Getting Better – A Mixed Bag

Larry was a very pleasant, intelligent, honest and motivated man in his 20s.  He had been working for the last five years in a high-end Manhattan retail establishment in a supportive role, somewhat higher than a stock boy but not a salesperson who earned significantly more money.  His employer frequently told him that his promotion was in the works, but it never seemed to materialize.

As much as Larry wanted the promotion and raise to make his job more interesting and his financial situation better, his dream was to be an actor.  I didn’t quite see him as an actor the first two times I met with him.  His affect was rather constricted.  He didn’t have that wide or even dramatic range of expression to which I had become accustomed from the multitudes of aspiring actors who inhabit Manhattan.  However you can never know.  Perhaps on stage he is a master thespian.

He had seen three psychiatrists in the last seven years prior to his consultation with me.  The turnover in clinicians was due to circumstances outside of his control as all prior psychiatrists had unexpectedly relocated.  All of his prior treatment was talk therapy.  He had never taken any medications.  After all, his complaint was that he was not progressing either in his day job in retail or in his acting career.  He felt trapped and was searching for ways to break through in his life.  To his thinking, was he insecure?  Did he lack self-confidence?

After meeting with him roughly four times, I was perplexed as to why his life was not progressing, and why all his previous psychotherapy had seemingly been completely ineffective at helping him.  The last thing I wanted was to perpetuate a treatment approach that had not helped him in the past.

Having access to the treatment notes by all his prior psychiatrists, nothing in his records provided clues as to his lack of progress.  Each note read something like this: “Patient discussed frustration with lack of progress in acting career.  Plan – continue supportive therapy.”  Hmmmm.

Although reading through his voluminous records provided a rather complete picture of his past and present, the old adage from medical school returned:  “Do not take anyone’s word at face value.  Perform a comprehensive evaluation and form your own opinion.”

So on the fifth visit, I informed Larry that I was going to perform a comprehensive evaluation as if I knew nothing about him.  Every component of a thorough, complete and comprehensive psychiatric examination was performed.

And then the truth emerged.  Every day when Larry returns home to his apartment, a giant anaconda emerges and bites him.  It then recoils, watching his every move, hissing at him from time to time before slithering back into the closet.  When Larry climbs into his bed to sleep at night, the skeleton of a woman dressed in a lace wedding garment comes and sits at the foot of his bed and watches him, until he falls asleep.

Larry is psychotic.  He is schizophrenic but not like the ones most people imagine, the conspicuous ones standing on the street, disheveled, hearing or seeing people who don’t exist, screaming about conspiracies.  In fact, there are many, many more individuals with schizophrenia, like Larry, than like those more conspicuous ones.  Larry is intelligent, well-spoken, related, amiable.  You would never imagine that he is also psychotic.  You would not want to believe that he is psychotic because he is too much like you.

Ironically this revelation was a relief because it was now clear why he had been struggling so much to move forward in his life.  The revelation also engendered in me a tremendous amount of respect and regard for him.  It must be a living nightmare to have such terrifying hallucinations.  The fact that he had gotten as far as he did in life was admirable and inspiring.

I did not mince words with him, and told him that he has schizophrenia.  As is my experience with being truthful and direct with patients, it was comforting to Larry that not only did he not have to hide this terrible secret, but someone finally completely understood and knew him.  During his entire life, he had to always hide this dark secret.  As a result, I thought he would be delighted that there were medications that could banish those demons from his life.

But that was not the case.  Larry was extremely reluctant to try any medication, responding, “I can live with it.  I’ve been living with it for all these years.”  He was right.  Nonetheless, over the next two months, every week was an attempt to emphasize how difficult it is to move on with your life if snakes and ghosts are haunting you.  Since Larry had also expressed the desire to meet a woman, marry and have a family, the two of us had several moments of levity imagining how Larry, his wife, an anaconda and a dead bride could all fit in bed together.

Finally Larry agreed to a trial of a medication.  I chose a very mild one and began at the lowest dose, telling him he may not see any change until the dose is raised.  It didn’t take long until Larry began to report that the anaconda was at first, not biting him, and then not making an appearance every day he returned home.  The dead bride similarly began to visit less frequently and when she did, it was only for a few brief moments.

And just when these hallucinations were about to disappear completely, Larry informed me that he stopped taking the medication.  He felt lost and confused.  He missed the anaconda.  He missed the dead, skeletal bride.  As it turned out, they had been with him since he was nine years-old.  (Previously he told me it started at age eighteen.).  He had not only become accustomed to these demons; he became attached to them and was experiencing a profound sense of loss. They were his constant companions.

I waited another two months before raising the medication issue again.  By then, not only had the demons returned, but now they were again terrorizing him.  This time however he remembered what it was like to not only be rid of them, but to be rid of the daily sense of terror.  He didn’t want to live in a daily state of fear, so he then agreed to restart the medication and continued taking it thereafter.  We spent the next six months discussing how attached he had become to his hallucinations and validating his sense of loss while simultaneously highlighting his newfound freedom from terror and fear.

He didn’t need frequent visits at this point but just to check in every three months.  Over the next three years, he become a full salesman and was able to afford a much nicer life.  He got a small part in a play.  He wasn’t paid for it but it brought him tremendous joy and pride.  Then, Larry replaced his prior metaphysical world of snakes and corpses with an inspirational metaphysical world of God.  He became very active in a church and there he met Melissa who later became his wife and mother to his children.

It might be easy to read Larry’s story and find it hard to relate if one has never had a psychotic experience as most of us have not.  However our ability to not only acclimate but moreover to become extremely attached to negativity is astounding.  It is universal and not one of us is immune from the tendency to try to incorporate the most undesirable things into our lives no matter how much distress it causes us.   And later, when given or shown the opportunity to rid ourselves of the negativity, we are fearful, resistant and later experience a sense of profound loss when the negativity is gone.  A mixed bag indeed.