Trying To Reason With the Paranoid

Brought forward from August 2006.  Since then I have related lack of insight to some variants of autism as well.  That one can be very strange, frankly, as many autists have pretty good insight and are even humorous about it, laughing when they realize what they missed: the poor boy! Here he was always getting me into tickle-fights and I loved to join in, not realising that there was this huge sexual undertone. So we go to a conference together for our project and when he asks if we should share a room to save money, I say Sure! We get there and he's about as socially clumsy as I am and tries very unskillfully to seduce me, and I yell at him, shocked!  Shocked, I say, and then I laugh at him and he is just crushed. But OF COURSE he thought I was interested in him sexually and would be at least somewhat receptive.  I had been signalling that for three months...  It worked out.  We got back together three years later and got married! But the blood still goes out of his face when I bring it up. Yet there is another subset that will hear none of it.  There is nothing wrong with them and they are tired of other people suggesting that there is. They do not well-understand what others' motivations and thoughts are, so they just make it up out of what they think is likely, with um, highly-variable hit rates on those predictions. And even when it goes very badly it doesn't occur to them to step back and rethink the whole thing.  If you asked them as a general question whether people should do that sort of rethinking they agree.  Everyone knows that! Neither side ever fully understands the other, neither side is 100% right or 100% wrong! Yet they don't actually do it in real life.

I have come to the vaguely-professional opinion that lack of insight often comes from impaired or diminished functioning of the anterior cingulate gyrus, one of the storytelling areas of the brain, predicting what other people are thinking and comparing it to ongoing results. It has almost a Bayesian quality, and when it's not operating, it takes an overwhelming amount of contrary evidence to even get them to go Hmm...

 *********

On my 13-bed acute involuntary unit seven of the current patients are paranoid, an unusually high percentage. I have therefore spent a lot of the last week trying to reason with paranoid people, and I am wondering whether there is any insight to be gained for use in reasoning with paranoid governments or leaders. It is difficult to separate out the obsessions and misinterpretations by victim cultures from true paranoia; in unstable countries, it is also hard to tell what actions by leaders are actually paranoid, as it is true that some people are plotting against them and want to kill them. Most importantly, paranoia of the schizophrenic variety is a brain illness, not a cultural or personal expression, and it may not illuminate the cultural paranoia of nations in any way.

Still, I will follow the trail and see where it leads.

It’s easiest if one doesn’t have to deal with them at all, of course, and it is best not to go looking for extra arguments solely for the purpose of telling them their world-view is wrong. But the nature of hospital commitments – as well as life in general – is that they must be approached to have various rights explained to them, questions asked of them, signatures sought, and life-tasks to accomplish (like getting up, eating, hygiene). I am heavily involved in the first three of those. Do you want an appeal hearing? Can we call your parents?

Simple questions provoke angry tangents. “Why the f- am I here? Do you think it’s fair for the police to break in without knocking and drag me to the ER where I didn’t see a doctor, just a b- nurse who lied to me…” Fierce anger may be apparent even under the attempt to appear calm. “I’d prefer that you not call anyone. I’ve decided that those relationships are toxic for me. My mother has been very interfering.” Suppressed rage, voice dripping with polite venom, can be worn as a badge of honor – supposed proof that the speaker is in control and gentle, surrounded by angry, out-of-control others. This is more common in women, but I won’t guess whether that is biological or socially conditioned.

Interviewing a patient for information may elicit anger, but the interviewer can adopt a pliant or accepting posture to deflect confrontation. Others are not so lucky. When the law requires not only that a patient must have his rights explained fully, but signatures and permissions acquired, the sidestepping of anger can go on endlessly, until a halt must be called. “You may have valid complaints, but that’s not what we’re discussing now. I need you to decide if you want an appeal or not. You can change your mind later. There is no wrong answer. It’s entirely your choice…” Non-decisions must at some point be declared decisions, and then that has to be explained to them. There are some stalemates that cannot go on forever. You must move from here or we will move you.

Paranoid patients are not the only ones to present this difficulty, but the intensity is greater at the point of conflict. It is also more surprising, because it can surface after a pleasant conversation on other subjects. Especially in late-onset paranoid schizophrenics, much of the personality has been formed competently before the intrusion of the voices or delusions, and the patient can rattle on with easy animation about sports, literature, or humor.

The fury proceeds from some issue that is of overriding importance to the patient. The police really are beaming infrared rays into their apartment. Other people really must hear those voices, but pretend not to. Mites really do infest all the clothing, and must be sealed off. A personality disordered patient may grudgingly acknowledge that his father is merely stupid and selfish rather than vindictive. People with depression can understand that there may be another way to look at things, even if they cannot bring themselves to it. But a person with paranoia will have none of that. There is a fierce insistence on a single interpretation of the issue – there is no other way to understand events. The rest of the world may not believe that satellites are beaming messages into some people’s brains, but it is true nonetheless.

To person in the grip of paranoia, this issue must be dealt with and acknowledged by others before any discussion can proceed. The things the doctors and nurses want to talk about are considered merely derivative issues. I was only violent because I was falsely accused and mistreated by the police. Of course everyone should eat, but I refuse to eat the flesh of babies. If the exterminator had done their job right and gotten rid of the bugs, I wouldn’t have had to set the floor on fire. If the priest had preached on the prophecy I wrote to him, I wouldn’t have said that God should strike him dead.

If this is sounding a bit like Iran or North Korea to you at this point, I am wondering that myself.

To try and prove themselves right on this key issue, people of many diagnoses, but especially those with paranoia, will fasten on the most amazing details as evidence, rapidly twisting them out of recognition. You’re saying that what I put into my body isn’t important… (No, I’m saying that side effects that you don’t have aren’t important to discuss) You won’t let me meet with my attorney… (You may meet with your attorney when she comes here. You cannot go there.) The replies in parentheses are more hypothetical than the complaints, because you usually don’t get to complete your sentence. Those are the types of things I am usually trying to say.

This sounds more like Hamas and Hezbollah than Iran, actually.

Next up, a look at what strategies work, or more usually, don’t work.