Monday, September 17, 2007


You pot smokers out there know what I'm talking about.

You're chilling on the deck, your neighbor steps out to toss out the trash, gives you a funny look and you think, Busted.

I've had patients tell me they had to stop smoking pot because the paranoia got so bad. A cop pulls up at a stoplight, turns his head and looks at you. You freak, come down fast, and you're not the same for the rest of the day. Aw.

The rest of us might say, If you weren't stoned you wouldn't have to deal with that, would you? You'd have nothing to be worried about.

Yes and no. Well, yes, probably, if you're a habitual stoner.

Those of you who are dealing with elderly parents, however, have quite another kettle of fish boiling. As FD says, if the brain doesn't get enough oxygen, if circulation is poor, if the heart's not pumping like it should, if a person's on one too many medications and needs all of them, if sleep is wanting, well, there's an accident waiting to happen.

And I read a study associating hearing loss and paranoia. OF COURSE HEARING LOSS WOULD BE ASSOCIATED WITH PARANOIA IN THE ELDERLY--THEY DON'T HEAR THINGS CORRECTLY. Sorry for shouting.

And as my geriatric psychiatric consultant in California is wont to say, Those mini-strokes the elderly suffer are virtually undetected until the patient suffers from a delusion. Then the docs suspect stroke. And a little anti-psychotic can go a long way.

Great, more meds. And go tell someone suffering from a delusion that he's suffering from a delusion. He'll say, YOU'RE the one who's delusional. When the mind plays tricks on you, and it's YOUR mind, you basically are going to trust your mind, not someone else's.

Such a Catch 22.

Well let's get clinical. It's what you pay me for. If you learn about paranoia in graduate school, what you'll learn is that there are at least two types: There's the type associated with the intense anxiety of Paranoid Schizophrenia (Axis I), and there's the type associated with a personality disorder, Paranoid Personality Disorder (Axis II).

Like Obsessive-Compulsive Disorder and Obsessive-Compulsive Personality Disorder, they're difficult to differentiate sometimes. But unlike OCD versus OCPD, in which one makes the symptom bearer sick and the other makes everyone else sick, when the featured symptom is paranoia, everyone feels sick.

Let's take a quick look at the personality disorder. We do not diagnose this, of course, if a person is justifiably paranoid, as is often the case with immigrants who do not understand language or cues, minorities who suffer discrimination, and political or economic refugees who have been on the run.

The diagnostic criteria for 301.0 Paranoid Personality Disorder include:

A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more of the following:
(1) suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her

(2) is preoccupied with unjustified doubts about the loyalty or trust-worthiness of friends or associates

(3) is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her

(4) reads hidden demeaning or threatening meanins into benign remarks or events

(5) persistently bears grudges, is unforgiving of insults, injuries, or slights

(6) perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack

(7) has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner
B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, or another Psychotic Disorder and is not due to the direct physiological effects of a general medical condition.

If a person had the personality disorder before the onset of schizophrenia, it's considered premorbid. In other words, a person diagnosed with schizophrenia can also have this disorder, but we add the suffix, "Premorbid".

Oy, it's not a good thing. And of course, the spouses of these individuals are often accused of having affairs, their friends and children of stealing, business associates deliberately try to cheat them. People look at them the wrong way, people wrong them. People think they're stupid.

These are angry people.

There is a strong association with child abuse, and you can see why. If you can't trust your own parents to take care of you and protect you, who can you trust?

You learn to trust only yourself. You get VERY strong, VERY tough, impenetrable. You're FINE all on your own.

I'm fine all on my own trickles into all kinds of relationships, doesn't it? It's one of the reasons people avoid intimacy, and it's why I would say it represents a fear of intimacy. How can you let yourself be vulnerable, how can you tell people your true feelings, your fears, your sadness, if you think you'll be punished for divulging that information?

Having feelings makes you a weakling, don't you know?

I'm not going to go into treatment right now, and I'm not going to list the features of paranoid schizophrenia for you. They're on this blog somewhere, probably in the Cho posts.

But I will say that I think when you notice these features in a person at any age, if you're intimately involved with this person or perhaps you are a blood relative, it might be worth it to gently confront it, to bring it up as a disorder. A tricky disorder. Because at some point you'll have to address it yourself, probably. You'll be the object of suspicion.

Or better yet, somehow, somehow, somehow, get that person to join you in therapy for a problem of your own so that he/she has a relationship with a mental health professional.

Trust me. You're going to need it.



Mary P Jones (MPJ) said...

We have been dealing with this in my husband's father. Thanks. The information helps us deal with it. For my father-in-law, there isn't much time left in his life to address it.

Midwife with a Knife said...

This is one big reason why I find geriatrics so intimidating. I always sort of hated adding Haldol to the 80 or so meds that the old women on our oncology service were on when they started to get post op deleriums (deleria?).

So many geriatric patients are on so many meds, and they can get delerious so quickly. And then I really don't know what to do.

therapydoc said...

Sorry to hear it, MPJ. This will be an on-going discussion. I didn't even mention that as we age, certain qualities are exaggerated. This is one of them.

So it's especially hard with the elderly, but that's where it comes up most often. As we age we get more vulnerable, less able to cope with stress.

And there's so much more stress.

therapydoc said...

Midwife, that's where those MD's really come in handy. Haldol can be very harmful (as can most drugs).

As a non-MD I can never tell someone, take this or don't take that.

That's a good thing.

Midwife with a Knife said...

therapydoc: Yeah, when I was a resident, we'd always consult geriatrics on those patients (but not until after they were having their postop delerium, of course). What would be really great is if our gyn-oncology attendings would have touched base the the primary care docs of those women. Or, vice-versa, but I feel like the burden sorta lies on the surgeon in these cases. I suspect that the primary care docs would have been really happy to make postop recs for these people.

Hm.. I really should do some work..

Anonymous said...

Well feh, I've been paranoid AND delusional for years! (but not schizo)

therapydoc said...

ima, you're kidding, right?

jeanie said...

I have a friend who would be a classic example of this - except in her instance, it seems her paranoia is justified a fair bit.

Yes, she was a victim of child abuse. Yes, she has been a victim of government departments.
And yes, there are people out to "get" her.

As I am one of only two of her friends on her "inner circle" I really don't know where/when/why to tell her about this or how to address it.

Am I being paranoide? I am in a bit of a jitter that I may be next off her list if I did address her on it - and I think, for her sanity, it is better that she have at least two of us to talk to...

She is seeing therapists but to complicate crap childhood and life there is the suspicious suicide of her 16yo daughter at her ex's and the monumental grief associated...

Wow - sorry, didn't mean to just throw it all at you - main thing is, am waiting for your post on how to possibly handle such because I want to know.

therapydoc said...

Jeanie, I don't give any specific advice unless you're a patient. And then it wouldn't be here, right?

But in general, in this type of situation, if you like this person and want to be her friend, you'd want to bring up her natural suspiciousness and tell her that it seems she has trust issues that her therapist should be working on with her.

That's about as much as you can do, call them trust issues and encourage her to let them go, since life is too short to be worrying about who's out to get you next.

Anonymous said...

You know, I've done so much work to 'normalize' my own (sub-symptomal but annoying) paranoia, I could be a poster child for cognitive re-wiring. Your post reminds me that I lack empathy for the =truly= paranoid.

Is it typical for someone who's disorder-level paranoid to blindly misplace trust? My flatmate sees evil intentions all around, but insistently trusts 'allies' who seem to be acting in their own interest.

therapydoc said...

I can't comment specifically on your case, but the symptom is hardest when it hits home, when someone you live with or who should be close to you is suspicious of everyone who is close by, surely more capable of harm.

Yes, strangers, basically are okay. People who can get in are not.

If I can get in, I can hurt you, obviously.

But in worst cases, strangers are dangerous, too. And face it, sometimes they are, which makes it hard to deprogram someone who is really fearful that the intent of others is malevolent.

Anonymous said...

Well, kind of (!). I do have serious trust issues. I wouldn't say I'm full-blown paranoid, but I see myself in almost every trait at some point in my life. Could have to do with the other diagnosis... I hate labels and I hate seeing myself in them. But hey, that's the struggle and that's what therapy is for, right?...

Whose approach do you prefer, Clarkin, Linehan, Dean, Gunderson...?

therapydoc said...

I-- I tell it like I see it, perhaps more gently,than Linehan but along those lines.

This reminds me of myself reading through the DSM for the first time thinking, OMG, I've got EVERYTHING!

Anonymous said...

Ah, sorry - I wasn't asking for specific diagnosis of my flatmate ;) just a meta-level question about whether paranoia is applied universally.

What does Linehan say about paranoia? Years ago, I found her client handout book to be very helpful for me (a non-BLPer) in developing some skills (e.g. determining appropriate degree of force in saying no).

I would think that some of Linehan's approach, as I know it, would be counterproductive for someone w/ certain trauma issues.

therapydoc said...

Well, MOLL, I don't know. If an "accused" is innocent, it's not hard to look at an "accuser" in the eye and mean it while saying, "You're WAY off. You have NO idea what you're talking about."

The more direct, the more intense the eye contact, the more convincing. If there's any convincing.

Paranoia increases with wavering performances. Any sign of guilt or room for error is proof of guilt.

Anonymous said...

Slight change of topic... but, I was interested in your first paragraph or two
when you talk about paranoia and pot smokers. I've smoked pot in my
life, fairly regularly in my twenties, and as a result of this
experience have observed the following about pot when stoned (I don't
know if you've ever smoked, and thought you might be interested from a
therapy perspective).

Intense paranoia while stoned is the amplification of internal fear
relating to how people are perceiving you. Because your internal world
is so compressed and magnified all at the same time, and because for
most people the mind tends to rule the consciousness, this fear
generates strong recurring thoughts in the mind about what other people
are thinking about the smoker. However, once you start to master your
mind (say through meditation), plus lose your fear of what other people
think of you (finding strong self-confidence and/or coming from a place
of love), that paranoia completely disappears.

The mind is unable to
churn out those same thoughts because the spark is gone (fear) and the
fuel (monkey mind thoughts running wild) is not being added.

So paranoia is not caused by the pot per se... but by the combination of
pot with insecurity and fear.

It was something I observed in myself over a number of years - when I first started smoking, huge paranoia... but once I started going down a spiritual path and become Aware, rather than ruled by my mind, the paranoia completely disappeared.

Actually, for anyone suffering any disorders of the mind, I'd highly recommend any type of meditative practice because it creates Awareness that we are not our minds... which leads to mastery of the mind... which pulls disorders of the mind out at the roots.

much joy,

What's Going to Be with Our Kids?