Gaining a detailed clinical history of a patient’s paranoia is important. A clinician should look for changes in behavior, such as the patient becoming quieter or more hostile, and impaired academic or social functioning. After gathering sufficient evidence contrary to the delusion, clinicians can help patients improve their reality testing.
Rule out medical and neurologic conditions that may be contributing to paranoia and aggression.
TREATMENT: Some improvement
Ms. V is started on risperidone, 1 mg/d, which leads to a partial response. She starts interacting more with staff and her peers on the unit, but her delusions of her sister poisioning her persist. Given the severity of the crime, Ms. V is sent to adult court, where she is found not guilty by reason of insanity and committed to a state hospital.
The authors’ observations
New-onset paranoia is a serious symptom that requires immediate evaluation and treatment. We recommend an approach presened in a flowchart (Figure) that highlights the importance of early intervention and aggressive treatment.
The MacArthur Violence Risk Assessment Study10 indicated that a “suspicious” attitude toward others can be a precipitating cause for increased violence in some cases. In light of ongoing controversy regarding the link between violence and mental illnesses such as schizophrenia,10-12 addressing an individual’s psychiatric illness early is preferable to prevent possible complications such as violent crimes. Because patients with paranoid ideations may have severely impaired ego control, they may be at risk for acting out aggressive and/or destructive urges. Therefore, new-onset paranoia should be thought of as a medical emergency similar to chest pain. Although accurately predicting and preventing violence may be impossible, in Ms. V’s case, earlier mental health treatment and intervention may have been able to prevent a murder.
Figure: Paranoia: A suggested approach to treatment
aBased on clinical judgment and extent of social support
Symptoms may become less severe or more severe (bidirectional). Strong social support has a positive effect on all levels and complements therapy. Regular counseling sessions and enhanced family insight about the patient’s paranoia helps strengthen social support
- Marneros A, Pillmann F, Wustmann T. Delusional disorders—are they simply paranoid schizophrenia? [published online ahead of print November 15, 2010]. Schizophr Bull. doi: 10.1093/schbul/sbq125.
Drug Brand Names
Amphetamine and dextroamphetamine • Adderall
Risperidone • Risperdal
Disclosures
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Personal and clinical details of this case were altered to maintain patient confidentiality.