Case Study Schizophrenia Delusions Of Persecution

Abstract

Delusional paranoia has been associated with severe mental illness for over a century. Kraepelin introduced a disorder called “paranoid depression,” but “paranoid” became linked to schizophrenia, not to mood disorders. Paranoid remains the most common subtype of schizophrenia, but some of these cases, as Kraepelin initially implied, may be unrecognized psychotic mood disorders, so the relationship of paranoid schizophrenia to psychotic bipolar disorder warrants reevaluation. To address whether paranoia associates more with schizophrenia or mood disorders, a selected literature is reviewed and 11 cases are summarized. Comparative clinical and recent molecular genetic data find phenotypic and genotypic commonalities between patients diagnosed with schizophrenia and psychotic bipolar disorder lending support to the idea that paranoid schizophrenia could be the same disorder as psychotic bipolar disorder. A selected clinical literature finds no symptom, course, or characteristic traditionally considered diagnostic of schizophrenia that cannot be accounted for by psychotic bipolar disorder patients. For example, it is hypothesized here that 2 common mood-based symptoms, grandiosity and guilt, may underlie functional paranoia. Mania explains paranoia when there are grandiose delusions that one's possessions are so valuable that others will kill for them. Similarly, depression explains paranoia when delusional guilt convinces patients that they deserve punishment. In both cases, fear becomes the overwhelming emotion but patient and physician focus on the paranoia rather than on underlying mood symptoms can cause misdiagnoses. This study uses a clinical, case-based, hypothesis generation approach that warrants follow-up with a larger representative sample of psychotic patients followed prospectively to determine the degree to which the clinical course observed herein is typical of all such patients. Differential diagnoses, nomenclature, and treatment implications are discussed because bipolar patients misdiagnosed with schizophrenia are severely misserved.

schizophrenia, bipolar, mania, depression, Kraepelinian dichotomy, paranoia, psychosis

Introduction

Modern psychiatry began in the mid- to late 19th century when several syndromes including paranoia were consolidated by Emil Kraepelin and called dementia praecox,1 later renamed “schizophrenia” by Eugene Bleuler in 1911.2 The “Kraepelinian dichotomy” described 2 separate diseases to explain severe mental illness, schizophrenia and manic-depressive insanity or bipolar disorder.1 Bleuler2 and then Schneider3 emphasized that psychosis, to include a paranoid delusional system, was pathognomonic of schizophrenia and discounted the diagnostic implications of mood symptoms. A very different idea was presented in 1905 when Specht4 said that all psychoses were derived from mood abnormalities.5 Kraepelin had also linked paranoia and mood when he used the term “paranoid depression” to describe an illness with a high rate of suicide, severe depression, paranoia, and auditory hallucinations.1,5 The 1933 introduction of schizoaffective disorder6 recognized the diagnostic relevance of mood symptoms in psychotic patients, linked schizophrenia (psychosis) and mood disorders, and eroded the concept of the Kraepelinian dichotomy.7–11 Some now consider schizoaffective disorder to be a psychotic mood disorder and not a subtype of schizophrenia or a separate disorder.7–12 In addition, certain authors in the United Kingdom have associated paranoia with depression and delusional guilt.5 One group in the 1970s implied that about 95% of their sample of patients diagnosed with paranoid schizophrenia actually suffered from mania because “classic bipolar” patients were observed to suffer paranoid delusions.13

Despite these linkages of paranoia and psychosis with mood disorders, the concepts of Bleuler2 and Schneider3 that bound paranoia and all functional psychoses to schizophrenia prevailed, and such cases typically have been diagnosed with paranoid schizophrenia or postschizophrenic depression, not as psychotic mood disorders.5 Paranoia continues to be associated with schizophrenia, rather than with bipolar disorder, both as the most common subtype and as a core diagnostic symptom, as reflected in the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), the International Classification of Diseases, Tenth Edition (ICD-10), and major textbooks of psychiatry.14

However, when mood disorders are explored as a source of paranoia, a different causal relationship presents itself (figure 1). If psychotic mood disorders explain many paranoid presentations, as suspected over 30 years ago,13 questions arise about the distinction between schizophrenia and psychotic mood disorders.7,8,13,15–19Selected reviews of symptoms, course, prognosis, family heritability, and epidemiology conclude that there are no disease-specific characteristics of schizophrenia and that the DSM diagnostic criteria for schizophrenia are common to psychotic bipolar disorder patients.7,8,15–20 Further indications of closure toward one disease derive from recent basic science data, especially molecular genetic and neurocognitive studies, that show considerable overlap and similarities between schizophrenia and psychotic bipolar disorder.18–32 One author states that “ … of the (11) chromosome loci found for the transmission of schizophrenia and bipolar disorder, eight have been found to overlap ....”28 Crow30,31 advances an explanation for the 3 or more loci that do not overlap between schizophrenia and bipolar that is compatible with a single disease to explain all 3 of the functional psychoses: “Epigenetic variation associated with chromosomal rearrangements that occurred in the hominid lineage and that relates to the evolution of language could account for predisposition to schizophrenia and schizoaffective disorder and bipolar disorder and failure to detect such variation by standard linkage approaches.”

Fig. 1.

Psychotic Depression Can Cause Delusions of Exaggerated Severity of Past “Sins” Leading to Delusional Guilt. Such guilt stimulates thoughts that punishment is deserved and imminent. The fear of punishment, torture, and/or execution defines the paranoid psychosis that consumes these patients’ lives. Similarly, psychotic mania can cause delusional grandiosity of ownership of valuable possessions. A logical result is the delusional belief that others want these possessions and are going to kill to get them, leading to paranoid psychosis. Because these patients present with complaints of fear for their lives, the core symptoms of the mood disorder may be overlooked and a misdiagnosis of paranoid schizophrenia made.

Fig. 1.

Psychotic Depression Can Cause Delusions of Exaggerated Severity of Past “Sins” Leading to Delusional Guilt. Such guilt stimulates thoughts that punishment is deserved and imminent. The fear of punishment, torture, and/or execution defines the paranoid psychosis that consumes these patients’ lives. Similarly, psychotic mania can cause delusional grandiosity of ownership of valuable possessions. A logical result is the delusional belief that others want these possessions and are going to kill to get them, leading to paranoid psychosis. Because these patients present with complaints of fear for their lives, the core symptoms of the mood disorder may be overlooked and a misdiagnosis of paranoid schizophrenia made.

There are established differences between psychotic and nonpsychotic bipolar disorders.15–17 Psychotic mood disorders are often phenotypically indistinguishable from schizophrenia, so it is likely that psychotic mood-disordered patients have been misdiagnosed with schizophrenia. Differences considered to exist between “schizophrenia” and “classic” (nonpsychotic) bipolar disorder may be explained by the differences between psychotic and nonpsychotic (classic) bipolar.

The symptom of paranoia, in particular, has been the focus of genetic studies. For example, although preliminary, familial aggregation data reveal that paranoid delusional proneness is an endophenotype common to patients diagnosed with schizophrenia and psychotic bipolar disorder but not nonpsychotic bipolar disorder.16 Schulze et al17 extended this work by linking persecutory delusions (paranoia) to variance at a specific locus, the D-amino acid oxidase activator/G30, located on chromosome 13q34, in patients diagnosed with schizophrenia and with psychotic bipolar disorder. More recent results link this locus primarily to mood disorders “across the traditional bipolar and schizophrenia categories.”29 Such genotypic overlap, when considered with the phenotypic similarities, suggests the hypothesis that the disease called paranoid schizophrenia may be psychotic bipolar disorder and not a separate disorder. Bipolar disorder is more likely than schizophrenia to be the single disease because bipolar is scientifically grounded with unique, disease-specific diagnostic criteria, while schizophrenia has no disease-specific criteria.7,12,15 The following review of 11 patients, each initially diagnosed with schizophrenia but subsequently revealed to suffer from a psychotic mood disorder, serves to illustrate these ideas (table 1). All subjects gave their written informed consent to participate in this Institutional Review Board-approved research.

Table 1.

Case Characteristics

Case No. Age/Sex; Job/School ED Presentation Initial Symptoms Initial Diagnosis Subsequent Symptoms Paranoia Caused by Actual Patient Experience (“Thread of Truth”) Final Diagnosis 
58/M; Unemployed day laborer/college graduate, Vietnam Veteran Handcuffed, paranoid, fearful, agitated, resistant, involuntary Feared elimination by CIA; feared poison PSaDecreased sleep with increased activities; grandiosity; lost 20 pounds due to “no time to eat”; made over 300 phone calls to the CIA often between midnight and 4 AMBelieved that he possessed critical knowledge about the Vietnam war that was embarrassing to the US government who had sent the CIA to eliminate him Had fought in Vietnam BP-I manic, severe withb
46/M; Military officer/college graduate, PhD in engineering Escorted by MP’s, handcuffed, paranoid, fearful, agitated, resistant, involuntary Feared for his life from assassination by KGB and NSA; coded messages from TV PS Decreased sleep with increased activities; grandiosity; called President Reagan multiple times; moved daily from motel to motel to escape assassination Believed that he had a Star Wars missile design that the KGB and NSA wanted for themselves Was a rocket engineer BP-I manic, severe with 
28/M; Microbiology technician/college graduate Delusional paranoia, assaultive, restrained in ED, involuntary Feared his murder by Al Qaeda was imminent; feared poison PS Decreased sleep with increased activities; worked on his computer 24/7 for weeks; grandiosity; marked weight loss due to fear of poison Believed God had named him as a Christian prophet and that Al Qaeda would assassinate him with anthrax because of his Christianity Was a microbiologist and in New York City on November 11, 2001 BP-I manic, severe with 
29/M; Musician Police escort, delusional paranoia, violent, restrained, involuntary Feared execution by Cuban Mafia; messages from TV and radio PS Decreased sleep with increased activities; grandiosity; moved from city to city to escape harm Believed that he had a recording worth millions that the Cuban Mafia wanted Was a Cuban musician who supported the anti-Castro effort BP-I manic, severe with 
24/M; Unemployed/college graduate Delusional paranoia, disorganized, voluntary Feared execution by Cali Cartel PS Decreased sleep with increased activities; fleeing for his life; grandiosity; kept walking and lived on the street to avoid capture Believed that he possessed a formula to make synthetic narcotics so the Cali Cartel wanted it and him dead Was from Columbia, South America and a chemistry major BP-I manic, severe with 
56/M; Unemployed house painter/high school graduate Delusional paranoia, disorganized, suicidal, voluntary Feared death at the hands of the devil and God; feared poison PS, postschizophrenic depression Psychotic, suicidal depression followed by psychotic mania when he ordered 10 000 oysters in the shells for a party for the governor of the state of North Carolina Believed that he had sinned over 40 y before and deserved torture and death by God and the devil; believed that he was friend to the governor Did steal $5 from his boss’ gas station at 15 y of age MDD, severe withc; then BP-I, manic, severe with 
28/M; Fast-food restaurant worker/college graduate Delusional paranoia, handcuffs, catatonia, coprophilia, involuntary Feared his execution by hit men; poison PS Decreased sleep with increased activities; disorganization due to racing thoughts; grandiosity; premeditated corprophilia with a purpose to get transferred to escape hit men Believed that he was to gain ownership of his bank, but hit men were sent to kill him to get the bank for themselves; planned on millions in purchases Did make trips to the bank on a regular basis for his mom BP-I manic, severe with 
40/F; Unemployed lawyer/law school graduate Delusional paranoia, suicidal, voluntary Auditory hallucinations keeping up a running commentary PS Psychotic, suicidal depression; delusional guilt; persecutory delusions; persistent psychosis with downward drift to homelessness; history of hypomanic episodes Believed that she was such a failure that she deserved torture and death; then feared her torture and death Lost several legal positions and then was fired from even menial jobs BP-II, depressed, severe with 
54/F; Artist/master's degree Police escort, delusional paranoia, assaultive, involuntary Feared “rogue CIA and Cuban agents” trying to kill her; messages from TV PS Decreased sleep with increased activities; had flown from New York to Chicago at last minute; extensive grandiosity; angry; violent; loud; intrusive Complex grandiose delusional system incorporating the jewels of the Queen of Spain, Fidel Castro, and the assassination of President Reagan Had visited Spain and Cuba and had a distant relative with a low-level CIA position BP-I, manic, severe with 
10 62/F; Unemployed/college graduate Police escort, delusional paranoia, involuntary Feared her imminent assassination by “anti-Jewish foreign agents” PS Decreased sleep with extensive writing to the US Department of State for 20–24 h a day sustained episodically over decades; fled lodging when TV or radio indicated she had been located; walked all night to escape; slept on the streets Believed that she was an undercover foreign affairs advisor for the US State Department covertly tasked to protect the Jewish people Had held a low-level job in the US government in her 20s BP-I, manic, severe with 
11 36/F; Nurse/college graduate Ambulance, unconscious due to overdose in a serious attempt to die Feared her capture by law enforcement, sentencing to death and execution PS or postschizophrenic depression Psychotic suicidal depression; endorsed full manic episodes in the past with decreased sleep and a marked increase in dangerous activities due to spur of the moment impulses and lack of judgment Believed that she had “murdered” by neglect a terminal, 4-y-old patient under her care in hospice Had lost such a patient under her hospice care BP-I, depressed, severe with 
Case No. Age/Sex; Job/School ED Presentation Initial Symptoms Initial Diagnosis Subsequent Symptoms Paranoia Caused by Actual Patient Experience (“Thread of Truth”) Final Diagnosis 
58/M; Unemployed day laborer/college graduate, Vietnam Veteran Handcuffed, paranoid, fearful, agitated, resistant, involuntary Feared elimination by CIA; feared poison PSaDecreased sleep with increased activities; grandiosity; lost 20 pounds due to “no time to eat”; made over 300 phone calls to the CIA often between midnight and 4 AMBelieved that he possessed critical knowledge about the Vietnam war that was embarrassing to the US government who had sent the CIA to eliminate him Had fought in Vietnam BP-I manic, severe withb
46/M; Military officer/college graduate, PhD in engineering Escorted by MP’s, handcuffed, paranoid, fearful, agitated, resistant, involuntary Feared for his life from assassination by KGB and NSA; coded messages from TV PS Decreased sleep with increased activities; grandiosity; called President Reagan multiple times; moved daily from motel to motel to escape assassination Believed that he had a Star Wars missile design that the KGB and NSA wanted for themselves Was a rocket engineer BP-I manic, severe with 
28/M; Microbiology technician/college graduate Delusional paranoia, assaultive, restrained in ED, involuntary Feared his murder by Al Qaeda was imminent; feared poison PS Decreased sleep with increased activities; worked on his computer 24/7 for weeks; grandiosity; marked weight loss due to fear of poison Believed God had named him as a Christian prophet and that Al Qaeda would assassinate him with anthrax because of his Christianity Was a microbiologist and in New York City on November 11, 2001 BP-I manic, severe with 
29/M; Musician Police escort, delusional paranoia, violent, restrained, involuntary Feared execution by Cuban Mafia; messages from TV and radio PS Decreased sleep with increased activities; grandiosity; moved from city to city to escape harm Believed that he had a recording worth millions that the Cuban Mafia wanted Was a Cuban musician who supported the anti-Castro effort BP-I manic, severe with 
24/M; Unemployed/college graduate Delusional paranoia, disorganized, voluntary Feared execution by Cali Cartel PS Decreased sleep with increased activities; fleeing for his life; grandiosity; kept walking and lived on the street to avoid capture Believed that he possessed a formula to make synthetic narcotics so the Cali Cartel wanted it and him dead Was from Columbia, South America and a chemistry major BP-I manic, severe with 
56/M; Unemployed house painter/high school graduate Delusional paranoia, disorganized, suicidal, voluntary Feared death at the hands of the devil and God; feared poison PS, postschizophrenic depression Psychotic, suicidal depression followed by psychotic mania when he ordered 10 000 oysters in the shells for a party for the governor of the state of North Carolina Believed that he had sinned over 40 y before and deserved torture and death by God and the devil; believed that he was friend to the governor Did steal $5 from his boss’ gas station at 15 y of age MDD, severe withc; then BP-I, manic, severe with 
28/M; Fast-food restaurant worker/college graduate Delusional paranoia, handcuffs, catatonia, coprophilia, involuntary Feared his execution by hit men; poison PS Decreased sleep with increased activities; disorganization due to racing thoughts; grandiosity; premeditated corprophilia with a purpose to get transferred to escape hit men Believed that he was to gain ownership of his bank, but hit men were sent to kill him to get the bank for themselves; planned on millions in purchases Did make trips to the bank on a regular basis for his mom BP-I manic, severe with 
40/F; Unemployed lawyer/law school graduate Delusional paranoia, suicidal, voluntary Auditory hallucinations keeping up a running commentary PS Psychotic, suicidal depression; delusional guilt; persecutory delusions; persistent psychosis with downward drift to homelessness; history of hypomanic episodes Believed that she was such a failure that she deserved torture and death; then feared her torture and death Lost several legal positions and then was fired from even menial jobs BP-II, depressed, severe with 
54/F; Artist/master's degree Police escort, delusional paranoia, assaultive, involuntary Feared “rogue CIA and Cuban agents” trying to kill her; messages from TV PS Decreased sleep with increased activities; had flown from New York to Chicago at last minute; extensive grandiosity; angry; violent; loud; intrusive Complex grandiose delusional system incorporating the jewels of the Queen of Spain, Fidel Castro, and the assassination of President Reagan Had visited Spain and Cuba and had a distant relative with a low-level CIA position BP-I, manic, severe with 
10 62/F; Unemployed/college graduate Police escort, delusional paranoia, involuntary Feared her imminent assassination by “anti-Jewish foreign agents” PS Decreased sleep with extensive writing to the US Department of State for 20–24 h a day sustained episodically over decades; fled lodging when TV or radio indicated she had been located; walked all night to escape; slept on the streets Believed that she was an undercover foreign affairs advisor for the US State Department covertly tasked to protect the Jewish people Had held a low-level job in the US government in her 20s BP-I, manic, severe with 
11 36/F; Nurse/college graduate Ambulance, unconscious due to overdose in a serious attempt to die Feared her capture by law enforcement, sentencing to death and execution PS or postschizophrenic depression Psychotic suicidal depression; endorsed full manic episodes in the past with decreased sleep and a marked increase in dangerous activities due to spur of the moment impulses and lack of judgment Believed that she had “murdered” by neglect a terminal, 4-y-old patient under her care in hospice Had lost such a patient under her hospice care BP-I, depressed, severe with 

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Case 1

A 58-year-old Vietnam veteran living in a suburban neighborhood was presented to the emergency department (ED) in handcuffs accompanied by police. He reported to the interviewing psychiatrist that he had nailed shut his doors and windows except for small slits through which he “planned to fire on attacking Central Intelligence Agency (CIA) operatives.” Having amassed numerous small arms weapons including an illegal, fully automatic machine gun, he brought attention to himself by spraying automatic gunfire through his attic because he thought that “they had gotten into the attic.”

The patient's behavior and resistance in the ED necessitated involuntary commitment. On the unit, he was agitated and fearful, avoiding eye contact, any communication, and taking anything by mouth because he feared he would be poisoned. A thorough medical work-up for organic causes, including a urine drug screen, blood work, and imaging studies, was negative. He was diagnosed with schizophrenia, paranoid type. After 3 days of intramuscular (IM) haloperidol (Haldol) 10 mg twice a day, he began to eat and drink as well as to reluctantly cooperate with the staff, providing further history.

This individual said that he had led illegal US government operations in Cambodia and had become convinced that the CIA intended to eliminate him for fear he would “publish his memoirs.” He said that during the past 2 weeks, he had called the CIA over 300 times, frequently between midnight and 4 AM. Further, he said that he had not slept or eaten for fear of “getting overrun” and had lost over 15 pounds. He admitted that his thoughts had been racing. The patient said that a war buddy he had called had told him to slow down and had finally hung up on him. He had stopped using his telephone for calls other than the CIA for “fear of wiretaps.”

Although he endorsed prior episodes of major depression, he had not sought treatment. His diagnosis was changed to bipolar disorder, type I (BP-I), manic, severe with psychotic features. Lithium was rapidly titrated to a therapeutic blood level and effectively stabilized his mood. In subsequent outpatient follow-up, the patient revealed that he had a paternal uncle who had previously been diagnosed with BP-I and was also taking lithium.

Case 2

Prior to the fall of the Soviet Union, a 46-year-old divorced senior military aerospace engineer presented to military police (MP) afraid for his life and with his briefcase chained to his wrist. His chief complaint was that the (Soviet) State Security Committee (KGB) and the National Security Agency (NSA) were following him and planned to “erase him.” He tried to leave the ED when he became suspicious of the interviewing physician. He was restrained by the MP’s and forcibly admitted to the locked unit. With affect of agitation and paranoia, he was prescribed an antipsychotic combined with a benzodiazepine. The patient's absent without leave status for over 2 months, his rank as an officer, and his high-level security clearance were confirmed. After 2 days on the unit, he admitted that he had “gone underground,” had moved every 2–3 days, and had not reported for duty in order to escape assassination. He claimed to have received coded messages from the TV over the previous 3–4 weeks, telling him that he was in danger of attack by the KGB “who had conspired with the NSA to eliminate him.” He was diagnosed with schizophrenia, paranoid type.

4.3.4

Intoxication and Overdose

A psychotic-like state or excited delirium can be signs of overdose. Common psychological and behavioral symptoms include agitation, aggression, grandiosity, persecutory and paranoid delusions, and auditory and visual hallucinations (Dillon et al., 2003; Pomarol-Clotet et al., 2006). Dissociative states may present as feelings of impaired somatic or psychic control (passivity phenomena).

Ketamine is a mild respiratory depressant and cardiovascular stimulant inducing increases in heart rate, cardiac output, and blood pressure. Palpitations are sometimes a presenting complaint. Pulmonary edema has been described in ketamine overdose, and this may be related to a combination of increased cardiac output and respiratory depression (Kalsi et al., 2011). The median lethal therapeutic dose in animals is 100 times the average therapeutic dose, and no adverse effects were observed in nine children who had been injected with 100 times the intended dose (Green et al., 1999; Morgan & Curran, 2012). Mortality associated with ketamine is often the result of use within a polydrug cocktail as previously described with MDMA and GHB (Morgan & Curran, 2012). Between 1996 and 2006, only four cases of death associated with ketamine were reported in the United Kingdom (Bokor & Anderson, 2014; Schifano, Corkery, Oyefeso, Tonia, & Ghodse, 2008). Although there was a 10-fold increase in deaths mentioning ketamine as a cofactor between 1999 and 2008 (2–22), this is likely to reflect the increasing use of the drug on the club scene (Morgan & Curran, 2012).

Management of ketamine toxicity is targeted at psychiatric symptoms including auditory and visual hallucinations. As agitation or aggression can also be a feature, benzodiazepines can be used for sedation and the patient should be nursed in a low-stimulus environment. Evidence suggests that both typical and atypical antipsychotic medications may have a role in the treatment of acute ketamine intoxication, haloperidol (Giannini, Underwood, & Condon, 2000), and atypical antipsychotics (Duncan & Miyamoto, 2000) have been used, though low doses are advised as there is a risk of neuroleptic malignant syndrome in the neuroleptic naive patient.

Accidents are a common cause of injury or death in ketamine users, arising in the context of reduced pain perception combined with psychomotor aberration, reduced environmental awareness, grandiosity, perceptual disturbance, and thought disorder. Falls, drowning (Trujillo et al., 2011), jumping off buildings (Kalsi et al., 2011), and car accidents have been recorded as causes of death in ketamine-intoxicated patients. In Hong Kong, 9% of fatal crashes recorded over a 5-year period involved ketamine use (Cheng, Ng, Chan, Mok, & Cheung, 2007; Morgan & Curran, 2006).

Problems with chronic use include ketamine-induced ulcerative cystitis that can present as painful hematuria and suprapubic pain; the course of the condition is variable. Sometimes, this is resolved by abstaining from ketamine use; although up to 1/3 may have long-term difficulties and are at risk of obstructive nephropathy, K-cramps describe a vague abdominal pain associated with the long-term use of ketamine, which again abate following a period of abstinence (Morgan & Curran, 2012).

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