The Paranoid Patient:Perils and Pitfalls

Phillip J. Resnick, MD

Professor of PsychiatryCase Western Reserve UniversityDirector of Forensic PsychiatryUniversity Hospitals Case Medical CenterCleveland, Ohio

Did the psychiatrist fall below the standard of care by allowing the steelworker to go home?

Teaching Points

A building crescendo of paranoid fear creates a high risk of violence

A clinician should not surrender professional judgment to family

Posing a threat is different from making a threat

Psychosis and Homicide

Nielssen O, et al. Schizophr Bull. 2011;37(3):572-579.

The rate of homicide during first-episode psychosis is 15 times greater than the annual rate after treatment.

First-Episode Psychosis

Large MM, et al. Schizophr Res. 2011;125(2-3):209-220.

• One-third of patients commit violence before receiving treatment

• The longer the symptoms are untreated, the more the serious violence

Overview

• Delusions and violence• Paranoia and violence• Motives for paranoid violence• Paranoid safety behaviors• Evaluation of violence risk

Psychosis and Violence

Violent Behavior in the Last Year

Swanson JW, et al. Hosp Community Psychiatry. 1990;41(7):761-770.

Diagnosis %

No disorder 2Major depression 12Mania or bipolar disorder 11Schizophrenia 13Alcohol abuse or dependence 25Other drug abuse or dependence 35

SMI = serious mental illness.Junginger J, et al. Schizophr Bull. 2004;30(1):21-30. Junginger J, et al. Schizophr Bull. 2004;30(1):21-30.

Thomas Theorem

If people define situations as real, they are real in their consequences.

Dangerous Delusions

• Erotomania• Misidentification• Threat/Control-Override • Persecutory

Erotomania

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.

• A delusional belief that one is loved• It is usually toward a person of higher

status• Violence risk to love object and person

seen standing in the way

Misidentification Delusions

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.

• Capgras syndrome• Persons replaced by imposters• Threat by imposter → violence

Threat andControl-Override Symptoms

Borum R, et al. Journal Practical Psychiatry & Behavioral Health. 1996;2(4):205-215.

• Mind feels dominated by external forces

• Thoughts are being put into head• Feeling that people wish you harm

Non-Violent Delusions

Borum R, et al. Journal Practical Psychiatry & Behavioral Health. 1996;2(4):205-215.

• Feeling dead or not existing• Thoughts are broadcast• Thoughts are removed

Alexis

Paranoid Delusions

Freeman D. Clin Psychol Rev. 2007;27(4):425-457.

Schizophrenia 50%Psychotic depression 44%Dementia 31%Mania 28%

Threat Anticipation Model of Paranoia

Freeman D. Clin Psychol Rev. 2007;27(4):425-457.

• Patient attempts to make sense of odd feelings

• Patient interprets ambiguous experiences negatively

• Anxiety concerns about the anticipation of threats

• Ideas become persecutory when attribute intention to perpetrators

Paranoid Persons

Harris T. In: Cooper B (Ed). Psychiatric Epidemiology: Progress and Prospects. London: Croom Helm; 1987:81-102. Bentall RP, et al. Clin Psychol Rev. 2001;21(8):1143-1192.

• 20 times more likely to have a history of receiving threats

• Excessive sensitivity to others’ negative emotions

• Attend selectively to threat stimuli

Paranoid Delusions

Krakowski M, et al. Compr Psychiatry. 1986;27(2):131-148.

• Most dangerous• Well planned violence• Usually preemptive strike• Occasionally vengeance

Gender Response to Threats

Teasdale B, et al. Law Hum Behav. 2006;30(6):649-658.

• Men respond with violence— “Fight or flight”— Become aggressive

• Women respond without violence— “Tend and befriend”— Seek nurturing relationships

Increased Violence inParanoid Delusions

Bjorkly S. Aggression and Violent Behavior. 2002;7(6):617-631.

• Systematized delusions• Anxiety and distress• Anger and fear

Paranoid Violence

Gardner W, et al. J Consult Clin Psychol. 1996;64(3):602-609. Taylor JL. In: Freeman D, et al (Eds). Persecutory Delusions: Assessment, Theory, and Treatment. New York, NY: Oxford University Press; 2008.

• Occurs when there is a high degree of perceived threat

• Mediated by anger

• Severe dysfunction impedes violence

Delusions, Violence,and Anger

Coid, JW, et al. JAMA Psychiatry. 2013;70(5):465-471.

• Delusions of persecution• Delusions of conspiracy• Delusions of being spied on

Paranoid Violence Motives

Resnick PJ. From paranoid fear to completed homicide. Current Psychiatry. 2016;15(2):24.

• Self-defense• Defense of manhood• Defense of children• Defense of the world

Paranoia Formulation

Freud S, et al. The Schreber Case. Penguin Books; 2002.

I love you.I hate you.You hate me.

Paranoid Violence Motives

• Self-defense• Defense of manhood• Defense of children• Defense of the world

Paranoid Violence Motives

• Self-defense• Defense of manhood• Defense of children• Defense of the world

Paranoid Violence Motives

Resnick PJ. From paranoid fear to completed homicide. Current Psychiatry. 2016;15(2):24.

• Self-defense• Defense of manhood• Defense of children• Defense of the world

Responses to Paranoid Fear

Safety Behaviors

Freeman D, et al. Behav Res Ther. 2007;45(1):89-99.

• Avoidance• Protection• Decrease visibility• Enhance vigilance

Evidence of Paranoid Fear

• Changes of residence• Long trips to evade persecutors• Barricading their rooms• Carrying weapons for protection• Asking police for protection

Evaluation of the Paranoid Patient for Risk of Violence

Strategies forParanoid Patients

Yang S. Dangerously Paranoid? Overview Strategies for a Psychiatric Evaluation of a Highly Prevalent Syndrome. Psychiatric Times. 2008;25(14).

• Therapeutic alliance• Hear full paranoid story• Maintain some distance• Be nonjudgmental

Assaults Against Residents

Kwok S, et al. J Grad Med Educ. 2012;4(3):296-300.

• Psychiatry 54%• Surgery 38%• Internal medicine 28%• Emergency medicine 26%• Pediatrics 7%

Violence Risk Assessment

• Confront with persecutor• Perceived intentionality• Substance abuse• Weapons available

Stimulants and Violence

Brecher M, et al. J Clin Psychopharmacol. 1988;8(6):397-401.

• Disinhibition• Grandiosity• Paranoia

Violence Prevention Plan

Risk Factor Management/Treatment Status

1. 1. 1.2. 2. 2.

3. 3. 3.4. 4. 4.

Evaluation of Riskafter Paranoid Violence

• Prodromal symptoms• Warning behaviors• Quickness of onset

Timing of Violence

Hodgins S. Arch Gen Psychiatry. 1992;49(6):476-483.

The median length of time between the onset of an acute psychotic episode and violence is 30 days.

Summary

• Paranoia can lead to severe violence

• Assess how the patient is responding to paranoia

• Threats may or may not precede paranoid violence