Paranoia can be mild and the affected person may function fairly well in society, or it can be so severe that the individual is incapacitated. Because many psychiatric disorders are accompanied by some paranoid features, diagnosis is sometimes difficult. Paranoias can be classified into three main categories--paranoid personality disorder, delusional (paranoid) disorder, and paranoid schizophrenia.
An unmistakable sign of paranoia is continual mistrust. People with paranoid personality disorder are constantly on their guard because they see the world as a threatening place. They tend to confirm their expectations by latching on to any speck of evidence that supports their suspicions and ignore or misinterpret any evidence to the contrary. They are ever watchful and may look around for signs of a threat.
Anyone in a new situation--beginning a job or starting a relationship, for example--is cautious and somewhat guarded until he or she learns that the fears are groundless. People suffering from paranoia cannot abandon their fears. They continue to expect trickery and to doubt the loyalty of others. In a personal relationship or marriage, this suspiciousness may take the form of pathological, unrealistic jealousy.
Because persons with paranoid personality disorder are hyperalert, they notice any slight and may take offense where none is intended. As a result, they tend to be defensive and antagonistic. When they are at fault, they cannot accept blame, not even mild criticism. Yet they are highly critical of others. Other people may say that these individuals make "mountains out of molehills."
Cold and Aloof
In addition to being argumentative and uncompromising, the people with paranoid personality disorder are often emotionally cut off from other people. They appear cold and, in fact, often avoid becoming intimate with others. They pride themselves on their rationality and objectivity. People with a paranoid outlook on life rarely come to the attention of clinicians--it is not in their nature to seek help. Many presumably function competently in society. They may seek out social niches in which a moralistic and punitive style is acceptable, or at least tolerated to a certain degree.
DELUSIONAL (PARANOID) DISORDER
Psychiatrists make a distinction between the milder paranoid personality disorder described above and the more debilitating delusional (paranoid) disorder. The hallmark of this disorder is the presence of a persistent, nonbizarre delusion without symptoms of any other mental disorder.
Delusions are firmly held beliefs that are untrue, not shared by others in the culture, and not easily modifiable. Five delusional themes are frequently seen in delusional disorder. In some individuals, more than one of them is present.
The most common delusion in delusional disorder is that of persecution. While persons with paranoid personality might suspect their colleagues of joking at their expense, persons with delusional disorder may suspect others of participating in elaborate master plots to persecute them. They believe that they are being poisoned, drugged, spied upon, or are the targets of conspiracies to ruin their reputations or even to kill them. They sometimes engage in litigation in an attempt to redress imagined injustices.
Another theme seen frequently is that of delusional jealousy. Any sign--even a meaningless spot on clothing, or a short delay in arriving home--is summoned up as evidence that a spouse is being unfaithful.
Erotic delusions are based on the belief that one is romantically loved by another, usually someone of higher status or a well-known public figure. Individuals with erotic delusions often harass famous persons through numerous letters, telephone calls, visits, and stealthy surveillance.
Persons with grandiose delusions often feel that they have been endowed with special powers and that, if allowed to exercise these powers, they could cure diseases, banish poverty, ensure world peace,or perform other extraordinary feats.
Individuals with somatic delusions are convinced that there is something very wrong with their bodies--that they emit foul odors, have bugs crawling in or on their bodies, or are misshapen and ugly. Because of these delusions, they tend to avoid the society of other people and spend much time consulting physicians for their imagined condition.
Whether or not persons with delusional disorder are dangerous to others has not been systematically investigated, but clinical experience suggests that such persons are rarely homicidal. Delusional patients are commonly angry people, and thus they are perceived as threatening. In the rare instances when individuals with delusional disorder do become violent, their victims are usually people who unwittingly fit into their delusional scheme. The person in most danger from an individual with delusional disorder is a spouse or lover.
Paranoid thinking and behavior are hallmarks of the form of schizophrenia called "paranoid schizophrenia." Individuals with paranoid schizophrenia commonly have extremely bizarre delusions or hallucinations, almost always on a specific theme. Sometimes they hear voices that others cannot hear or believe that their thoughts are being controlled or broadcast aloud. Also, their performance at home and on the job deteriorates, often with a much diminished degree of emotional expressiveness.
In contrast, people with relatively milder paranoid disorders may have such symptoms as delusions of persecution or delusional jealousy, but not the prominent hallucinations or impossible, bizarre delusions of paranoid schizophrenia. Those with milder paranoid disorders are customarily able to work, and their emotional expression and behavior are appropriate to their delusional belief. Apart from their delusions, their thinking remains clear and orderly. On the other hand, those with paranoid schizophrenia are often intellectually disorganized and confused.
CAUSES OF PARANOIA
Little research has been done on the role of heredity in causing paranoia. Scientists have found that the families of paranoid patients do not have higher than normal rates of either schizophrenia or depression. However, there is some evidence that paranoid symptoms in schizophrenia may be genetically influenced. Some studies have shown that when one twin of a pair of identical twins with schizophrenia has paranoid symptoms, the other twin usually does also. And, recent research has suggested that paranoid disorders are significantly more common in relatives of persons with schizophrenia than in the general population. Whether paranoid disorder--or a predisposition to it--is inherited is not yet known.
The discovery that psychosis (a state in which the individual is out of touch with reality) is treatable with antipsychotic drugs has led scientists to look for the origins of severe mental disorders in abnormal brain chemistry. The search has become very complex, as more and more of the chemical substances that carry messages from one nerve cell to another--the neurotransmitters--have been discovered. So far, no clear-cut answers have been found. As with the genetic studies, biochemical studies have not examined paranoia except as a subtype of schizophrenia. There is, however, limited evidence that paranoid schizophrenia is biochemically distinct from nonparanoid forms of the disorder.
Abuse of drugs such as amphetamines, cocaine, marijuana, PCP, LSD, or other stimulants or "psychedelic" compounds may lead to symptoms of paranoid thinking or behavior. Patients with major mental disorders like paranoid schizophrenia may have their symptoms become worse under the influence of these drugs. Scientists are studying the biochemical actions of such drugs to determine how they produce their behavioral effects. This may help us to learn more about the neurochemistry of paranoid disorders, which is poorly understood at this time.
Some scientists believe paranoia may be a reaction to high levels of life stress. Lending support to this opinion is the evidence that paranoia is more prevalent among immigrants, prisoners of war, and others undergoing severe stress. Sometimes, when thrust into a new and highly stressful situation, people suffer an acute form--called "acute paranoia"--in which delusions develop over a short period of time and last only a few months.
Some studies indicate that paranoia has become more prevalent in the twentieth century. The connection between stress and paranoia does not, of course, rule out other contributing factors. A genetic defect, a brain abnormality, an information-processing disability--or all three--could predispose a person to paranoia; stress may merely act as a trigger.