Evaluating Rational Fears and Bizarre Delusions in Paranoia Paranoid Delusions Can Reveal a Number of Psychiatric Disorders; Building Trust Is Key to Treatment
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‘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