PARANOIA. — It generically signified madness, mental illness, until Boussier de Sauvages (1768), who was the first to reduce it to the concept of a particular form of mental illness. Various authors subsequently concerned themselves with defining it nosographically,
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PARANÀ, ARCIDIOCESI di — New seminary of P. inaugurated in 1950.
considering it predominantly from the semiological standpoint (French school) or from the pathogenetic standpoint (German school); it is, however, linked to the name of Kraepelin, who understood it as “a psychosis characterized by the development of an immutable chronic delusional system, produced by endogenous causes and evolving while preserving complete clarity of sensorium and the order of thought, will, and activity.” Alongside this picture, which is rather rare, are placed the “reactive paranoid syndromes” and the “periodic paranoid syndromes,” although the latter fall among the symptoms of “manic-depressive psychosis,” whose course they faithfully follow.
P. and reactive paranoid syndromes have in common the ground on which they arise and develop, which is more precisely defined as “disposition” rather than paranoid constitution. This means a particular reactivity that predisposes one to the onset of psychosis under the influence of exceptional external events (paranoid syndromes) or ordinary events of life (Kraepelin’s p.); in this abnormal disposition, overvaluation of one’s own personality and hypertrophy of the Ego predominate, signs that are almost pathognomonic; among such individuals, “intransigents,” often encountered in everyday social life, are frequent. Distrust, touchiness, and the perpetual defensive attitude toward the environment explain their poor adaptability, the isolation in which they often shut themselves away, and the emergence of antisocial reactions. The consequence of this abnormal disposition is an error of judgment concerning the Ego and the external world; logic is moreover distorted by the emotionality that temporarily or permanently colors events and memories.
a) Kraepelin’s p. (the chronic systematized delusion of French authors) is almost always characterized by the development of a delusion upon a pre-existing paranoid disposition (delusion [v.] is, according to classical psychiatry, an erroneous judgment endowed with irrefutable subjective certainty, against which neither criticism nor experience can prevail). The perfect integrity of the psychic functions outside the delusional construction is important, while the delusion itself is lucid, coherent, systematized, logical in its illogicality, and the patient succeeds in elaborating its material until almost every internal contradiction disappears. The delusion generally arises from external events or affectively experienced facts that are not in themselves pathological; because of the distortion they undergo in the patient’s psyche, little by little even events that were previously indifferent or unrelated come to be experienced by him in relation to his own delusion. Hallucinations (v.) are absent, while “revealing dreams” may appear with a certain frequency, in which the distortion lies only in the patient’s interpretation of them. The paranoid delusion develops slowly and remains crystallized for a long time, while the intensity of the affective involvement gradually diminishes.
According to variations in content, the following are distinguished: delusions of grandeur (inventive, reformative, and genealogical forms), jealousy, and persecution, which are often combined with the conviction of having suffered harm, while the persecutors may be family members, acquaintances, or an entire social class; erotic delusions, in which a platonic love develops toward a socially superior person, by whom the delusional subject feels reciprocated; religious or mystical delusions (which may be included under the form of grandeur); delusions of mission, reform, etc.; delusions of reference, in which events are experienced by the patient as clearly related to his own person (a form placed by Kretschmer in relation to the sensitive personality); and querulous delusions, in which the patient believes that his legitimate rights have been infringed, submits lengthy petitions to the authorities, files continual complaints, etc.; in this form, in which Bleuler recognizes the “combative paranoid temperament,” querulousness assumes, together with persecutory delusion, particular medico-legal importance, because, given the patient’s special characteristics, it may lead to lengthy and never-concluded legal disputes, while the persecutory variety may drive the subject to assault the supposed persecutors.
The age at which Kraepelin’s p. most frequently develops is around 30–40 years, but the first symptoms may appear as early as youth. It is an illness that does not always require hospitalization; nevertheless, antisocial conduct often necessitates security measures and sometimes also limitations on the capacity to act. P. must be distinguished from “paraphrenia” (Kraepelin), or the hallucinatory p. of French authors, which constitutes a transitional bridge between p. and schizophrenic paranoid syndromes.
b) Reactive paranoid syndromes are always related to affectively experienced facts (paranoid reactions), or to particular prolonged affective situations (psychoses due to situation); according to Jaspers, they fall within psychogenic reactions: that is, they arise from external events and depend closely upon them. As an intermediate link between these reactions and p., one may classify abortive p. (Gaupp), mild p. (Fiedmann), and latent p. (Kraepelin), in which the endogenous disposition and external events play roles of almost equal importance: this involves the sudden development of a hitherto latent delusion or the emergence of an abnormal conviction from facts that the patient overvalues; in such cases, complete remission, sufficient to return the patient to his previous psychic state, is difficult.
Among the pure reactions are forms analogous to querulousness, but differing from it because, at their origin, there is an actual legal dispute; often, with every dispute, a querulous attitude may recur: “recurrent querulous delusion” (Kaecke). A corresponding form of delusion of reference may likewise be found among the reactions.
Within the group of “situational psychoses,” the following are distinguished: “occupational psychosis,” that is, delusional developments arising in certain categories of persons because of the environmental conditions of their work (e.g., governesses, assistants, etc.), in whom the contrast between the position occupied and the subject’s cultural level or ideal aspirations may be brought to light. “Induced psychoses,” frequent among individuals who live in contact with a paranoiac, especially if they are isolated or mentally weak, hysterical, or themselves hypoparanoid; in these cases, the plausibility of the delusional ideas, the very character of the patient, who is driven to proselytize, and the persuasive force with which he is animated overcome the critical faculties, especially when defective, of those around him; thus it often happens that, even beyond the family’s social limits, paranoiacs win others over to their convictions and succeed in giving rise to sects, parties, societies, etc., in which every member blindly believes in the apparent logic and truth of the leader’s delusional ideas. “Psychosis of isolation,” occurring in individuals who, because of an illness or for other reasons, are isolated from their surroundings; this group includes the delusion of persecution among the deaf and, more rarely, among the blind; such a delusion may also be nourished by psychosensory disturbances of an illusory type; in the delusion of persecution among prisoners of war, the difference in language creates a state of isolation psychologically analogous to that of the deaf and blind. “Prison psychosis” may arise either in a reactive form or through the development of a paranoid personality; it is generally persecutory in type, following the loss of hope of freedom; Bleuler’s “prison complex” is something similar: the patients are convinced, often on the basis of hallucinations, that they have been acquitted, yet the elements of external reality contradict this conviction; consequently, delusional ideas of persecution, often accompanied by hallucinations, develop. The delusional ideas of degenerates (Birnbaum) are incoherent, illogical delusions, variable in content, characteristic of delinquents and frequently associated with psychosensory disturbances.
All these forms present a better prognosis than Kraepelin’s p., since removal from the environment or the cessation of psychogenic causes almost always has a decisive effect on the course of the psychosis, although the abnormal disposition invariably persists, without which, broadly speaking, the psychotic picture would not have arisen.
Sometimes, however, despite every effort to explain the origin of the illness, one finds oneself confronted with an incomprehensible fact; it is then necessary to conclude that something new has intervened, a “process” that must have modified the patient’s psyche: schizophrenia (v.); only in this case (“process”) are there true delusional ideas, inderivable, incomprehensible and therefore psychopathologically “primary.” Conversely, when such ideas can be derived comprehensibly, they represent only “secondary delusional ideas” (Wahnhafte Ideen). If the clinical pictures that may fall within paranoid symptoms are considered in the light of these concepts, it will be seen that, depending on how they present themselves to psychopathological analysis, they will involve either a “development,” when states of mind, desires, and instincts give rise to erroneous or del when more or less comprehensible; or a “process,” when, on the contrary, subjective experiences of the patient that are psychologically inderivable (true delusional ideas) are shown to lie at the origin of the delusion. Kraepelin’s p. is therefore not, according to current psychopathological concepts, a nosographic entity in its own right, but constitutes the “development” of a particular disposition, or a schizophrenic “process.” This concept does not, naturally, concern reactive paranoid syndromes.