[Microdeletion 22q11.2. A too rarely diagnosed genetic change in psychiatric illnesses]

Microdeletion 22q11.2 with an estimated incidence of 1:4000 is known to cause the DiGeorge syndrome (DGS) or the velocardiofacial syndrome (VCFS), both usually being diagnosed in the newborn period or childhood. Recent studies have shown that children suffering from VCFS frequently develop psychiatric disorders in late adolescence or adulthood. Here we report the case of a 30-year-old man presenting with slight facial dysmorphisms, hypoparathyreoidism, minor cardiac anomalies, and slight cognitive impairments who had developed a severe personality disorder which eventually led to the diagnosis of microdeletion 22q11.2 with maternal inheritance. Psychiatric patients should be thoroughly examined for typical signs associated with this chromosomal anomaly. Genetic diagnosis is necessary because of the 50% probability of inheritance with possibly severe congenital anomalies. In view of a prevalence of 2% in an unselected group of patients with schizophrenic psychosis, microdeletion 22q11.2 is likely to be underdiagnosed.

Anger and narcissism: between the void of being and the hunger for having

The borderline syndrome, a typical marginal structure, is certainly a specific, autonomous pathology, with its own distinctive characteristics: among them, acting out, cyclical repetition of events without historical progression and anaclitic depression. Kohut's concept of 'narcissistic hunger' is particularly pertinent to the borderline condition: the borderline patient hungers to have that which is missing in his being. Through the application of the related notions of 'tragic man', 'self objects', 'grandiose self', and 'damaged self', the authors further develop their theory that the borderline syndrome has much in common with paranoid personalities.

Assumptions in borderline personality disorder: specificity, stability and relationship with etiological factors

The specificity and stability of a set of assumptions hypothesized to be characteristic of Borderline Personality Disorder (BPD) was investigated. BPD patients (n = 16) were compared to cluster-C personality disorder patients (n = 12) and to normal controls (n = 15). All subjects were female and diagnosed with SCID-I and -II. Subjects rated a short version of the Personality Disorder Beliefs Questionnaire (PDBQ), with six sets of 20 assumptions each, hypothesized to be characteristic of avoidant, dependent, obsessive-compulsive, paranoid, histrionic and borderline personality disorder. The BPD assumptions (Cronbach alpha = 0.95) proved to be the most specific to BPD patients. Subjects rated the shortened PDBQ again after viewing an emotional video fragment one week later. Despite increased negative emotions, the PDBQ ratings remained relatively stable. Confirming the cognitive hypothesis, regression analyses indicated that the BPD assumptions mediate the relationship between self-reported etiological factors from childhood (sexual abuse and emotional/physical abuse) and BPD pathology assessed with the SCID-II. It is suggested that a set of assumptions is characteristic of BPD, and is relatively stable despite the instability of the behaviour of people diagnosed as having BPD.

Murder-suicide of the jealous paranoia type: a multicenter statistical pilot study

The authors present a pilot statistical study of murder-suicide comprising 32 cases from the years 1990-1992, collected from the offices of the medical examiners of seven counties in five of the United States. The study includes brief reviews of previous statistical surveys of murder, murder-suicide, and suicide. This present study's conclusions parallel the findings of previous research on the demographic characteristics of the perpetrators of murder-suicide, the relationship between killers and victims, the types of weapon used, locations of the incidents, and the time intervals between the murder and suicide. It also highlights the similarities between the characteristics of the perpetrator of murder-suicide and those of persons who commit only suicide, supporting the thesis that murder-suicide is an extended suicide. Suggestions for prevention of such a type of crime are offered.

A mind of one's own

The author argues that in the transference the patient unconsciously identifies the analyst with what he has projected into him, creating what Strachey called an external phantasy object. In the intimate rapport of the analytic session, the analyst tends to identify with these projections as well, which brings him into a relationship with the patient that complements the patient's narcissistic object relationship with him. The analyst's identification with the patient's projections is a type of pathology of his receptivity to the patient that is exacerbated by the patient's skill at producing states of mind in the analyst with which the analyst is supposed to identify. The analyst's ability to distance himself from the patient's projections and therefore to interpret them depends on his having links to his internal objects that survive the patient's projections and unconscious manipulations. Interpretations make the patient aware simultaneously that he and the analyst are separate and that the analyst has a link to internal objects that are not under the patient's control. The latter is a rudimentary oedipal situation. The author argues that these two 'awarenesses' are really the same, and that working through the depressive position and working through the oedipal situation are therefore fundamentally the same thing.

The MMPI Suspiciousness Scale on the MMPI-2

Information is provided to facilitate use of the Minnesota Multiphasic Personality Inventory (MMPI) Suspiciousness scale of Endicott, Jortner, and Abram-off with the MMPI-2.

Querulous paranoia in Chinese patients: a cultural paradox

OBJECTIVE

There has been no reported case of querulous paranoia from the Asian population. A prospective study was undertaken to identify patients with querulous paranoia in an outpatient clinic.

METHOD

One thousand, five hundred and fifty-one new referrals to a university-affiliated psychiatric outpatient clinic in Hong Kong were screened for querulous paranoia during routine clinical work.

RESULTS

Three patients with querulous paranoia (0.19%) were identified during 1 year. The case histories of these three patients are reported.

CONCLUSION

Possible reasons for the low reporting rate are discussed and the importance of sociocultural traditions in the development and recognition of querulous paranoia is emphasised.

Covert visual attention in schizophrenia spectrum personality disordered subjects: visuospatial cuing and alerting effects

A recent study observed lateralized deficit in the disengagement of covert visual attention in schizophrenic patients. Subsequent attempts to replicate this finding have had mixed results. Differences in the neuroleptic treatment or other secondary factors associated with schizophrenia are some of the possible reasons for these inconsistent findings. In this study, we examined the ability to shift covert visual attention in neuroleptic-naive, schizophrenia spectrum personality disordered (SSPD; n = 35) subjects and normal controls (n = 34) under a variety of spatial cuing and alerting conditions. We hypothesized that SSPD subjects would have difficulty with disengagement of covert visual attention from an invalidly cued left visual field when the target appeared in the right visual field in comparison to the normal subjects. As predicted, schizophrenia spectrum personality disordered subjects had significantly longer latencies for the right visual field invalid targets than normals (p = .014). Under the remaining cue conditions, spectrum subjects performed normally. Consequently, the cost of left visual field invalid cueing for the right visual field target was significantly higher in spectrum personality subjects than in normals. The cost for the invalid right visual field cue and the benefits of valid cue in both fields were very similar in the two groups. The findings of an asymmetrical deficit in the disengagement and shift of covert visual attention in schizophrenia spectrum subjects are similar to the one's observed in patients with unilateral left hemisphere lesions.

Urinary excretion of bufotenin (N,N-dimethyl-5-hydroxytryptamine) is increased in suspicious violent offenders: a confirmatory study

We previously reported that violent offenders with paranoid symptoms or whose violent actions had been directed against family members had higher urinary levels of bufotenin than other violent offenders. In the present study, patients were evaluated with the Karolinska Scales of Personality (KSP), and urinary levels of bufotenin were determined by mass spectrometry. In drug-free patients suspiciousness was positively correlated, and socialization was negatively correlated, with urinary bufotenin excretion. These two personality variables were strongly interdependent. In drug users, bufotenin excretion was correlated positively with social desirability and negatively with irritability, but not with suspiciousness. Bufotenin excretion was not found to be associated with violence toward family members in the present study. The results are in keeping with the earlier finding that violent offenders with paranoid personality traits have higher urinary levels of bufotenin than other violent offenders.

Obsessional harassment and erotomania in a criminal court population

The criminal behaviors of harassment and menacing are difficult to control, and of increasing concern to the general public and local law enforcement officials. In 1992, the New York State Legislature modified the Penal Law, responding to public fears and concerns that stalking behavior may become violent. Some persons charged with these types of offenses are suffering from psychiatric disorders. Among these disorders are those classified as Delusional Disorders. According to both DSM-III-R (1987-1993) and DSM-IV (1994), there are five specific types of Delusional Disorder: erotomanic, grandiose, jealous, persecutory and somatic. This type of disorder tends to be chronic. Forty eight cases of persons charged with harassment and menacing in the New York County Criminal and Supreme Court and referred for evaluation to the Forensic Psychiatry Clinic between January 1987 and January 1994 are reviewed. When cases of erotomania and other affectionate/amorous complaints were compared with persecutory/angry forms of harassing behavior, there was a great deal of similarity. When all harassers were compared to the Clinic population as a whole, major differences in ethnicity, age, educational level and sex were noted. Findings are presented regarding incidence, other demographic data, recidivism, violence and clinical diagnosis. The researchers conclude that erotomania does exist, however, there are other psychiatric disorders which can also be diagnosed in individuals accused of harassing and menacing behavior. From the point of view of the victim and the criminal justice system, the similarities in behavior patterns are more important than the different diagnoses.

Examining the relationship between Machiavellianism and paranoia

To investigate the relationship between Machiavellianism and paranoid tendencies we administered the Mach IV scale and Fenigstein and Vanable's Paranoia scale to 150 students enrolled in 4 sections of a course, Introduction to Psychology, at a university in the Middle South. Scores on the 2 were significantly and positively correlated (Pearson r = .50). Men had a significantly higher mean score on Machiavellianism than women. Although men obtained a higher mean on the Paranoia scale than women, the difference was not statistically significant. Implications are discussed.

Paranoid personality traits in a panic disorder population: a pilot study

To better understand the relationship between panic disorder and paranoid personality, panic disorder patients (N = 28) who were referred to an anxiety disorder clinic in a community mental health center were evaluated for paranoid personality traits on a standardized personality self-report instrument. Paranoid personality disorder was found in 54% of subjects. Paranoid subjects were found to have an earlier age of onset, longer duration of illness, and more psychopathology. Possible etiologies and implications for treatment of these findings are discussed.

A case of paranoid disorder associated with hyperthyroidism

This paper describes a patient presenting with paranoid symptoms who eventually was diagnosed as having Graves' disease. In this patient, paranoid disorder appeared to occur concurrently with hyperthyroidism in a clear state of consciousness. This case underscores the need to maintain a high index of suspicion of possible medical conditions in psychiatric patients. This is especially the case in the presence of unexplained symptoms and when there is a difficulty communicating with the patient. The importance of carrying out a careful physical examination on admission to a psychiatric unit is emphasized. Another indication for further medical investigation in a patient with psychiatric symptoms is the absence of a psychological explanation for a worsening of the psychiatric symptoms.

Delusions in schizophrenia spectrum disorders: diagnostic issues

Family studies of schizophrenia frequently include relatives of schizophrenia probands with diagnoses falling within the schizophrenia spectrum. As part of an ongoing genetic linkage study of schizophrenia, the authors examined case material from 50 relatives (of schizophrenia probands) who received a DSM-III-R diagnosis of a nonaffective psychotic disorder or schizotypal or paranoid personality disorder. Eleven exhibited episodic or chronic delusions that resulted in diagnostic dilemmas, often arising from issues pertaining to the classification of delusional phenomena. Four of these cases are presented here. Unusual beliefs were often difficult to classify as odd beliefs versus full delusions, brief/transient versus persistent delusions, bizarre versus non-bizarre delusions. It is suggested that these might be considered continuous rather than dichotomous dimensions. Several possible implications for genetic studies of schizophrenia are discussed.

Schizotypal and paranoid personality disorder in the relatives of patients with schizophrenia and affective disorders: a review

This review considers the possible familial relationship of schizotypal and paranoid personality disorders (SPD, PPD) to schizophrenia (SCZ) and affective disorders (AD). There have been few controlled studies on familial risk of SPD and PPD based on direct semi-structured interviews of relatives, blind to proband diagnosis. Three of six studies reported increased familial risk of SPD for SCZ probands, but with considerable variability in estimates of this risk. None of four studies reported a significant relationship between AD and familial SPD. There is substantial but less consistent evidence for a familial relationship between PPD and SCZ: three of six studies supported such a relationship, but one large study reported increased familial risk of PPD for AD and not for SCZ probands. There is also some evidence that negative symptoms are most characteristic of SPD in relatives of SCZ probands. Also discussed are issues concerning the adequacy of current criteria for defining schizophrenia spectrum pathology, and of diagnostic methods in this area.

[Apropos of a misdiagnosed form of paranoia: paranoia of the elderly]

The expression of elements of a paranoid symptomatology (suspicion, mistrust, hostility, etc.) is frequently seen in the elderly patients. Paranoid symptom is non-specific in geronto-psychiatric practice. The association with a cognitive disorder is frequent. The relationship between this trouble and a previous paranoid personality disorder appears, according to literature, looser than in the younger patients. The paranoid behavioral pattern often stands for the elderly as a defense against feelings of inferiority and humiliation. The expression of a paranoid symptomatology is a hamper for the subject's social autonomy, as well as an actual risk factor so far as it may involve a delay in the demands for medical care. Therapeutical attitudes, reassurant and preventing the patient from a rough awareness of his deficit, seem to be useful in the alleviation of the trouble.

A fundamental dilemma of psychoanalytic technique: reflections on the analysis of a perverse paranoid patient

The work refers to the general topic of the traumatic effects of transference in the analytic situation. The author defines the fundamental dilemma of interpretive technique as the technical difficulty, sometimes insurmountable, faced by the therapist in the treatment of severely ill patients, particularly in the case of narcissistic, self-centred disorders, where the interpretive action itself often produces negative side effects that are not countered by the curative effect of the insight achieved through interpretation. In a brief theoretical introduction, this dilemma is described as a longstanding problem in psychoanalysis that has been systematically concealed by the protracted discussion on the subject of 'analysability' and which has still not been resolved by the theory of technique. Clinical case material on a perverse patient is then presented to illustrate the dilemma described and to demonstrate some general strategies by which it may be overcome.

Assessment of potential violence in the paranoid worker

Violence in the workplace is sometimes a manifestation of an untreated psychiatric disorder. Paranoid personality disorder, paranoid schizophrenia, and delusional (paranoid) disorder are three psychiatric syndromes in which paranoid ideation is a prominent feature. While the vast majority of people with these conditions are not violent, paranoid workers can exhibit violent behavior as a reaction to beliefs that co-workers or supervisors are threatening or persecuting them. Three cases are described to illustrate the clinical presentation of these disorders and their management in an occupational setting.

Paranoia: a part of most analyses

Paranoid defenses appear during most analyses, sometimes with great intensity, but often subtly, and require specific analytic attention. Preoedipal conflicts, inner fears around passivity, narcissistic injury and rage, and subsequent masochistic and projective defenses lie at the core of these patients' pathology. In addition, specific cognitive, object-relational, and affective distortions reflecting multiple developmental levels emerge during analysis. A case vignette is provided to demonstrate the analysis of a neurotic patient without borderline features who showed prominent paranoid formation.

Covariance of personality, neurocognition, and schizophrenia spectrum traits in the community

Clinical researchers have observed in relatives of schizophrenic individuals abnormal personality traits resembling the psychopathology of schizophrenia. Further similarities have been observed in correlations between measures of brain function, including attention and executive abilities, and these personality psychopathologies. However, two methodologic factors might account for the covariation of these 'schizophrenia spectrum' personality traits and measures of brain function. Clinical selection bias (Berkson's bias) might result in subjects with overlapping conditions being more likely to be studied, and normal personality attributes could affect performance on neurobehavioral tasks. This study investigated relationships between neurobehavioral correlates of schizophrenia, clinical schizophrenia spectrum personality traits, and normal personality dimensions in the five-factor model of personality. To avoid Berkson's bias, subjects expected to have a high probability of spectrum traits were recruited from the Baltimore Epidemiologic Catchment Area Survey community sample. About 40% of the sample were found to have DSM-IIIR Schizotypal, Schizoid, or Paranoid Personality Traits or Disorders. Schizophrenia Spectrum traits showed significant associations with personality dimensions of the five factor model, particularly Openness to Experience and Neuroticism. In ordinary linear regression models, after adjustment for a number of normal personality characteristics, Schizotypal Personality Traits were still strongly associated with perseverative responses on the Wisconsin Card Sorting Test (WCST). In logistic regression models, subjects with Schizotypal, Schizoid, or Paranoid Traits differed in terms of normal personality profiles and WCST performance.

Assessment of a man with a dual diagnosis

This case assessment of a man with dual diagnosis exemplifies the use of recent psychological measures, computerized programs, and structured assessment, including the Reiss Screen for Maladaptive Behavior, the Psychopathology Inventory for Mentally Retarded Adults, the Apperceptive Personality Test, and the Residential Services Indicator. In this case, computerized scoring of two very different tests (the Reiss Screen and the Apperceptive Personality Test) yielded very similar results.

Paranoid character and the intolerance of indifference

This paper suggests that aspects of paranoid character are structured around fantasies of magical and concrete connectedness to objects; these fantasies serve to avoid the terrors of object inconstancy. The authors describe how these fantasies are expressed in the psychoanalytic situation and explore their relation to common paranoid phenomena. The paranoid person must maintain these fantasies of connectedness at all cost or risk experiencing unbearable indifference between self and object. Paradoxically, the sacrifice of self and object boundaries inherent in these fantasies makes object constancy even more difficult to achieve because of the secondary defensive use of anger mobilized to protect the boundaries of the self.