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WHILE in a general way paranoia is recognized as belonging to the psychoses - the insanities - there are many important forms of this disorder which are worthy of consideration in connection with the study of the neuroses. Paranoia is sometimes associated with a mild type of dementia precox, and it no doubt can exist as a mental condition separate and apart from other psychic disorders.
In paranoia the unfortunate victim is living a fairy tale - not simply reading about it, or telling it. A study of the technique of the subconscious serves to afford a better understanding as to the origin of both the delusions and the hallucinations of paranoia. In the previous generation, hallucinations were regarded as one of the diagnostic earmarks of insanity; but many students of these problems no longer hold this view. I am meeting every few weeks in my office, nervous individuals, sensitives, psychics, mystics, and hysterics, who undoubtedly have hallucinations, either auditory or visual, and sometimes both; yet careful study of these people would hardly warrant us in classifying them as insane.
I meet with individuals in whom I can induce or suggest these hallucinations of hearing and vision by experimental means, sometimes not going so far as to put them in a state of hypnosis or even of hypnoidisation, which is a sort of vestibule or antechamber to the deeper state of hypnosis. Crystal vision, as already considered, is little more than a suggested visual hallucination. From an experimental standpoint, visual hallucinations are much more easy to suggest or induce than auditory hallucinations.
Both visual and auditory hallucinations are common in connection with highly emotional experiences and sudden religious conversions. It is not uncommon for hysterical subjects, under the stress and strain of religious excitement, to see visions of Christ and the angels, and to hear spirit voices and recognize the Divine call. This same sort of religious intensity and conscientious devotion, in connection with the mechanism of the unconscious, needs only to be focused upon spiritualism - to be dedicated to the task of communicating with the dead - and the stage is set, the machinery provided, for the production of all the subtle and spectacular phenomena which characterize the psychic manifestations of mediumship.
We have given considerable space to the technique of projection, and attention should be called to the fact that in paranoia we have present the opposite condition, that of introjection. Introjection means that the patient is possessed with the mania for ascribing a personal meaning to everything going on about him. The paranoiac, as he walks down the street, thinks that everybody is talking about him and casting significant glances toward him. Street noises, noises in the kitchens of restaurants - all the things that happen about him during the day's work or in places of public entertainment - he believes are directed in some subtle manner toward himself.
Paranoia is, after all, a sort of return to the infantile state of mental existence - that state in which the individual believes himself to be the center of the universe. There is, along certain lines, more or less complete regression from adult life back to the infantile mental status. All normal individuals are accustomed to revert more or less, periodically, to the state of childhood; but we do it in our ordinary play, in our week-end diversions and annual vacations. This is a natural, restful form of regression; but in paranoia it becomes exceedingly distressing when an individual feels that everything that is going on in the world about him is centering about his personality and has something to do with his happiness - or more especially with his unhappiness and psychic torture.
When paranoiacs begin to get tangled up in their thinking, when they begin to suffer persecution at the hands of various persons or groups, they naturally - being fairly sane in all other directions - try to figure out why they are thus tortured and persecuted. And they are usually able to discover what seems to them to be a satisfactory explanation of it. In the olden days a great deal was ascribed to telepathy. Paranoid sufferers maintained that people were telepathing disagreeable thoughts to their minds, or that other individuals were stealing their thoughts and knew everything that was going on in their minds. The more recent radio vogue has given these patients a cue, and they now maintain that their minds are receiving stations for the undesirable emanations from numerous other minds.
While paranoia is one of the most common forms of dementia precox - there being at least three other forms - it is also found in other conditions. We see many of these cases which really get well, and it is this type that I am most interested in describing - cases that we might denominate simple paranoia.
When an otherwise apparently normal mind picks up a delusion which it holds on to persistently, or when this individual describes hallucinations which you cannot reason with him about, we call the condition paranoia. These delusions and illusions, when they become fixed in the mind, are almost always associated with suspicion, persecution, or some dominant or grandiose idea. If we make a diagnosis of simple paranoia we presuppose there is no dementia. I must admit that in this pure form paranoia is a rather rare disorder - that marked cases of paranoia are usually associated with a more general psychic condition which we commonly call dementia precox.
Having arrived at a fixed point for their delusions of persecution, these paranoiacs begin to ransack their memories of past events for experiences which could serve as possible explanations for their persecution; in this way they sometimes dig up secondary delusions, coming to regard themselves as supermen, or as emissaries of God, and offering this as an adequate explanation of their persecution.
Sometimes the paranoiac will endure delusions of persecution for weeks and months, or even years, in silence. I knew of one who had gone along for months, working in an office under the delusion that he was being spied upon and followed and otherwise harassed by his fellow workers, but never giving intimation of his feelings until one afternoon he turned around to the man at an adjoining desk, and, figuratively speaking, "knocked him into the middle of next week". Whereupon he went over to the closet, got his coat and hat, and walked out of the place. This is the only time this man has ever shown any tendency to become violent, tho he has been bothered for two or three years with these delusions.
Patients of this kind are running around loose among us in large numbers. They are sometimes spoken of as being slightly "cracked", a little bit "off", "cranks", and so on. When but mildly afflicted they are often found vigorously functioning as members of anti-this or anti-that, or pro-this and pro-that, and aside from being just a bit one-sided, not very well balanced, they are quite normal.
Other mild cases of this disorder manifest themselves only by an inordinately quarrelsome tendency; these people, when opposed, are liable to become violent, and not infrequently they attack some innocent person whom they have come to believe to be among those responsible for their miseries. Or perhaps they suddenly plunge into protracted litigation in court over some trifling incident. The quarrelsome type of female belonging to the paranoid group is a dangerous individual and not infrequently prefers serious charges against innocent citizens.
Paranoia is probably due to a working association between a group of powerful but perverted complexes, and experience shows that when it is not a phase of dementia precox, or when, in case of dementia precox, the underlying condition is comparatively slight, much can be done to help the patient out of his troubles.
Paranoia also seems to be the possible accompaniment of another form of insanity known as manic-depressive psychosis, and in this case the paranoid state is sometimes found in association with depression and at other times with exaltation.
Hallucinations are common in association with fevers and acute alcoholism. In the alcoholic victim they are very real and are able thoroughly to terrorize the patient. In cases of paranoia the danger of using drugs to overcome hallucinations should be emphasized, tho we do occasionally, as a last resort, put these patients under the influence of non habit forming drugs for several weeks at a time in an effort to break the train of thought in the mind and help them to find themselves. I have seen this plan work to great advantage. Several years ago a man from a western state came to Chicago, thoroughly incapacitated for carrying on his business, having for more than six months been leading a life of abject fear. He was terror-stricken over the idea that a group of men had entered into a conspiracy first to mutilate and torture him and then to murder him. The foundation for this fear was a trifling incident in his early life, before his marriage. He had, through failure to understand the character of a certain young woman, just about become engaged to her; but, learning more about her, he had broken off all relations. The young woman had an older brother, who became very angry over the affair, and threatened violence to the young man. Although twenty-five years had gone by, when, as the result of both overwork and over-worry, this man became a little run down, that old fear came back into his mind, and it required only about six weeks for him to become literally obsessed by the idea that the girl's brother had organized a vast conspiracy. He admitted himself that no less than one to two thousand people were involved, and he actually saw himself being followed and even chased by all these people. The police force of his home town and the civil authorities of his State, he felt, had all entered into this conspiracy to "get him". It was pathetic to hear him talk. His sufferings were intense and no amount of reasoning had any influence on him. I have many times seen the use of quieting drugs fail in such cases, but in this particular case it was a complete success. Six weeks in the hands of doctors and under the careful supervision of a day and night nurse, brought such a change in this man's thinking, so arrested the current of his thoughts, that when he waked up and cam e back to normal living, he was practically delivered from his delusion.
I regard this case as one of simple paranoia. The subsequent performance of the patient goes a long way toward establishing the fact that his was not a case of dementia precox, at least not as we ordinarily see it. Of course, time will be required to see whether or not there is any return of his trouble; but observation of a number of the milder cases of paranoia leads me to believe that some of them are really curable if the patients are properly instructed and come to understand themselves.
It should be explained that the man whose case we are discussing was not finally cured of his delusion until he was, after being greatly improved, taken back to his home town and there, through the cooperation of his family physician and friends, brought face to face with many of the supposed arch conspirators in the plan to harm him. When he found them back at home instead of out on this mission of persecution, he went right out and called me on the long distance telephone, saying: "Dr. Sadler, you are right. You are dead right. I am convinced, and completely convinced, that nobody has been trying to harm me. This is all a notion I got into my head, and I am glad to be delivered from it. You watch my smoke. I am going back on the job to-day, and I am not going to make my wife or anybody else any more trouble". And he hasn't. He has been behaving perfectly from that day to this. We were frank with him throughout. The facts of his case were fully explained to him; the psychology of his condition, the tendency of the complexes that form, and the technique of his deceiving himself and leading himself into believing that his delusions were real - all these matters were fully explained to him; he has been instructed, also, that if there is any tendency for this condition ever to recur, he is to report immediately to his physician.
I believe that these hallucinations sometimes originate in night terrors, and we must not confuse paranoia with the anxiety neurosis on the one hand, or with the anxiety and apprehension of hyperthyroidism - goiter disturbances - on the other.
Sensory illusions are commonly met. We can amputate a cancerous leg, and yet for weeks or even months the patient will go on complaining of pain in the amputated limb. The nerves going up from this former member were so habituated to carrying up painful impressions and then carrying them back to be experienced in the diseased leg, that they go right on doing this even after amputation. In another case we may have illusions as the result of some defect in the function of the ordinary sensory mechanism of the body. The real difficulty in the case of illusions is not that patients have them, but that they are often unwilling logically to check them up and then disbelieve them. The mechanism for producing them is present with all of us, and doubtless we have had passing illusions from time to time; but we wake up and snap out of our day-dreams instead of becoming victims of them.
An illusion is nothing more nor less than a false perception concerning an objective reality, while an hallucination is a more serious perception-like process working in the mind and having no external object or source as its basis.
The most common hallucinations met with in paranoia are auditory. The patient hears voices speaking to him. Another type, not so often met, is that of the so-called audible thinkers. The patient complains that his thoughts are so loud that everyone near is able to hear them, and his belief in this fact is very distressing.
Visual hallucinations are not so common in paranoia, although we meet with cases now and then where they say they see many queer things. One man complained of seeing small human beings everywhere, about six inches tall.
Skin hallucinations are very common. Who has not felt pricking, tingling, and other queer cutaneous sensations - perhaps of bugs crawling on the skin? I remember the case of a patient who spent thirty minutes every night brushing off the sheets in order to get the sand out of the bed (later it was bread-crumbs). She believed it was there - it was very real to her.
Smell and taste illusions are also commonly met with. They usually are described as smelling unpleasant odors - occasionally pleasant perfumes. Still rarer hallucinations are those of sensations of flying; of having lead in the stomach; or of having a hardened head, as if made of wood.
When the hallucinations of the paranoiac become associated with the idea of persecution, they often produce profound depression, and sometimes even terror. We can imagine something of the suffering of these unfortunates by recalling our own fright at the time of waking immediately following some nightmare.
It is hard to tell just how many of the extraordinary characters of history were paranoiacs. Mohammed heard voices; even Martin Luther, on one occasion, threw an inkwell at the devil he thought he saw in his study; Joan of Arc certainly heard voices. It would seem that Columbus, Napoleon, and Cromwell all had experiences of this character.
I have a patient who is terribly distressed because he thinks people are constantly talking to him or about him. He would not leave his room were he not forced by hunger to go out in quest of work. Automobiles that pass the house carry people whose remarks come in to him, and he is sometimes in a rage as the result of the uncomplimentary comments he thinks he hears them make.
Our more common hallucinations are the seeing of bright zig-zag lights when the eyes are shut, seeing stars and other unreal things. These conditions are commonly associated with nervous sick headache and are usually in no way indicative of either paranoia or insanity.
Some mild forms of sensory hallucination are due to a disturbed condition in the eye, ear, nose, or other sensory organs; but these rather deserve the name of pseudo-hallucinations, because the normal person quickly checks them up and throws them out of court as unwarranted and foolish - as sensory deceptions. We also have queer sensations and experiences bordering on hallucinations, in the twilight zone just before falling asleep, or between the time we begin to awake in the morning and the point where we fully regain consciousness. Even in our dreams, things become twisted so that rain on the roof is converted into beautiful music.
The real secret of this whole hallucination business, of course, is the dislocation of that floating attribute of consciousness which we call the reality feeling. In paranoia the reality feeling becomes attached to something which is not real, and then we find the patient is not open to reason - will not listen to reason on this point as he does on almost every other point. So the possible causes of paranoia, aside from its association with the insanities, are to be found by looking for organic changes or functional disturbances in some of the organs of special sensation. The trouble may often be found in an organic change in the brain itself, or in the central nervous system. In other cases a mild form of paranoia may com e on as the result of imperfect development in the technique of forming nerve patterns or memory designs and association centers in the brain. It may also be possible for paranoia to come on as the result of some highly specialized and terrific drive of energy, due to some wish which has been imperfectly suppressed or incompletely controlled by elimination or sublimation.
Several years ago a young electrical engineer, twenty-eight years old, came in complaining that a certain great religious organization was engaged in persecuting him. The purpose of the conspiracy, he declared, was so to distress him that he would do something violent, get arrested, and be committed to prison. It required almost six months to talk him out of this idea, to convince him that this organization must be engaged in more important matters than following him up; furthermore, that if its tens of thousands of members had wanted to "get" him, they could have done so long before. Finally, he gave up this notion, but in less than two weeks he had a new one. His new obsession was built around the idea that there were many people in the world who took fiendish delight in being cruel.
He had been reading psychology at the public library, and had decided that he had become the butt of all the people who enjoy seeing other folks suffer. He explained that he had a very sensitive mind which acted as a telepathic receiver (he had found sufficient support in scientific literature to warrant his believing in telepathy), that all the vulgar, belittling, and oft-times obscene thoughts which came pouring in upon him were put there by hostile men and women who enjoyed seeing him tortured by being made the dumping ground for all this unpleasant mental material. This delusion lasted for almost a year. I am sure I never would have stuck to the case with any hope of helping the patient had it not been for the importunities of his wonderful mother, who would never listen to the advice of his medical advisers that the case be given up as one of paranoid dementia precox and that the lad be committed to an institution.
He did get better. He began gradually to improve, and it is a pleasure to report that he finally come to the place where he said: "Doctor, I am going to believe you. You must be right. I don't seem to be getting much better, but I must be wrong. At any rate, there seems to be more evidence against me than for me. You ought to know your business as I know mine as an engineer. You tell me this is in my head. I have tried to believe it. It is hard for me to accept it, but logic is on your side. I am going to do my very best to act on your diagnosis from now on". And in a recent letter to his mother he says that the "activity", as these patients so often designate their trouble, continues, but in less degree. He is not free from it yet, but is greatly improved. He has gone back to work and is doing well. In fact, he was at work the larger part of the time he was under treatment.
This is a borderline case of paranoia, and I presume we are not warranted now in trying to settle the diagnosis, but rather should wait and let time tell whether he has been cured of paranoia, or whether he is merely experiencing a period of improvement in connection with a more serious mental and nervous state.
Not long ago I met a business man from the East who had some trouble about fifteen years ago with a competitor, and this competitor, when he last saw him, threatened to get even with him some time. The man worried over this threat for years, and at length, while traveling from New York to his home town, he fell ill after eating a meal in the dining car. The thought suddenly flashed through his mind that he had been poisoned, that his former business enemy had at last gone into action, had gone out to "get" him, as he put it.
Two years have gone by, and he has not ceased to entertain the idea that a vast number of conspirators are working to poison him. He will not eat food as it is ordinarily served in hotels and restaurants. He will not buy food except in the original package, and then he goes out to pick it up in the open market where it is being sold to the public, and is very careful about the first meal out of a package of crackers, or from an original box of cheese. He has numerous digestive upsets as the result of all this, and he explains them all by declaring that someone has "got" him again. I showed him one day that his enemy must be spending no less than five thousand dollars a day to carry on this vast network of conspiracy, but he believes that his former business competitor has been able to enlist vast resources in this work of "getting" him. A year and a half ago he left home, deciding that his wife was so unsympathetic with his predicament that she must have sold out to his enemies. He has not since been back to see his wife and three children. He is a very efficient man, and by working a few weeks now and then makes enough money to keep body and soul together and pay for a cheap room; but sooner or later there comes a digestive upset, and he has to flee that section and go five hundred or a thousand miles away; and in the end his enemies always find him. They have a vast network of spies observing him - and so on.
When this man came to Chicago to see me he carried some cheese and a loaf of bread with him, which he ate for a day or two; then for another day or two he refrained from eating. A ten days' examination showed him to be sound physically; and all his mental tests, his psychic observations, showed him to be all right in every way, aside from this delusion. But he disappeared suddenly. He had ventured to buy some food in Chicago, and after eating it in his room, had become slightly nauseated; so he decided that "they" had located him again.
I am reciting this patient's sufferings and wanderings merely to illustrate what paranoia really is. Simple paranoia is nothing more nor less than monomania - getting some absurd idea in your head; you are all right on everything else, but this one idea persists in the mind. It is a glorified compulsion neurosis, an obsession raised to the nth power, which com es so thoroughly to possess the mind that reason and judgment are of no avail against it.
I presume many of our queer freaks in society belong to this order. I had many a talk with the late John Alexander Dowie, the great healer who came from Australia and founded a religious settlement just north of Chicago. I haven't the slightest doubt in my mind that Dowie really believed in himself. He was a victim of paranoia. When he stood up in the Auditorium in Chicago on Sunday and announced that he was Elijah the Prophet, reincarnated, my own opinion is that he was sincere - he really believed it.
I have a patient, a man who is well up in the insurance world, who is developing paranoia. His wife brought him in a few months ago and said he was nervous, restless, anxious, and worried. One Sunday afternoon she had coaxed him into telling her his troubles, and he had explained that, owing to a little business mistake he made about three years ago, one of his business associates had started in to "get" him. Of late he thinks of nothing else, talks of nothing else at home, and when away from the office he pays attention to little else than this conspiracy which is ever widening - more and more people are joining it - until he has now developed a very definite paranoid reaction. His wife and I both have made careful inquiry about his business connections, and have convinced ourselves that there is no more trouble or friction with his associates than would be found in any large corporation. He has agreed to submit to teaching and treatment, and as his case has been taken in hand early, with good health and otherwise sound mental state on our side, we have every reason to believe that he can be reeducated to see that his fears are without a real foundation.
And so the story goes on with paranoia, one case after another coming in, apparently all right in every way, mentally speaking, except on some one point, the domain of monomania. In business, in religion, and in various other realms we find these people going astray; and, of course, in connection with dementia precox we find a whole group of them; but it is not my intention in this work to discuss the insanities.
In efforts to prevent the development of latent paranoid or other nervous tendencies, it is highly important to curb all tendencies toward excessive suspicion, queerness, and sensitiveness, as well as any inclination to indulge in undue fault-finding. Early in life, individuals who give evidence of being potential neurotics, hypochondriacs, or paranoiacs should be thoroughly studied by means of emotional analysis, and should be put through a course of systematic psychic training, designed to bring about such reconstruction of their personality behavior as will enable them to avoid the full development of these undesirable tendencies.