Paranoid & Delusional Disorders


The boundary between normal and abnormal appears to be largely subjective.  “One person’s excessive suspiciousness is another’s due caution, and one person’s trust is another’s gullibility.”  (Blaney & Millon, 2009, p. 362)  The “trade-off between vigilance and vulnerability” is something I had not considered… that balance is perceived to be the issue when it comes to paranoid personality disorder (PDD), paranoid schizophrenia (PS), and or delusional disorder (DD).  “Any stubborn genius will have ideas that happen to be wrong as well as those that happen to be right.”  This observation seems to suggest that the people who often suffer from these disorders are extremely intelligent, and thus, may have some beliefs that are in fact sane, relevant, and true.  It would suffice to say that I am going to use caution when pursuing this diagnosis… Einstein was considered to be delusional!

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Most studies that have been done to date have focused on persecutory delusions… either by design or because they are more common and subsequently easier to find suitable samples.  Persecutory delusions involve a degree of suspiciousness, or are generally mistrustful and/or wary.  It is suitably difficult to measure the tangible levels of suspiciousness via self report, however, since some sufferers may be too guarded to admit that they are suspicious.  The very process of self report is likely to “trip the defenses of” and subsequently increase guardedness.  Further compounding the efficacy of self-report inventories is the issue that sufferers may be reporting reality, betraying hypersensitivity, or some combination of both.  This highlights the necessity of multiple-peer reports that can confirm the interpersonal difficulties of the sufferer.  We, as clinicians, will have to be diligent about securing 3rd party sources (schools, work environment, relatives, other individuals whom are close to the client) in order to get as many perspectives on the conditions as possible.

There are several dimensions of delusions… most notably belief certainty (emotional commitment, conviction), self-monitoring (insight), distress, and frequency.  I was particularly interested in the “double awareness phase” in which a patient wavers between embracing a delusion and recognizing that its delusionality.  Of note, is the observation that psychotropic medications reduce engagement in delusions, thereby improving overall functionality, but ultimately leave actual beliefs untouched?  This seems to parallel the overall trend of medications “treating the symptoms and not the cause.”

Some patients may possess some distinctly protective attributes that account for the fact that they do not become delusional.  As a result, quasi-delusional or aberrant beliefs may not always be associated with clinical conditions indicative of a general mental disturbance or distress.  For example, low levels of anhedonia and high levels of openness are commonly thought to be a psychological asset… despite the fact that they may be quasi-delusional.  Such individuals may demonstrate greater levels of control over their unusual perceptions.  (Blaney & Millon, 2009, p. 366)  Perhaps this natural protection can be leveraged to direct treatment of people whom do not have that natural protection.  It seems to me that if we know what can prevent delusions, we should make every attempt to instill those protections in our clients whom suffer without them?

Paranoia and delusions are thought to arise from several different situations or events.  One possible event is migration, in which an individual finds themselves in a new environment that does not provide a sense of security.  Growing frustration with the new locale may leave migrants vulnerable to paranoid disorders.  As is the case with many other disorders, abuse and trauma during childhood often precede delusional experiences in adulthood.  In some cases the delusions are related to that specific event, like trauma flashbacks, or they may be more generalized due to negative schematic models of the self and the world.  This manifests in high levels of self-reported suspiciousness and/or resentment.  Paranoid individuals tend to be characterized by experiences involving victimization or stigmatization by others, whereas depressed individuals were characterized by interpersonal losses.  (Blaney & Millon, 2009, p. 369)  Personally, I am not at all surprised by the childhood abuse antecedent.  The toll of child abuse rises again this week… I am hard pressed to find a disorder that can NOT be predicated by child abuse.

Biologically speaking, some researchers have attempted to attribute these behaviors to processing defects or bias.  Theory of Mind (ToM), for example, suggests that the human mind is characterized by a system that facilitates inferences about the mental processes of other persons.  (Blaney & Millon, 2009, p. 377)  In essence, patients have difficulty discerning others’ intentions correctly.  Some have suggested that delusion-prone individuals are overconfident and quick to reach certainty in the face of incomplete information.  Other research suggests that delusional individuals may have a proposed tendency to attribute specific persons as a source of danger (personalization), thereby revealing an inability to distinguish between external negative events that are situational as opposed to interpersonal.  It has been posited that they may have an exaggerated version of self-consciousness in which they continually preoccupy themselves with how they are seen by others… and subsequently generalize that everyone feels like that.  (Blaney & Millon, 2009, p. 379)  On the whole, there are several theories… all of which seem “plausible.”  I can’t wait to get into the field to test the theory.

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Reference

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

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