Dr Shyamala Vatsa

Wonder Years

Psychosis: Loss of touch with reality - Dr Shyamala Vatsa

Shraddha, a 20-year-old Indian girl studying in the UK, called her mother late one night screaming that somebody was trying to kill her. She said her computer had been hacked into, and the hacker spoke to her through the computer. He kept telling her to run out into the traffic as she didn’t deserve to live. Sometimes he called her vulgar names and mocked her.

She had shared a flat with two other girls for a couple of years when she started her undergraduate course in the UK. Everything had been fine and the girls had become good friends. Six months ago she had begun suspecting that her flatmates were  spying on her. So she had taken to staying holed up in her room, door locked and curtains drawn. As she avoided going to the kitchen to cook, and the bathroom to bathe, her health and hygiene were neglected. She stopped attending classes and exams as well, and her grades suffered.  Finally, she moved out into a small flat to live alone. As she had informed her parents about the move and given a credible reason for it, they did not suspect anything to be amiss.

Following that phone call, her panic-stricken mother caught the first flight out and brought her home.

She came in for a consultation a day or two later accompanied by her mother. As her mother laid out the facts, Shraddha sat quietly in her chair looking utterly exhausted and blank. She did not add anything, nor did she contradict her mother. She did not even seem to register where she was, or with whom. When I asked her a simple question - was she sleeping well? - she merely directed a perplexed gaze at me but did not reply. She seemed to be somewhere else altogether.

This is not an uncommon presentation in psychiatric clinics. All the symptoms Shraddha experienced were typical:

  • Hallucinations -  she heard a voice saying things to her
  • Delusions – she completely believed that her computer was hacked, also that her friends were spying on her
  • Disorganisation – the way she had started to live, neglecting herself, lacking motivation to do things
  • Social withdrawal, lack of normal feelings, poverty of speech

When people bring in a family member or a friend who has been through this harrowing experience they usually refer to it as a nervous breakdown.  In psychiatric parlance it is simply called an acute psychotic episode, meaning it is something that has suddenly happened (acute), there are symptoms like hallucinations and delusions that show a lack of touch with reality (psychotic) and it may be temporary (episode).

Sometimes people present with sleeplessness, along with mild psychotic symptoms such as odd thoughts or behavior that they recognise as irrational, or vague doubts about the intentions of neighbours or co-workers. There is an awareness of this change at a subliminal level, a feeling that something is not quite right. This is called the prodromal phase. A prodromal phase lasting a few months before the full syndrome develops is common. This might have been the clinical picture if Shraddha had presented four or five  months before. Had her mental state been examined once a week or so by a psychiatrist, treatment could have been started earlier, and the breakdown averted.

When such a person is first seen in the hospital the focus is on controlling psychotic symptoms with antipsychotic medications. However, as there are other disorders that present with psychotic symptoms in adolescence, it is necessary to wait for a few months and watch what happens. These disorders are relatively rare, e.g. tumours of the temporal lobe, metabolic diseases like disorders of copper metabolism, certain types of epilepsy, etc. Even a head injury that was not considered serious when it happened may cause similar symptoms days or months later. These can be diagnosed only by regular reviews and appropriate  investigations. It is  important to comply with the prescribed treatment, because the doctor’s next step depends on the patient’s response to medication and other parameters used to assess progress.

Early intervention is imperative. For one thing, it improves the chances of complete recovery. Secondly, there are these benefits:

  • Good response to medication and lower risk of relapse
  • Quicker return to school/work and normal life
  • No loss of social skills, intact interpersonal relationships
  • No need for hospitalization
  • Reduced risk of suicide (that can happen in response to hallucinations, as it could have in the case above)
  • Less stress on family members

In this series Dr Shyamala Vatsa highlights the fact that teenage changes can mask incipient mental health problems. These articles show how early symptoms of mental disorder can be taken for ordinary teenage behavior. As illustrated by the stories of young people who have suffered unnecessarily, it is important for friends and family to recognize when a behavior is outside normal limits, and seek help before things spin out of control.

Dr Shyamala Vatsa is a Bangalore-based psychiatrist who has been practicing for over twenty years. If you have any comments or queries you would like to share, please write to her at columns@whiteswanfoundation.org