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DEFINITION Paranoid states involve distorted attitudes and beliefs, often concerning persecution. For practical purposes, the important distinction is whether the beliefs are delusions or overvalued ideas (for the difference, please see Glossary).
PREDISPOSING FACTORS
- Paranoid personality characteristics: paranoid personalities are abnormally sensitive, conscious of their own rights, tend to see other peopleís behaviour as hostile, and are prone to develop ideas of reference. Overvalued ideas have often been present throughout adult life and influenced choice of lifestyle, for example living alone with minimal social contacts. The personality disorder may not present medically, but would colour the presentation of a superimposed mental illness, for example a paranoid person who became depressed might lack trust towards doctors or suspect that medication was poisonous.
- Deafness, and other forms of sensory deprivation.
- Social isolation.
- Cultural isolation, for example due to migration.
DIFFERENTIAL DIAGNOSIS OF PARANOID STATES Paranoid symptoms are found in many of the common psychiatric conditions described elsewhere in this book, including: - schizophrenia
- affective disorders (depressive illness and mania)
- drug and alcohol misuse
- dementia
The following list describes some other syndromes in which paranoid symptoms are a primary feature. - Persistent delusional disorder (older terms include paranoid psychosis, paraphrenia, paranoia): delusions are present, but in contrast to paranoid schizophrenia there are usually no hallucinations, the rest of the personality is preserved, and onset is in later life. The majority of patients have a paranoid premorbid personality, and interviews with informants may be essential to sort out whether the symptoms are new (an illness has developed), or whether they have always been present (personality) and have come to light for other reasons.
- Acute paranoid reaction: a transient condition provoked by stress.
- Induced delusional disorder (folie ‡ deux): a rare condition in which the same persecutory delusions are shared by two people, or sometimes several people, who live in close contact and are often genetically related. The ěprincipalî who initiates the delusions suffers from schizophrenia or other mental illness. The ěassociateî who copies the delusions often has a dependent personality and low intelligence, and usually gives up the delusions if separated from the principal.
- Morbid jealousy (pathological jealousy, Othello syndrome): patients, usually men, are deluded that their sexual partners are unfaithful. Morbid jealousy is often part of another syndrome: paranoid schizophrenia, depressive illness, organic brain syndrome, or alcoholism. Many patients have sexual dysfunction and/or poor personality adjustment. A small percentage may show homicidal behaviour, and lesser degrees of violence are even more common, so morbid jealousy is an important condition despite being rare. A formal risk assessment must be made in such cases, and an appropriate care plan put in place. Referral to forensic psychiatric services may have to be considered. Antipsychotic drugs may be effective. Separation from the partner may have to be advised depending on the risks as evaluated.
MANAGEMENT Establishing a trusting relationship with the patient, though not always easy, is of prime importance in the treatment of paranoid states. Objective information about the social setting and cultural background must be sought. Some ěparanoid delusionsî are based on genuine persecution, and some ěreligious delusionsî could be viewed as spiritual experiences rather than a manifestation of mental illness. A psychotherapeutic approach is often suitable for milder cases, but if delusions are present, an antipsychotic drug is indicated: small doses of the strongest antipsychotic drugs such as haloperidol are probably the treatment of choice. Some patients are reluctant to take medication because they suspect it is poisoned, or insist they are not ill. Compulsory detention and treatment under the Mental Health Act 1983 may be necessary if there is disturbed or violent behaviour, or a risk thereof.
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