'They're out to Get Me!': Evaluating Rational Fears and Bizarre Delusions in Paranoia: Paranoid Delusions Can Reveal a Number of Psychiatric Disorders; Building Trust Is Key to Treatment

[ILLUSTRATION OMITTED] Even among healthy individuals, feelings of paranoia are not unusual. In modern psychiatry, we consider paranoia to be a pattern of unfounded thinking, centered on the fearful experience of perceived victimization or threat of intentional harm. This means that a patient with paranoia is, by nature, difficult to engage in treatment. A patient might perceive the clinician as attempting to mislead or manipulate him. A therapeutic alliance could require patience on the part of the clinician, creativity, (1) and abandoning attempts at rational "therapeutic" persuasion. The severity of symptoms determines the approach. In this article, we review the nature of paranoia and the continuum of syndromes to which it is a central feature, as well as treatment approaches. Categorization and etiology Until recently, clinicians considered "paranoid" to be a subtype of schizophrenia (Box, (2-7) page 30); in DSM-5 the limited diagnostic stability and reliability of the categorization rendered the distinction obsolete. (8) There are several levels of severity of paranoia; this thought process can present in simple variations of normal fears and concerns or in severe forms, with highly organized delusional systems. The etiology of paranoia is not clear. Over the years, it has been attributed to defense mechanisms of the ego, habitual fears from repetitive exposure, or irregular activity of the amygdala. It is possible that various types of paranoia could have different causes. Functional MRIs indicate that the amygdala is involved in anxiety and threat perception in both primates and humans. (9) Box Paranoia: An old term with a new meaning A variety of paranoid conditions have been described in society for centuries. The term paranoia is derived from the Greek "para" (beside) and "noos" (mind). In other words, a condition of mental illness where a preoccupation of the mind occurs. (2) Before the 19th century, the term paranoia could be used for almost any form of delusional thinking. In 1863 Kahlbaum used the term paranoia to describe chronic delusions of persecution. (3,4) In describing dementia praecox, Kraepelin initially regarded paranoia as a distinct disorder. (5) Bleuler argued that there was no need for distinction between paranoia and his concept of schizophrenia. (6) In 1921, Mayer concluded that paranoid psychosis could not be separated from schizophrenia, based upon phenomenology. (7) Rational fear vs paranoia Under the right circumstances, anyone could sense that he (she) is being threatened. Such feelings are normal in occupied countries and nations at war, and are not pathologic in such contexts. Anxiety about potential danger and harassment under truly oppressive circumstances might be biologically ingrained and have value for survival. It is important to employ cultural sensitivity when distinguishing pathological and nonpathological paranoia because some immigrant populations might have increased prevalence rates but without a true mental illness. (10) Perhaps the key to separating realistic fear from paranoia is the recognition of whether the environment is truly safe or hostile; sometimes this is not initially evident to the clinician. The first author (J.A.W.) experienced this when discovering that a patient who was thought to be paranoid was indeed being stalked by another patient. Rapid social change makes sweeping explanations about the range of threats experienced by any one person of limited value. Persons living with serious and persistent mental illness experience stigma-harassment, abuse, disgrace--and, similar to victims of repeated sexual abuse and other violence, are not necessarily unreasonable in their inner experience of omnipresent threat. In addition, advances in surveillance technology, as well as the media proliferation of depictions of vulnerability and threat, can plant generalized doubt of historically trusted individuals and systems. …