NYTimes.com Article: Self-Protection or Delusion? The Many
Varieties of Paranoia
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Self-Protection or Delusion? The Many Varieties of Paranoia
April 1, 2003
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
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
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
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
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
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
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.
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