and the resulting delusion is then said to be “systematized.”
As such delusions are coherently formed there is no
manifest mental confusion in their expression. Notwithstanding
the fixity of the delusion it is subject in some cases to
transformation which permits of the gradual substitution of
delusions of grandeur for delusions of persecution. It happens also
that periods of remission from the influence of the delusion may
occur from time to time in individual cases, and it may even
happen, though very rarely, that the delusion may permanently
disappear.
It is necessary to point out that there is undoubtedly what may be called a paranoiac mental constitution, in which delusions may appear without becoming fixed or in which they may never appear. The characteristics of this type of mind are credulity, a tendency to mysticism and a certain aloofness from reality, combined, as the case may be, with timidity and suspicion or with vanity and pride. On such a soil it is easy to understand that, given the necessary circumstances, a systematized delusional insanity may develop.
The term paranoia appears to have been first applied by R. von Krafft-Ebing in 1879 to all forms of systematized delusional insanity. Werner in 1889 suggested its generic use to supplant Wahnsinn and Verrücktheit, the German equivalents of mental states which originally meant, respectively, the delusional insanity of ambition and the delusional insanity of persecution—terms which had become hopelessly confused owing to divergences in the published descriptions of various authors.
The rapid development of clinical study has now resulted in the isolation of a comparatively small group of diseases to which the term is applied and the relegation of other groups bearing more or less marked resemblances to it to their proper categories. Thus, for example, it had formerly been held that acute paranoia was frequently a curable disease. It is now proved that the so-called acute forms were not true paranoias, many of them being transitory phases of E. Kraepelin’s dementia praecox, others being terminal conditions of acute melancholia, of acute confusional insanity, or even protracted cases of delirium tremens. While it removes from the paranoia group innumerable phases of delusional insanity met with in patients labouring under secondary dementia as a result of alcoholism or acute insanity, such a statement does not exclude patients who may have had, during their previous life, one or more attacks of some acute mental disease, such as mania, for the paranoiac mental constitution may be, though rarely, subject to other forms of neurosis. Attempts have been made to base a differential diagnosis of paranoia upon the presence or absence of a morbid emotional element in the mind of the subjects, with the object of referring to the group only such cases as manifest a purely intellectual disorder of mind. Though in some cases of the disease the mental symptoms may, at the time of observation, be of a purely intellectual nature, the further back the history of any case is traced the greater is the evidence of the influence of preceding emotional disturbances in moulding the intellectual peculiarities. Indeed it may be said that the fundamental emotions of vanity or pride and of fear or suspicion are the groundwork of the disease. We are justified therefore in ascribing the intellectual aberrations which are manifested by delusions, in part at least, to the preponderating influence of morbid emotions which alter the perceptive and aperceptive processes upon which depend the normal relation of the human mind to its environment. Although, generally speaking, paranoiacs manifest marked intellectual clearness and a certain amount of determination of character in the exposition of their symptoms and in their manner of reacting under the influence of their delusions, there is, without any doubt, an element of original abnormality in their mental constitution. Such a mental constitution is particularly subject to emotional disturbances which find a favourable field of operation in an innate mysticism allied with credulity which is impervious to the rational appeal of the intellect. In those respects the paranoiac presents an exaggeration of, and a departure from, the psychical constitution of normal individuals, who, while subject both to emotion and to mystic thought, retain the power of correcting any tendency to the predominance of these mental qualities by an appeal to reality. It is just here that the paranoiac fails, and in this failure lies the key to the pathological condition. For the present the question as to whether this defect is congenital or acquired owing to some superimposed pathological condition cannot be answered. However that may be, it is frequently ascertained from the testimony of friends and relatives that the patients have always been regarded as “queer,” strange, and different from other people in their modes of thought. It is usually stated that nervous or mental diseases occur in the family histories of over 50% of the subjects of this affection.
Paranoia is classified for clinical purposes according to the form of delusion which the patients exhibit. Thus there are described the Persecutory, the Litigious, the Ambitious and the Amatory types. It will be observed that these divisions depend upon the prevalence of the primary emotions of fear or suspicion, pride or vanity and love.
According to V. Magnan, the course of paranoia is progressive, and each individual passes through the stages of persecution and ambition successively. Many authorities accept Magnan’s description, which has now attained to the distinction of a classic, but it is objected to by others on the ground that many cases commence with delusions of ambition and manifest the same symptoms unchanged during their whole life, while other patients suffering from delusions of persecution never develop the ambitious form of the disease. Against these arguments Magnan and his disciples assert that the relative duration of the stages and the relative intensity of the symptoms vary widely; that in the first instance the persecutory stage may be so short or so indefinite in its symptoms as to escape observation; and that in the second instance the persecutory stage may be so prolonged as within the short compass of a human life to preclude the possibility of the development of an ambitious stage. As however there exist types of the disease which, admittedly, do not conform to Magnan’s progressive form it will be more convenient to adopt the ordinary description here.
1. Persecutory Paranoia.—This form is characterized by delusions of persecution with hallucinations of a painful and distressing character. In predisposed persons there is often observed an anomaly of character dating from early life. The subjects are of a retiring disposition, generally studious, though not brilliant or successful workers. They prefer solitude to the society of their fellows and are apt to be introspective, self analytical or given to unusual modes of thought or literary pursuits. Towards the commencement of the insanity the patients become gloomy, preoccupied and irritable. Suspicions regarding the attitude of others take possession of their minds, and they ultimately come to suspect the conduct of their nearest relatives. The conversations of friends are supposed by the patient to be interlarded with phrases which, on examination, he believes to contain hidden meanings, and the newspapers appear to abound in veiled references to him. A stray word, a look, a gesture, a smile, a cough, a shrug of the shoulders on the part of a stranger are apt to be misinterpreted and brooded over. The extraordinary prevalence of this imagined conspiracy may lead the patient to regard himself as a person of great importance, and may result in the formation of delusions of ambition which intermingle themselves with the general conceptions of persecution, or which may wholly supplant the persecutory insanity.
At this juncture, however, it generally happens that hallucinations begin to appear. These, in the great majority of instances, are auditory and usually commence with indefinite noises in the ears, such as ringing sounds, hissing or whistling. Gradually they assume a more definite form until isolated words and ultimately formed sentences are distinctly heard. There is great diversity in the completeness of the verbal hallucinations in different patients. Some patients never experience more than the subjective annoyance of isolated words generally
