Paranoia

Paranoia (Gr. rapa, beyond, and voeiv, to understand), a chronic mental disease, of which systematized delusions with or without hallucinations of the senses are the prominent characteristics. The delusions may take the form of ideas of persecution or of grandeur and ambition; these may exist separately or run concurrently in the same individual, or they may become transformed in the course of the patient's life from a persecutory to an ambitious character. The disease may begin during adolescence, but the great majority of the subjects manifest no symptoms of the affection until full adult life.

The prominent and distinguishing symptom of paranoia is the delusion which is gradually organized out of a mass of original but erroneous beliefs or convictions until it forms an integral part of the ordinary mental processes of the subject and becomes fused with his personality. This slow process of the growth of a false idea is technically known as " systematization," and the resulting delusion is then said to be " systematized." As such delusions are coherently formed there is no manifest mental confusion in their expression. Notwithstanding the fixity of the delusion it is subject in some cases to transformation which permits of the gradual substitution of delusions of grandeur for delusions of persecution. It happens also that periods of remission from the influence of the delusion may occur from time to time in individual cases, and it may even happen, though very rarely, that the delusion may permanently disappear.

It is necessary to point out that there is undoubtedly what may be called a paranoiac mental constitution, in which delusions may appear without becoming fixed or in which they may never appear. The characteristics of this type of mind are credulity, a tendency to mysticism and a certain aloofness from reality, combined, as the case may be, with timidity and suspicion or with vanity and pride. On such a soil it is easy to understand that, given the necessary circumstances, a systematized delusional insanity may develop.

The term paranoia appears to have been first applied by R. von Krafft-Ebing in 1879 to all forms of systematized delusional insanity. Werner in 1889 suggested its generic use to supplant Wahnsinn and Verriicktheit, the German equivalents of mental states which originally meant, respectively, the delusional insanity of ambition and the delusional insanity of persecution - terms which had become hopelessly confused owing to divergences in the published descriptions of various authors.

The rapid development of clinical study has now resulted in the isolation of a comparatively small group of diseases to which the term is applied and the relegation of other groups bearing more or less marked resemblances to it to their proper categories. Thus, for example, it had formerly been held that acute paranoia was frequently a curable disease. It is now proved that the so-called acute forms were not true paranoias, many of them being transitory phases of E. Kraepelin's dementia praecox, others being terminal conditions of acute melancholia, of acute confusional insanity, or even protracted cases of delirium tremens. While it removes from the paranoia group innumerable phases of delusional insanity met with in patients labouring under secondary dementia as a result of alcoholism or acute insanity, such a statement does not exclude patients who may have had, during their previous life, one or more attacks of some acute mental disease, such as mania, for the paranoiac mental constitution may be, though rarely, subject to other forms of neurosis. Attempts have been made to base a differential diagnosis of paranoia upon the presence or absence of a morbid emotional element in the mind of the subjects, with the object of referring to the group only such cases as manifest a purely intellectual disorder of mind. Though in some cases of the disease the mental symptoms may, at the time of observation, be of a purely intellectual nature, the further back the history of any case is traced the greater is the evidence of the influence of preceding emotional disturbances in moulding the intellectual peculiarities. Indeed it may be said that the fundamental emotions of vanity or pride and of fear or suspicion are the groundwork of the disease. We are justified therefore in ascribing the intellectual aberrations which are manifested by delusions, in part at least, to the preponderating influence of morbid emotions which alter the perceptive and aperceptive processes upon which depend the normal relation of the human mind to its environment. Although, generally speaking, paranoiacs manifest marked intellectual clearness and a certain amount of determination of character in the exposition of their symptoms and in their manner of reacting under the influence of their delusions, there is, without any doubt, an element of original abnormality in their mental constitution. Such a mental constitution is particularly subject to emotional disturbances which find a favourable field of operation in an innate mysticism allied with credulity which is impervious to the rational appeal of the intellect. In those respects the paranoiac presents an exaggeration of, and a departure from, the psychical constitution of normal individuals, who, while subject both to emotion and to mystic thought, retain the power of correcting any tendency to the predominance of these mental qualities by an appeal to reality. It is just here that the paranoiac fails, and in this failure lies the key to the pathological condition. For the present the question as to whether this defect is congenital or acquired owing to some superimposed pathological condition cannot be answered. However that may be, it is frequently ascertained from the testimony of friends and relatives that the patients have always been regarded as " queer," strange, and different from other people in their modes of thought. It is usually stated that nervous or mental diseases occur in the family histories of over 50% of the subjects of this affection.

Paranoia is classified for clinical purposes according to the form of delusion which the patients exhibit. Thus there are described the Persecutory, the Litigious, the Ambitious and the Amatory types. It will be observed that these divisions depend upon the prevalence of the primary emotions of fear or suspicion, pride or vanity and love.

According to V. Magnan, the course of paranoia is progressive, and each individual passes through the stages of persecution and ambition successively. Many authorities accept Magnan's description, which has now attained to the distinction of a. classic, but it is objected to by others on the ground that many cases commence with delusions of ambition and manifest the same symptoms unchanged during their whole life, while other patients suffering from delusions of persecution never develop the ambitious form of the disease. Against these arguments Magnan and his disciples assert that the relative duration of the stages and the relative intensity of the symptoms vary widely; that in the first instance the persecutory stage may be so short or so indefinite in its symptoms as to escape observation; and that in the second instance the persecutory stage may be so prolonged as within the short compass of a human life to preclude the possibility of the development of an ambitious stage. As however there exist types of the disease which, admittedly, do not conform to Magnan's progressive form it will be more convenient to adopt the ordinary description here.

r. Persecutory Paranoia. - This form is characterized by delusions of persecution with hallucinations of a painful and distressing character. In predisposed persons there is often observed an anomaly of character dating from early life. The subjects are of a retiring disposition, generally studious, though not brilliant or successful workers. They prefer solitude to the society of their fellows and are apt to be introspective, self analytical or given to unusual modes of thought or literary pursuits. Towards the commencement of the insanity the patients become gloomy, preoccupied and irritable. Suspicions regarding the attitude of others take possession of their minds, and they ultimately come to suspect the conduct of their nearest relatives. The conversations of friends are supposed by the patient to be interlarded with phrases which, on examination, he believes to contain hidden meanings, and the newspapers appear to abound in veiled references to him. A stray word, a look, a gesture, a smile, a cough, a shrug of the shoulders on the part of a stranger are apt to be misinterpreted and brooded over. The extraordinary prevalence of this imagined conspiracy may lead the patient to regard himself as a person of great importance, and may result in the formation of delusions of ambition which intermingle themselves with the general conceptions of persecution, or which may wholly supplant the persecutory insanity.

At this juncture, however, it generally happens that hallucinations begin to appear. These, in the great majority of instances, are auditory and usually commence with indefinite noises in the ears, such as ringing sounds, hissing or whistling. Gradually they assume a more definite form until isolated words and ultimately formed sentence are distinctly heard. There is great diversity in the completeness of the verbal hallucinations in different patients. Some patients never experience more than the subjective annoyance of isolated words generally of an insulting character, while others are compelled to listen to regular dialogues carried on by unknown voices concerning themselves. A not uncommon form of verbal hallucination is formulated in the complaint of the patients that " all their thoughts are read and proclaimed aloud." Even more than the enforced listening to verbal hallucinations this " thought reading " distresses the patient and often leads him to acts of violence, for the privacy of his inmost thoughts is, he believes, desecrated, and he often feels helpless and desperate at a condition from which there is no possible escape.

Though some of the subjects do not develop any other form of hallucination, it is unfortunately the lot of others to suffer, in addition, from hallucinations of taste, smell or touch. The misinterpretation of subjective sensations in these sense organs leads to the formulation of delusions of poisoning, of being subjected to the influence of noxious gases or powders, or of being acted on by agencies such as electricity. Such are the persons who take their food to chemists for analysis; who complain to the police that people are acting upon them injuriously; who hermetically seal every crevice that admits air to their bedrooms to prevent the entrance of poisonous fumes; or who place glass castors between the feet of their beds and the floor with the object of insulating electric currents. Such patients obtain little sleep; some of them indeed remain awake all night - for the symptoms are usually worse at night - and have to be content with such snatches of sleep as they are able to obtain at odd times during the day. It is obvious that a person tormented and distracted in the way described may at any moment lose self-control and become a danger to the community. But perhaps the most distressing and most distracting of all hallucinations are those which for want of a better name are termed " sexual." The subjects of these hallucinations, both male and female, under the belief that improper liberties are taken with them, are more clamant and threatening than any other class of paranoiac.

During the course of a disease so distressing in its symptoms the patient's suspicions as to the authors of his persecution vary much in indefiniteness. He often never fixes the direct blame upon any individual, but refers to his persecutors as they" or a " society," or some corporate body such as " lawyers," " priests " or " freemasons." It not infrequently happens however, that suspicions gradually converge upon some individual or that from an early stage of the disease the patient has, generally under the influence of hallucinations, fixed the origin of his trouble upon one or two persons. When this takes place the matter is always serious from the point of view of physical danger to the inculpated person, especially if the patient is of a violent or vindictive disposition.

The persecutory type of the disease may persist for an indefinite period - even for twenty or thirty years - without any change except for the important fact that remissions in the intensity of the symptoms occur from time to time. These remissions may be so marked as to give rise to the belief that the patient has recovered, but in true paranoia this is hardly ever the case, and sooner or later the persecution begins again in all its former intensity.

2\. Ambitious Paranoia. - After a long period of persecution a change in the symptoms may set in, in some cases, and the intensity of the hallucinations may become modified. At the same time delusions of grandeur begin to appear, at first faintly, but gradually they increase in force until they ultimately supplant the delusions of persecution. At the same time the hallucinations of a disagreeable nature fade away and are replaced by auditory hallucinations conformable to the new delusions of grandeur. Undoubtedly, however, this form of paranoia may commence, so far as can be observed, with delusions of grandeur, in which case there is seldom or never a transformation of the personality or of the delusions from grandeur to persecution, although delusions of persecution may engraft themselves or run side by side with the predominant ambitious delusions.

The emotional basis of ambitious paranoia is pride, and every phase of human vanity and aspiration is represented in the delusions of the patients. There is moreover considerably less logical acumen displayed in the explanations of their beliefs by such patients than in the case of the subjects of persecution. Many of them affect to be the descendants of historical personages without any regard for accurate genealogical detail. They have no compunction in disowning their natural parents or explaining that they have been " changed in their cradles " in order to account for the fact that they are of exalted or even of royal birth. Dominated by such beliefs paranoiacs have been known to travel all over the world in search of confirmation of their delusions. It is people of this kind who drop into the ears of confiding strangers vague hints as to their exalted origin and kindred, and who make desperate and occasionally alarming attempts to force their way into the presence of princes and rulers. The sphere of religion affords an endless field for the ambitious paranoiacs and some of them may even aspire to divine authority, but as a rule the true paranoiac does not lose touch with earth. The more extravagant delusions of persons who call themselves by divine names and assume omnipotent attributes are usually found in patients who have passed through acute attacks of insanity such as mania or dementia praecox and are mentally enfeebled.

A not uncommon form of paranoia combining both ambition and persecution is where the subject believes that he is a man of unbounded wealth or power, of the rights to which he is, however, deprived by the machinations of his enemies. These patients frequently obtain the knowledge on which they base their delusions through auditory hallucinations. They are often so troublesome, threatening and persistent in their determination to obtain redress for their imagined wrongs, that they have to be forcibly detained in asylums in the public interest. On the whole, however, the ambitious paranoiac is not troublesome, but calm, dignified, self-possessed, and reserved on the subject of his delusions. He is usually capable of reasoning as correctly and of performing work as efficiently as ordinary people. Many of them, however, while living in society are liable to give expression to their delusions under the influence of excitement, or to behave so strangely and unconventionally on unsuitable occasions as to render their seclusion either necessary or highly desirable.

3\. Amatory Paranoia. - A distinguishing feature of this form of paranoia is that the subjects are chivalrous and idealistic in their love. Some of them believe that they have been " mystically " married to a person of the opposite sex usually in a prominent social position. The fact that they may have never spoken to or perhaps never seen the person in question is immaterial. The conviction that their love is reciprocated and the relationship understood by the other party is unshakable, and is usually based upon suppositions that to a normal mind would appear either trivial or wholly unreal. The object of affection, if not mythical or of too exalted a position to be approached, is not infrequently persecuted by the admirer, who takes every opportunity of obtruding personally or by letter the evidences of an ardent adoration. The situation thus created can easily become complicated and embarrassing before it is realized that the persistent wooer is insane.

The failure of their schemes or repeated repulses may, in the case of some patients, originate delusions of persecution directed, not against the object of affection, but against those who are supposed to have conspired to prevent the success of the patient's desires. Under the influence of these delusions of persecution the patient may lose self-control and resort to violence against his supposed persecutors.

The subjects of this form of paranoia are in the majority of instances unmarried women well advanced in years who have led irreproachable lives, or men of a romantic disposition who have lived their mental lives more in the realm of chimeras than in the region of real facts. The delusions in this form of paranoia are never accompanied by hallucinations.

Closely allied, if not identical with amatory paranoia, is the form in which jealousy forms the basis of morbid suspicions with or without definite delusions. The subject is usually poor in mental resource, but proud, vindictive and suspicious. It is eminently a condition which arises spontaneously in certain persons whose mental constitution is of the paranoiac type, i.e.  persons who are naturally credulous, mystical and suspicious. The subjects are extraordinarily assiduous in watching the objects of their jealousy, whether husbands, wives or sweethearts. Their conduct in this respect is fertile in producing domestic dispeace and unhappiness, and in the case of unmarried persons in creating complicated or delicate situations. It not infrequently happens, just as in the case of the class of amatory paranoiacs, that delusions of persecution establish themselves, usually directed towards persons who are believed to have secured the affections of the object of jealousy. The disease then follows the ordinary course of the insanity of persecution but usually without hallucinations of the senses. The subjects are highly dangerous and violent. Under the influence of their delusions murder and even mutilation may be resorted to by the male, and poisoning or vitriol-throwing by the female subjects.

4\. Litigious Paranoia (paranoia querulans). - The clinical form of litigious paranoia presents uniform characteristic features which are recognized in every civilized community. The basic emotion is vanity, but added to that is a strong element both of acquisitiveness and avarice. Moreover the subjects are, as regards character, persistent, opinionative and stubborn. When these qualities are superadded to a mind of the paranoiac type, which as has been pointed out, is more influenced by the passions or emotions than by ordinary rational considerations, it can readily be appreciated that the subjects are capable of creating difficulties and anxieties which sooner or later may lead to their forcible seclusion in the interests of social order.

It is important to observe that the rights such people lay claim to or the wrongs they complain of may not necessarily be imaginary. But, whether imaginary or real, the statement of their case is always made to rest upon some foundation of fact, and is moreover presented, if not with ability, at any rate with forensic skill and plausibility. As the litigants are persons of one idea, and only capable of seeing one side of the case - their own - and as they are actuated by convictions which preclude feelings of delicacy or diffidence, they ultimately succeed in obtaining a hearing in a court of law under circumstances which would have discouraged any normal individual. Once in the law courts their doom is sealed. Neither the loss of the case nor the payment of heavy expenses have any effect in disheartening the litigant, who carries his suit from court to court until the methods of legal appeal are exhausted. The suit may be raised again and again on some side issue, or some different legal action may be initiated. In spite of the alienation of the sympathy of his relations and the advice of his friends and lawyers the paranoiac continues his futile litigation in the firm belief that he is only defending himself from fraud or seeking to regain his just rights. After exhausting his means and perhaps those of his family and finding himself unable to continue to litigate to the same advantage as formerly, delusions of persecution begin to establish themselves. He accuses the judges of corruption, the lawyers of being in the pay of his enemies and imagines the existence of a conspiracy to prevent him from obtaining justice. One of two things usually happens at this stage. Though well versed in legal procedure he may one day lose self-control and resort to threats of violence. He is then probably arrested and may on examination be found insane and committed to an asylum. Another not uncommon result is that finding himself non-suited in a court of law he commits a technical assault upon, it may be, some high legal functionary, or on some person in a prominent social position, with the object of securing an opportunity of directing public attention to his grievances. The only result is, as in the former instance, his medical certification and incarceration.

Paranoia is generally a hopeless affection from the point of view of recovery. From what has been stated regarding its genesis and slow development it is apparent that no form of ordinary medical treatment can be of the least avail in modifying its symptoms. The best that can be done in the interests of the patients is to place them in surroundings where they can be shielded from influences which aggravate their delusions and in other respects to make their unfortunate lot as pleasant and as easy to endure as possible.

As has been frequently stated, the subjects of most forms of paranoia are liable to commit crime, usually of violence, which may lead to their being tried for assault or murder. The question of their responsibility before the law is therefore one of the first importance (see also Insanity: Law). The famous case of McNaghten, tried in 1843 for the murder of Mr Drummond, private secretary to Sir Robert Peel, is, in this connexion, highly important, for McNaghten was a typical paranoiac labouring under delusions of persecution, and his case formed the basis of the famous deliverance of the judges in the House of Lords, in the same year, on the general question of criminal responsibility in insanity. Answer 4 of the judges' deliverance contains the following statement of law: If "he labours under such partial delusion only and is not in other respects insane we think he must be considered in the same situation as to responsibility as if the facts to which the delusion exists were real. For example, if under the influence of his delusion he supposes another man to be in the act of attempting to take away his life, and he kills that man, as he supposes, in self-defence, he would be exempt from punishment. If his delusion was that the deceased had inflicted a serious injury to his character and fortune, and he killed him in revenge for such supposed injury, he would be liable to punishment." In considering this deliverance it must be remembered that it was given under the influence of the enormous public interest created by the McNaghten trial. It has also to be remembered that in a criminal court the term responsibility means liability to legal punishment. The dictum laid down in answer 4 is open to several objections. (1) It is based upon the erroneous assumption that a person may be insane on one point and sane on every other. This is a loose popular fallacy for which there is no foundation in clinical medicine. The systematization of a delusion involves, as has been pointed out, the whole personality and affects emotion, intellect and conduct. The human mind is not divided into mutually exclusive compartments, but is one indivisible whole liable to be profoundly modified in its relation to its environment according to the emotional strength of the predominant morbid concepts. (2) It does not take into account the pathological diminution of the power of self-control. The influence of continued delusions of persecution, especially if accompanied by painful hallucinations, undermines the power of self-control and tends ultimately to reduce the subject towards the condition of an automaton which reacts reflexly and blindly to the impulse of the moment. (3) The opinion is further at fault in so far as it assumes that the test of responsibility rests upon the knowledge of right and wrong, which implies the power to do right and to avoid wrong, an assumption which is very far from the truth when applied to the insane. The number of insane criminals who possess no theoretical knowledge of right and wrong is very few indeed, so few that for practical purposes they may be disregarded.

The true paranoiac is a person of an anomalous mental constitution apart from his insanity; although he may to outward appearances be able, on occasion, to converse or to act rationally, the moment he is dominated by his delusions he becomes not partially but wholly insane; when in addition his mind is distracted by ideas of persecution or hallucinations, or both, he becomes potentially capable of committing crime, not because of any inherent vicious propensity but in virtue of his insanity. There is therefore no middle course, from the medical point of view, in respect to the criminal responsibility of the subjects of paranoia; they are all insane wholly, not partially, and should only be dealt with as persons of unsound mind.

See Bianchi, Textbook of Insanity (Eng. trans., 1906); Clouston, Mental Diseases (6th ed.); Krafft-Ebing, Textbook of Insanity  (American trans., 1904); Kraepelin, Psychiatrie (6th ed., Leipzig, xx. 25 1899); Magnan, Le Delire chronique (Paris, 1890); Stewart Paton, Psychiatry (Philadelphia, 1905); Percy Smith, " Paranoia," in Journ. of Mental Science (1904), p. 607. (J. MN.)