Yesterday my patient said to me, “I got fucked by the snake tip. It was waving a flag.” He then shifted his head toward me, looked directly into my eyes, and while grinning said, “Yeah that’s right, you know what I mean. We got fucked by the snake tip. You know what I’m talking about, I know you do. Right?” Still staring into my eyes, but now raising his voice and becoming agitated he continued, “Jesus came and I was going to gangsta parties. Like real gangsta. And I came out alive and I know it’s because I am Jesus. I wasn’t treated like Mary did, but I got fucked by the snake tip.”
In psychiatry there is something known as a defense mechanism. Defense mechanisms can be mature, neurotic, or immature, they are ways that people deal with feelings of anxiety, pain, and internal conflict. One of my personal favorites is suppression. It’s classified as a mature defense mechanism, and is defined as conscious burrying of troubling thoughts so that you can continue to function. Just push it out of your head an keep on truckin’. Acting out is an immature defense mechanism. Projection is transference of anger to a more acceptable recipient. Intellectualization is when one can’t wrap his head around a painful thought or uncomfortable experience so he finds a rational way to process the info. A classic example always given the text books is that of a man who finds out he has cancer. This causes him to learn everything he can about the pathophysiology of the disease and instead of telling his son he has cancer he teaches his son about the aberrant cell cycle, P53, and the Rb gene.
So, what do you do when your patient is searching your eyes, talking about being f-ed by a snake tip, and is making no sense whatsoever? Well, you nod your head, return the stare, remain expressionless, and intellectualize:
Psychosis has many, many causes. In general the etiology can be considered primary (functional) or secondary (organic). Schizophrenia, for example, is a primary/functional reason for the development of psychosis. A secondary cause can be due to things like a general medical condition or drug intoxication. When psychosis is primary (like in schizophrenia) the neurochemical abnormalities have to do with an altered dopamine/acetylcholine ratio. There is a relative increase in the neurotransmitter dopamine, and antipsychotics work because they lower dopamine levels (usually by antagonizing the D2 receptor). Organic (secondary) psychosis, on the other hand, is often treated by anti-convulsants rather than anti-psychotics. This is because this type of psychosis is thought to be ictal, that is, it is thought to be induced by seizure activity (ie. increased neuronal firing) within the brain. Not only are anti-convulsants used alone, they can be used to augment the anti-psychotics because they are also thought to act on dopamine indirectly (through neurotransmitters like glutamate and GABA) which in turn enhances the antagonistic dopaminergic effects…. la la la.
Sorry but if you’re gonna raise your voice and get all crazy on me my brain is going to move into science mode. Intellectualization at it’s best.