‘They’re out to get me!’: Evaluating rational fears and bizarre delusions in paranoia Paranoid delusions can reveal a number of psychiatric disorders; building trust is key to treatment

James Allen Wilcox, MD, PhD ven among healthy individuals, feelings of paranoia are not Professor of Clinical Psychiatry University of Arizona unusual. In modern psychiatry, we consider paranoia to be a pat- Staff Psychiatrist tern of unfounded thinking, centered on the fearful experience of Southern Arizona Veterans Administration E Health Care System perceived victimization or threat of intentional harm. This means that Tucson, Arizona a patient with paranoia is, by nature, difficult to engage in treatment. A P. Reid Duffy, PhD, RN patient might perceive the clinician as attempting to mislead or manipu- Mental Health Research Coordinator late him. A therapeutic alliance could require patience on the part of the Southern Arizona Veterans Administration clinician, creativity,1 and abandoning attempts at rational “therapeutic” Health Care System Tucson, Arizona persuasion. The severity of symptoms determines the approach. Disclosures In this article, we review the nature of paranoia and the continuum of The authors report no financial relationships with any syndromes to which it is a central feature, as well as treatment approaches. company whose products are mentioned in this article or with manufacturers of competing products. Categorization and etiology Until recently, clinicians considered “paranoid” to be a subtype of schizophrenia (Box,2-7 page 30); in DSM-5 the limited diagnostic stability and reliability of the categorization rendered the distinction obsolete.8 There are several levels of severity of paranoia; this thought process can present in simple variations of normal fears and concerns or in severe forms, with highly organized delusional systems. The etiology of paranoia is not clear. Over the years, it has been attrib- uted to defense mechanisms of the ego, habitual fears from repetitive exposure, or irregular activity of the amygdala. It is possible that various types of paranoia could have different causes. Functional MRIs indicate that the amygdala is involved in anxiety and threat perception in both primates and humans.9 continued

Current Psychiatry

CHRISTOPHER ZACHAROW Vol. 15, No. 10 29 Box sonable in their inner experience of omni- Paranoia: An old term present threat. In addition, advances in with a new meaning surveillance technology, as well as the media proliferation of depictions of vul- variety of paranoid conditions have nerability and threat, can plant generalized A been described in society for centuries. doubt of historically trusted individuals The term paranoia is derived from the Greek “para” (beside) and “noos” (mind). In other and systems. Under conditions of severe Paranoia words, a condition of mental illness where a social discrimination or life under a totali- 2 preoccupation of the mind occurs. Before tarian regime, constant fear for safety and the 19th century, the term paranoia could be used for almost any form of delusional worry about the intentions of others is rea- thinking. In 1863 Kahlbaum used the term sonable. We must remember that during the paranoia to describe chronic delusions Cold War many people in Eastern Europe of persecution.3,4 In describing dementia had legitimate concerns that their phones praecox, Kraepelin initially regarded paranoia as a distinct disorder.5 Bleuler argued that were tapped. There are still many places in there was no need for distinction between the world where the fear of government or 6 paranoia and his concept of schizophrenia. of one’s neighbors exists. In 1921, Mayer concluded that paranoid Clinical Point psychosis could not be separated from In a case of vague paranoia, clinicians 7 Perhaps the key to schizophrenia, based upon phenomenology. must take care in diagnosis and recom- mending involuntary hospitalization separating realistic because psychiatric treatment can lead to fear from paranoia scapegoating persons for behavior that is the recognition Rational fear vs paranoia is not pathological, but merely socially of whether the Under the right circumstances, anyone could undesirable.11 sense that he (she) is being threatened. Such Symptoms of paranoia can take more environment is truly feelings are normal in occupied countries pathological directions. These 3 psychiatric safe or hostile and nations at war, and are not pathologic conditions are: in such contexts. Anxiety about potential • paranoid personality disorder danger and harassment under truly oppres- • delusional disorder sive circumstances might be biologically • paranoia in schizophrenia (Table, ingrained and have value for survival. It page 32). is important to employ cultural sensitivity when distinguishing pathological and non- pathological paranoia because some immi- Paranoid personality disorder grant populations might have increased The nature of any personality disorder is a prevalence rates but without a true mental long-standing psychological and behavioral illness.10 pattern that differs significantly from the Perhaps the key to separating realis- expectations of one’s culture. Such beliefs tic fear from paranoia is the recognition and behaviors typically are pervasive across of whether the environment is truly safe most aspects of the individual’s interactions, or hostile; sometimes this is not initially and these enduring patterns of personality evident to the clinician. The first author usually are evident by adolescence or young (J.A.W.) experienced this when discover- adulthood. Paranoid personality disorder ing that a patient who was thought to be is marked by pervasive distrust of others. paranoid was indeed being stalked by Typical features include: another patient. • suspicion about other people’s motives Discuss this article at Rapid social change makes sweeping • sensitivity to criticism www.facebook.com/ explanations about the range of threats • keeping grudges against alleged CurrentPsychiatry experienced by any one person of limited offenders.8 value. Persons living with serious and per- The patient must have 4 of the following sistent mental illness experience stigma— symptoms to confirm the diagnosis: harassment, abuse, disgrace—and, similar • suspicion of others and their motives to victims of repeated sexual abuse and • reluctance to confide in others, due to Current Psychiatry 30 October 2016 other violence, are not necessarily unrea- lack of trust • recurrent doubts about the fidelity of a der might appear rational—as long as they significant other are in independent roles—and their general • preoccupation with doubt regarding functioning could go unnoticed. This could trusting others change when the delusions predominate • seeing threatening meanings behind their thoughts, or their delusional behavior benign remarks or events is unacceptable in a structured environment. • perception of attacks upon one’s char- Such individuals often suffer from a highly acter or reputation specific delusion fixed on 1 topic. These • bears persistent grudges.8 delusions generally are the only psychotic Individuals with paranoid personality feature. The most common theme is that of disorder tend to lead maladaptive lifestyles persecution. For example, a person firmly and might present as irritable, unpleasant, believes he is being followed by foreign and emotionally guarded. Paranoid person- agents or by a religious organization, which ality disorder is not a form of delusion, but is is blatantly untrue. Another common theme a pattern of habitual distrust of others. is infidelity. The disorder generally is expressed ver- Paranoia in delusional disorder is about bally, and is seldom accompanied by hallu- something that is not actually occurring, but Clinical Point 3 cinations or unpredictable behavior. Distrust could. In other words, the delusion is not Paranoia in of others might result in social isolation and necessarily bizarre. The patient may have litigious behavior.8 Alternately, a patient with no evidence or could invent “evidence,” yet delusional disorder this disorder might not present for treat- remain completely resistant to any logical is about something ment until later in life after the loss of sig- argument against his belief system. In many that is not actually nificant supporting factors, such as the death situations, individuals with delusional dis- occurring, but could of parents or loss of steady employment. order function normally in society, until the Examination of these older individuals is delusion becomes severe enough to prompt likely to reveal long-standing suspiciousness clinical attention. and distrust that previously was hidden by family members. For example, a 68-year-old woman might present saying that she can’t Paranoia in schizophrenia trust her daughter, but her recently deceased In patients with schizophrenia with para- spouse would not let her discuss the topic noia, the typical symptoms of disorga- outside of the home. nization and disturbed affect are less The etiology of paranoid personality dis- prominent. The condition develops in order is unknown. Family studies suggest young adulthood, but could start at any a possible a genetic connection to paranoia age. Its course typically is chronic and in schizophrenia.12 Others hypothesize that requires psychiatric treatment; the patient this dysfunction of personality might origi- may require hospital care. nate in early feelings of anxiety and low self- Although patients with delusional disor- esteem, learned from a controlling, cruel, or der and those with schizophrenia both have sadistic parent; the patient then expects oth- delusions, the delusions of the latter typi- ers to reject him (her) as the parent did.13,14 cally are bizarre and unlikely to be possible. Such individuals might develop deep-seated For example, the patient might believe that distrust of others as a defense mechanism. her body has been replaced with the inner Under stress, such as during a medical ill- workings of an alien being or a robot. The ness, patients could develop brief psychoses. paranoid delusions of persons with delu- Antipsychotic treatment might be useful in sional disorder are much more mundane some cases of paranoid personality disorder, and could be plausible. Karl Jaspers, a cli- but should be limited. nician and researcher in the early 20th cen- tury, separated delusional disorder from paranoid schizophrenia by noting that the Delusional disorder former could be “understandable, even if Delusional disorder is a unique form of untrue” while the latter was “not within the Current Psychiatry psychosis. Patients with delusional disor- realm of understandability.”5 Vol. 15, No. 10 31 continued Table Differentiating 3 disorders with paranoia as a key feature Paranoid Pervasive feelings of distrust personality Might lack delusions, but the patient still feels that people are acting maliciously disorder and cannot be trusted Might believe in conspiracy theories or feel that he (she) is the target of ill will. These patients often are litigious and unhappy Paranoia Usually there is no evidence of overt psychosis. Antipsychotics might be helpful if the patient is willing to take them; cognitive-behavioral therapy could be effective in patients with intact insight Delusional Persistent false beliefs of persecution disorder Delusions often are about finances or marital fidelity The beliefs might appear possible, but are not based on fact Hallucinations do not usually occur and the delusions are never bizarre A combination of antipsychotic medication and cognitive therapy might be useful Schizophrenia Patients are quite disturbed; they often have bizarre persecutory delusions that are Clinical Point with paranoid unlikely to be possible features Auditory hallucinations are common Persons with Treatment with antipsychotic medication often is successful, but poor insight dementia often causes compliance issues are paranoid; a delusion of thievery is common A patient with schizophrenia with para- chotic symptoms, such as paranoia,18,19 in a noid delusions usually experiences auditory dose-dependent manner. A growing body hallucinations, such as voices threatening of evidence suggests that a combination of persecution or harm. When predominant, Cannabis use with a genetic predisposition patients could be aroused by these fears and to psychosis may put some individuals at can be dangerous to others.2,4,5 high risk of decompensation.19 Of growing concern is the evidence that synthetic can- nabinoids, which are among the most com- Other presentations of paranoia monly used new psychoactive substances, Paranoia can occur in affective disorders could be associated with psychosis, includ- as well.13 Although the cause is only now ing paranoia.20 being understood, clinicians have put forth theories for many years. A depressed person Dementia. Persons with dementia often are might suffer from excessive guilt and feel paranoid. In geriatric patients with demen- that he deserves to be persecuted, while a tia, a delusion of thievery is common. When manic patient might think she is being perse- a person has misplaced objects and can’t cuted for her greatness. In the past, response remember where, the “default” cognition is to electroconvulsive therapy was used to that someone has taken them. This confabu- distinguish affective paranoia from other lation may progress to a persistent paranoia types.2 and can be draining on caregivers.

Paranoia in organic states Treating paranoia Substance use. Psychostimulants, which A patient with paranoia usually has poor are known for their motor activity and insight and cannot be reasoned with. Such arousal enhancing properties, as well as individuals are quick to incorporate oth- the potential for abuse and other negative ers into their delusional theories and eas- consequences, could lead to acute para- ily develop notions of conspiracy. In acute noid states in susceptible individuals.15-17 In psychosis, when the patient presents with addition, tetrahydrocannabinol, the active fixed beliefs that are not amenable to reality Current Psychiatry 32 October 2016 chemical in Cannabis, can cause acute psy- orientation, and poses a threat to his well- being or that of others, alleviating underly- ing fear and anxiety is the first priority. Swift Related Resources pharmacologic­ measures are required to • Freeman D. Persecutory delusions: a cognitive perspective on understanding and treatment. Lancet Psychiatry. decrease the patient’s underlying anxiety or 2016;3(7):685-692. anger, before you can try to earn his trust. • Skelton M, Khokhar WA, Thacker SP. Treatments for delusional Psychopharmacologic interventions disorder. Cochrane Database Syst Rev. 2015;(5):CD009785. doi: 10.1002/14651858.CD009785.pub2. should be specific to the diagnosis. Antipsychotic­ medications generally will Drug Brand Names help decrease most paranoia, but affec- Divalproex • Depakote Lithium • Eskalith, Lithobid tive syndromes usually require lithium or divalproex for best results.14,21

Develop a therapeutic relationship. The some patients with paranoia can learn to clinician must approach the patient in a take a detached view of their thoughts and practical and straightforward manner, and emotions, and consider them impermanent should not expect a quick therapeutic alli- events of the mind that make their lives dif- ance. Transference and countertransference ficult. Practice good judgment when aiming Clinical Point develop easily in the context of paranoia. for recovery in a patient who does not have The clinician must Focus on behaviors that are problematic for insight. For example, a patient can recognize the patient or the milieu, such as to ensure that although there could be a microchip approach the patient a safe environment. The patient needs to in his brain, he feels better when he takes in a practical and be aware of how he could come across to medication. straightforward others. Clear feedback about behavior, In the case of paranoid personality dis- manner, and should such as “I cannot really listen to you when order, treatment, as with most personality not expect a quick you’re yelling,” may be effective. It might disorders, can be difficult. The patient might be unwise to confront delusional paranoia be unlikely to accept help and could distrust therapeutic alliance in an agitated patient. Honesty and respect caregivers. Cognitive-behavioral therapy must continue in all communications to could be useful, if the patient can be engaged build trust. During assessment of a para- in the therapeutic process. Although it might noid individual, evaluate the level of dan- be difficult to obtain enhanced insight, the gerousness. Ask your patient if he feels like patient could accept logical explanations for acting on his beliefs or harming the people situations that provoke distrust. As long as that are the targets of his paranoia. anxiety and anger can be kept under control, As the patient begins to manage his anxi- the individual might learn the value of adopt- ety and fear, you can develop a therapeu- ing the lessons of therapy. Pharmacological tic alliance. The goals of treatment need be treatments are aimed at reducing the anxi- those of the patient—such as staying out of ety and anger experienced by the paranoid the hospital, or behaving in a manner that individual. Antipsychotics may be useful for is required for employment. Over time, short periods or during a crisis.14,21 work toward growing the patient’s capac- The clinician must remain calm and reas- ity for social interaction and productive suring when approaching an individual with activity. Insight might be elusive; however, paranoia, and not react to the projection of continued on page 50 Bottom Line Paranoia can be a feature of paranoid personality disorder, delusional disorder, or schizophrenia, as well as substance abuse or dementia. Determining whether the paranoid delusion is bizarre or plausible guides diagnosis. Patients with paranoia typically have poor insight and are difficult to engage in treatment. Pharmacotherapy should be specific to the diagnosis. Establishing a consistent Current Psychiatry therapeutic relationship is essential. Vol. 15, No. 10 33 Paranoia continued from page 33 paranoid feelings from the patient. Respect 10. Sen P, Chowdhury AN. Culture, ethnicity and paranoia. Curr Psychiatry Rep. 2006;8(3):174-178. for the patient can be conveyed without 11. Szasz TS. The manufacture of madness: a comparative study agreeing with delusions or bizarre think- of the inquisition and the mental health movement. New York, NY: Harper and Row; 1970. ing. The clinician must keep agreements and 12. Schanda H, Berner P, Gabriel E, et al. The genetics of appointments with the client to prevent the delusional psychosis. Schizophr Bull. 1983;9(4):563-570. 13. Levy B, Tsoy E, Brodt T, et al. Stigma, social anxiety erosion of trust. Paranoid conditions might and illness severity in bipolar disorder: implications for respond slowly to pharmacological treat- treatment. Ann Clin Psychiatry. 2015;27(1):55-64. 14. Benjamin LS. Interpersonal diagnosis and treatment of ment, therefore establishing a consistent personality disorders. New York, NY: Gilford Press; 1993. therapeutic relationship is essential. 15. Busardo FP, Kyriakou C, Cipilloni L, et al. From clinical application to cognitive enhancement. Curr References Neuropharmacol. 2015;13(2):281-295. 1. Frank C. Delirium, consent to treatment, and Shakespeare. A 16. McKetin R, Gardner J, Baker AL, et al. Correlates of transient geriatric experience. 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