|Year : 2020 | Volume
| Issue : 2 | Page : 230-232
Reciprocal Paranoid pseudo-community in a patient with schizophrenia - A phenomenological case study
Prashant Chaudhari1, Pragya Lodha2, Sagar Karia1, Nilesh Shah1, Avinash De Sousa1
1 Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
2 Clinical Psychologist and Research Associate, Desousa Foundation, Desousa Foundation, Mumbai, Maharashtra, India
|Date of Submission||23-Feb-2020|
|Date of Decision||10-Apr-2020|
|Date of Acceptance||19-Apr-2020|
|Date of Web Publication||24-Sep-2020|
Dr. Avinash De Sousa
Carmel, 18, St. Francis Road, Off. SV Road, Santacruz West, Mumbai - 400 054, Maharashtra
Source of Support: None, Conflict of Interest: None
Paranoid pseudocommunities may at times be a resistant and interesting symptom in patients with schizophrenia. A paranoid pseudocommunity is defined as an imaginary group of real persons or imagined persons believed in delusions to be conspiring against a paranoid individual. Herein, we report the case of a 61-year-old male with untreated schizophrenia for 36 years with auditory hallucinations constituting voices of twenty different people that were a part of a reciprocal paranoid pseudocommunity, and we explore the symptom phenomenologically and clinically.
Keywords: Hallucinations, paranoia, paranoid pseudocommunity, schizophrenia
|How to cite this article:|
Chaudhari P, Lodha P, Karia S, Shah N, Sousa AD. Reciprocal Paranoid pseudo-community in a patient with schizophrenia - A phenomenological case study. Ann Indian Psychiatry 2020;4:230-2
|How to cite this URL:|
Chaudhari P, Lodha P, Karia S, Shah N, Sousa AD. Reciprocal Paranoid pseudo-community in a patient with schizophrenia - A phenomenological case study. Ann Indian Psychiatry [serial online] 2020 [cited 2021 Jan 21];4:230-2. Available from: https://www.anip.co.in/text.asp?2020/4/2/230/295904
| Introduction|| |
Pseudocommunity is defined as a group of people who appear to be a community but between whom there are no connections and interactions as perceived by the observer. The current psychopathological definition of paranoia includes two key components, namely unfounded ideas of harm and the notion that the harm is intended by others. Both of these essentially mean internal negative social representations of others. In the context of paranoia, a reciprocal paranoid pseudocommunity is defined as an imaginary group of real persons or imagined persons believed in delusions to be conspiring against a paranoid individual. The pseudocommunity is reformulated as a cognitive structure which for the patient attempts to solve the problem of reconciling social reality with the products of paranoid projection sometimes by means of aggressive action.
The history of defining delusions dates back to Karl Jaspers who explained that delusions were abnormal beliefs that were held with extraordinary conviction, were impervious to experiential evidence or counterarguments, and were often bizarre., The development of delusions is seen as a consequence to regressive functions and loss of social reality. The formulation of a pseudocommunity can then be understood as a means of replacing this lost social reality due to regressive behaviors where the partially regressed person begins to feel estranged experiences when he/she attempts to regain object relations and successively reinforces to reconstruct reality until a cognitive solution is reached which seems to justify the paranoid action.
The present case report presents the concept of reciprocal paranoid pseudocommunity in a case of schizophrenia. Herein, we report the case of a 61-year-old male with untreated schizophrenia for 36 years with auditory hallucinations constituting voices of twenty different people giving rise to the delusions of grandeur and persecution.
| Case Report|| |
A 61-year-old male reported to the psychiatry outpatient department of a tertiary general hospital with chief complaints of suspiciousness for the past 36 years which began after the death of his firstborn son. He started to exhibit disorganized behavior in the form of not taking care of himself, muttering to self, gesticulating behavior, getting angry, and being abusive and aggressive even without provocation for the past 30 years. He was taken to a private psychiatric hospital and was given a course of electroconvulsive therapy (ECT) at the time of the first episode, in response to which he got better as claimed by his relative (spouse).
The patient discontinued treatment against medical advice and had a relapse of the same symptoms without any apparent stressor. Two years after the first episode, he had all the symptoms previously shown and also stopped going for work. He was hearing the voices of four people not recognizable to him and stated that the content was commanding, referential, and derogatory in nature. He started confining himself to his house for days. He began consuming alcohol, and this consumption increased from occasional use to 3 quarters of country liquor every day. He had been consuming alcohol for the past 27 years regularly. He claimed to have been able to sleep well with alcohol, and it provided him relief from the voices temporarily. Over time, gradually, this relief with alcohol waned off. Currently, he uses alcohol off and on 1–2 quarters once or twice a week, but it provides no relief to his symptoms. He began to hear voices of more people to such an extent that he failed to keep count of the number of voices, and he stated approximately that he currently heard twenty different voices, some of them belonging to national leaders such as Dr. Babasaheb Ambedkar, one of Lord Buddha, and some of his relatives from a distant village. The voices talk to him about day-to-day things, the state of the country, they speak to him about his current life, and at sometimes, they get angry and derogatory. Details of all treatments taken in the past were unavailable as the patient had torn and misplaced all the papers. The spouse was not aware of the exact details and names of medications that the patient had taken.
His speech and behavior were disorganized in nature. He would collect urine in empty liquor bottles and hang them by his bed. He would throw the collected urine on family members during arguments with them. He claimed that these bottles acted as a shield from attack by someone from the outside world, which he regarded as his enemy. He would listen to commands given by the voices. He would state that the voices told him things like “we don't feel comfortable with the treatment you are offering. You want to kill all of us”. The patient claimed that by giving him medication, the doctors wanted to kill his friends. On asking who these friends are, he would say that these are the people who are inside of him, and he has been living with them for a long time. At times, he would suddenly stop talking and say that I am instructed by them to stop talking as we do not trust doctors. The family members corroborated the history as he had been talking to these different people by referring to them with some imaginary names during the course of illness. The patient had received multiple combinations of medications over the years. The patient had also received four courses of ECTs over the past 36 years. The patient always took medications for just 2–3 weeks and then had stopped medication on his own.
His mental status examination revealed delusions of persecution, auditory hallucinations of more than twenty voices that spoke to him, his mood was euthymic, and his affect was paranoid in nature. He also had occasional delusions of reference. He seldom maintained eye contact during the assessment and showed muttering and gesticulating behavior. His judgment and memory was intact and insight was Grade 1 (on a scale of 1–6).
On administering a Positive Negative Syndrome Scale (PANSS), his score was 186 at presentation. The reason for not having sought treatment was stated to be his noncooperation and assaultive behavior. They could bring him this time, as he was brought to the hospital because of a fall he sustained 1 day before the presentation. His computed tomography scan revealed age-related cerebral atrophy and no evidence of head injury or stroke. He was admitted to our ward at the time of presentation, and all routine investigations done were within the normal limits. His behavior responded within 2 weeks to medication, but voices were persistent, and he was still obeying the commands they gave him. He was discharged on request of the family members as they could not stay in the hospital and had a PANSS score of 166. He was discharged on oral clozapine 100 mg at night, haloperidol 10 mg/day, and trihexyphenidyl 4 mg/day (both in divided doses). The patient was started on clozapine in view of his resistant status and haloperidol as the relatives claimed that to be the only drug that controlled him. The patient had been started on clozapine in the past but never in a good enough dose and always the patient had failed to comply with the treatment. A diagnosis of chronic paranoid schizophrenia was considered clinically, and the patient was diagnosed as schizophrenia as per the Diagnostic and Statistical Manual of Mental Disorders, 5th edition criteria.
On his follow-up visit, though his behavior got stable with PANSS score of 162 and he showed improvement, the auditory hallucinations persisted, and he claimed to be sad as he is not able to identify himself and losing the voices felt like losing a part of his mind. Unfortunately, the patient was lost to follow-up and did not visit us after that visit.
| Discussion|| |
Cognitive models have postulated that auditory hallucinations arise from the misattribution of internally generated cognitive events to external sources. For the case reported here, these voices have become part of the patient and him starting to believe what is fed to him by his internally generated cognitive events in response to his environment. This case is presented to challenge the definition of paranoid pseudocommunity and present a reciprocal definition to the same. A pattern emerged of increasing complexity of the auditory verbal hallucinations over time by a process of accretion, with the addition of more voices and extended dialogues and more intimacy between subject and voice. Such evolution seemed to relate to the lessening of distress and improved coping.
Paranoia and delusions are often separately categorized; however, it is an etiological challenge to do so and is difficult to separate them as presenting symptomatology in patients with schizophrenia. The perceived humiliation and aggression in paranoid patients often lead them to refuse psychiatric help because they firmly believe that their belief is not a symptom that needs to be changed. Suspicious thinking in given situations can be useful and helps the adaptation as events occurring in the world also corroborate this. It has been found that suspicious/mistrustful ideations are common in nonclinical samples, and some of these are comparable to that seen in patient population. It would be prudent to say that in this case that when the voices formed a community with the host patient, they were following the paranoia pyramid to make sense of the world around him and providing him comfort forming a nested reciprocal paranoid pseudocommunity for the patient.
This is reaffirmed with the following depression that set in once the patient stopped hearing voices. A plausible explanation that can be adopted to explain the case is the argument that delusions allow people to attribute meaning to their experiences. It is discussed that delusions have benefits of psychological adaptiveness and biological adaptiveness that act as protection for the person. The psychological adaptiveness of delusions that are adopted at a time of conflict serve to reduce anxiety and stress temporarily in patients by either providing meaning to their experiences or helping the person delay or avert unpleasant experiences. Delusions can serve the function to bring a sense of adjustment to life circumstances and life fulfillment which are understood as the psychological benefits of delusions.
Yet, another explanation is about elaborated delusions that have been found to have a relationship with “sense of coherence.” Researchers have found that the sense of coherence is not reduced in people in acute delusional state and the sense that one's life is meaningful might even be enhanced in comparison with the nonclinical population, especially when the delusional system is elaborated. Sense of coherence and meaningfulness have been found to correlate with well-being. Literature on delusions and hallucinations confirms that there are some “successful psychotics” who are people with positive symptoms of psychosis who function with little impairment to their well-being as a consequence to their hallucinations and delusions. This is when the delusions and hallucinations serve the purpose of conferring meaning to people's lives due to either good social connections or the uplifting nature of their delusional experiences. This explains for why people with such delusions and hallucinations defer psychiatric treatment.
Disappointingly, many auditory hallucinations remain resistant to standard treatments and persist for many years. There is a need to develop novel therapies to augment the existing pharmacological and psychological therapies with more individually tailored and content-driven formulations. The clinical implications of the case are to elaborate the concept of reciprocal paranoid pseudocommunity in schizophrenia and discuss the same from a phenomenological perspective so that clinicians are aware of the same. It is also worth mentioning that this is a single case study, and the findings of the case cannot be generalized.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Myers PL. Paranoid pseudocommunity beliefs in a sect milieu. Soc Psychiatry Psychiatr Epidemiol 1988;23:252-5.
Freeman D, Garety PA. Paranoia: The Psychology of Persecutory Delusions. New York: Psychology Press; 2004.
Cameron N. The paranoid pseudo-community. Am J Sociol 1943;49:32-8.
Cameron N. The paranoid pseudo-community revisited. Am J Sociol 1959;65:52-8.
Jaspers K. General Psychopathology. New York: JHU Press; 1997.
Cermolacce M, Sass L, Parnas J. What is bizarre in bizarre delusions? A critical review. Schizophr Bull 2010;36:667-79.
Fawzy A, Khater M, El Boraie M, El-Atrony M. Sociocultural aspects of paranoid states and paranoid schizophrenia. A comparative study. Egypt J Psychiatry 1984;1:47-55.
Waters F, Allen P, Aleman A, Fernyhough C, Woodward TS, Badcock JC, et al
. Auditory hallucinations in schizophrenia and nonschizophrenia populations: A review and integrated model of cognitive mechanisms. Schizophr Bull 2012;38:683-93.
Singh G, Sharan P, Kulhara P. Role of coping strategies and attitudes in mediating distress due to hallucinations in schizophrenia. Psychiatry Clin Neurosci 2003;57:517-22.
Bentall RP, Rowse G, Shryane N, Kinderman P, Howard R, Blackwood N, et al
. The cognitive and affective structure of paranoid delusions: A transdiagnostic investigation of patients with schizophrenia spectrum disorders and depression. Arch Gen Psychiatry 2009;66:236-47.
Tsuang MT, Faraone SV, Johnson PD. Schizophrenia: The Facts. USA: Oxford University Press; 1997.
Blackwood NJ, Howard RJ, Bentall RP, Murray RM. Cognitive neuropsychiatric models of persecutory delusions. Am J Psychiatry 2001;158:527-39.
Landsverk SS, Kane CF. Antonovsky's sense of coherence: Theoretical basis of psychoeducation in schizophrenia. Issues Ment Health Nurs 1998;19:419-31.
Penn DL, Sanna LJ, Roberts DL. Social cognition in schizophrenia: An overview. Schizophr Bull 2008;34:408-11.
Chaudhury S. Hallucinations: Clinical aspects and management. Indian Psychiatry J 2010;19:5-12.