When Reality Begins to Blur

Patient details, including the name used here, have been changed to protect privacy.

Settling into work at Mathari Teaching and Referral Hospital has been an education of contrasts. There is the intellectual reward of seeing theory take shape in real lives, as concepts once confined to textbooks sit across from you and speak to you. And there are the moments that unsettle, when you become aware of your own vulnerability and are reminded that the mind, which we often assume we command, can move in ways that are unpredictable and at times beyond immediate control.

What becomes clear in this work is the capacity of the mind not only to create, adapt, and endure, but also to convince, to build a reality that feels internally coherent even when it diverges sharply from shared reality. The clinical difference lies in how anchored those perceptions are to the reality others can confirm. Consider a patient I will call Justin. He was brought in by a parent, not out of defiance but out of confusion and quiet urgency. Justin believed he had been sent on a divine mission to deliver a special message to the country’s senior leadership. He spoke with conviction, not hesitation and not metaphor. He also believed that the obstacles he met were not ordinary difficulties but punishments for trying to fulfil this task. To him this was not unusual. It was purpose.

When belief becomes a clinical concern

Clinically, this presentation is consistent with a manic episode in bipolar disorder, accompanied by grandiose delusions. Mania is not simply an elevated mood. It is a state of heightened energy, reduced need for sleep, accelerated thinking, and at times a distorted sense of one’s own importance or ability. From inside the experience it can feel like clarity, as ideas connect rapidly and the world seems charged with significance. From outside it appears as disorganisation. This raises a question that reaches beyond the clinic: how does an ordinary observer tell the difference between strong belief and clinical concern? Human societies are built on belief systems, religious, cultural, and personal, and conviction alone is not illness. The distinction lies not in what is believed but in how the belief functions.

There are several markers clinicians attend to, which can also guide the public. One is the degree of certainty, since in states such as mania beliefs are often held with unshakeable conviction even when there is clear evidence to the contrary. Another is the impact on functioning, that is, whether the belief is disrupting sleep, work, or relationships. A third is behavioural consequences, whether the person is acting in ways that put them at risk financially, socially, or physically. A fourth is change from baseline, whether there has been a clear shift from how the person usually thinks and behaves. A fifth is the presence of associated symptoms, such as reduced need for sleep, rapid speech, impulsivity, irritability, or a surge in goal-directed activity. It is the pattern, rather than any single idea, that signals concern.

Recognition, treatment, and a livable life

For families these distinctions are rarely clear at first. What they notice is change, subtle and then pronounced: a loved one who sleeps less, talks more, and becomes unusually certain, sometimes charismatic and sometimes irritable. At first it may even look positive, full of energy and ambition, until it crosses a threshold and the coherence begins to fracture. In many Kenyan settings, as elsewhere, these changes are read through several lenses at once, psychological, spiritual, and moral, and a person may be seen as inspired, troubled, or called. These interpretations are attempts to make sense of something complex, but without clinical grounding they can delay help, and timing matters. Early recognition and treatment of manic episodes improve outcomes. Medication, particularly mood stabilisers and antipsychotics, can help regulate the processes underlying an episode, and psychotherapy provides insight, structure, and longer-term strategies.

This leads to a question that often goes unspoken: can people who experience these conditions live meaningful, good-quality lives? Grounded in both research and practice, the answer is yes, but not passively. Bipolar disorder is a long-term condition that usually requires ongoing management. Stability is not the absence of vulnerability but the presence of structure: consistent treatment, psychoeducation, supportive relationships, and attention to early warning signs. With these in place, many people live productive and meaningful lives, though outcomes vary and some people continue to face significant difficulties. Without support, the cycle of episodes can become disruptive for the person and for those around them. Working at Mathari has shown me that mental illness does not sit at the margins of society. It exists within it, in families, workplaces, and communities, often unnoticed until it is not. The responsibility, then, is shared. Not to diagnose, which remains the work of trained professionals, but to notice when something has shifted and to respond with informed concern rather than fear or dismissal, asking whether this is different from how the person usually is, whether it is affecting their wellbeing, and whether they might need help.