You're Not Paranoid Schizophrenic: You Only Have Posttraumatic Stress
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
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
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.
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
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
(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
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
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
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.
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
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
(3) Inability to recall an important aspect of the trauma (psychogenic
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.
(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?
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.
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.
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
American Psychiatric Association
(1987). Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised
Washington, DC: Author.
American Psychiatric Association
(1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth
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),