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 Meprobamate was the first anti-anxiety medication and by the late 60s had been replaced by the Benzodiazepines (Valium, Librium and their relatives) for the treatment of anxiety. Since then, although the Benzos continue to be prescribed (over-prescribed, to my way of thinking), they too have been superceded by more effective and less problematic medications.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.
Meprobamate, almost never used today, is an addictive medication. Abruptly stopping it can lead to withdrawal symptoms, including formication, a feeling of bugs crawling over (or under) the skin. If the withdrawal state progresses much further, seizures and death can ensue.
Since her SRO was only a few blocks away, I told Ms. W to come to the clinic immediately. I thought I had a medical emergency on my hands; yet when she came in she was her usual calm self showing no signs of agitation, sweating, sniffling, tremors, or any other signs of withdrawal. I asked her about the bugs, were they still crawling on her? She said they were and offered to show me.
Before I could protest, she took off her sweater. It was not a comfortable moment. (Luckily, she was wearing a t-shirt, torn and filthy, under her sweater.) There was no evidence of any bugs and I wondered aloud if she still saw them.
Although rare, formication can be found in Schizophrenics. It is a very unusual symptom but can occur in the absence of the toxic state of withdrawal. Maybe she was not toxic, in withdrawal, but suffering a psychotic exascerbation.
At that point Ms. W turned her sweater inside out and announced, "there they are."
I still didn't see; she leaned across the desk, showed me the seam and said, "See?" And I saw. There, lining the seam on the inside of her sweater was a robust population of Pediculus humanus humanus, the human body louse. Once my nausea passed, I proceeded to press Ms. W on her medication. Even though the lice were prima facie evidence of the reality of her feelings, ie she had real lice not a tactile hallucination, she could still be in danger of withdrawal. When had she run out? When was her last dose?
She matter-of-factly told me she hadn't run out yet and still had enough for several more days. She had told me she was out of her medication because after she took her last bottle of pills she had no more. That such an eventuality would not occur for another several weeks was not germane to her. Her time sense, and grasp of cause and effect, were not her strong suits.
Her logic may have been psychotic but her perceptions were clear. If I had not seen the lice, if they did not in fact exist, or if she had worn a clean sweater and they were not accompanying her, I would have concluded that this woman, with Chronic Schizophrenia, was having an exacerbation of her illness or was in a potentially life threatening withdrawal state. I would certainly have admitted her to the hospital, even if she did not want admission (although she would probably have been quite content to spend a few days in the hospital), and would have ordered hourly vital signs and monitoring.
Consider a hypothetical situation with Ms. W today in our connected world. Let us imagine she is living in an SRO in an area without Psychiatric care available. Her Case Manager could set up an on-line appointment where I could virtually examine Ms. W. I would have to believe that the Case Manager was trustworthy and that what I was seeing on my screen was trustworthy. A malevolent reporter could conceivably hack the signal and erase the lice or, in the absence of lice, add them to the signal. How could I ever know? A Case Manager who wanted to get extra Meprobamate, perhaps to abuse or sell, could erase the lice from the signal and convince me to send a new prescription for Meprobamate. A Case Manager determined to use the patient to support an agenda, perhaps "documenting" how poorly such patients are treated and that more money should be spent on their care, could add lice to the signal to advance the argument. In either case, the image would trump reality.
Obviously, in this hypothetical case there is little reason for suspicion. The benefits of tampering with the signal are minimal and the risk of exposure high. However, at this point almost all of what we know of the world is mediated by other people and by electronics. What we see is no longer certain to be what we get, nor is it likely to be what actually exists. Those who can manipulate the images we see define the reality that those images can either illuminate of obfuscate.
It is a difficult problem and is only going to get worse as time goes on. The implications for the Information War are significant. Let us hope that the Army of Davids can gain traction and level the playing field. The forces arrayed against the West, from within and without, are formidable.
Please keep this in mind when reading an important essay from Charles Hill at MESH, Chasing illusions in the Middle East. Pay special attention to the role of perception and management of images that infect our understanding of the Middle East.
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