Posted by wendy b. on March 31, 2003, at 18:36:52
From the NY Times web site - thought some people might be interested... ---- W.
April 1, 2003
Self-Protection or Delusion? The Many Varieties of Paranoia
By RICHARD A. FRIEDMAN, M.D."I am being harassed by the guy next door and I want him to stop," the woman in my office said with firm conviction. The man would leer at her in the elevator just to make her squirm, she said.
But when I inquired further, she described a lingering feeling of being mistreated by people she said were jealous of her. She was even sure that someone had once tried to poison her.
Then I asked a question that gave me a direct taste of her problem. Is it possible that you are mistaken?
Her pleasant manner instantly shifted to icy contempt before she denounced me for implying that she was paranoid.
Of course, she was right. And the unshakable nature of her belief was the clincher.
Certainly none of her ideas were bizarre or impossible. People are harassed and envied all the time. But her absolute absence of doubt was what made her psychotic. She could not imagine being wrong.
Probably no psychiatric term is bandied about as loosely as paranoia. But paranoia covers a broad terrain, from a stable personality trait to a symptom of severe mental illness.
Paranoia may even confer an adaptive advantage in some instances. After all, someone who is always watching his back and is mindful that his peers are driven by self-interest is more likely to have a competitive edge when one is needed.
In politics, mild paranoia is probably an asset; no politician could survive for long with a rosy and trusting view of the world.
But there is a world of difference between having a paranoid streak and harboring a delusion.
Some people, like my patient, develop a delusional disorder in middle or late life, having had no trace of paranoid thinking before. Their disorder is fairly rare but striking. These patients falsely believe that they are the objects of persecution, envy or even love. Yet they often function effectively at work and can superficially pass for normal in social settings.
Ian McEwan's "Enduring Love" describes a man in the grip of a mistaken but unyielding belief that he is loved by a complete stranger whom he meets by chance.
Celebrity stalkers often fall into this category. They insist that they are secretly loved by a powerful or famous figure. Clearly, there is more than a little self-importance at the heart of these delusions. Whether it is being persecuted or loved, it is all about being the center of attention.
And all attempts to convince them that their beliefs are mistaken fail. Because they have no doubt about their delusions, they are immune to reason.
The most common cause of paranoia is also the least understood by the public, schizophrenia. A chronic mental illness that is generally believed to affect 1 percent of Americans, schizophrenia is characterized by delusions, often paranoid in nature; hallucinations; and so-called negative symptoms that include social withdrawal and apathy.
Contrary to popular notion, schizophrenia has nothing to do with split or multiple personality. It is thinking and perception, not personality, that are so disordered in schizophrenia.
What is intriguing is that drugs can produce symptoms that mimic schizophrenia, and they have yielded clues about the neurobiology of psychosis. Cocaine and amphetamines, for example, flood the brain with the neurotransmitter dopamine, producing psychosis in vulnerable people. And the cocaine-induced delusions are easy to confuse with those of schizophrenia.
Antipsychotic drugs alleviate psychosis by blocking dopamine receptors in important brain areas. In doing so, they normalize the excess dopamine activity in schizophrenia and stimulant-induced psychosis.
Curiously, antipsychotic drugs, which are so effective in treating the paranoia of schizophrenia, are of limited use in delusional disorder. That suggests that the neurobiology of paranoia is diverse, just as the illnesses that produce it are.
An intriguing clue to the origin of psychotic thinking comes from recent brain imaging studies. Dr. David Silbersweig and Dr. Jane Epstein at the New York Weill Cornell Center used PET scans to study schizophrenic patients who were having delusions and auditory hallucinations while their brains were being imaged.
The paranoid subjects showed increased activity in the amygdala, a part of the brain involved in the emotional processing of fear and danger, not only in response to threatening words, but also to neutral words. Healthy people respond like this only in threatening situations.
The implication is that the brain is responding to a nonexistent threat, at least in these paranoid schizophrenic subjects. It is like a faulty burglar alarm set off in the absence of an intruder. The paranoid patient is correctly responding to real brain activity that indicates danger, but those neural circuits have no good reason to be firing in the first place.
To make matters worse, the schizophrenic subjects also showed decreased activity in the prefrontal cortex compared with healthy people. The prefrontal cortex serves an executive function, critically evaluating signals from brain regions and shaping responses to them. So in addition to having an overactive fear circuit, these paranoid subjects have an impaired ability to judge whether their fears are rational.
Sure, paranoid people, like the rest of us, do occasionally have enemies. But if these imaging studies are replicated, the results will mean that the real enemies of paranoid people are their own brains.
poster:wendy b.
thread:214838
URL: http://www.dr-bob.org/babble/20030329/msgs/214838.html