Dr. Grossi's Blog
One week ago a patient was talking to me in the office and disclosed that he was paranoid about a particular upcoming experience. He was using the word as a synonym for anxious, tense, apprehensive. This represents a colloquial slang usage of the word "paranoid." Psychiatrists use the word paranoid to mean suspicious, mistrustful. I will not be addressing a common form found in paranoid schizophrenia, because that would be mixing two confusing diagnoses, i.e., paranoid and schizophrenia. Paranoia is a way of thinking or feeling that is pervasive and whose severity varies from relatively mild to loss of reality as, for example, in delusions. The more severe, the more normal functioning is compromised.
Traits of people who are often paranoid include those who are emotionally constricted, fearful, and suspicious. Others are rigidly arrogant and more aggressively suspicious.The trait or attitude of suspiciousness involves the continual expectation of trickery and if chronic leads to a way of thinking. Rigidity refers to having something on a person's mind which causes that person to look at their experience with certain expectations and search for confirmation of those expectations. If someone tries to dissuade the individual from his original view, that person will become an object of suspicion. So, the paranoid person does not pay attention to new facts, doesn't see apparent meaning, but "looks through" the obvious and sees an aspect that confirms the original view, i.e., examination of the data takes place with prejudice so that there is confirmation of the original thought. Anything that contradicts this is dismissed as mere appearance. The paranoid individual is incapable of any other type of attention. His attention is tense, rigid, actively searching with a biased purpose and intensely concentrating.
Everyone has some expectations to help guide them in their view. We are all influenced by what we see and what we don't expect. Those people that are suggestible are easily influenced by whatever striking fact or view or opinion presents itself. People with strong views impose their anticipation on the facts. Paranoid people seek confirmation of their anticipations and these in turn allow them to disregard apparent contradictory facts. In this way the paranoid's mind becomes an instrument of bias and leads to "brilliantly perceptive mistakes", that is, the perception can be correct but the judgment wrong. They are hypersensitive and hyperalert. Anything out of the ordinary or surprising triggers their suspiciousness and heightens their extreme tension. What would appear to be obvious to most people in a given circumstance is to them mere appearance and disregarded. They need to look beyond. They listen for clues. In this was they loose the tone and color of experience and those features that modify and qualify experience or convey a sense of proportion or scale. They are over represented in fanatics. These are the cognitive mechanisms that lead to a distortion of reality or in the extreme a loss of reality.
Two well known psychiatric researchers, Kendler and Gardner, recently published the results of examining over a thousand twins in the Virginia Twin Registry. These results have shown light on new and added weight to prior findings regarding gender differences in males and females. The most important factors contributing to major depression in women included divorce, lack of social support, marital dissatisfaction, and personality traits of shyness, anger, and anxiety. For men occupational stressors, financial stressors, drug abuse and childhood sexual abuse were most important. In keeping with these findings, men's depressions are defined by inability to achieve goals and lowered self-esteem whereas women's depressions are associated with deficiencies in caring relationships. These are stereotypical findings and may be related to the population studied which is not age representative for the country nor is it representative of the urban/rural mix of the country.
There are other putative gender differences. About ten years ago, another group including Alan Schatzberg of Stanford, published their treatment response findings in many hundreds of depressed men and women. They found that men responded better to imipramine (Tofranil) a tricyclic antidepressant than women did and that women responded better to sertraline (Zoloft) and SSRIs than men. From the point of view of impact on children, there have been several studies in recent years showing that depressed mothers produce a greater risk for depression in their children. There are also several studies demonstrating that children's depression in a family with a depressed mother show marked improvement if the mother's depression remits. These studies underline the need for prompt and effective treatment for depressed individuals in families especially mothers of young children.
Recently I was moving some books from one room to another when I saw a book written in 1884 by the famous psychologist, William James. In the book he discussed the physiology of feeling states. This got me to thinking that he had conflated emotion and feeling, a common conflation often heard in the office. What then is the difference between emotion and feeling? Emotions are unlearned, programmed automatic actions such as external motions, internal motions, or even release of molecules with some cognitive component used in a strategic way to manage the challenges and opportunities of life. Emotion often regulates drives, motivation, and reward/punishment routines with a homeostatic goal. The emotional experience of happiness in two members of the same species is essentially the same. Feelings are compulsive perceptions of the emotional action programs, real or simulated, states of altered resources, or deployment of responsive scripts. These are represented in specific brain regions such as the insula, the cingulate gyrus, and the amygdala. We are always in an emotional state in response to the world and its challenges or opportunities. Emotions are transmitted by the genome and are conserved across species and through evolutionary time. We are always in an emotional state except when asleep or in a coma. We humans are constantly being confronted by events and are constantly reacting to and thinking about them. The emotional degree of engagement is dependent upon their importance of those happenings to us. These emotional programs have been in place through evolutionary time and are short cuts to decisions relative to threats such as predation, dangerous environmental hazards, or adverse weather events or alternatively opportunities which are either organized around seeking food or sex. While these processes are automated and unconscious, once they are perceived and made conscious they enter the thought flow and can be used subsequently for planning. The rationalist view of human nature glorifies rational decision making processes which depends on facts and logical analysis and eliminates what is viewed as the negative influence of emotion. This is a view which overlooks the important biological and evolutionary facts that animals, many much more primitive that we are, manage the challenges posed by living, sometime in a very inhospitable environment, frequently with great speed and without being able to think. If someone experiences emotions such as fear, anger, disgust, happiness or sadness there will be concomitant changes in the body such as changes in body temperature, circulation, heart rate, and increased motility of the intestines. These are recorded and stored for future reference and can be used in planning for future like circumstances. We are indeed feeling machines.