Ms. V also has a history of periodic temper problems characterized by verbal aggression such as threatening the assistant principal at her school, and throwing her cellphone at her mother a few weeks before the murder, but no other aggressive episodes. Ms. V’s history does not suggest conduct disorder. She has no history of suicidal ideation or suicide attempts. Ms. V has used alcohol since age 15, but her mother reports that she was not a heavy or frequent user. Her last reported alcohol use was 10 days before the murder. A maternal uncle had been diagnosed with schizophrenia.
Before the murder, Ms. V lived with her sister and mother. Her parents were divorced. At age 9, Ms. V was sexually abused by a soccer coach; however, she denied symptoms of posttraumatic stress disorder related to the sexual abuse. She had no criminal history before the murder.
The authors’ observations
Based on Ms. V’s presentation and history, schizophrenia, paranoid type seems to be the most likely diagnosis because of her negative symptoms, including affective flattening, positive family history for schizophrenia, and paranoid delusions leading to dysfunction (Table).7 Delusional disorder seems less likely because Ms. V is young and has negative symptoms. Because she is generally healthy and her medical workup is negative, psychotic disorder due to a general medical condition is ruled out. She does not appear to be over-reporting, malingering, or exaggerating symptoms. In the context of psychosis, adolescent psychopathy does not seem likely even though there is evidence of grandiosity and a lack of remorse.
Table
DSM-IV-TR criteria for schizophrenia
A. Characteristic symptoms: ≥2 of the following, each present for a significant portion of time during a 1-month period:
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| B. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, ≥1 major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset |
| C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms that meet Criterion A and may include periods of prodromal or residual symptoms |
| D. Schizoaffective and mood disorder exclusion: Schizoaffective disorder and mood disorder with psychotic features have been ruled out because either (1) no major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms; 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 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 1 month |
| Diagnostic criteria for paranoid type: A type of schizophrenia in which the following criteria are met: A. Preoccupation with ≥1 delusions or frequent auditory hallucinations B. None of the following are prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect |
| Source: Reference 7 |
The authors’ observations
Various treatments can be used for paranoia with aggression, but the severity of the paranoia should be assessed before initiating treatment. Although categorizing paranoid ideations as mild, moderate, and severe is mainly a clinical judgment, Freeman et al1 have attempted to design a paranoia hierarchy from social concerns to severe threats. CBT8 and antipsychotic medication may help reduce mild to moderate paranoid delusions, particularly those associated with schizophrenia or mood disorders. For severe paranoia, hospitalization should carefully be considered.
When a patient exhibits moderate paranoia, the probability of progressing to severe symptoms or improving to mild symptoms depends on several variables. Pharmacologic treatment, family insight, and social support may be important variables in such circumstances. Psychoeducation for the family is vital.
In patients experiencing paranoia, violence may be prevented by proper assessment and treatment. The patient’s family should be educated about paranoid ideation and the need for treatment to improve symptoms and ensure safety. The long-term effects of untreated paranoia and types of treatment modalities available should be discussed with the family and the patient. During these teaching sessions, focus on improving the overall insight of the family and the patient about the psychotic illness to improve treatment adherence.9 This step may be challenging if the family is resistant to the patient receiving mental health treatment.