Dr. G's Six Tips for Dealing with Paranoid Psychosis
insider knowledge
For the past week and a half, I’ve been experiencing an episode of paranoid psychosis. It hasn’t been as severe as my episode in March, and it seems to have lost much of its force over the past couple of days. Nonetheless, I still have moments when I think that people are sending me coded messages and threats, that my digital devices are communicating with me through autocorrect, that I’m days away from being sued and imprisoned.
Sigh.
It’s always when you think you’re out of the woods that shit hits the fan.
Honestly, it’s a massive pain in the ass.
But for once, I’m actually proud of how I handled it. I still went into work, and although I believed my coworkers were continually sending me secret signals, I didn’t leave early, call in sick, or make a scene. I did my work, ate lunch, did more work, and left. I read novels, wrote, and practiced the bass when I was able to, and I even went downtown to see some friends yesterday and ate the worst ramen I’ve ever had in my life.
Not bad.
I’ve had a number of these episodes over the past year. None have been as severe as the one in March, but they’ve all been exhausting and terrifying. I’m not sure why it keeps happening. It’s almost as if my first manic-psychotic episode in 2022 changed the wiring of my brain to make me more susceptible to this sort of thing.
But what do I know.
This will be a strange post. I’m going to list my psychiatrist Dr. G’s six tips on dealing with paranoid psychosis. Dr. G is 76 years old and specializes in bipolar, so I’m sure he’s seen more cases of paranoid psychosis that he can count. These tips represent over four decades of clinical experience, but at the end of the day they’re nothing more, nothing less than his personal take on things. I’m sure there are psychiatrists who would disagree with one, if not all, of the suggestions I’ll list below. So, please do not take this as a clinical guide.
I know this list won’t be directly relevant to the vast majority of you, but if nothing else, I’m hoping it’ll be somewhat interesting.
With all that out of the way, here are Dr. G’s tips on dealing with paranoid psychosis:
Increase the dosage of your antipsychotic medication.
This one is actually less straightforward than it seems. If you’re experiencing a paranoid psychotic episode, isn’t it a no-brainer to take more of your antipsychotic? And yet, Dr. G is extremely careful and conservative when raising my medication dosages. I take 45mg of an antipsychotic called Latuda every day, and Dr. G only had me increase the dosage to 60mg for three days. Folks, this is not a particularly significant increase. When I had my psychotic episode in March, we went from 45mg to 80mg. But Dr. G determined that my most recent episode, although concerning, did not warrant such drastic measures. In fact, he consistently encourages me to handle my symptoms without relying on medication changes. This may seem bizarre coming from a psychiatrist, but it has helped me develop confidence in my ability to deal with my symptoms myself, an attitude which bore fruit over the past week and a half.
Focus on tasks.
This has probably been the most impactful piece of advice he has given me. Tasks include cleaning my room, doing laundry, playing the bass, moving furniture around, writing, drawing, coloring, walking. The most important thing is to focus on the task at hand. The worst place to be when you’re in paranoid psychosis is inside your own head. When you’re there, things that should never fit together are melded together as one, words continually bounce off the walls of your skull, and thoughts become scarier and scarier until they reach a breaking point. You have to find a way to leave your mind behind, and the best way to do this is to act into the world. A task has a clear starting point, procedure, and goal. It forces you to concentrate, to structure your subjectivity. When I get paranoid at work, I focus the entirety of my attention on the same mindless, repetitive administrative task I’ve been doing for the past four months. Just move my hands, I tell myself. Just move my hands. It really helps.
Keep your eyeballs pointed outward, not inward.
The paranoid psychotic thinks everyone he interacts with is sending him coded messages and threats through their words, actions, and gestures. He interprets all sense data as directed towards himself — he is the universal referent. He attempts to watch and listen very carefully, but everything he perceives is slotted into the burning conviction within his heart. A coworker’s casual flick of his wrist transforms into undeniable evidence of impending imprisonment. Thus, it is never enough to tell a paranoid psychotic to “look at the facts,” for every fact becomes fuel for his pre-existing hypothesis. The key is to pay attention to your surroundings, not for what they say about you, but for what they say about themselves. A tree trunk is brown and tall and flaking. An office chair is black and soft and spinning. A street sign is green and white and rectangular. Keeping your eyeballs pointed outward becomes especially important when you’re having a conversation with someone. The paranoid psychotic is wont to believe that his interlocutor’s words are all directed at him, that words such as “table” and “lightbulb” are actually personal criticisms, denunciations, threats. You must try your best to “think like a psychologist” — in other words, when your interlocutor is speaking, focus on what they are saying or revealing about themselves, not what they are saying about you. Of course, this is often easier said than done. But it’s a way of re-establishing contact with the world around you and can be strangely grounding. Not inside, but outside.
If you have a hypothesis, look for evidence to disconfirm it, not confirm it
This attitude, ladies and gentlemen, is the basis of the scientific method. It also relates to a fundamental characteristic of human psychology: confirmation bias. When I’m convinced my coworkers are trying to hurt me, I always frantically search for evidence to confirm my hypothesis. There! He walked past me without looking at me. I knew it, he’s hiding something, something he’s going to use to hurt me. There! She let out a long sigh in her office. I knew it, she’s tired of waiting, she wants to hurt me now. I’m desperate to identify conclusive evidence that shows beyond a shadow of a doubt that my suspicions are justified. As a result, I disregard all information that runs contrary to my terrifying beliefs — friendliness is interpreted as trickery, smiles as sarcasm. So, the key is to place more weight on data that runs contrary to my convictions, rather than aligns with them. This, too, is easier said than done. It’s also advice we could all probably take.
Common sense, not private logic
Paranoia is an incredibly private experience. By this, I mean that it occurs entirely within your own head, and your thoughts follow a logic that is so intensely personal it is often incommunicable. So, when you’re thinking about a situation, you have to try your best to consider the dictates of common sense. “Would most people you know want to hurt you? Are most people manipulative and conniving? Would it make sense to your father, mother, friend that the U.S. government is tracking the movements of you, a random 27-year-old paralegal? Would it make sense to your father, mother, friend that you would be imprisoned for an off-handed comment made at work?” If the answer to any of these questions is yes, you’re engaging in private logic, not common sense. This piece of advice may seem obvious, but it’s really important. Last week, I only told my parents a fraction of the things I’d been thinking day in and day out, for while I was absolutely and utterly convinced in the truth of my beliefs, a part of me knew that I’d sound ridiculous if I verbalized them in front of other people. This speck of self-awareness is evidence of your continued — albeit tenuous — connection to the world of common sense, and your inability to articulate your beliefs to others out of fear of derision and disbelief can paradoxically serve as a signal that you’re sinking into the depths of private logic.
You don’t need to be right.
I find this tip, which Dr. G imparted upon me during our last session, to be the most intriguing of the six. He believes that the foundation of my paranoia is my “need to be right.” I’m still having some trouble understanding this point, but what I do know is that I have a tendency to cling onto my paranoid beliefs — despite the abject terror they inspire — when they begin to fizzle out. On the face of it, this makes no sense. Why would I want to keep believing that the U.S. government is going to airstrike me? I’m just thinking out loud here, but perhaps it has something to do with pride. When you’re in paranoid psychosis, you believe that the thoughts you’re having are completely, absolutely true. You believe them with the same conviction that you, dear reader, believe you’re currently reading this Substack post. The paranoiac’s entire life becomes structured around these beliefs, and they dictate his every thought and action. So, when my belief system starts to fall apart, a part of me can’t accept that I was utterly and undeniably wrong about everything I’d been thinking until that point. Above all else, I feel like an idiot. And it can be hard to feel like an idiot, an idiot who staked his existence on a set of convictions that has increasingly come to seem preposterous. I have to take seriously the possibility that I’d seen things wrongly, heard things wrongly, understood things wrongly. And not only wrongly, but profoundly, cataclysmically wrongly. This can be a bitter pill to swallow, at least for me. But as Dr. G says, you’re right sometimes, you’re wrong other times, and when you’re wrong, it’s not a big deal because you can learn from it and life keeps chugging along. You don’t need to be right.
You may have noted that Dr. G’s advice largely applies to all people, whether or not they’re experiencing paranoid psychosis. I’ve had a number of psychotic episodes since 2022, and I’ve increasingly come to believe that they are continuous, and not disjunctive, with my normal, everyday experience. Yes, paranoia and psychosis are extreme, unusual, and undesirable states. But insofar as they occur within my mind, the same mind that allows me to type these very words, they are an inseparable part of me and my existence. All of my psychotic episodes have had a lasting impact on the way I see myself, others, and the world around me. For I, too, am an inseparable part of my psychosis. I, Elai, am its fuel, its origin, its destination. It is not something foreign or alien. My psychotic episodes are deeply entangled with my subjectivity: since they come from within me, since they are me, they reflect and reveal things that are fundamental to who I am as a person.
That being said, would I rather amputate my left arm or have another severe psychotic episode?
This, my friends, is a rhetorical question.