Tag Archives: persecutory delusions

Comparing Parnaoid Schizophrenia and Delusional Disorder

In comparing delusional disorder and paranoid schizophrenia I noticed that paranoid schizophrenia is actually a step or two further than delusional disorder, even though these two disorders are not related.

The delusions in delusional disorder are not out of the ordinary meaning the delusion a person is currently suffering from could actually happen, but is still considered to be slightly farfetched.  Generally the delusion is something that does not happen to a large amount of people.  The disorder is generally undetectable until the person suffering from it decides to talk about what they feel is happening to them.  This is because the person suffering from delusional disorder had no abnormal behavior and there are either no or very minimal hallucinations.  People suffering from this disorder usually have a scapegoat.  That is, they can always find a way for things that go wrong to be someone else’s fault rather than accept responsibility.  There are several subtypes of delusional disorder.  People suffering from persecutory delusional disorder believe other people are out to get them.

Erotomanic sufferers walk around proclaiming that there is someone of importance is secretly in love with them.  The grandiose delusion disorder causes a person to believe that they are extremely important, or that they have some type of super human powers.  Where the somatic delusion disorder occurs the person believes there is something significantly wrong with their own body, and with the jealous subtype the person believes their spouse has cheated on them even when there is no evidence to support that.

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Research supports findings that a genetic link to a close relative who suffers from delusional disorder is possible.  Another cause could be dysfunctional cognitive processing, in which the patient has a indistinguishable way of looking at life.  The speculations they develop are by assuming everything instead of fact checking.  Another cause could be through stress, through being unable to handle stressful situations.  Treatment for delusional disorder most often involves an antipsychotic medication and sometimes involves therapy either on an individual level or on a familiar level, but treatment is only as successful as the patient allows it to be.

Paranoid schizophrenia patients do not have hallucinations that are possible, the hallucinations these patients suffer from are a much distorted view of their own reality.  There are various symptoms for paranoid schizophrenia patients; these can include auditory hallucinations, anxiety, anger, having a patronizing manner and serious thoughts of suicide, along with suicidal behavior.  These people are less affected by these kinds of symptoms and are generally more affected by what are known as positive symptoms, which are symptoms that are point toward a loss of the knowledge of what reality is.  This usually involves an abnormal view.  While the cause of this disorder is unknown, there is evidence to imply that it is caused by a brain dysfunction and that there are factors which increase the likely hood of paranoid schizophrenia.  These factors seem to be things that people would be unable to avoid, like having a family history or being exposed to viruses in the womb or being malnourished in the womb, or having severe trauma such as childhood abuse.  Even with such early risk factors taking place, paranoid schizophrenia is not generally seen until sometime between the teenage years and the mid-thirties.

Several treatments are available for this disorder but there is no cure, so treatment is there to help people learn how to cope and to learn life skills so they can have a full and productive life.  There are medications which are antipsychotics and they have two different levels.  Tier one medications are typical and have been found to be effective in helping a patient with the positive symptoms such as delusions and hallucination.  There is a side effect of some movements which are completely uncontrolled and seem erratic.  The second generation antipsychotics are atypical and help the patient cope with hallucinations and delusions as well as helping with increasing drive.  The side effect for these medications however is a slow in the metabolism, resulting in weight gain, or worse.  Other treatments available are psychotherapy which is usually recommended with the use of medications and can include social and vocational skills training.  ECT or electroconvulsive therapy and hospitalization are also available if the patient and the therapist feel they are appropriate.  If this disorder is left untreated, adverse affects may start to become visible.  Symptoms become much worse and turn into dangerous and/or deviant behavior.  Abuse of alcohol or drugs may become prevalent, family conflicts, self destructive behavior which can then lead to poverty, homelessness and health problems.  Any of these behaviors can lead to incarceration.

These two disorders seem to have a lot of similarities but in reality they are very different in almost every way including the outcomes of each one.  A more in depth article would be able to show the variations of each in a much better light.

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Child and Adolescent Psychological Disorders.

Oxford Textbook of Psychopathology.

Delusional Disorder. Psych-uknet.com.  http://psychnet-uk.com/dsm_iv/delusional_disorder.htm

Paranoid Schizophrenia.  Mayoclinic.com.  http://mayoclinic.com/health/paranoid-schizophrenia/DS00862

Paranoid Schizophrenia. Schizophrenia.com  http://www.schizophrenia.com/szparanoid.htm

Paranoid Schizophrenia vs Delusional Disorder

Analysis of the common psychopathological features in the various psychotic disorders suggest that symptoms can be clustered into five main categories: (Os & Kapur, 2009, p. 635)

1)      Psychosis, encompassing positive symptoms of delusions and hallucinations.

2)      Alterations in drive and volition, encompassing negative symptoms including lack of motivation, reduction in spontaneous speech, and social withdrawal.

3)      Alterations in neurocognition, encompassing cognitive symptoms including difficulties in memory, attention, and executive functioning.

4)      Affective dysregulation giving rise to depressive symptoms or 5) manic (bipolar) symptoms.

The term schizophrenia is typically applied to a syndrome that is characterized by a long duration, bizarre delusions, negative symptoms, and few affective symptoms (non-affective psychosis).  (Os & Kapur, 2009)  Formerly called dementia praecox, some of its associated features include inappropriate affect, anhedonia, dysphoric mood, lack of insight, depersonalization, and delrealization.  (Colman, 2009, p. 674)  Schizophrenia affects approximately 0.7% of the world’s population, with prevalence greater in men throughout adulthood, but equal by the end of the risk period.  Schizophrenia is highly heritable, with onset being rare before adolescence or after middle age (although men become ill earlier in life than women).  (MacDonald & Schulz, 2009, p. 495)  Schizophrenia subtypes include paranoid, disorganized, catatonic, undifferentiated, and residual types.  This article will focus on paranoid schizophrenia, which tends to be the least severe subtype of schizophrenia.

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“The essential feature of the Paranoid Type of Schizophrenia is the presence of prominent delusions or auditory hallucinations” where no disorganized speech, disorganized or catatonic behaviors, or flat or inappropriate affect is present.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 313)  Differential diagnosis is an exclusionary process since of all the other subtypes must be eliminated before diagnosing the paranoid subtype.  Paranoid schizophrenia sufferers typically have delusions that are persecutory and/or grandiose; they also typically have a recurrent theme.  Hallucinations are usually related to the same content theme as the delusions, and may include the associate features of anxiety, anger, aloofness, and/or argumentativeness.  Onset tends to be later in life when compared with other subtypes of schizophrenia, and the distinguishing characteristics are often more stable over time.  The prognosis is considerably better when compared with other schizophrenia subtypes, especially regarding occupational functioning and independent living.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 314)

“The essential feature of Delusional Disorder is the presence of one or more non-bizarre delusions that persist for at least 1 month.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 323)  Bizarreness is mostly subjective since it is contingent on socio-cultural norms and expectations.  Bizarre delusions (as in schizophrenia) are “clearly implausible, not understandable, and not derived from ordinary life experiences.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 324)  In contrast, non-bizarre delusions (as in delusional disorder) involve situations that could conceivably happen in real life… like being followed, poisoned, etc.  Subtypes of delusional disorder are categorized based on the content of the delusions or the theme thereof.  They include erotomanic, grandiose, jealous, persecutory, somatic, mixed, and unspecified types.  This essay will focus on persecutory delusions, although persecutory delusions often coexist with and are comorbid with other delusion types (particularly grandiose, in mixed presentation).

A determination of persecutory delusions is complicated by the fact that the incidence of persecutory thoughts is relatively common among the general population.  (Brown, 2008, p. 165)  “The criteria used to distinguish between these different categories of psychotic disorder are based on duration, dysfunction, associated substance use, bizarreness of delusions, and presence of depression or mania.”  (Os & Kapur, 2009, p. 635)  In delusional disorders, distortions of reality coexist with realms of rational, realistic thinking.  (Blaney & Millon, 2009, p. 361)  Delusional disorders are distinguished from schizophrenia by the absence of active phase symptoms of schizophrenia (e.g. prominent auditory or visual hallucinations, bizarre delusions, disorganized speech, grossly disorganized or catatonic behavior, and/or negative symptoms).  “Compared with schizophrenia, delusional disorder usually produces less impairment in occupational and social functioning.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 327)

“The assessment of bizarreness is generally absent among lists of delusion dimensions, notwithstanding its key role in the distinction between DD and PS.”  (Blaney & Millon, 2009, p. 365)  To improve decision-making and reduce the chance of misdiagnosis, Brown (2008) suggests we ascertain, to the extent available, base rates of the specific persecutory beliefs (e.g. discrimination and harassment, mental illness stigma, criminal victimization, relationship infidelities, conspiracies, stalking, surveillance, poisoning, etc) in our area.  Secondly, he suggests we consider alternative hypotheses, especially in decisions that have a very low base rate.  While actively searching for disconfirming information, we should postpone decisions until further information is collected.  I agree with his suggestion that we should rely more on information, and less on intuition, when it comes to confirming or disconfirming persecutory beliefs.  (Brown, 2008, p. 172)

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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Brown, S. A. (2008). The reality of persecutory beliefs: Base rate information for clinicians. Ethical Human Psychology and Psychiatry, 10(3), 163-179. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1646112241&sid=7&Fmt=3&clientId=4683&RQT=309&VName=PQD

Colman, A. M. (2009). Oxford dictionary of psychology (3rd ed.). Oxford, NY: Oxford University Press.

MacDonald, A. W., & Schulz, S. C. (2009, May ). What we know: Findings that every theory of schizophrenia should explain. Schizophrenia Bulletin, 35(3), 493-508. doi: 10.1093/schbul/sbp017

Os, J. V., & Kapur, S. (2009, Aug 22-Aug 28). Schizophrenia. The Lancet, 374(9690), 635-645. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1843730411&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Paranoid & Delusional Disorders

The boundary between normal and abnormal appears to be largely subjective.  “One person’s excessive suspiciousness is another’s due caution, and one person’s trust is another’s gullibility.”  (Blaney & Millon, 2009, p. 362)  The “trade-off between vigilance and vulnerability” is something I had not considered… that balance is perceived to be the issue when it comes to paranoid personality disorder (PDD), paranoid schizophrenia (PS), and or delusional disorder (DD).  “Any stubborn genius will have ideas that happen to be wrong as well as those that happen to be right.”  This observation seems to suggest that the people who often suffer from these disorders are extremely intelligent, and thus, may have some beliefs that are in fact sane, relevant, and true.  It would suffice to say that I am going to use caution when pursuing this diagnosis… Einstein was considered to be delusional!

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Most studies that have been done to date have focused on persecutory delusions… either by design or because they are more common and subsequently easier to find suitable samples.  Persecutory delusions involve a degree of suspiciousness, or are generally mistrustful and/or wary.  It is suitably difficult to measure the tangible levels of suspiciousness via self report, however, since some sufferers may be too guarded to admit that they are suspicious.  The very process of self report is likely to “trip the defenses of” and subsequently increase guardedness.  Further compounding the efficacy of self-report inventories is the issue that sufferers may be reporting reality, betraying hypersensitivity, or some combination of both.  This highlights the necessity of multiple-peer reports that can confirm the interpersonal difficulties of the sufferer.  We, as clinicians, will have to be diligent about securing 3rd party sources (schools, work environment, relatives, other individuals whom are close to the client) in order to get as many perspectives on the conditions as possible.

There are several dimensions of delusions… most notably belief certainty (emotional commitment, conviction), self-monitoring (insight), distress, and frequency.  I was particularly interested in the “double awareness phase” in which a patient wavers between embracing a delusion and recognizing that its delusionality.  Of note, is the observation that psychotropic medications reduce engagement in delusions, thereby improving overall functionality, but ultimately leave actual beliefs untouched?  This seems to parallel the overall trend of medications “treating the symptoms and not the cause.”

Some patients may possess some distinctly protective attributes that account for the fact that they do not become delusional.  As a result, quasi-delusional or aberrant beliefs may not always be associated with clinical conditions indicative of a general mental disturbance or distress.  For example, low levels of anhedonia and high levels of openness are commonly thought to be a psychological asset… despite the fact that they may be quasi-delusional.  Such individuals may demonstrate greater levels of control over their unusual perceptions.  (Blaney & Millon, 2009, p. 366)  Perhaps this natural protection can be leveraged to direct treatment of people whom do not have that natural protection.  It seems to me that if we know what can prevent delusions, we should make every attempt to instill those protections in our clients whom suffer without them?

Paranoia and delusions are thought to arise from several different situations or events.  One possible event is migration, in which an individual finds themselves in a new environment that does not provide a sense of security.  Growing frustration with the new locale may leave migrants vulnerable to paranoid disorders.  As is the case with many other disorders, abuse and trauma during childhood often precede delusional experiences in adulthood.  In some cases the delusions are related to that specific event, like trauma flashbacks, or they may be more generalized due to negative schematic models of the self and the world.  This manifests in high levels of self-reported suspiciousness and/or resentment.  Paranoid individuals tend to be characterized by experiences involving victimization or stigmatization by others, whereas depressed individuals were characterized by interpersonal losses.  (Blaney & Millon, 2009, p. 369)  Personally, I am not at all surprised by the childhood abuse antecedent.  The toll of child abuse rises again this week… I am hard pressed to find a disorder that can NOT be predicated by child abuse.

Biologically speaking, some researchers have attempted to attribute these behaviors to processing defects or bias.  Theory of Mind (ToM), for example, suggests that the human mind is characterized by a system that facilitates inferences about the mental processes of other persons.  (Blaney & Millon, 2009, p. 377)  In essence, patients have difficulty discerning others’ intentions correctly.  Some have suggested that delusion-prone individuals are overconfident and quick to reach certainty in the face of incomplete information.  Other research suggests that delusional individuals may have a proposed tendency to attribute specific persons as a source of danger (personalization), thereby revealing an inability to distinguish between external negative events that are situational as opposed to interpersonal.  It has been posited that they may have an exaggerated version of self-consciousness in which they continually preoccupy themselves with how they are seen by others… and subsequently generalize that everyone feels like that.  (Blaney & Millon, 2009, p. 379)  On the whole, there are several theories… all of which seem “plausible.”  I can’t wait to get into the field to test the theory.

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Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.