Pseudopsychosis: Does It Differ From Real Psychosis?

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What is pseudopsychosis? How does it differ from true psychosis?

Pseudopsychosis is a symptom of an underlying condition. In Brain on Fire, Susannah Cahalan appeared to be having a psychotic break but was suffering from an autoimmune disease.

Read more about pseudopsychosis and what caused it in Susannah’s case.

Experiencing Pseudopsychosis

On Susannah’s second day in the hospital, a team of doctors and nurses arrives to conduct another neurological exam. Susannah interrupts the exam to tell one of her neurologists, Dr. Russo, that the people on the TV are saying bad things about her. She throws herself off the bed and pushes her way past the team toward the door. Russo later diagnoses Susannah as manic and psychotic, with two possible diagnoses: bipolar disorder or postictal psychosis, psychotic behavior generated by seizures.

Later that morning, Dr. Siegel arrives. He’s a world-famous neurologist, and he assures Susannah’s mom that everything will be fine. Susannah’s mom clings to his words as if they’re a lifeline.  

The next day, Susannah is visited by a psychiatrist, Dr. Khan, who describes Susannah as “disheveled” and “fidgety,” noting that her pajamas are “revealing.” This visual description matches the psychological profile of mania. 

While Khan takes notes, Susannah announces that she has multiple personality disorder. She repeats her belief that it’s not safe for her in the hospital and says that she can hear the nurses’ thoughts. Khan asks what else Susannah can hear, and Susannah says, “The people on the TV.” Khan concludes that the team should be looking for neurological causes for Susannah’s pseudopsychosis. If they can’t find a neurological cause of the pseudopsychosis, Khan suggests they consider a diagnosis of bipolar I, a mood disorder characterized by manic and depressive episodes. That means it wouldn’t be considered a pseudopsychosis. 

Susannah stares at the doctor as she writes her notes. As she’s staring, she has a visual hallucination: The doctor ages right before her eyes. Susannah turns to Stephen, who’s also in the room, and sees him age too. “I can make people age with my mind,” Susannah thinks to herself. “I’m more powerful than I’ve ever been.”

Later that day, a fifth doctor joins Susannah’s team. Dr. Arslan is a psychopharmacologist, who suggests that Susannah might be suffering from “schizoaffective disorder,” a condition in which mood disorders overlap with thought disorders. He does not tell Susannah’s parents about his suggestion, believing the severity of the diagnosis would upset them.

Recordings Capture Erratic Behaviors

The video recordings made by the cameras over Susannah’s bed reveal that at 11:06 that evening, Susannah is trying to conduct a phone call using the TV remote control. “Oh my God,” she suddenly cries out and hits the call button for the nurse. “I’m on the news. PUT THE TV BACK ON!”  

“We’re investigating Susannah Cahalan. Her father recently murdered his wife,” Susannah hears the news reporter say. On the video recording, Susannah grabs the remote and speaks into it again. “Please get me a doctor,” she moans. “Please.” She hears the woman in the next bed talking on her cell phone: “There’s a Post reporter in the bed next to me. I’m going to record her and we can sell it to the Post.” Then the woman whispers to Susannah, “I don’t trust the nurses here. They’re bad news.” 

Susannah grabs the wires on her head and pulls them out along with chunks of hair. She leaps out of bed, sprinting past the security guard, racing into the arms of a nurse. The purple lady holds her down on the cold floor. “Let me go,” Susannah spits out, her teeth clenched. “Please.”

Susannah’s behavior prompts Dr. Russo to change her diagnosis from “seizures” to “psychosis.” Without telling Susannah’s parents, she recommends transferring Susannah to a psych ward if warranted.

As Susannah continues to deteriorate physically, her pseudopsychosis seems to recede. She begins to spend most of her time staring off into space. On her fifth day in the hospital, the doctors seize on Susannah’s passivity to give her a spinal tap. 

Many adults diagnosed with the disease were originally diagnosed with schizophrenia or autism. A small number of doctors, including Dr. Najjar, are currently researching the link between schizophrenia, autism, and autoimmune disease. (Shortform note: In 2018, Dr. Najjar suggested the term “autoimmune psychosis” to designate a subset of diseases in which autoimmune disorders masquerade as psychosis. See Najjar’s recent research published in the Journal of Neuroinflammation.)

Pseudopsychosis: Does It Differ From Real Psychosis?

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Like what you just read? Read the rest of the world's best summary of Susannah Cahalan's "Brain On Fire" at Shortform .

Here's what you'll find in our full Brain On Fire summary :

  • How a high-functioning reporter became virtually disabled within a matter of weeks
  • How the author Cahalan recovered through a lengthy process and pieced together what happened to her
  • How Cahalan's sickness reveals the many failures of the US healthcare system

Rina Shah

An avid reader for as long as she can remember, Rina’s love for books began with The Boxcar Children. Her penchant for always having a book nearby has never faded, though her reading tastes have since evolved. Rina reads around 100 books every year, with a fairly even split between fiction and non-fiction. Her favorite genres are memoirs, public health, and locked room mysteries. As an attorney, Rina can’t help analyzing and deconstructing arguments in any book she reads.

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