You smell like…
#43 - Letters to the Rest of Us
Hey you,
The other day I was talking with a colleague about how I first learned to recognize psychotic disorders. As I said it out loud, I realized how strange it sounded. “I could smell psychosis before I knew what it was clinically.”
Since then, I’ve found myself bringing up this story with friends and colleagues because it reopened a question I hadn’t thought about in years. I’ve always known my sense of smell was different.
Of course, I wasn’t diagnosing psychosis by smell. What I meant was much harder to explain. Before I had the DSM. Before years of supervision refined my clinical judgment. Before I could confidently distinguish psychosis from mania, delirium, trauma, or severe depression. My brain had already begun noticing a pattern that I didn’t yet have the language to describe.
I’ve always had an exceptional sense of smell. For as long as I can remember, I’ve experienced the world through my nose. I could tell when someone had just come in from outside before I heard the door open. I could often tell when something wasn’t right with a car before anyone else noticed. I was convinced electricity had a smell because, to me, it did. More than once, I’ve told someone they were getting sick before they had any obvious symptoms, only to get a text a day or two later saying, “How’d you know I’d be sick?” or a “yeah, my tooth is infected.”
For most of my life, I assumed everyone experienced the world this way. It wasn’t until I was diagnosed as autistic that I began revisiting those experiences with a different question. What if my senses weren’t simply more sensitive? What if they were attending to different information?
Early in my career, I responded to mental health codes in the the emergency department at the VA. I was learning how to recognize severe mental illness the same way every new clinician does. I had the DSM. I had incredible supervisors. I had colleagues who challenged my thinking and helped me develop sound clinical judgment, but before I had the clinical language to explain what I was seeing, I noticed something I couldn’t explain.
Some patients experiencing severe psychosis had a subtle physiological scent. I still struggle to describe it because it wasn’t like any other smell I knew. It wasn’t poor hygiene, alcohol, cigarettes, or the smell of the emergency department. It was simply… different.
I never documented it because there was nothing to document. I never considered it evidence because it wasn’t. It certainly wasn’t how I diagnosed psychosis. What it did do was make me slow down. It made me ask another question, spend another ten minutes in the room, and bring the case back to supervision. Looking back, I don’t think I learned psychosis by smell. I think smell caught my attention before my clinical training helped me understand why I was paying attention in the first place.
Years later, while reading about volatile organic compounds (VOCs), I found myself unexpectedly revisiting those early experiences. Research exploring metabolic signatures in psychiatric disorders, including schizophrenia, offered a possible biological perspective on something I had noticed long before I had the language to describe it.
We’ve gotten pretty good at talking about autistic sensory sensitivities. We know they can be overwhelming. We know they can make fluorescent lights unbearable, clothing tags intolerable, and crowded rooms exhausting. What we don’t talk about nearly as much is how those same sensory differences might shape perception, observation, and pattern recognition. I think those are two very different conversations.
More recently, I started reading about predictive processing theories of autism. One idea is that autistic brains may process incoming sensory information differently, placing greater attention on present sensory input than on prior expectations. The theory is still evolving, and I have no idea whether it explains my experience. It made me wonder. Was I noticing subtle physiological changes?
Was my brain simply paying attention to sensory information that most people unconsciously filtered out? Was it some combination of both?
I don’t know.
The older I get, the more comfortable I become with not knowing. What interests me now isn’t proving that an observation is correct, but it is understanding why I noticed it in the first place. It has changed the way I think about autism, mental health, science, and clinical reasoning.
Maybe neurodivergent perception isn’t about noticing more. Maybe it’s about noticing differently. That doesn’t replace evidence nor does it replace careful assessment, supervision, or science. It simply reminds me that every meaningful question begins the same way.
Someone notices something they can’t yet explain. I still don’t know exactly what I was noticing all those years ago.
I just know it was enough to keep me curious. I suspect curiosity has been one of my greatest teachers.
Until next time,
ericonda
P.S. Has there ever been an observation you couldn’t explain until years later?