What is paranoia: symptoms and signs

Paranoia - what kind of disease is it, how does it affect the life of a person and the people around him. What is the urgency of the problem? What are the main causes and signs of paranoia, what is its differential diagnosis based on? Is it possible to effectively treat this disease? The answers to these questions are offered by the Chief Medical Doctor, practicing psychiatrist, psychiatrist-narcologist and psychotherapist Vladislav Sipovich.

What is paranoia and how relevant is its problem?

Paranoia, translated from Greek, literally means “next to the mind,” which can be regarded as a deviation from normal thinking towards exaggeration of one’s own personality and the ideas it produces while maintaining the logic of judgments. A person actually retains the ability to reason, but all his thoughts are aimed exclusively at proving his significance and recognition by society of his extremely valuable ideas. At the same time, self-criticism is practically absent, but the critical attitude towards people who do not share the idea of the exclusivity of the patient himself is literally off scale.

Paranoia is a rare type of chronic mental disorder that develops mainly in people who have reached adulthood. According to statistics, among patients undergoing treatment in psychiatric hospitals, the proportion of patients with paranoia is only 0.5-1%, and among all mental disorders it is 2-4%. Perhaps such low statistics are due to low detection, which in turn is associated both with the difficulty of differential diagnosis and with the patient’s non-recognition of his painful condition and maintaining the ability to integrate and function in society. A paranoid person is a person who is convinced of the value of his ideas and the prejudiced attitude of others. Attempts to prove the irrationality and unreality of the thoughts put forward by a paranoid only cause anger, distrust, hostility and even aggressiveness not only towards strangers, but also to close people themselves, as well as to specialists trying to help. Establishing contact with such a patient is extremely difficult and requires at the initial stage a partial recognition of the super-value and uniqueness of even the most crazy ideas. Paranoia is a disease that has such features as: • Gradual development without aggravating the pathological dynamics of symptoms and without increasing personality changes. In practice, this means the absence of apathy, decreased vitality, and abulia (loss of will and motivation). The patient’s nervous and energetic potential remains invariably high, aimed at achieving the goal, and internal dissatisfaction finds a way out in conflict with the outside world and the fight against imaginary injustice. • Logical validity and consistency of false ideas, which is almost impossible to refute. All objections have seemingly logical antitheses. • The theme of ideas is usually monodirectional, i.e. concerns a certain sphere of knowledge and activity of society. A classic example is graphomania, when a person, having once achieved the publication of his poems or stories, begins to consider himself an outstanding and unsurpassed poet or writer. The constant refusals of publishing houses to publish his “masterpieces” are perceived as the machinations of envious people, unprofessionalism and bias of editors, publishers, etc. It is almost impossible to prove the inconsistency of a paranoid’s claims, because he takes criticism as a personal insult and reacts with extreme hostility. Switching to another topic is uncharacteristic; the patient persistently achieves his goal and attacks various publishing houses ad infinitum. All these ordeals last for years and decades, causing extreme anger and hostility towards the whole world. • No hallucinations, e.g. distortions in the perception of reality. By the way, experts do not have a consensus on this matter; many sources acknowledge the existence of various types of illusions in paranoids, but usually these symptoms are observed in combined mental disorders, for example, paranoia-like delusions in schizophrenics. These phenomena have nothing to do with classical “pure” paranoia. • Consistent and generally predictable behavior based on the formal connection of many real elements with the false beliefs of the paranoid.

A patient with paranoia is characterized by extreme suspicion, blaming imaginary enemies for his failures, and a tendency to construct conspiracy theories against him in his imagination. The urgency of the problem is that one paranoid person can complicate the lives of many people, including not only those closest to him, but also those to whom he turns with his “projects”. The interests of a paranoid person include officials, specialized specialists, writers, directors, producers, public figures, judicial authorities, etc. Received refusals to satisfy requests and logical explanations do not stop the paranoid, but only strengthen his persistence. Sometimes he turns into a manic pursuer and may even descend to physical violence against those who refuse his protection.

Symptoms

Paranoia is a serious condition accompanied by a pathological mania of persecution that occurs in a paranoid person due to mistrust and the expectation of a threat from people around him. In simple words, this is the development of delusions of grandeur that arise in a person when overvalued or delusional ideas appear, associated with confidence in one’s own exclusivity and the presence of unique abilities, underestimated by others.

The first symptoms of paranoid personality disorder appear in a child aged 7-10 years and are associated with the development of excessive suspicion and significant overestimation of one’s physical or mental abilities. Children suffering from this pathology are disdainful of the people around them, have practically no friends, conflict with teachers, and are distinguished by rancor and resentment.

With age, the symptoms of the disease worsen, reaching their peak at 30-35 years of age. At this age, the patient gradually develops highly valuable ideas related to the circumstances of his life, and any criticism is perceived as a feeling of envy and provokes an aggressive reaction.

As paranoia develops, it manifests itself:

rigidity of the psyche and the development of stable “black and white” thinking;
a tendency to perceive unfriendly or neutral actions of surrounding people as potentially hostile;
confidence that those around them constantly want to use the patient for their own purposes, taking advantage of his property, the results of physical or mental labor;
pathological jealousy and confidence in the infidelity of one’s partner, despite the lack of evidence of infidelity.
excessive arrogance and sensitivity to criticism from others.

In any actions of others, including those performed by accident. A paranoid person tries to find malicious intent in everything, for example, believing that colleagues deliberately conspired to prevent his promotion, and neighbors are renovating the house only to force him to leave their home.

Such confidence becomes the cause of constant quarrels and conflicts, and the intolerance, inadequacy and belligerence of the paranoid force him to file complaints against imaginary enemies to various authorities, provoking endless legal proceedings.

Paranoid people take criticism very hard. They also do not know how to forgive any offense, even an accidental one. For such patients, fictitious or real minor damage becomes the reason for a long, protracted conflict, forcing the offender to repeatedly apologize. For a paranoid person, disrespect is the basis for a sudden outburst of uncontrollable anger, an immediate counterattack, or carefully planned plans for revenge.

Patients with paranoid disorder are prone to prejudice, attributing negative intentions to others that appear in their own fantasies. Being biased towards the collection of information, they manage to build their own logical and consistent picture of what is happening, excluding from it aspects that are undesirable for themselves.

Gradually transforming into persecutory delusions or delusions of grandeur, the ideas created by the paranoid force him to believe in his own uniqueness and the presence of outstanding abilities (artistic, mental, acting), the implementation of which is hindered by the malice and envy of others who specifically do not read his works or refuse film roles.

A patient with paranoia believes that he is constantly being watched, wanting to cause harm, while the presence of delusions of grandeur prevents him from sharing his suspicions, forcing him to hide his delusional system even from his closest relatives.

The emotional background of such people is poor and monotonous, and the predominant emotions are anger, irritation, indignation, disappointment and dissatisfaction. Empathy, responsiveness and a sense of humor in paranoid people are very weak or completely absent. Such people are characterized by a disdainful attitude towards the weakness of others and admiration for strength and power.

In severe cases of paranoia, a person quits his job in order to control the actions of his spouse, bring his “superideas” to life, or seek justice in the courts.

What is the differential diagnosis of paranoia based on?

If earlier in classical psychiatry paranoia was considered for a long time as an independent disease, then according to the modern international classification of diseases, 10th revision (ICD-10), it is not classified as a separate category, but is classified under the subcategory of delusional disorder. Paranoia should be differentiated from similar paranoid (paranoid) personality changes. The latter often accompanies many mental disorders, in particular schizophrenia, paraphrenia, social phobias, anxiety disorders, post-traumatic stress and borderline states, and alcoholic psychoses. The difference between paranoia and paranoid personality disorders (hereinafter BPD): • Paranoia is characterized by following one idea, for example, if a paranoid person is convinced that a neighbor is harming him, then he will not communicate with him, maintaining communication with another environment. A hostile and aggressive attitude towards certain people develops when they do not recognize the patient’s highly valuable ideas and when they make critical statements about him. With paranoid disorder, distrust of everyone and everything comes to the fore; colleagues, the CIA, the FSB and the whole world can be the objects of distorted ideas. At the same time, the presence of an initial extremely valuable idea is not at all necessary. • Paranoia is always distinguished by a consistently constructed and logically connected system of ideas, which is based on the acceptance of some idea as an axiom that does not require proof. Otherwise, thinking retains its rationality and allows paranoids to exist and function normally in society. They usually do not make friends, but they can have family relationships. In BPD, delusions are unsystematized and inconsistent. • In paranoia there are no hallucinations or illusions. Paranoid disorder is characterized by a distorted perception of reality. • Paranoid disorders are much more common than paranoia. For example, in the USA, about 2-4% of the population suffer from more or less severe mental disorders of the paranoid type. This is due to the fact that the very concept of BPD is broader and includes paranoia itself, endogenous (paranoid schizophrenia) and exogenous (provoked by stress, an unusual situation, etc.) paranoid psychoses. • With BPD, there is a progressive change in personality, which can lead to complete disorganization of thinking, which is not typical for classical paranoia with the preservation of structure, consistency and logic of thought processes. • The cause of paranoia is unknown. There are only hypotheses about genetic predisposition, but the gene itself responsible for its development has not been found. An external trigger that starts a psychopathological process can be any event, which is extremely difficult to identify. A number of factors predispose to the development of paranoid disorder. These include schizophrenia and delusional disorders in close relatives, problems of upbringing in a family with the use of violence, totalitarianism and increased parental care, as well as limited communication due to physical defects or illness. In fact, paranoid disorder is formed as a hypertrophied instinct of self-preservation, which leads to isolation, pathological suspicion and distrust of close and distant surroundings, constant readiness to defend against hostile, harmful persons and events. In addition, hallucinogens, amphetamines, alcohol and other chemicals can cause transient paranoia-like disorder. Only an experienced specialist can differentiate paranoia from paranoid disorder. Moreover, there is no complete clarity on this issue in psychiatry. The importance of the problem is that the choice of an effective method of treating it depends on the nature of the mental disorder.

Causes

Paranoia is, in simple words, a severe form of psychosis that combines illogical and delusional ideas characteristic of mental disorders while maintaining a normal way of thinking, emotional background and mental abilities.

This pathology can occur both in childhood and at the age of 25-30 years, and the exact reasons for its development by specialists have not yet been established. There are several theories regarding the development of paranoid personality disorder:

Evolutionary theory

Proponents of this concept call the disease the result of a long-term stable behavior associated with the ability to survive, inherent in all representatives of the animal world. Proponents of this theory defined this principle for humans as “survival of the fittest,” where it is necessary to clearly separate the concepts of “black” and “white,” “us and foes.” This concept determines the characteristic tendency of a paranoid person to become angry and distrustful of others, causing him to fear for his life.

Hereditary theory

In an attempt to explain the development of paranoid personality disorder, scientists have repeatedly conducted studies of twins, establishing as a result that paranoia is equally inherent in each of them.

Scientists have not yet established the mechanism for the development of paranoid traits, but experts suggest that the disease is more common in people whose relatives previously suffered from schizophrenia.

Psychological theory

Psychiatric experts associate the development of paranoia with:

with humiliation and physical punishment that the patient faced in childhood;
living in a family with overly demanding parents;
with maternal or paternal overprotection.

According to this theory, the main reason for the development of paranoid disorder is the patient’s trust in his parents, undermined in early childhood, which gradually transforms into distrust and suspicion of all people around him.

Medical concepts of disease development

From a medical point of view, it is believed that the appearance of paranoia is associated with a disorder of protein metabolism in the brain, provoked by both pathological changes and unfavorable (stressful) life situations.

Thus, paranoid personality disorder can occur due to:

development of a depressive state;
low self-esteem;
strong feelings;
feelings of loneliness and forced isolation from society;
taking medications;
abuse of alcohol, narcotic or psychotropic substances;
Alzheimer's or Parkinson's disease;
as a result of a previous stroke, epilepsy or encephalopathy.

The delusional ideas that arise in the patient are closely related to his character and personality type. His value system does not coincide with the real world, which causes a conflict with others, causing the paranoid to believe that enemies live around him, constantly weaving intrigues.

The main desire of the patient is to achieve a significant place in society, but persistence and aggressive actions not only do not help the paranoid, but also pushes him away from the surrounding society, leading to complete isolation from society and immersion in his inner world.

What types of paranoia are there?

The classification of individual types of paranoia is based mainly on the prevailing fixed idea. Depending on this, the most common forms of paranoia are distinguished: • Involutional paranoia, which develops at the mature age of 45-60 years, in women often coinciding with the menopause. It is characterized by systematized delusions of persecution, jealousy, and, less often, grandeur. The onset is usually acute, the course is long, and treatment is inpatient. • Paranoia of grandeur, or megalomaniacal with ideas of reforming society, science and art, as well as invention and “great” discoveries. • Paranoia of jealousy is based on the dogma of adultery or adultery. Moreover, betrayal does not need to be recorded and proven, but is accepted as an axiom. No arguments from the other half can shake the confidence of a pathological jealous person that he is right. Initially, the patient accuses the partner of coquetry, the desire to attract the attention of people of the opposite sex, cheeky behavior, shameless snuggling while dancing, and even a bashful reaction to compliments. This continues for several years, after which suspicions develop into a firm belief in treason. • A religious form that develops against the background of religious beliefs. • Erotic paranoia, in which the main content of delusional ideas is erotic fantasies. It develops mainly in women between 40 and 50 years of age. • Persecutory form – paranoia with systematized delusions of persecution. • Senile paranoia of old age, often coinciding with senile dementia, Alzheimer's disease, Parkinson's disease and other degenerative diseases of the brain. • Alcohol paranoia, which is a chronic psychosis caused by alcoholic encephalopathy. Most often it occurs in men and is manifested by delusions of jealousy and/or persecution. There are other types of paranoia, for example, with delusions of a complainer or hypnotic charm, but they are much less common.

How is the disease paranoia treated in psychology?

A psychiatrist treats paranoia. The main method of treatment is medication. Groups of drugs that a doctor can use:

antipsychotics are drugs that block dopamine receptors. In simple words, they inhibit the development of delusional ideas by reducing the chemical activity of the brain;
tranquilizers - reduce anxiety during persecution paranoia;
antidepressants - normalize mood if paranoia is accompanied by severe depression.

The doctor prescribes medications individually - each drug has several effects at once, and thanks to experience, a competent psychiatrist can quickly select adequate therapy. Read more about treating paranoia.

The prognosis of the disease depends on the character of the person and his willingness to make contact. Paranoia is a disease that tends to be protracted. But this does not mean that it cannot be dealt with. If you follow the recommendations of your doctor, it is quite possible to reduce the severity of symptoms or get rid of them altogether.

What are the main signs of paranoia and its clinical picture?

The main symptoms of paranoia include such mental manifestations as: • The presence of overvalued ideas that become fixed ideas and haunt the patient throughout his life. At the same time, paranoids are as persistent as possible, spending all their energy and finances on proving the importance of their invention, discovery or method of reforming society. The literature describes a case when a man from Vladivostok “discovered” a new method of fishing, taking into account the location of the stars. He came to Moscow, knocked on the thresholds of various authorities, which gradually began to ignore him, went down and even spent the night at train stations. At the same time, the fate of his family abandoned in Vladivostok - parents, wife and children - did not bother him at all. • Overestimation of the role of one's own personality, leading to delusions of grandeur or persecution. In the first case, the patient considers himself capable of benefiting all of humanity, and in the second, that all the forces of the world are directed against him. For example, a neighbor's dog barks because the neighbors tease her to spite him, March cats yell specifically to disturb his sleep, children in the yard make noise in order to annoy him, etc. • Pathological suspicion, in which a person sees in everything the machinations of enemies and ill-wishers. He connects even the most insignificant events into a conspiracy theory he has built against himself. All this is accompanied by suspiciousness, rancor, vindictiveness, an inadequate assessment of criticism and a complete lack of a critical attitude towards one’s own actions. The patient does not accept other people's opinions; it is useless to prove the fallacy and inconsistency of his ideas. The paranoid person is convinced that everyone around him wants to harm him, take away his property, downplay his merits, exploit him and try to manipulate him in their own interests. As a result, a hostile attitude towards everyone around is formed, which, during an attack of acute paranoia, can turn into aggressive actions and make the patient dangerous even for the closest people. • Extreme susceptibility to stressful situations. The state of passion lasts a long time and with any memory of it “comes to life with renewed vigor. Even if a paranoid person does not show his emotions, then only with an eye to future revenge, because... he does not forgive insults. One’s own failures and mistakes are experienced very acutely due to wounded pride. Paranoids are extremely ambitious, characterized by arrogance and a tendency to overestimate their abilities and achievements.

What is the difference between paranoia and paranoid disorders?

As has already been clarified, paranoia and paranoid disorders are different diseases. What symptoms of paranoia will help distinguish it from other diseases? Here are some examples:

With paranoia, there is one obsession and thought. For example, it seems to you that your work colleague wants to set you up. Therefore, all working moments are accompanied by this single thought. When you are upset, it seems that all the people around you want to set you up and deceive you. That is, there is a large-scale manifestation of the disease;
The paranoia itself is very logical and consistent. That is, the patient builds a fairly reasoned sequence and cause-and-effect relationships between the delusional idea and the surrounding circumstances. Delusional disorders have no logic and no relationship with events;
Paranoia does not imply the occurrence of any hallucinations or real distortions of reality. In disorders, delusions and hallucinations are observed together.

What are the main ways to treat paranoia and how should others behave during an attack of paranoia?

Paranoia is a psychiatric illness that is very difficult to treat. This is explained by the fact that, due to his supernatural suspicion, the patient does not trust anyone or anything, spreading his suspicions to the doctor and the drugs he prescribes. He perceives psychotherapy as another attempt to manipulate his consciousness. In addition, the paranoid person categorically denies the painfulness of his condition, and loved ones who prove the need for treatment are transferred by the paranoid person to the category of “enemies.” The need for treatment becomes especially acute if a person ceases to be socialized, which is manifested by a readiness to isolate himself from the “persecuting” society or even to attack an object that he believes is harmful. This transition from the passive course of the disease to the active phase is an indication for inpatient treatment. In case of an attack of paranoia, it is necessary to call an ambulance, and unnoticed by the patient. Before the arrival of a specialized team, do not contradict the patient under any circumstances, accept his position and even play along slightly. Don't try to prove anything or appeal to common sense. This is useless and even dangerous, since the delusions of a paranoid cannot be corrected. If the arriving specialists cannot stop the attack and relieve psycho-emotional stress on the spot, the patient is hospitalized. In case of chronic paranoia, outpatient complex treatment is indicated, the main element of which is drug therapy with the use of anti-delusional antipsychotics. Their action is aimed at normalizing the exchange of neurotransmitters and blocking the excitation of nerve centers responsible for the symptoms of paranoia. The prescription of other pharmacological drugs is symptomatic in nature and is aimed at eliminating the symptoms of paranoia that prevail in a particular patient. For example, antidepressants are used to relieve depressive moods, tranquilizers to eliminate fear and anxiety, and sleeping pills to normalize sleep. An additional and important area of comprehensive treatment of paranoia is psychotherapy. It is aimed primarily at restoring socialization and eliminating elements of irrational behavior in patients with paranoia.

At the first stage of treatment, the main thing is to establish contact and trusting relationships with the patient. This is extremely difficult to achieve, but it is possible. If the patient himself has decided to undergo treatment and correctly assesses his condition, this is already half the success in getting rid of paranoia. Unfortunately, such a development of the situation is rarely observed. Most of these patients remain outside the attention of psychiatrists and psychotherapists (what is the difference between a psychiatrist and a psychotherapist) for a long time, sometimes for decades. If, during an exacerbation, situations arise that are life-threatening to the patient himself (auto-aggression) and/or his environment, then only then does treatment begin, usually in an inpatient setting. The choice of drugs, as well as psychotherapeutic methods of correction, depends on many factors - on the general physical condition of the body, mental characteristics, gender, age and basic symptoms.

When taking medication, it should be borne in mind that abruptly stopping medication can lead to the so-called withdrawal syndrome, when, after stopping treatment, the symptoms of the disease return again and sometimes with greater force than before treatment.

Only drug therapy, not supported by psychotherapy, is not capable of completely returning the patient to normal life in society. It is possible to achieve stable and long-term remission only with the use of both methods of therapy - medication and psychotherapy. The most effective treatments for paranoia include Gestalt therapy, cognitive behavioral therapy (CBT) and psychodynamic psychotherapy. Unfortunately, paranoia is a disease that takes a long time and is difficult to treat, sometimes for 10 years. If treatment is carried out on an outpatient basis, then it is important to take medications according to the regimen developed by the doctor, regular psychotherapy sessions, follow the recommendations of the psychotherapist, use the acquired communication skills, and after achieving remission, periodic consultations with the specialist supervising the patient.

Diagnosis and treatment of the disease

Diagnosis of paranoia is carried out by a psychotherapist based on the results of a conversation with the patient, collecting data about the patient’s medical history and identifying characteristic personality traits that persist throughout his life. Of particular importance for establishing a diagnosis are also the reasons for the appearance of the “superidea”, the principles of its formation and the logical conclusions underlying it.

When deciding on a diagnosis, the specialist also needs to separate paranoia from:

paranoid personality disorder, which is characterized by distrust of others and “superideas”;
isolated delusional disorder (in the presence of delusions);
schizophrenia.

Treatment of the disease is carried out on an outpatient or inpatient basis and consists of prescribing:

antipsychotics with antidelusional effect;
tranquilizers;
antidepressants.

Since patients rarely realize their problem, psychotherapy here is an ineffective method that requires a long process of building trusting contact between the specialist and the patient. Most often, a paranoid person treats the doctor as his enemy, so the decision to conduct psychotherapy is decided in each case individually.

The following sessions are considered acceptable for the treatment of paranoid personality disorder:

family therapy;
cognitive behavioral therapy;
hypnotherapy.

In addition to the patient himself, the psychiatrist also works with the patient’s relatives, teaching them to avoid critical remarks towards the paranoid person, fill the patient’s life with positive moments and turn conflicts into a humorous direction, thereby preventing their aggravation.

As we saw in the chapters on schizophrenia and paraphrenia, the position of paranoia has always been unclear. In a certain period of development of psychiatry, mainly before Kraepelin, it was understood very broadly, and it included many cases that later came to be regarded as a paranoid form of dementia praecox. Due to the fact that the latter soon grew to very large proportions, and cases that were quite diverse in symptoms and course began to be included in it, Kraepelin proposed to identify some cases with long-term preservation of mental alertness and a certain height of intelligence under the name paraphrenia. It must be said, however, that the position of this group turned out to be as precarious as the paranoia of the pre-Kraepelin period or its paranoid form of schizophrenia. It turned out that many cases of paraphrenia essentially belong to schizophrenia, some should probably be attributed to protracted forms of a manic state of circular psychosis; Finally, there are cases that occupy a special position and constitute a relatively small group that deserves the name of paranoia. According to Kraepelin’s definition, it is characterized by the fact that, on the basis of a peculiar predisposition, with full preservation of meaningfulness and correctness in thinking, feeling and behavior, a persistent system of delusions slowly develops, representing the processing of life experiences. Despite the sometimes quite significant similarity with the paranoid form of schizophrenia and paraphrenia in the paranoia group, we are talking about completely different essentially pictures with a different genesis and different mental mechanisms. There is always a certain, although very slowly growing, weakening process, and in the genesis of delirium the main role is played by altered organic sensations and hallucinations. Delirium is established due to the fact that the perception of the surrounding world changes, and the degrading intellect cannot cope with new sensations and hallucinations and makes errors of judgment. For paranoid forms of schizophrenia, cathethetic delusional formation is typical, suggesting the presence of a weakening of the intellect. What is significant here is that the delusion of a schizophrenic is not organically united with his entire personality, appears to be some kind of heterogeneous formation, and often appears to the patient himself as something alien, parasitic. With paranoia, pictures of delusions similar in content develop as a kind of reaction of a painfully sensitive personality to actual events. The driving force in this case is not changes in the world of sensations, but the needs of feeling, due to which the very genesis of delirium can be called catathymic.

The question of the genesis of delusions in paranoia and related questions about the scope of the concept itself and the delimitation of paranoia from other diseases have received a lot of attention in recent years. Kehrer and Kretschmer attach the most importance to emotional moments and think that the conflicts underlying paranoia differ from hysterical ones only in their great depth and affect the vital layer of the personality, while hysterical ones proceed more superficially. Kehrer also talks about disorders in the area of personality drives, the dynamics of which are determined by contrasting experiences, and social aspects play a role. Schultze strives to further clarify the concept of “conflict,” which plays a role in the genesis of paranoia. According to his formulation, the paranoid constitutes his delusion from the contradictions between the desire for social inclusion of himself in society and for the recognition of the value of the individual, on the one hand, and from the insufficiency caused by a painful predisposition that has been revealed in life, on the other.

Lange, developing the concept of his teacher Kraepelin, accepts the presence of a unique, constitutionally determined nature of reaction, the same for all cases of paranoia. The role of constitutional aspects, however, is not denied by other authors, but still the main one should be considered a special paranoid development of the individual with a change in attitudes towards everything around him: the delusion itself is not a central, axial disorder, but only a regional one and to a certain extent optional, so how with a change in life situation it can smooth out or even disappear. In the above definition of Kraepelin, it is undoubtedly necessary to make a significant amendment, namely by rejecting the criteria of persistence, the inaccessibility of delirium for correction, in view of the fact that, as Kronfeld and V. Shterring rightly point out, this persistence, although it is a commonly observed clinical fact, does not indicate the very essence of delirium. In general, delusions with paranoia develop in the presence of two factors: a peculiar inclination towards paranoid attitudes of the individual and an unfavorable situation. As for the first point, here we have people who, from their youth, have revealed certain features of their mental makeup in the sense of great pride, egocentrism, increased self-esteem, a tendency to fantasy and the search for truth, for whom not everything is smooth in their sexual life and who do not adapt well to surrounding life. These features, which distinguish the patient from those around him, themselves create a situation in which the patient becomes in a special position in relation to others, which, with his increased self-esteem and sensitivity, gives him reason to somewhat overestimate himself in comparison with others and assume that he is not being given due, they envy him, strive in one way or another to belittle his dignity. In the presence of such mental characteristics, if life circumstances are not particularly favorable, the patient may develop distrust, suspicion, a tendency to interpret everything in a special way, see injustice everywhere, a conscious intention to harm him, humiliate him, and insult him as permanent character traits. Very often, painful phenomena remain throughout life at this stage of a paranoid nature, the manifestations of which, depending on life circumstances, either become aggravated or are largely smoothed out. Sometimes, in a particularly unfavorable situation, things can lead to painful shifts in the patient’s thinking with the formation of delusional concepts. The starting point is always some kind of conflict in life, a failure at work, an unsuccessful marriage, an unfavorable outcome for the patient in some legal case. The emotional reaction, which is an inevitable consequence of an unpleasant experience in every person, in this case is usually especially emphasized due to increased sensitivity and leads to an intensification in the patient’s character of those features that prevent him from giving a correct objective assessment of the case. Morbid resentment and conceit often push the patient to various wrong actions, aimed at eliminating the unfavorable consequences of the case for him, but usually leading to even more significant misunderstandings and grief for him. As a result, the suspicions that arose from the very beginning not only do not dissipate, but are increasingly strengthened, and even the most insignificant events and in no way affecting the interests or pride of the patient begin to be regarded as delusional. In this way, persistent delirium develops, which, under circumstances unfavorable for the patient, grows like a snowball. Hallucinations usually do not occur in such cases, and they cannot play any role in the formation of delusions, but the illusory nature of perception is of a certain importance. It often seems to the patient that the persons whom he suspects of having an incorrect attitude towards him are making some signs to each other, whispering to each other. On the other hand, false memories and memory errors are of great importance, due to which the past is distorted in the direction that corresponds to the patient’s delusional attitudes. For example, it seems to him that the facts that he himself reported at one time are distorted by his opponents, that the protocol on which his own signature is, is forged, etc. The development of delirium undoubtedly requires intellectual changes for itself, often original, but in in any case, not of the nature of dementia in the usual sense. The formal abilities of the intellect, memory, consideration, criticism remain at the same height, just as the external correctness of the patient’s behavior is preserved. Thanks to all this, the patient, at least up to a certain point, gives the impression of a completely sane person to everyone around him. In the views of a paranoid, however, it is always possible to state that the judgment is erroneous, and, moreover, in the most basic points. Some kind of shift in mental mechanisms that makes the patient’s logic crooked, does not give him the opportunity to see the true state of affairs and pushes everyone to new erroneous conclusions. This is facilitated by the special gullibility of patients and the weakness of criticism that they reveal when they encounter facts related to I'm delirious about them. It matters that such patients always find people who sympathize and are convinced of the validity of their complaints about the injustices caused. These are usually the people closest to the patient, members of his family, who often, together with the patient, became victims of an unfavorable life situation. Sometimes in such cases we can definitely talk about induced delirium. Such people who sympathize and assent to the patient often themselves look for various facts that confirm the assumption of the patient, who in this case shows special gullibility, accepting these facts without any criticism. Since delirium always develops as a reaction to painful experiences, the source of which can be the life situation itself, sometimes one has to take into account such moments that for some reason put the patient in a particularly disadvantageous position for him. Dependence on others and a low position may be important, as a result of which paranoia can more easily develop in people of certain professions. According to pre-revolutionary data, paintings of this kind were relatively often owned by governesses. Specht includes here folk teachers whose increased sense of self-esteem, if observed as a constitutional feature, does not find sufficient satisfaction in the attitudes of those around them (we are talking about Germany).

To get acquainted with the essence of paranoia and the mechanisms of delusion formation during it, it is very interesting to get acquainted with the history of one typical case described by Gaupp and known to all psychiatrists under the name Fall Wagner.

At about 5 o'clock in the morning on September 4, 1913, the senior teacher in the village of Degerloch, Ernst Wagner, killed his wife and four children, stabbing them to death with a dagger while they were asleep. Covering the corpses with blankets. Wagner washed, got dressed, took with him three revolvers and over 500 cartridges and set off by rail to the place of his former service - the village of Mühlhausen. There he set fire to several buildings, and then ran out into the street and, holding a revolver in each hand, began shooting at all the residents he encountered. As a result, 8 people were killed by him, and 12 were seriously wounded. Only when he had shot all the cartridges he had at the ready and the revolvers were empty, they managed to disarm him in a difficult struggle, and he received such serious injuries that at first he seemed dead. Due to the strangeness of the motives put forward by him to explain this bloody crime, a psychiatric test was carried out on him, which gave the following results.

Wagner turned out to be extremely burdened by heredity on both his father's and mother's sides. As a child, he was a very sensitive, O5ID and proud boy. Extreme truthfulness did not leave him even if he was threatened with punishment for telling the truth. He was scrupulously true to his word. Very early on, he developed an attraction to women, a rich and indomitable imagination, and a passion for reading. At the teacher's seminary where he studied, he was distinguished by spiritual independence, increased self-esteem, love of literature and extreme conscientiousness in relation to his duties. Early on, he acquired a hopeless outlook on life: “The best thing in this life is never to be born,” he writes as a 17-year-old boy in the album of one of his comrades, “but if you are born, you must persistently strive for the goal.” At the age of 18, Wagner fell into the grip of a vice that turned out to be fatal to his fate - under the influence of increased sexual excitability, he began to engage in masturbation. The stubborn struggle he waged against his weakness was unsuccessful. From that time on, his self-esteem and his frank truthfulness received a severe blow, and pessimism and a tendency towards hypochondriacal thoughts provided fertile ground for development. For the first time, his personality experienced a deep internal discord between the feeling of guilt and self-contempt that had now gained dominance in his soul and his former aestheticism, attraction to women and high opinion of himself. He began to suspect that his comrades noticed his secret vice and mocked him. However, this mental conflict did not have a noticeable impact on his successes and external relationships with people. He passed his first teacher's exam with flying colors and entered the service as a teacher's assistant. He established good relations with his fellow officers: they considered him a good-natured, although somewhat arrogant and too touchy young man. However, due to his conceit, he soon had a clash with the senior teacher, as a result of which he was transferred to another place - the village of Mühlhausen. He began to have relationships with women quite early. Nevertheless, despite all his struggle with this vice and attempts to be treated, he could not give up masturbation even at the age of 26-27 years. More than 10 years before the crime, under the influence of wine fumes - and at this time, in order to drown out the remorse of his conscience, he began to drink heavily - he, returning home from the tavern, committed sodomistic acts several times. Since then, the main content of his thoughts and feelings has been remorse for these disgusting acts. How did he, a man with artistic taste, with high moral aspirations, with his ambition and contempt for everything ignoble, succumb to such a wild unnatural attraction! The fear that his sodomy would be discovered again made him extremely suspicious, forcing him to fearfully, distrustfully look closely and listen to the faces and conversations of those around him. Already having this sin on his conscience, Wagner passed his second teacher's exam, and, fearing to be arrested, he always carried a revolver in his pocket - upon arrest he was going to shoot himself. The further he went, the more and more his suspicion grew. The thought that his relations with animals had been spied on began to haunt him. It began to seem to him that everything was already known and that he was under special surveillance. If they talked or laughed in front of him, then a cautious question immediately arose in his mind whether they were talking about him or whether they were laughing at him. Checking his daily observations and pondering their smallest details, he became more and more convinced of the validity of such thoughts, despite the fact that, according to his own words, he had never been able to hear a single phrase that would fully prove his suspicions. Only by comparing the views, facial expressions and individual movements of his fellow citizens or interpreting them in a special sense of the word, did he come to the conviction that all this undoubtedly relates to himself. What seemed most terrible to him was that while he himself was tormented by cruel self-accusations, cursing and executing himself, those around him mercilessly turned him exclusively into an object of universal ridicule. From that time on, the whole picture of life began to appear to him in a completely distorted form; The behavior of the peaceful inhabitants of Mühlhausen, who were not at all aware of Wagner’s spiritual drama, in his mind takes on the character of deliberate mockery of him. The further development of delirium is interrupted by Wagner's transfer to another village. Having accepted the transfer as a punishment, he still initially felt relief from the thought that no one would know him in his new place. Indeed, although even there deep darkness and melancholy dominated his soul, for 5 years he did not notice any ridicule of himself. During this time, he married a girl with whom he accidentally met, he married solely because he considered it impossible to refuse a marriage with a woman who became pregnant from him. Despite the fact that Wagner was now living a completely normal sex life, suspicion still demanded food, and gradually the old fears awoke again. Comparing the innocent remarks of friends and acquaintances, he began to come to the conclusion that rumors about his vices had reached here too. Of course, the culprits for this were the Mülchausens, who were not content with mocking the unfortunate man themselves, but needed to make him an object of ridicule in a new place. A feeling of deep indignation and anger began to grow in his soul. There were moments when he reached extreme levels of angry excitement, and only the thought of revenge, which began to mature in him from that time on, kept him from direct reprisal. His favorite subject of dreams now became a detailed discussion of his planned business. He developed the crime plan in great detail already 4 years before it was carried out. Wagner wanted to achieve two goals at the same time. The first of them was the complete destruction of his family - a family of degenerates, burdened with the shame of the most disgusting vice: “Everything that bears the name Wagner is born for misfortune. All Wagners must be destroyed, all of them must be freed from the fate that weighs on them,” he later told the investigator. Hence the idea of killing all his children, his brother’s family and himself. The second goal was revenge - he was going to burn the entire village of Mühlhausen and shoot all its male inhabitants for their cruel mockery of him. The bloody deed conceived by Wagner at first frightened him. To cheer himself up, he kindled his imagination and dreamed of the greatness of the task facing him, which now turned into a great mission for him, “the work of his whole life.” He armed himself with reliable weapons, learned to shoot in the forest, prepared a dagger to kill his wife and children, and yet, every time. Just as he was thinking of starting to carry out his plan, an irresistible horror seized him and paralyzed his will. After the murder, he told how often at night he stood at the bedside of his children, trying to overcome internal resistance, and how the moral impossibility of this matter scared him away every time. Gradually life became an unbearable torment for him. But the deeper the melancholy and despair become in Wagner’s soul, the greater the number of his enemies seems to him and the greater the task at hand. (The medical history in this part is taken from the translation given in the book by P. M. Zinoviev “Mental illnesses in pictures and images.”)

To understand the essence of changes in paranoia, the further fate of the patient is very interesting. After being declared mentally ill and insane by the court, he spent 6 years in a psychiatric hospital when he was again examined by Gaupp. It turned out that he retained mental alertness and correctness of behavior and did not show any signs of dementia or dullness. By all indications, the diagnosis of schizophrenia had to be rejected in the most decisive manner. There was no further development of delirium and, on the contrary, one could state a certain weakening of it and an awareness of the painfulness of at least some of one’s experiences. He told the doctor: “My criminal actions stemmed from mental illness... perhaps no one regrets the Mühlhausen victims more than me.” In this way, a significant part of the delirium, which arose on the basis of difficult experiences associated with life conflicts, was corrected in such a way that with a superficial acquaintance with the patient one could think of a complete recovery. In reality, the delusional attitudes remained the same, just as the personality retained its previous paranoid structure. The imprisonment and subsequent stay in a psychiatric hospital undoubtedly contributed to the calming of the patient and the paling of his delirium. During this time, he worked a lot, continued his previous literary and poetic experiments, and in particular wrote dramatic works, in one of which he made himself the hero; he also wrote a long autobiography. For understanding the genesis of delirium, it is important that the main role was played by a painful interpretation of actual facts that did not have the meaning that the patient attributed to them. His following statements are typical: “I could understand some conversations as if they were talking about me, for there are accidents and unrelated things that, taking into account certain circumstances, may seem to have meaning and a specific purpose; thoughts with which your head is full, you willingly place in the heads of others.” With such a seemingly critical attitude towards his most vivid delusional ideas, he retained his former suspicion and, at the slightest reason, began to think that those around him were making fun of him.

In the genesis of painful phenomena in this case, as is generally the case with paranoia, there was a combined effect of heavy heredity, relatively high talent, and mental influences associated with failures in life, which had a particularly strong effect on the young and proud teacher. In this case, the presence of proud ideas of greatness also deserves attention. In the descriptions of paranoia in the old sense, which can be found in old manuals on psychiatry, there are indications of the transformation of delusions of persecution into delusions of grandeur, which always seems to occur at a certain period of development. This transformation in the form of some kind of turning point in the disease, timed to a certain time, hardly ever takes place, but there is a grain of truth in the observations of old psychiatrists. Delusions of grandeur sometimes genetically seem to follow from delusions of persecution. The same Wagner speaks very clearly about this: “The delusion of grandeur that appears in my works represents a natural reaction to my depression.”

Paranoia in the sense that we now understand it is not a common disease. According to Kraepelin, 40% of all diseases characterized by paranoid symptoms are classified as schizophrenia, slightly more than this are paraphrenia, and only a small remainder is paranoia. According to Bumka, this remainder is estimated at 3-4% of all psychoses in this group. Bumke classifies the entire group of paraphrenia (in the textbook published in 1930) without any reservations as schizophrenia. The following table, taken from the monograph by K. Kolle (Die primère Verrücktheit, 1932), can give an idea of the relative frequency of paranoia and its position among other diseases. During the period 1904-1922, when Kraepelin was the director of the Munich clinic, for approximately 30 thousand patients admitted there were diagnoses:

Men	Women
a) Paranoia	12	4
b) Nonsense of querulists	10	3
c) Paranoid psychopaths	14	11
d) Prison paranoids	18	—
e) Induced delirium	2	2
f) Alcoholic delirium of jealousy	23	—
g) Delusions of persecution in people with hearing loss	12	13

The majority, approximately three quarters of the diseases, occur in men. The onset of the disease usually falls after 30 years of age.

Collet's 66 cases in this regard are distributed as follows:

Age……	30 l.	35 l.	40 l.	45 l.	50 l.	Over 50 y.o.
Number of cases...	3	2	17	15	14	15

As a rule, there is a severe hereditary burden. It is natural, therefore, that in the neuropsychic organization of a subject who subsequently develops paranoia, from the very beginning traits are discovered that give the right to talk about the presence of psychopathy. Relatively often, certain sexual perversions are observed.

The course of paranoia, as we saw in the example of Wagner, is chronic, partly gradual, but largely characterized by individual outbreaks associated with life conflicts.

In some cases, the emphasis has to be placed either on constitutional features, or on reactive changes, or on the painful development of the entire personality. Since situational aspects, which naturally can be very diverse, play a role in constructing the picture of the disease, the clinic of paranoia, understanding it even within the relatively limited framework in which paranoia is now understood, is quite diverse. Kehrer schematically reduces various paranoid pictures to the following groups:

1) habitual paranoid attitudes (other names—paranoid psychopaths or constitutions);

2) chronic, non-progressive paranoia;

3) paranoid reactions (paranoid situational psychoses and phases);

4) chronic, paranoid development.

The features of these forms are clear from the names themselves. Only two groups need explanation. Chronic, non-progressive paranoia occupies an intermediate position between constitution and development. In these cases, delirium, without further development, but also without correction, remains as something persistent for a long period of life.

According to our observations, paranoid pictures (paranoische Zustände Kehrer), in general with essentially the same genesis, i.e., reduced to a personal reaction to life experiences and to its unique development, can be observed against the background of other constitutions. It is especially easy to imagine the development of paranoid pictures against the background of an epileptic or epileptoid psyche with its sthenicity and egocentric attitudes. and with a tendency to get stuck on individual thoughts, especially from the category of overvalued ones. The same conditions can be found in cycloid individuals in old age. In the presence of a traumatic situation, we have seen several striking cases of both types.

In the past, when paranoia was understood very broadly, several separate forms were distinguished—typical delusions of persecution, religious insanity, erotic insanity, delusions of invention, etc. Genealogical study indicates their relationship with paraphrenia and, consequently, with schizophrenia. Typical delusions of persecution and clinical picture correspond to the so-called systematic paraphrenia. On the other hand, not so much according to the clinical picture, but rather according to the mechanism of development, delusions of litigiousness, or delusions of querulants, can be classified as paranoia. In this case, the matter begins with the fact that the patient very painfully perceives some kind of injustice actually caused to him, sometimes recorded by a court order. He considers it necessary to achieve justice, files complaints in court, seeks a trial of the case and, dissatisfied with its outcome, transfers it to a higher authority. He begins to think that the unfavorable turn of the matter for him is not accidental, but is explained by the machinations of his ill-wishers and direct enemies, who conspired among themselves, formed a whole gang, bribed judges, acted on them with threats and tried in every possible way to drown the patient. Increasingly worried by failures and suffering from his painful sensitivity from injections of pride, he loses his balance, he himself makes various injustices and mistakes, which further complicate his situation. All the time he is busy with his court affairs, carries with him a whole pile of papers, complaints, copies of court verdicts, certificates. It is natural, therefore, that his financial situation suffers more and more, since he is not able to engage in any productive work. This is how your whole life usually goes, and only physical weakening and loss of energy that comes with age bring a certain calm. However, if your life situation changes, for example when you move to another city, significant, albeit temporary, improvements are possible.

Recognizing Paranoia

When distinguishing paranoia from diseases that are similar in external form, one must remember the main symptom in this case—the development of delusions on the basis of painful personality development as a result of some painful collisions for the patient. If new delusional ideas arise that have no connection with the original conflict, then the diagnosis of paranoia becomes doubtful and one has to think about the paranoid form of schizophrenia or paraphrenia. The same doubts should arise in the presence of clearly expressed hallucinations, especially if they provide material for the development of delusions. The preservation of mental alertness and correctness of behavior should also be considered characteristic of paranoia, since delusional attitudes are not involved here. It is especially typical for paranoids that, despite the complex and extensive patterns of delusion, they usually turn out to be quite good practitioners and are very good at managing their personal affairs. This, of course, also speaks about the safety of their intelligence. It may present certain difficulties in distinguishing from some cases when delusional ideas also reactively arise in psychopathic individuals. Friedman and Gaupp talk about special mild, abortive and treatable forms of paranoia. In these cases, delusional ideas of persecution, sometimes with a hypochondriacal tinge, arise in persons with endogenous nervousness under the influence of external factors. Since in this case the matter is limited to individual ideas and, moreover, related more likely to the type of uberwertige Ideen, and not to delirium, and in relation to them a complete correction soon occurs, then one can hardly talk about paranoia here. It is also possible to differentiate from the delusional imaginations of degenerates. Litigative delirium must sometimes be distinguished from psychopathic debaters and so-called pseudo-queerulants. In these cases, in the presence of querulant inclinations, there is actually no delusion. The presence of a certain amount of excitement and increased emotionality in the delusions of querulants sometimes makes one think about distinguishing it from chronic mania, especially since Specht is inclined to see an internal affinity between both diseases. The roots of paranoid illness are seen in mistrust as a kind of mixed state of manic and depressive moments. Taking into account the conditions for the development of delirium, delimitation is generally possible. In relation to the delusions of querulyants, the most difficulties arise due to the fact that its individual components are simultaneously associated with different diseases. It is not surprising that not all psychiatrists accept its attribution specifically to paranoia. Kraepelin at one time considered it the only typical form of paranoia. Lately he attributed it to psychogenic reactions. It seems to us that Kraepelin’s original point of view, which is also supported by Bumke, is more correct, especially since we associate paranoia in general with psychogenic reactions on psychopathic grounds.

We can talk about treatment only in the sense of some kind of palliative measures. Changing your living situation, changing your job and place of residence can be helpful. Hospitalization, which is sometimes necessary due to a tendency to commit antisocial acts, usually worsens the course, contributing to the strengthening and development of delusions. Of the 66 cases carefully monitored by Collet, only 16 turned out to require long-term hospitalization.