263 Schizophrenia, Paranoid Type (295.30)

DSM-IV-TR criteria

• A. Characteristic symptoms:
  • Preoccupation with one or more delusions or frequent auditory hallucinations. None of the following is present: disorganized speech, disorganized/ catatonic behavior, flat/ inappropriate affect.
  • Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other.
• B. Social/occupational dysfunction:
  • For a significant portion of the time since the onset of the disturbance one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).
• C. Duration:
  • Continuous signs of the disturbance that persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
• D. Schizoaffective and Mood Disorder exclusion:
  • Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either
    • (1) no Major Depressive Episode, Manic Episode, or Mixed Episode have occurred concurrently with the active-phase symptom, or
    • (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

• E. Substance/general medical condition exclusion:
  • The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
• F. Relationship to a Pervasive Developmental Disorder:
  • If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated)
• For the paranoid subtype, the above criteria must be met, but one must have a preoccupation with one or more delusions or frequent auditory hallucinations and none of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

Hitler as an example

The DSM-IV-TR has 5 diagnostic criteria for schizophrenia.

The first is the characteristic symptoms in which two of the following five must be present: (1) delusions, (2) hallucinations, (3) disorganized speech, (4) grossly disorganized or catatonic behavior, (5) negative symptoms such as affective flattening, alogia, or abolition.

Hitler had two of these. He had delusions that people were out to hurt him; delusions that the Jews were evil, unclean, and the cause for all of chaos and downfall of Germany; delusions that he was a wonderful artist, possibly one of the best of the time; delusions that he was all powerful and deserving.

The second symptom Hitler demonstrates is negative symptoms of affective flattening. The only time Hitler showed any type of appropriate emotion was when he was angry. The second criterion is social or occupational dysfunction. Hitler was able to gain millions of followers but he rarely had true good relations with friends or family. Also considered is the duration, continuous signs for at least six months with at least one month of straight symptoms. Hitler portrayed these symptoms from young adulthood onward. Other criteria considered are ones of exclusion, exclusion of schizoaffective and mood disorders, exclusion of substance or general medical conditions, and exclusion of pervasive development disorders.

It may also be possible that Hitler had Cyclothymic Disorder, which is a mild form of bipolar disorder where a person has mood swings from mild to moderate depression to euphoria, but stays connected to reality.

DSM-IV-TR states that the essential feature of Paranoid type Schizophrenia is the presence of prominent delusions or auditory hallucinations in relation to preservation. The delusions are usually of grandiose theme. Hitler had many delusions about the Jew being evil and out to harm and infect everyone. Hitler often believed that he was a better artist and architect than he was and was appalled when others did not find him so. He believed he was better than everyone else, even while homeless living in the Men’s Shelter.

Associated features include anxiety, anger, aloofness, and argumentativeness, most of which Hitler displayed in almost every way. According to the DSM-IV-TR it may have been possible that Hitler had schizophrenia paranoid type.

Associated features

The paranoid subtype is the most common of subtypes. Those with the paranoid subtype will have delusions and suspicions that increase during the course of the illness. Their delusions are mostly persecutory, grandiose, or feelings of inadequacy, and will tend to have interpersonal problems. The delusions may be multiple, but usually have a theme. Other features include anxiety, anger, aloofness, and argumentativeness.These features become increasingly suspicious of relatives and close friends. The indiviual may display a superior or patronizing manner, and may be extremely formal or intense in their interactions. They function at a higher level than most other schizophrenics because of the lack of negative symptoms. Their diagnosis is more stable than for the other types, and they respond better to treatment as well. Individuals suffering from the paranoid subtype also suffer from social withdrawal and persistently hold grudges and perceive attacks.

Child vs. adult presentation

The illness is presented much the same for adults as for children, except the symptoms appear before age 12. The illness manifests itself gradually in children and is often preceded by lags in motor development, speech development, etc. The paranoid subtype often manifests itself later than the other subtypes. If there is an onset of Schizophrenia in childhood or adolescence, a failure to achieve an expected level of interpersonal, academic, or occupational achievement is thought to occur. His or her social and occupational functioning needs to be on a steady decline during the disorder.

Gender and cultural differences in presentation

Schizophrenia presents itself three to six years later in women than in men, but it presents itself the same way between genders. Schizophrenic disorders present themselves consistently across the world, but one must take into account cultural attitudes on the symptoms which typically make up schizophrenia. In other words, what we see as symptoms of paranoia may be normal behavior to different cultures. Recent studies show that men are more likely to receive treatment for the disorder. In fact, most research on the treatment of schizophrenia is conducted on samples ranging from 60% to 100% male. Misdiagnosis of mood disorders as schizophrenia is the most common problem with the diagnosis of ethnic minorities in the United States.

Epidemiology

Schizophrenia has a lifetime prevalence of about 1%, and that prevalence may differ greatly from country to country. It is diagnosed disproportionately among the lower class. There is very little epidemiological data for Paranoid Schizophrenia specifically.

When the diagnosis of Schizophrenia came in use, almost half were considered in the Paranoid category. Now, new drugs can help decrease the paranoia and this diagnosis is on the decrease.

Etiology

Etiological factors for schizophrenia include genetic factors, environmental factors, and physiological factors.

The more severe a parent’s schizophrenia, the more likely it is that a child will have schizophrenia. Monozygotic twins have a 46% concordance rate for schizophrenia, and dizygotic twins have a 9% concordance rate. There is also a lower fecundity level (the ability to produce viable offspring) for schizophrenics: a 70% reduction in males and a 30% reduction in females.

Paranoid Schizophrenia does not seem to be as affected by genetics as the other subtypes.

There are also many environmental factors which could lead to schizophrenia.

Such factors include living in an urban environment, a lower social economic status, and childhood experience of abuse or trauma.

Since concordance rates are not at or near 100%, it is certain that there are many environmental factors which play into schizophrenia. Adoption studies have shown that a healthy family environment can serve as a protective factor from schizophrenia.

Poor parenting is not held responsible for schizophrenia, but might increase the risk.

The diathesis stress model is accepted by many psychologists as an explanation for the development of schizophrenia. This model states that the person is born with a genetic vulnerability to Schizophrenia and is afterward exposed to a traumatic event with which he/she cannot cope. If the person can effectively handle the stress brought about by the trauma, Schizophrenia may never develop.

There are also some prenatal factors which influence the development of Schizophrenia. These factors include prenatal exposure to influenza, malnutrition, and birth complications.

There are also some physiological factors to consider:

One hypothesis states that Schizophrenia is caused by excess levels of dopamine. Some say that the dopamine receptors may have become hypersensitive.

There are some problems with this hypothesis. There are schizophrenics who do not respond to dopamine-decreasing drugs. Also behavior changes in schizophrenics occur over time, while dopamine receptors are effective usually within a few weeks. Schizophrenics also have anatomical differences in their brains. The total brain mass is less than average, and the ventricles are enlarged.

Paranoid schizophrenics do not show these neuropsychological differences.

Empirically supported treatments

The two modalities of treatment for Schizophrenia are psychotherapy and anti-psychotic medication.

Psychotherapy for Schizophrenia focuses on making changes that will be effective over time. Family therapy has been shown to have a positive outcome on the schizophrenic and to help the family cope with the disorder. The family is educated about the disorder and taught what to expect and how to handle different situations that the illness may present. They also learn how to improve communication between each other and the schizophrenic.

Social Skill Training teaches the schizophrenic to improve on the social skills he or she may be lacking, and the difference between acceptable and unacceptable behavior. In Assertive Community Treatment, an interdisciplinary team provides skills training, rehabilitation, education, and support so that the schizophrenic can be kept in the community as opposed to being hospitalized. Schizophrenics are also taught to recognize indicators of stress and how to cope with them effectively. For those who cannot reach the point of being able to be without sheltered care, token economies have been shown to be useful. Tokens are given in return for desirable behaviors which have been laid out and are exchanged after a period of time for snacks or privileges. Inappropriate behaviors are ignored and are punished only when necessary. All of these treatments are used in combination with anti-psychotic medications

Anti-psychotic medications for Schizophrenia include: Clozaril, Compazine, Etrafon, Haldol, DecanoateInapsine, Lidone, Loxitane, Mellaril, Moban, Navane, Orap, Permitil, Prolixin, Decanoate, Enanthate, Proketazine, Risperdal, Serentil, Sparine, Stelazine, Taractan, Thorazine, Tindal, Trilafon, and Vesprin.

Paranoid Schizophrenia responds very well to medication and has the best prognosis of all the subtypes.

Antipsychotic side effects include: motor side effects, for example pseudoparkinsonism (shake uncontrollably), bradykinesia, rigidity, & tardive dyskinesia, seizures, anticholinergic effects, antihistaminic effects, & neuroleptic malignant syndrome.

Links

• “Schizophrenia May Be Linked To Immune System”: A short story about three genetic studies believed to show possible causes for Schizophrenia.
  • “Schizophrenia May Be Linked To Immune System.” All Things Considered. National Public Radio. July 1, 2009
• An interview with Patrick Tracey, who traced his family’s history with Schizophrenia back five generations
  • Family’s History with Schizophrenia
  • “Tracing the Roots of ‘Irish Madness’.” Talk of the Nation. National Public Radio. Aug. 28, 2008
• Radio contributor Scott Carrier tells the story of a job he had at a particularly bleak point in his life, interviewing people diagnosed with Schizophrenia. Story begins at minute 3, and ends at minute 18:30.
  • “The Friendly Man.” This American Life. Chicago Public Radio. April 24, 2009
  • Interview with a paranoid schizophrenic

Articles

• New hope for people with schizophrenia
• A recipe for schizophrenia symptoms?
• Murry (1943) also provided a psychological evaluation of Hitler for the Office of Strategic Services. He believed that Hitler showed signs of schizophrenia paranoid type. Along with Schizophrenia he believed that Hitler exhibited signs of panic attacks, irrational jealousy, and delusions of persecution, omnipotence, megalomania, and ‘messiah ship’. He is one of the many theorist who believe that these psychopathic symptoms derived from his stay at Pasewalk. He noted that Hitler was able to gain control over his hysterical and paranoia. He used them to enhance his own standing by inflaming the nationalistic passions of the German people and fan hatred. (Murry, H. A. (1943). Analysis of the personality of Adolf Hitler with prediction of his future behavior and suggestion for dealing with him now and after Germany’s surrender. A report prepared for the Office of Strategic Services, October, 1943. Retrieved from www.lawschool.cornell.edu/library/donovan/hitler. )
• Coolidge, Davis, and Segal (2007) did an experiment in which they had five academic historians, with 10 years of hitlerian studies, current or former university faculty appointment, and a published book or article about hitler or Nazi Germany, completed the CATI of Hitler. They found that Hitler would have most likely been diagnosed with schizophrenia paranoid type. The mean consensus T score for schizophrenia scale was almost two standard deviations above the normal mean. His scoring on the Psychotic Thinking and Paranoid scales also support this diagnosis. The researchers also found high scores for PTSD. He was three standard deviations above the normal mean.(Coolidge, F. L., Davis, F. L., & Segal, D. L. (2007). Understanding madmen: A DSM-IV assessment of Adolf Hitler. Individual Differences Research, 5(1), pp. 30-43.)

• A Beautiful Mind is a 2001 movie about a man who develops paranoid schizophrenia and experiences delusional episodes.