For most of you, people with paranoid disorders are encountered more frequently online than in regular life. Not for me, of course, but my situation is unusual. I would like to explain them to you a bit. Parts of their thinking that seem strange are quite reasonable once you understand what they are starting from. They may end up in a crazy set of ideas, but the reasoning to get there often makes an internal sense. This is part of why you can’t argue them out of these ideas.  It’s not that their reasoning is broken, it’s that something else is broken. Chesterton’s first chapter of Orthodoxy goes into the idea quite well from the perspective of a nonprofessional writing over a century ago. And fun.

First, they retain most of the knowledge and abilities they had before, not necessarily impaired in any way.  If she knew horses well, she still knows about horses; if she played the cello well, she can still play well.  She may have developed suspicions about people in the horse barn or the orchestra.  These may grow until she can no longer manage to stay involved with either. She may or may not be attracted to new theories that explain things to her and decide that horses or music are far more important in the cosmic scheme of things than others have noticed.

There is a sense that some things are important that others have overlooked.  In the same way that theme music plays in a movie, telling us that the villain has arrived, (cue Darth Vader music) the person with paranoia has a sense (quieter, though no less sure) that something ominous is occurring when they hear the news or even just go to the supermarket.  The number 7 is occurring too frequently, there are people who have Russian names, or look Russian, the cashier exchanges a look with the bagger that tells the person she knows something. They wonder for a time what it all must mean, but settle quickly on an explanation.  The brain will not allow events to stand unexplained.  They must be fit in somehow. The insignificant data that is regarded as significant continues to accumulate.  This is supplemented by real data , sought or unsought. The ATM has twice not been available when you needed it most.  A guy who you met just last week and told about these growing plots has a car accident.  There must be a Russian (or more frequently, a Jew) behind this.  Those forces are signalling to you to back off.  They know you are onto them and will punish you.

Think what this must be like from the inside.  This plot is real, you know it is.  You try to explain it to others to warn them, but they cannot be made to see. The fools.  They must be stupid, or unobservant, or easily misled, because what else could it be? These things are obvious, but no one believes you.  You conclude that you must be very knowledgeable, very important. You see behind the superficialities and know what is really happening.  That thing you call the news?  It’s just what they want you to think. If you were religious, that is likely incorporated in to give you a special status. Even people who were naturally quite humble will get caught up in such things. “I’m nobody important myself, but God has called me to preach this message.”  And what is the message?  “That the last days are happening.” “That I am a prophet.” Or “That people should love more.” There are other variants for Eastern traditions.

One would think that with such rigidity the specific delusions would remain constant, but this is not always so.  I have had patients whose explanations have changed over the years, though they deny this.  On a milder note, I know people who are sure that the non-obvious is more real than the obvious who have changed their focus for exactly who is pulling the strings over the years. (If it goes on long enough, it seems to inevitably become the Jews.) Memory changes as well.  It is very common when bad events happen for many of them to say “I predicted all this long ago, but you wouldn’t listen.” There is an advantage online is that sometimes you can go back and check what they did say, and no, they didn’t predict this.  What happened is that they had a sense way back then that something was wrong and that evil would come of it, and they had many suspicions. They said something. When the bad event occurs they remember that one, or something that vaguely looks like it and insist “I told you so.  I knew.” As they have suspicions about everything, all the time, it is hardly surprising that they had suspicions in 2015 or 2012.  They change their memory – I think almost instantly – of what they thought then.

Nonetheless, it becomes one more reinforcing bit of data. I have been saying brilliant things for years, but no one acknowledges me. It only goes to show how evil the great powers are and how stupid nearly all others are. It has all happened again.

It is hardly surprising that they are particularly upset at those who tell them that they are psychotic, and they devote energy to sloughing off that claim.  They will tell you that the psychiatric medications recommended make you psychotic, which is 10% true – true in certain circumstances that are easily remedied. They will sometimes even focus on a particular mental health professional who they believe has ruined their life.  I never had any of these problems in life until they brought me to the hospital and I had Dr. Katz. Yes, and you didn’t have to wear a cast until they brought you to that other hospital and Dr. Killani put one on you, but that doesn’t mean he broke your leg.

They are attracted to other paranoid theories and may come to adopt them as better explanations than their own, and they gravitate toward other paranoid people, but these seldom last.  They cannot sustain relationships with people who don’t agree, and sometimes this has to be 100% or nothing. Even the groups that have stability over time do not often have stability of membership.  People drift out.  There are Feeneyites who claim that they are “just traditional Catholics” that have existed as groups for decades. Yet (I am told) the individuals last less than a decade in the fold. They move and become regular Catholics with a bit of paranoia in the background, or they drift away altogether, or decide that they have been duped and aggressively make some other religious choice. The great multiplicity of hate groups the SPLC keeps uncovering is often the same guys leaving one small group and starting or joining another. Not that this is noted by the Dees group, who attract funds by identifying as many problems as possible.

Does this paranoia get better over time, receding on its own?  I don’t think so. My observation is that it grows worse:  more strident, more disconnected from reality, more bizarre.  I admit that is not a professional opinion or supported by any research I know of.  It is my impression, both online and from live experience, but both could be unrepresentative samples.

Are they dangerous?  Well, we are all dangerous.  If they have lots of money or power they could become dangerous.  If they are trained in weaponry or martial arts they could be.  If they can exploit a particularly technology, sure, dangerousness could flow from that. Only a little different from the rest of us. I had a friend long ago who had paranoid schizophrenia, who believed the people next door to him were killing babies in the basement.  That might prompt any of us to turn violent to try and stop that, mightn’t it?  Yet he was a gentle soul, and so just kept reporting it to the Nashua PD and picketing the front of the house with signs. He could not stomach being violent himself. Yet I have known other gentle, responsible souls who did become at least somewhat violent over time because they had just had it.  They saw no other solution. I would say “more than the average person, but perhaps still not very much.” Here is a story about the lack of predictability to scare you.  Up in Wolfeboro about two decades ago there was a paranoid man who lived off on his own, deep into his property, who seldom came out over thirty years except to buy a few things.  The police had known about him for years and even had a pretty good relationship with him.  Someone wished to speak with the man – perhaps to buy property? I forget – and asked the police if it was okay to approach him.  The PD assured him it was.  The visitor drove up the long dirt driveway, got out of the care and waved, asking to approach, and was shot.  You would think a track record of thirty non-shooting years would be enough to make a prediction from.

On the internet, you have no way of knowing whether this is a guy who is making serious plans or just a guy in an attic grousing.

14 thoughts on “Paranoia”

  1. AVI — Can you cast some light on how a professional draws the line on what constitutes paranoid behavior? After all, one man’s paranoia is another man’s common sense.

    A useful example might be “Climate Change”. Some people genuinely believe that anthropogenic CO2 will destroy the planet within a decade. Other people believe that “Climate Change” is a scam. Both people could point to items which they believe support their point of view. Each may think the other is being obtuse (at best) or downright evil (at worst). Is either being paranoid?

    Another test case might be the case of Senator McCarthy, who was widely condemned at the time for believing – correctly, as it later turned out — that the Post-WWII US government had been infiltrated by Communists. Was he paranoid, or simply smarter than his critics? Were his critics being paranoid when they refused to consider what he was telling them?

  2. Gavin: My understanding is that all definitions of mental illness require first that whatever the behavior or thought is be severe enough to impact living.

    If you talk about, say, bipolar without specifying the intensity, normal people are happy sometimes and sad others. Which completely fails to capture the extremes and cycling of someone bad off enough for diagnosis. If you are around someone severe enough bipolar that the meds are lifesaving, when they are off their meds, it is pretty obvious that the highs and lows are not merely the variation the healthy experience.

    Climate change arguing does not at all have to be paranoia. Someone who adjusts to social pressure, and does not do their own analysis could become partisan to either side, without being paranoid.

    AVI: My takeaway is that an episode I had earlier this week might have been specifically a paranoid episode. Following a discussion, I had a disrupted night’s sleep, and woke up convinced that I had figured out a new and correct insight into the discussion’s topic. I kept my mouth shut, because I know that there are times I can’t trust my thinking. Eventually caught up on my sleep, and was able to convince myself that my ‘insight’ was not correct.

    Beyond that, you make paranoia sound like a disordered intensity of mental process. Like a breakdown in some ordering behavior or process, that either gets ever worse, or stabilizes at some level of dysfunction. The metaphors that come to mind are not ones I understand well enough to describe right now. a) I’ve got to wonder if the right sort of neurofeedback could do some good, if you had a cooperative patient. b) I’ve got to wonder about the mechanisms of chemically caused paranoia.

  3. Back when I was teaching medical students, I would take them to the “Psychosomatic” ward at County Hospital. Since the Psych Unit had been closed, there was no other opportunity for medical students to meet psychotic patients. There were many good examples but one that stands out was a Korean-American man who was a paranoid psychotic who was so well organized that his family had put a long letter in his chart explaining that he really was crazy and had attacked their mother in one of his fits. He had a story that he had $5 million to invest in South Korea and a plane reservation in a few days.

    There were other stories. One student, a very very bright girl, talked to a black woman who was schizophrenic, pregnant and on dialysis. It turned out this student was the only person on the ward who could get this woman to talk and she went back again and again.

    I spent a summer in 1961 in the VA Psych Hospital in LA and that was early in the era of the psych drugs like Thorazine. I spent hours talking to psychotics. It was exhausting but I learned to talk to them. The chief of the service was a man named George Harrington who was the single most impressive man I have ever met in Medicine. One of his UCLA residents, named William Glasser, wrote a book about his methods titled “Reality Therapy.” It was quite popular in the LA City school system until leftist ideology took over.

    One fascinating paranoid schizophrenic I met was a black man who had been the highest graduate of USC (Order of the Palm for highest GPA) and married the white daughter of a famous US diplomat. He was on a locked ward as dangerous. His psychological testing suggested he was not psychotic.

  4. Have figured out the words to my metaphor.

    You obviously can look at the brain as a dynamical system. There are elements of that system that can be understood as feedback control loops.

    When people talk about positive feedback, or negative feedback, those are special cases of a feedback control loop. A more complex design of the feedback control can cause a system’s output to follow an input reference signal. Furthermore, in electrical engineering, feedback concepts are used for basic subsystems like stable oscillators.

    Bipolar, at least some cases, is pretty clearly caused by this sort of behavior in some of the neurochemical subsystems. Using the feedback control loop metaphor, there is something really wrong with the damping, so the subsystem oscillates, instead of following whatever reference signal.

    AVI’s description of paranoia sounds more like drift in the reference signal. I see two elements of problem from his description. One is perception, the intense sense of ‘this has significance’. The second is in calibration against what one believes others believe.

    We know that healthy normal has a definition that includes calibration against what others believe. That is part of the mechanism of culture. (I understand definitions of sane have to be culture specific. There are definitely culture specific illnesses like fox possession and wendigo.) Forex, autistics who are dysfunctional when they come up with technically correct answers that are different from the incorrect but functional conclusions that are consensus.

    Weird fixated perceptions I think can sometimes be shifted with the right neurofeedback. Organic problems can cause the brain to learn to operate in dysfunctional ways. If the organic problems can be addressed, neurofeedback can teach the brain different, more functional ways to operate.

    If the perceptions are the first cause, neurofeedback could potentially be used to shift the ‘reference signal’ back, and fix the paranoia.

    But if the perception ‘reference signal’ is normally adjusted by feedback from a ‘social model’ (that predicts the thoughts and perceptions of others), then weaknesses in the social model, or the feedback, could permit the reference signal to drift.

    My theory that neurofeedback can address some cases of paranoia has a flaw. It assumes that most or all of the irreversible entropy is organic problems. But how does memory work? How much of the weird perceptions are recorded more or less permanently? Is there a point where one doesn’t have the skills to integrate a shift in perception back to ‘normal’, and could not cope with a transition to healthy, even if all organic problems were addressed?

  5. The quick answer is that I did not strongly diffferentiate between paranoid schizophrenia and other medical disorders and paranoid personality disorder, which is more of an extreme of typical behavior. That was intentional at the time, because it is not always clear, especially when substance abuse or traumatic experiences cloud the picture. I wanted to give an overview. The medical disorders are genrally new, and not adaptive. The personality styles seem to have been around for centuries, and are likely somewhat adaptive. I’ll give it a go to answer the excellent comments above. However, I have to rehearse reading the Mad Tea Party to the young girls my wife is having over for a formal tea today, so I may not have much time.

  6. Obsessive Compulsive Disorder (OCD) is really a feedback disorder and it is treatable using surgery or deep brain stimulation.

    Thirty-one studies involving 116 subjects were identified. Eighty-three subjects were implanted in striatal areas–anterior limb of the internal capsule, ventral capsule and ventral striatum, nucleus accumbens and ventral caudate–27 in the subthalamic nucleus and six in the inferior thalamic peduncle. Global percentage of Y-BOCS reduction was estimated at 45.1% and global percentage of responders at 60.0%. Better response was associated with older age at OCD onset and presence of sexual/religious obsessions and compulsions.

    A lot of psychiatry is becoming neurology as we get better at brain chemistry.

    One of my students who was very interested in pediatric neurology I encouraged to study autism and Oxytocin.

    The Prairie Vole studies got this going. It seems to affect all mammals.

  7. Ah, but that’s what they want us to think… /kidding

    Despite spending years in Berkeley, which God knows is full of lunatics, the only certified psychotic I ever knew was a faculty colleague. He was heavily medicated, and under psychiatric care (spending about a month a year in a psychiatric hospital), but on a day to day basis he was not obviously nuts. Difficult, but not obviously nuts, at least on brief contact.

    What was striking about him was his lack of sense of humor. At departmental meetings someone would make a joke, and everyone would laugh, but this guy would take the comment as a serious suggestion, while everyone else would cough and shuffle their feet in embarrassment. He seemed incapable of recognizing incongruities, which of course are the essence of humor. Fascinating.

  8. @ Jay – good pickup. You are describing one of the “negative symptoms” of mental illness.

    @ Mike K – good stuff. Yes, neurology is slowly pushing everything else out, and I approve. I will be writing more, but in the meantime you might find it interesting to check out EMDR, which I thought was pure voodoo when it came out, but now think is going to be very close to the road home on PTSD. Ketamine is going to be in play there as well. Fascinating stuff.

  9. you might find it interesting to check out EMDR,

    I know almost nothing about this except 5 minutes of reading.

    Is it related somehow to REM sleep ?

  10. No, it purports to move memories to different storage in the brain, to pry them apart from overwhelming negative emotions. Rather, I should say, it does not move them so much as create them in a new place, and teach your brain to use that version rather than the other. The analogy would be using the music from a tape recording that has a lot of screaming going on in the background and getting you to sing just the music part onto a CD, to be played by a different device. The tape is still there, but you learn to leave it be and listen to the CD instead. EMDR does this with eye-movements, which they insist are necessary but I think is the suspect part. There has also been work done with ketamine, to separate the emotion, the sting out of memories and then re-remember them for use. I don’t know what the state of the research is at present.

    One frightening possibility of this is abusers making the victims take the treatment, so that they are not angry, or even have the memories messed with enough to be useless in testimony. Parents could have this done to minor children, and governments to citizens. Very uncomfortable sci-fi stuff.

  11. AVI and Mike K, you might appreciate Theodore Dalrymple’s book “A Pinch of Salt,” which discusses at length the limitations and problems associated with medical research. “Theodore Dalrymple” is the pen name of a psychiatrist with a fascinating personal history and career path, including stints in a variety of Third World countries and as a prison psychiatrist in a dodgy neighborhood of a city in Britain.

    He’s an astute observer of the human condition, and a talented and erudite author of many perspicacious books.

  12. No, it purports to move memories to different storage in the brain,

    I would not rule out a role from REM sleep and some relationship to the EMDR effect.

    Consider this.

    Although recent evidence indicates that non-rapid-eye movement sleep (NREMs) is directly involved in memory consolidation, the role of rapid-eye movement sleep (REMs) in this process has remained controversial due to the extreme difficulty in experimentally isolating neural activity during REMs. Using a combination of electrophysiological recording and optogenetic techniques, recent work demonstrated for the first time that neural activity occurring specifically during REMs is required for spatial and contextual memory consolidation.

    Maybe EMDR has an effect that is related. Anyway, a thought.

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