Is humanity a matter of delusions
PsychosesDelusion and reality
"That was reality. And what a reality! Much more real than anything else. And the feeling that I am going astray, that only came with the following times."
"Do you know that psychotics pretend to look us in the eye, but don't do that at all? They look at the mouth. And we don't even really get it. That's something very strange, that of course also happens different interpretations come about. Decoding a face based on the position of the mouth is different from decoding a face based on the eye area. "
"I felt as if I were really awake for the first time in my life and for the first time I would really understand. What was before, I was kind of blind, I didn't really perceive it all, daytime on the wall of the house , the color of the bus, the faces of the passers-by. Really see it, all the details, all the little things. "
At the age of 24, Judith Behrend experienced her first psychosis. The world around her is suddenly full of signs and messages that are aimed directly at her. Everything seems like one big production. She is the Truman in the Hollywood classic "The Truman Show", the only real person, while all the others are actors. The only difference: unlike Truman, she "knows" that the other roles are playing. She "knows" that the people she meets on the street are instructed to give her sign:
"I suspected that from my boyfriend too. I thought you weren't going to work, you'd get paid to spy on me."
But while Truman lives in the pastel-colored world of a 1950s suburb, Judith Behrend's world is dark and threatening. For them, the world is on the brink of an abyss. Violence, injustice, hunger in the world - everything that healthy people somehow ignore on a daily basis is something that they feel very directly. The filters no longer work:
"News is a catastrophe because you feel the catastrophe. So you feel that it is directly related to your own life. And when things get really bad, connections are made between how I behaved today and how they are Representing the world in the news in the evening. "
"It is your fault?"
"Yes, it's my fault."
"I also went secret routes to avoid large crowds. Gladly in the dark, happy when it was raining."
Initially no insight into the disease
Delusion is the most common symptom of a psychotic disorder. I know that. My good old friend Lars has been back in psychiatry for a few weeks. He's the reason I'm trying to understand psychosis in the first place, and why I'm talking to Judith Behrend. Lars is crazy about love right now. When I visit him, he tells me that he urgently needs to see a woman in Frankfurt. On every advertising poster he sees encrypted messages from her, messages of love. He met her briefly a few years ago and is now convinced that she is the love of his life. Pictures of bouquets of flowers, a bottle of champagne - for him these are all encrypted invitations. The more I try to reason against it, the more he clings to it. He comes up with crazier and crazier ideas to keep the story going. Then suddenly the messages also appear in the newspaper - to confirm that they are real:
"The normal thing is that a psychotic has no real insight into the disease, at least not at the beginning of his illness. And then they won't come, Mr. Voigt, I'm crazy, do something. They think it's true. That is yes no belief for them, that is a certainty that they are being persecuted. They don't believe that, they know that. "
I sit in Jürgen Voigt's therapy room on the armchair on which his patients usually sit. A comfortable leather chair with a high back that you can feel safe on. The Berlin psychotherapist - gray hair, an inquiring, friendly face - sits across from me at a distance. About a third of his patients suffer from psychosis. Unusually many for a resident psychotherapist:
"I'm also so socialized. Well, that was completely clear in the past, you shouldn't touch this delusional system. If you even talk about it, then you only solidify it. That is not treatable, that was completely Sure, madness cannot be corrected. The only thing you can do is give pills. "
Nowadays, cognitive behavioral therapy is about not only addressing the delusions, but also questioning them. - I wonder how they do it? To talk about the delusion without your patients closing down, as I experience it with Lars? How can you rely on your mind when the other is acting completely insane?
"The classic is always, I'm being persecuted. If I were to say since when do you think you are being persecuted? Then I would have done something wrong. The other question would be, when did you first notice that you were be pursued? "
Jürgen Voigt does not want to confirm or reject the delusional content. He would never say to his patients: It can't be, that's rubbish, as I sometimes say to Lars. Instead, he systematically goes through the ideas with his patients and checks them for plausibility. For example: If everyone you meet on the street is watching you - how many is that per day? Per month? And how expensive is it a year? Who can pay for that?
Anxiety in the early stages
On the other hand, the therapist tries to look for the deeper reasons for the delusion:
"Psychotic patients often say that they had a vague feeling of fear in the early stages, which was very strong but had no real explanation. A flood of a negative emotion. Then you make an explanation out of it and the kind of diffuse fear subsides And they experience that as a relief. Because there is an explanation, the child has a name. Then new fears arise. Because being persecuted also creates fear. But that is a different fear, because it is no longer so diffuse. You can name them, they can be explained. "
"At that time there was a connection between pain, the real cause of which I didn't want to look at. I wrote a lot of diaries during that time. And then it was also a feeling of mysticism. Now I get the revelation, now I get the answer to all my questions. And that's all quite logical, of course, why have I never seen that? "
Judith Behrend can still remember how her first breakdown came over 20 years ago. A construction site in the apartment, the relationship with her boyfriend broken, she herself tense with two part-time jobs and overwhelmed by the demands of her own studies - at some point she couldn't take it anymore:
"Always the feeling that it is not enough. My gravestone could read," She made an effort ". Because, I really did. I don't know why it is always rated so negatively when you say this sentence. And this one too Perfectionism, if so, then it has to be one hundred percent. In work contexts and also during studies. So, it took forever before I wanted to - or was able to write a term paper! "
"This is often quite easy to understand when you go back to the beginnings of the delusional developments. There might have been problems at work and then there were arguments, and then there were funny looks from colleagues, and then you thought they were having talked about me. And then you withdrew, then they really weren't that friendly anymore. Then the next thought came up, maybe they want to kick me out, that's all still within the comprehensible range. And then it gets more and more extreme. But also then you can often still understand how one belief and one behavior leads to the next. "
Distorted thinking understandable, transitions flowing
The psychologist Tania Lincoln heads an outpatient clinic for psychosis therapy at the University of Hamburg. It is important to convey to the patient that their ideas are not crazy, but can be explained logically: They have interpreted certain events in an exaggerated manner. Because, in principle, many distortions of thought that occur in mental disorders are all too human: We all like to have fixed ideas about the world. Because of this, we perceive information that confirms our beliefs more than information that contradicts them. Holding on to beliefs helps us sort the world. However, we always run the risk of getting lost. Many people have even experienced hallucinations in one form or another, even without a mental disorder:
"It's not that there is such a clear line between healthy and sick, but that there are flowing transitions. And, yes, most people have something like paranoid thoughts sometimes, some even stronger."
A group comes towards me on the street. As I walk past them, they laugh. Did you laugh at me Sure, I've already seen that:
"And there are also quite a few people who hear voices. Or similar phenomena such as loud daydreaming, or the feeling that others can read your mind. That is not limited to the group that is then diagnosed afterwards. For example, when you come home from an event or a party where there has been a lot of talk. That you have such an echo, still hear the voices in your head. That is actually quite common. "
Psychoses can occur, among other things, in bipolar disorder and severe depression, but it is mostly about schizophrenic illnesses. However, the term schizophrenia is technically controversial because it encompasses so many different clinical pictures. But above all, it is stigmatizing for the patient. Therapists therefore prefer to speak of psychoses, even when they mean schizophrenic illnesses. How exactly they come about is still unknown today. There is the vulnerability-stress model, according to which people who are genetically, epigenetically or psycho-socially particularly vulnerable are ill due to a serious event in their life or due to a constant high level of stress. The idea: Information processing is reaching its limits and "cracks". The external stimuli can no longer be filtered, and events that are actually insignificant suddenly seem very important. People experience hallucinations and develop delusions.
Psychotic patients often have a negative self-image
However, cognitive psychology assumes other factors that play a role in the development of the disorder: According to this, psychotic patients tend to jump to conclusions and see the blame only on one thing or one person, even though an event has complex reasons. In addition, they often have a very negative image of themselves. Accordingly, they interpret the events in their life in a correspondingly distorted and negative way:
"Why does one have a delusional explanation and why does the other say, okay, I'm obviously stressed right now? And it's interesting to see why one is delusional. And then you have the link to the assumptions that the person has formed about himself and the world over the years. And that influence the nature of the explanation. "
Cognitive behavior therapy and medication
The common procedure in Germany is cognitive behavioral therapy, as recommended in the official treatment guidelines for schizophrenia. In the mid-90s, especially in Great Britain, new methods were developed specifically for psychoses, which are also used by more and more therapists in this country. It's about breaking thought patterns. Jürgen Voigt describes the ABC of cognitive behavioral therapy: A as in activating event, i.e. the triggering stimulus, B as in belief, i.e. the interpretation, and C as in consequence, i.e. the consequence for the behavior:
"A patient walks past a bus stop. That is the situation, A. And C, as a consequence it comes out, they all looked at me and they all think I'm crazy, and they all watch me to keep on watching say at the Office for the Protection of the Constitution and so on. And there is fear. But the fact is that there was something in between, namely B, the Believes, interpretations of this situation. What the others think, the patient doesn't even know. He thinks that they think like that. And you have to make it clear again, that you say, we don't know that now, that's what they have made of it. "
Indeed, this approach seems to be working. In general, it is not easy to prove the effectiveness of such psychotherapeutic procedures. Often only a relatively small number of participants are available to individual studies. Different questions and framework conditions make it difficult to compare the results. But last year a large-scale, international review was published by the Munich psychologist Irene Bighelli and colleagues. 53 individual studies were included. According to this, cognitive behavioral therapy, in addition to standard treatment with medication, can significantly reduce symptoms such as delusions and hallucinations and improve quality of life. Psychotherapy also seems to help patients who refuse drug treatment. A 2014 study by the University of Manchester followed patients for 18 months after therapy. After all, 41 percent still showed a significant improvement in their symptoms - compared to 18 percent in the comparison group who received neither medication nor therapy. Cognitive behavioral therapy - this means dealing consciously with the delusions. How plausible are they? But also: What role do these ideas play in my life?
"But it is actually even more important to look at each other, would there be any advantages if the assumption were not correct? What is the motivation to hold on to the assumption or not to hold on to?"
That also happens - sometimes the delusion is an asset that someone does not want to give up. Because he may be convinced that his actions are doing something good somewhere in the world. Or because his megalomania is good for him - and he manages to leave his surroundings alone with it.
Delusion as an enrichment for those affected
My friend Lars is in an acute ward, but he can also go out if accompanied. We go for a walk in the park, he talks, I listen. Or at least I pretend to be. It's just too taxing to follow all of the associative loops your thoughts make over the course of an afternoon. If I want to tell something in between, he hardly listens, his attention is quickly elsewhere. I tell Judith Behrend about it:
"I always try to be patient. You have to."
"No, actually it's much better to be normal. My current partner doesn't mince his words, even when I'm in psychosis."
It is assumed that 7 out of 1000 people develop psychosis, in Germany around 400,000 people are affected. Her treatment has always been a special challenge. The founder of psychoanalysis, Sigmund Freud, doubted whether it was even possible to treat psychoses. In his introductory lectures in psychoanalysis in 1916 and 1917, he referred to them as narcissistic neuroses and wrote:
"Narcissistic neuroses show no transference and that is why they are inaccessible to our endeavors and cannot be cured by us."
Neuroleptics for acute psychoses
The first neuroleptic came onto the market in the mid-1950s, in Germany under the name "Megaphen". Suddenly, quick and effective help with acute psychoses seemed to be possible. Research shifted to the field of pharmacology. Neuroleptics have now become the standard treatment, but they also have many disadvantages.
"The fact is that I've been trying to get rid of neuroleptics for 20 years, sometimes more, sometimes less ambitiously, and I just don't want to succeed. And that's a limitation, because of the side effects. So I'll soon be three times as much. what I used to be. And that's actually something that doesn't really suit me, from the point of view of the soul. "
Judith Behrend tried four or five times to stop taking the neuroleptics - each time she slipped back into psychosis. And so are many of you. The neuroleptics have an effect on the metabolism and many patients gain weight considerably. In addition, the drugs not only throttle the psychotic experience, all other sensations are also reduced. Affected people complain that they hardly feel anything. And the clearer the limits of treatment with psychotropic drugs become, the more interest in psychotherapy increases - not only among behavioral therapists, but also among competitors: psychoanalysts and depth psychologists:
"But Freud also said, at the same time and again and again, that his method as he is currently using it is not sufficient for this. But that there will probably be tools that can be used to treat people with psychosis."
In Germany in the 1980s the Frankfurt psychiatrist and psychoanalyst Stavros Mentzos laid the foundations for today's "modified psychodynamic psychosis therapy". For Mentzos, at the beginning of a psychosis there is an insoluble dilemma: In relationships with other people, the person affected fluctuates between excessive closeness and extreme distance. As a way out, the person concerned leaves reality and "saves" himself in the madness.
"Either I am with myself and lose the rest of the world and cannot survive. Or I am with the other and am no longer with myself and lose myself. So when I fall in love, I am absorbed in the other, symbiotically. If I don't fall in love, I'll stay with myself and never get anyone to be with. So falling in love is a very classic moment where they get psychotic. They can't because they can't get into staying with yourself in a relationship. "
The Berlin psychiatrist and psychotherapist Dorothea von Haebler co-founded the umbrella association for German-speaking psychosis psychotherapy in 2011 and co-authored a manual for this procedure. While behavior therapy primarily looks at the symptoms, the psychodynamic approach is about the patient having so-called model experiences together with the therapist. Exemplary experiences in which the dilemma is weakened:
"That is the most valuable thing we have. These are the small situations that people go into psychosis, that we also experience this in therapy, too much closeness, too much distance, we also experience that in therapy. That we can speak and learn from it, because it can be experienced relatively fearlessly in such a protected setting. The feeling, ok, we can sit here with two opinions in one room, nothing will break. "
The studies on the effectiveness of the psychodynamic approach in psychoses that have been carried out to date do not correspond to current research standards. Nevertheless, psychoanalysts are also turning more and more to the treatment of psychoses:
"The other thing is that there are now many young psychotherapists who see the need and are motivated. And there are also some who are in the field and say I want to get a foundation to treat people with psychoses didn't learn that, I may have done it, but I want to learn that again. "
Psychosis treatment by resident therapists
Psychotherapy for psychoses has been officially recognized since 2014 and is paid for by health insurance companies. Nevertheless, it remains the exception. If you take the number of illnesses as a starting point, mathematically nine percent of the patients at the resident therapists would have to be people with psychosis. In fact, only a third of them are in treatment, "says Lincoln.
"I went to psychiatry on Sunday. So these reservations, of course, are greater for me. Is that something like that for professionals too?"
"Yes, uncertainty in dealing with patients also plays a role for some. Our survey also showed this. So, the resident psychotherapists who refused treatment for psychosis patients, were some of the reasons for this."
Outbreaks of violence, as they occur in acute psychiatric wards, hardly play a role with resident therapists and in outpatient departments. Above all, psychotherapists fear greater effort or simply do not dare to treat these severe disorders. The older of them have not even been trained for it. But there are also other reasons why patients with psychoses do not receive psychotherapy too rarely. Many suffer from weak drive and fail at the first hurdle, namely to even call a therapist:
"And yet I would say that a lot of things are just prejudice. Well, that's a prejudice that these patients are so different. Because the therapists who work with these patients come to the conclusion that they are not that different at all. You can understand most of it, in terms of early experience, learning history and so on. It's not that you can't build a relationship. On the contrary, treating this group of patients is actually more interesting. No two delusions are alike and each is really different. "
"But then there is no such thing as the simple key."
"Yes, that's right. But that's actually the challenge, that's why they became therapists."
Lars ordered me to come to him, "by car, please". He is slowly preparing for his discharge from the hospital. We brought things from the clinic to his apartment in bags. How could he have accumulated so much stuff in his half of the two-bed room in a few months? And can he really already be alone? Psychiatric hospitals are no longer custody facilities. Patients will be let home as soon as possible. But Lars still looks very vulnerable.
Limitations of the drugs
He will have to take his neuroleptic for a long time. He's glad the drugs are there, and at the same time hates them. It is like many of those affected. It has now become clear that tablets are not the solution. They can provide relief in acute psychoses and suppress severe symptoms. But in the long term they are not the right remedy for most patients, says Haebler's psychiatrist:
"The drugs are not enough. The decade of brain research that has promised so much has partly become neuro-mythology. Some of them have actually achieved successes that cannot, however, be directly converted into therapy. We are with drugs, with genetic ones Research has reached its limits. The gene has not been found either, just a whole host of complicated mechanisms, which, however, do not yet allow for any therapy. Now we are coming back to talking therapy, which obviously also has an effect. "
Judith Behrend has now had five years of therapy behind her. She has learned a lot about herself, about her self-doubts, her high demands on herself and about how she can deal with situations:
"There is still this thinking and there is this remembering. And when I walk through the streets, then I know very well how I would perceive some things if I were emotionally on a different level. But I can put it away quite well. That is of course a success of the therapy, but also of the other building blocks that I had, the experience with it, the exchange with very good friends. "
She feels stable enough to work again and has started writing applications. She has retained her tendency to think about disasters. But now she can laugh about it:
"Yesterday I was looking for my watch in the garden, I didn't find it. And I really thought that the neighbor or whoever came along and got it. It is not materially valuable, but ideal. But that's the first thought, I can't find something and immediately think something negative. Then I found her and laughed. "
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