Letters

• stigma
• narrative truth

Editor:

In their otherwise interesting review of The Silent Patient¹, Drs. Friedman, Magalotti, and Bodnar express the concern that the novel stigmatizes forensic psychiatry by portraying clinicians treating a character as delusional, when his beliefs are later revealed to be based in reality.

In my two decades of practice, I have come across several patients who appeared psychotic on presentation who, after investigation, were found to have been accurately reporting personal historical events. In some cases, the patient was indeed psychotic, but parts of the story we called delusional were nonetheless true. As an example, when I was working at a state hospital in Maryland, we had a man admitted on a competency order who, during our workup, told us he was a bassist who played with various famous jazz musicians in the 1960s. Given his fairly severe psychosis and his obvious poverty and social disconnection, we initially concluded that he had grandiose delusions. Our social worker determined that his story was true. Once we realized he was who he said he was, we were able to join forces with community providers and his supporters to engage him in community-based care and to help him resume, in his twilight years, his musical career. Before he died, he was public about his story, including his struggles with mental illness and addiction.²

In other cases, the patient was not psychotic at all, but the story appeared so outlandish given the circumstances that the treating or evaluating physicians wrongly concluded that the patient was delusional. One case involved a man who was jailed for minor nuisance charges. He came to the country as a refugee in the 1970s. He told jail clinicians that he made a living by playing chess in a public park, and that his story had been told in a documentary. Staff documented him to be “extremely delusional, guarded, evasive, paranoid, and grandiose,” despite showing no signs of psychosis other than his presumed delusion. He was quickly diagnosed with a psychotic disorder. Even when he provided ways for the treating staff to confirm his story, they did not do so. Given the unique details of his story, it only took a few moments with an online search engine to fully substantiate his story, yet he was documented to be refusing treatment for an illness he did not have. After two months in jail, he was released with time served.

These are just two examples of cases in which patients' stories at first appeared incredible yet were true, and in which we wrongly concluded they were delusional. Forensic psychiatrists are primed to examine the differences between people's narrative truth and objectively determined historical truth. We name those differences reality distortions. But sometimes the narrative truth is in fact the historical truth, and we should always be attuned to such a possibility. In diagnosing psychosis where there is none, we are the authors of our own stigma, and, even worse, we harm the people who are under our care or who are subject to our evaluations.

• © 2020 American Academy of Psychiatry and the Law