What is the progression of recovery from paranoid psychosis?

December 31, 2012 5:49 PM

How does a paranoid psychotic episode end? Assuming that someone is on medication that starts working, does it tend to be a sudden thing where they wake up one day and they no longer believe in any of the huge conspiracy their mind had created? Or do they gradually stop believing the least plausible delusions one by one? Or do they stop feeling the terror associated with it first, and maybe even continue to believe that all that stuff DID happen to them, but that it isn't an ongoing threat any more? Or do they maybe just become more open to logical arguments against their beliefs?

I realise this is most likely different for different people, but I'm wondering whether there are commonalities at all.

I'm asking because a close friend is currently going through an episode (and is under close supervision by a psych, etc, who believes he is not a danger to anyone or to himself, so he isn't in an inpatient facility). While I know people who have experienced psychosis in the past, they recovered in hospital and I was not close enough to visit regularly so I didn't see how the recovery progressed.

I'm just wondering because I'd like to be able to spot possible signs of recovery in my friend. In case it's relevant, his diagnosis is bipolar, currently with a manic/psychotic episode, and he started a different medication last week to try to control the psychosis. His delusions are along the lines of large government conspiracies trying to destroy his life.

posted by lollusc to health & fitness (11 answers total)

It's really all of the above, for different people at different times, although the part about logical argument has been less present in my experience working with folks with active psychosis. This is in part because people can still want to maintain that they were not wrong during the psychosis even when they are not psychotic. (This is more true for delusions like you describe than for hallucinations, which many people who are psychotic feel are essentially "wrong" even when they are in their grip.)

Were I looking for signs of improvement in someone with active psychosis I would pay attention to whether the talk about the delusions receded, and whether they have a greater sense of doubt about what they were previously sure was occurring.
posted by OmieWise at 6:18 PM on December 31, 2012 [2 favorites]

Operators and Things is a first-person account of a woman's descent into and recovery from a delusional state brought on by schizophrenia. I know it's not the same thing as a psychotic break but the underlying dissonance of a freshly-recovered mind trying to make sense of its own recently-held but obviously crazy beliefs seems pretty darn close.
posted by contraption at 6:31 PM on December 31, 2012 [9 favorites]

That's a great book!
posted by OmieWise at 6:32 PM on December 31, 2012

Someone I know recovered from paranoid psychosis, but she was in a hospital for a while before she returned. I knew about the details because we were involved in a project together and I had to manage her communications with the client, and make sure the work she was assigned did not trigger anything in her. If it did I would have to switch out that particular work element.

I knew a lot of the details of her delusions, such as that large corporations were trying to trap us by hiding their logos in the tree branches of client-supplied art. Then when we delivered it we would be sued out of existence by the big companies.

When she recovered, she could talk about the whole episode while laughing about it. She told me in detail about the onset, which involved a number of strange coincidences that occurred while she was shopping in Duane Reade. They had to do with the shelving of certain items that confirmed statements that had been forming in her head. Then, being a very smart and observant person, she followed up on these anomalies by inspecting the bar codes for these items. She found disturbing evidence in the improbable content of the price stickers.

As she told me the story of the onset, and gave me the details of the strange coincidences, I believed what she described actually seeing. In her telling I found a compelling compilation of evidence that something fishy was indeed going on with the world. Had I noticed what she noticed, and then kept noticing more corroborating things around me in Duane Reade, and then went home to find those same coincidences fully evident in my work materials, then I would have unanswered questions in my mind, as well.

We were laughing about all this as she went on with the narrative, but then her husband came in the room and made us stop talking about it. He thought that the kind of detailed retelling she was giving me could somehow trigger a relapse. I respect that, but I was glad that I got the chance to tell her that the way she described it, it really did seem like the paranoid interpretations were logical in context.

When I say she laughed about it, I mean that she was indeed looking back on her folly and shaking her head at how deluded it all was. The coincidences that happened were funny, and she did have the insight that something in her own head had caused her to seek these out, but they were kind of funny.
posted by StickyCarpet at 6:40 PM on December 31, 2012 [9 favorites]

For my brother, more than once, it ended in an emergency room, with massive doses of haldol and high dosage soporifics, and/or other anti-psychotic meds, to simply put him under, or to make him "controllable," to make him docile, to make his terror less terrifying to the rest of us. To make him, in the grossest sense, "sleep."

"To Sleep, perchance to Dream - ay, there's the rub."

For my brother was not only a paranoid psychotic schizophrenic, by the DSM-IV definition, and a clinical history spanning more than 25 years, but his form of the disease meant he thought, often, that either God the Father, The Holy Spirit, Jesus, or Lucifer, depending on the day, and his mood and recent thoughts and behavior, were individually or in weird chorus, speaking directly to him, although none of the rest of us, around him, could hear.

What I learned from my brother is that Hell is real, and that the Devil whispers in your ear, to make it so. A life lived in cringing fear of not fully understanding and instantly obeying the rustling voices you alone among those you love seem to hear, lest horrors beyond description be visited upon you and those you love, is crippling. But when those voices can't, any longer, be ignored, even against the loving arms and entreaties of real family members who hold you, and love you, and struggle with you, for your own good, you KNOW, and never can forget, that Hell has gaping jaws, and fires that "reasonable" people can not hope to understand.

In the periods his medications seemed to be working, I sometimes asked my brother what he remembered about the times they didn't. Aphasia is a common negative symptom of schizophrenia, as I understood, long ago; when you ask questions of a schizophrenic, you have to be prepared to sit, sometimes for a long while, for any answer. I sat, sometimes an hour at a time, in front of a man who seemed to be about to say something, but didn't, and maybe, couldn't. After several of such sessions, I began to believe, in his struggle to speak that ended so often in silence, that, simply, there are no words to describe Hell.

He never could say anything rational, about the times he was screaming, on the floor of his bedroom, in my house, trying to get away from a devil only he saw, as 2 firefighters, 2 EMTs, and 2 cops held him, and tried to get him on a gurney. But I saw the terror in his eyes, in those moments, and you know what?

I, a "rational" and educated man, couldn't describe the Hell he so clearly saw in those moments any better than he never described it to me.
posted by paulsc at 9:21 PM on December 31, 2012 [17 favorites]

For me, it was pretty sudden as soon as the manic episode ends, all of the symptoms of the mania go away as well. So, yeah, it was basically wake up one morning and Bam! all that stuff that made perfect sense the day before suddenly made no sense anymore. Of course, the thoughts I had the previous day are still a part of me because I had them, but the feelings behind them are no longer there.

I never ended up in the ER nor was I hospitalized during my periods of paranoia, and some of them were pretty intense. Paranoia isn't something to be afraid of, it's the reaction to the paranoia that can turn out to be dangerous. For example, during one of my not so intense episodes I knew, just knew that every business executive in the city I lived in had conspired against me and they were keeping me from finding work. I knew that they were having some kind of correspondence, passing around my resume and telling each other not to hire me. No one could convince me otherwise that they weren't talking to each other and laughing at me. Every interview just strengthened this conviction, even if they went well.

But thinking that the executives of the city were keeping me from working wasn't dangerous. If I got it into my head that I needed to "get back" at these business owners for conspiring to keep me from earning a living, that's when people would need to worry. I'm only telling you this because people hear "paranoid" and think "dangerous", but if his psychiatrist says he's not a danger to himself or others, then I wouldn't be overly concerned about it.
posted by patheral at 11:44 PM on December 31, 2012 [4 favorites]

For me, the bad manic stuff typically vanishes completely - usually I wake up and it's like what the crap was I thinking yesterday. I never see it coming, and I generally can't tell - while I'm being irrational - that I'm being irrational. It doesn't feel wrong at all. I think that's probably a fundamental characteristic of being irrational, actually ("if you're able to ask, you aren't really crazy.")

Moreover, I still can pretty easily fall into understanding exactly how I thought that [wacky impossible idea] must have been true, and there are things I've done that still seem like they made sense, even though I also know they would have ended badly no matter how awesome I felt, and I wouldn't voluntarily take those actions again right now.

It's hard to describe.

Basically: sometimes I really can't remember what I was thinking or why, and sometimes I can. Sometimes I know that it wasn't right but it still feels like it was, and sometimes it's completely alien to me.

But there's always this... detachment. It's not really like it's an experience that's outside of me, but more like... like how you can remember how mortified you were when you did X in junior high school, but you can also look those people in the eye and function normally today.

Also: new manic stuff doesn't undo the knowledge that earlier manic stuff was wrong/irrational. I really can save the world right now, but I really couldn't afford to fly around the world last time. This time is different, this time is real.

By contrast, my relative with full-blown paranoid schizophrenia has never recovered to that point. The same stuff/ideas bother him each time he goes off his meds, and he doesn't believe that he's ever been irrational about any of it (even if he has, in the interim, agreed that he had been irrational.) I kind of suspect that he may be agreeing that he was irrational due to an increased understanding of how much he's been upsetting other people, rather than because he actually believes it.

It's worth pointing out that people with mental illness often have excellent reasons for their paranoia.

The world is in many ways really out to get them - for instance, a completely healthy person subjected to the involuntary commitment process would probably emerge with a significant amount of paranoia and mistrust of others. Even the standard intake procedures at the ER are generally somewhere between profoundly uncomfortable and outright terrifying: at support groups, one of the standard topics is which hospitals around here are the worst ones. No one bothers to try to talk about which one is the best - just which ones you should really make an effort to avoid because they're extra awful.

My relative's paranoia mostly centers around the government and mental health profession, and the fact that he has schizophrenia doesn't change the fact that he has in fact been seriously mistreated by the government and mental health care profession. He can reasonably expect to be seriously mistreated by the government and mental health care profession periodically, for the rest of his life. It's just that the story around that mistreatment, and his reaction, is huge and crazy-looking (involves needing to sue at the Supreme Court for an immediate and unspecified redress of his grievances) - and that sadly makes future mistreatment more likely.

The evidence never ever goes away, is what I'm saying. And meds won't do squat for that.

[All of the above is speaking to delusions, not to hallucinations. Hallucinations for me have no particular connection to delusions - I usually don't "believe" the hallucinations, and find them deeply disturbing even when they tell me things that match up with how I feel about life in general. I also don't have huge hallucinations, though - more like seeing things out of the corner of your eye that aren't there, or hearing a voice calling your name incessantly.]
posted by Fee Phi Faux Phumb I Smell t'Socks o' a Puppetman! at 6:46 AM on January 1 [7 favorites]

My own wall-o-delusion just sort of crumbled once I got home and started getting enough sleep. The larger chunks of rubble took a while to finish disintegrating, though; I was pretty desperate to hang onto what I still thought of as valuable insights gained during psychosis. Some of them were so pleasing that it took years before I finally reality-checked them even though I was pretty sure by then that they were as rubbish as all the rest.

Of all the insane scribbling I did while psychotic (and there was a lot of insane scribbling, on every available piece of paper and cardboard and assorted other writeable surfaces) I've kept only what's left on the back of my chessboard. Reading over it now, it's just a bunch of embarrassingly trivial, random and not particularly original inconsequentia but I still recall the delight of seeing it all written out in front of me and floating on the certainty that at last I had hold of a pattern that made the universe make perfect sense.

That feeling of perfect unquestionable certainty was the cement that held the whole delusional edifice together; I had basically forgotten how to doubt and question. Then one day I woke up wondering whether or not something (can't recall what) was actually true, and the whole thing just fell to bits.

While in the grip of psychosis I was absolutely immune to arguments against any of the things I was certain I knew. But after the crumble I recalled many of the arguments that had been put to me by friends during the episode and realised that I did in fact possess no good counter-arguments to any of them. I believe this sped the process of recovery along quite substantially.

Took a few months to accept that the whole thing was a total crock, then about two years to stop feeling sickening fear whenever I found myself mulling over the kinds of issues I remembered thinking about on the way into it.
posted by flabdablet at 8:32 AM on January 1 [7 favorites]

I think it's a bit like when you're trying to remember something hard and you can't do it... then when you relax like going to bed all of a sudden you remember
posted by jago25_98 at 10:57 AM on January 1 [1 favorite]

I've worked with a number of people with paranoid delusions, due to schizophrenia, mania or psychosis NOS. Insight varies by the person, and generally the more insight a person has, the better the prognosis. Some people can recognize that while they are *sure* something is real, logically it doesn't make sense. Others couldn't be convinced no matter how hard you tried. I do know of a case in which a man who believed he was a historical figure later stopped "being" that person. However, he still believed that, for a few months, he was that historical figure, and then returned to being himself.

So the scenarios you proposed could all be the case. When I'm working with somebody, my first sign of improvement is generally that you can talk to them for longer periods of time without delusions cropping up in conversation. As people begin to recover, they are likely to be less preoccupied and/or are better at realizing that perhaps they should be inhibiting that line of conversation for social reasons
posted by gilsonal at 3:14 PM on January 1

Wow, thanks everyone. I especially appreciate people giving personal experience. Even though I was only asking about what recovery involves, the insights into what it FEELS like to be in the grips of paranoia or psychosis is very interesting (and gives me some empathy for what my friend is going through right now).

With regard to patheral's point, I am not at all worried that my friend is dangerous. I trust his psychiatrist to be able to judge these things. I just brought up the fact that he isn't in hospital but is under the care of a psychiatrist to try to fend off suggestions that I should be trying to get him committed or something, which is how these sort of threads sometimes end up.

Fee Phi Phaux's points about the paranoia sometimes being grounded in reality are exactly what I am seeing with my friend. I find it really hard to talk with him about his current experiences, because I think some of the stuff he is seeing is real (former friends laughing at him behind his back, people spreading rumours about him) and some of it is not out of the range of plausibility (e.g. an ex-girlfriend playing some revenge games), while other stuff is much more clearly delusional (e.g. that all these people are being paid by the government to do this stuff, that he is being followed, that the police are involved in the conspiracy). So if even I find it hard to untangle reality from delusion, it must be much harder for him!

I'm hoping I might be seeing some signs of progress, though - a few days ago he admitted that some of the more serious stuff he had thought was going on might be imagined, and today he said he has realised he is sicker than he had thought (he had always agreed with his psych that he was having a manic episode, but not that he was having delusions or paranoia), and he said he was going to take his medication more consistently from now on. He volunteered all that without me asking about it, and he also took time in the conversation to ask about how I am, and to listen to the answers and follow up on them, which he hasn't done for weeks. I think many of your answers above suggest that these are things I can be optimistic about.
posted by lollusc at 1:08 AM on January 2 [2 favorites]