CHAPTER XIV

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.