an attempt to manage the hallucinations,
rather than the hallucinations being a consequence of his alcohol use.
I was allocated as his
care coordinator, and the team psychiatrist prescribed him an antipsychotic.
I began to visit Greg
regularly, and got to know him well.
Greg is a fiercely
intelligent man, who despite suffering from these tormenting hallucinations,
succeeded in a variety of jobs, ranging from car salesman, to wine merchant, to
a care worker rehabilitating offenders. He is very creative, and had at one
point won £5000 in a national poetry competition. But since the breakdown that
precipitated his hospital admission 15 years previously, he had not worked.
It was hard to know
what to make of his hallucinations. They were exceptionally vivid, but Greg did
not present with other symptoms of psychosis. He also had full insight – he
knew that the voices and images weren’t real, although that did not reduce the
horror for him. Neither did the hallucinations appear to be depressive in
origin.
So it was difficult to
make a formal diagnosis of schizophrenia, and it was also difficult to diagnose
psychotic depression.
Greg revealed that he
had been sexually abused by a teacher when he was a child. Did this give a
clue? Hallucinations, often very vivid, can certainly be a feature of
Borderline Personality Disorder. But these hallucinations usually centre around
hearing or seeing the abuser, and again the nature of Greg’s hallucinations did
not fit this formulation.
Whatever the origin,
the antipsychotic he was taking, while taking the edge off these experiences,
did not stop them occurring.
One day, Greg
described having a sense of when the hallucinations were going to begin. The
quality of the light changed, and he always smelled coffee.
Could this be a clue?
Could Greg be describing the aura some people experience immediately prior to
having a seizure? Could Greg have a neurological disorder, such as temporal
lobe epilepsy?
There were other clues.
One day, I took a detailed life history from him. Greg described a life of transience,
moving frequently, and never staying in the same job for more than a year or
so. He also said that he always threw himself completely into any job he took,
aiming to be the best he could, but getting bored quickly. He also described
long periods when he would be intensely active and creative. I had also become
aware of occasions when I visited when he would be calm, polite and friendly,
while at other times he would be agitated and extremely irritable.
Could Greg have a mood
disorder, such as bipolar affective disorder?
Greg had an EEG, but
this was inconclusive. Nevertheless, the psychiatrist decided to prescribe
carbamazepine, which is both a mood stabiliser and anticonvulsant.
Although here was no
immediate change, over a period of months, the intensity and duration of Greg’s
hallucinations reduced markedly. At the same time, his mood became much more
stable, and he was always cheerful and affable during my visits.
I discussed with him
ways in which he might manage the hallucinatory episodes. The commonest
hallucination was seeing people peering in through his living room window. He
did not have any curtains on this window. I asked him if it might help if he
put a blind on the window, so that he could shut the images out.
He tried this simple
expedient, and reported delightedly the next time I saw him that it had worked!
If he begins to see anything outside, he closes the blind, and although he can
then still hear voices, the intensity is much more manageable.
With these
improvements, his creativity returned. He began to write poetry again. This
poetry was accepted and published in a range of poetry magazines. He began to write
a children’s book. When he finished it and sent it to a publisher, it was
accepted and published.
Writing serves two
purposes for him. He found that the act of writing could distract him
sufficiently from the hallucinations that he could exclude them entirely from
his awareness. He therefore took to writing if he was ever troubled by the
voices or images. The success he achieved in writing also improved his self
esteem, and provided a shape to his day. He began to look forward to getting up
in the morning, so that he could get on with his writing.
In order to prepare
himself for his writing day, he spontaneously began jogging first thing in the
morning. This improved his fitness, and set him up for the rest of the day.
From being adrift in a
sea of hopelessness, with no motivation to do anything, and dreading the day
ahead, Greg now has days full of anticipation and achievement.
I do not know to what
extent Greg’s improvement is due to the change in his medication, and what is
due to my regular visits and support. I suspect it is a combination of the two.
I also still do not know what diagnostic label to give Greg.
Which is probably just as well. Greg after all is a person first. The important thing is that, with some assistance from mental health services, who are at last supporting him rather than ignoring him, Greg is leading a life full of meaning and enjoyment. He no longer thinks about killing himself. His “symptoms” have not gone away completely, but Greg now knows how to accommodate them within his life rather than them being his life.
I would recommend a book by Oliver Sacks called Hallucinations - it is a really interesting book on all the different experiences we might have of hallucinations that are not connected to psychosis, e.g. hallucinations through neurological disorders such as epilepsy. I have sometimes wondered if people might get misdiagnosed with something like schizophrenia, when actually it is something else.
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