11. Paranoid Disorders

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Paranoid Disorders 55

affective symptoms is brief relative to the total duration of the illness. In manic-depressive illness,delusions and hallucinations primarily occur during periods of mood instability.

A DSM-IV diagnosis of schizoaffective disorder requires an uninterrupted period of illnessduring w hich there is eithera major depressive, manic, or m ixed (manic and depressive) episod e that

is concurrent with active symptoms of schizophrenia. In addition, during the same period of illness,there are delusions or hallucinations for at least 2 weeks in the absence of prominent mood symp-toms, and mood episode symptomsa r e present for a substantial portion of the active and residualphases of the illness.

It is important to makeas clear a diagn osis as possible, as the cornerstone of treatment forschizophrenia is antipsychotic medications, whereas mood stabilizers and antidepressants are crucialin treating affective disorders.

15. Does significant depression rule out schizophrenia?Although the diagnosis of schizophrenia emphasizes that psychotic symptom s predominate over

mood sym ptom s, schizo phre nic patien ts may suffer significant depression, which stro ngly con-tributes to their increased suicide risk. Increased su icide risk may extend even after an episode of de-pression resolves, an d may result from the patients inability to com e to terms w ith the debilitatingeffects of schizophrenia.

Pharmacologic treatment of depression in schizophrenia is somewhat controversial, because an-tidepressants apparently reduce the efficacy of antipsychotic medications in acutely ill schizophrenicpatients. O n the other hand, adjunctive antidepressant medications have been show nto be effectivein the acute maintenance treatment of depression in schizophrenic and schizoaffective patients.

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BIBLIOGRAPHY

Adler LE, et al: Schizophrenia, sensory gating, and nicotinic receptors. Schizophr Bull 24:189-202, 1998.American Psychiatric Association: Diagnostic and Statistical Manualof Mental Disorders, 4th ed.

Buckley P F (ed): Schizophrenia. Psychiatr Clin N orth Am21 1), 1998.DeLisi LE (ed): Depression in Schizophrenia. Washington, DC, American Psychiatric Press, 1990.Hales R E, Yudofksy SC, Talb ott JA eds): The Am erican Psychiatric Press Textbook of Psychiatry, 3rd ed .

Kaplan HI, SadockBJ (eds): Comprehensive Textbook of Psychiatry, 6th ed. Baltimore, Williams Wilkins,

Tamminga CA (ed): Schizophrenia in a Molecular Age. Ann Rev Psychiatry 18(4), 1999.Yudofsky SC, Hales RE (eds): T he American Psychiatric Press Textbookof Neuropsychiatry, 3rd ed.

Washington, DC , American Psychiatric Association, 1994.

Washington DC, American Psychiatric Press, 1999.

1995.

Washington DC, American Psychiatric Press, 1997.

1 1 PARANOID D ISORDERSTheo C. Manschreck, M. D.

1. What are paranoid disorders?The term paranoid disord ers refers toa variety of conditions characterized bydelusions and re-

lated behavior. On e of the earliest described of these disorders was paranoia, now called delusionaldisorder, which is of unknown cause. The cardinal psychopathologic feature is the delusion.Paranoia actually is uncomm on; other forms are seen frequently.

There are two broad categories of paranoid disorders:disorders with known causes (medicaland substance disorders) andidiopathic disorders, which include delusional disorder, paranoid per-sonality disorder, shared psychotic disorder, atypical psychosis (psycho tic disorders not otherwisespecified), schizophrenia and schizophreniform disorder, mood (psychotic forms of mania and de-pression) disorder, and schizoaffective disorder.


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56 Paranoid Disorders

2. How did the term paranoia originate?The G reeks used the termparanoia (mean ing beside ones self) to designate a symptom that we

regard now as a nonspecific and gen eral feature of many mental disorders. The term was not used fo ralmost 2000 years until it was revived by Karl Kahlbaum, who in 1863 identified a disorder he calledparanoia. He described this condition as a form of partial insanity, which, throughout the course ofthe disease, principally affected th e sphe re of the intellect. Em il Kraep elin, a contemporary ofKahlbaum, was influenced by these observations. H e retained th e concept of paranoia as a separatedisorder in his groundbreaking classification of mental illnesses.

3. What is the current meaning of paranoid?In recent yearsparanoid has referred to a m ultitude of behaviors, fr om ordinary suspiciousness

to persecutory delusions. It a lso has been used to chara cterize grandiose, litigious, hostile, jealous,and even angry behavior, regardless of the fact that these behaviors may be w ithin the norm al spec-trum. The key principles for understanding the current m eaning of paranoid are:

1. It is a clinical construct used to describe various subjective and objective behavioral featureswhich are deemed to be psychopathologic. The se features are interpreted to b e abnormal based onevidence accumulated from patients and oth er informants. Th is judg me nt requires som e humilityand care. It is suppo rted by the occurren ce of specific features (see table) a s part of a behavior pat-tern which is extreme, intense, based o n false assertions, inappropriate, disturbing to others, andpos-sibly bizarre or dangerou s. Often the patient is convinced and resolute in hisor her belief; counterevidence and argum ent fail to persuade.

2. I t refers to no specific condition.For exam ple, the presence of paranoid featu res does notmean that a schizophrenic condition is present.

Features of Paranoid Disorders

Objective FeaturesAnger HateCritical, accusatory behavior HostilityDefensiveness HumorlessnessFragile self-esteem Hypersensitivity

ObstinacyResentmentSeclusivenessSecretiveness

Grandiosityor excessive self- Inordinate attention to small details Self-righteousness

Grievance collection Litigiousness (letter writing, Suspiciousn essGuardedness, evasiveness complaints, legal action) Violence, aggressiveness

Delusions of self-reference,persecution, g randeur, infidelity, love , jealousy, imposture, infestation,disfigurem ent, and disease

importance Irritability, quick annoyance Sullenness

Subjective Features*

Part of private mental experience. The patient often discloses these features duringthe clinical interview, butmay not do so, even with specific questioning.

4. How common are paranoid conditions?Paranoidfeatures are among the most com mon and serious manifestations of psychopathology.

They occu r in a variety of psychiatric and m edical illnesses and are, perhaps, the most frequently en-countered sym ptom s of severe psychopathology. However, the frequency of so me of the idiopathicconditions is less clear. Delusional d isorder may be uncom mon; shared psychotic disorder is consid-

ered rare. Atypical psych osis, because of its lack of specificity, is difficult to estimate. T he incidenceof organic delusional syndrom e (medical and substance disorders) is presumed to be common .The essential strategy in evaluating conditions in which paranoid features are presentis a com-

petent and thorough differential diagnosis.

5. What is the etiology of paranoid disorders?The etiology of paran oid disorders is largely unknown except, of course, in those cases for

which an organic factor can be isolated. Paranoid features, including the types o f delusions that are


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encountered in delusional disorder, occur in a large number of medical and psychiatric conditions.Many theories exist about the origin of delusions, but evidence to support them is limited.

6. Is there a neuropathology for the paranoid disorders?

Except for those conditions in which a specific organic factor can be identified, determining aspecific neuropathology or brain pathology to correlate with the psychopathology of the delusionalexperience is more hope than reality. Nevertheless, clues based on neuropsychiatric studies suggestwhere we might find some neuropathologic evidence. For example, patients who have severe corti-cal disorders, such as Alzheimers disease, tend to experience simple and transient persecutory delu-sions. Delusions of a more systematized, elaborate, and complex character tend to be more chronicand resistant to treatment and have been associated with subcortical neurologic conditions that gen-erally produce greater cognitive impairment than the typical idiopathic disorders.

7. Define delusional disorder.In recent years delusional disorder has become a better-recognized form of paranoid presenta-

tion. The term delusional disorder refers to a condition of unknown cause whose chief feature is anonbizarre delusion present for at least 1 month. The diagnosis of delusional disorder correspondsclosely to an older concept, paranoia, as formulated by Kraepelin and others over a century ago.There are several types of such delusions, and the predominant type is identified to make the diagno-sis. Minimal deterioration in personality or function and the relative absence of other psychopatho-logic symptoms have been considered important evidence for distinguishing this disorder fromschizophrenia and other psychotic conditions.

8. What are the clinical features of delusional disorders?The core feature is persistent, nonbizarre delusions not explained by other psychotic disorders.

The delusion may emerge gradually and become chronic, and sometimes is associated with a precip-itating event. Behavioral, emotional, and cognitive responses generally are appropriate, and neithermood disorders nor schizophrenic illness is present.

Delusional Disorder DSM-IV)

Nonbizarre delusion s) is., involving situations that occur in real life, such as being followed, poi-soned, infected, loved at a distance, being deceived by spouse or lover, or having a disease) of at least 1-month duration.

The symptom criteria for schizophrenia have never been met. Note: Tactile and olfactory hallucinationsmay be present in delusional disorder if they are related to the delusional theme.

Apart from the impact of the delusion s) or its ramifications, functioning is not markedly impaired andbehavior is not obviously odd or bizarre.

If mood episodes have occurred concurrently with delusions, their total duration has been brief relativeto the duration of the delusional periods.The disturbance is not caused by the direct physiologic effects of a substance e.g., a drug of abuse or amedication) or a general medical condition.

From the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. American Psychiatric Association,1994; with permission.

9. What is a nonbizarre delusion?Nonbizarre means that the delusion concerns situations that can occur and are possible in real

life, such as being followed, having a disease, being secretly in love, and the like.

10. List the types of delusional disorder.There are five main types and two residual ones.

Erotomanic: the predominant theme of the delusion is that a person, usually of higher status,is in love with the subject.


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58 Paranoid D isorders

Grandiose: the theme is oneof inflated worth , power, know ledge, iden tity, or special relation-ship to a deity or important fam ous person.Jealous: ones sexual partner is unfaithful.Persecutory: the person is being malevolently treated or con spired against in some w ay.

Somatic: the person has some phy sical defect, disorder, or disease.Mixed: more than on e of the above types are present but no on e theme i s predominant.Unspecified: the delusions do no t fit into any of the categories.

11. Why is it difficult to recognize delusional disorder?Delusional disorder is at best unco mm on; many clinicians probably have encountered o ne or

two cases, but many have not. It is difficult to recognize because o ne of its hallmarks is an absence,or modest occurrence, of psychopathology other than delusions. Such patients, if they are patients atall, are in all likelihood misdiagn osed, perhapsas having mild cases of schizophrenia. B ecause theymay seek o ut internists, d ermatolog ists, lawyers, or the police, they m ay never be diagnosed at all.

12. Which is the most common type of delusional disorder?

highly litigious and their delusions often are highly systematized (elaborate and detailed).Persecutory, which is also the classic form of the cond ition. Such individuals frequently a re

13. What features are characteristic of the jealous type?This type, som etimes referredto as the Othello syndrom e or conjugal paranoia, is comm on and

associated with dangerousness. Jealousy isa powerful emotion. Individuals with this delusion mayresort to assault, hom icide, even suicide in response to their delusional con cerns about a lovers un-faithfulness. It generally affects males, often with no history of psychiatric difficulty. The delusionsmay appear suddenly and serve to explaina host of remote and recent events involving thespouses fidelity. Th is type is p articularly difficult to treat, often d iminishing only up on separation,divorce, or deathof the spouse.

14. What is morbid jealousy or pathologic jealousy?These terms are used in relation to o ther disorders. Jealousy isa common symptom and may

derive from several conditions, su chas epilepsy, mood disorder, schizoph renia, or substance abuse.

15. What is another name for the erotomanic type?

disorders, such as schizophrenia.The erotomanic typeis called D e Clerambaults syndrome when th e sym ptom occurs in other

16. Describe the characteristic features of erotomania.It is the delusion of secret love, usually fro m an individual of high er social standing. Although

erotomania may o ccur in both sexes, it is more com mon in females. Such patients u sually pester, andpossibly harass, the object of their love w ith letters, phone calls, or unexpected visits. The delusiontypically concernsa more spiritual union or romantic love, rather than sexual attraction.

17. What behavior might a patient with the grandiose type of delusional disorder exhibit?

corner, proselytize their beliefs, or attem pt to associate w ith popular or em inent individuals.

18. List other names for the somatic type of delusional disorder.

delusion of infestation, and epiderm ozooph obia.

Th ese patients suffer from megalomania. Th ey are inclined to join cults, preach on the street

Mo nosymptomatic hypochondriac psychosis, mon odelusional psychosis, delusional parasitosis,

19. What are the characteristics of the somatic type?Som atic patients seek out professional attention for diseases they believe they have. When indi-

vidual tests fail to detect their diseases, they often moveon to other physicians, unable to respond


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to reassurance and the evidence collected in their evaluations. There are several patterns:1 ) patientsconcerned about parasites or insect infestation;( 2 )patients convinced that their body, nose, face, orhair has been altered; and 3) patients concerned that they em it foul bodily odors. Patients w ith suchdisturbances are mo re likely to seek help from derm atologists, exterminators, plastic surgeo ns, and

dentists than psychiatrists. Somatic conditions differ from simple hypochondriasis because of thedegree of reality impairm ent associated with them .

20. Define organic delusional syndrome.Organ ic delusional syndrome o r disorder refers to delusional illness for which a specific etiol-

ogy can be determined. It is a DSM-111 term that has been replaced in DSM -IV by psycho tic disor-ders du e to a g eneral medical condition or sub stance-induced psychotic disorder. In g eneral,many conditions arising f rom infectious, neurologic, toxicologic, m etabolic, or even genetic or ch ro-mosom al sources can be causative. They have been described in both case reports and other observa-tions for many years. For the clinician, of course, it is important to be aware of the most commoncauses, so that these can be identified and diagnosed rapidly.

21. What are the most common sources of organic delusional disorder?The m ost comm on form s of organic delusional disorder result from su bstance intoxication and

withdrawal. Usual substances are alcohol, stimulants (e.g, cocaine, amphetamine), sympath-omimetic agents, antihistamines, steroids, marijuana, and phencyclidine.

Common Causeso Organic elusions

Alcohol abuseDrug abuse (especiallyCNS stimulants)Iatrogenic: anticholinergic poisoning , steroid poisoning, diet pills, sedative-hypnoticwithdrawalDeliriumDementiaOther neurologic sources: human immunodeficiency virus(HIV) syndromes, brain tumors,

epileptic disorder, especially complex partial seizure disorder

22. What are the features of organic delusional syndrome?The essen tial feature is prom inent delusions resulting froma specific organic factor. The diag-

nosis is not made if the delusions occur in the context of difficulties in the maintenance of attentionor orientation, as in confusion (a syndrome referred to asdelirium . he nature of the delusions isvariable and, to some extent, depend s on the etiology of the d isorder. Persecutory delusions are prob-ably the most commo n type.

Amphetamine use, as well as that of cocaine and other stimulants, has been associated with thedevelopment of organic delusional syndro me, but other sources are unrelated to substance abuse. Ithas been f oun d in temporal lobe epilepsy (complex partial seizure disorder),as an interictal syn-drom e often indistinguishable from schizophrenia, and in cases of Huntingtons disease.Additionally, cerebral lesionsof the right hemisphere have resulted in this disorder.

Hallucinations may be present, but they are usually not the prominent characteristic. Associatedfeatures include mild cognitive impairment an d the presenceof various sym ptoms, many of themfound in schizophrenia, suchas perplexity, unusual dress an d behavior, abnormalities of psychomo-

tor activity, unusual speech, and dysphoric m ood. In contrast to delusional disorder in which impair-ment is uncomm on or modest, these conditions are associated w ith impairments in social, cognitive,and occupational functioning.

23. What is shared psychotic disorder?Also called induced paranoid disorder, double insanity(folie deux),and other terms, it was

first described by Lasegue and Falret in1877. It is believed to be rare, but accurate inciden ce an dprevalence figures are not available. The literature consists almost entirely of single case reports.


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The delusion is characterized by its transfer from on e individual to another. Involved persons mayhave been intimately associated for a long time and typically live in relative social isolation fromother people. In its most common form, the individual who first has the delusion is chronically illand is the influential m ember of a close relationsh ip with a mo re su gges tible person; the weaker

partner becom es the induced psych otic disorder patient. Typically the latter is less clever, moregullible, submissive, and passive, and lower in self-esteem.Old age, low intelligence, impairment of sensory function, alcohol abuse, and cerebrovascular

disease have been amon g the factors that have been associated w ith this peculiar disorder.A geneticpredisposition to idiopathic psychosis has been suggested as a possible risk factor.

There is some question asto whether such people are truly delusional or m erely highly im pres-sionable. Frequently, there is passive acceptance of the delusional beliefs of the dominant person,until they are separated, at w hich point the unusual belief may remit spontaneously. The criteria forthe diagnosis require an absence of psychotic disorder before onset of the induced delusion.

24. What is paranoid personality disorder?Paranoid personality disord er is a nonpsychotic condition involving a marked change in person-

ality traits as the indiv idual becomesa young adult. These traits include a pervasive and unwantedtendency to interpret the actionsof other people as dem eaning o r threatening. Behaviors include ex-pecting to be exploited, questioning the loyalty or trustof friends o r asso ciates, reading hiddenmeanings into benign remarks or events, bearing grudges, not confiding in others because of fearthat the information will be used against the person, tending to be easily slighted and quick to reactwith anger, questioning the fidelity of spouses o r sexual partners, and intense changes in m ood.Little is known about this disorders prevalence, association with familial transmission patterns, andpredispositions. Its relationship to schizophrenia and even to other paranoid disorders is also unclear.It is an interesting clinical phenom enon abou t which w e need considerably mo re information.

25. What is Capgras syndrome?In 1923, Capgras and R eboul-Lach aux described a synd rome consisting of the delusion that

doub les of impo rtant or significant others and of oneself exist.For example, the patient may claimthat his or her spouse has been replaced by an impostor. The syndrome is not relatedto hallucina-tions, simple misrecognition, or illusions. It is a delusion. In 198 3, Berson summarized 133 cases ofthis syndrome reported in the literature. H is conclusions were that the disorder appears in both menand women, over a wide range of ages, and with a wide range of other mental disorders. The mostcomm on diagnosis in suc h cases has generally been schizophrenia (about60 ); 23 of patientsidentified with this disorder suffered from diagnosab le brain disorder.

26. How important is the differential diagnosis?It is the most important process in the evaluationof patients with paranoid disorders. Most of

these disorders are, at the very least, uncom mo n, and theyare idiopathic. In addition, they have fea-tures characteristic of many medical and psychiatric conditions. Diagnosis of paranoid disorders re-quires the exclusion of other conditions an d the matching of the features of a particular c ase to theappropriate criteria.

27. What are the steps in forming a differential diagnosis for paranoid disorders?First, recognize, characterize, and jud geas pathologic those features that are identified as possi-

bly paranoid. Be sensitive to the range of subjective and objective characteristics frequently found inparanoid conditions. This step is critical as well as difficult because of the patients unwillingness toreveal him- o r herself in the proc ess of the interview or to coo perate with clinica l investigation.Careful interviewing of the patient and other informantsis usually the basis for determ ining that thebehavior is psychopathologic.

Second, having determined that a paranoid condition is present, evaluate premorbid characteris-tics, the course of the disease, associated s ymp toms, andso on. Im portant in this process is the dis-covery of confusion, perceptual disturbances, mood and m otor disturbances, signs of physical


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illness, or con fusing sym ptom s that may su ggest different cau ses for paranoid features. Isolatedacute symptomsof paranoid behavior often are present in early stages of medical conditions.

Third condu ct a com pete medical and psychiatric history, with special attention to alcohol anddrug use. A thorough p hysical examination includes neurologic and mental status exams and appro-

priate labor atory studies-particularly serolo gic, toxic, endo crino logic, and mic robio logic fea-tures-as well as radiograph ic and electroencephalog raphic investigations. W here possible, CT andpossibly M RI studies should be performed to identify structural brain disease (e.g, a tumor, or multi-infarct deme ntia) associated with psychopathologic changes.

28. What are the most important conditions to consider in the differential diagnosis?Certain conditions with delusional features should be routinely considered in a differential diag-

nosis because of their seriousness or frequency and because they are the most likely sou rces of delu-sional presentations.

Medical diseases and syndromes: typically feature a disturbance of perception, especially ofvisual or auditory functioning.Drug intoxications are particularly relevant; abused dru gs and evenprescribed drugs, such as steroids and L-dopa, have been kn own to cause delusional syndromes, oftenwithout cognitive impairment. Among elderly people,dementia should be considered. Mental statusexam should uncover th e characteristic cognitive changes that generallydo not occu r in delusionaldisorder. Delirium for example, has a fluctuating course, with confusion, memory impairment, andtransient delusions that contrast with thepersistent delusions in most idiopathic paranoid disorders.

Schizophrenia: should be considered when the delusions are bizarre; affect is blunted or in-congruent with thinking; thought disorder, if present, is pervasive; and role functioning is impaired.Paranoid schizophrenic patients may have somewhat less bizarre delusions than patients with othertypes of d elusions; however, their role fun ctioning is impaired, and auditory hallucinations areprominent.

Mood disorders: in particular, depression and m ania. Profoun d changes in moo d suggest de-pression. In paranoid d isorders, mood may b e depressed, but the change usually is not as over-whelming and pervasive as in depression. Delusions in depression frequen tly are related to themood of depression, the so-called mood congrue nt delusions. Th e key is to consider the associatedpsychop athologic features. Depression refers to a group of signs and sym ptoms, such as changes inappetite, sleep, libido, concentration, decisiveness, interest, and energy. Depression o ften is cyclical,and may follow a fluctuating course. It also may be associated with a positive family history.

Manic delusions often are grandiose and, therefore,to some extent mood-congruent. They usu-ally occur during severe stages of man ia and are relatively easy to recognize as part of the manic syn-drom e. Marked instability of mo od, intense euphoria or irritability, reduced need for sleep, increasedenergy, lack of inhibition, and increased activity levels distinguish mania from paranoid disorder.

29. Name other conditions that should be considered in the differential.Other personality disorder: paranoid features can occur in sch izoid and schizotypal personality

disorders as well as in paranoid personality disorders. The decisive distinction with mostof the otherparanoid d isorders is the presence of clear-cut delusions, hallucinations, and other psycho tic features.

Obsessive-compulsive disorder: delusions and hallucinations typically are absent in thesedisorders. F ears, rituals, rumination, and preoccupation are generally more pervasive and more likelyto influence functioning than in delusional or paranoid disorders.

Somatoform disorder: Body dysmorphic disorder may be difficult to distinguish. The degree

of conviction about imagined disfigurement may be helpful in making this distinction. Other psy-chopathologic features are more likelyto be present in som atoform disorders as well. Hypochon-driasis may present some difficulty in differential diagnosis. Patients almost always retain, however,some degree of uncertainty about their health concerns.

30. What principles apply to the differential diagnosis of elderly paranoid patients?In the elderly, the differential diagnosisis, if anything, even broader du e todisorders associ-

ated with aging. Although it is possible for idiopathic paranoid disorderso begin late in life, the


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likelihood is low. There is, however,a high risk for paranoid featuresto recur in depression, schizo-phrenia, and as a result of organic factors. Th e sudden on set of paranoid features shou ld be consid-ered a sign of m edical illness, possibly cerebrovascular disease, and an acute onset may b e aharbinger of acute organic delusional synd rome. The incidence of m any medical diseases associated

with paranoid features increases with age. Other sou rces of increased risk for paranoid disturbanceamo ng older individuals include a lack of stimulating company, physical illness, aging itself, and re-ductions in sensory functioning, suchas visual acuity and hearing.

31. Are laboratory tests of value in the assessment of paranoid disorders?Yes, they often are criticalto reaching a proper diagnosis. A range of assessments usually is nec-

essary, but som e are more likely t o detect key factors in particular cases.Drug screening measures(urine toxicology) are essential. Check for commo nly abused sub stances such as alcohol, marijuana,stimulants such as cocaine and amphetamine compunds, and hallucinogens sushas phencyclidine;substance-induced delusional responses are frequent. Prescribed substances suchas sedatives andhypnotics also can be detected. O therroutine laboratory tests (e.g., blood cou nts, HIV assays, thy-roid, liver functions, electrolytes, blood sugar) as well as E EG and brain radiography (CT scan)often help to disclose the presence of pathology (e.g., temporal lob e seizure disorders, mass lesions)that can be related to paranoid presentations.Neuropsychological assessment may help discloseevidence of impaired intellectual functioning and suggest brain abnormalities. Assessment of intelli-gence through I.Q. testing may show discrepancies between verbal and performance scoresas wellas scatter in overall performance, suggesting the need f or further assessment of m edical disorders.

32. What is the treatment for paranoid disorders?N o set treatment guidelines applyto all cases of paranoid disorders. Each of the conditions is

sufficiently different to require a separate approach. Consid er paranoid p ersonality, which, in ad di-

tion to being uncommon, is unlikely to come to the attention of clinicians. Such patients may, be-cause of depressive symptomatology or anxiety, eventually fall into the care of psychiatricprofessionals. B ut generally speaking, these patients m aintain an arms-length d istance from anyhealth care, and specifically p sychiatric, facility. Sym ptom atic therapies and supportive coun selingfrequently are attempted in such cases. Success is, at best, m odest.

Organic delusional syndrome, on the other hand, may be treatableso long as the treatment fo-cuses on the underlying organic fac tor that initiated and perpetuated the delu siona l presentation.For example, in substance abu se, removalof the initiating factor m ay result in a rapid improvementin the patients m ental state. Often such patients also require treatm ent w ith antipsychotic medica-tion (e.g., risperidone, halop eridol), which m ay have the added effect of reducing the agitation,sus-

piciousness, and even the delusional think ing associated with these conditions. However, if theoriginal initiating factor remains, the prognosis is likely to be poo r unless sym ptom atic treatmentiscontinued. With progressive disorders, such treatment may only serv e to delay severe deterioration.

33. Is delusional disorder treatable?Delusional disordermay be treatable. Due to the conditions very natu re, the patient may have

difficulty admitting a psychiatric illness exists and is not likely to seek care. Psychotherapy, medica-tion, and even hospitalization can be im portant comp onentsof care, but in refractory conditions thedelusion will not remit with these interventions.

34. Is psychotherapy helpful?

Psychotherapy createsa therapeutic alliance that can allow patients with delusional disorder todeal with whatever stressors and concerns contributeto the overall impairment associated with thedelusional experience. For exam ple, if the patient is dyspho ric and finds it difficult to work, a chanceto share someof these concerns witha sympathetic clinician may provide co nsiderable relief.

35. What role does pharmacology play in the treatment of delusional disorder?Medications have been promoted recently, but the data concerning their use is limited. Certainly

there is value in considering an antipsychotic: delusion is, after all, a major sy mptom of psychosis,


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and it stands to reason that an antipsychotic agent might have some role in treatment. In practice,however, the success of such interventions as well as other somatic treatment is meager.Hypochondriacal delusions of the somatic type have been reported to respond to pimozide, a potentdopamine blocking agent and antipsychotic medication. These observations have been based on asmall series of cases and are uncontrolled. Antidepressants have been prom oted by som e individualswho have treated patients with delusional disorder. Again, the observation is that patients who havedysphoric m ood in association w ith presence of the delusions respond nicely.

36. When is hospitalization advisable?Hospitalization is recommended in circumstances in which the patients behavior has become

dangerous or self-destructive. Hospitalization may be a satisfactory temporary solution, allowing thepatient t o be confronted with the impact of the behavior and the n eed for greater restraint.

37. Have there been any advances in the somatic treatment of delusional disorder?For years psychiatrists have reported limited success and often negative results from somatic

treatment of delusional disorder. A recent examina tion of some200 cases reported in the literaturesince 1961, consistent withDSM-IV criteria and w ith sufficient detail to m ake comparisons, showedthat approximately80 of patients either recovered fully o r partially with the treatme nt. The m ostfrequently reported treatment waspimozide, which produced full recovery in 69 and partial recov-ery in 22 ; typical neuroleptics produced full recovery in23 and partial recovery in45 .

No specific conclusions were drawn regarding treatment with antidepressants, althougha numberof reports were favorable. Th e most commonly treated subtype was som atic, but meta-analysis su g-gested that patterns of response were similar across subtypes of delusional disorder. Reports that in-cluded followup indicated that persistent useof medication is necessary to maintain remission.

Results of treatment with newer atypical antipsychotic m edicines, i.e., clozapine, risperidone,olanzapine, and quetiapine, are preliminary but promising. Several case reports indicate risperidoneand clozapine effectiveness.

Th e review co nclud ed that antip sych otic drug s may be effective, and a trial, possibly of pi-mozide or an atypical agent, is warranted. Certainly trials make sense when the agitation, apprehen-sion, and anxiety that accomp any delusions are prom inent.

Treatment with a ntipsychotic medicationis, of course, no t a substitute for treatment o f theun-derlying factor in an organic delusional syndro me. Antipsychotic m edication usually is for tempo-rary symptomatic relief.

38. Is there treatment for shared psychotic disorder?

Little is know n about treatment for this condition. O bservations have had a tantalizing quality insuggesting that separation (e.g., divorce, death) of the tw o parties m ay lead to dim unitio n of thedelusion in the induced psychotic partner, even to the point that the patient can no longer be consid-ered delusional. Apart fro m this, there are no systematic con trolled observations about interventionin the literature.

39. What is the therapy for atypical psychosis?Patients who have these conditions must be dealt with individually, identifying the symptoms

that constitute the basis of their com plaint.If a specific, or particularly prominent, delusional formof thinking is present, antipsychotic medications may be helpful. Again, very little systematic litera-

ture is available for this condition, and general guidelines are not possible.

40. Has there been any progress in identifying the cause@ of delusional disorder?Th e cause of delusional disorder is unknown. How ever, factors such as advanced age, sensory

impairment, family history of delusional psychopathology, and recent immigration are associatedwith increased risk. Of these, perhaps the b est suppo rted is thefamilial psychopathology. If delu-sional disorder is merely a form of schizophrenia or mood disorder, then the incidence of theseconditions in family studies of delusional disorder patients should be higher than that of the general


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6 4 Paranoid Disorders

population. However, this is not the consistent finding. In addition, a recent study conclud ed that pa-tients w ith delusional d isorder are m ore likelyto have family members who exhibit paranoid symp-toms (e.g., suspiciousness, jealousy, secretiveness) or have pa ranoid illness themselves than familiesof controls. Other studies show that parano id personality disorder an d avoidant personality disorders

are more comm on among relatives of d elusional disorder patients than am ong relatives of normalcontrols or schizophren ic patients. Th ere is recent evidence for increased risk of alcoh olism amo ngrelatives of delusional disorder patients compared t o those of patients with schizophrenia, other psy-chotic disorders, and schizophreniform disorder.

41. How dangerous are paranoid conditions?It depends. Factors associated with the presentation of parano id sym ptoms often are decisive in

permitting inference of risk. For exam ple, the intensity of the delusional thinking and its associatedmood qualities(such as increased expression of anger and hostility in association with the delusion)are particularly relevant. Other im portant factors are the presence or likelihood o f substance abuse

and organized thinking an d behavior. Greater personality intactness can increase the risk of d anger-ous ness in individuals afflicted by de lusion al feature s. Ero tom ania and jealou sy create powerfulemo tional energy and have been associated with v iolent behavior frequently enoug h to w arrantheightened awareness when these sym ptom s are prominent.

Delusional disorder subtypes associated with these delusions occasionally present problems ofdangero usness. Notably, of the delusional disorder subtypes, the som atic subtype is low-risk. Thesepatients generally do not show intense anger, hostility, or enraged responses associated with theirdelusional thinking.

42. What is stalking?Stalking is uninvited an d unwelcom e pursu it or following, often with harassm ent and pestering

of the victim, who feels threatened a nd often fearful. It is a behavior in which the stalker directs in-tense emotions toward the victim. Stalkers may have a variety of psychiatric difficulties, but maybe free of psychiatric illness.Of the paranoid conditions, the erotomanic sub type of delusionaldisorder and other disorders with erotomanic symptomatology are the most likelyto be associatedwith stalking behaviors. These behaviors are known to be particularly onerou s to deal with becauseof their pronounced refractoriness. However, if the delusion can be adequately treated, it is unlikelythat these behaviors will persist.

BIBLIOGRAPHY

1. Am erican Psychiatric Association: Diagnostic and S tatistical Manu al of M ental Disorders, 4th ed (D SM-

2. Berson RJ: Cap gras syndrome. Am J Psychiatry 140:969-978, 1983.3 . Cum mings JL: Psychosis in n eurologic disease: Neurobiology and pathogenesis. Neuropsychiatry

4. Gawin FH, Ellinwood E: Cocaine and other stimulants. N EnglJ Med 3 18: 1173-1 182, 1988.5 . Howard RJ, Almeida 0 Levy R, et al: Quantitative magnetic resonanc e imaging volumetry distinguishes

6. Kraepelin E: Ma nic Depressive Insanity an d Paranoia. Edinburgh, Livingstone Press, 192 1.7. Krakowski M , Volavka J, Brize r D: Psychopathology and violence:A review of literature. Com pr Psychlatry

8. Manschreck TC, Petri M: The paranoid syndrome. Lancet 2951 -253,1 978.9. Manschreck TC: Delusional disorder and shared psychotic disorder. In Kaplan H , SadockB (eds):

Comprehensive Textbook of Psychiatry, 7th ed. Baltimore, Lipp incott, Williams Wilkins, 2000.

IV). Washington DC, American Psychiatric Association, 1994.

Neuropsychol Behav Ne uro l5: 144-150, 1992.

delusional disorder from late-onset schizophrenia. BrJ Psychiatry 165:474-470, 1995.

27:131-148, 1986.

10. Manschreck TC: Pathogenesis of delusions. Psychiatr Clin North Am 18:213-230, 1995.1. Manschreck TC:The assessmentof paranoid features. Com pr Psychiatry 20(4):37&377, 1979.

12. McAllister T Neuropsychiatric aspec ts of delusions. Psychiatr Ann 22:269-277, 1992.13. Meloy JR (ed): The Psychology of Stalk ing. San Diego, Academic Press, 1998.14. MunroA: Delusional D isorder. New York, Cam bridge University Press, 1999.15. Munro A, Mok H: An overview of treatment in paranoiddelusional disorder. CanJ Psychiatry 40:616422,

1995.


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16. Opler LA, Klahr DM, Ramirez PM : Pharmacologic treatment of delusions. Psychiatr Clin North Am

17. SerretiA, Lattuada E, Cusin C, SmeraldiE: Factor analysis of delusional disorder syrnptomatology. Comp r

18. S toude mire A, Rieth er A: Evaluation and treatmentof paranoid syndromes in the elderly. GenHosp

19. Webb W Paranoid conditions seen in psychiatric medicine. Psychiatr Med 8 :37 -48 ,1990.

18:379-391, 1995.

Psychiatry 40(2): 143-147, 1999.

Psychiatry 9:267-274, 1987.

12. BIPOLAR DISORD ERSMarshall R. Thomas, M.D

1. What is bipolar disorder? How is it different from manic-depressive llness?Bipolar disorder encompasses a heterogeneous grou p of disorders characterized by cyclical dis-

turbances in m ood, cognition, and behavior. The diagnosis requires a history of mania for at least1week or hypomania for at least4 days. Bipolar I disorder refers to patients w ho have had at leastone episod e of mania.Bipolar I1 disorder refers to patients with a history of hypo man ia and majordepressive episodes. Cyclothymia refers to patients with chronic (at least 2-year dur ation) moodswings that fluctuate between hypom ania and m inor but not m ajor depression.

M D Md M m md d

M = Maaic EgisodeD = Major Depressive Episodc

= H y p d c pisode

d = Minor epnssivc Episodc

Modified from GoodwinF, Jamison K: Manic-Depressive Illness. New York, Oxford UniversityPress 1990.

In 1921, the Germ an psychiatristEmil Kraepelin introduced the term manic-depressive insanity,which included patients with recurrent unipolar depression as well as bipolar disorder and distin-guished both groups from schizophrenia, w hich he termed dem entia praecox. Kraepelin emphasized

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11. Paranoid Disorders

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