Depression and paranoia
It has long been recognized that psychotic symptoms, including paranoia, occur along with severe depression. It seems reasonable to propose that paranoia can be a consequence of the pathologic realignment that accompanies de-differentiation. Making connections that would not be made by a normal person is one way of understanding what the paranoid person does.
All of Janice's paranoid ideas have this kind of distorted structure: She believes that people are following her because she sees the same people day after day (so do most of us); she believes that her phone is being tapped because she hears stray clicking sounds (these sounds are common now and are mostly due to the failure of automatic-dialing computers to complete calls); she believes that people are breaking into her house, even though there has never been any sign of forced entry (a normal person would reality-test this hypothesis and dismiss it for lack of evidence); she believes that she had been raped twice (again, this hypothesis doesn't match up with the evidence, because her husband would have had to have slept through these attacks not to notice what was happening and there were no physical signs of a sexual assault found either by the police or by the ER staff).
The paranoid person's world is one in which the control of everyday events has been largely ceded to others and to outside forces. Paranoia in a depressed person can be understood as a distorted cognitive component of a highly de-differentiated, "de-pressed" world. This is especially likely if that person is experiencing severe anxiety. I can imagine a very anxious Janice, struggling with pathologically altered meanings and structures, implicitly and subconsciously reconstructing her world according to the following schema: "If nothing is working for me, at least I can have people in my life who are working against me." Recalling what the psychoanalyst Erik Erikson said about negative identity, this kind of self-made anguish may trump the lack of identity that someone living in a seriously de-differentiated world might be expected to experience.
Since Janice reported being a lifelong loner, the possibility that she may have a schizoid or schizotypal personality or a schizophrenia spectrum disorder must be considered. That Janice may have a primary brain illness responsible for both her depression and her paranoia cannot be ruled out. A late-onset paranoid schizophrenia needs to be kept in the differential until the course of her illness plays out a bit furtherparticularly considering Janice's denial of significant mood symptoms and her brother's schizophrenia diagnosis. (Many diagnoses of schizophrenia are wrong; her brother's diagnosis would have to be confirmed before considering it a possible risk factor for Janice.)
It is not easy to know what to make of Janice's acknowledgment that she would consider anyone else who was thinking and acting as she was to be "crazy." Perhaps she simply does not want to see herself, or be seen by others, in this way. Or maybe, through some schizotypal process, she has succeeded in detaching herself from her situation.
My best therapeutic guess is that Janice was in the grip of an unacknowledged major depression, which was a psychological and biologic response to a plethora of losses she suffered during the previous several years, and that her depression had spawned a paranoid psychosis. Among the possible reasons she did not see herself as being depressed was that she had never learned to put words to her feelings, a condition known as alexithymia,6,7 and that her depression was "masked."
May Janice refuse psychiatric treatment?
Even before I recommended that Janice sign herself into a psychiatric hospital, she shot down the idea: "I came to the ER to see if this was due to something medical. If it's psychological, I can deal with it myself." She was covered under her husband's insurance, and I gave her the name and phone number of a female psychiatrist, whom she promised to call. I told Janice that if she felt she could not handle her situation at home, she could return to the ER and be evaluated again for hospitalization.
Everything I have learned about working with psychotic patients says that someone who presents the way Janice did should be treated. After Janice rebuffed my suggestion that she be hospitalized, I briefly considered an involuntary hospitalization, but it was clear to me that she did not meet the criteria for this drastic imposition on her freedom. She left the ER with her supportive and long-suffering husband, who at no time had pressed for her hospitalization, voluntary or otherwise.
Although Janice did not reveal the ultimate reasons for refusing the help that we offered her, she gave me the impression that she had her reasons. Outside of her paranoid beliefs, Janice's mind seemed to be working rationally. "It really helped getting this all out," she told me near the end of the interview. To some degree, we were able to talk rationally about her irrationality.
One month after I saw Janice in the ER, I called her at home. In a bright but quivering voice she told me that things were all right, though she would not provide any details. Janice had not followed up with the psychiatrist I recommended nor with any other clinician. She thanked me for my interest, and then asked why I had called "so late in the evening." Although she seemed reassured by my explanation that 9:30 PM was not that late for someone who routinely works the night shift, I had the feeling that some lingering doubts remained about my intentions. The night has its own demons, even more so for those who are anxious and paranoid.
I suspected that Janice was as paranoid as ever, but that she had decided to go it alone. As much as I wanted to question her further, I felt she would very likely take this as a sign that I, along with most of the world, was against her and meant her harm.
I was now staring down a paradox I had confronted in the ER many times before: A floridly psychotic patient was refusing any kind of psychiatric treatment. In the end, the need to allow Janice the autonomy to deal with her illness or not to deal with ittook precedence over my desire to act on her behalf and for her presumed good.9
Dr Muller formerly evaluated psychiatric patients in the emergency room at Union Memorial Hospital in Baltimore. His most recent book, Psych ER: Psychiatric Patients Come to the Emergency Room, was published by The Analytic Press in 2003.
Drugs Mentioned in This Article
1. Muller RJ. To understand depression, look to psychobiology, not biopsychiatry. Psychiatric Times. 2003;20:41-46.
2. Sartre JP; Frechtman B, trans. The Emotions: Outline of a Theory. New York: Philosophical Library; 1948:65.
3. Nietzsche F; Kaufmann W, trans; Hollingdale RJ, ed. The Will to Power. New York: Random House; 1967.
4. Cate C. Friedrich Nietzsche. New York: The Overlook Press; 2005.
5. Muller RJ. Psych ER: Psychiatric Patients Come to the Emergency Room. Hillside, NJ: The Analytic Press; 2003:3-10.
6. Sifneos PE. Alexithymia: past and present. Am J Psychiatry. 1996;153:137-142.
7. Muller RJ. When a patient has no story to tell: alexithymia. Psychiatric Times. 2000;17:71-72.
8. Fisch RZ, Nesher G. Masked depression. Help for the hidden misery. Postgrad Med. 1986;80:165-169.
9. Slavney PR. Psychiatric Dimensions of Medical Practice: What Primary-Care Physicians Should Know about Delirium, Demoralization, Suicidal Thinking, and Competence to Refuse Medical Advice. Baltimore: The Johns Hopkins University Press; 1998:97-120.