hidden psychosisIn the last six months I’ve had a couple of experiences that I’m still trying to make a sense of.

Two very bright and personable women who seemed to have everything going for them, who both have bipolar, revealed to me that they have been suffering from severe symptoms that they had not told me about, symptoms which suggest that they really would benefit from an atypical antipsychotic.

The older of the two is a successful advertising executive who has been as unsuccessful in her romantic life as she has been successful in her professional one. This was a source of some perplexity because, to me, she seemed to have everything going for her, but the fact was that she could not manage a long term healthy relationship.

I had known that she had transient magical beliefs that bordered on the psychotic, but they didn’t seem to interfere with her functioning, and they also seemed very circumscribed, what I have elsewhere called “Berkeley normal” -eccentric beliefs in paranormal phenomenon that were just a small step beyond what I consider truly normal. And every time we talked about treating her with an atypical antipsychotic she expressed severe concern about potential adverse effects, including weight gain, metabolic disturbances and cognitive impairment.

She is incredibly articulate and these seemed to be very realistic concerns. I

A few months ago she moved away from the Bay Area and then ended up in a pretty severe mood crisis with manic symptoms and clear psychosis.

Her new psychiatrist stood firm on the need for ongoing treatment with an atypical antipsychotic, and a month after she started the medication, she wrote to tell me that she was finally free of the internal psychotic thoughts that had prevented her from moving ahead with her life. Psychotic thoughts that were much more extensive than she had ever mentioned.  Definitely food for thought. I hope to stay in touch with her to find out how things turn out for her.

The other story is more immediate. A graduate student in Sociology who I had been seeing for a couple of years before she went to graduate school, developed severe environmental sensitivities that resulted in her having to abandon her graduate program, at least temporarily. Returning to see me she started talking about what she describes as “dissociation” – parts of her mind that interfere with her memory and her capacity to follow through on decisions and projects. Although dissociation seems like a good phrase to describe the phenomenon, I can’t help thinking that it could, equally, turn out that there are elements of psychosis present. In any event, a trial with an atypical antipsychotic seems clearly indicated.

At this point I don’t know how the second story turns out, but the coincidence has me thinking very deeply about how the capacity to be articulate and to express oneself well can, sometimes, get in the way of getting the most effective treatment.

Both of these women, even when very severely affected by disruptive internal mental processes, nevertheless are able to present themselves in a way that makes it hard to believe that they are as troubled as they are.