The term paranoia is one of the oldest in the history of psychiatry. It appears in the writings of Hippocrates, as well as of Plato and Aristotle, and was apparently used by the ancient Greeks and Romans to refer to a variety of mental disorders, more or less as the term insanity is used today. The term fell into disuse after about the second century and does not reappear prominently in the psychiatric literature until the latter part of the eighteenth century, when, again, it was used with a variety of meanings. The much more specific sense in which paranoia is used today was formulated explicitly in 1893 by Kraepelin, who reserved the term for a syndrome characterized by insidiously developing fixed, systematized delusions, unaccompanied by hallucinations or by general personality deterioration.
The essential feature in the diagnosis of paranoid reactions is the presence of delusions—“Erroneous judgments not subject to correction by experience,” Kraepelin called them (Waelder 1951, p. 167). In addition, symptoms which figure prominently in other disorders, such as hallucinations, deterioration, and inappropriate affect, must be absent or else the diagnosis (e.g., paranoid schizophrenia, depression with paranoid tendencies) will reflect the more complex symptom picture.
Depending mostly upon the chronicity, rigidity, and degree of systematization of the delusional structure, it is current practice to distinguish two diagnostic categories, paranoia and paranoid state,together constituting the superordinate categoryparanoid reactions. (Paranoid schizophrenia is not included in this classification.)
Paranoia is a psychotic disorder that occurs relatively rarely. The delusional structure develops slowly, over a prolonged period, and reaches an extreme degree of organization and rigidity. Delusions are highly systematized and intricately elaborated. Details of the delusional system are often worked out with considerable respect for logic, and the patient may provide a persuasive account of his plight if only the initial premise is conceded. The delusions resist attempts at refutation and alteration and may persist for years. Outside the arena of the delusional system the personality remains relatively intact. There are no hallucinations, there is no general personality disorganization or deterioration, and intellectual functioning is well preserved. The psychotic features seem, superficially at least, to be isolated from the rest of the personality, and many patients have been able to continue in business or professional activities with unimpaired efficiency. Paranoia is considered to be relatively unresponsive to therapy.
Paranoid state is a less severe psychosis than paranoia. It occurs more commonly and has a more favorable prognosis. The delusional system lacks the close-knit logic and elaborate systematization seen in paranoia. Delusions are briefer and vaguer; they are more in flux and less resistant to change. On the other hand, they are not so bizarre or fragmented as those found, for instance, in schizophrenia. The delusions in paranoid states often develop more suddenly than they do in paranoia, perhaps in response to a specific situational stress. They are usually of shorter duration and may even clear up spontaneously with the passage of an emotional crisis. Sometimes, though, the delusions become chronic. Again, as in paranoia, there is no general personality or intellectual deterioration.
In this article, a distinction will be made between paranoia and paranoid state where data are available for the two conditions separately. For the most part, the two forms of the disorder will be discussed collectively as paranoid reactions or paranoid disorders.
The content of paranoid delusions varies widely and it is not uncommon to find several types of delusions in a single patient. By far the most frequent are delusions of persecution. The patient may believe himself to be pursued and plotted against by a person or persons who intend him a variety of harms. He may be concerned that his food has been poisoned or his mail tampered with. In carrying out their evil designs his adversaries may enlist the aid of numerous technological devices, which, incidentally, tend to keep pace with scientific progress: what used to be blamed on telescopes and magnets is currently attributed to television and radar. Political ideologies, too, may be involved in the delusional system, again often reflecting contemporary polarities; in the United States, persecutors are frequently held to be communist agents.
Delusions of grandeur are much less common than delusions of persecution and usually occur in the more severe forms of the illness. They are more typical of paranoia than of paranoid states and are characteristically stable, persistent, and well organized. The patient may consider himself a person of great importance, noble birth, unique and superior endowment, or divine appointment. He may attempt (sometimes successfully) to obtain a patent on a most remarkable invention, or he may have discovered an elusive cure for a crippling disease. Religion, science, and politics provide the principal sources of subject matter for delusions of grandeur.
Other types of delusions have been described in paranoid patients, most notably erotic delusions and delusions of jealousy. At one time, it was customary to classify paranoid reactions in terms of the type of delusion manifested. This practice has proved ineffective because of the great diversity of delusions and the many ways in which they can combine in a single patient. Delusions also occur as secondary symptoms in a wide variety of psychotic disorders, and a differential diagnosis is not always easy to achieve with confidence. They appear frequently in schizophrenia and manic-depressive states and in such organic illnesses as general paresis, senile dementia, and alcoholic psychosis.
In addition to the prominence of delusions, the symptom picture in paranoid reactions is rounded out by a number of other traits which may be viewed as reinforcing and maintaining the general delusional structure. The patient displays exaggerated self-reference, perceiving himself as the object of what goes on around him. He assigns special meanings, consistent with his delusions, to the remarks and gestures of others, or to items in newspapers and on the radio, and interprets them as directed toward him personally. Past incidents, too, may be reinterpreted in the light of present beliefs (“retrospective falsification”). There is, however, a considerable degree of selectivity in the patient’s response to his environment. He is reaction-sensitive (Cameron 1959a, p. 513), singling out those events, no matter how trivial, which fit into his system of preconceived ideas, while ignoring all disconfirming evidence. He is especially sensitive to attitudes and tendencies of others which coincide with his own impulses and conflicts. His perception of his environment reflects the fact that the paranoid person is almost invariably an intensely hostile person. He is characteristically suspicious and vigilant, living in a world teeming with potential dangers and implied threats. His delusions may lead the patient to outbursts of verbal hostilities and accusations and, much less frequently, to direct physical attacks on others.
Paranoid reactions are relatively rare in the mental hospital population, currently constituting about 0.5 per cent of first admissions and less than 1.5 per cent of resident patients in mental hospitals in the United States. Most likely, these figures greatly underestimate the incidence of the illness in the population at large; many patients are able to control the more blatant, socially disruptive manifestations of their delusions and are never hospitalized; others, especially where the disorder is less severe, are tolerated at home and at work as eccentrics. Also, many psychiatrists tend to avoid diagnoses of paranoia and paranoid state, preferring, where possible, another category, such as paranoid schizophrenia.
Paranoid reactions are chiefly disorders of middle age. The majority of first admissions to mental hospitals occur in the 35-50-year age range, though, especially in cases of paranoia, the illness may have been a number of years in developing. A large percentage of patients hospitalized with paranoid reactions have never married, and many are divorced or separated. Little is known about the sex distribution of paranoid states, and the opinion of most earlier writers that paranoia is more common in men is not supported by more recent statistical evidence indicating that the disorder occurs almost twice as frequently in women (Tyhurst 1957, p. 47). Again, there are no conclusive data regarding intelligence and educational level in these disorders; it is generally believed, however, that the paranoid patient is more intelligent and has had more formal education than the average hospitalized patient.
Social isolation. Paranoid reactions appear to be more prevalent among groups who are to some extent isolated from the larger societal setting. Relatively higher rates of the disorder have been reported for displaced persons and refugees and for migratory and minority groups. Paranoid reactions are more common, too, in “lingually isolated persons,” whose language differences interfere with their effective communication (Tyhurst 1957, p. 61).
Alongside Kraepelin’s contributions of classification and description must be placed Freud’s contributions of interpretation and reconstruction. In 1911 Freud published the first and still most influential attempt to work out in detail the interplay of psychological forces leading to the development of paranoid symptomatology. Freud based his thinking mostly on the autobiographical account of a psychosis with prominent delusions written by Daniel Paul Schreber, a German jurist. Freud concluded: “what lies at the core of the conflict in cases of paranoia among males is a homosexual wishful phantasy of loving a man . . .” (Freud  1958, p. 62). According to this view, the paranoid individual has been fixated at the psychosexual stage of primary narcissism but has been able during his prepsychotic lifetime to keep repressed the homoerotic impulses characteristic of this stage. When, perhaps because of a series of frustrations or because of overstimulation, the repressive process fails and permits a reactivation of homosexual impulses (“return of the repressed”), a regression occurs to the stage of primary narcissism. Seeking desperately to repair the breach in his defensive structure, the patient draws excessively upon the defense mechanisms characteristic of this stage, most notably denial and projection. Within this framework, Freud demonstrated how the various forms of delusions may be understood as contradictions of the proposition “I (a man) love him (a man).” In delusions of persecution, for example, this proposition is converted, by denial and reaction formation, into “I do not love him—I hate him.” By the mechanism of projection, the second proposition is further transformed into “He hates (persecutes) me, which will justify me in hating him.” “Observation leaves room for no doubt,” Freud wrote, “that the persecutor is some one who was once loved” ( 1958, p. 63). In a later paper, Freud (1915) demonstrated that homosexuality played a significant role in the development of paranoia in a female patient, too. In essence, then, the paranoid patient’s delusions represent his way of coming to terms with unacceptable homosexual feelings [seeDefense Mechanisms].
In addition, Freud emphasized that delusions also serve a restitutive function. They represent an attempt at reconstruction, at re-establishing, albeit in an unrealistic manner, the object relations relinquished in the initial withdrawal and regression.
Evaluation of Freud’s explanation
Experimental and clinical attempts to evaluate Freud’s work have, for the most part, focused on comparing paranoid and nonparanoid patients on indexes of homosexuality. In a typical experimental approach to the problem, Zamansky (1958) gave male mental hospital patients an opportunity to examine paired pictures of men and women; he found that, on the average, paranoiacs and paranoid schizophrenics looked longer at pictures of men, while nonparanoid schizophrenics (and, in another study, a normal control group) looked longer at pictures of women. Not all the delusional patients preferred the male pictures, however. Clinical studies (e.g., Klein & Horwitz 1949), too, have typically uncovered evidence of homosexuality in some, but by no means all, paranoid patients. Other workers have reread Schreber’s autobiographical material and have disagreed with Freud about the source of Schreber’s difficulties. For example, MacAlpine and Hunter (who published the first English translation of Schreber’s memoirs) attribute Schreber’s psychosis to a reactivation, not of unconscious homosexual tendencies, but of archaic pregenital fantasies of procreation and self-impregnation (Schreber  1955, pp. 369-411). They suggest, furthermore, that Schreber’s regression was to an earlier stage, “absolute ambisexuality,” than Freud postulated.
Two issues must be considered in examining Freud’s explanation of paranoid disorders. There is first the question of whether a homosexual conflict is invariably a part of the patient’s psychodynamic make-up. The failure to uncover a homosexual concern in some paranoid patients suggests that conflicts other than homosexual ones may also serve as a focus for the illness. There is further the question of whether homosexuality plays precisely the role specified by Freud in the development of the psychosis—whether it is the primary etiological agent or merely a link (perhaps itself serving a defensive function) in a chain of psychodynamic factors leading ultimately to the delusional structure. Interpretations favoring this latter view are reviewed in the following section.
Beyond the importance assigned to homosexual conflicts in paranoid disorders, the broad outlines of the psychodynamic picture sketched by Freud have never been seriously challenged. The illumination of such concepts as regression, restitution, projection, repression, and return of the repressed remains a hallmark in the history of psychiatry.
Some later psychoanalytic contributions
Later theorists have differed most sharply with Freud in their emphasis on the primacy of hostility in the development of delusions. The frequent presence of a homoerotic conflict is not denied, but it is assigned a position of much less central importance. For some theorists, homosexual stirrings serve merely to emphasize and reinforce generalized feelings of inferiority and inadequacy. For others, the relationship posited by Freud between homosexuality and hostility is turned around, and homosexuality is seen as a defensive maneuver against more basic destructive wishes. Knight (1940), a spokesman for this latter notion, believes that the homosexual wish of the paranoid patient is in actuality an intense and desperate attempt to neutralize and erotize a tremendous unconscious hate. The powerful need to keep the homosexual urges from awareness is based not on cultural pressures, which prohibit their expression, but on the fact that the least approach to the love object arouses intense anxieties that both the object and the patient will be destroyed by the hostility in the patient and the consequent hostility aroused in the object.
The British psychoanalyst Melanie Klein (1948) also singles out aggression as the central problem in paranoid disorders. In addition, she stipulates that the related fixation is at a much earlier age than Freud believed: at the phase of “maximal sadism” occurring during the first year of life. The infant in this phase is said to be dominated by intense primitive feelings of hostility, and it is the projection of these feelings that leads the infant (and the adult psychotic who regresses to this phase) to attribute hostile designs to the people around him. Again, homosexuality, where it occurs, is considered to serve a secondary, defensive function against the hostile and destructive fantasies.
Prepsychotic personality and breakdown
Paranoid symptomatology may be most profitably regarded as an exaggeration and intensification of personality patterns characteristic of the individual during much of his life. As children and throughout their prepsychotic adult years, paranoid patients are mostly described as having been suspicious, secretive, hostile, resentful, and seclusive. A craving for praise and recognition, coupled with a hypersensitivity to criticism, signifies the presence of profound feelings of inadequacy and insignificance (Schwartz 1963), though not necessarily at a conscious level. Undoubtedly for some, a vulnerable self-esteem is further threatened by the borderline awareness of homosexual interests or by the guilt and anxiety that accompany destructive fantasies. The refusal to admit their own shortcomings and the tendency to blame others for their own difficulties are obvious antecedents of the patients’ later more unrealistic use of the mechanisms of denial and projection, suggesting that repression alone had never been a wholly successful defense. Other traits which frequently characterize the lifelong behavior of the paranoid individual—aloofness, airs of superiority and self-importance, arrogance, pride, disdain—may be regarded as related maneuvers to maintain self-esteem. For many persons such an array of defensive traits provides a successful adaptation to potentially threatening impulses and fantasies—successful at least in that the individual is not pressed to the development of a full-blown delusional system.
For the paranoid patient, however, something goes wrong. He encounters an experience or, more likely, a series of experiences which overburden his defensive structure, and anxiety-laden impulses threaten to break through to consciousness. Perhaps doubts about masculinity are fanned by an unsuccessful love affair or, as Freud suggested in Schreber’s case, by the failure to have a son; perhaps excessive hostility is provoked by rivalry and competition in business or by a social rebuff. In any event the patient presses into use the wellpracticed, overlearned, often-reinforced modes of reaction at which he has become expert; only now they are applied excessively and with greater intensity and rigidity. He becomes more suspicious and vigilant, desperately probing the motives and acts of others for an explanation of the unfamiliar, disturbing impulses that are at the outposts of awareness. Not uncommonly, his hostility and suspiciousness evoke rebuffs from family and business associates, and a vicious circle between the patient’s perceptions and the behavior of others is set into motion. By an excessive application of such mechanisms as denial, reaction formation, rationalization, and projection, ego-alien impulses are disowned and attributed to sources outside the self. Ultimately, it becomes necessary to construct a new version of reality, and the patient’s misinterpretations are woven together into a full-blown delusional system. Self-esteem is once again safe, but the price is insanity.
Cameron’s notion (1959b) of the paranoid pseudo community is a useful one in this context. The development of normal, socially organized behavior, Cameron points out, depends heavily on the maintenance of effective channels of communication with others. Through a constant interchange of ideas, the normal person acquires considerable skill in role taking, in shifting his social perspective so that he can see things from other points of view than his own. As a result, he comes to perceive himself and other people relatively objectively, since he can check and modify erroneous ideas before they develop to any considerable extent. In the paranoid person, Cameron believes, these skills have been inadequately developed, in part because of a lifelong tendency to seclusiveness. A realistic appraisal of his beliefs about the attitudes and motives of others is limited by a chronic deficiency in role-taking skills and therefore in social-reality testing. In an emotional crisis this lack of corrective experience leaves the patient vulnerable to his inner promptings and fantasies, and he is pushed toward an increasingly delusional interpretation of the happenings around him. Where the delusions are chiefly persecutory, the process may culminate in the conviction that the patient “is the focus of a community of persons who are united in a conspiracy of some kind against him” (Cameron 1959b, p. 53), a paranoid pseudo community. This imaginary organization is made up of actual and imagined persons and usually resembles in form such undisputedly menacing groups as spy rings and the secret police. The paranoid pseudo community provides the patient with an explanation of his strange, altered world, and it represents as well a restitutive attempt to re-establish a relationship with social reality.
The prognosis for paranoia is generally unfavorable, especially if treatment is not undertaken until the illness has progressed beyond its early stages. Complete recovery is not the rule, though a number of patients achieve a “social recovery” and do not require hospitalization. The outlook is much brighter for the more transitory paranoid states: spontaneous recovery is not uncommon, and the majority of cases respond partially or completely to treatment.
The differential prognosis for paranoia and paranoid states may be directly related to the different history of the delusional structure in the two disorders. In paranoia, a complex, highly organized delusional system has developed slowly, over a prolonged period of time, establishing itself firmly, after countless reinforcements, as an effective defensive network against a variety of stressful, anxiety-producing situations. Little wonder that it is so stubbornly resistant to change! In contrast, the delusions in paranoid states are much more recent and lack the organization and structure to prove wholly effective in binding anxiety and in preserving self-esteem. One might say that these patients have less to lose in discarding their delusions.
The psychotherapy of paranoid reactions, whether on an individual basis or in groups, requires that effective channels of communication be established between the patient and the therapist. It is first necessary to gain the patient’s trust and confidence, a formidable task when confronting someone who believes himself to be surrounded by spies and assassins who are plotting his downfall. The problem of establishing a productive relationship is accentuated by the patient’s extreme sensitivity to even the slightest tendencies toward hostility in the therapist. Probably it is best if the therapist is a sincere, sympathetic, and accepting person who indicates that he is interested in understanding the patient’s ideas without necessarily subscribing to them. Reasoning and logical refutation are generally ineffective and tend only to increase the patient’s vigilance. Ultimately, the patient must experience a sufficient decrease in anxiety to be able to relax his defenses and reexamine his views of the world.
Paranoid reactions are also treated with one or more of the somatic therapies. The recovery process, especially in paranoid states, may sometimes be accelerated by the use of insulin-shock and electroshock therapy. More recently, tranquilizing drugs have been widely used in treating paranoid reactions. Despite conflicting reports, a number of studies have indicated that such drugs as chlorpromazine and reserpine may be helpful in reducing or clearing up delusions, perhaps because they tend to lower the general level of anxiety. Again, the chances for recovery are much better if the patient is treated early in the illness, and the improvement is more likely to be maintained if somatic treatments are supplemented by psychotherapy [seeMentaldisorders, treatment OF, article onSomatic Treatment].
Harold S. Zamansky
Cameron, Norman 1959a Paranoid Conditions and Paranoia. Volume 1, pages 508-539 in American Handbook of Psychiatry. Edited by Silvano Arieti. New York: Basic Books. → A comprehensive survey of the area. Contains a bibliography of 82 titles. Cameron, Norman 1959b The Paranoid Pseudo-community Revisited. American Journal of Sociology 65: 52-58.
Freud, Sigmund (1896) 1962 Further Remarks on the Neuro-psychoses of Defence. Volume 3, pages 157-185 in The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth; New York: Macmillan. → Freud’s earliest published discussion of paranoia in terms of repression and the return of the repressed. The concept of projection is introduced for the first time in this paper.
Freud, Sigmund (1911) 1958 Psycho-analytic Notes on an Autobiographical Account of a Case of Paranoia (Dementia paranoides). Volume 12, pages 1-82 in The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth; New York: Macmillan. → The classic psychoanalytic interpretation of the Schreber case.
freud, Sigmund (1915) 1957 A Case of Paranoia Running Counter to the Psycho-analytic Theory of the Disease. Volume 14, pages 261-272 in The Standard Edition of the Complete Psychological Works of Sigmund Freud. London: Hogarth; New York: Macmillan. → Demonstrates that Freud’s theory of paranoia also applies to a female patient.
Jelliffe, Smith E. 1913 A Summary of the Origins, Transformations, and Present-day Trends of the Paranoia Concept. Medical Record 83:599-605. → Traces the history of the paranoia concept from the time of Hippocrates to the beginning of the twentieth century.
Klein, Henrietta R.; and Horwitz, William A. 1949 Psychosexual Factors in the Paranoid Phenomena.American Journal of Psychiatry 105:697-701. → A clinical study of 80 delusional patients. Reports data on sexual adjustment before the illness and on sexual preoccupation during the illness.
Klein, Melanie 1948 Contributions to Psycho-analysis: 1921-1945. International Psycho-analytic Library, No. 34. London: Hogarth.
Knight, Robert P. 1940 The Relationship of Latent Homosexuality to the Mechanism of Paranoid Delusions. Menninger Clinic, Bulletin 4:149-159. → A classic paper emphasizing the fundamental importance of hostile impulses in the etiology of paranoid disorders.
Schreber, Daniel P. (1903) 1955 Memoirs of My Nervous Illness. Translated and edited by Ida Macalpine and Richard A. Hunter. London: Dawson. → First published as Denkwiirdigkeiten eines Nervenkranken. The translators take issue with Freud’s interpretation of Schreber’s experiences and offer their own.
Schwartz, D. A. 1963 A Re-view of the “Paranoid” Concept. Archives of General Psychiatry 8:349-361. → Emphasizes the central importance of feelings of insignificance and unimportance in the development of paranoid disorders.
Tyhurst, James S. 1957 Paranoid Patterns. Pages 31-76 in Alexander H. Leighton, John A. Clausen, and Robert N. Wilson (editors), Explorations in Social Psychiatry. New York: Basic Books. → A useful, critical survey of the area, with emphasis on interpersonal and environmental factors. Contains a bibliography of 49 titles.
Waelder, Robert 1951 The Structure of Paranoid Ideas. International Journal of Psycho-analysis 32: 167-177. → An interesting treatment of the thesis that denial is the basic mechanism in the development of delusions. Projection is considered to be merely a special form of denial.
Weinstein, Edwin A. 1962 Cultural Aspects of Delusion: A Psychiatric Study of the Virgin Islands. New York: Free Press. → A study of 148 patients from several cultural groups in the Virgin Islands, demonstrating that delusional content is related to such cultural variables as emphasis on religion, attitudes toward children, and sexual values.
Zamansky, Harold S. 1958 An Investigation of the Psychoanalytic Theory of Paranoid Delusions. Journal of Personality 26:410-425.
Zilboorg, Gregory; and Henry, George W. 1941 A History of Medical Psychology. New York: Norton.