Paranoia

   (See also Erotomania; Folie à Deux; French Chronic Delusional States; Psychosis: Emergence.)

   Paranoia means a fixed false belief formed via logical reasoning (making it distinct from schizophrenia); aside from his delusional system, the patient is perfectly normal in every other respect. In the eighteenth and early nineteenth centuries, the Greek term "paranoia" had surfaced occasionally in psychiatric discussions, to become common by the late-nineteenth century. The term "delusion" is a synonym for it.

   Heinroth calls paranoia a disorder of intellect (1818). Johann C. A. Heinroth (1773–1843) began to chisel the modern meaning into the term "paranoia" in his 1818 Textbook of Disturbances of Mental Life (Lehrbuch der Störungen des Seelenlebens) as a disorder of intellect with preserved feeling and volition. (See German "Romantic" Psychiatry: Heinroth.) He said of "insanity with dementia (ecstasis paranoia)": "The symptoms of pure insanity are associated with perversion of concepts and judgment. . . . The disease has gained sway over both the intellect and the imagination of the patient. . . . The field of insanity is narrowed down and reduced, and as a result its form is altogether altered. . . . The intervention of the intellect results in partial consciousness" (p. 155 of George Mora’s English translation). Yet, throughout much of the nineteenth century, as the outlines of the syndrome were being hammered in place, the term "paranoia" was not used. (The preferred expressions for delusional psychosis had been delusion in English, délire in French, and Verrücktheit in German.)

   Esquirol’s "intellectual monomania" (1838). Among major landmarks in the formation of the modern doctrine of paranoia is Étienne Esquirol’s "intellectual monomania" (monomanie raisonnante) as discussed in 1838 in his textbook Des maladies mentales. For Esquirol, patients with this kind of monomania seem to have derived their delusional systems via logical reasoning; they seem otherwise normal. "There are monomaniacs who do not appear insane, whose ideas retain their natural associations and whose reasoning is logical and their speech coherent [suivis], often lively and full of spirit. But the actions of these patients are contrary to their emotions, to their self-interest and to social mores. . . . However irrational their actions might be, these monomaniacs always have more or less plausible arguments to justify them, in the manner that one might say of them they are rational madmen (des fous raisonnables)" (Des maladies mentales, II, pp. 49–50). Esquirol’s definition is really the fundamental paving stone in the modern doctrine of paranoia.

   Griesinger’s notion that delusions represent "partial" remnants of insanity (1845). Wilhelm Griesinger suggested in his 1845 textbook, The Pathology and Therapy of Mental Diseases (Die Pathologie und Therapie der psychischen Krankheiten), the concept of delusional "partial insanity" ("die partielle Verrücktheit") as a sequel of total insanity. "We understand here those secondary forms of insanity, where even after a significant reduction . . . of the original pathological affect the patient has not recovered, but remains ill, exhibiting most conspicuously fixed delusional ideas that he carefully cultivates and repeats again and again; this is always a secondary form of illness, arising from melancholia or mania" (p. 258). Griesinger gave as an example of such fixed delusional thinking, "The patients believe themselves persecuted, surrounded by plots, tortured with electricity by secret enemies, menaced by Freemasons, possessed by the devil and damned to eternal torment, robbed of their dearest possession etc." (p. 262).

   Delusions of persection (1852). Ernest-Charles Lasègue introduced into the French literature—in General Archives of Medicine (Archives générales de la médecine)— the idea that paranoid delusions (délires de persécutions) constituted an illness separate from undifferentiated madness. (The French term "délire" may be translated as delusion, delirium, or psychosis depending on the context.) As Lasègue complained of his predecessors (neglecting to cite Griesinger), "Under this common label of madness (aliénation), the most dissimilar forms of pathology have been grouped together if not confused in a false unity" (p. 129). He applauded efforts to separate "generalized insanity" (délires généraux), affecting all mental functions, from "partial insanity" (délires partiels), leaving much of the intellectual realm intact; he proposed as an entity in partial insanity the delusion of persecution (le délire de persécutions) (p. 133). This use of "délire" to mean fixed delusional beliefs became a keystone of French psychiatry for the next 100 years.

   Kahlbaum: In paranoia the personality does not deteriorate (1863). A major contribution to the growing understanding of paranoia as a syndrome was that of Karl Kahlbaum. If his views were often overlooked by his successors perhaps it was because he chose such an ungainly word for delusions: "diastrephia." ("Paranoia" he reserved for "disturbances in the sphere of intelligence, Gruppirung," p. 96.) Kahlbaum observed in his Classification of Mental Diseases (Die Gruppirung der psychischen Krankheiten) in 1863 that in the diastrephias, the patients’ personalities did not deteriorate, as in the Vesaniae (full madness), and that they could go through life otherwise perfectly normal except for the "exquisitely partial nature" of their mental disorder. "The pathological abnormalities of their intellectual life will long be considered moral perversities, their bizarre enterprises, their insults and injuries to man and beast will be endured by their friends and family or willingly accepted, until the conflict affects some outsider, or otherwise comes to the attention of the authorities" (pp. 102–103). Unlike Griesinger, he did not consider it secondary to some other deeper illness.

   Mendel restores the term "paranoia" (1883). In a lecture to the Berlin Psychiatric Society on "secondary paranoia" in 1883 (published in the Archiv für Psychiatrie in 1884, pp. 289–290), Berlin psychiatrist Emanuel Mendel (1839–1907) proposed a revival of the older term "paranoia." As a "secondary" complication of melancholia, the paranoid patient attributed the fault to the surrounding world rather than, as in melancholia, to himself. At a professional meeting in 1890, Mendel rather indignantly called attention to his priority as Karl Wilhelm Werner (1858–1934), an asylum psychiatrist in (Stadt-) Roda, announced that he himself had just authored the distinction between what he proposed to call "paranoia" and madness (Wahnsinn) (Allgemeine Zeitschrift für Psychiatrie, 1890, p. 531). Werner said that patients often found the term "Verrücktheit" (in common speech "craziness") offensive.

   Magnan’s "chronic systematized delusional disorder" (le délire chronique à évolution systématique) (1886). Valentin Magnan introduced the notion of "chronic systematized delusional disorder" in 1886 in a lecture at the Medical-Psychological Society, a chronic kind of well-circumscribed delusional disorder that went through four stages after a period of incubation: inquietude-hallucinations, persecution, manic-grandeur, dementia. The delusions were highly structured, hence the adjective "systematic," or "systematized." In 1888, Magnan published a series of articles on it in Le Progrès médical, then in 1892 together with his colleague Paul Sérieux (1864–1947) he described the illness in a monograph entitled Le délire chronique à évolution systématique. The two authors contrasted the "insanity of the degenerate"—for example la bouffée délirante (see Psychosis: Emergence [1886])—with "the chronic systematized delusional disorders" of the nondegenerate but mildly predisposed. Henceforth in the French tradition, Magnan’s "great discovery," as it was often called, was preferred to the term "paranoia."

   Chronic nonhallucinatory delusional states (Le délire d’interprétation) (delusional thinking) (1909). Around 1900, Magnan’s views about degeneration started to go out of style. This occasioned a new bout of Parisian thinking about delusional disorder. In 1909, psychiatrists Sérieux and Capgras in their book, Intelligent Insanity: Delusional Thinking (Les folies raisonnantes: le délire d’interprétation), hived these off from the larger block of psychotic illness on the grounds that the absence of hallucinations and the failure to progress to dementia were important diagnostic features.

   At the time, Paul Sérieux (1864–1947) was the chief psychiatrist at a private nervous clinic, and Jean-Marie-Joseph Capgras (1873–1950) was about to become chief psychiatrist at the Maison-Blanche asylum. Both were pupils of Magnan. The authors de-fined "delusional thinking" (délire d’interprétation) as "false reasoning having as its point of departure a real sensation, a precise fact which . . . driven by erroneous deductions or inductions, takes on personal significance for the patient, who ineluctably is compelled to relate everything to himself" (p. 3). The various delusions were in turn subject to elaborate subclassification on the basis of their object and whether they were tightly focused on a given notion or not. Le délire d’interprétation was asserted to be different from Kraepelin’s paranoia because the French diagnosis did not include individuals with querulancy. (For Kraepelin, Querulantenwahn was a part of paranoia.)

   The délire’d’interprétation, in its turn, was part of a larger group of chronic delusional states that the authors called "intelligent insanity" (les folies raisonnantes). (See FRENCH CHRONIC DELUSIONAL DISORDERS.) Its characteristics: "With the exception of their well-circumscribed delusions [délire partiel], the patients retain all of their liveliness of intellect, often with a remarkable propensity to argue about and defend their convictions. The interprétateurs do not qualify for the epithet insane [aliénés] . . . remaining in contact with their milieu and appearing normal; some succeed in living in liberty up to the end of life. . . . The majority become institutionalized, not because of their delusional notions but because their violent and impulsive character makes them dangerous" (p. 5).

   Jaspers’s "pathological jealousy" as development not process (1910). In a fundamental article in the Journal of Combined Neurology and Psychiatry (Zeitschrift für die gesamte Neurologie und Psychiatrie) in 1910, Karl Jaspers called delusional jealousy (Eifersuchtswahn) the result of a slow development within the patient’s personality rather than the sudden inexplicable eruption of psychosis, a "process." This clearly separated developmental kinds of delusional systems from "process" illnesses such as schizophrenia. Paranoia thus became more a kind of personality disorder than a pathological brain disease. "You can reconstruct a patient’s entire life on the basis of a personality trait," Jaspers said (p. 612).

   Freud’s view of paranoia (1911). For Freud, the distinction between psychosis and neurosis was never watertight. Paranoid thinking could also be neurotic in nature, a defense against homosexual desires. In his analysis of the case of Daniel Paul Schreber (1842–1911), a high official in Leipzig who had become psychotic and was admitted to the psychiatric clinic of Professor Paul Flechsig (1847–1929), Freud articulated a theory of paranoia as the withdrawal of libido from the outside world. Based on Schreber’s published autobiography, Memoirs of a Nervous Patient (Denkwürdigkeiten eines Nervenkranken, 1903), Freud argued in "Psychoanalytic Remarks on an Autobiographically-Described Case of Paranoia (Dementia Paranoides)" ("Psychoanalytische Bemerkungen über einen autobiographisch beschriebenen Fall von Paranoia ([Dementia paranoides])" in the Yearbook for Psychoanalytic and Psychopathological Research (Jahrbuch für psychoanalytische und psychopathologische Forschungen) that when libido is withdrawn from external objects and has further inflated the ego, paranoia—an overweening kind of grandiosity— eventuates. In paranoia, the child’s sexual development undergoes a "fixation" somewhere between autoeroticism and narcissism. Freud concluded the essay by pointing out that "neuroses basically arise from the conflict of the ego with the sex drive, and that their various forms retain the print marks of the developmental history of the libido and of the ego" (Gesammelte Werke, VIII, p. 316). (Some observers believe, however, that Schreber was suffering from neurosyphilis rather than intrapsychic conflict.)

   Paranoia in Kraepelin’s work (from 1893). It was with the fourth edition of his textbook Psychiatry (Psychiatrie), published in 1893, that Emil Kraepelin’s innovative thinking about diagnosis began, soon after his arrival in Heidelberg. In this edition, he distinguished two forms of paranoia: (1) "die Verrücktheit (Paranoia)," which he understood as a "durable delusional system in the presence of an intact personality" (dauerndes Wahnsystem bei vollkommener Erhaltung der Besonnenheit) having a relatively unfavorable prognosis. (Verrücktheit translates into English as "craziness" but Kraepelin meant it more in the sense of dislocation of a patient’s life as a result of crazy ideas.) The discussion makes clear that he is trying to filter delusions from the larger soup of "madness," because he includes affective disorders and hallucinations in the psychopathology of paranoia. (2) Kraepelin coined the term "dementia paranoides" and classed it among the "psychic processes of degeneration," to characterize patients with confused ideas, rather than tidy delusional systems, who sink rapidly into dementia; Freud thought Daniel Paul Schreber was one (see above). The fifth edition in 1896 did not change these two diagnoses themselves but shifted them to larger disease categories: Dementia paranoides had become a dementing process under the larger rubric of "metabolic diseases"; and Verrücktheit-Paranoia had been assigned to the class of "hereditary illnesses" (Geistesstörungen aus krankhafter Veranlagung).

   The sixth edition in 1899—famous for its creation of "manic-depressive illness"— (1) shifted "dementia paranoides" to a subform of dementia praecox (Bleuler’s schizophrenia) (see Schizophrenia: Emergence); (2) retained Verrücktheit-Paranoia; and (3) added as a special illness, paranoia in the pre-senile elderly (der praesenile Beeinträchtigungswahn).

   The seventh edition in 1904 made no changes to the above.

   In the eighth edition, a sprawling document published in multiple volumes during the years 1909–1915, Kraepelin (1) retained Verrücktheit-Paranoia; (2) discussed paranoid forms of dementia praecox; (3) dissolved pre-senile paranoia into the larger picture of presenile "insanity"; and (4) set up "paranoid dementia," also called "paraphrenias,"* as a separate category of "endogenous dementias" (endogene Verblödungen) alongside dementia praecox (see PARAPHRENIA); by paranoid dementia he meant maintenance of the personality as semi-intact, heavily paranoid pathology, yet downhill course.

   In sum, despite the several meanders in Kraepelin’s thinking, his version of paranoia differs from the Freudian in being profoundly organic, hereditary, and nonpsychogenic. As well, Kraepelin maintains a clear boundary between the major psychiatric illnesses, such as paranoia and dementia praecox, and the "psychogenic" ones (he uses the term in the eighth edition in 1915), such as "nervous exhaustion" and the traumatic neuroses; also as distinct from "hysteria." It was one of Kraepelin’s main contributions to have isolated the notion of paranoia from schizophrenia and other psychoses.

   Gaupp’s reactive paranoia (abortiva paranoia) (1909). At a meeting that year, Robert Gaupp (1870–1953), professor of psychiatry in Tübingen, proposed reactive paranoia as an independent illness entity, distinct from manic-depressive illness and from obsessive-compulsive disorder. Occurring typically in middle-aged individuals with previously healthy personalities (but with an inborn disposition to paranoia or depression), the paranoid ideation tended to be well-circumscribed (usually not involving the physician, for example); the patients did not deteriorate and often recovered completely with full insight. The paper was published in 1910 in the General Journal of Psychiatry (Allgemeine Zeitschrift für Psychiatrie). (Gaupp did not use this precise diagnosis in analyzing what was probably the most famous case of paranoia in pre–First World War Germany: the schoolteacher Ernst Wagner, who in 1913 committed mass murder in a Swabian village and was referred by the court to Gaupp for a psychiatric opinion. See Gaupp’s article in the Munich Medical Weekly [Münchener Medizinische Wochenschrift] of March 24, 1914. In Gaupp’s view, the case demonstrated the "purely affective" nature of paranoia.)

   Kretschmer’s "sensitive delusions of reference" (1918). Kretschmer’s book Sensitive Delusions of Reference: A Contribution to the Question of Paranoia and to the Doctrine of Character in Psychiatry (Der sensitive Beziehungswahn: ein Beitrag zur Panaroiafrage und zur psychiatrischen Charakterlehre) was inspired by Gaupp’s teaching at Tübingen, where Ernst Kretschmer was on staff. (See Psychosis: Emergence: sensitive delusions of reference [1918].)

   * In the ninth edition of the Kraepelin textbook (published posthumously in 1927), editor Johannes Lange (1891–1938), a staff psychiatrist at Kraepelin’s German Psychiatric Research Institute in Munich (known as the DFA), made paraphrenia part of paranoid schizophrenia, after Wilhelm Mayer’s research published in the Zentralblatt für Neurologie in 1921 on the poor outcomes of these patients. (Mayer practiced psychiatry in Munich and was affiliated with the DFA.)

   Paranoia in the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (after 1952). The first volume of DSM in 1952 was notable for making many psychiatric illnesses into "reactions" of various types. Among the "psychotic disorders," there were "schizophrenic reaction: paranoid type," as well as "paranoid reactions," subdivided into "paranoia" and "paranoid state." This distinction between schizophrenic paranoia and nonschizophrenic paranoia corresponds roughly to Kraepelin’s distinction between "paranoid dementia" and "Verrücktheit-Paranoia." It also upheld the Kraepelinian distinction between major, often "endogenous," illnesses and psychoneuroses. DSM "One" also included "paranoid personality." (See Personality Disorders.)

   DSM-II in 1968 maintained the paranoid schizophrenia of DSM-I and the paranoid reactions, but called them "paranoid states": "paranoia" was one such state (said to be an "extremely rare condition"); "involutional paranoid state" (also called "involutional paraphrenia") was another. "Paranoid personality" of DSM-I was retained.

   In DSM-III (1980), notable for bone-wrenching change in much psychiatric diagnosis, little was changed in paranoia. There was the schizophrenia: "paranoid type," and then the "paranoid disorders." One such disorder was "paranoia," with its insidious development and unshakable delusional system; another was "shared paranoid disorder" (once known as folie à deux); a third was "acute paranoid disorder" of rapid onset often under stress. This edition admitted, as before, "paranoid personality disorder."

   DSM-III-R in 1987 saw considerable innovation. (1) Shared paranoid disorder became "induced psychotic disorder." (2) Although schizophrenia: paranoid type was kept, paranoia as such was renamed "delusional disorder." "The essential feature of this disorder," according to the Manual, "is the presence of a persistent, nonbizarre delusion that is not due to any other mental disorder" (p. 199). One compares that with the definition in DSM-III that said paranoia meant basically delusions of persecution or jealousy. Delusional disorder was divided into subtypes: erotomanic, grandiose, jealous, persecutory, and somatic. (3) Paranoid personality was unchanged in essence.

   DSM-IV (1994) changed little.