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Thinking in psychosis

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VOL: 96, ISSUE: 44, PAGE NO: 42

Peter Chadwick, PhD, BSc, C.Psychol, lectures in psychology at Birkbeck College, London, and the Open University

Peter Chadwick, PhD, BSc, C.Psychol, lectures in psychology at Birkbeck College, London, and the Open University

Faced with a newly admitted psychotic patient, any nurse is liable to feel apprehensive. How do they think? What kinds of thoughts go through their heads? What is the best way to behave towards them? Knowing the main features of psychotic thought can help to make these patients seem less strange and more approachable.

People with a diagnosis of psychosis have difficulty controlling their own thoughts. They have difficulty discriminating reality from fantasy and seem to have problems cognitively taking account of other people's perspectives although, at the level of feelings, they can be very empathic. These features have been identified over the years through experimental research with people experiencing psychosis. But what are the main problems of practical significance to the nurse?

The first thing to recognise with such patients is that psychotic thoughts are an attempt to find meanings. Everything going on around the person, when they are in an acute state, is loaded with significance - usually of a kind that relates to their delusions. Because of this, short cryptic remarks that could be taken any number of ways are best avoided. For example, one man in distress was told by his social worker: 'We've got to get you out of this state,' which he took to mean that people were going to get him out of town. When I was psychotic myself, in 1979, one nurse said to me: 'We always succeed.' Another, entering my side ward, said: 'Don't come in here if you're not good looking.' Both of these short remarks prompted agonies of rumination as I wondered what they could possibly mean.

Because of this heightened sensitivity, a nurse needs to avoid vagueness and ambiguity. What is healing to a psychotic patient is certainty, clarity and unambiguity. Speech that is several sentences long in delivery is less ambiguous; people who are upfront, direct, clear and distinct are liable to be more trusted and less liable to set off chains of associative meanderings in the patient. When you say something, it needs to mean just what you say and nothing else. No nurse can be sure that a patient won't get the wrong end of the stick when spoken to but it is worth striving for the ideal of clarity and unambiguity.

Another bias that psychotic patients have, particularly young ones, is a tendency to overly spectacular interpretation. For example, when I was psychotic I thought glistening moisture on the ceiling of my side ward represented the souls of the dead looking down on me. A fellow patient thought that all the staff were secretly detectives.

In psychosis, everything seems larger than life, as if the person is trying to extract from life more than it really has to offer. It is worthwhile working against this bias in patients and encouraging them to recognise the mundane when it occurs.

Patients also have a tendency to jump to conclusions, as well as holding on to ideas on the basis of very slender evidence. However, if they are challenged they can use contradictory evidence and change their beliefs. It is quite wrong to think that it is useless arguing with a person with psychosis.

To give a brief example of psychotic thinking, imagine the following. A man has a delusion that the mafia are plotting against him and may well be trying to kill him. Bravely he has left his home for a few minutes and is walking down the street. Another man is walking towards him. This other man stops suddenly, turns round and walks back in the direction he came from.

Our hero is shaken. This clearly fits the delusion: the man must have recognised him and may even now be hightailing it to report to the mafia where our hero is.

Frightened he walks on and tries to cross the road at a junction. A car roars up and our man has to jump out of the way to avoid being knocked down. This also fits the delusion: it might have been a murder attempt made to look like an accident.

Very shaken now, he continues. A woman with a small child is approaching. When they come alongside, the child reaches out a hand to our hero but the mother abruptly pulls him away. 'Stop that Darren,' she says.

Again this fits. After all, it is best not to be associated in any way with a man on the wrong side of the mafia. A car honks its horn; girls across the street laugh; 'anytime now', a man leaving a shop calls back to the shop assistant. Everything 'fits'. And so it goes on.

A delusion can structure one's reactions to every minor event and it provokes a totally different interpretation of the meaning of these events from what any sane person might construe. One has to realise that this process will continue, not end, when the person reaches hospital. A delusion can sprawl like a massive magnetic net attracting virtually anything and everything to it.

The incessant experience of noticing things that 'fit' the delusions is very disturbing in itself for patients. It is worth telling them that this process or bias - called confirmation bias - is something everybody experiences when they have a really strongly held dominant belief. It happens a lot to politicians and scientists and indeed anyone emotionally involved with a singular idea. It is not in itself a sign of abnormality, even if it can get out of hand in psychosis.

Some patients, especially those with manic, paranoid ideas, can present with a rather grandiose front. Experiments have shown that this superficial self-esteem is not genuine. Chadwick (1996) has distinguished between two types: 'poor me' paranoids and 'bad me' paranoids. In the former, the person consciously feels badly treated and undeservedly persecuted. In the latter, the person feels that they are 'no good' and are being punished as that is all they deserve. In the former case it is best to assume the delusion is false so as to get at the underlying negative self-evaluations; in the latter, assume that the delusion is true to do this.

Delusions are not just intellectual constructions but have great emotional and personal significance. The particular mistake that psychotic patients make is that they take their beliefs to be facts when it is far better to regard them as hypotheses based on evidence and - as in science - to be contested. If the person shifts to this approach they come eventually to see the light at the end of the tunnel. The trouble is, however, that patients won't drop their beliefs unless they have an alternative to move to. This is quite normal. So if, eventually, delusions are challenged, alternative interpretations of the evidence have to be given.

Psychotic patients are worth talking to, they need to talk and benefit from it. Just leaving them to stew in the juice of their medication on the wards is not the best strategy. However, it is worth noting that talking in-depth about patients' problems is not necessarily the only approach that should be adopted and, when they are troubled by the side-effects of medication, is not always that easy.

General chat about everyday things of no great significance is immensely healing to the psychotic mind and starts the job of leading one back into society. It gives a feeling of brotherliness with other people that one has basically lost when deluded.

Finally it is worth appreciating that what goes wrong with thinking in psychosis is not something qualitatively different from processes that go on in perfectly sane people. Jumping to conclusions; being centred on oneself; over-focusing on things that fit one's beliefs; thinking in a way that compensates for one's own deficiencies and having difficulty distinguishing reality and fantasy to some degree - these are all things that can be found in the thinking of sane people. The patient is not psychologically a 'weirdo' but someone who is probably highly empathic, sensitive and understandable if nurses will only listen. It is quite wrong to think that psychotic patients are 'not making any sense at all'.

Psychotic thinking can also fill a void in a life that the person may see as worthless and meandering. It has spiritual and existential significance and indeed delusions can often be 'true' in a metaphorical sense. That is what happened to me. Talking about psychotic thought can therefore take the sufferer on a very challenging and at times frightening journey. Medication may help to make that journey just a little bit less threatening and more controllable. In these respects, doctors, nurses, clinical psychologists and social workers all have parts to play in helping the person through what is potentially an important experience.

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