THE SCHIZOPHRENIAS AND PARANOID STATES
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other forms of mental illness, notably schizophrenia, manic-depressive disease, Alzheimer disease, Lewy-body disease, toxic or alcoholic psychosis, general paresis, etc This fact about paranoia was known from the beginning, when Heinroth originally described it in 1818 and classi ed it as a limited disorder of the intellect Krafft-Ebing, in his monograph on the subject, took pains to distinguish two syndromes: (1) original paranoia, developing about the time of puberty and attributable to heredity (surely paranoid schizophrenia by present-day criteria), and (2) acquired paranoia, developing in later life, particularly in the involutional period (the condition under discussion) Kraepelin, in agreement with the ideas of Kahlbaum, distinguished between paranoia and dementia praecox but remarked that approximately 40 percent of patients who developed paranoia early in life went on to become schizophrenic The others represented true paranoia or a closely related condition that he called paraphrenia, a term no longer used In DSM-IV, this disorder is classi ed as delusional (paranoid) disorder and de ned as a persistent delusion that is not part of any other mental disorder Furthermore, the delusions are nonbizarre, ie, they involve situations that could occur in real life, such as being followed, poisoned, infected, loved at a distance, deceived by a spouse, or having a disease Figures on the frequency of true paranoia are probably not reliable because they are of necessity based on hospital records Doubtless there are many individuals with mild forms of the disorder who have never crossed the threshold of a mental hospital They are relatively harmless and in their communities are judged to be mildly cracked, or monomaniacs Males and females are about equally affected Among psychiatric hospital patients, true isolated paranoia is rare (01 percent of admissions, according to Winokur)
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It would be dif cult in a neurology text to give an account of all the many ways in which patients with paranoia behave A simple paradigm will suf ce that of a middle-aged man of uneasy, brooding, asocial, eccentric nature who gradually develops a dominating idea or belief of his own importance, of having in his possession special powers that make him the envy of others, who become bent on persecuting him As the delusion grows, he becomes more preoccupied, less ef cient, and increasingly suspicious of others, with a tendency to interpret every one of their words, gestures, or actions as having some reference to himself Only when his behavior becomes noticeably bizarre or when he does something to annoy others does his condition come to medical attention On examining such a person, one is impressed with his capacity for careful reasoning, even betraying good intelligence Whatever the delusional theme erotomanic (a delusion that another person, usually of higher status, is in love with the patient), grandiose, jealous, persecutory, or somatic, the last being the most common the patient s arguments are logical and buttressed cogently by evidence The patients express their false beliefs with certainty and conviction and are totally unaccepting of all arguments that impugn their rationality Also, the views of such patients about matters other than their delusions can be quite sensible As mentioned, the illness usually does not lead to hospitalization, and if admitted to hospital, the patient does not stay long The querulous patients with paranoia are the most annoying They usually remain in the community, ooding the mails with copies of documents accusing people falsely, incessantly writing to news-
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papers, and expressing their worthless opinions about anything and everything As the years pass, the patient changes little, though a few such patients may later break down and begin to hallucinate and nally end in a deteriorated state much like that of schizophrenia This trend supports Bleuler s opinion that the illness is often a variant of schizophrenia Regarding causation, there have been several interesting but unveri able ideas The Freudian school attributed paranoia to repressed homosexuality and xation at the narcissistic level Meyer invoked a long-standing personality disorder, the paranoid constitution He used the term to refer to persons with a lifelong tendency to hold biased views, to be overly concerned about what others think of them, and to attribute deliberate intentions to indifferent actions This behavior seems but an exaggeration of a mild suspiciousness that is part of the personality makeup of many individuals Manschreck presented a detailed discussion of the proposed psychologic mechanisms of paranoia The authors experience with pure paranoia in a general hospital has been rather limited One sees deluded patients, to be sure, but usually their abnormal ideas have centered on self-persecution, health and bodily functions, in delity of a spouse, theft of possessions, and the like The claim that poisoning by carbon monoxide has left the person with ill-de ned defects in concentration and other mental functions or the belief that there exists an unobservable parasitic skin infestation have been the most common delusions in our experience One of our patients, functioning normally in every other way, carried the unshakable idea that people were sneaking into her house at night and when she was away and rearranging the furniture Also, several physicians under our care have woven extensive or more limited delusional ideas around tenuous scienti c theories; these ideas have applied to personal life events as well as physical and psychologic symptoms, and in some cases have resulted in bizarre regimens of self-medication Rarely, a patient comes to the hospital for some other medical reason and it is found that he or she has been living quietly in the community, preoccupied with a bizarre delusional system yet appearing neither depressed nor schizophrenic Certainly one often sees delusions in depressed patients who decompensate as their depression deepens Sharply separated from the more or less pure delusional disorders are the ones that occur as part of a confusional state or delirium Delusions occurring in the latter setting are characteristically bizarre, changeable, poorly systematized, and, with rare exceptions, transitory; they are associated with many other aberrations of mental function The same can be said for delusions that occur in the early stages of a dementing disease Such events are common, of course, in elderly persons with an incipient or wellcompensated dementia ( beclouded dementia, page 363) Rarely, one of the degenerative dementing diseases of middle and late life (Alzheimer, Huntington, and especially Lewy body) presents with a delusional disorder Otherwise healthy persons without known mental illness may experience a brief delusional episode, notably after surgical procedure or the administration of sedative drugs In most, there are no subsequent mental problems but a proportion of these older patients will be found to later develop dementia Certain drugs have a tendency to produce paranoia in otherwise nonpsychotic individuals; phencyclidine, amphetamine, and cocaine are the main offenders seen in patients arriving in emergency departments, and anticholinergic drugs are often responsible in hospitalized patients These organic delusions have been discussed by Cummings
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