Paranoia

PARANOIA, paranoia (from Greek para-besides and nous-mind), a term introduced by Kahlbaum in 1863 instead of the previous designation 'insanity' for mental disorders with predominant disturbances of rational activity. The very origin of the term P. dates back to the early 19th century, to the time of Vogel and Heinroth, but at that time it had a different meaning. According to the teaching of Griesinger in the mid-19th century, which recognized a single mental illness, P. was for some time considered as a stage of this single psychosis, following the stage of disturbance of the affective sphere. In the late 1860s, thanks to the works of Snell, Sander, and especially Westphal, P. received the status of an independent disease. In 1887, Griesinger changed his view of P., designating by this name such pathological 4.Н0ЙЯ

states, in which 'both main types of primordial delusion develop very slowly one next to the other and where, continuing for many years, contradictory delusional ideas of grandeur and persecution manage to gradually merge, mutually penetrate each other and fuse into firm connections, into the so-called system of delusional ideas'. In this definition, a concept close to modern views is already given. The concept of P. is later expanded and becomes extremely vague and chaotic. This vagueness reaches its climax with Cramer, who brings P. closer to confusion and insanity as psychoses of reason, in which affects play only a secondary role. Subsequently, in German psychiatry, the concept of P. is limited. With the isolation of large nosological units - manic-depressive psychosis and early dementia - the name 'paranoia', especially in German-speaking countries, remained only for cases of systematic delusion in individuals with preserved personality. The presence or absence of hallucinations only determined the form of P. (hallucinatory and combinatory forms). The different course of the disease in various cases of P. during this period, the disintegration of personality in a certain number of cases, and the frequent presence of abundant hallucinations in these cases forced Kraepelin to reconsider the question of P. He, by isolating a new form, paraphrenia, further narrows the boundaries of P., which he characterizes as follows: 'The matter concerns a gradual development, caused by internal reasons, of a chronic irrefutable delusional system, which is accompanied by the complete preservation of clarity and orderliness of thinking, will, and actions'. One type of P., which until then was considered classical, namely, querulant or litigious delusion (see Querulants) - by this time Kraepelin isolates it as a separate form and attributes it to the group of psychogenic diseases (this view on litigious delusion was however far from shared by all psychiatrists). Thus, P. is already considered as a functional psychosis; in its further development, P. approaches to some degree the group of psychopathy. Already Bleuler expresses the cautious assumption that P. may be nothing other than a pathological reaction of a psychopath to unfavorable circumstances. According to Jaspers, the paranoiac syndrome has its source in the development of a personality that is in interaction with the environment and reacts in a characteristic way to experiences. Subsequently, the concept of P. as a reactive disease in a psychopath is particularly emphasized by Kretschmer. According to Kretschmer, there are paranoiacs, but no P. Character, experience, and environment create a paranoiac. Psychopathic reactions and development that show systematic combinatory delusion should be called paranoiac. The main difference between the doctrine of Kraepelin and the viewpoint of Kretschmer, who considers his views a further development of Kraepelin's doctrine, lies, as Kretschmer himself notes, in the significance of experience, in the significance of reaction for the development of P. The evolution of the concept of P. is extremely characteristic for all psychiatry: previously applied to cases close to paraphrenia, delirious states, certain forms of confusion, certain cases of manic-depressive psychosis; the concept of P. is now limited only to cases of systematic combinatory delusion occurring in predisposed individuals. However, even today some psychiatrists (for example Krueger) include cases of hallucinatory delusion within the framework of P. Thus, the boundaries of P. fluctuate between diseases with a character of process and reactions of psychopaths to severe experiences. Another direction was taken in the study of P. in France. While the doctrine of P. developed in Germany to a large extent in the sense of establishing the concept and boundaries of P., the French were occupied with describing various delusional syndromes. Falret in 1872 gives a description of systematic persecution delusion, to which ideas of grandeur are added and which ends in dementia. The doctrine of chronic delusion by Magnan deserves great attention. He distinguished delusional forms developing in non-predisposed individuals from the delusion of degenerates. He attributed the first type to chronic delusion with systematic development, a disease apparently almost completely coinciding with one of Kraepelin's forms of paraphrenia, and the second type, among others, to litigious delusion. The doctrines of Falret and Magnan represented a new stage in the doctrine of delusional insanity. They introduced the concept of systematic persecution and grandeur delusion. The next stage in the development of P. was represented by the works of Sérieux and Capgras, who drew attention to a special form of systematic persecution and grandeur delusion, in which incorrect explanations, interpretations are present, while hallucinations are not observed at all. The delusional psychosis isolated by these authors sharply differs from hallucinatory psychosis. Thus, French psychiatry arrived by other paths at the same views that we see in German psychiatrists, and the boundaries of P. of modern French psychiatrists coincide with the boundaries established by German authors of the Kraepelin school. The etiology and pathogenesis of P. to some extent follow from what has been said above about the boundaries of this disease. Heredity in P. has been far from sufficiently studied. The data of Economo, Kehrer and mainly Lange indicate that in families where P. is observed, other members of the family (parents, and especially brothers and sisters) have mental diseases and psychological anomalies. Among these, various psychopathies, various delusional states, and, according to some, schizophrenia deserve attention. There is no disagreement regarding predisposition to P. within the outlined boundaries. The question of 'paranoiac character', paranoiac constitution, paranoiac thinking, paranoiac predisposition has been frequently discussed in psychiatric literature. Recently, authors tend to the view that one should not speak of a paranoiac constitution or character, but of paranoiac characters. They point to the irritability, excitability of paranoiacs, their inconstancy, willfulness, distrust, ambition, dishonesty. Attention is drawn to pride, vanity, hypertrophy of the 'self', self-love, touchiness, etc. Kraepelin especially emphasizes the heightened consciousness of one's own dignity, noted even in cases where there is constant dissatisfaction with oneself. According to Bleuler, predisposition to P. lies in the disproportion between stable affectivity and too weak resistance of logical functions, in the conflict between ambitious plans and incapacity or the feeling of incapacity in their realization. Kretschmer identified two psychopathic predispositions (characters), on the basis of which, in the presence of corresponding experience and under certain environmental conditions, paranoiac delusion formation develops. In the structure of an abnormal character with predominance of sthenic traits, an asthenic 'spark' is noted. Under certain circumstances, such a paranoiac loses confidence and the feeling of strength, and features of vulnerability, increased sensitivity come to the fore. In the structure of an abnormal character with predominance of traits of impressionability, tendency to prolonged processing of external impressions, a sthenic 'spark' is noted, in which along with softness, weakness, vulnerability, features of consciousness of one's own dignity, a certain ambition and even willfulness and stubbornness are revealed. This sthenic 'spark' predisposes to the activation of delusional concepts. Kraepelin emphasizes the infantility of paranoiacs with their fantastic dreams of unattainable ideals and egocentric thinking. There are quite numerous indications of peculiarities in the sexual constitution of paranoiacs. In them, homosexual tendencies, frigidity, hypererotism, sexual weakness, lack of desire for offspring were noted. As mentioned above, recently many authors include within the framework of P. those cases of systematic delusion in which the latter is closely connected with some specific affectively vividly colored experience. Bleuler tends to believe that the starting point of any paranoiac delusion are affectively colored complexes. We speak of experience when we deal with states of an acute nature of mental shock. With prolonged influences of the environment, we already speak of the situation. It is quite obvious that the experience itself is in the closest connection with the peculiarities of personality and cannot be separated from it. An old maid's love is a pathogenic factor only if she has to some extent a sensitive character; a lost lawsuit without basis will also cause litigious delusion only in an expansive psychopath. It goes without saying that the experience of the individual is not only connected with the environment but is also a function of it. Here is where the law of 'division of the one' (personality-environment) is revealed. The importance of the environment in the pathogenesis of P. has been pointed out for a long time. All the content of paranoiac delusion is based on the conflictual relationship between personality and environment.

The desire to gain power and strength, to defend one's rights against others, to assert one's rights to the object of one's love, and the fear of being wronged—such is the pathogenic soil for paranoia. Kerer notes that Robinson Crusoe could not have contracted P. While noting the importance of the environment in the development of P., Western psychiatrists do not point out that all conflicts between the individual and society are typical of class society, of individualistic conditions of labor and daily life. In socialist society, with the new quality of relations between the individual and society, these conflicts are resolved. Speaking of the pathogenesis of P., one cannot fail to mention the views of Bleuler and Kahn (Kahn), that paranoid delirium develops on the soil of schizophrenia in a mild form, as well as the views of Specht and Ewald (Ewald), that all P. dissolves into the manic-depressive psychosis, mainly into its mixed state. No patho-anatomical changes are observed in P. within the limits currently established for it. However, it should be noted that some authors attempt to precisely localize this disease. Among them is Kleist (Kleist). Among Russian psychiatrists, Ostanov considers P. as a result of damage to the frontal lobes. Course and symptomatology. The syndrome of P. represents a systematic delirium, developed into a coherent sequential system and most closely connected with the personality of the patient. All the interests of the patient are concentrated on this delusional system. It often spreads, involving new elements from the surroundings. The delirium is revealed in the form of ever-expanding interpretations of both real facts and false memories, often illusions. True hallucinations do not play a major role in P., although they may sometimes occur, especially in connection with great emotional strains; clarity and orderliness of thinking do not leave the patient, except in some emotionally colored states. The beginning of the delirium is difficult to establish. It creeps in gradually, but to the patient himself it always seems that they were suddenly 'enlightened'. Sometimes they speak of a dream or a vision, during which they 'saw through', they 'understood' and so on. More and more of the surroundings is covered by the delirium. Patients usually willingly share their delirium. Many years after the onset of the illness, the emotional coloring of the delirium becomes somewhat duller, but never disappears completely. In these cases, the impression of a residual delirium is obtained. Intelligence in the narrow sense is not impaired in P. Lack of flexibility of thinking and incorrectness of judgment are noted only within the delusional system. Mood is most closely connected with the experiences of the delirium. It should be noted that some paranoids always exhibit elevated mood, sometimes ignoring serious life troubles, which makes them resemble manic patients. Other paranoids are more focused and withdrawn. In the closest connection with the content of the delirium, we also see among paranoids irritable, embittered people. The core of paranoids consists of those in whom the delirium continues throughout life, and most authors only include this group in P. In the so-called mild forms of Friedman (Friedman) and abortive forms of Gaupp (Gaupp), the delirium fades, usually without clear criticism of the delusional state experienced. Regarding acute P. (paranoia acuta), the question of which has been almost completely removed from discussion in the last 20-25 years, since gradual onset and chronic course were considered typical for P., the following must be said. The cases described under this name begin acutely, exhibit delirium, very often connected with hallucinations, and end either in recovery or in dementia. Among Russian authors, Gannushkin studied these cases. The study of these cases forces one to attribute them either to infectious psychoses, or to delusional outbreaks in psychopaths, or to manic-depressive psychosis, or finally to episodes in schizophrenia. The so-called hallucinatory P. (paranoia hallucinatoria), if by it is meant a delusional illness with systematic abundant hallucinations, observed outside of emotional outbreaks, where the hallucinations are reflected in the content of the delirium, and in some cases may even cause it, differs from P. in its delusional mechanisms and outcome and is by the vast majority of authors attributed to schizophrenia or paraphrenia. Zander called the cases of delirium whose onset must be attributed to childhood paranoia originaria (paranoia originaria). However, the existence of this form is not confirmed by other authors. Apparently, the matter here concerns the false memories of the patients themselves, who attribute their 'enlightenment' to the period of childhood. The grouping of paranoid pictures presents difficulty in the sense that there are essentially as many forms of P. as there are paranoids. Nevertheless, one can divide them in relation to the nature of the delirium into P. with delirium of grandeur and P. with delirium of persecution. Very often in the same case, ideas of grandeur are observed alongside ideas of persecution. The patient for example considers himself persecuted, but at the same time as that significant—high-ranking or highly gifted—person whom out of revenge, out of envy, for selfish purposes persecutors persecute. According to content, forms of P. with delirium of persecution (the most common form), with delirium of jealousy, with delirium of invention, with delirium of high origin ('interpretateurs filiaux' of the French), with delirium of religious reformism (Prophetenwahn of the Germans), with erotic delirium are distinguished. The hypochondriacal P. of former authors apparently should be attributed to other nosological units. The group of querulants, as was said above, has been separated by Kraepelin into a separate form of mental disorder (see Querulants). The so-called persecuted persecutors (persecuteurs persecutes of the French), i.e., patients who consider themselves persecuted and are aggressive towards their imaginary persecutors, belong partly to querulants, partly to paranoids with delirium of persecution. The content of the delirium of each of the described groups follows from the name itself (see Delirium). The development of the most common system of delirium of persecution usually proceeds as follows. Patients begin to note that their attitude towards them has changed, that they are being ignored or mistreated. When meeting them, people whisper, point at them with their finger, stick their tongue out at them, avoid them, cough meaningfully. In their food they notice something suspicious. In their room they notice disorder upon returning home, indicating that someone was making themselves at home in their absence, etc. They become convinced that a certain group of people is persecuting them, plotting against them, wishing them death. The surroundings then become involuntary instruments of these plots or are drawn into this persecution by tricks. Life becomes unbearable. Patients can hardly distract themselves from their thoughts. At a certain stage of development, the delirium becomes stable, developing and being supplemented only in details. The development of other forms of delirium is more or less similar. Kretschmer groups P. according to the form in which the paranoid attitude is lived out in the surrounding world. He distinguishes three groups: paranoids-fighters, paranoids with delirium of fulfilled desires, and sensitive paranoids. The first are querulants, persecuted (persecuted persecutors), jealous persons; the second exhibit delirium of grandeur; the third are the aforementioned sensitive delirium. According to course and partly pathogenesis, Kerer notes among paranoid states the following forms: 1) paranoid habitual attitude (paranoid psychopaths or constitutions), 2) chronic non-progressive P., 3) paranoid reactions, situational psychoses and phases, 4) chronic paranoid developments. Thus all forms of combinatorial delirium from the so-called paranoid thinking, i.e., habitual attitudes of being wronged by others or overestimation of one's own personality, to classical P. are covered. - In view of the fact that a paranoid sometimes does not come into the hands of a psychiatrist during his entire life or comes many years after the onset of the illness, the question of the frequency of P. is difficult to clarify. According to some statistical data, cases of P. constitute about 1/2% among hospitalized mental patients. Men get sick more often (about 70% of all cases) than women, especially with delirium of invention and religious reformism. The age at which the classical form of P. begins varies between 30-40 years, although there are cases of earlier and later onset. The diagnosis of P. does not present great difficulties if its boundaries are precisely established. It must be differentiated from a whole series of delusional states, which are sometimes called paranoid states. From paranoid schizophrenia (paranoid dementia), P. is distinguished by its systematic nature, interpretive character, thoughtfulness, stability, good emotional coloring of the delirium, the negligible role of hallucinations in the unfolding of its picture, and the orderliness of thinking. However, it cannot be noted that some initial stages of paranoid schizophrenia with delirium of persecution, in the absence of emotional dullness, can very easily be confused with P.

Such confusion is all the more possible because in these initial stages of schizophrenia there is also a tendency toward interpretation, although mainly the delusion exists for patients as something that does not require explanation. The natural transition from a healthy state to illness without noticeable shifts in the patient's personality, the naturalness of behavior that completely harmonizes with the nature of the experience, together with the already mentioned differential diagnostic signs, speak for Paranoia. It is more difficult to distinguish it from paraphrenia as an indistinctly outlined form, especially at the beginning of the illness. But the minimal significance of hallucinations, greater consciousness of self-worth, better social adaptation, greater caution in expressing one's delusion and in actions undertaken in connection with one's delusion, the long-term uniformity of the picture distinguish the paranoid from the paraphrenic even in the early stages of the illness. Mild, abortive, and reactive forms of Paranoia must be differentiated from delusional outbursts in psychopaths (bouffees delirantes, delire d'emblee of the French), delusional psychoses in degenerates (Birnbaum), since the latter arise only as reactions to severe experiences, in them systematic delusional interpretation is not observed, and their pictures are more varied. Sometimes the differential diagnosis with manic-depressive psychosis can also present difficulty, especially if one takes into account the elevated mood of some paranoids and the delusional nature of some manic phases. The absence of interpretation, some lack of seriousness in the delusion, occasionally breaking through manic symptoms in connection with the phasic nature of the illness, lesser social adaptation speak for a manic state. The delusion of depressive states is easily distinguished from paranoiac by the presence of the main depressive background in the clinical picture. Paranoia must also be differentiated from one of the forms of involutional psychosis, namely from involutional paranoia of Kleist (Kleist), from which it differs (see Involutional Psychoses) by an earlier onset, greater systematicity of the delusion, and the presence of hypertrophy of self-worth. The delusion of jealousy in Paranoia must be differentiated from alcoholic delusion of jealousy. In Paranoia there is not that absurd form of proof that we encounter in the latter. Furthermore, the paranoiac delusion develops more gradually. The absence of severe alcoholism in the anamnesis also speaks for Paranoia. It is almost impossible to confuse Paranoia with syphilitic delusion (syphilitic paranoid): the latter does not have a strictly interpretive character and is usually closely connected with hallucinations. The same applies to the paranoid-hallucinatory syndrome, in alcoholism-alcoholic paranoia. Neurological and serological data, absent in Paranoia, help in recognition in rare difficult cases. The prognosis of classical Paranoia is considered poor. The delusion usually remains persistent until the end of life, although its intensity often decreases with the years. With the fading of the delusion, the social adaptability of paranoids improves. The so-called mild forms of paranoiac delusion smooth out, recovery occurs with or without criticism in relation to the delusion. Reactively developing paranoiac delusion gives a better prognosis, but not in all cases. In a forensic psychiatric respect, it should be noted that the possibility of crime in paranoids up to murder must be mentioned, especially on the basis of persecution? among persecuted persecutors. As a persecuted person, a paranoid may take revenge on his persecutor, may try to free himself from him. On this basis, all kinds of unpleasantness as well as the deprivation of life of the persecutor are possible. Similarly, patients with delusion of jealousy, unrecognized inventors, etc., act. As a social reformer or prophet, a paranoid commits crimes not with an egoistic, but with an altruistic purpose. It is necessary to destroy the enemies of God, the enemies of the people, who are hindering the introduction of a beneficial reform. Crimes? against property are not frequent in paranoids, but are possible with some idealistic purpose, e.g., for returning property to the victim, etc. In defending their¹ rights, fighting with persecutors, a paranoid: may violate public peace and order and thus come into conflict with the law. Suicides in Paranoia are also possible. There is no drug treatment other than sedatives during agitation. Patients with classical Paranoia do not respond to psychotherapy. In milder forms in paranoiac reactions, some influence of mental, resp. social, methods of treatment may have. The social prevention of Paranoia above all is a radical" change in the structure of society and the closely related reorganization of upbringing. This eliminates the basis for conflicts that find reflection in paranoiac delusion. A society based on exploitation and slave labor breeds paranoids, promoting their identification through the class conflicts that lie at the heart of its nature. Only a decisive struggle with the exploiting classes will create true prevention also in relation to the mentioned disease. In individual cases, especially in the presence of psychopathic predisposition, special importance is attached to instilling correct social orientations, communicated in the period preceding the delusion.

P. Golant..