"O, let me not be mad, not mad, sweet heaven,
Keep me in temper: I would not be mad."
When a patient says, spontaneously and early in an interview, "I am not delusional," it could be either a good or a bad sign, prognostically, but it does portend an interesting session. Patients with schizophrenia or bipolar disorder are often in denial, but not typically in such an explicit and articulate fashion. Delusional Disorder is something of an oddity, a diagnostic stepchild. Patients suffering from it often have well-preserved cognitive and behavioral function, such that they are less likely to come to clinical attention than other psychotic patients. Age of onset is somewhat later, often middle age, and in my experience at least, women are more commonly affected.
In many cases of psychotic disorder the pathology hits you in the face, figuratively speaking; the question is primarily how to manage it, how to try to rebuild. If schizophrenia is a half-demolished city block, then delusional disorder is an outwardly unremarkable one: a little faded, perhaps, and somewhat deserted, but seemingly intact. Then suddenly you walk around a corner and nearly fall into a gaping sinkhole; picking up a volume of Thomas Mann, you open it and instead find a Kafka story. Or maybe it's more like stepping into an Escher print--no matter how far you seem to walk, you always end up where you started.
I find it uncanny at times to be with patients like this. It is as if our respective realities only partially overlap; the person seems only halfway within "my" usual epistemological universe. We witness the same states of affairs, in a literal sense, but we make totally different inferences from them. With other psychotic patients I don't really get this sensation. They may hear voices or they may think they're Jesus Christ, but they're either with me or they're not (in a metaphysical, not a moral, sense); patients with delusional disorder are half with me, half not, sort of like the Nazgul in Middle Earth (but without sinister implication). Maybe it's a bit like confronting a hologram--it seems like you could just reach out and connect, but you miss every time.
I thought of this for some reason the other day when I read a fascinating, and inexpressibly sad, profile (encountered by way of Arts and Letters Daily) of a family who perished in the Jonestown mass suicide in Guyana. If loving parents cannot get through to an only daughter in the grip of delusion, then who could? Fanaticism of all stripes as well as cult behavior provokes the same experience with me, the disconcerting feeling that some people may be physically next door but, in another sense, inhabiting parallel, and shocking, universes.