Most people implicitly trust their own perceptions. We believe that what we think we see is an accurate reflection of what we actually see. When we don't see what we think we see, often we prefer to question reality rather than our own perceptions. When our senses feed us inaccurate perceptions, those perceptions become the basis for our understanding and defining of reality. Perceptions do not just inform reality but in many ways define reality. At the same trime, we are typically much less cognizant of the ways in which our perceptions are shaped by our expectations of what reality looks like.
[My clinical example is actually pretty trivial, but it is an interesting story and I wanted to tell it. There is a serious point to it, a point that has been made repeatedly here and elsewhere, but the main reason for this post is the story.]
Many years ago, during my Residency in Psychiatry at Bellevue Hospital, I ran an out-patient medication clinic. Most of the patients were chronically ill with severe Psychiatric disorders. They lived in SRO (single room occupancy) hotels, tended to neglect their hygiene and appearance, and often exhibited residual symptoms such as ongoing auditory hallucinations, mild, persistent paranoid delusions, etc. One woman in particular, in her late 50s at the time, had already been maintained on Meprobamate for ~20 years by the time I saw her. Meprobamate was the first anti-anxiety medication and by the late 60s had been replaced by the Benzodiazepines (Valium, Librium and their relatives) for the treatment of anxiety. Since then, although the Benzos continue to be prescribed (over-prescribed, to my way of thinking), they too have been superceded by more effective and less problematic medications. Ms. W liked her Meprobamate.
Ms. W had Chronic Schizophrenia and had been started on Meprobamate in the 1950s, at a time when anti-psychotic medications were not yet available. She had remained on Meprobamate ever after. As with many chronic Schizophrenics, she was extremely resistant to change and even though her medication was not a particularly appropriate choice for her (the anti-psychotics had become available in the 60s and would have been the drugs of choice) she was comfortable with her medication and her life.
Ms. W missed an appointment and the following week when I was back in the Medication clinic she called. In her typical rambling way she told me she had run out of her medicine and didn't feel well. She couldn't sleep and wanted to come in. She casually mentioned, with the same flat affect in which she described the malevolent voices she often heard, that she had bugs crawling all over her. At that point I became alarmed. Formication was not a symptom I had seen from Ms. W before.
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