Guest Post: Delusional Patients, Delusional Characters

Guest post by Kathy Crowley, M.D.

Late in my second pregnancy, Mrs. G., a patient of mine, fell victim to a serious psychiatric illness. She was later diagnosed with something called Schizoaffective Disorder.  Mental illness is common of course, and perhaps more so in the population my clinic serves, but she was not the patient I would have predicted.  Mrs. G was in her middle 60s, a cheerful lover of art, books and music, who taught in the Boston Public Schools. I had been following her for three or four years and her only health problem – other than a touch of arthritis in the knees — was high blood pressure.  She lived with her husband, an artist, in the city, and theirs was a long and stable relationship.

I don’t remember the details of the last visit I had with her before she became ill, but I do remember she asked me about how much time I intended to take after my baby arrived.  I was tired, my answer may have been a bit flip.  The maternity leave policy had changed since my previous pregnancy, and I would be back sooner than I might like to be.  But — whatever.  We would all survive.

This piece of news disturbed her.  Why couldn’t I take as much time as I needed? she asked.  It’s important for mothers to be home with their newborns.  I had people waiting and was feeling pressure to get to the next patient.  I’ll be fine, I reassured her. My baby will be fine.  I refilled her blood pressure medications so that she would have enough until my postpartum return and we said our goodbyes.

A few weeks later I got a call from one of our Emergency Department docs.  Mrs. G had come to the ER for an unusual reason.  No pain, no injury, no fever, no car accident.  None of the regular stuff.

“She says she’s come in protest.”  He cleared his throat. “She says she’s not leaving until Dr. Crowley gets all the maternity leave time she needs.”

You’ll have to take my word for it — our ER staff has just about seen it all, but this was a new one, even for them.

To make a long story short, closer questioning revealed that her concern about me was just the tip of a very worrisome iceberg, a complicated set of beliefs quite disconnected from reality – or at least, what most of us agree upon as reality.

She landed at an inpatient psychiatric facility just outside of Boston. A few days later, the psychiatrist who was in charge of her care called me.  “It’s an impressively detailed delusion,” she told me.  “Your maternity leave may have been the trigger, but she’s clearly been harboring a lot of these ideas for a long time.”

A day or two after that I squeezed my large pregnant self behind the wheel of my car and drove out to see her.  Not the usual thing for me to do, but I had never been at the apex of a delusion before and I was under the impression that my visit might be important.  I know she was happy to see me, but looking back it’s clear that I didn’t have much effect on what was going on in her head.

We met in a visiting room on a lovely spring day, an oval of sunlight like a kitchen table between us, and talked.  There was none of her cheerful chatter as she related the series of events that brought her to the Emergency Room.  It was clear that she expected me not to agree with what she described – and it was equally clear that my disagreement meant nothing.

As the psychiatrist had told me, this delusion was an impressive one.  True to my patient’s educated and cultured mind, it involved political issues and electrical systems and her husband’s art work and a shoulder injury she had suffered years before, and which she felt had been mismanaged at our emergency room.

I wish I had written it all down, or at least diagrammed it.  I wish I had a recording of our conversation.  The scheme of causality she described was brilliant and, in it’s own way, a creation of beauty.

I also wish that this story had a happy ending.  She was medicated, of course, and the medication shrank the delusion, sanded down its precise edges, deflated its energy, all to make room for the ability to manage her Activities of Daily Living—to feed and dress and above all, not hurt herself or anyone else.  She never got back to the person she was before.

Speaking as a physician, she is a patient I will never forget.  Speaking as a writer, she reminds me how difficult it is to replicate authentically the thought processes of a person with mental illness. While it is always the challenge of fiction to bring us inside the hearts and minds of strangers, it is that much more difficult when the basic neurologic and psychological processes of that character are alien.

Writers who have done this successfully often suffered from mental illness or drug addiction themselves. (Think Charlotte Perkins Gilman’s The Yellow Wallpaper, for example, which describes a post-partum depression much like what the author experienced, or Philip K Dick, who was victimized by both drug addicition and mental health issues. Or Ken Kesey, who used his own experience as a test subject for psychoactive drugs to write One Flew Over the Cuckoo’s Nest. Or Virginia Woolf.  Or Edgar Allen Poe. Or Chuck Palahniuk. Or… well, you get the idea.)

If I were trying to write this as a “How to”, it would be ugly. (“Step 1. Get your hands on amphetamines or hallucinogens and/or experience extreme personal trauma …”)

The next best thing I can pull off is a set of observations which may (or really may not at all) be helpful in writing a character who suffers from mental illness.

Observation 1: Crazy is not random.

Of course there are different kinds of crazy, but a crazy character does not behave in a random fashion.  For example, not all persons with delusional disorders  experience as detailed and orderly an alternate reality as the one described by my patient, but there is always an internal consistency and logic.

Observation 2: Delirium is a horse of a different color.

It would be handy at times to have a patient who is delirious. Delirium is so convenient — people can hear and see things that aren’t there (or not), experience all kinds of disordered thinking (or not) and fluctuate wildly over time.  As a writer, think what can be accomplished! However, if this is the way your character behaves, you had better have a good reason (like a fever or a drug overdose) and you’d better be ready to re-envision this character when the fever is gone or the drugs have cleared.

Observation 3: This is not your grandfather’s crazy.

By which I mean, we know much more about mental illness than we did 50 or 100 years ago. It might be that you could get away with the crazy guy on the street corner or the woman in the attic and not have to elaborate.  Not any more.  Mental illness has more flavors than Ben and Jerry.  Which brings me to number 4.

Observation 4: Those DSMs are thick for a reason.

There’s a lot of knowledge out there — if you’ve got characters with mental illness, make use of it in your writing.  You might want to understand psychosis versus delusion, schizophrenia versus schizoaffective disorder and both of them versus multiple personality disorder.  Early symptoms, what age of onset, treatment, prognosis — all this information is easy to find. No one wants to create characters straight out of a psychiatric textbook, of course, but like anything else you’re writing about, it’s a lot easier if you know your stuff.

Anyone else there who has struggled with getting this right?  Favorite characters in literature with mental illness?

Kathy Crowley’s short stories have appeared in Ontario Review, Fish Stories, The Literary Review, New Millenium Writings and The Marlboro Review. Her stories have been short-listed for Best American Short Stories, nominated for a Pushcart Prize and anthologized. In 2006 she was awarded a Massachusetts Cultural Council Grant. She recently finished her first novel, On Locust Street. When she’s not busy preparing for her future literary fame and fortune, she provides care and feeding to her three children and works as a physician at Boston Medical Center. She is a graduate of Brown University and Tufts University School of Medicine. Kathy can be found on Twitter at @Kathy_Crowley.