Delirium: everyone's psychosisBMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6977.473 (Published 18 February 1995) Cite this as: BMJ 1995;310:473
- Malcolm Bowker
I had been feeling jaded and mildly unwell but had attributed this largely to a normal reaction to the reforms in the NHS. Fairly acutely this psychosomatic explanation became less convincing. An abdominal appendix abscess was identified, leading to an immediate laparotomy and then tertiary referral as peritonitis developed with respiratory distress. There was further surgery, renal failure, and a continuing inability to sustain normal respiration.
While being ventilated in the intensive care unit, I do not recall sleeping or waking, except once when it seemed that I had opened my eyes after a nightmare and consciously tried to disengage from the dream, only to find that the dream and reality were identical. I had entered an oneroid state in which there were frightening delusional and hallucinatory experiences of a dramatic and fantastic kind. These incorporated uncomfortable personal existential truths, contemporary themes of serial killing, my recent correspondence with the editor of the BMJ, Satanism, and cruel fundamentalism, in which I, as an accused, would suffer horribly.
Although protesting my (real) innocence to declared crimes, seeds of doubt developed in the isolation of my delusions, and passive acceptance of my fate and even culpability became conceivable.
I was sure that my life was threatened in the most unpleasant way—reflecting Orwell's chilling concept of room 101 in his novel 1984*—by those caring for me and by my colleagues from my own hospital to the extent that, to avoid imagined tortures I pulled out the intubation tube with the intention of dying. Another feature of the experience was then apparent—the possibility of delusional reality and reality existing together. I recall saying that I could breathe without the tube with, for the moment, all thoughts of death and the persecutions displaced.
Similarly, interactions with staff and visiting colleagues who were implicated negatively in my delusions seemed to be acceptable and welcomed in most instances. I remember being irritable with a physiotherapist and the doctors, one of whom I suspected was deliberately spilling samples of my blood, reasoning that there was no point in continuing treatment if the intention was to eliminate me later.
Psychiatric colleagues were aware early of my troubled state of mind. I prefaced my concerns to them with the confidence that they knew I was a little sensitive, perhaps even a touch paranoid at times, but indicated that really I was in serious danger. Their unspoken assessment was clear: “Poor chap, he really is paranoid this time.” This was strangely comforting.
While ventilated, communication was limited to written notes. This required enormous concentration and was subject to mistakes in spelling and organisation—a clue to the compromised function of my brain despite being alert and partially oriented. Staff were patient with my efforts and much paper was consumed. “Occupational” delirium surfaced in my scribbled recommendation that an individual, whom I perceived to be threatening the intensive care unit, should be detained under the Mental Health Act.
Although I had difficulty in believing that my position was anything other than dire, the steady support of colleagues and relatives, and the regular care from staff, all tended to keep alive the possibility of another more benign reality. This has emphasised something of which I was already aware—the importance of simple psychotherapeutic measures in the treatment of psychotic patients.
A friend properly deprived me of the ability to make potentially bizarre revelations by refusing to deliver my mobile telephone.
Cessation of the delirium occurred after a fluctuant course of about a week, with a sudden absence of disturbed perception and the return of a normal pattern of sleep. Physical recovery was much slower with severe weakness—experienced as if gravity had been increased many times—only resolving over a period of months.
What else did I learn from the other side of the bed? I was asked on numerous occasions where I was and dutifully replied, as if following the rules of a game, with the name of the hospital, even though on one occasion I believed I was in a ship bound for an Irish prison and on another en route to a psychiatric hospital in Wales. I have been unable to unravel the psychodynamic significance of these delusional misorientations. Clearly correct orientation alone does not preclude significant mental disturbance. It has been useful, if unsettling, to experience at first hand how adept the deranged brain is in forming an illustrated and coherent fiction from disparate elements of the present and the past.
I can now identify on rational grounds experiences which must have been psychotic. I remain unable to distinguish more ordinary or conceivable experiences on the ward as having been real or not real, without the observations of those with whom I felt I was interacting. Despite this vividness of the psychotic process, the strongest image I retain and which still evokes in me a marked sense of guilt, is the look of intense concern on the face of a nurse as I separated myself from the ventilator.
It was helpful to return to the intensive care unit to see both the staff and the ward; both had played dual roles in my disturbed perceptions. But the embarrassingly strong emotion felt on visiting the intensive care unit was evidently associated with a positive transference to the staff who had cared so well for me, rather than from unpleasant memories arising from the psychosis.
I retain an overwhelmingly appreciative view of the treatment I received, both locally and at the tertiary unit. During the five weeks in the university teaching hospital communication with patients and relatives seemed exemplary and provoked some feelings of contrition about the time and effort spent in comparable activity in my own discipline—which arguably should set an example in this area.
I do not think that the relatively common phenomenon of delirium should usually require specialist intervention, which could compromise the essential primacy of the nursing staff, particularly in the intensive care unit. I did not recognise before that delirium can be at least as distressing as severe pain and needs to be identified and treated with the same diligence as soon as it develops.
It does not surprise me that there is published evidence for significant psychological trauma arising from some experiences of delirium, with later psychiatric morbidity.—MALCOLM BOWKER is a consultant psychiatrist in Rochdale
↵* Everyone knows (what is in Room 101). The thing that is in Room 101 is the worst thing in the World. It goes beyond fear of pain or death. It is unendurable and varies from individual to individual. It may be burial alive … or any other thing.