Differential diagnosis of paranoid states

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Paranoid symptoms are found in many of the common psychiatric conditions described elsewhere in this book, including schizophrenia, affective disorders (depressive illness and mania), drug and alcohol misuse, and the dementias. The following list describes some other syndromes in which paranoid symptoms are a main feature:

• Persistent delusional disorder (older terms include paranoid psychosis, paraphrenia, and paranoia): delusions are present, but, in contrast to paranoid schizophrenia, there are usually no hallucinations, the rest of the personality is preserved, and onset is in later life. The majority of patients have a paranoid premorbid personality, and interviews with informants may be essential to determine whether the symptoms are new (an illness has developed), or whether they have always been present (personality) and have come to light for other reasons.

• Acute paranoid reaction: a transient condition provoked by stress.

• Induced delusional disorder (folie a deux): a rare condition in which the same persecutory delusions are shared by two people, or sometimes several people, who live in close contact and are often genetically related. The 'principal', who initiates the delusions, suffers from schizophrenia or other mental illness. The 'associate', who reproduces the delusions often has a dependent personality and low intelligence, and usually gives up the delusions if separated from the principal.

• Morbid jealousy (pathological jealousy, Othello syndrome): patients, usually men, are deluded that their sexual partners are unfaithful. Morbid jealousy is often part of another syndrome: paranoid schizophrenia, depressive illness, organic brain syndrome, or alcoholism. Many patients have sexual dysfunction and/or poor personality adjustment. A small percentage may show homicidal behaviour, and lesser degrees of violence are even more common, so morbid jealousy is an important condition despite being rare. A formal risk assessment must be made in such cases, and an appropriate care plan put in place. Referral to forensic psychiatric services may have to be considered. Antipsychotic drugs may be effective. Separation from the partner may have to be advised depending on the risks as evaluated.

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