On a cold and wet afternoon in Dublin when one feels more like taking tea than working, a junior doctor receives a referral that a 31-year-old patient from the psychiatric ward has been shifted to the medical ward and will now be seen by your team. I was working in the Liaison department during those days and our team provided treatment to psychiatric patients in medical and surgical wards of the entire hospital and in emergency as well. I thought there would be a case of overdose or eating disorder that we usually see. It turned out that this patient was a little different and has caused a stir first in the hospital and then in the law chambers. Against the woman’s will, she was admitted to a psychiatric ward under the Mental Health Act. She was on hunger strike for ten days and said that she was God’s wife and God had instructed her to go on hunger strike for forty days to register a protest against the health services. Under the Mental Health Act, doctors could provide psychiatric treatment but Not force full feeding by inserting a feeding tube. Based on the physical condition of the patient, a written permission was taken from the High Court to forcefully feed her by inserting a naso-gastric tube. If the country was ours, I don’t know what would have happened to this woman. Even if nothing happened, for involuntary treatment, one would have to pay so much money to take the help of the law and fill in countless forms and then take orders from the High Court to give food.
The patient was transferred to the medical ward because she was suffering from salt and sugar depletion due to ten days of fasting and her heart rate was also slow. She had to stay there till she was physically rehabilitated and our team had to do psychological treatment in the medical ward. The problems were piled up and each problem was more serious than the other. The first problem was the correct diagnosis of mental illness in this case. The choice of medicines was also extremely limited due to her not taking pills by mouth and slow heart rate. Her physical health was deteriorating day by day and a High Court order was required for forced feeding. A meeting of cardiology, general medical and psychiatric teams decided on the best course of action to try the most effective way to help the patient.
What is psychosis? Losing touch with reality. Hearing sounds that others do not hear (Hallucinations) or believing things that do not exist for others (delusions). Alteration in brain chemistry takes the patient into another world that is real for him and unreal for others. The assumptions become reality and the nature of these assumptions can be dangerous. The belief that the hereafter is better than the world can force you to take your own life and the belief that your neighbour is against you and wants to kill you can compel you to kill him. Believing that you are God or His messenger can put your life at risk, and until the religious leaders realize that the divine claim is not your fault, it is a dopamine manipulation; you would have reached six feet below the ground.
Our patient was also suffering from psychotic illness (Schizophrenia). She used to hear the voices of God and believed that she was God’s wife. She can register her protest only by staying hungry for forty days. She expected more from me to understand her point because I also fast for thirty days of the year on God’s command. So how did her hunger become illness and my fasting became religion. When explaining Delusions, I often tell medical students that part of the definition is a false belief or belief that is not explained by religion or culture. No one has seen God, but many people believe in his existence, so it does not meet the definition of delusion. Hearing the voices of God, believing that she is God’s wife and recording her protest by starving could not be explained from the local culture or religion and treating her against her will was the appropriate course of action.
The lack of mental health infrastructure here is acutely felt after seeing the experience of the government hospital in Pakistan and the alleged accused brought in from the jail. Many bipolar disorder and schizophrenia patients are spending their days in prison cells for blasphemy or divinity claims. Many patients with bipolar disorder are completely healthy between attacks of the disease and have full knowledge of the disease. The other side of the picture is even more dangerous that these people’s stay in prison is probably a guarantee of their lives in our society. The so-called normal and religious people of the society would probably cast them into hell before knowing the motive of their actions.
Weekly anti-psychotic shots stopped the divine voices, the starvation disbelief was finally broken, the tube was taken out, oral feeding was started and she was shifted from the medical ward to the psychiatric ward and then discharged home. From ceasing food in faith to hear God’s voices and becoming his wife to accepting these symptoms as part of the illness and vowing to heal with medication, we walked through with the patient as a team. When self-boundaries are blurred and assumptions become reality and become only for you, you need empathy and treatment. Ridicule, imprisonment, accusations and discrimination, whether by individuals or by society, are counter-productive. Timely diagnosis and management can help them to become functional for their own selves, their families and society.