Paranoia

PSYCHIATRIC CLASSIFICATION

CAUSAL THEORIES

SYMPTOM-LEVEL APPROACHES

BIBLIOGRAPHY

Paranoia is a term commonly used to describe people who are preoccupied with the idea that others are “out to get them” or “talking about them.” This common usage of the term by the lay public reflects a key feature of the concept in the social and behavioral sciences, particularly in the mental health literature. Constant worry about harm to the self is self-referential thinking. Self-referential thinking is a major feature of the paranoid condition. A paranoid person is also mistrustful, suspicious, and has an exaggerated sense of self-importance. These are the basic elements of paranoid thinking. The various ways that paranoia is discussed in the social and behavioral science literature include psychiatric classification, causal theories, and symptom-level approaches.

PSYCHIATRIC CLASSIFICATION

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV (American Psychiatric Association 1994), defines paranoia as a symptom of mental illness. The DSM-IV includes three types of mental illnesses or syndromes of which paranoia is a significant symptom: paranoid personality disorder, delusional disorder, and paranoid schizophrenia. Paranoid personality disorder involves strong feelings of suspiciousness, jealousy (in romantic relationships), and defensiveness without justification or evidence, but the individual does not have a psychotic illness such as schizophrenia. Delusional disorder is more severe and involves psychotic thinking, but the themes of the delusions are not bizarre. Instead, the themes of the paranoid delusions involve situations that can occur in real life such as a spouse cheating, being poisoned, or contracting an infectious disease. Finally, paranoid schizophrenia is the most severe form of mental illness in this category. The delusions are more bizarre, such as the belief that other people can read the patient’s thoughts or take them out of his or her head.

Attempts have been made to conceptualize paranoid personality disorder, delusional disorder, and paranoid schizophrenia as reflecting a continuum from mild to severe psychopathology, respectively. This perspective assumes that the type of delusional symptom defines the relationship between the different types of psychiatric disorders. Genetic studies of patients with delusional disorder using the family history method are one line of research that does not support the continuum perspective (Kendler, Masterson, and Davis 1985; Schanda et al. 1983). Schanda et al. (1983) found that risk for “atypical psychosis” was higher in the first-degree relatives of delusional disorder patients than in those of patients with paranoid schizophrenia. Kendler et al. (1985) found that paranoid personality disorder may have a stronger familial link to delusional disorder than to schizophrenia. These two findings are at odds with the notion that there is greater genetic vulnerability among patients with schizophrenia. Thus it may be more useful to consider paranoid symptoms apart from diagnoses.

CAUSAL THEORIES

Causal theories of paranoia fall into three basic categories: biological, psychological, and social. Biologically, Strider et al. (1985) claim that various neuropsychological impairments such as memory problems and hearing loss associated with brain injuries or the cognitive decline that accompanies old age may engender paranoia because individuals may attribute their inability to find misplaced objects and inaudible conversations to the deliberate attempts of others to keep things from them. Moreover, both clinical and experimental data indicate that injury to the right hemisphere of the brain is more likely to produce paranoid thinking because of the inability verbally to label sensory and emotional experiences (Strider et al. 1985). Thus paranoid thinking may be manifested as a result of damage to the brain.

There may also be a genetic component to paranoia. Genetic studies of patients with delusional disorder using the family history method indicate that the percentage of first-degree relatives (i.e., parents, siblings, or offspring) with schizophrenia ranges from 0 percent to 3 percent and affective disorder ranges from 3 percent to 6 percent (Kendler, Masterson, and Davis 1985; Schanda et al. 1983). Bentall et al. (2001) argued that because diagnoses include multiple symptoms that involve multiple genes, heritability estimates may be higher for diagnoses than for paranoid symptoms alone. Taken together, these findings suggest that paranoid conditions have very limited inheritability, which may manifest differently in various forms of psychopathology.

Classical and modern psychological theories view paranoia as a defense against threats to the self. The classical theory of Freud defines paranoia as an unconscious defense against repressed homosexuality, chronic problems of self-esteem regulation, and sensitivity to narcissistic injury (Bone and Oldham 1994). The idea that paranoia protects against threats to self-esteem is the only aspect of Freudian theory that survives in modern theories of paranoia. Bentall et al. (2001) propose an attribution–self-representation model of persecutory delusions (i.e., paranoia). In their model, individuals make attributions for positive or negative events based on available self-representations stored in memory, which, in turn, influence future attributions in an ongoing cycle. Paranoia occurs when the individual attempts to engage in self-esteem regulation after experiencing a negative event, where the cognitive search does not yield a negative self-representation to explain the event, resulting in a shift to external-personal causes (Bentall et al. 2001). In other words, the person maintains a positive view of the self because those self-representations could not account for the negative event.

Social theories of paranoia emphasize that it is a reaction to threatening environments or inadequate resources (Mirowsky 1985; Marcus 1994). Marcus (1994) extends the psychoanalytic perspective to paranoid tendencies expressed by social groups in organizational contexts. He considers the paranoid reaction in social groups and organizations a manifestation of a survival instinct when there are behavioral constraints on members because of unequally distributed resources that are hidden or protected (Marcus 1994). Mirowsky (1985) proposes a similar theoretical explanation for paranoia in social groups. It is a form of self-protection from exploitation and oppression among social groups that are powerless. He demonstrated that paranoid beliefs in the general population are the product of interactions between feelings of mistrust and exposure to social environments that are threatening (Mirowsky 1985). This may be why paranoia appears to be more common among individuals in the lower social classes and among ethnic/minority groups (Mirowsky 1985; Whaley 1998). Self-protection is a theme that links biological, psychological, and social theories of paranoia. In this way, paranoia may be a coping response that is adaptive. However, extreme paranoia as evidenced in paranoid schizophrenia with no basis in social reality is dysfunctional.

SYMPTOM-LEVEL APPROACHES

Paranoia is not an all-or-none condition. It is best to think of paranoid symptoms as falling on a continuum of severity, with the mild end being represented by suspiciousness, mistrust, and self-consciousness and the severe end represented by delusions of persecution often involving hallucinatory experiences (Fenigstein 1996; Whaley 1998). Both mentally ill patients and normal persons have these types of paranoid tendencies, and the difference between them is a matter of degree or severity (Fenigstein 1996). Whether a person recovers from a mental illness depends more on the diagnosis (e.g., paranoid personality disorder versus schizophrenia) than on the presence of paranoid symptoms. The notion “once paranoid—always paranoid” is not correct; people with paranoid conditions can recover (Retterstol 1991). Finally, the types of cultural experiences that people have may influence whether they exhibit paranoid behaviors.

Immigrants are at increased risk for developing paranoid responses (Kendler 1982). Social groups that have been oppressed or discriminated against such as African Americans also develop paranoid-type coping responses (Whaley 1998). The social and psychological theories of paranoia provide some insight into why this may be the case (Bentall et al. 2001; Marcus 1994; Mirowsky 1985). Under these circumstances, the responses to real threats in the environment or adjustment to new experiences may appear similar to conditions of clinical paranoia, but these expressions often are normative and not pathological. Understanding that paranoia falls on a continuum from mild to severe, as opposed to a symptom that is either present or absent, allows us to appreciate that just because someone is paranoid does not always mean that the person’s reaction is sign of mental illness.

SEE ALSO Coping; Mental Illness; Psychotropic Drugs; Schizophrenia

BIBLIOGRAPHY

American Psychiatric Association. 1994. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, D.C.: Author.

Bentall, R. P., R. Corcoran, R. Howard, et al. 2001. Persecutory Delusions: A Review and Theoretical Integration. Clinical Psychology Review 21: 1143–1192.

Bone, S., and J. M. Oldham. 1994. Paranoia: Historical Considerations. In Paranoia: New Psychoanalytic Perspectives, eds. J. M. Oldham and S. Bone, 3–15. Madison, CT: International Universities Press.

Fenigstein, A. 1996. Paranoia. In Personality Characteristics of the Personality Disordered, ed. C. G. Costello, 242–275. New York: Wiley.

Kendler, K. K. 1982. Demography of Paranoid Psychosis (Delusional Disorder): A Review and Comparison with Schizophrenia and Affective Illness. Archives of General Psychiatry 39: 890–902.

Kendler, K. S., C. C. Masterson, and K. L. Davis. 1985. Psychiatric Illness in First-Degree Relatives of Patients with Paranoid Psychosis, Schizophrenia, and Medical Illness. British Journal of Psychiatry 147: 524–531.

Marcus, E. R. 1994. Paranoid Symbol Formation in Social Organizations. In Paranoia: New Psychoanalytic Perspectives, eds. J. M. Oldham and S. Bone, 81–94. Madison, CT: International Universities Press.

Mirowsky, J. 1985. Disorder and Its Context: Paranoid Beliefs as Thematic Elements of Thought Problems, Hallucinations, and Delusions under Threatening Social Conditions. In Research In Community Mental Health, ed. J. R. Greenley, 5: 185–204. Greenwich, CT: JAI Press.

Retterstol, N. 1991. Course and Outcome in Paranoid Disorders. Psychopathology 24: 277–286.

Schanda, H., P. Berner, E. Gabriel, et al. 1983. The Genetics of Delusional Psychosis. Schizophrenia Bulletin 9: 563–570.

Strider, M. A., C. Chu, C. Golden, and R. J. Bishop. 1985. Neuropsychological Dimensions of Paranoid Syndromes. International Journal of Clinical Neuropsychology 7: 196–200.

Whaley, A. L. 1998. Cross-Cultural Perspective on Paranoia: A Focus on the Black American Experience. Psychiatric Quarterly 69: 325–343.

Arthur L. Whaley

Paranoia

John’s Experience

What Is Paranoia?

What Causes Paranoia?

Resources

paranoia (par-a-NOY-a) refers to either an unreasonable fear of harm by others (delusions* of persecution) or an unrealistic sense of self-importance (delusions of grandeur). While paranoia is often associated with a severe mental illness such as schizophrenia, people without such illnesses can have paranoid feelings, think that people are talking about them, or have difficulties trusting others.

* delusions

(de-LOO-zhuns) are false beliefs that remain even in the face of proof that they are not true.

Keywords

for searching the Internet and other reference sources

Delusions

Mental illness

Paranoid personality disorder

Schizophrenia

John’s Experience

One day John came across a group of his friends huddled together on the soccer field. As he approached, they were all talking and laughing and enjoying themselves. However, when he reached where they were standing, the group suddenly became quiet. John could not help feeling that his friends had been talking about him and that was why they had all stopped talking when he approached. He found himself thinking about this throughout the rest of the day. He even began to believe that his friends had been plotting against him.

The next morning, John saw the same group of guys huddled around his locker. This time when he approached, they shouted “surprise” and presented him with a new CD for his birthday. With embarrassment he realized that they had probably been discussing his birthday surprise the day before on the soccer field. He wondered what had caused him to doubt himself and his friends like that? Was it paranoia or a simple misunderstanding?

What Is Paranoia?

Paranoia is not a particular disorder so much as a way of experiencing (or incorrectly experiencing) reality. For example, John experienced paranoia when he wrongly believed that his friends were out to get him. A person whose phone was once tapped and was thereafter cautious about saying confidential things over the telephone might be considered reasonably concerned rather than paranoid. In contrast, a person who unrealistically feared that his or her phone was tapped even though it never had been before, and who persisted in the belief even when presented with compelling evidence that it was not true, would be considered paranoid. The key issue is not the behavior itself so much as its basis in reality.

Common characteristics of people who tend to be paranoid include:

• poor self-image
• social isolation
• an expectation that others are trying to take advantage of them
• an inability to relax
• an inability to work with others
• a deep mistrust of others
• an inability to let go of insults or to forgive others
• a poor sense of humor

Like many personality traits, paranoia is something that can occur in different degrees of severity. In its milder forms, paranoia may be something that a person feels only occasionally or only in certain situations. John, for example, experienced paranoia one day, but he did not usually feel this way. In its more severe forms, however, paranoia can seriously limit an individual’s life. People with significant levels of paranoia may consistently misinterpret reality and experience delusions. Delusions are classified as bizarre or nonbizarre. A person who believes that others are out to get him and are somehow monitoring his actions through the television set is experiencing a bizarre paranoid delusion; this type of delusion is called bizarre because it is completely unbelievable. An example of a nonbizarre paranoid delusion is a person’s belief that he or she is under surveillance by the police; while the belief might be false, it is not out of the realm of possibility. Because everyone’s experience of reality seems real to them, it is hard to tell individuals with paranoid delusions that they are not in danger. For a person with paranoia, minor hassles or mild insults may be seen as dangerous threats.

Even people with severe paranoia may function normally much of the time if, for instance, they have a paranoid delusion that affects only a part of their life. For example, they might become obsessed with the idea that a particular chain of restaurants is conspiring to poison unsuspecting customers like themselves. They might stop eating in those restaurants and even go so far as to call the health authorities to investigate while they still function normally in other parts of their lives.

What Causes Paranoia?

The cause or causes of paranoia are not precisely known. Many healthy people experience paranoid feelings at some point in their lives, just as John did. Certain situations may make it more likely for someone to experience paranoid feelings. For example, there is evidence to suggest that immigrants are more prone to suspiciousness and paranoia as a result of the language and other cultural barriers they face. People in the majority culture may misunderstand the immigrants’ suspiciousness and react with hostility, which creates even more mistrust.

Paranoia can accompany a number of illnesses. It is associated with certain neurological conditions such as temporal lobe epilepsy* and some forms of dementia* associated with aging, such as Alzheimer disease*. It can be caused by the repeated use of drugs such as cocaine or amphetamines. Paranoia is also known to be associated with mental disorders such as schizophrenia (skit-so-FREE-nee-a) and paranoid personality disorder.

* temporal lobe epilepsy

(EP-ilep-see), also called complex partial epilepsy, is a form of epilepsy that affects the part of the brain that is located underneath the sides of the head, near the ears. Epilepsy is a condition of the nervous system characterized by recurrent seizures that temporarily affect a person’s awareness, movements, or sensations. Seizures occur when powerful, rapid bursts of electrical energy interrupt the normal electrical patterns of the brain. Epilepsy is generally treated with medication that helps prevent these “electrical storms” from beginning.

* dementia

(duh-MEN-shuh) is a decline in mental ability that usually progresses slowly, causing problems with thinking, memory, and judgment. It is most often seen in older individuals and is caused by deterioration in parts of the brain.

* Alzheimer (ALTZ-hy-mer) disease

is a condition that leads to a gradually worsening loss of mental abilities, including memory, judgment, and abstract thinking, as well as to changes in personality.

A paranoid person may feel extremely threatened by someone at the door, especially a stranger, and may keep her personal life private and hidden. Custom Medical Stock Photos

Paranoid schizophrenia

Schizophrenia is a serious mental disorder that causes people to experience hallucinations*, delusions, and other confusing thoughts and behaviors that distort their view of reality. Doctors have come to understand that schizophrenia likely is the result of brain differences or chemical imbalances within the brain. However, schizophrenia is a complex and disabling disorder, and there is still much to learn to fully understand it. Schizophrenia is also a disorder that can assume many different forms. These forms (catatonic, disorganized, paranoid, undifferentiated, and residual) are known as subtypes.

* hallucinations

(huh-loo-sin-AY-shuns) are sensory perceptions that a person believes are real but that are not actually caused by an outside event. People who experience hallucinations may, for example, hear threatening voices (auditory (AW-dit-or-ee) hallucinations) that are not really there or see things (visual hallucinations) that others cannot see.

Paranoid schizophrenia is characterized by the presence of one or more prominent delusions or auditory hallucinations in a person who seems to have otherwise relatively normal thinking ability and emotions. The delusions are usually organized around a consistent theme relating either to the idea that the person is being persecuted (someone is after him or her) or that he or she has special powers; the hallucinations, when they are present, are typically related to the delusional theme. People with paranoid schizophrenia often act anxious, aloof, angry, and argumentative, and they may also exhibit either a stiff, formal attitude or be quite intense in their interactions with others.

None of the other major characteristics associated with schizophrenia, such as disorganized speech, inappropriate behavior, or inappropriate emotional reactions, are present in people with paranoid schizophrenia, and the age at which this disorder begins tends to be later than it is for the other forms of schizophrenia. People with paranoid schizophrenia are more likely to succeed in holding a job and at living independently when compared to people with other subtypes of schizophrenia.

Paranoid personality disorder

Just as there are several types of schizophrenia, there are also different types of personality disorders (for example, narcissistic, dependent, avoidant, antisocial, and paranoid). All of the personality disorders involve consistent ways of behaving inappropriately across many different situations. Personality disorders lead to problems in social, school, and work settings and to significant internal distress. The personality patterns that later develop into personality disorders typically begin during adolescence or childhood. The longstanding nature of these conditions makes them particularly difficult to treat.

The key characteristic of paranoid personality disorder is a pattern of deep distrust of others. Unlike people with paranoid schizophrenia, whose ideas may be totally bizarre or out of touch with reality, a person with a paranoid personality disorder is not out of touch with reality so much as out of step with it. The belief that other people cannot be trusted colors all of life. As a result, individuals with this disorder have difficulty forming close relationships.

Some common characteristics of people with paranoid personality disorder include:

• suspecting, without justification, that others are trying to harm or trick them
• doubting the loyalty of friends
• avoiding talking about themselves for fear that the information will be used against them
• interpreting casual remarks or events as threats or insults
• carrying grudges and seeking revenge
• overreacting with anger to minor slights
• being overly jealous and suspicious about others (e.g., girlfriend, boyfriend, or spouse) without justification

One of the difficult things about paranoid personality disorder is its self-fulfilling quality; paranoid people’s suspicious and combative natures may provoke a hostile response from others, thus confirming their fears that others are hostile and not to be trusted. Rather than seeing their own role in creating the situation, they might instead mistakenly conclude that their suspicions are justified.

Possible signs of paranoid personality disorder that may be seen in childhood or adolescence include difficulties making friends and relating to others, the tendency to be a loner in social situations, and poor performance in school. Paranoid personality disorder is more common in males than in females. Overall, it affects about one percent of the population. The higher likelihood of finding paranoid personality disorder among relatives of individuals with schizophrenia suggests that there may be a genetic link between the two conditions, but further research is needed to confirm this.

See also

Alzheimer Disease

Delusions

Dementia

Hallucination

Personality Disorders

Psychosis

Schizophrenia

Resources

National Institute of Mental Health (NIMH), National Institutes of Health, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. The NIMH posts information about schizophrenia at its website. Telephone 301-443-4513 http://www.nimh.nih.gov/publicat/schizoph.cfm

The Personality Disorders Foundation has a website that provides information about personality disorders, including paranoid personality disorder.

http://pdf.uchc.edu/

The National Alliance for the Mentally Ill (NAMI) is a nonprofit organization that provides education, support, and advocacy for people with severe mental illnesses and their families. NAMI’s website provides information about many mental illnesses. Telephone 800-950-NAMI http://www.nami.org

PARANOIA (FREUDIAN FORMULAS OF)

"Paranoia" is one of the oldest concepts in the history of the description of mental states. It initially appears in Greek tragedy, on two occasions; first to describe the passionate love of Oedipus and Jocasta and then to refer to Orestes' state following his murder of his mother, Clytemnestra.

For most of the 19th century, the term paranoia occupied a position of the same importance as the term "schizophrenia" today. It was then understood as a mental state that was characterized by feelings of persecution on all sides. Freud's approach to paranoia, as to psychopathology in general, brought to it a perspective that is simultaneously dynamic, topographical, genetic, and economic. It is dynamic in that Freud regards paranoia as deriving from a form of psychic activity, namely projection; topographical because this projection, initially connected with incestuous fantasies and later with homosexuality, is based on unconscious impulses; and genetic because the seduction experiences that stimulate these incestuous or homosexual impulses occur at an early stage. Finally, this perspective is also economic in that paranoia, like every other symptom, is an "attempt at reconstruction" directed at protecting the subject from more acute problems.

Freud took an interest in paranoia from the outset of his work, comparing it with other forms of psycho-pathology. His analysis (Freud, 1911c [1910]) of Daniel Paul Schreber's Memoirs of My Nervous Illness, which contains the essence of his theories on the subject, nevertheless poses a few problems.

The connection between paranoia and homosexuality emerged late in Freud's work. Initially, if homosexual elements were present at all, they were overlooked and it was incestuous relationships or fantasies that were emphasized. In fact, the connection between homosexuality and paranoia seems to have resulted from some collaborative work by Freud, Carl Gustav Jung, and Sándor Ferenczi. Furthermore, the analysis of homosexuality based on the Memoirs differs from the analysis based on Leonardo da Vinci's childhood memory. Whereas the former involves a romantic fixation on someone of a different sex from the subject, the latter is entirely focused on his relations with someone of the same sex.

What Schreber reveals of the progress of his "nervous illness" demonstrates few of the characteristics of paranoia, or even paraphrenia or paranoid dementia. In fact, he describes the natural and spontaneous development of a psychosis, throughout its progression and in all its forms, without any substantial medical intervention. Instigated by a moment of hypochondria that rapidly turns into a catatonic breakdown, this progression leads him into a paraphrenic phase that gives way to paranoia before concluding in a transvestite perversion with strong hysterical components, which is followed by a rather successful professional reintegration.

Freud incorporates within paranoia the classic forms of delusions of persecution, erotomania, jealous delusions, and megalomania, but he overlooks querulousness and discursive mania. The formulas that Freud puts forward for understanding repression and the return of the repressed in paranoia are problematic in spite of their value. He suggests that a single formula—"I (a man) I love him" is denied in four ways:

1. "I do not love him—I hate him," which is transformed by projection into, "He hates (persecutes) me " (1911c, p. 63), giving rise to delusions of persecution;
2. "I do not love him —I love her." As a result of projection, this becomes: "I observe that she loves me" (p. 63), which leads to erotomania;
3. "It is not I who love the man [or woman]—she [or he] loves him [or her]" (p. 64), which characterizes jealous delusions;
4. "I do not love at all—I do not love any one " (p. 65), which becomes "I love only myself."

Karl Abraham made some variations to these formulae to deal with manic-depressive psychoses. He grafted the essence of formula (a), that is, the inversion of the affect combined with projection, on to formula (d). The formula "I do not love anyone " that Freud proposes is only one of the possible consequences of "I do not love at all "; the other obvious consequence is "I do not love at all—I hate," or even "I hate the whole world," a fantasy that can appear in conjunction with "I love only myself." Schreber's delusion of grandeur in fact portrays a world that has been completely destroyed. Freud explains this fantasy purely in terms of libidinal decathexis but the need for libido to be cathected does not necessarily mean that this concerns the ego. The libido can disperse, with "I hate the whole world " being extended into "including myself." Schreber attempted suicide and asked to be killed.

Finally, formula (d) can also appear in another form in delusions of grandeur: "I do not love anyone—I love the whole world," which is expressed in the delusions of mystics concerning the salvation of humanity and the transformation of the world, which also appear in the Memoirs.

There is a further equation of this: "I love the whole world, but the world hates me," which is expressed in paranoid masochism, when hatred presents itself as the guarantee of a supreme love.

The application of the formula for delusions of persecution (a) to the formula for jealous delusions (c) concerns the subject's feeling of persecution by the couple of whom he is jealous. The complete formula here is: "It is not I who love the man and the woman—it is they who love each other. I hate them "; and, by projection, "it is they who hate me," who despise me and so on.

The formula (b) applied to formula (c) produces "It is not I who love the man and the woman—it is they who love me," a fantasy that is not unusual in erotic delusions, particularly in the form that leads to the "ménageà trois," whether preceding or following the jealousy, the pleasurable aspect of which barely conceals the anxiety. Daniel Lagache pioneered the study of the connection between erotomania and jealousy, as well as the study of ideas of homosexual infidelity in jealousy.

There is also the application of formula (a) to formula (b) and vice versa, as elaborated by Luiz Eduardo Prado de Oliveira. In the first case, the formula for homosexual erotomanic delusion appears as: "I (a man) love him (a man)" and by projection: "I do not love him—he loves me," a fantasy that emerges clearly in Schreber's Memoirs and in clinical practice. In the second case, there is a close connection both between jealousy and erotomania and between erotic delusions and feelings of persecution. If these formulae are then applied to each other: "I love her (a woman). No, I hate her," and by projection, "I observe that she hates me," the woman appears as the man's persecutor, just as the man can appear as the woman's persecutor. These observations, entirely based on the wide range of phenomena in clinical practice, are an extension of the foundation constituted by Freud's work.

These developments as a whole illustrate the heuristic innovativeness of Freud's and they encompass a much broader spectrum of possibilities in the clinical field. Freud's for understanding paranoia also gave rise to the concept of foreclosure, developed by Lacan as a result of an error in the early French translations and initially accepted as an adequate basis alone for understanding the psychoses.

At very early stage, Freud drew a distinction between three variations of repression: repression concerning affect alone; repression concerning mental representation alone; or, finally, in the most extreme case, concerning both affect and mental representations, in which all the processes occur outside the ego. In his early studies on paranoia, each of these forms of repression found an outlet in projection. In his Schreber study, Freud uses the term Verwerfung (foreclosure or repudiation) to characterize the third form of repression. Freud's first translators into French had simply—and incorrectly—retained the term "projection" Lacan, seeing this as a flagrant mistranslation and connecting it with his work on the symbolic law, introduced the term "foreclosure" (forclusion ) in its place. In an everyday linguistic system such as Freud used, the term would have been better translated into French by the concept of "rejet" or "refus" ("rejection" or "refusal"), which is more closely reflected in the alternative English term repudiation. The correction of this translation error at the origin of the concept of foreclosure has certainly indicated a difficulty concerning the formation of psychoses and today this term is as widely accepted as the term "projective identification" which originates from Tausk's writings.

Luiz Eduardo Prado de Oliveira

Bibliography

Abraham, Karl. (1912). Préliminairesà l'investigation et au traitement psychanalytique de la folie maniaco-dépressive et desétats voisins OC, t. I, p. 99-113.

Freud, Sigmund. (1896b). Further remarks on the neuro-psychoses of defence. SE, 3: 157-185.

——. (1911c [1910]). Psycho-analytic notes on an autobiographical account of a case of paranoia (dementia paranoides). SE, 12: 1-82.

Lagache, Daniel. (1977). Contributionà l'étude des idées d'infidélité homosexuelle dans la jalousie. (Communication au XVe Congrès International de Psychanalyse. Paris 1938). In Les hallucinations verbales et travaux cliniques (Oeuvres I [1932-1946], pp. 225-242). Paris: Presses Universitaires de France. (Original work published 1938)

Prado de Oliveira, Luiz E. (1997). Freud et Schreber. Les sources écrites du délire, entre psychose et culture, Paris:Érès.

PARANOIA

Paranoia has individual and institutional, social and cultural forms and determinants. There is probably at least a germ of paranoia in everyone which may be activated in regressive states with increased vulnerability. Clinically, paranoia may be found in mild transient forms, paranoid states of varying degree and duration, fixed paranoid traits and paranoid character, and borderline schizophrenia. The range of paranoid conditions doubtless depends upon constitutional, characterological, and experiential variables.

Unlike other types of psychosis, a paranoid psychosis is usually well-defined, and more or less circumscribed in a delusional part of the personality. The disturbance may remain encapsulated or systematized without generalized tendencies toward deterioration of the overall personality.

The paranoid personality is characterized by a number of common traits: basic distrust; suspiciousness; readiness to feel slighted, injured or persecuted; a tendency to collect grievances and grudges; and vindictiveness. The paranoid personality either anticipates or fears being exploited and abused; is irrationally suspicious of hidden dangers or threats; and expects or believes in the infidelity of a spouse, the disloyalty of friends, and notions of hostile conspiracy. Betrayals are anticipated or assumed, so that for the paranoid friend may immediately become foe, and seeming affection may be replaced by an implacable animosity. Self-esteem issues are also apparent—connected with both the extraordinary sensitivity to narcissistic injury and humiliation, and concomitant grandiosity which may extend to megalomania.

The psychoanalytic understanding of paranoia was initiated by Freud (1911c) who, prior to the Schreber case, had already linked the defense mechanism of projection to the paranoia personality. Via projection, the paranoid defends against unacceptable impulses, especially hate and aggression, which are also related to paranoid defiance. The importance of regression to narcissism, with attendant hypersensitivity to narcissistic mortification and grandiosity associated with infantile omnipotence, was highlighted in the Schreber case. Grandiosity could also be a compensatory reaction to unconscious feelings of inadequacy and inferiority. However, Freud shifted the dynamic understanding of paranoia at the same time to a core oedipal conflict. The paranoid defense constellation warded off unconscious homosexual wishes. In the paranoid male the unconscious proposition: "I, a man, love him, a man," is contradicted in the following ways: (1) delusions of jealousy: "It is not I who love the man; it is she," (2) delusions of persecution: "I do not love him, I hate him. Because of this he hates and persecutes me," (3) erotomania: "I do not love him. I love her, and she loves me," (4) megalomanic disavowal: "I do not love anyone else, but only myself."

It should be noted that Freud's formulations in the Schreber case were based upon the utilization of the libido theory and an attempt to understand paranoia in terms of psychosexual disturbance, which reversed his earlier formulation of repressed hostility. Subsequent contributions have confirmed the importance of malignant narcissism and the defense of projection, but also of hatred, aggression, and splitting of the ego and of self and object representations.

This defensive splitting off (Klein, Melanie, 1932) is also recognizable in group processes, as in the tendency to idealize one's own group and to distrust and project evil and hostility to those outside the group, especially against defenseless minorities unable to counterattack. Paranoid processes may be discerned in various sects and ideologies, where there is devaluation and persecution of those who are seen as opposed to the sect or group's narcissistically-invested belief system. In such dynamics, those who diverge may be scapegoated, and those who deviate or depart may be persecuted as heretics. Individuals with paranoid proclivities are far more readily attracted and susceptible to paranoid demagogues and groups. Paranoid leaders may foment and foster group paranoid reactions among vulnerable individuals. On the other hand, paranoid tendencies may contribute to individuals being vigilant guardians of civil liberty, ever-ready to detect a base of power and threats of exploitation. Feelings of being watched and scrutinized, so commonly seen with paranoid superego regression and externalization, may also have adaptive functions.

Contemporary understanding of the paranoid personality sometimes relates to circumstances in which a traumatic reality is embedded in fantasy, and historical truth in delusion (Freud, 1937d; Blum, 1994). There is often a history of childhood paranoia, so that pronounced narcissistic and paranoid features are already present in childhood. Feelings of mistrust, suspicion, and susceptibility to feelings of insult and injury may have been lifelong. The nightmares of paranoid patients may leave a hangover effect, so that the paranoid nightmare and terror of attack invades reality.

Traumatic experience with the terror of helplessness and inevitable narcissistic mortification may also be associated with severe and enduring vulnerability to narcissistic hurt and humiliation. Some cases involve selective identifications with paranoid parents. Paranoid dispositions may be anchored in familial styles of paranoid suspicion and scapegoating, or blaming and vengeful familial attitudes.

Furthermore, the paranoid often not only detects the latent envy and hostility of others, but tends to activate and evoke hostile reactions as well. The paranoid's expectation of social slights and hurts becomes a self-fulfilling prophecy as their own suspiciousness and hostility arouses similar mistrusts and hostility in others. Freud (1922b) observed the tendency of the paranoid personality to recognize but exaggerate the imagined infidelity present in both partners. Since blame and guilt are projected, the paranoid remains indignant about innocent victimization and may become litigious. Narcissistic rage over feelings of injury and compensatory aggrandizement serve to undo and reverse traumatic helplessness and avenge prior narcissistic hurts and humiliations (Kohut, 1972). The paranoid's own urge toward betrayal becomes a means of vengeance, vindication, and mastery. A preemptive strike may be related to the paranoid's expectation of attack, betrayal, and the rationalization of a defensive counterattack. Any narcissistic frustration, disappointment, or traumatic disturbance may regressively activate a paranoid persecutory system. All levels of personality development may contribute to the paranoid persecutory system.

Current explanations of paranoia involve recognition of diffuse developmental disturbance without a single point of developmental fixation or deficit, appreciating the possibility of complex overdetermination. In paranoia, murderous hostility is now considered far more important than repressed homosexual love. There is a stress on preoedipal roots, leading to failure of oedipal resolution, and to the patient's vulnerability to malignant narcissistic regression (Kernberg, 1975).

Freud's proposition of the delusional reconstruction of the lost object world is still accepted by many analysts, while others have proposed different views concerning impaired reality testing and paranoid object relations. Reality testing, cognition, and affect regulation may be constitutionally fragile and further impaired by projection, traumatic injury, and ego regression. The paranoid personality may have many areas of intact ego, but it has been proposed (Blum, 1981; 1994) that the persecutor is a narcissistic object or a part object (Klein, 1932), incompletely differentiated from the self representation. In addition to the splitting of representations, there is a regressive failure of object constancy with incomplete separation-individuation (Mahler, Margaret, 1971), and a desperate effort to reestablish object constancy within a constant persecutory relationship. The persecutory narcissistic object is sought, followed, or is imagined to be following the paranoid patient. The split-off dangerous object is the lesser evil when compared to objectless disorganization and fragmentation. Extreme ambivalence prevails, with the dominance of hate over love and with predominant projection of destructive rage, hatred, and self-hatred. Fear of being attacked by an invading or engulfing object is readily fused and confused because of unstable self-object differentiation, intrapsychic representation, and ego integration. Masochistic wishes to be attacked are less unpalatable to the paranoiac than the potentially malignant narcissism.

In national and social paranoia, concern with ego boundaries and narcissistic injury is reflected in concerns about national boundaries and enemy betrayal. The nation's integrity, and its boundaries, must then be defended because of fear of destructive invasion and engulfment.

The paranoid personality, depending upon the degree and fixity of the underlying disturbance, may be variably amenable to psychoanalytic treatment. Mistrust and lack of confidence in the analyst or therapist, fear of humiliation and abuse, coupled with an entrenched and entitled narcissism make the paranoid patient a major therapeutic challenge. For those patients amenable to psychoanalysis, consistent interpretation of paranoid transference manifestations, management of paranoid regression, and awareness of the patient's ego fragility and extreme ambivalence are of critical importance.

Harold P. Blum

See also: Narcissism; Paranoid position; Paranoid-schizoid position.

Bibliography

Blum, Harold P. (1994). Paranoid betrayal and jealousy: the loss and restitution of object constancy. In J. Oldham, S. Bone (Eds.), Paranoia: New psychoanalytical perspectives. Madison: International Universities Press, p. 97-114.

Freud, Sigmund. (1911c [1910]). Psycho-analytic notes on an autobiographical account of a case of paranoia (dementia paranoides). SE, 12: 1-82.

——. (1922b [1921]). Neurotic mechanisms in jealousy, paranoia and homosexuality. SE, 18: 221-232.

——. (1937d). Constructions in analysis. SE, 23: 255-269.

Kernberg, Otto. (1975). Borderline conditions and pathological narcissism. New York: Jason Aronson.

Kohut, Heinz. (1972). Thoughts on narcissism and narcissistic rage. The search for the self. (Vol. 2.) New York: International Universities Press, p. 615-65.

Further Reading

Auchincloss, Elizabeth L., and Weiss, Richard W. (1992). Paranoid character and the intolerance of indifference. Journal of the American Psychoanalytic Association, 40, 1013-1038.

Blum, Harold P. (1980). Paranoia and beating fantasy: psychoanalytic theory of paranoia. Journal of the American Psychoanalytic Association, 28, 331-362.

Kernberg, Otto F. (1992). Psychopathic, paranoid, and depressive transferences. International Journal of Psychoanalysis, 73, 13-28.

Meissner, William. (1986). Psychotherapy and the paranoid process. Northvale, NJ: Jason Aronson.

Oldham, John M., and Bone, Stanley. (Eds.). (1994). Paranoia: New psychoanalytic perspectives. Madison, CT: International Universities Press.

Paranoia

Definition

Description

Demographics

Causes of paranoia

Treatments

Prognosis

Resources

Definition

Paranoia is a symptom in which an individual feels as if the world is “out to get” him or her. When people are paranoid, they feel as if others are always talking about them behind their backs. Paranoia causes intense feelings of distrust, and can sometimes lead to overt or covert hostility.

Description

An individual suffering from paranoia feels suspicious, and has a sense that other people want to do him or her harm. As a result, the paranoid individual changes his or her actions in response to a world that is perceived as personally threatening. Objective observers may be quite clear on the fact that no one’s words or actions are actually threatening the paranoid individual. The hallmark of paranoia is a feeling of intense distrust and suspiciousness that is not in response to input from anybody or anything in the paranoid individual’s environment.

Other symptoms of paranoia may include

• Self-referential thinking: The sense that other people in the world (even complete strangers on the street) are always talking about the paranoid individual.
• Thought broadcasting: The sense that other people can read the paranoid individual’s mind.
• Magical thinking: The sense that the paranoid individual can use his or her thoughts to influence other people’s thoughts and actions.
• Thought withdrawal: The sense that people are stealing the paranoid individual’s thoughts.
• Thought insertion: The sense that people are putting thoughts into the paranoid individual’s mind.
• Ideas of reference: The sense that the television and/or radio are specifically addressing the paranoid individual.

Demographics

Paranoia is a very human feeling. Nearly everyone has experienced it at some or another time, to varying degrees. Paranoia exists on a continuum, ranging from a feeling of distrust due to an occasional misinterpretation of cues that can be appropriately dealt with and reinterpreted, to an overarching pattern of actual paranoia that affects every interpersonal interaction.

Some research studies have suggested that 6% of all women and 13% of all men have some chronic level of mistrust towards the motivations of others towards

them. Only about 0.5% to 0.25% of men and women can actually be diagnosed with paranoid personality disorder, however. It remains interesting to researchers that men are more prone to paranoid traits and mental disorders with paranoid features than are women.

Causes of paranoia

Researchers do not understand fully what chemical or physical changes in the brain cause paranoia. Paranoia is a prominent symptom that occurs in a variety of different mental disorders, as well as a symptom of certain physical diseases. Furthermore, use of certain drugs or chemicals may cause symptoms of paranoia in an otherwise normal individual.

Paranoia is often manifested as part of the symptom complex of schizophrenia. In fact, one of the subtypes of schizophrenia is termed “paranoid schizophrenia,” which actually refers to a type of schizophrenia in which the individual is particularly preoccupied with delusions in which the world seems to be pitted against him or her. As with other forms of schizophrenia, sufferers often lack contact with reality, and display hallucinations, flat or emotionless affect, and disorganized thinking and behavior.

Paranoid personality disorder is diagnosed when an individual does not have other symptoms of schizophrenia, but a personality that is driven by chronic manifestations of paranoia. These individuals are mistrustful, suspicious, and convinced that the world is out to get them.

In order for an individual to be diagnosed with paranoid personality disorder, he or she must display at least four of the following traits:

• chronically suspicious that people are lying or cheating him or her in some way
• frequently preoccupied with whether people are loyal or trustworthy
• cannot confide in others for fear of being betrayed
• misinterprets benign comments or events as being personally threatening
• harbors long-term grudges against others who are perceived as having been threatening or insulting in some way
• sees others’ actions and/or words attacking him or her in some way, and therefore goes on the counterattack
• repeatedly assumes that partner or spouse is unfaithful

Paranoia can also occur as a symptom of other neurological diseases. Individuals suffering from the aftereffects of strokes, brain injuries, various types of dementia (including Alzheimer’s disease), Hunting-ton’s disease, and Parkinson’s disease may manifest paranoia as part of their symptom complex. The paranoia may decrease in intensity when the underlying disease is effectively treated, although since many of these diseases are progressive, the paranoia may worsen over time along with the progression of the disease’s other symptoms.

A number of different medications and drugs can cause paranoia. These include corticosteroid medications, H-2 blockers (cimetidine, ranitidine, famotidine), some muscle relaxants (Baclofen), antiviral/anti-Parkinson drugs (amantadine ), some amphetamines (including Ritalin), anti-HIV medications, antidepres-sants (Nardil). Abused drugs that can prompt paranoia include alcohol, cocaine , marijuana, ecstasy (MDMA), amphetamines (including Ritalin), LSD, and PCP (angel dust). Withdrawal from addictive drugs may also cause symptoms of paranoia.

Treatments

It can be quite challenging to get an individual who is suffering from paranoia to accept treatment. Their paranoid condition makes them distrustful of people’s motivations towards them, so that even a medical doctor appears to be a suspicious party. Medications that may be offered are usually looked at with great distrust, and efforts at psychotherapy are considered “mind control” by a profoundly paranoid individual.

The first step to be taken when someone is suffering from paranoia is that of determining whether an easily reversible situation (such as an adverse reaction to a medication) might be causing the paranoia. If so, discontinuing the drug (either immediately or by gradually weaning the dose) might end the symptoms of paranoia.

Patients who have other diseases, such as Alzheimer’s disease or other forms of dementia, Hunting-ton’s disease, or Parkinson’s disease may notice that their paranoid symptoms improve when their general medical condition is treated. The circumstance that can occur as their underlying disease progresses, is that the paranoia may return or worsen over time.

People who are suffering from diagnosable mental conditions such as schizophrenia or paranoid personality disorder may benefit from the use of typical anti-psychotic medications, such as chlorpromazine or Haldol, or from the newer, atypical antipsychotic medications, such as clozapine , olanzapine , or risperidone.

Cognitive-behavioral therapy (CBT) or other forms of psychotherapy may be helpful for certain people who have paranoia. CBT attempts to make a

person more aware of his or her actions and motivations, and tries to help the individual learn to more accurately interpret cues around him or her, in an effort to help the individual change dysfunctional behaviors. Difficulty can enter into a therapeutic relationship with a paranoid individual, due to the level of mistrust and suspicion that is likely to interfere with their ability to participate in this form of treatment.

Support groups can be helpful for some paranoid individuals—particularly helpful in assisting family members and friends who must learn to live with, and care for paranoid individuals.

Prognosis

It is difficult to predict the prognosis of an individual who has paranoia. If there is an underlying mental illness, such as schizophrenia or paranoid personality disorder, then the paranoia is likely to be a lifelong condition. It may improve with some treatments (remission), only to become exacerbated under other more stressful conditions, or with changes in medication.

Individuals who have symptoms of paranoia as part of another medical condition may also have a waxing-and-waning-course.

When paranoia is caused by the use of a particular drug or medication, it is possible that discontinuing that substance may completely reverse the symptoms of paranoia.

Resources

BOOKS

Tasman, Allan, and others. Psychiatry. Philadelphia: W. B. Saunders, 1997.

ORGANIZATIONS

National Alliance for the Mentally Ill. Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201. (703) 524-7600. http://www.nami.org National Institute for Mental Health. 6001 Executive Blvd.,

Room 8184, MSC 9663, Bethesda, MD 20892. (301)443-4513. http://www.nimh.nih.gov

Rosalyn Carson-DeWitt, M.D.