PARANOIA AND THE PARANOID CONDITIONS
A discussion of the part played by paranoia, or the paranoid
conditions however characterized, in the psychiatry of the present
day, is essentially a review of the final chapter in the history of
a psychiatric conception which is several centuries old. The word
paranoia, like many other terms still in use, is of Greek origin
and was apparently applied by Hippocrates in a very general way to
"madness" of any or all forms. It almost certainly had no more definite
significance than that, in the works of Plato and Aristotle, nor can it
be said to have been used in its modern sense by Celsus or Aretaeus.
It seems to have meant something more in the vocabulary of Vogel, an
eighteenth century writer. Under the heading of paranoia, according
to Jelliffe,[314] Plocquet in 1772 included Paracope or delirium with
six subdivisions:—(a) pathetica, (b) phronestica, (c) entomica,
(d) encephalica, (e) hyperesthetica, and (f) sympathica. It was not
recognized to any great extent by the earlier writers of the French
school, but occupied a very prominent place in the development of
German psychiatry. Heinroth in 1818 included the paranoias in his
disorders of the intellect under the name of verrücktheit, a word that
was destined to become one of great importance later, and spoke of an
exaltation of the feelings which he called "paranoia ecstasia."
Flemming[315] in his elaborate classification of psychoses in 1844
described paranoid forms of "mania adstricta" or partial mania
(monomania). Stark, a contemporary of Flemming's, made what seems
to be a very direct reference to paranoia in his discussion of
"Wahnsinn," as did Weiss in 1842. Von Feuchtersleben in 1845 wrote a
very exhaustive description of "fixed delusions" which he classified
as either involving the personality (mania metamorphosis) or as being
ambitious, religious or relating to love (erotomania). He also spoke
of a monomania or mania sine delirio which he attributed to Pinel. The
exact significance of these conceptions cannot be determined.
In 1845 Griesinger used the word verrücktheit as applying to a
secondary incurable condition, exhibiting delusions of persecution
and grandeur and usually developing after an attack of mania or
melancholia. He also defined Wahnsinn, which he compared to Heinroth's
"paranoia ecstasia," as including "states of exaltation characterized
by assertive, expansive emotions, associated with persistent excessive
self-estimation and extravagant fixed delusions which arise therefrom."
Magnan spoke of "folie systematisée progressive" and a "folie
systematisée des dégénérés." In his "Le Délire Chronique à Évolution
Systematique" he divided paranoia into a stage of subjective analysis,
one of persecution and a third of transformation of the personality.
Lasègue described this same condition under the name of persecution
mania in 1852. Falret and Ritti divided the course of this disease
into four periods, one of insane interpretations, one of visual
hallucinations, one of general sensory derangement and a stereotyped
state or mania of ambition. Morel was of the opinion that these
psychoses were always preceded by an initial period of hypochondriasis.
Pritchard described as monomania a form of insanity "characterized by
some particular illusion or erroneous conviction impressed upon the
understanding, and giving rise to a partial aberration of judgment."
Esquirol devoted as many as one hundred and thirty pages to a study
of monomania, which he subdivided into seven forms:—the erotic,
"raisonnante" or moral insanity, the alcoholic, the incendiary, the
homicidal, the suicidal and the hypochondriacal.
It was probably the work of Mendel in 1881 which was responsible for
the use of the word paranoia in its modern sense. He spoke of primary
and secondary paranoias.[316] The former was described as a "functional
psychosis characterized by the primary appearance of delusional ideas.
The delusions of primary paranoia, without being interfered with by
any opposing ideas, control the entire mental life of the patient.
The remaining ideas not affected by morbid processes stand in close
relation, but not in conflict, with the dominating delusions. The
feelings are determined by the content of the delusions and vary with
them. In the same way the abnormalities of conduct are due to the
content of the delusional ideas, with or without hallucinations." Régis
in 1892 described his systematized progressive insanity as involving
three distinct stages,—one of subjective analysis, a stage either
of persecution, religious exaltation or eroticism and jealousy, and
finally a megalomanic state ending occasionally in dementia. Cramer,
in an elaborate review of the literature of paranoia in 1894, refers
to twenty-eight different designations used by various writers in the
discussion of this subject up to that time. Serieux and Copgras (1909)
include deliria of interpretation and of vindication in their grouping
of these conditions.
In the words of Meyer, paranoia eventually reached its high water
mark in the work of Krafft-Ebing.[317] He defined it as "a chronic
mental disease occurring exclusively in tainted individuals, frequently
developing out of the constitutional neuroses, the principal symptoms
of which are delusions." These are devoid of all emotional foundation
and from the beginning are systematized, methodic and "combined by the
processes of judgment, constituting a formal delusional structure.
Consciousness is not disturbed and judgment as a rule is not impaired
but is entirely based on delusional premises." The conduct of the
individual is determined by his hallucinations and delusions. The
process of development is slow and the disease remains stationary for
many years, but never ends in dementia. In a study of over one thousand
cases Krafft-Ebing[318] never observed a definite recovery, although
lucid intervals occurred, generally in the beginning of the disease.
The taint of paranoia he describes as heredity, in the form of abnormal
character, psychoses, constitutional neuroses and alcoholism. In a few
instances he reported developmental defects in the brain. He found in
all cases an anomaly of personality which determined the later form
of the paranoia. Suspicious, retiring, solitary persons were usually
persecuted. Rough, irritable, egotistical individuals developed the
querulent forms and the over-conscientious eccentrics became the
victims of religious paranoia. He attaches a considerable importance
to the influence of the unconscious or subconscious mind. "Its
predominance is shown in the dreamy, romantic, enthusiastic life of
such individuals, and in the fact that accidental delusions occurring
in sickness, dream pictures, and reminiscences from reading or plays,
are elaborated in the depths of the soul, and early burst forth in
the form of imperative ideas and desultory primordial delusions,
which become latent, but later find their ultimate evaluation in the
delusional ideas of the disease."
It is interesting to note that Krafft-Ebing speaks of precipitating
factors as puberty, the climacteric, uterine disease and onanism.
There is a definite period of incubation followed by one of full
development in which judgment and reason are lost. Hallucinations
of hearing were found to be the more common form, followed in the
order of their numerical occurrence by disturbances of sensibility,
vision, taste and smell. Persecutory ideas, moreover, were said to be
much more frequent than delusions of grandeur. The terminal states
he speaks of as mental enfeeblements with a prominence of emotional
dulness, rather than intellectual defects. He divides the disease
into original paranoia and the later or acquired forms. Original
paranoia begins before or at latest during puberty. Hereditary taint
is always to be found. Conspicuous features are sentimental tendencies
inclining to hypochondria, eroticism with sensitiveness and emotional
instability. Delusions as to parentage are common, suggested often
by the fancied or real resemblance of the patient to pictures of
distinguished personages. Transitory ideas of persecution or grandeur
are nearly always present. The erotic element is more frequent in
females. Intermissions sometimes last for years. The termination is
often found in confusional states. The classic or acquired form of the
disease develops later in life, often during the involution period. Two
varieties are described,—the persecutory and the expansive. Subsidiary
types of the former are sexual paranoia, often with delusions of
jealousy, and querulous insanity with mania for lawsuits. The sexual
complex he attributes largely to masturbation or enforced abstinence.
The expansive group is divided into inventive or reformatory paranoia,
the religious and the erotic varieties (erotomania). The acquired
form as described by Krafft-Ebing is quite similar to the "folie
systematisée" of Magnan. It conforms, moreover, in a general way to
the views expressed in the English textbooks on delusional insanity
and is the paranoia of Spitzka, Chapin, Berkley, Peterson and many
other American psychiatrists. This conception of the psychosis was the
generally accepted one for many years.
The institutional reports of that day showed large numbers of paranoics
in some of the hospitals. It was a disease that played an important
part in many murder trials and has received more attention from the
courts and newspapers than any other form of insanity, so-called, ever
described in the textbooks. There was a time, according to Kraepelin,
when from seventy to eighty per cent of the patients in the German
hospitals were diagnosed as cases of genuine paranoia. Certainly that
cannot be said of the institutions of this country. In the New York
state hospitals, for instance, during a period of sixteen years, from
October 1, 1888, to September 30, 1904, when the classical form of
paranoia was officially recognized in statistics, 84,152 admissions
were reported. Of this number 1,655, or 1.9 per cent, were diagnosed
as cases of paranoia. At the Matteawan State Hospital for the criminal
insane during this time 1,728 admissions were shown, with no cases of
paranoia. At the Dannemora State Hospital for insane convicts during
the same period there were 354 admissions, sixteen, or 4.51 per cent,
of which were paranoiacs. This is exceedingly interesting but extremely
difficult to explain. It is very hard to understand why no cases of
paranoia reached Matteawan during a period of sixteen years. The
percentage shown in the other institutions can be looked upon as being
fairly representative of the incidence of paranoia as the disease was
then understood.
The decline and fall of the paranoia concept is to be attributed
to Kraepelin. In 1893 his classification included hallucinatory and
depressive forms of "Wahnsinn," both accompanied by persecutory ideas
to a rather prominent degree, and paranoia proper, which he described
as "Verrücktheit." This was defined as the "chronic development
of a permanent delusional system with complete preservation of
consciousness". In the sixth edition of his well-known textbook, which
appeared in 1899, he enlarged the dementia praecox group previously
described by him and added hebephrenia and katatonia to it as well
as describing a new and important "paranoid" form of that disease.
His own reasons for this were stated as follows[319]:—"The second
clinical group" (dementia praecox, paranoid form) "which I am inclined,
provisionally, to include under this head, is characterized by the
fact that extravagant delusions, usually accompanied by numerous
hallucinations, develop in a more coherent manner, and are maintained
during a series of years, either then entirely to disappear, or to
become entirely confused. Hitherto I have reckoned these forms, as
'phantastische Verrücktheit' to paranoia, as is the general practice.
It has, however, gradually become clearer to me that they are at all
events, more nearly allied to dementia praecox than to paranoia.
Whether we really have to do in this case only with a clinical variety
of the former disease or a distinct malady, the future must decide."
He did, however, at that time still recognize a small but well defined
group of cases as genuine paranoia. "On the other hand, there is,
without doubt, a group of cases, in which it is clearly recognizable
from the outset that a permanent, immovable system of delusions
slowly develops, with entire preservation of mental clearness, and
of the regulation of the course of thought. It is these forms for
which I would reserve the appellation of paranoia. It is they which
necessarily lead to a profound transformation of the entire view of
life; to a dislocation of the point of view which the patient assumes
toward the persons and events of his environment." In the eighth
edition of his book (1913) he separates out a considerable number
of cases and places them in an entirely new group designated as
"paraphrenias."[320] This is "a comparatively small group in which,
in spite of many similarities to the manifestations of dementia
praecox nevertheless on account of the much less marked development of
emotional and volitional disturbances the inner structure of the mental
life is considerably less affected, or in which at least the loss of
inner unity is essentially limited to certain intellectual functions.
Common to all of these clinical forms which cannot be sharply
differentiated is the marked prominence of delusion formation and the
paranoid colouring of the disease process. At the same time there are
also alterations in the disposition, but not until the last stages of
the disease that dulness and indifference which so often are the first
indications of dementia praecox." In other words, we are dealing with a
group which shows the paranoid features of dementia praecox but largely
lacks its deteriorative processes. This is a very decided change of
views and may be looked upon either as establishing a definite status
for a large number of cases not properly accounted for in the past
or as an indication of a tendency to return to former conceptions of
paranoia.
Of the paraphrenias as described by Kraepelin "approximately one-half
show that slow but progressively developing mixture of delusions
of persecution and grandeur which Magnan has described under the
designation of 'délire chronique à évolution systematique.' Certainly
this disease of Magnan's, as far as can be determined from the
descriptions available, is not a clinical entity in the sense of the
views expressed here; we would unhesitatingly include with the paranoid
forms of dementia praecox many of the cases, with well developed
mannerisms and the coinage of new words, which progress rapidly to
mental enfeeblement. At the same time, however, 'délire chronique' with
its slowly progressing forms lasting for decades includes a number of
cases which form the nucleus of the first paraphrenic disease group to
be described." Whether or not the paraphrenia of Kraepelin is accepted
as having been established, it must be conceded that the question as to
whether anything remains of the original paranoia group is one worthy
of serious consideration. Many have discarded the term entirely.
Kraepelin's paraphrenia is divided into the following
forms:—systematica, expansiva, confabulans and phantastica. The
systematic type is characterized by "the extremely insidious
development of continuously progressing delusions of persecution, with
the later appearance of delusions of grandeur without deterioration of
the personality." The expansive form shows "the prominent development
of delusions of grandeur with a predominant exalted mood and mild
excitement." The confabulans variety is a small group "distinguished by
the prominent rôle played by falsifications of memory." The phantastic
form shows "a marked development of phantastic, unsystematized,
changeable delusions." This was the paranoid dementia praecox of his
sixth edition. Of the cases heretofore assigned to the paranoia group
Kraepelin has expressed the opinion that about forty per cent belong
to dementia praecox. "A further somewhat larger part falls to the
paraphrenic forms to be described here." The practically negligible
remainder he apparently concedes to genuine paranoia. In his eighth
edition Kraepelin states that the latter constitute less than one
per cent of all admissions. He now limits the term paranoia to cases
arising from purely internal causes and showing a slowly developing
permanent system of delusions without any disturbance of thought,
volition or conduct. The delusional formations may be of various
types,—persecution, jealousy, self-importance (great inventions, ideas
of noble birth, etc.) or they may be of a religious or erotic nature.
The "querulents" he now classifies with the psychogenic disorders. His
present conception does not admit of the association of paranoia with
hallucinations.
The most interesting and important feature, perhaps, of Kraepelin's
presentation is his insistence upon internal causes only as etiological
factors. He assumes a psychopathic foundation for the development of
the disease. In more than one half of his cases he found well marked
personal peculiarities. These were manifested in some instances in the
form of irritability, excitability and abnormalities of conduct. Other
individuals were suspicious, unreliable, lacking in will power and
over-ambitious. Homosexual tendencies were not infrequent. External
factors, such as unpleasant experiences, may influence the form of the
delusional expressions but should not be looked upon as explaining
their origin. They develop in an emotional soil definitely related to
the hopes and fears of the healthy individual and are to be looked
upon as a morbid transformation of perfectly normal mechanisms. In
addition to this he speaks of an increased self-consciousness, a
natural tendency to resistiveness, an undeveloped type of thinking,
psychological compensations for the disappointments of life, evidences
of developmental inhibitions, improper habits of thought leading to
morbid conceptions, etc. He refers to exaggerated self-consciousness
as the fundamental basis of paranoia. In this soil delusions develop
as a result of inadequate intellectual processes due to developmental
inhibitions. All of these views have been elaborated more fully in
his recent discussions of the subject of "comparative psychiatry."[321]
These mechanisms, he says, have not escaped the notice of the Freudian
school. Kraepelin feels, however, that their arguments "are not based
either on a clear conception of paranoia or on any evidence at all
acceptable."
Bleuler's theory of the disease is summed up in the following quotation
from his "Affectivität, Suggestibilität, Paranoia"[322]:—"The exact
observation of the objective and subjective relations at the time of
the origin of the disease shows us therefore nothing more than the
appearance of errors, such as occur to normal persons under analogous
affects and a connection of accidental occurrences to a thought
complex which is kept continually awake by defects and his own trends
of thought, just as it is in a corresponding normal mental process.
The pathological feature is only the fixation of the error so that it
becomes a delusion, and then the further extension of the delusions so
that it finally becomes paranoia." In 1906 when this was written he
suggested no explanation for the extension of such errors and their
fixation in an actual psychosis. This might readily be interpreted as a
logical result of the paranoic "constitution."
The development of paranoic states was summarized by Meyer[323] as
follows:—"A. Feeling of uneasiness, tendency to brooding, rumination
and sensitiveness, with inability to correct the notions and to make
concessions—paranoic constitution and paranoic moods. B. Appearance
of dominant notions, suspicious or ill balanced aims. C. False
interpretations with self-reference and tendency to systematization,
without or with D. Retrospective or hallucinatory falsifications, etc.
E. Megalomanic developments or deterioration or intercurrent acute
episodes. F. At any period antisocial and dangerous reactions may
result from the lack of adaptability and excessive assertion of the
sidetracked personality."
Freud sees in paranoia a reversion to the homosexuality of the
developmental period of the individual with a projection of symptoms
resulting from mental conflicts due to a repression of complexes.
He described the sexuality of the infantile period as being purely
autoerotic in character, the sexual interests of the child being
centered in its own body. From this stage the object of interest is
gradually transferred to other individuals of the same sex, the normal
attraction to the opposite sex being a final development of later
years. Freud believes that in paranoia there is a fixation in one of
these early transitional stages. "Persons who cannot rise completely
out of the stage of narcissism and are thus prematurely fixed or
arrested in the evolution of their dispositions, are exposed to the
danger that a flood of libido which finds no outlet, sexualizes their
social tendencies and reverts the sublimations achieved in the course
of the development."[324] The resulting mechanisms may be looked upon
as defense reactions. The subconscious homosexual longings of the
individual are repressed but finally admitted to full consciousness
in the form of a projection, the sexual object usually being accused
of persecution, thus justifying the attitude of the paranoic towards
the cause of his troubles. In erotomania the antagonism is directed
not against the homosexual object but upon some person of the opposite
sex. Freud interprets the delusions of jealousy of the alcoholic as an
evidence of homosexual attraction, the individual justifying himself
by the charge that it is his wife and not himself who is the guilty
one. The delusions of grandeur he looks upon as a sweeping denial
of all extraneous influences, the individual building a defense for
himself by assuming a self-aggrandizement that leaves no room for
homosexual objects. Perhaps these mechanisms are, as Meyer suggests,
only another expression of the well recognized and more or less normal
tendency to accuse others of being at fault in some way when what we do
ourselves goes wrong. Certainly, if nothing more, they are exceedingly
ingenious and interesting theories. One cannot but be impressed by the
extraordinary skill of Freud in discovering the sexual origin of almost
any mental process with which we are familiar. The ready facility with
which his study of sexual conflicts and repressions can be shown to
serve as a complement to the anatomical, symptomatic, and prognostic
hypotheses of Kraepelin is also worthy of note.
As has already been said, there is considerable question as to how
much, if anything, remains of the old-time paranoia concept. The
uncertainties attending diagnosis have given rise to the modifying
term "paranoid" which has been very generally used for many years. It
should be remembered that paranoia when at its best only constituted
approximately two per cent of all psychoses reported from institutions.
These various considerations have resulted in its not having a
distinctive place in the classification adopted by the American
Psychiatric Association and it has been given official recognition as
follows:—
"From this group should be excluded the deteriorating paranoid states
and paranoid states symptomatic of other mental disorders or of some
damaging factor such as alcohol, organic brain disease, etc.
"The group comprises cases which show clinically fixed suspicions,
persecutory delusions, dominant ideas or grandiose trends logically
elaborated and with due regard for reality after once a false
interpretation or premise has been accepted. Further characteristics
are formally correct conduct, adequate emotional reactions, clearness
and coherence of the train of thought."
A study of the statistics of American hospitals shows quite clearly
the importance which should be attached to the paranoid conditions.
During 1918 and 1919 there were 13,588 admissions to the thirteen New
York state hospitals. Two hundred and fifty-six, or 1.88 per cent, of
these were cases of paranoia or paranoid conditions. During a period
of eight years there were 49,640 admissions of which 1,240, or 2.5
per cent, were paranoid conditions. In Massachusetts sixty-four, or
2.12 per cent, of the 3,011 admissions during 1919 were reported as
paranoid conditions. In twenty-one hospitals in other states there
were 18,336 admissions. Of these, 789, or 4.3 per cent, were paranoid
conditions. These statistics show quite a small admission rate for
these psychoses in New York and Massachusetts. The rate in other state
hospitals is noticeably higher. As the percentage for dementia praecox
is considerably lower in the reports from these institutions than it is
in Massachusetts and New York, it is fairly reasonable to assume that
many cases shown as paranoid forms of dementia praecox in Massachusetts
and New York are classified with the paranoid conditions in the other
states. If we consider the total admissions from all of the hospitals
in question, we find 2,093 paranoid conditions in all, constituting
2.94 per cent of a total of 70,987 cases. It has already been shown
that paranoia, at a time when it was a well recognized entity,
constituted only 1.9 per cent of over eighty-four thousand consecutive
admissions. This clinical grouping has, therefore, obviously been
enlarged by adding paranoid conditions which could not probably be
classified as well recognized types of other psychoses.