Some Peculiarities of the Delusional State
As a paranoid psychosis develops, certain cognitive defects appear in sequence.
Posted Feb 03, 2013
Some peculiarities of the delusional state (The patients described below have been disguised.)
In a way, everything about the delusional state is peculiar. An affected person (usually a paranoid schizophrenic) comes to believe that an outlandish series of events, incredible to everyone else, are taking place in which he/she is the center of attention, usually a malignant attention.
A typical, although severe, delusion:
A 24 year old man, Andrew, with no history of mental illness became over a period of a few weeks increasingly agitated for no obvious reason. In particular, he experienced more and more difficulty sleeping, sometimes, by his account, not sleeping at all. He then began to notice “funny things” going on. Large black cars were driving slowly by his apartment building. Andrew reported this seemingly strange fact to members of his family. He started to think that he was being filmed, perhaps for a television reality show. It came to him suddenly that he might be the son of a famous person. This thought was pleasantly exciting; but, as the days went by, he began to feel threatened by the attention being paid to him by strangers who looked up and smirked as he walked by, or who stopped talking when he came into the room, or who ran away from him up a flight of stairs.
He thought he heard whispering from the adjacent carrel in his college library. The whispers seemed to be alluding to his being homosexual, which he was not. These invisible speakers were also laughing. He thought they might be part of a conspiracy to test him in some obscure way. The conspiracy, he thought, might be run by the Mafia or the C.I.A.
One time, he saw a group of policemen across the street. When he accosted them and accused them of spying on him, he was taken into custody and brought finally to a psychiatric ward in a municipal hospital.
Although placed quickly on high doses of a neuroleptic, Andrew’s condition worsened. At night he could hear his parents screaming. He told the staff that his parents were on the floor above, and they were being tortured. The following morning, his parents came to the ward and told Andrew emphatically that they were fine. They had not been tortured. But that night, and subsequent nights, he continued to hear them screaming and continued to believe that they were being tortured, even though each following day they came to visit him and were manifestly well.
Andrew seemed to improve on increasing doses of the major tranquilizer he was taking; but he was not well enough to leave. He was transferred to a state hospital, where I came to know him.
One day, not long after admission, he called me over to the window. “See those cars,” he said. He was pointing out cars on a highway which was three blocks away. We were on the sixth floor. “They are spying on me.”
I pointed out that the cars were so far away, I could barely see them before they disappeared from view. I explained that no one would set out to spy on him that way. It was impossible. But he nodded knowingly to himself.
Three weeks later, he was well enough to be discharged. He was still somewhat paranoid; but he was less certain of those thoughts.
“I was watching a movie last night,” he told me. “I knew the actors were talking to me, but I couldn’t figure out how that could be since the movie was made ten years before I was born.”
In time, Andrew recovered completely, although he relapsed briefly a number of years later.
Certain particular aspects of Andrew’s psychosis are worth underlining. They are common in the delusions of other paranoid individuals:
Extraordinary elements of the delusional state:
- Andrew developed an inability to distinguish what was significant in his environment. The focus of his attention was disturbed by the ordinary background noises of his daily life. This reflects the distinction made in gestalt psychology between “the figure” and the “ground.” Ordinarily, we attend to what we are doing and thinking. This is the figure in the foreground. Everything else is a blur. For example, someone should be able to concentrate on the substance of a conversation without being distracted by other people walking by, or by noises coming from the next room. Under stress, this ability to focus on what is important is remarkable. Soldiers in combat, and athletes playing in a big game, have been known to suffer a broken limb without being aware of it until the stress of the game, or the fight, was over. Even a broken leg is subsumed under the heading of background noise. But in the paranoid state, the background begins to bleed into the center of focus. Andrew began to notice common things—black cars driving by in the street; and they and other such things were deemed to have significance.
- The significance experience. Andrew not only noticed the black cars driving by in the street, he spoke of them to his family as if they too would attach significance to them. He had lost his ability to discern accurately how other people interpret events. This behavior—telling of an ordinary event as if it is so redolent of meaning that the person listening is expected to see it too, is called the significance experience. It is thought by some to be specific to paranoid schizophrenia.
- As his attention was drawn to all those innumerable events that occur in the background of life, Andrew began to search for their meaning. There had to be a reason why the black cars were going by one after the other. And this reason must have to do with him. As he could no longer tell what was meaningful in the world, he could no longer separate himself from everything that happened in the world. He was the center of things. He was important. At first, as sometimes happens, that attention was exhilarating. He was the son of a famous person. He was the star of a reality show. These are called grandiose delusions.
- But as almost always happens, the world around him became threatening. People were communicating to him in subtle ways, whispering ugly thoughts. The particular ugly thoughts are reflective of the affected person’s real thoughts. If someone hears himself accused of being homosexual, it is because he regards homosexuality as shameful. In this respect there is a similarity to dreaming. The fact that someone dreams a lot at a particular time may have to do with, perhaps, his taking certain drugs; but the details of the dream are still a reflection of his real thoughts and feelings.
Other paranoid individuals may have the idea that other people are communicating to them telepathically—or even controlling them telepathically.
The boundaries of the individual begin to melt into the world at large.
- As Andrew conceived the idea that he was at the center of a malignant conspiracy, he imagined powerful forces arrayed against him. This is an example of a persecutory delusion. Most delusions have this character. Since there are not very many agencies or organizations that operate in the world powerfully and mysteriously, and out of sight, the villains of these delusions tend usually to be either the Mafia, the C.I.A., the government at large, or a religious villain, such as the devil.
An elderly woman who had worked all her life as a clerk, and who thought herself the most inconspicuous person in the world, thought that her employer, AT & T, had conspired together with blacks and the mob to make her automobile engine knock. She drove home every night by a circuitous route so that she could not be followed. She had an inordinate respect for me, but when I suggested that she was not, certainly by her own account, important enough to matter to these powerful agencies, and thatit was not reasonable to think they would bother to persecute her, she listened respectfully, but did not believe me.
Another elderly women, seventy-three, to be exact, became convinced that some criminal person was shooting rays of some sort at her from the roof of an adjoining building in order to cause her to become sexually excited. Why would anyone do that? I asked. No such ray exists, I pointed out. She was adamant, however. I told her not to tell anyone but me about these rays. She took my advice and managed the rest of her life to stay out of trouble.
- Ordinary cognitive abilities fail. It is perhaps the defining quality of a delusion that it is resistant to argument or evidence. The fact that the particular delusional beliefs Andrew had were impossible seemed not to matter. Andrew could imagine his parents dying, yet see them the next day without that idea going away. Memory and reason is affected. Contrary evidence is ignored. The basic unreasonableness of these ideas is striking. The actors in a movie can speak directly to the paranoid person, even though he knows they had died before he was born! These deficiencies appear in individuals who had previously perceived things normally—and will perceive them accurately once they are better.
The conversation that Andrew and I had about movie actors talking to him took place when he was getting better! When he was sicker, he would have noticed no contradiction in the idea that dead people were speaking to him.
Some patients never get entirely better, but manage their lives successfully nevertheless:
When I was a resident, a patient was admitted to the psychiatric service after crashing her car into a lamppost. She was driving at high speed because she felt she was safe. She had her neighbor, Joseph, who was really Jesus Christ, she thought, in the car with her. The reason why she was convinced he was Jesus Christ, she explained to me, was that he resembled a picture of a saint that was in her hymn book.
“That was a saint, not Jesus Christ,” I said to her.
“That doesn’t matter,” she replied.
She improved with medication, but the idea that she was chosen by Jesus Christ to have a special status did not leave her. She joined a church where everyone looked up to her for her special relationship with God. She went with her new friends door to door proselytizing. Her husband came to see me a few months later.
“I don’t know what you did to her, Doc,” he said, “but she’s better than ever.”
Whether or not there is group support for a particular delusional idea will determine how well that person does.
There are other varieties of delusional ideas, including jealous delusions; and there are other causes of delusional ideas, including drugs, Alzheimer’s disease, and a great number of other organic states; but they share many of the strange ways of thinking that Andrew exemplified and that I describe above.
It is not known why paranoid thinking takes exactly these shapes. They are, of course, the reflection of a diseased state of mind; but they illustrate by contrast how people ordinarily come to believe those things that they do.(c) Fredric Neuman 2013 Follow Dr. Neuman's blog at fredricneumanmd.com/blog