Paranoid symptoms and syndromes

Introduction

Paranoid symptoms

Paranoid personality disorder

Paranoid symptoms in psychiatric disorders

Delusional disorders (paranoid psychoses)

Specific delusional disorders

Assessment of paranoid symptoms

Treatment of paranoid symptoms and delusional disorder

Prognosis of delusional disorder

Introduction

The term paranoid can be applied to symptoms, syndromes, or personality types. Paranoid symptoms are overvalued ideas or delusions which are most commonly persecutory, but not always so (see Box 1.2, p. 11). Paranoid syndromes are those in which paranoid delusions form a prominent part of a characteristic constellation of symptoms, such as pathological jealousy or erotomania. In paranoid personality disorder, there is excessive self-reference and undue sensitiveness to real or imaginary humiliations and rebuffs, often combined with self-importance and combativeness. Thus the term paranoid is descriptive; if we recognize a symptom or syndrome as paranoid, this does not constitute making a diagnosis, but it is a preliminary to doing so. In this respect it is like recognizing stupor or depersonalization.

Paranoid syndromes present considerable problems of classification and diagnosis. The difficulties can be reduced by dividing them into two distinct groups:

• paranoid symptoms occurring as part of another psychiatric disorder, such as schizophrenia, mood disorder, or an organic mental disorder

• paranoid symptoms occurring without evidence for any underlying disorder. This group of disorders has gone by a variety of names, commonly paranoid states or paranoid psychosis, but the ICD-10 and DSM-IV category is delusional disorder. It is this second group that has caused persistent difficulties in several respects—for example, regarding their terminology, their relationship to schizophrenia, and their forensic implications.

This chapter begins with definitions of the common paranoid symptoms, expanding upon their descriptions in Chapter 1, and then reviews the causes of such symptoms. Next there is a short account of paranoid personality. This is followed by a discussion of primary psychiatric disorders with which paranoid symptoms are frequently associated, and the differentiation of these disorders from delusional disorders. The general features of delusional disorder and its major subtypes are then reviewed. A historical perspective is also given, with particular reference to paranoia and paraphrenia. The chapter ends with a summary of the assessment and treatment of patients with paranoid symptoms.

Paranoid symptoms

It was pointed out above that the commonest paranoid delusions are persecutory. The term paranoid is also applied to the less common delusions of grandeur and jealousy, and sometimes to delusions concerning love, litigation, or religion. It may seem puzzling that such varied delusions should be grouped together. The reason is that the central abnormality implied by the term paranoid is a morbid distortion of beliefs or attitudes concerning relationships between oneself and other people. If someone believes falsely or on inadequate grounds that he is being victimized, or exalted, or deceived, or loved by a famous person, then in each case he is construing the relationship between himself and other people in a morbidly distorted way.

The varieties of paranoid symptom were discussed in Chapter 1, but important ones are also outlined in Box 12.1 for convenience. The definitions are derived from the glossary to the Present State Examination (see p. 65; Wing et al., 1974).

Causes of paranoid symptoms

When paranoid symptoms occur as part of another psychiatric disorder, the main aetiological factors are those that determine the primary illness. However, the question still arises as to why some people develop paranoid symptoms, while others do not. This has usually been answered in terms of premorbid personality and social isolation.

Premorbid personality

Many writers, including Kraepelin, have held that paranoid symptoms are most likely to occur in patients with premorbid personalities of a paranoid type (see next section). Kretschmer (1927) also believed this, and thought that such people developed sensitive delusions of reference (‘sensitive Beziehungswahn’) as an understandable psychological reaction to a precipitating event. Modern studies of so-called late-onset paraphrenia have supported these views (see Box 12.2 below). Thus Kay and Roth (1961) found paranoid or hypersensitive personalities in over half of their group of 99 subjects with late-onset paraphrenia.

Box 12.1 Some paranoid symptoms

Ideas of reference

Ideas of reference are held by people who are unduly self-conscious. The subject cannot help feeling that people take notice of him in buses, restaurants, or other public places, and that they observe things about him that he would prefer not to be seen. He realizes that this feeling originates within himself and that he is no more noticed than other people, but all the same he cannot help the feeling, which is quite out of proportion to any possible cause.

Delusions of reference

Delusions of reference consist of an elaboration of ideas of reference, to the point that the beliefs become delusional. The whole neighbourhood may seem to be gossiping about the subject, far beyond the bounds of possibility, or he may see references to himself in the media. He may hear someone on the radio say something connected with a topic he has just been thinking about, or he may seem to be followed, his movements observed, and what he says recorded. The importance of distinguishing a delusion of reference from an idea of reference is that the former is a symptom of psychosis.

Delusions of persecution

When a person has delusions of persecution he believes that a person, organization, or power is trying to kill him, harm him in some way, or damage his reputation. The symptom may take many forms, ranging from the direct belief that he is being hunted down by specific people, to complex, bizarre, and impossible plots.

Delusions of grandeur

These may be divided into delusions of grandiose ability and delusions of grandiose identity. The subject with delusions of grandiose ability thinks that he is chosen by some power, or by destiny, for a special purpose because of his unusual talents. He may think that he is able to read people’s thoughts, is much cleverer than anyone else, or has invented machines or solved mathematical problems beyond most people’s comprehension.

The subject with delusions of grandiose identity believes that he is famous, rich, titled, or related to prominent people. He may believe that he is a changeling and that his real parents are royalty.

Freud proposed that, in predisposed individuals, paranoid symptoms could arise through a convoluted process involving the defence mechanisms of denial and projection, based upon his study of Daniel Schreber, the presiding judge of the Dresden Appeal Court (Freud, 1911). Freud never met Schreber, but read the latter’s autobiographical account of his paranoid illness (now generally accepted as being paranoid schizophrenia), together with a report by Weber, the physician in charge. Freud speculated that Schreber could not consciously admit his homosexuality, and projected his unacceptable desires (‘I do not love him, he loves me’) and then inverted this with another denial (‘he does not love me, he hates me’). This configuration was abandoned fairly early on, and never had much clinical support.

Social isolation and deafness

Social isolation may also predispose to the emergence of paranoid symptoms. Prisoners (especially those in solitary confinement), refugees, and migrants have all been considered to be prone to paranoid symptoms and syndromes, with social isolation being the common factor. However, there are no data that unambiguously support this view, and there are some which suggest other explanations. For example, the association between migration and psychosis is better explained in terms of broader psychosocial factors or marginalization, rather than just isolation (Singh and Burns, 2006; see also Chapter 11).

There is better evidence that the social isolation produced by deafness increases the risk of paranoid symptoms, as originally noted by Kraepelin. Houston and Royse (1954) found an association between deafness and paranoid schizophrenia, while Kay and Roth (1961) found hearing impairment in 40% of patients with late-onset paraphrenia. Subsequent studies have confirmed that hearing impairment is a risk factor for disorders in which paranoid symptoms occur, and that this relationship is stronger in but not limited to the elderly (David et al., 1995). However, it should be remembered that the great majority of deaf people do not become paranoid, and many deaf people may not be socially isolated.

Paranoid personality disorder

The concept of personality disorder was discussed in Chapter 7, and paranoid personality disorder was briefly described there. It is characterized by the following:

• extreme sensitivity to setbacks and rebuffs

• suspiciousness

• a tendency to misconstrue the actions of others as hostile or contemptuous

• a combative and inappropriate sense of personal rights.

This definition embraces a wide range of types. At one extreme is the excessively sensitive young person who shrinks from social encounters and thinks that everyone disapproves of him. At the other is the assertive and challenging woman who flares up at the least provocation. A recent American study found a 4.4% prevalence of DSM-IV paranoid personality disorder, which is higher than previous estimates; the study also showed that the disorder had a significant impact on social and role functioning (Grant et al., 2004).

Because of the implications for treatment, it is important to distinguish paranoid personality disorder from the paranoid syndromes (delusional disorders) to be described later. The distinction can be very difficult to make, and is based on the fact that in paranoid personality disorder there are no delusions (only overvalued ideas), and no hallucinations. Considerable skill is needed to separate paranoid ideas from delusions. The criteria for doing so were given in Chapter 1, and exemplified by the comparison made above between ideas of reference and delusions of reference. In reality, the conditions probably lie along a continuum. Thus family studies indicate a genetic relationship between paranoid personality disorder and delusional disorder (see below), whereas individuals with paranoid personality traits are at increased risk of developing a delusional disorder.

For a review of paranoid personality disorder, see Carroll (2009).

Paranoid symptoms in psychiatric disorders

Paranoid symptoms are often secondary to a primary psychiatric disorder. Thus when paranoid symptoms, especially persecutory delusions, are elicited it is important to assess for the other features of these disorders. The diagnosis of delusional disorder, to be considered below, is in many respects a ‘residual’ category, used for patients whose delusions cannot be attributed to one of these other conditions. As the primary disorders are described at length in other chapters, they will be mentioned only briefly here.

Paranoid symptoms in organic disorders

It is important to consider an organic aetiology for paranoid symptoms, especially in the elderly or in cases where there is other evidence for a medical illness. For a review of organic causes of paranoid symptoms and delusional disorders, see Gorman and Cummings (1990).

Paranoid symptoms are common in delirium. Impaired grasp of what is going on around the patient may give rise to apprehension and misinterpretation, and so to suspicion. Delusions may then emerge which are usually transient and disorganized; these may lead to disturbed behaviour, such as querulousness or aggression. Similarly, persecutory delusions commonly occur at some stage in dementia, and are occasionally the presenting feature. Finally, paranoid symptoms and delusional disorders may occur with focal brain lesions of various causes, including tumour, stroke, and trauma. Some examples are given later in this chapter when the specific delusional disorders are considered.

Paranoid symptoms in substance misuse disorders

Paranoid symptoms occur in many substance misuse disorders, especially those associated with amphetamines, cocaine, and alcohol. An important example is the association between alcohol misuse and morbid jealousy, described below. Some therapeutic drugs can also precipitate paranoid symptoms, such as L-DOPA (Gorman and Cummings, 1990).

Paranoid symptoms in mood disorders

Paranoid symptoms are not uncommon in patients with severe depressive disorders, and paranoid delusions are a feature of psychotic depression. Conversely, depressive symptoms often occur in delusional disorders, although the diagnostic criteria for the latter require that their total duration is relatively brief (see below). In practice, it is sometimes difficult to determine whether the paranoid symptoms are secondary to depressive disorder, or vice versa, as both scenarios are common. The distinction is of some importance, as the two disorders differ with regard to treatment and prognosis. A depressive disorder is likely if the mood changes have occurred earlier and are of greater intensity than the paranoid features. Previous psychiatric history and family history may also be useful pointers. Finally, in depressive disorder the patient typically accepts the persecution as justified by their own guilt or wickedness. This is a useful point clinically, as it contrasts with non-affective psychoses, in which such persecutions are bitterly resented.

Paranoid symptoms also occur in mania, and are typically mood-congruent and thus grandiose rather than persecutory.

Paranoid symptoms and paranoid schizophrenia

Paranoid schizophrenia was described in Chapter 11. Its distinction from delusional disorders has been particularly problematic, both conceptually and practically (see Box 12.2), but the difficulties can be decreased by noting the differences in their core features (compare Table 12.1 with Box 12.2). Three features aid the distinction in cases of doubt.

Box 12.2 Historical background: paranoia and paraphrenia

The terms paranoia and paraphrenia have played a prominent part in psychiatric thought. Much can be learned from reviewing the conceptual difficulties associated with them.

The term paranoia, from which the modern adjective paranoid is derived, has a long and chequered history. It has probably given rise to more controversy and confusion of thought than any other term used in psychiatry. A comprehensive review of the large body of literature, which is mostly German, and from the period before the 1970s has been provided by Lewis (1970) (see also Box 1.2). The word is derived from the Greek para (beside) and nous (mind). It was used in ancient Greek literature to mean ‘out of mind’ (i.e. of unsound mind or insane). This broad usage was revived in the eighteenth century, but when it came into prominence in the second half of the nineteenth century, in German psychiatry, it became particularly associated with conditions characterized by delusions of persecution and grandeur. The German term Verrucktheit was often applied to these conditions, but was eventually superseded by paranoia. There were many different conceptions of these disorders. The main issues, most of which remain today, can be summarized as follows.

• Did these conditions constitute a primary disorder, or were they secondary to another disorder?

▸• Did they persist unchanged for many years, or were they a stage in an illness which later manifested deterioration of intellect and personality?

• Did they sometimes occur in the absence of hallucinations, or were hallucinations an invariable accompaniment?

• Were there forms with a good prognosis?

Kahlbaum raised these issues as early as 1863, when he classified paranoia as an independent primary condition which would remain unchanged over the years. Kraepelin had a strong influence on the conceptual history of paranoia, although he was never comfortable with the term, and his views changed strikingly over the years. In 1896 he used the term only for incurable, chronic, and systematized delusions without severe personality disorder. In the sixth edition of his textbook he wrote:

The delusions in dementia praecox [schizophrenia] are extremely fantastic, changing beyond all reason, with an absence of system and a failure to harmonize them with events of their past life; while in paranoia the delusions are largely confined to morbid interpretations of real events, are woven together into a coherent whole, gradually becoming extended to include even events of recent date, and contradictions and objects are apprehended and explained. (Kraepelin, 1904, p. 199)

In later descriptions, Kraepelin (1919) used the distinction made by Jaspers (1913) between personality development and disease process. He proposed paranoia as an example of the former, in contrast to the disease process of dementia praecox. In his final account, Kraepelin (1919) developed these ideas by distinguishing between dementia praecox, paranoia, and a third paranoid psychosis, namely paraphrenia. He made the following suggestions:

• Dementia praecox had an early onset and a poor outcome, ending in mental deterioration, and was fundamentally a disturbance of affect and volition.

• Paranoia was restricted to patients with late onset of completely systematized delusions and a prolonged course, usually without recovery, but not inevitably deteriorating. An important point was that the patient did not have hallucinations.

• Paraphrenia was somewhat intermediary, in that the patient had unremitting systematized delusions but did not progress to dementia. The main difference from paranoia was that the patient with paraphrenia had hallucinations.

Bleuler’s concept of the paranoid form of dementia praecox (which he later called paranoid schizophrenia) was broader than that of Kraepelin (Bleuler, 1906, 1911). Thus Bleuler did not regard paraphrenia as a separate condition, but as part of dementia praecox. However, he accepted Kraepelin’s view of paranoia as a separate entity, although he differed from Kraepelin in maintaining that hallucinations could occur in many cases. Bleuler was particularly interested in the psychological development of paranoia; at the same time he left open the question of whether paranoia had a somatic pathology.

From this time, two views of paranoia predominated. The first was that paranoia was distinct from schizophrenia and psychogenic in origin. The second view was that paranoia was part of schizophrenia. Some celebrated studies of individual cases appeared to support the first theme. For example, Gaupp (1974) made an intensive study of the diaries and mental state of the mass murderer Ernst Wagner, who murdered his wife, four children, and eight other people as part of a careful plan to revenge himself on his supposed enemies. Gaupp concluded that Wagner suffered from paranoia in the sense described by Kraepelin. At the same time, he believed that Wagner’s first recognizable delusions developed as a psychogenic reaction. The most detailed argument for psychogenesis was put forward by Kretschmer (1927) in his monograph Der Sensitive Beziehungswahn. Kretschmer believed that paranoia should not be regarded as a disease, but as a psychogenic reaction occurring in people with particularly sensitive personalities. However, many of Kretschmer’s cases would nowadays be classified as schizophrenia. In 1931, Kolle put forward evidence for the second view, that paranoia is part of schizophrenia. He analysed a series of 66 patients with so-called paranoia, including those diagnosed by Kraepelin in his Munich clinic. For several reasons, both symptomatic and genetic, Kolle came to the conclusion that paranoia was really a mild form of schizophrenia.

Considerably less has been written about paraphrenia. However, it is interesting that Mayer (1921), following up Kraepelin’s series of 78 paraphrenic patients, found that 50 of them had developed schizophrenia. He found no difference in original clinical presentation between those who developed schizophrenia and those who did not. Since then paraphrenia has increasingly been regarded as late-onset schizophrenia or schizophrenia-like disorder of good prognosis. Kay and Roth (1961) used the term late paraphrenia to denote paranoid conditions in the elderly that were not due to primary organic or affective illnesses. These authors found that a large majority of their 99 patients had the characteristic features of schizophrenia.

In current classifications, the term paranoia has, in effect, been replaced by delusional disorder. Paraphrenia does not feature either, but it continues to be used clinically to describe chronic, atypical, paranoid psychoses of middle and late life.

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