Persecutory Delusional Disorder

Delusional disorders are characterized by fixed beliefs based on bizarre interpretations of reality (despite evidence to the contrary), not related to daily life experiences, and not specific to a given cultural group. There are five major subtypes: erotomanic (i.e., an individual delusionally believes that another person is in love with them), grandiose (i.e., delusional belief of having exceptional talent, ideas, or important discoveries), jealous (i.e., delusional belief that their significant other is unfaithful), persecutory (delusional belief that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals), and somatic (the delusion involves bodily functions or sensations), along with mixed type and unspecified type. In this chapter we will be focusing on persecutory delusional disorder (PDD), sometimes known as paranoid delusional disorder (see Table 5.1 ).

The PDD term was first formalized in DSM-III-R, after an extensive discussion on paranoia and its ill-defined use in common speech. Currently, PDD and paranoia are synonyms, and still stem from Emil Kraepelin’s 1915 idea of paranoid disorder.

Persecutory DD is often misdiagnosed as schizophrenia due to some symptoms common to the two disorders. This confusion resembles the historical notion that perhaps PDD is just a mild form of paranoid schizophrenia. Indeed, this outdated view was included in DSM-II. Since then, rigorous research has shown that PDD and schizophrenia diverge in premorbid personality traits, marital status, hospitalization index, and the fact that negative and cognitive symptoms are only pronounced in schizophrenia.

An example of what seems to be continuing confusion nonetheless supports a higher level of cognitive symptoms in schizophrenia than in PDD. A factor analysis study compared schizophrenia subjects with and without comorbid social anxiety, but the latter group may actually have been inadvertently misdiagnosed PDD. If so, their data offers useful support for the clinically accepted distinctions between schizophrenia and PDD.

The essential feature of PDD is the persistence of one or more delusions for 1 month or more without fulfilling any symptom from schizophrenia’s criteria A. If there are hallucinations, they are not related to delusional themes, and they are of brief duration. Aside from the adverse consequences of delusions, other behavior and psychosocial abilities are not affected. This is in contrast to the functional decline of schizophrenia. Lastly, the symptoms must not be a consequence of substance use (see Chapter 8 ) or other mental or medical conditions ( Chapter 9 ).

Certain duration and recurrence specifiers only apply after 1 year of illness, subdivided into acute (a period when the symptom criteria are fulfilled), partial remission (an improvement after a previous episode is maintained and full criteria are no longer met), and full remission (does not have any disorder-specific symptoms). These concepts characterize both first and multiple episodes, but continuous criteria fulfillment for most of the disease course is also possible.

Thinking epidemiologically, it is hard to know PDD’s true population prevalence, in view of exclusion criteria, patient avoidance of treatment, and the common confusion with schizophrenia. PDD-like symptoms are common within other schizophrenia spectrum disorders, but those symptoms are different than a clear diagnosis of “pure” PDD. Nevertheless, DSM5 declares prevalence to be around 0.02%, while female-to-male ratio varies across studies between 1:18 and 3:1. The mean age of onset is 40 years and represents 1% to 4% of all psychiatric admissions. Importantly, it is difficult for people with PDD to seek treatment, as they remain substantially functional, yet cannot recognize the negative effects of their fears on relationships and employability. Basically, they cannot doubt their own fixed beliefs, and they strongly reject any opposing opinions. As a result, they commonly develop social isolation, depression, and even an exacerbation of prodromal social anxiety.

Social Anxiety Disorder

Social anxiety disorder (SAD), also known as “social phobia,” is one specific kind of anxiety. SAD is characterized by great concern about others’ opinions due to the fear of being embarrassed, diminished, harmed by someone, or humiliated. People with SAD are usually afraid of being embarrassed in social situations; therefore, they tend to avoid places or circumstances where they could experience painful anxiety episodes. For example, they may be very shy people who avoid meeting strangers, public speaking, and situations where they may feel evaluated by others. As a result, most people with SAD reduce their investment in social relationships, which can present problems for differential diagnosis of SAD and schizophrenia spectrum disorder. Not surprisingly, people with SAD have smaller social networks than others.

For example, Hur et al. demonstrated that individuals with higher levels of social anxiety spend significantly less time with close companions, and that this results from smaller social networks. Because of this, socially anxious subjects spend significantly less time with others, and derive less emotional benefit.

According to DSM 5 (see Table 5.2 ), the essential feature of SAD is great fear or anxiety about social situations “in which the individual is exposed to possible scrutiny by others” (DSM 5, 2013, pg. 202). Examples include having a conversation, meeting new people, the feeling of being observed while drinking or eating, and performing in front of others.

The embarrassment is typically related to fear of being seen as somehow inferior. It can manifest in specific and varied places, including work, school, parties, and wherever public presentation is required. With an intense fear or anxiety of social situations, where the individual may be negatively evaluated by others, they may be afraid of being judged crazy, stupid, boring, or incapable, among others. The fear of embarrassingly negative evaluation can include fear that the anxiety itself will be noticed by others, not to mention such visible anxiety symptoms as blushing, sweating, switching words, and staring. Depending on the symptoms, people may avoid situations that could evoke those symptoms. An individual with trembling hands when anxious may avoid drinking, writing, or eating in public.

Social Anxiety Disorder and Comorbidity in Schizophrenia

Aside from the frequent misdiagnosis of PDD as schizophrenia, SAD is one of the five most common comorbidities in schizophrenia. Deeper analysis is essential for understanding the interactions and co-occurrence of these two disorders. Research shows that SAD symptoms are very common in patients with schizophrenia, and 17% of the schizophrenia individuals are diagnosed with SAD. Psychotic individuals manifest signs and symptoms of SAD much like individuals who only have SAD without comorbidity. Since psychotic symptoms are generally considered more significant and more clinically relevant, anxiety symptoms typically receive too little clinical attention.

SAD in schizophrenia is associated with high suicide attempt risk, low quality of life, impaired social functioning, and low self-esteem, and is a major determinant of early schizophrenia. In addition, comorbid SAD with schizophrenia may intensify the social stigmatization of psychotic individuals as useless or dangerous people. That type of experience can lead to avoidance of social situations and to distressing humiliation. People with schizophrenia have diminished affection in relationships, just as those with SAD have diminished assertive behavior. Lysaker et al. argues that the failure to recognize others’ emotions makes social relationships difficult to navigate, so that interacting with others is a source of frustration, rather than a more satisfying relationship.

Several studies indicate that certain environmental factors may be related to the development of anxiety in schizophrenia. Exacerbated expression of emotions due to stressful and conflicting relationships between patients and their relatives results in more pronounced manifestations of anxiety and psychosis in patients diagnosed with schizophrenia, as well as causing a significant increase in positive and psychotic symptoms.

Not surprisingly, premorbid SAD influences schizophrenia onset and prognosis. SAD also helps determine clinical presentation, such as greater anxiety and suspiciousness, increased concern about mind reading, and other ideas of reference. With lesser self-esteem, increased self-referential paranoid concerns often focus on societal authority figures. Paranoid delusions in schizophrenia are typically related to fearful suspicion of malevolent observation by powerful authorities such as the CIA, FBI, religious figures, and aliens.

Mild Quasi-Psychotic Features in Social Anxiety Disorder

Individuals with non-psychotic SAD may still have suggestively self-referential symptoms or ideas of reference. This may occur when SAD social fears overwhelm their mind’s ability to consciously process those concerns. The greater an individual’s ability to recognize that their concerns are internal exaggerations, the more these ideas are recognized as preoccupations or as anxiety. On the other hand, the lower their self-awareness, the greater the chance that their concerns seem real and immediate, resembling delusional self-referential experiences. These feelings of self-reference may be accompanied by more or less insight, varying across a broad range of perceived disapproval.

Veras et al. discussed three possible explanations for psychotic manifestations in SAD patients. As noted above, the first is related to limited ability to evaluate internal anxious thoughts and feelings. The second possibility is that some stressors and intensifying factors could make individuals more likely to experience psychotic symptoms (as in PDD). Third and last, some patients may have SAD caused by a primary thought disorder abnormality leading to intense concern about others’ opinions, with consequent psychotic self-reference rather than exaggerated anxiety.

The difficulty in distinguishing SAD from primary paranoia in some cases is related to the weakness of diagnostic constructs and current psychopathologic models, especially when the symptoms co-occur. In one sample of 161 patients, SAD patients had more cluster A personality disorders, especially paranoid personality. Non-clinical samples have demonstrated that higher paranoid ideation is associated with higher levels of social anxiety, avoidance, apprehension, self-observation, and low self-esteem.

Armando et al. reported that the prevalence of psychotic-like experiences in individuals with SAD is indeed five times higher than controls. The same study reported that patients with SAD also had higher levels of depression, intolerance of uncertainty, and negative symptoms. Individuals with SAD and psychotic-like experience often have pessimistic thoughts and low self-esteem. When combined with deregulated affectivity, this plays an important role in paranoid delusions and psychotic symptoms. These data are in accord with previous findings, which show that intolerance of uncertainty and related worries are linked to psychotic experiences, and that social anxiety increases the emotional responses to psychotic feelings.

Social Anxiety Disorder and Persecutory Delusional Disorder: Chronology and Comorbidity

Even though SAD alone can be associated with increased quasi-paranoia, patients do tend to retain both societal function and awareness of the thoughts and emotions present in other people’s minds (Theory of Mind). True paranoid delusions with preserved cognition look very much like the DSM-5 criteria for “pure” PDD. Indeed, some patients with clinically diagnosed SAD much later develop DSM5 PDD.

The median age that the first symptoms of SAD tend to appear is around 13 years old, and most have an age of onset between 12 and 17. Typically, SAD onset is preceded by earlier childhood social inhibition or shyness. The disorder may be influenced by humiliating or stressful situations, such as bullying, or embarrassment in front of other people. Moreover, since bullies tend to go after those who seem weak or shy, those with SAD are more likely to experience this kind of interpersonal trauma. Even a realistic hint of attack risk feeds into interpersonal fearfulness, causing increased anxiety and self-referential paranoia.

Onset in adulthood is relatively rare and more likely to occur after a highly stressful event or a major humiliation. Other risk factors for SAD development include temperamental behavioral inhibition, fear of negative evaluation, childhood maltreatment and adversity, and both genetic and physiologic traits. SAD and psychotic disorders share some common risk factors. Even with treatment, SAD tends to persist over time, although symptom severity can wax and wane, with some periods of significant exacerbation.

Observing the long-term course of diagnosed SAD patients, some of them later develop diagnosed PDD. From an evolutionary perspective, it is suggested that when conscious modulation of social ranking instincts linked to SAD are reduced by frontal cortex hypofrontality, then exaggerated amygdala reactivity of these patients may present as the actual delusions in PDD. This process may be further intensified by circumstances. It is also possible that reduced conscious modulation of hypofrontality and adverse circumstances may be even more exacerbated if resulting anxiety feeds back to further “break up” self-consciousness, and lead to psychosis. In the same report, researchers noted that some patients may develop moderate ongoing negative symptoms such as residual social withdrawal, apathy, and poor affective modulation. SAD, under certain conditions, may progress to PDD. Although further research is needed, PDD appears to be a psychotic form of SAD.

Case Study Part I (Fictional Case)

Jonathan, a 37 year-old male, an online video game programmer, seeks psychiatric care at age 40 because of his mother’s concern that he leaves their home only to buy essential food and supplies, although Jonathan does not believe that “this is a problem”.

Jonathan’s parents separated when he was 7 years old. His father was a harsh man who often quarreled with Jonathan’s mother. His father often called him useless and claimed that no one liked him. A shy and quiet child, he was bullied at school. Older boys called him homophobic names and often mocked or pushed him. Over time, due to innate shyness as well as fears of bullying, he became socially isolated, often spending school recess alone, and with few friends.

During his adolescence he did not date because “just thinking about talking to girls” made his hands sweat and made him feel faint and very anxious. Every time he tried to talk to a girl he felt so anxious that he backed off, and eventually he stopped trying. A college degree in computer science taught him software coding skills. Right out of college, he found work in video game programming, which allowed him to work alone at home but with a bit of online socializing. Basically, he has mostly stayed inside his mother’s house for about 15 years.

In his first interview he said that he prefers not to leave home because he has everything he needs there, and only leaves when he needs something. When he does go out, he has long felt non-paroxysmal tachycardia, anxiety, and excessive sweating. When he looks at people, he thinks they are saying something about him or making fun of him. He constantly thinks that he will embarrass himself in front of others, and thus be revealed as someone of little significance in society. He has no history of panic anxiety, even in social settings.

When reporting about his social world, he said that he usually communicates with his coworkers by text messaging, occasionally by telephone, and only infrequently by Skype when a video call is unavoidable. All of his work is done online from home. When he does need to deliver something for work, he uses a messenger service.

Jonathan had his first psychiatric contact at age 30. With a diagnosis of SAD, he complied with selective serotonin-uptake inhibitor (SSRI) antidepressant drug treatment for a few months, though he declined psychotherapy. He became a bit more social, outgoing, and cheerful, according to his mother. An online acquaintance even stopped by one day. Nonetheless, he quietly stopped medication, reporting later that he felt little real difference, and was concerned about what people would think about psychiatric medication use. When he leaves home now, he feels stressed out by the constant disrespect he suffers from men who walk past and look at him (sometimes looking at his back as he passes by). So, he sometimes leaves the shopping mall even before his shopping is completed. Early morning shopping trips can be easier, when there are fewer people around, and a bit easier still if he takes a shot of tequila beforehand.

Over time, SAD symptoms increased, and then psychotic symptoms began to appear. He started to think that people on the street could also read his mind, that television personalities were sending him special messages, and he was sure that the CIA was somehow behind it all—and they were waiting to pounce on any slight misstep. To protect himself, he reduced his already restricted activities. No more leaving the house: supplies were now ordered online and left at his doorstep. And to ensure no more Skype video sessions, he taped over the camera in his laptop. He also made sure to keep blinds drawn, and kept a baseball bat next to his bed. His mother’s reassurances were met with an angry glare and even a fear that she was part of the problem. After years of concern, she was now quite alarmed.

How to Interview

Like any other psychiatric disorder, a well-detailed investigation of the individual’s life history should include a primary focus on symptoms and their ages at onset. When thinking about SAD and PDD, it is important for the clinician to keep their symptoms and course clearly in mind.

The DSM-5 criteria present a clear summary of the core diagnostic features. In addition to these criteria, it is important to pay attention to additional important issues and aspects, as detailed below. As illustrated in the case, SAD and PDD are often associated with family and relational trauma history. To supplement the interview, there are scales that assess childhood trauma, for example the Early Trauma Inventory Self Report-Short Form.

As our focus here is on the assessment of SAD with PDD, it is important to investigate early symptoms such as excessive shyness, fear of public speaking, limited social relationships, low self-esteem, fear that self-embarrassment will cause others to look down on them, and frequent concerns about critical observers.

On the other hand, when assessing the possibility of psychotic symptoms in patients with SAD, attention should be paid to the level of self-awareness, as this factor is important for discriminating true psychosis from overvalued fears. That distinction applies to exaggerated SAD symptoms, as well as the paranoid and self-referential fears of PDD. For example, can the patient offer or seriously consider alternative non-psychotic explanations?

Last but not least, PDD patients may have thoughts of violence, and sometimes act on them. Be sure to ask about violent and suicidal thoughts, how the patient can avoid violent behavior, and about access to weapons. Ask family members and friends about those same issues and any related history.

Importantly, psychotic patients require special interviewing skills and approaches. They may offer vague, evasive, confusing, and poorly detailed information, while being careful not to mention some of their most profound or fearful concerns. This makes interviewing difficult for basic issues, fears, comorbid symptoms, and even for earlier symptomatic history. Thus, in many cases, it is useful to revisit the full history after psychotic stabilization. In order to identify SAD symptoms in cooperative and open psychotic patients, scales can also be used, such as the Liebowitz Social Anxiety Scale (LSAS). This should be administered for both current symptoms and earlier pre-psychotic SAD symptoms.

Some basic guidelines for interviewing acutely psychotic patients are included near the end of Chapter 1 .

Case Study Part II: Treatment

Due to the worsening of the patient’s anxiety, irritability, and social withdrawal, the mother decided to make another try at treatment. In view of his heightened psychosis and baseball bat, he was admitted to an inpatient unit as a precaution. After an initial full clinical interview, treatment with aripiprazole was indicated in order to acutely diminish paranoia. Some initial softening of paranoia was noted within days. This took the form of less preoccupation, rather than less certainty. This partial improvement then allowed a more detailed interview, with additional information about symptom history and progression, as well as medical and personal history.

In view of his prior history of SAD (a chronic, and possible underlying, syndrome) fluoxetine 20 mg qd was also added, and expected to start helping about 4 weeks later. Since fluoxetine has a very long half-life, it is useful for patients at risk of noncompliance on discharge. And aripiprazole has the added benefit of enhancing SSRI treatment of SAD. At the same time, with an eye to possible future noncompliance, he was also started on injectable depot aripiprazole, requiring roughly monthly injections in the future.

In addition to drug treatment, psychotherapeutic follow-up based on either supportive dynamically informed technique or cognitive behavioral therapy is indicated in order to work on the recognition of dysfunctional symptoms and criticism regarding the condition and severity of the patient. Despite adhering to the treatment, Jonathan at first had difficulty attending psychotherapy sessions because he believed that people would know he was sick and make fun of him. As his condition improved, he began to appreciate the value of medication and therapy.

Over time, the subject showed increasing response to medication. Within a few months, his paranoid delusions remained, but were much less important to him. Meanwhile, his SAD had improved enough that he was more social than he had been in many years. Since he fully complied with treatment, these benefits remained for a long time. Ongoing psychotherapy helped him rebuild his life, drawing in part on his career success even during most of his illness.

Social Anxiety Disorder and Persecutory Delusional Disorder Treatment

It is common that people with SAD tend to shy away from treatment, and this is even more true for PDD. Usually, looking for a psychiatrist or psychologist initially increases anxiety, even if family is in charge. Medication treatment of SAD has shown great efficacy with the use of SSRI antidepressants, which work by increasing serotoninergic activity, but with anxiolytic effects only starting after 4 weeks. Benzodiazepines such as clonazepam may show modest initial benefit for anxiety, but they do little for core SAD concerns about embarrassment and avoidance, and have little role beyond initial treatment.

Psychotherapy associated with medication treatment has also been shown to be effective for SAD. The psychotherapeutic process helps the individual to understand and change patterns of shyness and avoidant behavior. Although the medications offer pharmacologic benefit, long-term psychotherapy should also be part of the treatment of individuals with SAD. Once you have a lifetime of experience with SAD, the beliefs become rooted in cognition as well as biology, but improve with time and thoughtfulness.

For PDD, treatment avoidance is far more pronounced. Special efforts are often required to engage the patient in treatment, and initial hospitalization is often the wise choice. Initial medication starts with an oral antipsychotic, and aripiprazole has advantages as noted above (fewer side effects, depot formulation available, enhancement of SSRIs for SAD). As appropriate (i.e., prior history of SAD, a chronic and possibly underlying syndrome), and with little downside risk, oral fluoxetine 20 mg can be added, with expectation of initial benefits 4 weeks later.

Reports have noted that patients diagnosed with schizophrenia and symptoms of SAD can be adjunctively treated with a SSRI. Choices of SSRIs include citalopram, escitalopram, fluoxetine, fluvoxamine, and sertraline.

With these medications, delusions may start to become less important within a few days. Within months, delusions may fade to little importance, while SAD may continue to improve over the longer term. Psychotherapy is essential for compliance, making sense of illness history, and rebuilding a life.

Social Anxiety Disorder and Persecutory Delusional Disorder

While investigation of psychotic-like symptoms in SAD patients has been well reported in the literature, as well as studies of SAD concurrent with schizophrenia, there are few papers that address a progression of SAD to PDD. Patients with severe SAD symptoms often experience self-referential feelings. Such feelings may be accompanied by greater or lesser conscious assessment by the patient. Other works presented in this chapter point out that SAD and PDD are more than just consequences of stressful experiences: the disorders share common risk factors, and look like sometimes successive pathways of a common underlying psychopathologic process.

Although psychiatric diagnostic manuals long ago codified psychotic mood syndromes such as mania and delusional depression, companion psychotic anxiety disorders have been proposed but not yet accepted. Limited controlled research is one reason, but PDD is considered rare, and such research has found little funding. Even so, limited research evidence as well as clinical observation strongly suggest that the SAD/PDD construct may improve treatment approaches. If warranted by further research, future DSM diagnoses might consider PDD as “psychotic social anxiety disorder.” This codification seems to be in accordance with a dimensional diagnosis, reflecting the transition from SAD and PDD, and linking this anxiety disorder to the schizophrenia spectrum disorders.

Summary

SAD can be considered a lifetime disorder, in which the individual keeps himself trapped in his beliefs and fears, resulting in consequences for their personal, work, academic, and affective life. With the diagnostic description in the American Psychiatric Association’s DSM-5, it is possible to document specific characteristics of SAD. However, additional symptoms may also occur with this disorder. Escalation to psychotic symptoms, as in PDD, can worsen symptoms, function, and prognosis. It seems more than plausible that recognition of this connection suggests a novel treatment approach worth careful evaluation. Further research is also needed to better evaluate, document, and detail the relationship between SAD and delusional disorder.