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Psychiatry & Psychology--General/What is the best treatment for my sister's anxiety/paranoia?

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QUESTION: Dear Dr Borkosky,

I am getting in touch to see what treatment you would recommend for my sister. For the past 3 years, she has been suffering from severe anxiety and paranoia. My mum has taken her to the doctors numerous times, and she has tried anti anxiety medication and a brief course of counselling but this didn't seem to help significantly. She's now refusing to take medication and is adamant that she doesn't need to go back to the doctors.

Some of her symptoms and behaviours are below:

Anxious behaviour – constantly asking if the people around her are ok, mentioning that she’s worried about strangers around her. Not able to make decisions, even trivial ones i.e. which sandwich to buy.

Paranoid thought – almost every time she is around a lot of people, she thinks they are talking about her. It’s usually based on her appearance, i.e. saying she is ugly etc. She gets extremely upset about this. She has had other paranoid thoughts in the past, such as thinking people on the radio are talking about her.

Fear of rejection - both socially and academically. She worries about not fitting in and people not liking her. She goes over and over past social occasions in her head that haven’t gone well.

Denial – she can’t seem to accept any control over her circumstances; she finds it very hard to accept any kind of criticism or feedback. For example, when she was told she would have to re-sit her first year of university, as she had not completed the projects on time and the work was of a low standard, she felt this was unfair and that she had worked hard, when in fact she had spent a lot of time procrastinating, feeling anxious and overthinking everything instead of actually working. After she was not able to go on holiday due to anxious behaviour, she didn’t accept that this was a result of her anxious thoughts and instead blamed it on ‘people being nasty’ (she had thought people at a train station were talking about her)

OCD tendencies – she seems to have a fear of germs. She often picks things up using tissue paper or a kitchen towel. She dropped her purse in a bar and left it there rather than picking it up. After it had been retrieved from the bar, she refused to use it and worried about others getting ill from touching it.

Personal hygiene – she doesn’t look after her personal appearance and often goes out without washing/shaving etc.

I would really, really appreciate some help, as it's ruining her life.

Many thanks,

Katy

ANSWER: Hi, Katy, this is really a legal question. Even if I could determine the perfect treatment for her, one that would guarantee success, making her wonderfully happy and wildly successful, it would be for naught if she refused to take advantage of it. Thus, this is a legal question.

IDK what the British law is, but I suppose it is similar to the U.S. We have what are called guardianship(s) - if a court determines that the person is unable to make some (or all) decisions themselves, then the judge would appoint someone (family or professional) to handle those decisions. That is likely the only way you can force someone into treatment (based on the info you gave me).

It's a difficult decision to make, and the family member might hate you for it, but it is the only way. As a society, we have decided that people should be free to live an unhappy life, if that is what they want to do. That's why it requires a judge to take away that right.

---------- FOLLOW-UP ----------

QUESTION: Thank you so much for your advice, I really appreciate it! You're right, it would be very tricky to force her to get treatment and I'd be reluctant to go down that route. I guess a better way of framing the question would have been - is there any way I can try and reason with her and convince her that she needs treatment? and is there a good way to approach her problems in a constructive way? For example, if I say to her something along the lines of 'people aren't talking about you, you're just mishearing them because you're feeling anxious' this doesn't seem to help at all..

Thank you!

Katy

Answer
OK, thanks for the followup:

"is there any way I can try and reason with her and convince her that she needs treatment?"
---- well, is there any reason I can offer you to convince you that you need treatment? The answer is likely no, because you do not see a need for it. This is despite the fact that anyone's life can be improved with therapy. Besides, people rarely make decisions based on logical reasoning. So, no, not likely.

"is there a good way to approach her problems in a constructive way?"
---- not sure what you mean by this. If you mean how do you get her to change, then the answer is likely - you don't. You do not have a right to change other people, for the same reason that they do not have the right to change you.


--- if you mean 'how can I help her?', then the answer is:
1. you have to wait and listen for when she is ready / wants help. This is very difficult to do, but can be learned. It's a lot of waiting, though. A lot of what happens for therapists.

2. you have to listen to her well enough to be able to 'get inside' of her perspective, and understand her problems from her point of view. Thus, for example, if she says "people are talking about me", and you say "no they aren't", that is simply arguing - disagreeing with her point of view and discounting the validity of her view. If you can learn this, it is invaluable when raising kids - the reason is that people don't always literally mean what they say. Sometimes they speak in code, or rather, they only say half of what they mean, and cannot speak out loud the half that makes them too emotional. Other times, people say things they only half mean, and don't need a comeback - they just want to be heard. Learning those distinctions and when to respond appropriately can make a big difference.

Psychiatry & Psychology--General

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Bruce Borkosky, Psy.D.

Expertise

any related to psychology, especially related to forensic psychology

Experience

15 years as a licensed psychologist, 15 years in private practice. My practice began primarily doing individual and group psychotherapy, is now devoted to assessments, but I occasionally do take on clients in therapy.

Organizations
American Psychological Association

Education/Credentials
B.A. psychology, B.A., music, Ohio Wesleyan U., 1978 MCS, computer science, University of Dayton, 1984 MA, psychology, Miami Inst. of Psychology, 1991 Psy.D., psychology, Miami Inst. of Psychology, 1993 post doctoral training in Neuropsychology, Fielding Institute, 1995-1997

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