With the summary knowledge of paranoid states that you have acquired so far, I realize that so far you have become acquainted only with certain dominating symptoms; but many others that occur concurrently can also be found only as acute psychoses. However, you will now be able to discover the main features of the vast majority of paranoid states—and so satisfy the requirement which must be fulfilled, with examples, in each psychiatric report, namely that psychotic symptoms which constitute the mental disorder in each specific case must be recorded in precise detail—a requirement that sadly is seldom met in reports of even so-called authorities. I cannot emphasize strongly enough that you have the right to declare a person mentally ill only when you can produce evidence of this by establishing definite psychotic symptoms; only then will you be spared the embarrassment of your opinion being exposed to justified attacks by lay people. The ‘general impression’ [W] sometimes relied on even by better known representatives of our profession, when they fail to elicit definite psychotic symptoms, is no better than everyday parlance and must elicit the deepest suspicion, when used as the basis of diagnosis of a paranoid state. It deserves to be rejected most strongly when, in such cases, the claim is made that we are dealing with a well-known and relatively simple disease state, given the accurate name of paranoia chronica simplex. Then, it is easy to arouse the impression of intentional deception, for both judges and lay people, thereby harming the reputation of the entire alienist profession. If you want to avoid such mistakes, please note that the most obvious self-aggrandizement is far from any grandiose delusion; mistrust and hatred of a few—or many—people is not a persecutory delusion; and paranoid states are mental disorders which are always relatively easy to grasp, detected by very specific psychotic symptoms.

Perhaps it requires a certain apology, when, with motives such as I have just outlined, I choose the term ‘paranoid states’ [W] to cover all chronic mental disorders in which material alterations of consciousness are dominant. One might object by demanding that I at least make an attempt to delineate clearly the supposedly well-known paranoia chronica simplex [W]. I deliberately avoid such an attempt because, in my opinion, there is no well-known illness of this type, unless you want the name to monopolise that very small number of individual cases that happen to match one another. I come back to those cases shortly (p. 102).

A few remarks are directed to those latter cases with an extremely chronic course. They correspond to the rather more common type, of slowly emerging persecutory delusions, which, after some time, may evolve into grandiose ones. The period of slow, imperceptible development in such cases, which often makes it difficult to determine the precise starting date, is characterized by occurrence of delusions of relatedness, and, shortly afterward, by isolated phonemes with the same content. An overvalued idea may take hold as the first and foremost symptom, and determine the substance of delusions of reference. Gradually the phonemes get out of hand, and other sensory hallucinations and abnormal sensations may even join in. Persecutory ideas are then systematized in two ways. One is via delusions of explanation, which refer to the hallucinations themselves: the so-called physical persecution complex [Ed], with hallucinations related in turn to the agent behind the persecution, and his motives. Grandiosity preferentially links up with a series of explanatory delusions, because of the logical necessity of explaining how such a large following—an array of so many people—should develop. If discernment and formal thought processes are well preserved, this finally leads to formation of technical terms of a more or less adventurous nature, often appearing at first as phonemes, providing patients with newly formed words. Such patients express themselves in a changed manner, which is very characteristic. By means of their intact sense of logic, their entire world view is gradually transformed and, depending on the sick person’s state of mind, philosophical systems may be advocated with quite outlandish structures. Formally correct logic and unmistakable intellectual productivity remain right to the end. In the philosophical literature of the last decade, you may have been struck by a multi-volume work written by an apparently mentally ill scholar, which would have left you shaking your head. The final outcome of the full disease process is a material change in all three domains of awareness, because the patient sooner or later becomes aware of physical changes in his body. Thus, if you want to choose a name for such cases, then in the later stages you are dealing with ‘chronic total psychosis’ [Ed]. The initial symptoms are likewise beyond any question, the entire first period of the illness manifest predominantly in the allopsychic area. Delusions of relatedness are detectable by themselves for a long time, entirely of an allopsychic character as just described. Hallucinations with explanatory delusions bring about gradual, but inexorable, reinterpretation of the outside world; and for initial years of illness, the designation of ‘chronic worsening allopsychosis’ [Ed]—also ‘chronic hallucinosis’ [Ed]—is justified. The qualifier ‘worsening’ [Ed] indicates that the psychosis gradually becomes total, since, from the time of onset of grandiose delusions, it also encompasses the autopsychic domain. That it never comes to more severe symptoms in the area of motility also seems characteristic of such cases. While relatively common (pp. 63, 64), only a small absolute number belong to the class of ‘purely chronically progressing’ [Ed] cases. These correspond most closely to the commonly alleged paranoia chronica [W]. The two female patients, Schmidt and Reising, are examples of this—the latter, right from the outset, in conjunction with an overvalued idea.