I.

Old news, but I only just heard about it: Long Island woman says psych ward doctors believed she was delusional for insisting Obama follows her on Twitter.

The story: a woman was brought in for psychiatric evaluation. During the evaluation, she said President Obama followed her on Twitter. The psychiatrists decided she was psychotic and forced medication on her. But in fact, President Obama does follow her on Twitter, just as he does six hundred thousand other people. So they committed a perfectly sane person for telling the truth, leading to what the article calls a “frightening eight-day ‘One Flew Over the Cuckoo’s Nest’ ordeal”.

I don’t know anything about this case or this person, and I definitely don’t want this to sound like I have anything to say one way or the other about this person I have never met. But I’ve been involved in enough similar cases to have a different perspective, and wonder whether it was quite as much of an outrage as the article makes it out to be.

Consider: the comment occurred when she was in a hospital for psychiatric evaluation; that is, she was brought in before the Obama comment. According to the article:

The bizarre experience began Sept. 12, when the NYPD seized her prized 2003 BMW 325Ci in Harlem because they suspected she was high on weed, her attorney, Michael Lamonsoff, said. Cops found no marijuana but confiscated her ride anyway, he said. The NYPD declined to comment. The following day, Brock walked into the NYPD’s Public Service Area 6 stationhouse in Harlem to retrieve her car, her suit charges. Brock — an eccentric 32-year-old born in Jamaica with dreams of making it big in the entertainment business — admitted in an interview she was “emotional,” but insisted she in no way is an “emotionally disturbed person.” Nevertheless, cops cuffed her and put her in an ambulance bound for the hospital, her suit charges.

This sort of elides over everything in between “went into police station to ask for car back” and “cops put her in an ambulance bound for the hospital.”

I’ve had patients sent by ambulance from the police station. It’s almost always because they started screaming and yelling threats at the police. Now, screaming and yelling threats at the police, although not a very good idea, is not always evidence of psychiatric disorder. But it often is. If you’re manic or on drugs, you’re a lot more likely to have the particular type of bad judgment that makes screaming threats at the police a seem like a good idea.

I don’t know what happened with Ms. Brock, and the article doesn’t say. I did take a look at her Twitter account, which is mostly angry tweets about Trayvon Martin, Mike Brown, and police brutality. A typical example is “Police should NOT be allowed to Murder the Citizens of this Country!!! We are not Animals!!! @BarackObama fix it NOW!!! #BanGuns”. Other Tweets seem maybe a little threatening, like the ominous “@NRA you people deserve the wrath that will come on you in the very near future” and “#KillRacists”.

So – cops have just done something very unfair to a person who likes making threats and doesn’t like cops, and who herself admits to being “eccentric” and “emotional”. Again without knowing what went on, my guess was that her “discussion” with the police was sufficiently exciting that they thought calling an ambulance for a psych evaluation was in order.

So imagine you’re the psychiatrist, you’re receiving a patient from the police for evaluation after she got in some kind of screaming match with them. And now she tells you Barack Obama follows her on Twitter. The article says:

“I told (the doctor) Obama follows me on Twitter to show her the type of person I am. I’m a good person, a positive person. Obama follows positive people!”

This is weird. At best, it displays a surprising ignorance of how Twitter and/or the world works. Yes, Obama follows 600,000 people on Twitter, but this does not prove that each of them is “a positive person”. I would assume he has some program that auto-follows anyone who mentions him. When you think this is a good thing to bring up during, of all times, a psychiatric evaluation, then I start to wonder.

(I should also add here that, in my limited experience, social media is God’s gift to grandiose psychiatric patients. None of them are “a guy with a Facebook page”. They’re all “social media celebrities with hundreds of followers”. It’s always “YOU CAN’T DO THIS TO ME! DO YOU KNOW WHO I AM? I HAVE HUNDREDS OF FOLLOWERS ON TWITTER! EVEN [NAME OF TWITTER PERSON I HAVE NEVER HEARD OF] FOLLOWS ME! THIS IS GOING TO GO VIRAL!” One patient even told me, in a threatening manner, that his blog had over a thousand hits. “You mean a day?” I asked. “No, total,” he answered. Then he wondered why I was so utterly failing to look impressed.)

So I’ll be honest – if someone had just been brought in for a shouting match with police, and the first thing they told me was that President Obama follows them on Twitter, well – among the most common symptoms of mania are irritability, grandiosity, poor decision-making, and flamboyant dress/behavior. Getting in a fight with the police sounds like irritability and poor decision making, thinking the Obama follow is relevant sounds like grandiosity, and this woman’s Facebook photo certainly suggests a flair for the dramatic. I’m not saying I would commit her on these factors alone, and a lot would depend on the rest of the history. But she already would have started digging quite a hole for herself.

Remember, psychiatrists have to err on the side of admitting people. Even if this lady didn’t have bipolar disorder, admitting her for further evaluation seems like the sort of thing that could be an honest mistake.

(and remember, all we have here is her side of the story. Goodness only knows what other things she might have said or done that she didn’t leak to the news for their sympathetic article based entirely on her testimony.)

But then there’s the hospital’s subsequent conduct. They said that she was unemployed. She said she was employed and could prove it through her Internet presence. The hospital apparently didn’t check and continued to say she was psychotic for thinking she was employed. How could the hospital possibly be so incompetent as to not check the link to her employment documents that she was personally giving them?

II.

Let me tell you about Professor T.

(this would be a good time to reiterate that every patient story I tell here is a composite of multiple different people with all of the details changed around to protect anonymity. The gist of the story points out a true thing, but the specifics are all twisted around so thoroughly that even the people involved couldn’t recognize themselves.)

Professor T came to me in handcuffs. The police had picked him up in response to a call at the local university, where he was trying to give a lecture to a class that wasn’t expecting him and didn’t want him. The class’s actual professor had asked what the heck he was doing, and he had explained that he was Professor T, world-famous physicist, and that the head of the college had invited him to give a lecture on his theories that day, and it was too bad she hadn’t communicated this with the rank-and-file teachers, but he was a very busy man and they should all be honored by his presence and stop what they were doing and listen to him. A quick call to the administration confirmed none of them had any idea who he was either, and when he refused to go away or stop trying to lecture, the police were called to remove him. He started yelling and screaming at the police and telling them they were fools who were too small-minded to recognize a great scientist when they saw one, and they’d get what was coming to them. The cops decided this was a job for a psychiatrist and brought him to me.

Professor T said he’d just been really angry that the bureaucracy had screwed up badly enough to make him miss his lecture and that no one was willing to accommodate him. He was, after all, a very important leading scientist with a busy schedule. He moved in elite circles! Famous people like Edward Witten knew him well, and I was welcome to call to confirm that! He was used to being shown more respect!

I got a weird vibe from Professor T during our discussion. I know that distinguishing between professors and hobos is a famously difficult problem, but he just struck me as a little too much towards the hobo end for comfort. So I asked him if I could see any proof that he was who he said that he was.

He was happy to comply, and once we got to a computer he showed me some scientific papers with his name on top, suitably peppered with complicated words like “tachyon” and “chromodynamics”. He showed me a picture of him winning some prestigious physics prize, dressed in a lab coat with a medal around his neck. He even showed me what looked like a press release: “Professor T comes up with new Theory Of Everything that may explain Higgs Boson”. It was pretty convincing.

But.

A bunch of patients had cancelled on me that day, so I had way too much free time. I started looking into Professor T’s credentials a little more. His papers were hosted on a private site and didn’t show up on Google Scholar and didn’t seem to be affiliated with any journal. The press release was on the same website, and seemed suspiciously badly written. There was nobody else in his photograph, and it was impossible to see what was written on the medal. Was it possible that a crazy hobo had just written some things that looked like papers, written something that looked like a press release, and then bought a lab coat and medal and taken a picture with them? Do real theoretical physicists even wear lab coats?

So I asked him if I could talk to Dr. Witten, whom he said he knew well. Professor T agreed. I Googled his phone number and called him up.

(It wasn’t actually Dr. Witten whom I called, but the case I’m adapting this story from involved someone else about as famous)

His secretary answered the phone, and I said I was a psychiatrist, and I asked if I could speak to Dr. Witten. The secretary was reluctant, but when I said it was about Professor T, she immediately asked me to hold, and I got Dr. Witten himself. I asked him if he knew Professor T.

“Absolutely,” said Dr. Witten. “He’s a crazy guy who keeps calling me up and telling me he’s solved physics. I don’t think he’s actually a professor of anything. I read one of his papers once, just for kicks, and it’s just a bunch of science terms like ‘tachyon’ and ‘chromodynamics’ strung together without rhyme or reason. It might fool a layman, but trust me, it makes no sense. I told him to stop calling me, and he wouldn’t, and finally I had to block him on my phone, and now he’s sending me letters in the mail, and it’s always same ranting about tachyon chromodynamics, which isn’t even a real thing. Did you say you’re a psychiatrist? Perfect, I’m so glad he’s finally getting treatment.”

I told Professor T about this, and he nodded his head. “Yes,” he said “I told you that Dr. Witten knows me well. I didn’t say he liked me. He still doesn’t fully understand my theories. But I am sure he’ll come around.”

I kept Professor T in hospital for about a week, and I can’t count how many times he yelled at me and complained that I was being unfair to him by not doing whatever the heck he wanted me to do that day. Read another one of his papers that would convince me his theories were sound. Call up yet another famous physicist he “knew”. Look at yet another of his fake websites devoted to himself. Every day, he threatened to sue me and my boss and the entire hospital for keeping him there even though he’d “proven” to us he was who he said.

Remember, delusions are fixed false beliefs. People are quite sure they’re true, quite sure they have evidence for them, and nothing (except occasionally really good psychiatric treatment) will convince them otherwise. They’ll keep demanding you take time to investigate more and more bizarre “arguments” and “evidence”, and if you ever stop, even after days and days of everything they say being one hundred percent refuted, they’ll accuse you of acting in bad faith.

(it’s like Internet arguments, only more so)

In everyday life, we get by on an assumption of trust. If I tell my boss I’m sick, he probably believes me. If he doesn’t believe me, and I send him a doctor’s note, he probably believes that the doctor’s note isn’t forged. If he doesn’t believe that, and he asks me for a number to call the doctor at, he probably believes it’s a real doctor and not my brother pretending to be a doctor to help me out. Yes, there are a couple of people who abuse that trust, but few enough that the rest of us are usually able to get by.

In psychiatry, there are a bunch of delusional people, paranoid people, narcissists, compulsive liars, and others who deliberately or unknowingly stretch the truth past the breaking point. Worse, a lot of the cues we use to detect liars, like “Are they shifty-looking?” don’t work, either because the person involved really believes what they’re saying or because they’re too far from the neurotypical norm for our usual intuitions to apply. A lot of the assumptions of trust we usually use crash and burn. If the person sitting next to me on the train says he’s a physics professor, I believe him. If the person brought in by police for a psychiatric evaluation says he’s a physics professor, maybe I don’t, and “how much time do I spent assessing the evidence and how much do I believe?” is a really tough question.

I am not trained as a police officer, detective, or judge. I’m also not paid to do their jobs. I’m also stuck in a system where the primary incentive is that if I ever fail to commit someone, then if they do anything bad after that I can be sued for everything I own. So I am stuck drawing partial conclusions, from incomplete evidence, in time I don’t have, from people I can’t necessarily trust, without even the ability to err on the side of caution.

I don’t think the hospital in the article followed great practices – in particular I’m unclear on how they came to believe the person was unemployed. And sending her the bill for her own involuntary commitment is an obvious injustice (albeit a universally practiced one). But the mistakes in the admission process are all ones I can imagine any psychiatrist making. Including me.

And that means something. You can trust me. After all, four different Dalai Lama accounts follow me on Twitter.