You're Not Paranoid Schizophrenic: You Only Have Posttraumatic Stress Disorder¹

Richard A. Gardner^*

ABSTRACT: Patients with paranoid schizophrenia are being misdiagnosed as having PTSD by therapists who see child sexual abuse as rampant and as causing a wide variety of psychiatric problems.  The symptoms of paranoid schizophrenia can easily be distorted and manipulated so that the PTSD criteria in the DSM-III-R and the DSM-IV appear to be met.  The reasons for the proliferation of this misdiagnosis are that PTSD and the sexual abuse explanation for symptoms are more in vogue, are more satisfying and less complex to treat, and provide more financial benefits to the mental health practitioner compared to schizophrenia.

The sex-abuse hysteria we are witnessing today is the greatest wave of hysteria that we have ever experienced in this country.  It has been going on for at least a decade and, although there are some signs that people are increasingly coming to their senses, there is no question that we have a long way to go until this abomination has spent its course.  Unfortunately, psychiatry is playing an active role in promulgating what is clearly a national scandal.  In an earlier article in the Academy Forum, I described what I consider to be factors operative in its origins and development (Gardner, 1993).  More recently, I described the ways in which patients with paranoid schizophrenia are being given the specious consolation that they are only suffering with multiple personality disorder (MPD) (Gardner, 1994).

Here I describe how the posttraumatic stress disorder (PTSD) diagnosis is being used in a similar way.  I will first describe the PTSD misdiagnosis phenomenon and then comment on the purposes such alterations of reality serve.  I will follow the PTSD criteria provided in the DSM-III-R (American Psychiatric Association, 1987) and then describe how each of the symptoms of paranoid schizophrenia can be manipulated and distorted in such a way that it satisfies a PTSD criterion.  I am not claiming that this process is necessarily a conscious and deliberate one on the part of those who involve themselves in this procedure.  Many are overzealous in their need to see sex abuse as the cause for the wide variety of psychiatric problems with which they deal.  Some are simply incompetent and doing what is in vogue, and they may have been guided here by teachers who have been swept up in the wave of hysteria.

In order to accomplish the goal of converting paranoid schizophrenia into PTSD, the evaluator must start with the basic premise that the patient has been sexually abused.  I am not referring to situations in which there was bona fide sex abuse and PTSD is one of the reactions.  Rather, I am referring to the situation in which there is absolutely no good evidence that the patient was sexually abused, and the allegations are extremely improbable, bizarre, and even impossible.  The accusation, then, is part of a delusional system.

Paranoid delusions typically incorporate the scapegoats of the era.  In World War II, paranoids were persecuted by Nazi spies.  From the 1950s to the 1980s, Communists were the typical persecutors of paranoids.  Since the early 1980s, with the breakdown of the Communist empire, sex abusers have become the most common persecutors for paranoids.

At this point, I will address each of the PTSD items in the DSM-III-R and describe how diagnostic alteration is brought about.  DSM-IV criteria are, with minor changes, essentially the same as those that appear in DSM-III-R.  Accordingly, DSM-IV (American Psychiatric Association, 1994) will enable evaluators who involve themselves in these kinds of manipulations to use with equal facility the slightly revised DSM-IV criteria.
  

A. The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone.

In order to justify a PTSD diagnosis, there must be a real trauma.  Delusional traumas do not qualify for the diagnosis.  Therefore, the examiner must suspend disbelief and join in with the patient in the delusion that the sex abuse occurred.  With that basic assumption, all the other diagnostic criteria fall into place, especially if one is only able to use a little creativity and imagination in twisting logic.
  

B. The traumatic event is persistently reexperienced in at least one of the following ways:

(1) Recurrent and intrusive distressing recollections of the event.

Paranoid patients are preoccupied with their delusions.  Typically, they are obsessed with them and somehow work their delusional thoughts into most conversations.  For these patients, the idée fixe is their delusion that they were sexually abused.

(2) Recurrent distressing dreams of the event.

People in a state of psychotic decompensation may be viewed as experiencing a complete breakdown of the barriers that separate waking from dream states.  Not surprisingly, paranoid patients may dream about their delusions and their dreams may have the same content as their delusional material.  Accordingly, they commonly dream about being persecuted by their abusers, although the dream may include many bizarre components not present in the waking delusion.  Furthermore, many schizophrenics experience an ongoing eruption into conscious awareness of primitive unconscious material, with the result that they walk around in a state in which they are flooded with their primitive impulses.  Their waking lives are like ongoing nightmares.  Differentiation between dreams and reality become very blurred.  Not surprisingly, sex-abuse delusional material is usually present in this primitive outflow into both dreams and the waking state.

(3) Sudden acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative [flashback] episodes, even those that occur upon awakening or when intoxicated).

This criterion covers multiple phenomena and requires separate elaborations.  Paranoid patients actually do believe that they are currently reliving their traumas and such preoccupations are likely to take place when certain environmental triggers remind them of the original trauma.  For these patients, any kind of sexual stimulus may trigger an outburst of delusional accusations.  Such a patient may actually believe that a sex abuser has somehow made his way into the patient's room, undetected by observers.  In association with such delusional material there may be illusions, i.e., misperceptions and distortions of actual visual and auditory stimuli.  A person who resembles or sounds like the abuser may be responded to as if he were the abuser.  Furthermore, hallucinations involving the delusional material are likely to be part of the package.

The phenomenon of dissociation has been getting increasing attention in recent years.  The APA Psychiatric Glossary defines dissociation as "the splitting off of clusters of mental contents from conscious awareness ... the separation of an idea from its emotional significance as seen in the inappropriate affect of schizophrenic patients."  Professionals range from those who claim that dissociation does not exist to those who believe that it is ubiquitous and consider a wide variety of psychological phenomena to be manifestations of dissociation.  Many people in the field today use the term to refer to the total obliteration from conscious awareness of any thoughts or feelings about the alleged trauma.  Accordingly, it is considered to be a form of psychogenic amnesia, i.e. a repressed memory."

My own opinion is that total obliteration of all memories of a trauma is extremely rare and that the vast majority of people who have been genuinely traumatized have fairly good memories of the major events related to the trauma.  The psychotic patients discussed here, when they go into remissions in which the delusional material is not present (a common phenomenon), are considered to be "dissociating."  Schizophrenics typically fluctuate and the disorder is characterized by remissions and exacerbations.  What I would call a remission is referred to by overzealous evaluators as a "dissociative state."

The patient in remission who denies any recollection of sex abuse is considered by these examiners to be "in denial."  Schizophrenic patients typically "space out."  This occurs when they are preoccupied with their inner fantasy material or when they are responding to hallucinations.  But examiners I am referring to here will consider these patients to be dissociating at that time.  We see here how the word dissociation is being manipulated in such a way that it converts psychotic manifestations into a PTSD criterion, thereby justifying the conclusion that sex abuse occurred.

Flashbacks generally refer to the sudden eruption into conscious awareness of memories of a trauma.  They are especially likely to occur in situations that trigger such memories because of their similarity to the actual trauma.  A Vietnam veteran (the model for the PTSD diagnostic criteria), for example, may suddenly reexperience thoughts and feelings about his combat experiences when passing a movie house displaying a poster depicting a war movie.

When the paranoid delusional patient described here starts talking about his or her sexual abuses, they are referred to as flashbacks.  Examiners who do this do not seem to be bothered by the fact that these patients may exhibit a symptom-free or flashback-free period of many years between the time of the alleged abuse and the time of its "recovery from repressed memory."  This is especially the case in situations in which adult paranoid women belatedly recall having been sexually abused by their fathers in early childhood.

It would be an error for the reader to conclude here that I do not believe in the validity of many such accusations by adult women.  I am only describing here the parallel phenomenon, namely, adult women whose belated accusations are false, especially when they are products of a delusional system.  People who have suffered genuine trauma continue to have flashbacks from the time of the trauma until many years thereafter (often with diminishing frequency), possibly throughout the rest of their lives.  The symptom-free or flashback-free hiatus is one of the hallmarks of the false sex-abuse accusation.

(4) Intense psychological distress at exposure to events that symbolize or resemble an aspect of the traumatic event, including anniversaries of the trauma.

This phenomenon has already been discussed previously.  Delusional patients may experience a sudden exacerbation of their delusional preoccupations when confronted with a stimulus that is reminiscent of the persecutor.  For patients who have incorporated sex abuse into their delusional system, any sexual stimulus will serve this purpose.  This psychotic phenomenon is then used to justify the satisfaction of this criterion.
  

C. Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:

(1) Efforts to avoid thoughts or feelings associated with the trauma.

(2) Efforts to avoid activities or situations that arouse recollections of the trauma.

When there is a sex-abuse delusion, the patient tries to avoid the alleged persecutor.  Women who have the delusion that their father sexually abused them in childhood may seek refuge in shelters for battered women, may go into hiding, and may even take their children thousands of miles away in order to provide themselves and their children with a "safe" environment.  Commonly, their addresses are unknown to all but a few in the coterie of enablers who support the delusional system.

(3) Inability to recall an important aspect of the trauma (psychogenic amnesia).

As mentioned, schizophrenia characteristically manifests itself by remissions and exacerbations. When these patients do not recall the trauma, they are considered to be dissociating, repressing, in denial, or exhibiting psychogenic amnesia.  The notion that there is no recollection because there was no trauma is not often given consideration by the kinds of examiners who convert paranoid schizophrenia into PTSD.

(4) Markedly diminished interest in significant activities.

Schizophrenics typically withdraw interest in significant activities.  In fact, their formidable impairment in social functioning is one of the characteristics of the disease.

(5) Feeling of detachment or estrangement from others.

Schizophrenics typically feel detached or estranged from others. It is one of the hallmarks of the disorder.

(6) Restricted range of affect, e.g., unable to have loving feelings.

Again, this is a typical schizophrenic manifestation.  In fact, it was this "split" between cognition and affect that Eugen Bleuler was referring to when he coined the term schizophrenia (split mind).  And schizophrenics typically have difficulty with loving feelings because they have so little experience with that kind of human interaction.

(7) Sense of a foreshortened future, e.g., does not expect to have a career, marriage, children, or a long life.

Schizophrenics generally have some degree of reality testing, their psychosis notwithstanding.  They generally recognize, at some level, that they cannot function adequately in the realms of career, marriage, or child rearing.  These impairments do, in fact, shorten life span, and schizophrenics, especially in their clearer moments, recognize this fully.
  

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by at least two of the following:

(1) Difficulty falling or staying asleep.

In states of paranoid agitation, people do not sleep very much.  The ongoing levels of tension, anxiety, and agitation are often 24-hour phenomena.  This is especially the case prior to the administration of psychotropic medication, which produces some drowsiness, especially at the dosages commonly given.

(2) Irritability or outbursts of anger.

Lability of emotions and uncontrollable outbursts of rage are typical schizophrenic manifestations, especially in periods of decompensation.  These outbursts often bring such patients to the attention of police and other authorities who may have to overwhelm them physically in order to subdue them and place them in a protected environment.

(3) Difficulty concentrating.

In a state of psychotic decompensation, a patient is so flooded with primitive thoughts and feelings that concentration on one particular item may become almost impossible.  Furthermore, the high levels of tension, anxiety, and agitation also interfere with concentration.

(4) Hypervigilance.

(5) Exaggerated startle response.

Paranoids are typically hypervigilant.  Their world is a malevolent one and they ever anticipate being victimized by their persecutors.  When sex abuse is central to the delusion, then the hypervigilance relates to sexual matters.  The most nonsexual stimuli becomes sexualized and viewed as warnings of impending sexual abuse and/or attack.  In states of hypervigilance, there is likely to be an exaggerated startle response.  The patient flinches on the approach of anyone who might be considered a potential abuser.

(6) Physiologic reactivity upon exposure to events that symbolize or resemble an aspect of the traumatic event.

Schizophrenics commonly operate in accordance with the principle of predicative identification, i.e., if two subjects have a similar predicate (or attribute), they are identical.  Because the doctor's tie clip resembles one owned by the patient's father, the doctor is considered to be the father.  For these patients, any person who may resemble the alleged abuser is reacted to as if he were indeed the perpetrator.

The PTSD diagnosis provides a very neat way for "curing" paranoid schizophrenics who have incorporated sex abuse into their delusional system (sex abuse being in vogue as a delusional choice for paranoids).  Such patients are quite happy to welcome those who will "cure" them of their schizophrenia by providing them with treatment for their PTSD.  As can be seen, this is very easily done as long as the evaluator doesn't pay serious attention to the basic premise of the PTSD diagnosis, namely, that there be a known, proven trauma.  Examiners who do not give serious attention to this criterion can easily use just about every symptom of schizophrenia to justify a PTSD diagnosis.  The results, of course, are that the patient's reality testing is further compromised, the delusion becomes more deeply entrenched, and the patient is deprived of proper treatment for the schizophrenia.
  

Why is This Happening?

We can only wonder what is going on here.  Why are people doing this?  As is true for all phenomena, there are a multiplicity of answers, and I will only outline here the most important.  Sex abuse provides a simple solution for a complicated problem.  Rather than have to fathom the complexities of a paranoid schizophrenic process, one can point to a simple cause.  This is always more attractive.  It follows then that the sex-abuse explanation implies a more simple therapeutic approach than the more complex one necessary for the treatment (if possible) for paranoid schizophrenia.

Part of the "healing" process for many of these patients is to vent rage against the alleged perpetrator.  This is not only done directly but symbolically by cursing him profusely in therapeutic sessions, sometimes in association with group orgies of beating mats with clubs or rubber hoses.  I sometimes refer to this as "diarrhea therapy," a therapy based on the simplistic and naive notion that venting rage at symbolic targets is somehow therapeutic.  One problem with this approach is that it does not address itself directly to the party who is the cause of the difficulty and generally results in angry thoughts and feelings embedding themselves ever more deeply in the brain circuitry.  In many of these patients, suing their abusers for every penny they are worth and getting them incarcerated is also considered part of the healing process.  The fact that no one has been cured by such maneuvers does not seem to deter those who are committed to it.

Another factor relates to the prevailing explanations for psychopathology.  Sex abuse is now being considered the cause of a wide variety of psychiatric disturbances, disturbances which previously were thought to have other causes, often a multiplicity of causes.  Some of the disorders recently claimed to be caused by sex abuse are anorexia/ bulimia, multiple personality disorder, and borderline personality disorder.  There are some who even hold that mental retardation and autism are caused by sex abuse.  The theory goes that these children were threatened that if they ever speak about their abuses there will be terrible consequences.  So great is the fear engendered by such threats that there is almost total inhibition of meaningful communication.

Most people are very suggestible and are most comfortable when going along with the prevailing opinions of the majority.  Therapists are no exception to this principle.  Those who think differently are viewed with suspicion and may very well become outcasts.  The sex-abuse explanation is very much in vogue.  It is "the latest."  It is "in."  In sheep-like fashion, then, there is an ever swelling mass of mental health professionals who are chanting the sex-abuse litany, not only with regard to the etiology of a wide variety of mental disorders, but also with regard to the therapeutic approaches to their alleviation.

Then there is the money element.  Funding for the treatment of sex abuse from the federal level down is widely available.  Sex abuse victims are clamoring for their rights and for financial remuneration for their griefs.  Legislators who allocate money for the investigation, prosecution, diagnosis, and treatment of sex abuse enjoy popularity and honor.  There is little such notoriety gained for allocating money for psychotic people, especially paranoid schizophrenics who are usually thorns in the sides of most of those who encounter them.  Monies are pumped in at every level, and it behooves mental health professionals and police to work closely together if they are to avail themselves of these monies and enjoy the benefits that ensue.  The sex-abuse explanation promises money both for the patient and the therapist if part of the therapeutic process involves suing the alleged perpetrator.  Of course, this therapeutic maneuver is not seen among the poor.

Space does not permit me to elaborate on the other factors operative in motivating examiners to convert paranoid schizophrenic into a PTSD.  These have been elaborated upon elsewhere (Gardner, 1991).  In short, we see a situation here where the proverbial combination of money, sex and power have combined to fuel a national hysteria, a hysteria that has spread to other Western countries in which there are people who can make money as long as the hysteria continues to rage.  Not surprisingly, then, this phenomenon is not seen in Eastern Europe, but only in Western Europe.  In Eastern Europe, few people have money to hire lawyers, and there are even fewer people who are viable candidates for a lawsuit in that there is no point suing someone who is poor.  (Whoever heard of a poor person suing another poor person?)  Accordingly, sex-abuse accusations have not crossed the Iron Curtain, even though it was dismantled a few years ago.  In a sense, then, paranoid schizophrenics who live behind the former Iron Curtain are more fortunate than those in the West because they are more likely to get neuroleptic medication.  Those paranoid schizophrenics who live in the West do serve some important purpose, however, in that conversion of their diagnosis to PTSD enables lawyers and certain mental health professionals to enjoy enormous financial benefits.
  

References

American Psychiatric Association (1987). Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised (DSM-III-R) ()(). Washington, DC: Author.

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-TV) ()(). Washington, DC: Author.

Gardner, R. A. (1993). Sexual abuse hysteria: Diagnosis. etiology, pathogenesis, and treatment. Academy Forum, 37(3), 2-5.

Gardner, R. A. (1994). Finally! An instant cure for paranoid schizophrenia: MPD. Issues In Child Abuse Accusations, 6(2), 63-71.