Acceptance and Commitment Therapy (ACT)

Retrieved from Issue 346 of Institute Inbrief 20/01/2021

Paranoia: Definition and levels

When a person believes that others are “out to get them”, trying to stalk or harm them, or paying excessive attention to them for no reason, they may be experiencing paranoia. Occurring in many mental health conditions, paranoia is most often present in psychotic disorders. It involves intense anxious or fearful feelings and thoughts, most often related to persecution, threat, or conspiracy (Mental Health America, n.d.). It can be a symptom of illnesses such as schizophrenia, brief psychosis, paranoid personality, psychotic depression, mania with psychotic features, delusional disorders, or substance abuse (chronic or momentary) (Barron, 2016).

Mental health experts have identified three levels of paranoia:

1. Paranoid personality disorder (PPD): Characterised by odd or eccentric ways of thinking, PPD involves an unrelenting mistrust and suspicion of others when there is no reason to be suspicious. It is one of the personality disorders in the DSM-5’s Cluster A, along with schizoid and schizotypal personality disorders. Thought to be the mildest form of paranoia, a person with PPD may still be able to function in relationships, employment, and social activities. The onset is typically in early adulthood and is more common in men than in women.
    
2. Delusional (paranoid) disorder: Found in the DSM-5 chapter, “Schizophrenia spectrum and other psychotic disorders”, this is a condition in which an individual holds one major false belief or delusion; it will often be an implausible but not bizarre delusion. A delusional disorder typically occurs without any other signs of mental illness. So a person might think that others are talking behind their back if they have a persecutory delusion, or believe that they need immediate medical attention for a (non-existent) medical problem if they have a somatic delusion. This condition is slightly more common in women than men.
    
3. Schizophrenia with bizarre delusions: People with this condition do not function well in society and need consistent treatment (Sunrise House, 2018; WebMD, 2018).This is the most severe form of paranoia, involving bizarre delusions without basis, such as that aliens are trying to abduct them, or that an unseen enemy is removing their internal organs and replacing them with others’ organs.

This article is about Levels (1) and (2), the paranoid personality disorder (PPD) and delusional disorder, which you may encounter more commonly, either in your client or the client’s partner.

Identifying paranoia

We have several options for finding out what characteristics should be called “paranoid”: we can assess how we experience the person — how we describe them and what they evoke in us — and/or we can run with DSM-5 descriptions, which outline the clinical symptoms we can observe specifically with the paranoid personality disorder and delusional disorder. Let’s do both.

Descriptions of the paranoid person

Joe Navarro, who has written extensively about mental disorders, asked those who had either lived with or been victimised by paranoid personality types to describe this personality type from their experiences. Here is the list of some of their words:

“Angry, anxious, apprehensive, combative, complainer, contrarian, critical, delusional, demanding, difficult, distrustful, disturbed, eccentric, fanatic, fearful, fixated, fussy, guarded, hard-headed, inhospitable, intense, irrational, know-it-all, menacing, mentally rigid, moralistic, obsessed, odd, offensive, opinionated, sensitive, peculiar, pedantic, quarrelsome, questioning, rigid, scary, strict, stubborn, suspicious, tense, threatening, tightly-wound, touchy, unforgiving, unhappy, vindictive, wary, watchful, withdrawn” (Navarro, 2016).

What they evoke in us:

Experiencing a relationship with someone described by such intense words as those above cannot fail to bring forth a reaction in us. Laurel Nowak (2018) outlines the common feelings evoked by paranoid individuals in those with whom they are in relationship. She talks about: “feeling weighed down, negative, stressed, isolated from the people and activities you used to enjoy, and like you’re walking on eggshells”. Some have noted that it can feel to the other person like they are not being seen — ever — for who they truly are. The exaggerated negative spin on events or in response to statements occurs in the context of relating which lacks tenderness, humour, or comfort (Navarro, 2016). While these authors are describing feelings evoked in intimate relationships with paranoid individuals, they could have been talking about how therapists feel when faced with a client with this condition. Dealing with such a person eats away at the most robust sense of happiness and self-esteem. Here are the DSM-5 symptoms.

Paranoid Personality Disorder: DSM-5 symptoms description

According to the DSM-5, there are two primary diagnostic criteria for Paranoid Personality Disorder, of which Criterion A has seven sub-features. Four of these must be present to warrant a diagnosis of PPD:

Criterion A is: Global mistrust and suspicion of others’ motives which commences in adulthood. The seven sub-features of Criterion A are:

1. Belief others are using, lying to, or harming them, without apparent evidence thereof
2. Doubts about the loyalty and trustworthiness of friends and associates
3. Inability to confide in others due to the belief that their confidence will be betrayed
4. Interpretation of ambiguous or benign remarks as hurtful or threatening
5. Holding grudges (being unforgiving of insults, injuries, or slights)
6. In the absence of objective evidence, belief that their reputation or character are being assailed by others; retaliation in some manner
7. Being jealous and suspicious without cause that intimate partners are being unfaithful.

Criterion B is that the above symptoms will not be during a psychotic episode in schizophrenia, bipolar disorder, or depressive disorder with psychotic features (American Psychiatric Association, 2013).

Delusional Disorder: DSM-5 definition and types

According to the DSM-5, this condition is characterised by at least one month of delusions but no other psychotic symptoms. Delusions are false beliefs based on incorrect inference about external reality that persist despite the evidence to the contrary; these beliefs are not ordinarily accepted by other members of the person’s culture or subculture. In delusional disorder (a moderate level of paranoia), a person experiences non-schizophrenic (i.e., not bizarre) delusions, such as that they are that they are being spied on. Because only thoughts are affected, a person with a delusional disorder can act normal and function in everyday life, although they may display paranoia or other symptoms related to their delusion. The five types of delusions people with this disorder have are:

1. Erotomanic, where there is a belief that a person with higher social or financial standing (such as the president or a movie star) is in love with them; it can lead to stalking and obsession.
    
2. Grandiose, involving the false belief that the person has a special power or ability not shared by anyone else (such as that they are extremely lucky and will always win at the casino).
    
3. Jealous: a mistaken belief that a current or former loved one is unfaithful or even harmful. Paranoia about the loved one’s words or actions can be a symptom of these delusions.
    
4. Persecutory, in which the common sense of the paranoia is that someone is out to get the individual, because the person believes they are being threatened, mistreated, or that they will be harmed in the future.
    
5. Somatic: a delusion in which the individual believes that they have an illness, disability or physical defect (Sunrise House, 2018; Mental Health America, n.d.; Bourgeois, 2017).

Treating and coping with paranoia

For the therapist

First, we must note the common advice: a person suffering from either PPD or a delusional disorder needs to seek professional help, although most such individuals do not believe that they are paranoid; rather, they think they are perceptive, noticing things that no one else sees. In this sense, it can be difficult to get such a person to therapy, as the condition tends to be ego syntonic. If such an individual turns up in your therapy rooms, however, note that a referral to a medical doctor is in order to determine if medication is needed.

Medication generally is not a major focus of treatment for PPD; therapy is. However, medications, such as anti-anxiety, antidepressant, or anti-psychotic drugs, might be prescribed if the person’s symptoms are extreme, or if he or she also suffers from an associated psychological problem, such as anxiety or depression (WebMD, 2018).

With delusional disorders, the diagnosed individual begins a combination of medication and psychotherapy. The anti-psychotic medication helps the individual improve enough to be able to understand reality and the need for therapeutic help. In milder cases, the individual may receive anti-anxiety medications or anti-depressants, which allows them to undergo therapy, where they learn coping skills, how to recognise delusions as false, and how to manage stress or difficult feelings. Hospitalisation may sometimes be indicated to stop the person from harming themselves or others during violent delusions (Sunrise House, 2018).

As the condition affects the client’s thought patterns and beliefs, it can be worked with effectively using cognitive behavioural therapy, which transforms the unrealistic, maladaptive thoughts by replacing them with more helpful, realistic adaptive thoughts. In addition, some therapists have observed that psychodynamic work, such as object relations, can help paranoid clients look into reasons for becoming mistrustful and suspicious which arise from early childhood relationships (Everyday Health, n.d.).

You might be asking, “Wait a minute; chief symptoms are a tendency to be suspicious and an inability to trust. How, then, can a therapist make any reasonable headway with such a client, given that trust is the basis for any solid therapeutic alliance?” If you twigged to this issue, congratulations; you have nailed the problem: how to keep the paranoid client in therapy long enough for enough trust to be built so that real progress can be made. Building trust is where the challenge is, no matter what modality is being used with the client.

To help a client in relationship with a person living with paranoia

You are likely to see the partner of a person acting paranoid. Once it is established that some form of paranoia is indeed the diagnosis, some clear guidelines exist for helping the partner. Some of the following tips also hold true for therapists working with this client population.

Setting boundaries. The paranoid person needs compassion and understanding, true, but that does not equate to acceptance of poor treatment on the grounds that the person has a disorder and is frustrated. Clear lines of what is acceptable and what is not must be drawn; those expectations for decent treatment must be communicated clearly, including around the issue of refusing to collude with delusional thinking (compromising one’s own needs) because of the person’s paranoia or fear.

Practicing self-care. For therapists and partners alike, this one is paramount! Dealing with this disorder is exhausting and sometimes heart-breaking. Those in close relationships (whether intimate or therapeutic) with paranoid individuals must have regular, solid habits of self-care. All the usual practices go into this category: relaxation/meditation, exercise, decent diet, support systems activated, and perhaps journalling or creative work to vent frustrations. Particularly for partners of those with PPD or a delusional disorder, maintaining a healthy social life — not allowing oneself to become isolated — is important.

Don’t abandon own stance, but empathise with their fear. If either the partner of the paranoid person or you, as therapist, hear an accusation that seems really “off” — totally unfounded — you can employ the tactic of empathising with the feeling, but not necessarily agreeing with the facts (though outright disagreeing doesn’t work, either). Carrie Baron, M.D., and Director of the Resilience Program at Dell Medical School in Texas, explains that consoling the person and refuting what they have said will not likely alter any paranoid convictions or delusions. What works better is “observation, reflection, curiosity and openness without judgment”, which lead to better understanding (Barron, 2016). Thus, the partner could say to the paranoid person, “I can imagine you’re worried if you think that the inheritance you counted on for your retirement might be taken away through your dad marrying. Have you observed any behaviour that made you question her motives?” (curiosity). However they do it, partners of people with any form of paranoia must look beneath the surface before getting swept up in the partner’s claims (Barron, 2016).

Recognise that the paranoid person can still contribute to life. Because of the fact that mild or moderate forms of paranoia are circumscribed, showing up only in particular thoughts and delusions, only those involved or accused may be aware of the psychopathology of the condition. The person can thus contribute to family life, work, and aspects of social life in positive ways, which you as therapist can help highlight for the partner.

Having either a client or a client’s partner who is paranoid is not easy, but the worst heartbreak and chaos can be avoided if the person can engage treatment, including medication when necessary.

References:

1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders.(5th Edition). Washington, DC.: APA.
2. Barron, C. (2016). 7 Tips for coping with a paranoid partner. Psychology Today. Retrieved on 4 December, 2018, from: Website.
3. Bourgeois, J. (2017). Delusional disorder. Medscape. Retrieved on 9 December, 2018, from: Website.
4. Everyday Health. (n.d.) Coping with paranoia in a loved one. Everyday Health. Retrieved on 4 December, 2018, from: Website.
5. Mental Health America. (n.d.). Paranoia and delusional disorders. Mental Health America. Retrieved on 6 December, 2018, from: Website.
6. Navarrro, J. (2016). The paranoid partner: Identifying the paranoid personality in relationships. Psychology Today. Retrieved on 4 December, 2018, from: Website.
7. Nowak, L. (2018). Paranoid personality disorder and relationships: Moving past fear, together. Bridges to Recovery. Retrieved on 4 December, 2018, from: Website.
8. Sunrise House. (2018). Is there a difference between paranoia and delusional disorders? American Addiction Centers. Retrieved on 9 December, 2018, from: Website.
9. WebMD. (2018). Paranoid personality disorder. WebMD LLC. Retrieved on 9 December, 2018, from: Website.

I want to preface this post by stating that the concepts and suggestions I’ve made below are my own thoughts, opinions, and suggestions based on my own experience working in the mental health sector and lived experience. There may also be numerous grammatical and logical errors. I know that you’re intuitive enough to understand what I’m attempting to describe and explain. Therefore, there will be no references section at the end. This is merely an expression of thoughts, a stream of consciousness (William James coined the term Stream of Consciousness).

Episodic, acute, and chronic anxiety can be miserable and debilitating. Individuals living with anxiety have generally experimented with many techniques to cope with anxiety symptoms, and they have often been practicing these techniques for months, years, or decades. Anxiety is life changing. Current treatment can be efficacious at reducing the intensity or frequency of symptoms for the vast majority of people living with anxiety, but only at best. I, myself, have tried the deep breathing technique commonly advised by mental health professionals, and it can be about as useful as taking a sugar pill. There is credible science that supports deep breathing exercises can improve symptoms and recovery rates for stress, anxiety and depression levels – but what about for an anxiety attack or a panic attack or intense chronic symptoms of anxiety?

Sometimes nothing is effective enough for immediate relief. It is my contention that building a relationship with a trained psychiatrist, specialised in this domain, is an essential first step. Your treating specialist(s) will need to have extensive experience and a comprehensive understanding of the debilitating impacts of anxiety, anxiety attacks, and/or panic attacks. I recommend psychiatry because you will need someone who can prescribe short-term medication, schedule 4 or greater, to alleviate the pain rapidly. All symptoms a person may experience from any condition in the anxiety family present a risk for searching for any immediate relief. This is true for you or me or anyone. Without prompt and effective medical care readily available, many people who do not have a plan for managing anxiety will potentially search for an unhealthy substitute to acquire relief.

These substitutes are often unhelpful long term but effective short term. We all know what they are: alcohol and other drugs, sexual promiscuity or sex addiction, love addiction, gambling, excessive or unhealthy eating habits, self-injury, addictive forms of gaming, impulse spending, co-dependent or dependent behaviours on people, people pleasing, running away (avoiding reality), raging, reckless driving and other criminal behaviour, and relying on pharmaceuticals (legally prescribes or otherwise) that will have long-term unhealthy side effects. People know how to “doctor shop”, and although this area of medicine is becoming much more regulated, it still occurs. Unfortunately, there are people who do require certain types of legal drugs, in a timely manner, to find relief as a means of not engaging in any of the previously mentioned behaviours.

Some people may not have much faith in the field of psychiatry or psychology – HOWEVER – you may find yourself in a situation one day where you will need a doctor who knows your history to increase the likelihood of prescribing medication to treat anxiety when you need it most. This medication usually has addictive properties. An ethical psychiatrist will usually be unwilling to prescribe more than a single repeat of potentially addictive medication to treat their patients. This is standard, regulated medical practice in Australia.

Anyone working in the drug and alcohol sector or has regular contact with a person living with anxiety, or any form of addiction, will know that patients – people – are not being seen in a timely manner top treat anxiety before the patient starts looking elsewhere. Even once the patient has accessed some type of medical care, the length of care is not long enough for the patient to be “well enough” after discharge or ending their hourly session, to be on their own in the community safely without becoming vulnerable to their condition in a short time and looking for more relief to ease their pain and improve their well-being.

If a person or a patient cannot depend on the medical system in the way they need to feel safe and well, they will almost certainly begin to lose faith and trust in health professionals, and ‘the system’. This perpetuates their internalised stigma being reinforced, yet again.

I am not saying the patient doesn’t have a significant responsibly of their own to make valuable choices outside of medical treatment. I quote what someone once said to me, “You may not have asked for this disease, but it becomes our responsibility to stay well”. That is our duty as the person living with a health issue of any kind. There are things we certainly must do (or not do) to stay as healthy as possible. The help make not be there in a timely manner the next time we need immediate help.

It can take weeks or more to enter a detox facility. It can take months to enter a rehabilitation facility. It can take months for an available appointment to open with a psychiatrist. It becomes our responsibility to know that even when we’re feeling well and back to “normal”, we must continue those relationships with medication professionals. It becomes our responsibility to try alternative medicines if that’s something you’re interested in. Let’s face it, psychiatrists cease their practice, our professional relationship has reached it’s potential for adequate, loving care, or we want to try something new.

Start the process of finding a reliable, qualified, and credible psychiatrist today. I would recommend finding a counselling psychologist or other mental health professional that you have a productive and friendly working relationship with – and if you want to practice Buddhism, or acupuncture, or hypnotherapy, or any other complementary and alternative medicine – do it. If you want to connect with God – do it. If you want to see a naturopath – do it. Whatever it is, this may very well be a lifelong journey for you. Based on my own experience, don’t stop because you think you’re “all better now”. The previously mentioned professions or treatment options or lifestyle choices can be extremely expensive, but I would encourage you to save for it, find less expensive options. Sitting in church is free, or listening to an online guru can be the price or maintaining your mobile service bill.

I once knew of a fellow peer in treatment alongside me who said he saved money for years to travel overseas to have a procedure not available in Australia at the time for this purpose. He wanted blood transfusions and heat therapy for chronic pain that didn’t doctors could not determine had physiological origins. The peer was sure it had to, and medical investigations in Australia come up negative. The peer explained the theory behind blood transfusions and heat therapy – he believed – were supposed to improve his blood circulation and blood flow to treat the chronic pain he’d been living with for years after a workplace accident. Even this procedure overseas proved ineffective in mitigating his chronic pain. So, next he tried the wim hof method. He changed is diet. He exercised differently. He tried hypnotherapy. Finally, he turned psychology to treat stress and process childhood trauma. He was being treated for this a private facility where I was a patient at that time. I lost contact with him after I ended my own treatment episode. I don’t know if he’s still living with chronic pain or not.

The following are some very basic and well-known strategies in the Western world of psychology that you can begin to practice today, and then practice every day after that too – even for 5-20 minutes:

– learning about anxiety – your specific “causes” and the conditions more generally

– mindfulness

– relaxation techniques

– correct breathing techniques

– dietary adjustments

– exercise

– learning to be assertive

– building self-esteem

– cognitive therapy

– exposure therapy

– structured problem solving

– support groups

My firm believe is this:

Strong, healthy, quality relationships are essential to treating anxiety and other psychological illnesses. This about your life today: are you lonely (romantically or otherwise), are you a stressed individual, do you regularly feel like you job is stressful or unfulfilling, do you feel sad a lot, are you feeling pointless a lot, or feeling helpless a lot, feeling shame a lot, getting angry a lot over considerably minor things? etc. etc. etc. I would strongly encourage talking to a professional and begin exploring what options you have available to you.

Try, explore, play with a few methods of treatment. However, this must take a priority in your life. It must balance will all the many other obligations and responsibilities people encounter daily.

Type alternative medications or approaches to psychology. There are so many. It can be fun to try out a few when your finances permit. Even planning a holiday every 3-6 months is taking care of your well-being.

Many blessings friends.

Unhelpful Cognitions

Mental Filter: This thinking style involves a “filtering in” and “filtering out” process – a sort of “tunnel vision”, focusing on only one part of a situation and ignoring the rest. Usually this means looking at the negative parts of a situation and forgetting the positive parts, and the whole picture is coloured by what may be a single negative detail.

Jumping to Conclusions: We jump to conclusions when we assume that we know what someone else is thinking (mind reading) and when we make predictions about what is going to happen in the future (predictive thinking).

Mind reading: Is a habitual thinking pattern characterized by expecting others to know what you’re thinking without having to tell them or expecting to know what others are thinking without them telling you. This is very common, and most people can identify. Oftentimes, when we are telling someone a story about an interaction, we’ve had with someone else, we will make mind reading assumptions without actually having fact or evidence e.g., “They haven’t phoned me in two weeks so they must be angry with me for cancelling on them last week.”

Personalisation: This involves blaming yourself for everything that goes wrong or could go wrong, even when you may only be partly responsible or not responsible at all. You might be taking 100% responsibility for the occurrence of external events. It can also involve blaming someone else for something for which they have no responsibility. This can often occur when setting a boundary with someone and you take responsibility for their guilt or anger.

Catastrophising: Catastrophising occurs when we “blow things out of proportion” and we view the situation as terrible, awful, dreadful, and horrible, even though the reality is that the problem itself may be quite small.

Black & White Thinking: Also known as splitting, dichotomous thinking, and all-or-nothing thinking, involves seeing only one side or the other (the positives or the negatives, for example). You are either wrong or right, good or bad and so on. There are no in-betweens or shades of grey.

Should-ing and Must-ing: Sometimes by saying “I should…” or “I must…” you can put unreasonable demands or pressure on yourself and others. Although these statements are not always unhelpful (e.g., “I should not get drunk and drive home”), they can sometimes create unrealistic expectations.

Should-ing and must-ing can be a psychological distortion because it can “deny reality” e.g., I shouldn’t have had so much to drink last night. This is helpful in the sense that it communicates to us that we have exceeded our boundaries, however, saying “shouldn’t” about a past situation can be futile because it cannot be changed.

Overgeneralisation: When we overgeneralise, we take one instance in the past or present, and impose it on all current or future situations. If we say, “You always…” or “Everyone…”, or “I never…” then we are probably overgeneralising.

Labelling: We label ourselves and others when we make global statements based on behaviour in specific situations. We might use this label even though there are many more examples that are not consistent with that label. Labelling is a cognitive distortion whereby we take one characteristic of a person/group/situation and apply it to the whole person/group/situation. Example: “Because I failed a test, I am a failure” or “Because she is frequently late to work, she is irresponsible”.

Emotional Reasoning: This thinking style involves basing your view of situations or yourself on the way you are feeling. For example, the only evidence that something bad is going to happen is that you feel like something bad is going to happen. Emotions and feelings are real however they are not necessarily indicative of objective truth or fact.

Magnification and Minimisation: In this thinking style, you magnify the positive attributes of other people and minimise your own positive attributes. Also known as the binocular effect on thinking. Often it means that you enlarge (magnify) the positive attributes of other people and shrink (minimise) your own attributes, just like looking at the world through either end of the same pair of binoculars.

(CCI, 2008)