Paranoia, Part 2

We all have paranoid tendencies

In Part 1 we discussed “what” paranoia is:

In Part 2 we explore what it feels like to experience symptoms of paranoia. Suspicion, distrust, jealousy are three. These characterize an emotional state anticipating future harm.

A paranoid state or the feeling that something is wrong, is comprehensive. To feel paranoid is to experience the world alternatively to others. People who experience paranoia frequently feel afraid, but at the same time, they can also feel empowered by a sense that they “know” something is wrong, something is not quite right, and that they are privy to this anomaly. Paranoia involves general alterations in brain chemistry which then impacts how one feels, thinks, perceives, believes, and ultimately acts.

How is brain chemistry altered?

For example, when a biological insult such as becoming infected with the COVID 19 virus happens. In part 1, I shared a story of a man who never had symptoms of paranoia until he was infected with the COVID 19 virus. It was then that he experienced symptoms of paranoia. These symptoms ultimately became severe enough to produce psychotic paranoia requiring inpatient treatment. Paranoia can also be engaged externally such as when a person encounters a trauma and then there are alterations in brain chemistry (increased levels of cortisol, a steroidal hormone). This is seen in Post-Traumatic Stress Disorder where symptoms of paranoia often follow when someone has been traumatized even though the trauma event is no longer present.

In my practice, I see clients who complain that they are disturbed by suspicious or paranoid thoughts.

A central feature of paranoid thinking is:

Rigid Directedness of Attention

A paranoid person is not just occasionally intense, focused or searching for things. This behavior is continuous and can feel quite troublesome. Paranoid thinking is intentional and deductive. By deductive, I mean that the person is looking for confirmation that some threatening future event (or dangerous person or persons) is present. The paranoid person is seeking confirmation for this belief.

A Personal Experience with Paranoia

Some years ago, I attended a small community theater production. I’m not sure what the play was about, but I do remember that it was only after 15 minutes that the curtain abruptly closed for reasons unknown to me and I suppose everyone everyone else. The audience was given an unscheduled intermission, the lights went up, people started getting out of their seats. No explanation was provided for this unusual set of events.

I must have been somewhat disrupted by these circumstances because I perceived, incorrectly, that the early intermission was still part of the play and that the play was still going on during the intermission period and that somehow, I was now be tricked and somehow this intermission activity would be re-introduced as part of play. Once this thought was in place, I became quiet, more vigilant about what was going on around me, I needed to be careful about what I said or how I behaved. I started to notice things that fit my supposition. A person came up to me and introduced himself and I thought this was to get me off balance. I even thought my spouse was part of the play and I asked her. She said, “Bob, that’s non-sense. I’m as confused as you are.” Upon reflection, I must have experienced a minor delusional event when I made this errant interpretation, so everything that was happening, I interpreted as part of my created state-of-mind. It was a very uncomfortable feeling.

Soon, it was announced, the play ended abruptly because one of the actors had experienced a heart attack on stage. I still did not believe this statement, thinking it was, again, trickery. It is, after all, highly unlikely that an actor would have a heart attack on stage. But, after some minutes I heard the siren of an ambulance arriving. It was only then that there was sufficiently disconfirming information to shake me out of my delusional state.

I thought afterwards why it was that I was so susceptible to a delusional state of mind.

I was, in this setting, part of ambiguous circumstances (early curtain closing for unknown reason) and my brain chemistry responded (elevated stress due to an unpredictable event). I made some quick conjectures and mentally set up a set of expectancies based on my assumptions. Then, I started looking for confirmation.

This story indicates just how susceptible we are to emotional states such as paranoia, misperceptions, and in the case of trauma, where fear of life is at stake, such symptoms can easily impact our whole world view.

Othello syndrome and dementia

In my work with older adults, I’ve encountered the features of paranoia embedded in pathological jealousy. The psychiatric disorder is known as: “Othello Syndrome” It can be, though not necessarily so, be linked to dementia disorders.

Ralph and Sally have been married for 55 years. They have four adult children. I initially saw Sally, who was referred to me by her General Practitioner. She described an unusual set of circumstances that ultimately fit with the features of “Othello Syndrome.”

I recorded in my clinical notes the following statement:

Client is caring for a spouse with pathological jealousy towards her. Jealousy is irrational, including extreme behavior, in which the spouse’s concern is with the client’s infidelity. Infidelity is not based on any meaningful evidence.

For the first 50 years of their marriage this couple lived a reasonably happy and content life. There were no instances in the past where either person suspected the other of infidelity. The husband, Ralph, learned in his 70’s that he had a severe form of brain cancer and treatment involved removal of brain matter along with chemotherapy and radiation therapy. It was after this procedure that Sally noticed some changes in Ralph’s disposition including Ralph’s feeling towards her.

Ralph began to question whether Sally might be seeing other men. He also suspected that she had been unfaithful for many years. Ralph was otherwise fully cognitively intact. He developed a scheme to track Sally and started recording who Sally spoke with on her cell phone.

At the time of our sessions, Sally said that Ralph would be willing to visit with me to explain why he was so sure that she was engaged in such behavior.

I took this opportunity to meet with Ralph who was a retired military aircraft mechanic. Although Ralph had never been in the military, he had a long and satisfying career with the air force as a federal civil service employee. Ralph was so convinced of Sally’s infidelity that he hired a private detective to follow her for a period of time in an attempt to find proof of her behavior. Although the private detective found no evidence, this did not satisfy Ralph. At the time I met with him he was considering tapping her phone because he surmised that most of the encounters were happening over phone or internet.

We discussed the situation because my client, Sally, had trouble living in the same home as Ralph. His behavior evolved to constantly accusing her of infidelity, and they were unable to host family gatherings because Ralph would become too agitated during these, raising questions about his wife’s infidelity with each of the children. The children were confused and concerned. They urged Sally to separate from Ralph because he was damaging her mental health.

Because Ralph’s behaviors were so confrontive, challenging, and difficult, Sally was considering divorcing him. At the same time, it occurred to her that Ralph might be experiencing an unusual form of dementia. He was certainly in the age-range for dementia and his mother was diagnosed with dementia five years before she died.

What to do?

Ralph did allow me to test his cognitive skills. On every test I gave him he performed far above the cut-off for dementia. To the outside world, Ralph was cognitively intact. But, this paranoia about his wife cheating on him persisted, evidence to the contrary was discounted, and the frequency with which he brought the issue up was increasing. Ralph felt like a victim, he hated Sally for what he believed she had done to him and the family, any time an uncertain event that occurred (a wrong number on his cell phone) Ralph would immediately conclude that this was his wife’s lover trying to contact with her.

In this story, the features of paranoia are clear. Both Sally and Ralph are living in a state of protracted misery. There is very little that can be done to change Ralph’s mind. It is already made up. Sally is guilty as charged. It is likely that Ralph is suffering from brain damage of some sort, perhaps a permanent alteration in brain chemistry that makes it impossible for Ralph to construe the situation in any other way. The fact that his symptoms are worsening also argues that the damage is progressive, likely a focal form of dementia.

Dee Rapposelli (June 5, 2015) in her study of 208 outpatients states, “Delusional jealousy is an organic psychotic syndrome characterized by pathologic belief in the infidelity of one’s spouse or partner…delusional jealousy is significantly higher among patients with dementia with Lew bodies than in patients with AD…Jealousy was preceded by the onset of serious physical illness…” Psychiatric Times.