Introduction
The term paranoid can be applied to symptoms, syndromes, or personality types. Paranoid symptoms are overvalued ideas or delusions that are most commonly persecutory, but not always so (see Box 1.4, page 12). 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-5 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
Although the vast majority of paranoid delusions are persecutory, the term 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.
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. Subsequent studies of so-called late-onset paraphrenia have supported Some paranoid symptoms
Ideas of reference
Ideas of reference are held by people who are unduly selfconscious. 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.