Paranoia is to be looked upon as the development of a morbid germ the existence of which manifests itself in early life by anomalies of character. These anomalies may be, to use the apt expression of Seglas, "summarized in two words: conceit and suspicion." At a certain time the pathological tendencies of the subject find their expression in a fixed idea, and the delusional state is established.
Sometimes it is slow and gradual, much more frequently rapid, almost sudden.
In the first case the dominant traits of the personality become accentuated little by little. The patient grows more and more suspicious and vain and believes himself to be the object of malevolent or, on the contrary, admiring reflections. Delusional interpretations become more and more numerous until finally the fixed idea appears, an idea of persecution or of grandeur, around which a whole delusional system is subsequently built up.
In the second case the fixed idea is primary in relation to the delusional interpretations. Sometimes the fixed idea appears in childhood, as in a case of Magnan's: the boy when questioned concerning his vocation replied that he was going to become a pope. Sander has described this form under the name paranoia originaire.
Usually the fixed idea appears at a later period, in youth or in adult age. Often it is based upon some real fact the significance of which the patient misinterprets or the importance of which he exaggerates: perfectly justifiable disciplinary measures to which he is subjected, loss of money, or sometimes, indeed, a true injustice, against which, however, nothing can be done, may determine the onset of the disease. Often, also, it has for its basis the extreme credulity of the patient, who takes in earnest a simple pleasantry or some idle remark. "He resembles Napoleon," was once remarked by someone in the presence of a psychopath. Immediately the latter conceived the idea that he belonged to the royal family and that he was "the Master of France," and this formed the starting point of his system of delusions. Fundamental Features of the Disease. - As soon as the theme, that is to say the fixed idea, is formed, the disease develops very rapidly and is characterized by:
1 Leroy. Les persecutes perse"cuteurs. These de Paris, 1896. - Ballet et Roubinowitch. Les persecutes persecuteurs. - Magnan, Lecons cliniques.
(1) The immutability of the basic fixed idea;
(2) The absolute faith which the patient has in his delusions;
(3) The apparent logic of the delusional system;
(4) The promptness and intensity of the reactions;
(5) The absence or at least extreme rarity of hallucinations and the presence of numerous false interpretations;
(6) The absence of mental deterioration regardless of the length of time that the disease has lasted.
The following brief abstract from the history of a case illustrates these characteristics in a somewhat schematic fashion:
A schoolmaster, who was a man of average intelligence, but suspicious and conceited, failed to receive a promotion which he believed he had a right to expect. The idea that he was the victim of a grave injustice arose in his mind and never left it (immutability of the fixed idea). The reasonings of his friends and relatives could not alter his conviction and failed to dissuade him from addressing a letter of strong protestation to the school director (absolute faith in his delusions, promptness and intensity of the reactions). This producing no effect other than the loss of his position, he applied to the minister of public instruction, to the president of the republic, to the tribunals. He found no justice, but nevertheless retained confidence in the excellence of his cause, attributing his successive disappointments to dishonesty of the representatives of authority and justice, who he claimed were in league against him because his high intellect overshadowed them. Everything now became clear to him; he understood the distrust shown towards him and the attention which he attracted wherever he went (apparent logic of the delusions, false interpretations). Finally committed, he continued to protest against his persecutors, among whom were included, as might be expected, the physician who treated him and the police officer who arrested him; the memory still remains perfect and the mind lucid, although the disease has now lasted over twenty-five years (absence of mental deterioration).
It is often stated that the delusions of paranoiacs are, in a manner, logical; that is to say, when the fixed idea once appears, the secondary delusional conceptions are the natural outcome. Thus presented, this statement is not correct. In fact, if these patients possessed a faultless logic it would render apparent to them the inconsistency of their fixed idea, which would be immediately abolished. It is quite true that these patients are very apt to use and abuse deductions and syllogisms, which trait has gained for them the name of the reasoning insane. But their logic is only apparent; their reasoning is always tainted with the same original vice that leads them to the systematic rejection of arguments opposing their ideas, and the ready acceptance of hypotheses which arise in their minds as a result of their pathological preoccupations. Hence their delusional interpretations, which become more numerous each day and upon which they base their arguments, and the childish character of the proofs which they accumulate. A vague word or an evasive reply often suffices to convince them that their point of view has been adopted and that their cause has been accepted.
The concessions occasionally made by those against whom their delusions are directed, become, in their eyes, ample proof that these people admit their guilt; thus misinterpreted chance occurrences serve to feed the system of delusions.
Quite frequently their reasoning, subtle and plausible, though radically false, is imposed upon suggestible individuals or upon those of shallow minds. Thus they often have defenders who show more zeal than intelligence.
"According to their special morbid tendencies paranoiacs may be classed in different groups: the litigious paranoides (paranoia querulens of the Germans), who prosecute their imaginary rights in the courts; the hypochondriacal paranoiacs, who, believing themselves to have been once improperly treated by a physician, bear a grudge against all physicians whom they may meet in the course of their treatment, and annoy them in various ways; the filial paranoiacs, who believe that they have found their father in some stranger, whom they constantly annoy with their expressions of tenderness and with their claims. Another group is formed by the amorous paranoiacs: Teulat, the lover of Princess de B------, was a splendid example of this type." (Magnan.)
To the preceding groups should be added the jealous paranoiacs, in whom the delusions assume the form of morbid jealousy; inventors who are indignant for the rejection of their fantastic inventions;1 mystics and founders of religions who often succeed in gathering under their banners an imposing train of feeble-minded, or at least unbalanced, individuals, etc.
The list might be extended indefinitely; it is useless, however, for whatever be the nature of the fixed idea, the clinical characteristics of the delusional state do not vary.
The first question that may arise in the mind of the physician is, Are the ideas of the subject delusional or not? It is not always easy to answer this question. Delusions sometimes appear very plausible, while, on the other hand, well-based claims may resemble the delusions of paranoia on account of the obstinacy with which they are urged. Only by a very careful investigation of each case can errors be avoided.
The diagnosis is to be based upon the fundamental characters enumerated above; all these characters in combination are not observed in any other psychosis.
1 Delarras. Contribution d I'etude du delire des inventeurs. These de Bordeaux, 1900.
In favor of paranoid dementia are mental deterioration and the more mobile character of the delusions. In delire chronique there are the constant presence of hallucinations and a progressive evolution of the disease. In alcoholic delusion of jealousy we find less perfect systematization, presence of hallucinations, history and physical signs of alcoholism, and tendency toward recovery.
Paranoia is a chronic, incurable affection which, as we have seen, entails no mental deterioration.
The violence of the reactions sometimes renders commitment necessary. There are no known means for combating the delusions. Psychic treatment has no influence whatever.