[Paranoia and persecution]. / Paranoia et persécution.

The idea of paranoia has existed since Antiquity, but it was only in the 19th centurythat psychiatrists became interested in it and sought to describe it. Delusion and the feeling of persecution are common in all paranoiacs. The origins of the disease can be found in the patient's psychic structure. Establishing and maintaining contact with a caregiver is one way of helping the patient.

Understanding attributional biases, emotions and self-esteem in 'poor me' paranoia: findings from an early psychosis sample.

OBJECTIVES: Trower and Chadwick's (1995) theory of two types of paranoia ('poor me' and 'bad me') provides a framework for understanding the seemingly contradictory evidence on persecutory delusions. Paranoia has been argued to defend against low self-esteem, but people with persecutory delusions report high levels of emotional distress and, in some instances, low self-worth. The current study investigates attributions and emotions in a sample of people with early psychosis who have persecutory delusions. 'Poor me' paranoia has been found to be more frequent than 'bad me' paranoia in the early stages of psychosis. Anger and a tendency to blame other people are hypothesized to characterize 'poor me' paranoia. DESIGN AND METHODS: The study had a cross-sectional design. Twenty individuals with early psychosis, 21 clinical controls with depression and 32 healthy volunteers completed a thorough assessment of emotions and attributions. RESULTS: The 'poor me' paranoia group showed higher levels of anger, anxiety and depression than the non-clinical control group. Self-esteem and guilt were however preserved. A tendency to blame others but not themselves was characteristic of the 'poor me' paranoia group whereas people in the clinical control group tended to self-blame for failures. Anger, but not self-esteem, was associated with an attributional bias characterized by blaming other people instead of oneself. CONCLUSIONS: In conclusion, anger, a previously overlooked emotion in the study of persecutory delusions, warrants further attention. The other-directed nature of this emotion highlights the potential role of interpersonal schemas in understanding paranoia.

The Genealogy of Dementia Praecox I: Signs and Symptoms of Delusional Psychoses From 1880 to 1900.

We can trace, with high congruence, the clinical syndromes of depression and mania as described over the 20th century in psychiatric textbooks back to 1880 and to the earliest writing of Kraepelin published in 1883. However, this is not the case for Kraepelin's 2 delusional syndromes central to his overall nosology: Dementia Paranoides (later paranoid schizophrenia) and Paranoia. A detailed examination of 28 textbook descriptions of delusional psychoses from 1880 to 1900 reveals a diverse and partially overlapping set of syndromes with an admixture of symptoms and signs that would later be considered indicative of Dementia Paranoides and Paranoia. A similar pattern in seen in Kraepelin's own description of "Primäre Verrücktheit" from the first edition of his textbook (1883). No clear prototypes emerged in these textbooks or in Kraepelin's early writings for the 2 distinct delusional syndromes that would later evolve in his mature writings. Rather, the nosologic approach taken in these writings was symptom based and assumed that a viable diagnostic category could be constituted by including all delusional patients once those suffering from organic or mood disorders were excluded. While Kraepelin used the historical syndromes of mania and depression, with no appreciable change, as building blocks for his category of manic-depressive insanity, his nosologic system for the psychotic disorders-the syndromes of Dementia Praecox and Paranoia-was more innovative and without clear precedent in the prior psychiatric literature.

Refining the borderline personality disorder phenotype through finite mixture modeling: implications for classification.

Borderline personality disorder (BPD) is characterized by considerable heterogeneity. Prior approaches to resolving heterogeneity in BPD pathology have used factor and cluster analytic as well as latent class analysis strategies. These prior studies have been atheoretical in nature, but provide an initial empirical corpus for further sub-typing efforts in BPD. A model-based taxonomy for BPD that is supported by evidence from an advanced statistical methodology would enhance investigations of BPD etiology, pathophysiology, and treatment. This study applied finite mixture modeling analysis, in a model-guided fashion, to selected dimensions of pathology within a group of well-characterized BPD patients to determine if latent groups are harbored within the disorder. Subjects with BPD (N = 90) were examined on a variety of model-relevant psychopathology dimensions. We applied finite mixture modeling to these dimensions. We then evaluated the validity of the obtained solution by reference to a variety of external measures not included in the initial mixture modeling. Three phenotypically distinct groups reside within the overall BPD category. Group-1 is characterized by low levels of antisocial, paranoid, and aggressive features. Group-2 is characterized by elevated paranoid features, whereas Group-3 is characterized by elevated antisocial and aggressive features. External correlates reveal a pattern of differences consistent with the validity of this proposed grouping structure. A theory-guided finite mixture modeling analysis supports a parsing of the BPD category into three subgroups. This proposed BPD taxonomy represents an approach to reducing heterogeneity observed among BPD patients and it may prove useful in studies seeking to understand etiologic and pathophysiologic factors as well as treatment response in BPD.

De Clérambault Syndrome, Othello Syndrome, Folie à Deux and Variants.

Non-bizarre delusion, defined as a false belief possible although highly unlikely, is the main manifestation of delusional disorders, previously known as paranoia. Based on the predominant delusional themes, 5 main subtypes may be described - erotomanic, grandiose, jealous, persecutory, and somatic. We present here 2 main delusional disorders, the De Clérambault syndrome and the Othello syndrome, and another closely related to the previous ones - Folie à deux. In the De Clérambault syndrome, the main delusional theme is erotomanic type, related to passional delirium where the patient has strong sexual feelings towards another person and has the belief that this other person is deeply in love with him or her. Patients with the Othello syndrome present a delusional disorder of jealous type, a pathological delusion that the partner is unfaithful. In Folie à deux, 2 individuals shared the same psychiatric symptom. However it may be variable, describing variants such as folie imposée or folie simultenée. The risk of aggressive behavior exists in these patients. Knowledge of these syndromes is essential to allow an accurate diagnosis and prompt treatment.

Do paranoid delusions exist on a continuum with subclinical paranoia? A multi-method taxometric study.

BACKGROUND: There is widespread interest in whether psychosis exists on a continuum with healthy functioning. Previous research has implied that paranoia, a common symptom of psychosis, exists on a continuum but this has not been investigated using samples including both patients and non-patients and up-to-date taxometric methods. AIM: To assess the latent structure of paranoia in a diverse sample using taxometric methods. METHOD: We obtained data from 2836 participants, including the general population as well as at-risk mental state and psychotic patients using the P-scale of the Paranoia and Deservedness Scale. Data were analysed using three taxometric procedures, MAMBAC, MAXEIG and L-MODE (Ruscio, 2016), and two sets of paranoia indicators (subscales and selected items from the P scale), including and excluding the patient groups. RESULTS: Eleven of the twelve analyses supported a dimensional model. Using the full sample and subscales as indicators, the MAMBAC analysis was ambiguous. Overall, the findings converged on a dimensional latent structure. CONCLUSIONS: A dimensional latent structure of paranoia implies that the processes involved in sub-clinical paranoia may be similar to those in clinical paranoia.

Genotype-phenotype studies in bipolar disorder showing association between the DAOA/G30 locus and persecutory delusions: a first step toward a molecular genetic classification of psychiatric phenotypes.

OBJECTIVE: The authors previously reported an association between the D-amino acid oxidase activator (DAOA)/G30 locus and both schizophrenia and bipolar affective disorder. Given the presumed role of DAOA/G30 in the neurochemistry of psychosis and its localization in a schizophrenia and bipolar affective disorder linkage region (13q34), it was hypothesized that the bipolar affective disorder finding would be mainly due to an association with psychotic features. METHOD: The marker/haplotype associations obtained in a subset of 173 bipolar affective disorder patients with psychotic features were similar to those in the overall patient group, suggesting that stratification on the basis of psychotic features in general might be too crude a procedure. The authors therefore tested whether confining caseness to specific psychotic features would improve detection of genotype-phenotype correlations. RESULTS: In a logistic regression, "persecutory delusions" were found to be the only significant explanatory variable for the DAOA/G30 risk genotype among 21 OPCRIT symptoms of psychosis. The authors therefore tested for association between DAOA/G30 and bipolar affective disorder in the 90 cases with a history of persecutory delusions. Whereas this subset showed strong association (odds ratio=1.83 for the best marker), the remaining larger sample of 165 patients with no such history did not differ from comparison subjects, suggesting that the association between DAOA/G30 and bipolar affective disorder is due to persecutory delusions. This was confirmed in an independent study of 294 bipolar affective disorder patients and 311 comparison subjects from Poland, in which an association between bipolar affective disorder and DAOA/G30 was only seen when case definition was restricted to cases with persecutory delusions. CONCLUSIONS: These data suggest that bipolar affective disorder with persecutory delusions constitutes a distinct subgroup of bipolar affective disorder that overlaps with schizophrenia.

The spectrum concept of schizophrenia. Problems for diagnostic practice.

The spectrum concept of schizophrenia posits that a number of psychopathologic states, both psychotic and nonpsychotic, may share some genetic basis with schizophrenia, and may therefore constitute, together with schizophrenia itself, a genetic spectrum of schizophrenic disorders. While this is a valuable and promising research concept, its application to diagnostic practice could broaden the boundaries of schizophrenia to include patients with other conditions, thus rendering a larger population at risk for the untoward effects of the schizophrenia disgnosis itself. This may have already occurred in the Soviet Union, where a diagnostic system derived from a variant of the spectrum concept is used in routine diagnostic practice. The adoption of a spectrum-based diagnostic system should await further research on the boundaries of the spectrum, and more detailed descriptions of confirmed spectrum states.

Erotomania revisited: from Kraepelin to DSM-III-R.

Erotomania, the persistent delusion of being loved from afar by another person, has defied easy categorization for years. Kraepelin and de Clérambault both discussed the syndrome in detail, but it has recently appeared officially for the first time, in DSM-III-R, as a subtype of delusional (paranoid) disorder, in a return to the original Kraepelinian formulation. The author reviews the history, theories of etiology, course, and treatment of erotomania. He concludes that the DSM-III-R classification is correct and that neuroleptics and enforced separation, although only moderately effective, are the best treatments for troublesome cases.

Diagnosis and clinical course of erotomanic and other delusional patients.

Twenty-eight patients with erotomanic delusions were compared with 80 patients with other delusions to clarify questions about diagnosis and course of illness in erotomania. The erotomanic patients were a heterogeneous group with respect to both diagnosis and course. They had significantly more manic symptoms than the comparison group and more affective diagnoses than would be expected from the literature; 25% (N = 7) had schizoaffective disorder and 7% (N = 2) had bipolar disorder. A subgroup of monodelusional erotomanic patients was identified who met the DSM-III-R criteria for delusional disorder, thus supporting the decision to include erotomanic delusions in this diagnostic category in the revision of DSM-III.

General hospitals and the severely mentally ill: changing patterns of diagnosis.

OBJECTIVE: The author's goal is to determine whether there has been a recent change in the number and proportion of severely ill psychiatric patients treated in general hospitals. METHOD: He analyzed the discharge data from the National Hospital Discharge Survey for the years between 1970 and 1987, focusing particularly on the discharges of patients with psychiatric versus nonpsychiatric diagnoses. The number and proportion of discharges of patients with psychiatric diagnoses in four major diagnostic groups (depression, bipolar spectrum disorders, schizophrenia, and other psychoses) were determined. RESULTS: Between 1970 and 1987, discharges of patients with psychiatric diagnoses from general hospitals increased by a factor of 0.8. The percentage of discharges of patients with the diagnoses of depression (18.0%-22.7%), schizophrenia (9.4%-13.6%), and paranoid or other nonorganic psychoses (3.1%-4.0%) remained relatively constant. The percentage of discharges of patients with the diagnosis of nondepressed bipolar disorder increased from 0.6% in 1970 to 3.2% in 1987. CONCLUSIONS: Although there has been a recent absolute increase in the number of general hospital patients with severe psychiatric diagnoses, the increase has been tempered by a concomitant increase in the number of patients with nonsevere diagnoses. Changes in classification systems (DSM-II or ICDA-8 to DSM-III or ICD-9-CM) and questions regarding the rigor with which the nosologic changes have been incorporated into practice complicate the interpretation of these findings.

Obsessive-compulsive disorder with psychotic features: a phenomenologic analysis.

The authors review the literature on obsessive-compulsive disorder and present clinical vignettes to illustrate that delusions can arise in the course of this illness. These delusions do not signify a schizophrenic diagnosis but represent reactive affective or paranoid psychoses, which are generally transient. Using a phenomenologic analysis of 23 patients, the authors further argue that obsessive-compulsive disorder represents a psychopathological spectrum varying along a continuum of insight. Patients at the severe end of this spectrum are best described as having an "obsessive-compulsive psychosis." The authors discuss the implications of these considerations for DSM-III revisions.

The origin of the concept of paranoia.

The concept of paranoia has developed virtually simultaneously in Germany and France at the beginning of the nineteenth century. Originally, the idea of a disease of only a part of the soul was in the foreground of discussions. At the era of positivism and the belief of psychiatric illnesses purely as consequences of organic disorders, the concept changed to psychopathologic findings. Now delusions and particularly their systematic character were emphasized. Moreover, the absent impairment of "mental life in its entirety" was given prominence. At the beginning of the twentieth century, the arising concept of schizophrenia thrusts the discussion of paranoia into the background. It was not possible to find out which parts of paranoia were absorbed by dementia praecox. Finally, the development of modern diagnostic manuals revived the old clinical picture mainly because of its clinical evidence and the distinction from schizophrenia.

Paranoids in the legal system. The litigious paranoid and the paranoid criminal.

Paranoid symptomatology involving suspicions, a sense of being wronged and persecuted, along with an implacable will to retaliate against one's enemies, often translates into litigious struggles. Paranoids resort to the judicial arena to act out their own internal psychopathologic needs. Examples are offered of the many ways litigious paranoids may present within the legal system, as well as how interventions by the psychiatrist may be useful. Criminal behavior by paranoids, under the sway of full-blown delusions of various types, is discussed and analyzed. Historical cases are described (Hadfield, M'Naghten), and more contemporary cases are discussed according to diagnostic subtypes. The central importance of paranoid delusions in insanity defense cases and the exculpatory effect of various delusional subtypes are examined.

[Difficulties in the classification of paranoid disorders]. / Trudnosci klasyfikacyjne zaburzen paranoidalnych.

This paper discusses the complexities of symptomatological psychotic disorders with particular emphasis on the paranoia and arising difficulties in their classification. The essential problems are: 1) their rich and varied psychopathology, 2) the unclear and spurious systems of classification, 3) the superficial definition of psychopathic syndromes and their diagnozed groupings. The diagnostic criteria of paranoid disorders in the International Classification of Diseases, Traumas and Cause of Deaths: ICD-9 and ICD-10 and also in the Classification of the American Psychiatric Association: DSM-III R and DSM-IV were considered and found to be inadequate.

[Nosologic position of confabulatory-paraphrenic psychoses of old age]. / K voprosu o nozologicheskom meste konfabuliatorno-parafrennykh psikhozov pozdnego vozrasta.

Three groups of elderly patients were studied. The state of these patients was characterized by confabulatory-paraphrenic delusion which developed for the first in senility. The nozological character of the first two groups of patients did not cause any doubt about their close connection with senile dementia. The third group of patients varied only by the presence of the confabulatory-paraphrenic delusion without any signs of endogenous or senile-atrophic processes. The comparative study of the psychopathological traits of confabulatory-paraphrenic delusion in all patients showed that in all three groups there was a similarity of this symptomatology. Besides, the type of personality traits and hereditary loading in all three groups of patients appeared to be similar. It is suggested that nosologically studied group of psychoses in old age developing only with confabulatory-paraphrenic delusion without endogenous or organic dementia first appearing in seniscence should be referred to be senile dementia.

[A computer algorithm for diagnostic assessment with DSM-III in the early course of schizophrenic diseases]. / Ein Computer-Algorithmus zur Diagnosevergabe nach DSM-III im frühen Verlauf schizophrener Erkrankungen.

The purpose of the computer algorithm described here is the evaluation of diagnostic criteria according to DSM-III for schizophrenia and schizophreniform disorders. It also dates the first time point of the assessment of these diagnoses. The necessary information comes from a semistructured interview, called IRAOS (Interview for the Retrospective Assessment of the Onset of Schizophrenia). With this interview early indicators of a beginning schizophrenia can be evaluated in their chronological order and their type of course. The algorithm was first used in a sample of patients admitted for the first time with a diagnosis of either schizophrenia or paranoid psychosis. One third of these patients fulfills the DSM-III-criterion of a duration of at least six months. The other patients fulfill criterion B of a schizophreniform disorder. To strengthen the validity of a diagnosis including the criteria A up to E successively, the sample is reduced to 70%. The average time point of the first assessment of the diagnosis by the computer algorithm is about 1.5 years before the index-admission. Together with the IRAOS the computer algorithm allows an operationalized assessment of the real onset of schizophrenia.