Living with a person who eavesdrops, feels rejected for no reason, seeks endless reassurance (but is never reassured), thinks others are looking askance, sneaks into private communications, and makes false accusations takes a toll. While many of us may feel suspicious, rejected, excluded or hypersensitive from time to time, chronic paranoia in a functioning person (one who works, socializes, and has a family) can be a monumental problem. It is painful for the paranoid person and heartbreaking for the accused.
Persecutory interpretations of normal events might include: “How come I got the cheaper present?” “Why are you talking about me behind my back?” “You are having dinner with someone else and leaving me out!” “She gave me a dirty look because I did not open the present right away.” “They are ganging up on me!”
Paranoia can be a symptom of several illnesses including schizophrenia, brief psychosis, paranoid personality, psychotic depression, mania with psychotic features, or substance abuse, chronic or momentary. It can range in intensity from a character style to a severe impairment.
One form of paranoia that is particularly difficult to diagnose and treat is Delusional Disorder of the Persecutory Type. In DDPT, the sufferer is gripped by a delusion (a fixed false belief) that involves a singular situation or person—a “circumscribed” delusion. A wife “knows” that her husband is cheating on her with the neighbor, a person is convinced a co-worker is snooping in his desk, a manager is clear that employees are plotting to get her fired, an adult child is immovable in his belief that his father’s new wife cut him out of the will. The fixed false belief plays out around this one notion or person, while in other ways the afflicted may function just fine.
DDPT involves plausible situations—the delusions are non-bizarre and could really happen. (Spaceships landing in the bedroom, an alien light beaming into the kitchen brain, or a World War II platoon in the backyard would not be characteristic.) In DDPT, the sufferer may appear to be in touch with reality because terrible things do happen, people do betray each other, etc. In most cases, however, the individual's imagined horror is just that—imagined.
People with DDPT do not think they are paranoid, but rather perceptive. They believe that they alone are onto a conspiracy, crime, or act of malevolence. Their conviction that a crime is being committed is rock solid. If you try to talk them out of it, you may alienate them and they could become even more staunch and defensive. Their inner reaction might be, “You do not get it and now I am even more alone with this problem.” Their misguided fight for truth, justice and revenge ramps up and the delusion becomes more deeply entrenched.
“Never argue with a delusion,” one of my mentors often said. Paranoid people are fragile and ill, in the sense that they are out of touch with reality. However, they can become terrifying if fantasy turns to action. The need to retaliate against imagined assaults combined with intact “executive function” (the ability to think and plan) leads to aggressive behaviors and schemes. Calling the police or summoning lawyers is not uncommon. Innocent people, accused and besmirched, are traumatized. (Manipulators may also lie to law enforcement in familial or domestic disputes, but this is different: I have heard stories of raging spouses calling the police with false claims of abuse more than once and an innocent person put in jail for a night.)
Well-meaning colluders fuel the flames. Head shakes, back pats, disdain towards the accused, and meddling on behalf of a false underdog can destroy relationships or lives. Gentle consideration and curiosity about all that is presented and some ability to see beneath the surface is key, as opposed to automatic acceptance. Some people (trained or untrained) are talented at perceiving underlying phenomena, while others are more likely to take things at face value.
Think about an accusation: Does something seem off? A good tactic is to empathize with the feeling, but to neither agree or disagree with the facts. Be empathic with the emotion and let the thought be there. Observation, reflection, curiosity and openness without judgment lead to a deeper understanding. One cannot truly grasp this confusing illness without an understanding that characteristics can conflict, people can say one thing while another may be true, and people can be far more troubled than they appear.
At any rate, if you can get the person to treatment, then chaos, heartbreak and destruction can be avoided and the afflicted relieved of oppressive fears. Paranoid assaults and magnanimous moments are not mutually exclusive—severe illness can present dramatically or subtly.
A quip like, “It cannot be possibly be true, so and so is such a nice guy,“ is common. It is not cruel or judgmental to recognize an illness. It is not necessary to dismiss positive qualities in a person with a sickness.
The truth is a form of loving support.
Since any person may decline professional help unless they are a danger to self or others in the moment, the illness DDPT is underreported. (Kaplan and Sadock Synopsis of Psychiatry, 2014)
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