Editorial Comment:    A recovery without joy  (De-identified case following 16 APR 2019 notes on “hyperkatifeia”)

Decades ago, as an older resident in a second career, I met with a 17-year-old Chinese-Hawaiian-Filipino male in the emergency room of a large acute-care hospital. He will be “Kyle”.  He was agitated and acknowledged intense anxiety.  The basis for his evaluation was his inability to communicate coherently, plus his acknowledgment that he was experiencing auditory hallucinations. He had appeared angry, even threatening when at home, but only later did it seem that this was because of a failure to be understood.  Also later, he conceded that his anxiety was really apprehension about what would happen to him in an emergency room: in all of his life he had not been in one. His only reasons for medical care had been routine immunizations and health checks, and several mild sports injuries. Urine toxicology disclosed methamphetamine.  At that time the initial approach was, and is largely still, a conventional D2 blocker such as haloperidol and a benzodiazepine. He was voluntarily admitted to the hospital and by the second day his symptoms had largely remitted. But the significance of this case was in the timeline of the illness, and in his central complaint in each of multiple relapses.  He was again seen by me, again in the emergency room, two weeks later. Admitted once more to the hospital, he did not enjoy a remission for almost 4 days. He confirmed that he had returned to use of methamphetamine. When asked why - not usually a useful question - Kyle described not merely dysphoria, but a sense of being incomplete and off-balance. In trying to characterize his feelings, he stated that he felt less sad than exasperated, exasperated that he could not emerge into a remembered normal affective state. Over time, I came to see him coincidentally in the series of locales that is also the leapfrog journey of a general psychiatry resident: longer and longer stays in the hospital, long follow-ups in an outpatient clinic interrupted by periods of complete disappearance, incarceration for public misconduct, followed finally by an extended stay in the state hospital. At that time, we did not know clearly the natural history of recovery from severe methamphetamine use, later elucidated by Nora Volkow and Linda Chang with imaging studies at Brookhaven Institute, so when he posed prognostic questions to me, my responses were more encouraging than based in evidence; psychiatric cheer-leading, if you will. He would ask me on each occasion, 1) when will the hallucinations stop?  …and, 2) when will I stop feeling so incomplete? …He added, “I don’t really care so much about the voices as they are now fairly calm, even tame; but I am forgetting what it felt like to feel ‘normal’.”

The questions are of course similar for those who experience schizophrenia, although in this case the patient understood and clearly associated his illness with his use of methamphetamine; he had insight. And as all who practice in a community setting understand, the diagnostic distinction between an idiopathic psychosis and a toxic psychosis is confounded both by the usual time of onset of both, in late teens or early adulthood; and further by the inclination of people with psychosis to use street psychoactive substances.  But for Kyle, as each episode’s weeks stretched into months, the discomfort was quite nearly physical. He asked, “What is vertigo like?”  And, after I had explained that phenomenon as best as I could, he responded that it was not the same, and yet he felt that he could sympathize with people with vertigo.

It was a lengthy fight with despair.  But the story does not end unhappily; by misbehavior and so by serendipity, he found himself remanded to a long-term abstinence-based therapeutic community for those with alcoholism.  After approximately a year there, he was reminiscing to another patient when he realized that he was experiencing a state of wellness that had characterized his early ‘teens.

He cheerfully caught me up on all of these events when I inadvertently ran into him on the street of our city, as he walked to his job, by that time in his early 30s. I could not recall all the details but did remember his strange reference to being off-balance and asked him if that, too, had resolved; he smiled, and said that it had. He had entered the therapeutic community on a day after the New Year’s.  On Christmas he awoke looking forward to the day.

- W. Haning, MD