Once upon a time I saw a patient for followup, a woman I had seen for several visits in the past. She had voiced the usual oft-heard complaints about insomnia, changes in appetite, lack of energy, diminished interest in pleasurable activities, and other associated symptoms of chronic depression. Most of these had been addressed and had gotten at least partially better, to the point that her overall quality of life had improved, a clinical benchmark that I pay close attention to in all my patients. After all, if you’re not living better every day, what we’re doing is not working.

The sticking point here was that her chief complaint for this particular visit was continuing visual hallucinations. She would see people, most often a silent, ghostly woman, who would walk through the house, mostly staying in her bedroom. She never said anything (this patient never complained of any auditory hallucinations, just visual), but she would move things around on the dresser and sometimes even knock things off the dresser onto the floor when the patient came into the room. I pressed the patient for more details.

The objects were physically moving on the dresser, to different places than they started?

Yes.

They actually physically fell off the dresser onto the floor?

Yes.

Hmm.

Now, there are a few things about hallucinations in psychiatric patients that usually hold true. The first is, most folks are very reticent to come right out and tell me about these symptoms, for fear that I will think they are “crazy”. Patients who are truly psychotic will often just not want to reveal it to others, and they may suffer silently for some time before the severity of their symptoms comes out. Secondly, hallucinations of various types are things that the patient experiences, but by definition others around them do not. If you are hearing music playing in the room where we are sitting and having coffee together and I do not hear it, and there is no discernible source for this music, you may be hallucinating it. Stands to reason.

So, we discussed this for a few minutes more, and then I turned to her very quiet boyfriend, who was sitting in the opposite corner from the patient. He was sliding down into the chair, and it appeared that he was trying to become one with it. This was my second clue that something was not quite right here. I asked him some similar questions.

When she is seeing this woman who sweeps things off the dresser onto the floor, do you see her too?

No.

Ah. Do you see the objects on the dresser actually move?

Yes.

Ah.

Do you see them actually fall off onto the floor, as she describes?

Yes.

Hmm.

Now, before we go any further, some of my readers are most likely already aware that there is such a thing (or was, in the DSM) as folie a deux, a shared psychotic disorder.

This was not that.

I was unsure at the get-go that the visual hallucinations that the patient described were legitimate. I was pretty much certain that the descriptions the boyfriend gave were bogus. The story just did not ring true from what we know and from my decades of experience interviewing and treating folks who are truly floridly psychotic.

Why is all this important? Well, this lady was already taking medications for her depression, and they had seemed to help her. The level of her depressive symptoms was not nearly as bad as it had been on initial presentation. She was better, functioning better overall, as I alluded to in the very first paragraph. The problem that she and I had to come to grips with was that if she truly had psychotic symptoms that happened this often and were this obvious and that impaired her functioning, then I was going to at least consider and discuss with her the use of antipsychotics, big-gun drugs that treat these types of symptoms. As some of you know, they are useful and helpful drugs, but they are not without potential serious and significant side effects and risks.

Use of antipsychotics can lead to weight gain, elevations in blood sugar and blood lipids, and even irreversible abnormal involuntary movements that can be quite debilitating, more-so than the symptoms they were prescribed to treat. They should  not be prescribed lightly, and with informed consent.

The bottom line in this case? I decided, along with the patent, not to prescribe antipsychotics. I thought the risk to benefit ratio was too high to justify their use at this point. I was not convinced that these symptoms were severe enough to warrant that next step in medication treatment.

There are at least two major issues in play here, when all is said and done.

One: it takes time and effort to sort out histories and stories and elicit details about symptoms, to better understand what we are treating. This is a necessary step to avoid shooting from the hip and simply writing a prescription for serious drugs that someone may not really need at all.

Two: with the ongoing changes in out healthcare system, it is going to be much easier to do exactly that — get minimal and superficial information about symptoms, reduce everything to the common denominator, and treat. Next patient.

Complicating this, especially in the south where I practice, is the fascinating fact that people will report seeing their deceased relatives days, weeks or months after they die, hear them talk to them in actual conversations that they swear are real, and find that these phenomena are perfectly culturally acceptable.

Are we dealing with hallucinations? Haints? Hooey?

Do people have hallucinations that are true psychiatric symptomatology? Do they actually communicate with those who have already passed on and is this a perfectly acceptable cultural norm in some places? Are stories like this made up for reasons of secondary gain or other reasons?

Greg Smith is a psychiatrist who blogs at gregsmithmd.