Dangerously Paranoid?Overview and Strategies for a Psychiatric Evaluation of a Highly Prevalent Syndrome

The term “paranoia,” derived from the Greek &lduo;para” (beside) and “nous” (mind), was coined as a descriptor of psychopathology by Heinroth in 1818.¹ By the end of the 19th century, 50% to 80% of patients in asylums in German-speaking coun­tries had received a diagnosis of paranoia.¹ Beginning in 1899, Kraepelin’s efforts to define paranoia more precisely resulted in a decrease in diagnoses of paranoia in favor of dementia praecox and, later, schizophrenia.^1,2 This narrowing of the definition of paranoia is reflected in current nosology and practice. In DSM-IV-TR, the prevalence of delusional disorder is estimated at 0.03% of the general population and accounts for 1% to 2% of psychiatric admissions. The prevalence of paranoid personality disorder is 0.5% to 2.5%; this condition accounts for 10% to 30% of psychiatric admissions.³

The association of paranoia with violence was most rigorously theorized in the French psychiatric literature by Jacques Lacan.⁴ In the context of ongoing efforts by psychiatrists to distinguish paranoia from schizophrenia, Lacan outlined a review of the literature on paranoia, parsing earlier theories into 2 main groups:

• The first argued that paranoia is largely psychogenic and integrated into, or continuous with, the individual’s preexisting personality and life story.
• The second argued for an organic basis for the disorder, citing the experience of strangeness at the time of onset, taking the form of an abrupt eruption of symptoms that the individual experiences as alien and meaningless.

Lacan synthesized these views by conceptualizing the latter eruption of symptoms as the sudden appearance of an affective state with an organic basis that was initially devoid of meaning. The symptom in a second step, became necessarily situated within the person’s life story and premorbid personality. Because of their role in the onset of psychotic illness, these early symptoms marked the spot within the psyche where the person was most vulnerable to future decompensation, including passage to the act of violence, with implications for treatment and prevention.⁵

The assessment of violence risk: risk status vs risk state
Contemporary violence risk assessment in both criminal and psychiatric populations can emphasize either the prediction of an individual’s level of future risk or the management of risk.⁶ The latter takes a dynamic approach, which focuses on variables that are susceptible to change with treatment.⁷ In this context, for the assessment of violence risk, it is more relevant to know whether a person is paranoid than whether he or she is a paranoiac, and to know what makes him less paranoid.

The 3 main types of contemporary risk assessment integrate information about paranoid states in distinct ways:

Clinical judgment. The most common approach-clinical judgment in usual practice settings-;takes paranoia into account in the diagnostic process, and not only in schizophre­nia, delusional disorder, or paranoid personality disorder. Many other psychiatric disorders are associated with paranoid delusions and even more with paranoid ideation. In his 2007 review, Freeman⁸ noted that in addition to the nearly 50% of patients with schizophrenia who have persecutory delusions, 44% with psychotic unipolar depression, 31% with de­mentia, and 28% of patients who have had a manic episode also have persecutory delusional thoughts.

Freeman⁸ also reported that in studies of a nonclinical population from which persons with psychotic disorders were excluded, at least 10% to 15% of individuals regularly experienced paranoid thoughts, and these were increased in the presence of anxiety or depression. Whether paranoid ideation is related to a risk of harm to others is then evaluated on a case-by-case basis in the context of other factors, including ones that may be highly specific to the individual.

Actuarial risk assessment. A second type of risk assessment, actuarial risk assessment, has not consistently integrated an assessment of paranoid ideas into its approach. This may be because of a lack of reliable constructs for measuring nondelusional paranoia in the types of large studies on which actuarial instruments are usually based. For instance, the MacArthur Violence Risk Assessment Study demonstrated that fear and anger are 2 of the strongest predictors of violence, which suggests that perceived threat or a feeling of being wronged by another are at issue in the individual’s violent behavior.⁹

But an analysis of delusions in the MacArthur study showed that the presence of delusions alone did not predict future violence in the 10-week period following discharge from a hospital¹⁰ The study did show an increased level of violence among men with delusions when gender was taken into account.¹¹ In their discussion, Appelbaum and colleagues¹⁰ propose that suspiciousness may be a more relevant predictor of violence than delusions.

The literature on the relationship between paranoid delusions and violence nonetheless indicates that under certain conditions paranoid delusions are associated with an increased risk of violence. Threats made by eroto­manic stalkers or unusually persistent litigants with delusional vindications should be taken seriously because they may lead to violence.^12,13 Persecutory delusions in patients with schizophrenia correlate with higher rates of violence than those with other types of delusions.^14,15

Threat/control-override (TCO) de­lusions, which can be conceptualized as a form of paranoia, involve the belief that one is being threatened or controlled by forces outside oneself. These delusions have been generally found to be associated with increased violence.¹¹

Structured clinical judgment. This type of risk assessment involves psychometrically validated categories that are broad and are rated on a clinical basis, using objective features of the case as well as subjective features gleaned from the clinical interview.

The most robust of this type of rating scales, the Historical, Clinical, Risk Management–20 (HCR-20), includes the possibility of accounting for paranoid ideas under the variables “major mental disorder” and “active psychotic symptoms.”¹⁶ However, there is no specific item that focuses on persecutory or paranoid ideas per se.

Although there have been tremendous advances in our understanding of risk factors, recent trends in violence risk-assessment research emphasize the need for an explanatory theory of the choice to act at a particular moment and the evolution of dynamic risk over time.¹⁷ These elements are difficult if not impossible to measure at the time that violence is occurring. Strategies for approaching an explanatory model include observation of the temporal convergence of risk factors and hypotheses regarding the possible existence of a final common pathway for known risk factors.

Susceptibility to transient paranoid ideation would appear to be a good candidate for such a convergent pathway for variables as diverse as previous violence, substance abuse, personality disorder, and exposure to environmental stressors. Each of these may contribute to the experience of perceived threat and feelings of fear or anger, while examining paranoid delusions per se as a risk factor for violence may have limited utility. The study of paranoid ideation as a dynamic process that varies over time under specific conditions may allow us to develop a picture of what happens immediately before an act of violence.

Attribution style
What is the evidence to date that transient paranoid ideation contributes to risk of violence? In current research, transient paranoid ideation has been most precisely studied by way of the construct of attribution style, which has been examined to a limited extent in relation to violence.

Attribution style is a concept of cognitive processing used to characterize the extent to which an individual attributes causation for positive events to his own abilities while attributing negative events to chance or external factors and vice versa.¹⁸ This general concept, however, is related to one of the main psychopathological mechanisms present in paranoid states, described by Freud as projection. In projection, an internal state that is otherwise unbearable is experienced by the person as a property of the external environment. In 1922, Freud remarked that:

"[S]ufferers from persecutory paranoia . . . cannot regard anything in other people as indifferent, and they . . . take up minute indications with which these other, unknown people present them, and use them in their delusions of reference. The meaning of their delusion of reference is that they expect from all strang­ers something like love . . . the paranoic is not so far wrong in regarding this indifference as hate, in contrast to his claim for love. . . . They let themselves be guided by their knowledge of the unconscious, and displace to the unconscious minds of others the attention which they have withdrawn from their own."¹⁹

Current conceptualizations of attribution style diverge from this psychoanalytic formulation of projection, and divide the phenomenon into 4 classes of explanations for paranoid behavior in the context of persecutory delusions:^20,21

1. Heightened perception of threat from the content of delusions, particularly TCO delusions
2. Theory of mind abnormalities, which involve the ability to envision the minds of others but without empathy
3. Attributional bias, which is characterized by a hostile and threatening outlook regarding others and external stimuli
4. Early adverse experience

Also described as a paranoid cognitive personality style, attribution bias involves distortions in the interpretation of innocuous events.

Bentall and Taylor²⁰ emphasize that because these constructs have been studied separately, their combination or convergence in risk for violence has yet to be elucidated, since many persons with such traits do not commit acts of violence. Recent efforts to examine the interrelations of different reasoning abnormalities in schizophrenic delusions may allow further study of these dimensions as contributors to violence risk.²²

In a comprehensive review of persecutory delusions, Bentall and colleagues¹⁸ propose a heuristic model of persecutory thought processes, proceeding from data to attention and perception, to inference, belief, and the search for further data regarding the belief. This progressive feedback loop leads the authors to posit an attribution–self-representation cycle that can account for the evolution of the paranoid individual’s self-concept and behavior over time, in relation to biological as well as experiential and environmental factors. They remark that the distinction between persecutory delusions and delusional guilt, as found in psychotic depression, is difficult to make because of the perception of imminent harm in both concepts that may be viewed as either intentional malevolence or deserved punishment. They note alternative definitions that include defining delusions that would properly be classified as persecutory by attributing the experience of intent to a perpetrator.

The difficulty in arriving at clear definitions speaks to the wide range of paranoid delusions that may be found in conditions other than schizophrenia or delusional disorder. A study of acute, remitted (nonacute) paranoid, and remitted nonparanoid patients with schizophrenia or schizo­affective disorder indicates that acutely paranoid patients are more likely to demonstrate external-personal attributions when confronted with negative events, and that remitted patients are more likely to do so than controls.²³ This suggests that there is a stable, chronic component to attribution style that is associated with specific disorders. Another component of attribution may be state-dependent and augmented during psychiatric decompensation, either of a primary psychotic disorder or an affective disorder, such as depression.

Attributional style has been operationalized outside the realm of delusions per se in a study by McNiel and colleagues²⁴ on violence in an inpatient sample. These investigators found that “an aggressive attributional style is associated with increased rates of violent behavior by psychiatric patients” in the 2 months before admission. Impulsiveness was also associated with violence but did not independently contribute to violence once attributional style was taken into account. The findings indicate that aggressive attributions predict violence beyond demographic variables and diagnoses, as well as beyond other established predictors of violence.²⁴

Nestor²⁵ presents 4 key dimensions of personality that were each hypothesized to be predictive of violence risk in patients with a particular mental disorder. In addition to impulse control, affect regulation, and narcissism, paranoid cognitive personality style was examined in schizophrenia and chronic psychotic disorders using the construct of attribution bias. Nestor proposes that personality traits associated with specific disorders, such as substance abuse, personality disorders, and schizophrenia, may be useful to study in a transdiagnostic manner as refined predictors of a propensity for violence.

Clinical strategies for the psychiatric interview
Strategies for managing the clinical interview with patients who have paranoid personality disorder are equally useful in the more general setting of paranoid states. These strategies are summarized in the following points.^26,27 The detection of discreet delusions with nonbizarre content essentially requires a high index of suspicion. Because of the plausible nature of the delusion and the reticence of the individual, detailed serial examination is sometimes required. Attention should be given to the presence of a delusion that may appear to be an overvalued idea that is particularly intense in the context of anxiety or depression. Nonbizarre delusions require assessment of the reasoning process in addition to the elaboration of thought content.

Fixity of belief that rises to the level of a delusion may be experienced by the patient as a feeling or intuition rather than a thought per se. The patient may be unable to explain why he is certain of this belief. A tendency to jump to conclusions and extrapolate from improbable features of the story may indicate a lack of flexibility in internal logic that is fundamentally impervious to counterexample. Individuals may have some superficial ability to integrate data that run coun­ter to the delusion, but this should not be mistaken for a dialectical capacity to question the basis of their suppositions in a nondelusional manner.

Some general strategies may help the clinician exercise appropriate judgment in the interview and maintain safety when speaking with an acutely paranoid patient. The following includes key points elaborated on by McWilliams²⁶ and Gabbard²⁷ regarding patients with paranoid personality disorder, grouped into 5 main principles:

Establish a therapeutic alliance, without expecting trust. Paranoid patients are by definition distrustful. To promote a constructive clinical encounter, the interviewer often must tolerate the patient’s suspicion and reticence. Acknowledgment of the patient’s hostile attitude may be reassuring to him, in that the interviewer thereby conveys an acceptance of the patient’s psychic reality centered on fear. Paranoid patients may require a sense of control over the interview and over treatment decisions, when this is possible. Efforts of the interviewer to ensure the personal safety of both parties may provide additional comfort for the patient, who often fears his own destructive impulses arising from paranoid ideas.

Let the patient recount his theory-and listen. Whether delusional or a set of overvalued ideas, paranoid thinking is an attempt to create meaning that serves a purpose for the patient. The patient has an explanatory theory of events that surround him, an account that is impervious to ordinary reason or reassurance. Attempts to reassure the patient or correct delusional beliefs may lead him to feel humiliated or result in the incorporation of the interviewer into the delusional system.²⁶

Lacan²⁸ described the listener’s stance as that of being “a secretary to the madman,” learning, registering the patient’s account, and helping shape the thought content into a form that is more tolerable to the patient. Interpretations by the clinician are likely to be experienced by the patient as destabilizing or invasive, and result in an increase in persecutory ideation. Conversely, simply naming the emotions that are close to the surface of the patient’s discourse (for example, fear and anger) may attenuate the intensity of persecution. In general, allow the patient to speak of the paranoid ideas, to the extent that this is not disorganizing, and focus on his experience, without expressing an opinion on the ideas themselves.⁵

Maintain optimal distance. Readily threatened or invaded by the presence of another person, paranoid patients tend to benefit from having greater physical space between themselves and the interviewer than would ordinarily seem appropriate. Physical movements should not be sudden or unexpected, and any movements, such as reaching into a desk drawer, should be explained beforehand.²⁷

Although empathy and recognition of the patient’s expressed feelings is generally beneficial, clinicians should exercise caution by maintaining careful emotional distance. Levels of empathy that are appropriate for other patients may be felt by the paranoid person as intrusive or humiliating.

Separate thoughts and speech from actions. Paranoid patients who experience the urge to act on persecutory ideas often fear their own impulses and are reassured when the clinician reminds them of the distinction between thoughts, fantasies, and speech, on the one hand, and action on the other.²⁶ Verbalization of feelings and thoughts is often constructive, and patients should be encouraged to express themselves in words rather than action. Verbalization may also allow the individual to identify stressors and triggers of violence that he may then choose to avoid, as well as to clarify strategies for managing overwhelming anxiety or impulses.

Maintain a position of ethical integrity. Patients with paranoid ideas and attribution bias are particularly observant of and sensitive to the re­actions of others. The interviewer should strive to be fair and consistent, as well as straightforward. Equivocal or hesitant statements may be interpreted in a persecutory manner. Countertransference issues may pose significant obstacles, leading the clinician to avoid asking about topics that may be uncomfortable for the patient but that require assessment, such as a history of violence.²⁶

The interviewer may feel afraid or angry in the patient’s presence, and should be attentive to excessive fear that may accompany the escalation of the patient’s hostile or threatening attitude. Careful observation of boundaries along with the clinician’s willingness to honestly acknowledge his or her own mistakes (when these occur) allow the paranoid patient to feel safe and in the presence of a clinician with credible authority who will not abuse the power he has over the patient. It is essential to maintain a nonjudgmental attitude, to treat the patient respectfully, and to take his paranoid ideas seriously to the extent that they are a central feature of his subjective reality.

Summary
Specificities of violence risk assessment in patients with paranoid ideation include the evaluation of intent to take action in the immediate future. Of particular relevance for this assessment is the presence of a designated persecutor or an intended victim, or whether a conflict has been endured to the point where the patient feels there is no other solution but to act in a violent manner.

Paranoid thinking is likely to be stimulated or worsened by triggers that are highly idiosyncratic and embedded in the life history and experience of the person. Clinicians who provide ongoing psychiatric care to such individuals have the opportunity to learn over time about these particular characteristics. From the perspective of research, detailed case studies of violent offenders may help clarify the specific mechanisms by which an individual acts on ideas or feelings of persecution, and may lead to refinement of our understanding of how to prevent future violence.

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Evidence Based References
Attributional style in delusional patients: a comparison of remitted paranoid, remitted nonparanoid, and current paranoid patients with nonpsychiatric controls. Schizophr Bull. 2008 May 20. [Epub ahead of print].Freeman D. Suspicious minds: the psychology of persecutory delusions. Clin Psychol Rev. 2007;27:425-457.
McNiel DE, Eisner JP, Binder RL. The relationship between aggressive attributional style and violence by psychiatric patients. J Consult Clin Psychol. 2003;71:399-403