Paranoia.

Message from the Director of the National Institute of Mental Health 

The year 1996 marks the fiftieth anniversary of the National Institute of Mental Health (NIMH). Throughout the past 50 years, the results of research supported by the Institute have brought new hope to millions of people who suffer from mental illness and to their families and friends. In work with animals as well as human participants, researchers have advanced our understanding of the brain and vastly expanded the capability of mental health professionals to diagnose, treat, and prevent mental and brain disorders.

During this last decade of the twentieth century--designated "The Decade of the Brain" by the U.S. Congress--knowledge of brain function has exploded. Research is yielding information about the causes of mental disorders such as depression, bipolar disorder, schizophrenia, panic disorder, and obsessive-compulsive disorder. With this knowledge, scientists are developing new therapies to help more people overcome mental illness.

The National Institute of Mental Health is part of the National Institutes of Health (NIH), the Federal Government's primary agency for biomedical and behavioral research. NIH is a component of the U.S. Department of Health and Human Services.

Paranoia - The Word

Paranoia is a term used by mental health specialists to describe suspiciousness (or mistrust) that is either highly exaggerated or not warranted at all. The word is often used in everyday conversation, often in anger, often incorrectly. Simple suspiciousness is not paranoia--not if it is based on past experience or expectations learned from the experience of others.

Paranoia can be mild and the affected person may function fairly well in society, or it can be so severe that the individual is incapacitated. Because many psychiatric disorders are accompanied by some paranoid features, diagnosis is sometimes difficult. Paranoias can be classified into three main categories--paranoid personality disorder, delusional (paranoid) disorder, and paranoid schizophrenia.

Paranoid Personality Disorder 

Some people regularly become suspicious without cause--so much so that their paranoid thoughts disrupt their work and family life. Such people are said to have a paranoid personality. They are:

Suspicious

An unmistakable sign of paranoia is continual mistrust. People with paranoid personality disorder are constantly on their guard because they see the world as a threatening place. They tend to confirm their expectations by latching on to any speck of evidence that supports their suspicions and ignore or misinterpret any evidence to the contrary. They are ever watchful and may look around for signs of a threat.

Anyone in a new situation--beginning a job or starting a relationship, for example--is cautious and somewhat guarded until he or she learns that the fears are groundless. People suffering from paranoia cannot abandon their fears. They continue to expect trickery and to doubt the loyalty of others. In a personal relationship or marriage, this suspiciousness may take the form of pathological, unrealistic jealousy.

Hypersensitive 

Because persons with paranoid personality disorder are hyperalert, they notice any slight and may take offense where none is intended. As a result, they tend to be defensive and antagonistic. When they are at fault, they cannot accept blame, not even mild criticism. Yet they are highly critical of others. Other people may say that these individuals make "mountains out of molehills."

Cold and Aloof

In addition to being argumentative and uncompromising, the people with paranoid personality disorder are often emotionally cut off from other people. They appear cold and, in fact, often avoid becoming intimate with others. They pride themselves on their rationality and objectivity. People with a paranoid outlook on life rarely come to the attention of clinicians--it is not in their nature to seek help. Many presumably function competently in society. They may seek out social niches in which a moralistic and punitive style is acceptable, or at least tolerated to a certain degree.

* Derek worked in a large office as a computer programmer. When another programmer received a promotion, Derek felt that the supervisor "had it in for him" and would never recognize his worth. He was sure that his co-workers were subtly downgrading him. Often he watched as others took coffee breaks together and imagined they spent this time talking about him. If he saw a group of people laughing, he knew they were laughing at him. He spent so much time brooding about the mistreatment he received that his work suffered and his supervisor told him he must improve or receive a poor performance rating. This action reinforced all Derek's suspicions, and he looked for and found a position in another large company. After a few weeks on his new job, he began to feel that others in the office didn't like him, excluded him from all conversations, made fun of him behind his back, and eroded his position. Derek has changed jobs six times in the last seven years. Derek has paranoid personality disorder.

Delusional (Paranoid) Disorder

Psychiatrists make a distinction between the milder paranoid personality disorder described above and the more debilitating delusional (paranoid) disorder. The hallmark of this disorder is the presence of a persistent, nonbizarre delusion without symptoms of any other mental disorder.

Delusions are firmly held beliefs that are untrue, not shared by others in the culture, and not easily modifiable. Five delusional themes are frequently seen in delusional disorder. In some individuals, more than one of them is present.

The most common delusion in delusional disorder is that of persecution. While persons with paranoid personality might suspect their colleagues of joking at their expense, persons with delusional disorder may suspect others of participating in elaborate master plots to persecute them. They believe that they are being poisoned, drugged, spied upon, or are the targets of conspiracies to ruin their reputations or even to kill them. They sometimes engage in litigation in an attempt to redress imagined injustices.

Another theme seen frequently is that of delusional jealousy. Any sign--even a meaningless spot on clothing, or a short delay in arriving home--is summoned up as evidence that a spouse is being unfaithful.

Erotic delusions are based on the belief that one is romantically loved by another, usually someone of higher status or a well-known public figure. Individuals with erotic delusions often harass famous persons through numerous letters, telephone calls, visits, and stealthy surveillance.

Persons with grandiose delusions often feel that they have been endowed with special powers and that, if allowed to exercise these powers, they could cure diseases, banish poverty, ensure world peace, or perform other extraordinary feats.

Individuals with somatic delusions are convinced that there is something very wrong with their bodies--that they emit foul odors, have bugs crawling in or on their bodies, or are misshapen and ugly. Because of these delusions, they tend to avoid the society of other people and spend much time consulting physicians for their imagined condition.

Whether or not persons with delusional disorder are dangerous to others has not been systematically investigated, but clinical experience suggests that such persons do not often resort to violence. Delusional patients are commonly angry people, and thus they are perceived as threatening. In the rare instances when individuals with delusional disorder do become violent, their victims are usually people who unwittingly fit into their delusional scheme. The person in most danger from an individual with delusional disorder is a spouse or lover.

* Ruth is a clerk typist who is efficient and helpful. Her employers and co-workers value her contribution to the office. But Ruth spends her evenings writing letters to State and Federal officials. She feels that God has opened her mind and given her the cure for cancer. She wants some leading treatment center to use her cure on all its patients so that the world can see she is right. Many of her letters go unanswered, or she receives noncommittal replies that only make her feel that no one understands that she can save all cancer patients if only given the chance. When one of her letters is answered by an employee of the official to whom she wrote, she is sure that the official is being deliberately kept unaware of her knowledge and power. Sometimes she despairs that the world will ever know how wonderful she is, but she doesn't give up. She just keeps writing. Ruth suffers from one of the delusional disorders, grandiose delusion.

Paranoid Schizophrenia

Paranoid thinking and behavior are hallmarks of the form of schizophrenia called "paranoid schizophrenia." Individuals with paranoid schizophrenia commonly have extremely bizarre delusions or hallucinations, almost always on a specific theme. Sometimes they hear voices that others cannot hear or believe that their thoughts are being controlled or broadcast aloud. Also, their performance at home and on the job deteriorates, often with a much diminished degree of emotional expressiveness.

In contrast, people with relatively milder paranoid disorders may have such symptoms as delusions of persecution or delusional jealousy, but not the prominent hallucinations or impossible, bizarre delusions that sometimes occur in paranoid schizophrenia. Those with milder paranoid disorders are customarily able to work, and their emotional expression and behavior are appropriate to their delusional belief. Apart from their delusions, their thinking remains clear and orderly. On the other hand, those with paranoid schizophrenia may be intellectually disorganized and confused.

* Steven had not liked high school very much and was glad to graduate and get a job. But when he realized he needed more education to reach his goals, he applied for admission into a nearby college. He rented a house with several other young men and did well in his studies. Near the end of his second year, Steven stopped eating with the others and ate only food directly out of a can so he could be sure it wasn't poisoned. When he crossed the campus, he tried to avoid girls as he felt they shot poisoned webs at him that encompassed his body like a giant spider web. When he began to feel that his housemates had put poisoned gas in his room, he dropped out of school and returned home. He cleaned up his room at home and put a lock on the door so his parents could not enter it and contaminate it. He bought a small electric hot plate and prepared all his own food. If his mother urged him to eat a meal with the family, he accused her of wanting to poison him. His parents finally were able to convince him to see a psychiatrist who diagnosed "schizophrenia, subtype paranoia." With medication, individual and group therapy, Steven has improved enough to work in an office under the supervision of an understanding and supportive employer.

Causes of Paranoia

Genetic Contribution

Little research has been done on the role of heredity in causing paranoia. Scientists have found that the families of paranoid patients do not have higher than normal rates of either schizophrenia or depression. However, there is some evidence that paranoid symptoms in schizophrenia may be genetically influenced. Some studies have shown that when one twin of a pair of identical twins with schizophrenia has paranoid symptoms, the other twin usually does also. And, recent research has suggested that paranoid disorders are significantly more common in relatives of persons with schizophrenia than in the general population. Whether paranoid disorder--or a predisposition to it--is inherited is not yet known.

Biochemistry

The discovery that psychosis (a state in which the individual is out of touch with reality) is treatable with antipsychotic drugs has led scientists to look for the origins of severe mental disorders in abnormal brain chemistry. The search has become very complex, as more and more of the chemical substances that carry messages from one nerve cell to another--the neurotransmitters--have been discovered. So far, no clear-cut answers have been found. As with the genetic studies, biochemical studies have not examined paranoia except as a subtype of schizophrenia. There is, however, limited evidence that paranoid schizophrenia is biochemically distinct from nonparanoid forms of the disorder.

Abuse of drugs such as amphetamines, cocaine, marijuana, PCP, LSD, or other stimulants or"psychedelic" compounds may lead to symptoms of paranoid thinking or behavior. Patients with major mental disorders like paranoid schizophrenia may have their symptoms become worse under the influence of these drugs. Scientists are studying the biochemical actions of such drugs to determine how they produce their behavioral effects. This may help us to learn more about the neurochemistry of paranoid disorders, which is poorly understood at this time.

Stress

Some scientists believe paranoia may be a reaction to high levels of life stress. Lending support to this opinion is the evidence that paranoia is more prevalent among immigrants, prisoners of war, and others undergoing severe stress. Sometimes, when thrust into a new and highly stressful situation, people suffer an acute form--called "acute paranoia"--in which delusions develop over a short period of time and last only a few months.

Some studies indicate that paranoia has become more prevalent in the twentieth century. The connection between stress and paranoia does not, of course, rule out other contributing factors. A genetic defect, a brain abnormality, an information-processing disability--or all three--could predispose a person to paranoia; stress may merely act as a trigger.

Treatment of Paranoia

Paranoid people's mistrustfulness makes treatment of the condition difficult. Rarely will they talk casually in an interview. They are suspicious of the kind of open-ended questions many therapists rely on to learn about the patient's history (for example, "Tell me about your relationships with your co-workers."). They may try to avoid hospitalization and drugs, fearing a loss of control or other real or imagined dangers.

Drug Treatment

Treatment with appropriate antipsychotic drugs may help the paranoid patient overcome some symptoms. Although the patient's functioning may be improved, the paranoid symptoms often remain intact. Some studies indicate that symptoms improve following drug treatment, but the same results sometimes occur among patients who receive a placebo, a "sugar pill" without active ingredients. This finding suggests that in some cases the paranoia diminishes for psychological reasons rather than because of the drug's action. Paranoid patients receiving medication must be closely monitored. Their fearfulness and persecutory delusions often lead them to refuse or sabotage treatment--for example, by holding the drug in their cheek until they are alone and then spitting it out.

Psychotherapy

Reports on individual cases suggest that the regular opportunity to express suspicions and self-doubts afforded by psychotherapy can help the paranoid patient function in the community. Although paranoid ideas do seem to persist, they may be less disruptive. Other types of psychotherapy that have reportedly led to improved social functioning without appreciably diminishing paranoid delusions are art therapy, family therapy, and group therapy.

Outlook for Paranoid Patients

In spite of the treatment difficulties, patients with paranoid personality or delusional disorder may function quite well. Even though their paranoid views are apparently unshakable, various treatments appear effective in improving social functioning. The symptoms are less bizarre than those associated with paranoid schizophrenia. Also, the paranoid personality and delusional disorders seem to cause less disorganization of the personality and disruptions in social and family life.

For Further Information

Diagnostic and Statistical Manual of Mental Disorders, Fourth Ed. Washington, DC: American Psychiatric Association, 1994.

Schizophrenia Bulletin, Special Issue: Paranoia, Volume 7, Issue Number 4, (available in most medical libraries) 1981.

Kendler, Kenneth S., Spitzer, Robert L., and Williams, Janet B.W. Psychotic disorders in DSM-III-R. The American Journal of Psychiatry, 146:953-962,1989.

Munro, Alistair. Delusional (paranoid) disorders. Canadian Journal of Psychiatry, Vol. 33(5):399-404, 1988.

Opjordsmoen, Stein. Long-term course and outcome in delusional disorder. Acta Psychiatrica Scandinavica, Vol. 78(5):576-586, 1988.

Sorensen, Donna J., Paul, Gordon L., Mariotto, Marco J. Inconsistencies in paranoid functioning, premorbid adjustment, and chronicity: Question of diagnostic criteria. Schizophrenia Bulletin, Vol. 14(2):323-336, 1988.

Williams, Janice G. Cognitive intervention for a paranoid personality disorder. Psychotherapy, Vol. 25(4) :570-575, 1988.