Psychological Medicine, 1970, I, 2-12

Paranoia and paranoid: a historical perspectiveAUBREY LEWIS

From the Institute of Psychiatry, De Crespigny Park, London

SUMMARY The history of the words paranoia and paranoid is traced from the Greeks to the presentday and their fluctuations of usage and concept are explored.

The words paranoia and paranoid have becomepart of common literate speech. Some peoplethink their meaning is sufficiently clear. But, like'hysterical', 'sadistic', and a good many otherterms that have passed from psychiatry intoordinary usage, their technical meaning haswavered, and their everyday meaning becomecorrespondingly loose.

In Greek literature 'paranoia' and the verbparanoeo were used as loosely as we are accus-tomed to use 'crazy' or 'out of his mind'. Theyoccur in Euripides, Aeschylus, Aristophanes,Aristotle, and Plato. Hippocrates applies 'para-noia' to the delirium of high fever; several otherwriters put it in a context where it denotes seniledeterioration, justifying action by the patient'sson, according to Attic law. However, 'paranoia'did not always refer to madness or dementia,or other severe disturbance, but sometimesmeant 'thinking amiss', 'going astray', 'folly'. Inany case it was not a technical term, as melan-cholia was, and was not preserved in medicalwritings. Its revival in the 18th century, to meetclassificatory needs, was therefore practically a re-birth. This was effected by Boissier de Sauvages.

In his Nosologia Methodica (1763) de Sauvagesgave paranoia as the Greek equivalent ofamentia: 'Amentia, Graecis paranoia; Latinisdementia, fatuitas, vecordia; Gallis imbecillite,betise, niaiserie, demence.' Some years earlier,in his Pathologia Methodica (1759) he had terselydescribed it as 'universale mite chronicum sinefebre delirium': In the Nosologia he expandedthe characteristics of paranoia as a 'deliriumparticulare mite sine furore et audacia cummorbo diuturno. Est ineptitudo ad recte ratio-cinandum et judicandum'. Clearly he haddementia in mind.

R. A. Vogel, while treading in de Sauvages'sfootsteps (1772), enlarged the scope of the Greekterm, making it equivalent to vesania, or morbusmentis, which should include mania and melan-cholia, fatuitas, stupiditas, amentia, oblivio.

William Cullen (1783-84) who had greatrespect for Vogel, accepted without reservationhis use of the term as equivalent to vesania:'vesaniarum ordinem hie instituere velim quaecum classe Vogelii nona Paranoiae inscriptaeadem omnino sint'. Cullen cited as their mainfeatures impaired judgment and afebrile course;he excluded hallucinations and 'erroneousappetites' or morositas.

HEINROTH

In spite of the ascendancy which was enjoyedby Vogel in Germany and Cullen in Scotland,their classification of mental disorders did notcommand general assent, and paranoia did notfigure in succeeding diagnostic schemata. It wasonly after a retirement of 40 years that it waslaunched on a second career, destined to bemuch more troubled, mutable, and insecurethan its sponsor could foresee. The sponsor wasHeinroth (1818), consciously harking back toVogel and Cullen: 'Cullen beschaftigte sich, mitAusschuss dieser (Halluzinationen, Morosi-tates) unter der Rubrik der Seelenstorungenbloss mit den von ihm genannten Vesaniis dieVogel Paranoias genannt hatte.'

Heinroth's system is a significant part of thehistory of psychiatry, and cannot be brieflystated or grasped without regard to the philo-sophy that underlay it. He initiated the Germanpractice of treating paranoia and Verriicklheit as

Paranoia and paranoid: a historical perspective

completely interchangeable synonyms. SinceGerman writers have been chiefly responsiblefor the exceptional gymnastics through whichthe term paranoia passed on its way to Nirvana,the relevant German concepts command dis-proportionate attention.

Of his three great classes of mental disorder,Heinroth regarded Verriicktlwit (paranoia) asfalling within the first class, the exaltations orhypersthenias, and affecting the understandingpredominantly. He recognized, however, thatpure types are rare and that mixtures with dis-orders predominantly of the will or the affects arethe rule. These he regarded from the Linnaeanstandpoint as species, and to describe them hedevised Greek and Latin terms which he evi-dently felt he must defend: 'Die Form selbstwird jedesmal die Bezeichnung, wenn gleich neuund auffallend, rechtfertigen. Die Not trieb zureigenen Wahl, wo sich kein Vorganger fand; undder Reichtum der griechischen Sprache bei derArmut der romischen fu'hrte die Mehrzahl dergriechischen Benennungenherbei.'

His schema is the logical expression of hisreligio-biological outlook and convictions, inwhich spiritual freedom was equated withmental health. He defined paranoia as 'Un-freiheit des Geistes mit Verstandesuberspannungin Verkehrtheit der Begriffe und Urteils'.Perception is unaffected. There are four species ofparanoia: ecnoia, paraphrosyne, moria, andparanoia catholica. In ecnoia a single false idea isresponsible for gross distortion of a subject'srelation with the outside world, and correspond-ing practical activity on his part: there are threevarieties of the disorder. Jn paraphrosyne thereare delusions about the supernatural; moria is asort of megalomania; and paranoia catholica ageneral mixture of emotional, cognitive, andvolitional aberrations.

Heinroth did not regard delusions as indicat-ing disorders of mood but of the understanding;nevertheless he recognized the importance ofemotion in generating delusions: 'Der inLeidenschaft Befangene tauscht sich iiber dieGegenstande und iiber sich selbst; und dieseTauschung, und der daraus springende Irrthumheisst Wahn. Der Wahn ist kein krankhafterZustand des Gemiithes sondern des Verstandes;aber im Gemuthe, na'mlich in der Leidenschaft,liegt der Grund des Wahns." He tended to

equate passion, vice, and delusion as three stagesin a progressive disorder.

In associating paranoia with a particular formof delusional state, Heinroth was to some extentanticipating future developments. His psycho-logy, however, was so intimately interwoven withmetaphysics and his clinical syntheses that italienated many psychiatrists: thus Bucknill andHack Tuke, after quoting in their Textbook(1874) a paragraph in which Heinroth alleged thatinsanity is the loss of moral liberty, burst intounrestrained invective: 'It would seem impossibleto compress within a single paragraph a largeramount of false and mischievous psychologicalteaching. . . . It should only be retailed afterbeing duly labelled Poison!'

Heinroth's views attracted some* of his con-temporaries, such as Ideler, and prepared theway for the vigorous debates about the whollypsychogenic or wholly somatogenic nature ofmental illness. Paranoia, however, did not occupya place in the front line of the polemics or in thetextbooks which were appearing in increasingnumbers during the first half of the 19th century.

KAHLBAUM S CLASSIFICATION

The concept of paranoia entered on a new andbolder phase when Kahlbaum (1863) proposed asystem of classification which depended not ontheoretical schemata but on the methods foundmost suitable in the natural sciences and em-pirical medicine. Full observations of clinicalphenomena, pathology, causation, and courseand outcome were the basis on which he de-limited symptom complexes. Griesinger hadproposed (1845) that the term Partial Verriick-theit should be reserved for an incurable dis-order, in which there were prominent ideas ofpersecution and of grandeur and which wasalways secondary to a preceding acute orprimary mental illness; General Verriicktheit, heheld, was a severe state of confusion in which thepatient is active but demented. Kahlbaum like-wise distinguished between partial and general,placing the 'family' Paranoia among the partialvecordias which, in his system, were as a class'primary' or 'original' in that they would remainessentially unchanged during a lifetime, in con-trast to the general or complex disorders(vesanias) which passed through four stages, a

Aubrey Lewis

delusional condition of the same form asVerrucktheit sometimes preceding the finalstage (dementia). Kahlbaum, like some otherpsychiatrists of the 19th century, was notattributing a meaning to the term paranoiabecause of a passion for labelling, but in orderto denote a logical concept of mental diseasedifferent from that generally held or propoundedby outstanding contemporaries. It is difficult todo justice to the changes advocated in the mean-ing of paranoia or its synonym without embark-ing on a history of 19th-century psychiatry,which would lead far from the bare facts oflinguistic usage.

Kahlbaum had been influenced by the Frenchpsychiatrists Morel and Guislain in laying greatweight on the course and outcome of a mentaldisease, as distinct from a mere symptomcomplex. Although at first his proposals did notfind ready acceptance, the central question had tobe answered: was 'paranoia' to be exclusivelythe name of a persistent chronic condition orcould the same clinical picture be produced asone rather late stage in the vesania typica—thatis, as a secondary feature supervening on theway to dementia ?

The restriction of the term to an independentor 'primary' delusional condition thenceforwardgained ground. In 1865 a prominent exponent,Snell, suggested (following Esquirol's term-inology) that the condition should be namedPrimare Monomanie: two years later he abjuredthis, and wrote about Primare Verrucktheit. Hestressed the systematic nature of the delusionalstructure, which is sharply imprinted and firmlyheld. Another prominent contemporary, Sander(1868), substituted the adjective origindre forprimare and maintained that this OrigindreVerrucktheit (paranoia) was a hereditary diseasein which intelligence remained intact, but thepatient had delusions of persecution and self-aggrandisement, indicating abnormal judgmentabout the relation between self and outer world.

For the next half-century the words and theconcept they denoted were given so many shadesof meaning that, although the delusional corewas always there, the diagnostic applicationvaried enormously, and there was general dis-content. A firm effort to tidy the semantic con-fusion was made by Westphal in 1878. He laid itdown that paranoia {Verrucktheit) was always an

independent "primary" psychosis, which couldbegin with a hypochondria or acute hallucinosis,or show from the outset the features described bySander. The clinical picture and course variedwith the degree of involvement of formal think-ing and motor behaviour. It was primarily anaffection of the intellect, never secondary tomelancholia (as Griesinger had thought it atfirst): 'Das Wesentliche bei der Verrucktheit istder abnorme Vorgang im Vorstellen; in derSphare der Vorstellungen (mit oder ohne Sinnes-delirien) spielt sich der Vorgang ab und derallgemeine Inhalt dieser krankhaften Vorstel-lungen bleibt sich immer gleich.'

'THE PARANOIA QUESTION'

Important contributors to the discussion of(what came to be called) the 'paranoia question'were Meynert, Mendel, Wernicke, Krafft-Ebing,Schiile, Neisser, Cramer, Arndt, and Kraepelin.Krause said in 1897, with general approval,that there was hardly any problem in psychiatrythat had for the last few decades been so muchdebated and led to such extreme differences ofopinion among the leading authorities as this.The apparent frequency of the condition con-sequently varied greatly. In reports from manyhospitals paranoiacs constituted 50% of alladmissions, while at the other extreme Wey-gandt, for instance, said that he had diagnosedparanoia on only three occasions, out of 3,000patients he had seen. His reluctance was prescient.

Mendel and Werner had a considerable sharein getting 'paranoia' more widely used than thesynonym Verrucktheit. Mendel had advocatedthe exclusive use of 'paranoia' in 1880, Wernertook the same standpoint in 1891, and Verruck-theit, though it did not entirely fall out of cur-rency, was regarded generally as an old-fashioned,, ambiguous term.

The nosological position of the litigious'querulant' became a controversial matter whichwent on for 20 years: a subdivision, paranoiaquerulantium, was created for it. Other refine-ments of classification within paranoia wereproposed: the arguments bespeak much subtletyand sharpness but have a very musty odour now.It is hardly possible to speak of a consensus amidthe wrangling, but the nearest approach to onein the 1890s was provided by Snell, who in 1890

Paranoia and paranoid: a historical perspective

reformulated his definition: paranoia is a chronicdisease whose essential feature is delusions ofinfluence (Beeintriivhtigung) and persecution,based on hallucinations and usually accompaniedby delusions of grandeur. The content of thedelusions was given varying weight in thedelimitation of the disease. Neisser (1891)insisted that the delusions should be logicallyarticulated, internally consistent, and lastingunchanged till death: the delusional system is aproduct of the essential disease, of which theinvariable immediate expression is heightenedself-reference (krankhafte Eigenbeziehung). Inother respects Neisser's views were out-of-stepand excessively comprehensive: they harked backto the notions of paranoia prevalent in the '50sand '60s. Almost all writers during this periodstress that in paranoia consciousness is clear,thinking is formally correct, and it is not untilthe senium (or last stage) that dementia maysupervene.

KRAEPELIN'S VIEWS

Because of the great influence he exercised andthe clarity and honesty with which he expressedhis changing views, Kraepelin is the best guide tocentral opinion. In. 1892 he affirmed his strongadherence to Kahlbaum's criteria for delimitingmental diseases, which relied on community ofcause, course, duration, and outcome; and heurged that the term paranoia should be restrictedto a chronic, persisting, incurable delusionalsystem, on a constitutional basis. He specificallyrejected 'acute curable paranoia' as a tenableconcept.

In the 1896 edition of his textbook, Kraepelinagain insisted on the overriding importance ofcourse and outcome. He accordingly treateddementia praecox, catatonia, and dementiaparanoides as three distinct degenerative diseases(Verblodungsprozesse). Paranoia he classified asa further and distinct disease, with a differentcourse and outcome.

In the next edition of the Textbook (1899) hefused the three 'degenerative processes' into theone disease, 'dementi i praecox'; and put into it(as 'dementia paranoides') all conditions that areinitially thought to be paranoia but which dementquickly and in other ways show that they areforms of dementia praecox. The reasons for thischange had been explained in an address he

gave in Heidelberg in 1898. He could not includein paranoia conditions in which there were mood-swings, peculiarities of demeanour (Haltung),progressive fading and disorganization of thedelusions, pronounced feelings of bodily inter-ference, or hallucinations (except in very rarecases). He added, after the discussion thatfollowed his paper, that this was not just adispute about names: agreement about suchnosological matters was essential.

In a carefully reasoned paper in 1912 he con-sidered whether, in view of its shabby record,paranoia had better be dropped altogether as alegitimate category. He wished to retain it todenote insidious, endogenous development ofunshakeable delusions, while the personalityremains intact. It is, he held, a psychologicalmalformation, with its roots in a peculiarparanoid disposition: its clinical manifestationin each affected individual is a response to thestresses of life. The differential diagnosis fromdementia praecox depended mainly on whetherthe characteristic features of the latter (dis-ordered thinking, apathy, volitional anomalies,rigid personality) were evident, and it could bevery difficult to decide. He chose the term 'para-phrenia' to designate those who have a paranoiddisturbance of personality which develops laterthan in dementia praecox and is milder; they are,in brief, patients who could have been calledparanoiac if they had not had hallucinations,especially auditory hallucinations. Kraepelinwas prepared to call paranoia a psychogenicdisorder, grouped with hysteria. It is clear, fromhis many changes of posture, that Kraepelin wasnever comfortable with paranoia: if he had liveda little longer he would perhaps have surrenderedit altogether at last.

The trend towards reductive definition ofparanoia was evident in many articles thatappeared about the turn of the century. Thus in1901 Gustav Specht, after noting how paranoiahad in a few years changed from a very com-monly diagnosed condition to a rarity, declaredhimself to be in complete agreement with thestrict and narrow criteria specified by Kraepelin:'Falle in denen sich von Anfang an klar erkenn-bar ganz langsam ein dauerndes unerschutter-liches Wahnsystem bei vollkommener Erhaltungder Besonnenheit und der Ordnung des Gedan-kenganges herausbildet.' The slightest deviation

Aubrey Lewis

from this formulation, he said, would leadeventually to the inclusion of every so-calledfunctional psychosis in the paranoia group.Specht's paper was important on another count.He dissented sharply from Westphal's generallyaccepted dictum that paranoia was essentially adisorder of the understanding: he argued thatparanoia must be a primary disorder of affect.This contention roused Bleuler, among others, toenter the fray. His monograph (1906) Ajfek-tivitcit, Suggestibilitat, Paranoia began with ablunt assertion that paranoia is a splendidexample of how a psychiatrist who works withunclear concepts can be lost in a bottomless sea.He accepted Kraepelin's definition but notSpecht's psychopathology. The bulk of themonograph is devoted to expounding his ownview of the psychological development ofparanoia, but in the final clinical section he takesup the question of whether hallucinations can beprominent in the disease. He holds that theyoccur in many cases, are then often of briefduration and in a confusional setting. He regar-ded it as likely that there are intermediategroups which span the gap between paranoiaand dementia praecox. He left the question of asomatic pathology of paranoia open, but con-cluded that so long as we do not know thefundamental process underlying paranoia, wecannot know whether it is a unitary disease;delusions of grandeur and delusions of perse-cution may be essentially different diseases:alternatively a number of hallucinatory formswhich Kraepelin did not include in paranoiamay be identical with the common forms of thedisorder.

KRETSCHMER

So long as the delimitation of any mental diseasewas taken to depend on clinical pattern, courseand outcome, Kraepelin's formulation of para-noia stood firm, but when psychopathology (aspart of aetiology) was included in the criteria,some awkward readjustments had to be made.The chief exponent of this necessity was Kretsch-mer. His monograph on Sensitiver Beziehungs-wahn took account of the views of some pre-decessors, particularly Birnbaum who describedwahnhafte Einbildungen bei Degenerierten (1908);Friedmann who reported cases of'mild paranoia'(1905); and Gaupp with his 'abortive paranoia'.

These men put forward evidence in support oftheir view that a favourable outcome waspossible in some forms of paranoia, and that itwas in part a psychogenic disorder occurring inpeople of psychopathic personality (then called'degenerate'). Kretschmer juxtaposed these con-ditions with his Sensitiver Bezielmngswahn, and indetailed review sustained the thesis that there isno disease to be called 'paranoia': 'Dannhabenwirdie LosungdesParanoiaproblemsfertig, wennwir klar zugestanden haben, dass es Paranoiker,aber keine Paranoia gibt.' He recognized threetypes: Kampfparanoiker, Gewissensparanoiker,and IVunschparanoiker, with overlapping clinicalfeatures but differing aetiology. It is hardlypossible to give in brief summary the complicatedreasoning with which Kretschmer explained anddefended his position. It is noteworthy that inspite of the apparently irreconcilable viewsseparating the Kraepelinian from the Kretschmerconcepts, Johannes Lange, Kraepelin's pupiland closest associate, was content to say thatKraepelin's paranoia was extremely rare andthat it sometimes arose on the basis of a mildschizophrenic defect or schizoid character: oreven became evident in the lingering phases ofa manic-depressive psychosis. Lange dealt withparanoia broadly as an abnormal reaction, insome respects similar to hysteria. There was verylittle to choose between Lange's standpoint andKretschmei's, or indeed even Eugen Bleuler's.

Important observations and hypotheses wereput forward by Gaupp and by Kolle. Gauppover a long period (1914-1939) published hisfindings on the psychopathology of the mass-murderer Wagner, whom he studied with extra-ordinary thoroughness, and reviewed otherexamples and aspects of paranoiac personality.Kolle (1931) analysed a relatively large numberof patients with this diagnosis (including thoserecognized by Kraepelin in the Munich clinic)and came to the conclusion on many groundsthat what had been called paranoia was really arare form of schizophrenia; to add to the seman-tic confusion he renamed it paraphrenia—theterm used by Kraepelin to denote an intermediategroup lying between paranoia and dementiaparanoides—and as an alternative title broughtback Snell's term primdre Verriicktheit.

Jaspers' distinction between 'process' and'personality development' (Entwicklung einer

Paranoia and paranoid: a historical perspective

Personlichkeit) had an obvious relevance for thenosological status of paranoia, just as 'disease'and 'symptom complex" had for the previousgeneration. Most of the theoretical moves thatsometimes enlivened and sometimes desiccatedGerman psychiatry affected the prevalent conceptof paranoia, so that it is a recurring themeillustrating or complicating contentious issues.Its shadowy, fluttering existence qualified it foruse in darkening counsel.

FRENCH VIEWS

While there was this intense concern with the'paranoia question' in Germany, a parallel butindependent line of development was takingshape in France. It began with Esquirol (1838)who delimited monomania as a delire partiel, achronic affection in which there is some impair-ment of intelligence, affections, and volition,with one or very few delusional objects, noimpairment of logical reasoning, and noabnormal general behaviour. He describedseveral varieties: folie raisonnante, homicidalmonomania, an erotic form, and impulsiveforms—for example, pyromania—which com-prehended obsessional acts. Obviously mono-mania was a heterogeneous class.

In 1852 Lasegue collected all the cases inwhich delusions of persecution were paramount,and insisted on the frequency and significance ofauditory hallucinations in the syndrome. Bearingin mind Morel's views about 'degeneration' heemphasized that in these patients the disorderwas 'autre chose que l'exageration d'unetendance naturelle . . . c'est un element patho-logique nouveau introduit dans l'organismemoral'. Then Falret (1878) attributed to thedisorder a series of phases: incubation (fewsymptoms or indications); hallucinations ofhearing and systematized ideas of persecution;hallucinations of smell and stereotyped delusions;delire ambitieux (ideas of grandeur). He heldthat this last megalomanic stage (on which hiscontemporary Foville had written a mono-graph) occurred in only about a third of thepatients. Like Lasegue he described the persecu-teurspersecutes who, as Querulanten, had figuredlargely in the German literature. Falret's viewswere the subject of very lively debate in theFrench psychiatric world, and in particular the

clearly expressed and firm proposals of Magnanwere to the fore. Magnan (1893) had it in com-mon with Kraepelin that he put great noso-logical weight on course and outcome. He wasacquainted with German writings on the subject;he noted that Verriicktheit connoted delusionsand hallucinations, and that it corresponded tothe French delire chronique or monomania(though he thought the Germans at fault in notdistinguishing between the degenerations andwhat Magnan called delire chronique a evolutionsystematise. He postulated stages: incubation;persecution; grandeur; and then dementia. Asharp distinction was made between thisprogressive systematized disorder and delusionalstates which lacked coherent organization orwere transitory. He correlated his own schemewith Schiile's (1894) and with Krafft Ebing's(1888). He recognized, however, the pitfallsand difficulties that lay in assuming equivalenceof diagnostic terms and, though aware of thegrowing German preference for the term 'para-noia', he showed no disposition to adopt itinstead of his delire chronique, nor have Frenchpsychiatrists collectively taken to 'paranoia' as agood designation. Exceptions in this respect areSeglas, Genil-Perrin, and Jacques Lacan.

S6glas (1895) defined paranoia as 'un etatpsychopathique fonctionel, caracterise par unedeviation particuliere des fonctions intellectuellesles plus elevees, n'impliquant ni une decadenceprofonde ni un desordre general, s'accompag-nant presque toujours d'idees delirantes plus oumoins systematisees et permanentes, avec hal-lucinations frequentes'. He held that it isdoubtful whether secondary paranoia occurs:and, in common with almost every contributorto the elucidation of what the term 'paranoia'stands for, he utters a heartfelt comment:'cette question de delimitation, deja difficile aupoint de vue clinique, est d'une etude encoresingulierement embrouillee par l'emploi desdenominations usitees tres nombreuses et sou-vent employees dans des sens differents.' Hisown discussion of the clinical features of acuteparanoia illustrates his complaint.

Among the obstacles to any faithful conversionof the French terms for paranoia into English,pride of place must be given to delire. It is thekey word in all French discussion of the chronicsystematized delusional state, and indeed in all

Anhrey Lewis

French discussions of the principles of classifica-tion. Henri Ey faces the discrepancy, butcomplacently rejoices in the French idiosyncrasyon this point. 'Pour nous, psychiatres de languefrancaise, . . . il est facile de saisir la continuitedes divers degres des etats "delirants" car nousn'avons qu'un mot . . . pour designer l'ideedelirante, le theme delirant, le delire aigu ou ledelire alcoolique. Par contre, dans les pays delangue allemande (Wahn et Delirium) ou delangue anglaise (Delusion and Delirium) latradition (plus que la science) a introduit unesorte de separation "contre nature" qui a faussecompletement le probleme.'

To trace the fluctuations of usage and conceptin French studies of paranoia at the hands ofSerieux and Capgras, Ballet, de Clerambault,Regis, Ey, and Lacan would be a rewardingexercise, but it would lead too far from the themeof this article, the vicissitudes of the word'paranoia'—a word never heartily welcomed inFrance. Italy was more receptive, and from 1882the term was widely used following the powerfulexample of Morselli, Tanzi, and Lugaro.

BRITISH PSYCHIATRISTS

British psychiatrists were by no means of onemind about it. Hack Tuke wrote in 1892: 'Theuse of this word (paranoia) has become veryfrequent in Germany and in the United States,but it has not obtained favour in Great Britain.. . . The Greek etymology does not render us anyassistance in the endeavour to comprehend theparticular class of case to which it is applied. Itis regarded as synonymous with that very favour-ite word of the German alienists "Verriicktheit",in respect of which there has been so muchdifference of opinion and so much change sincethe time of Griesinger to the present day that alamentable amount of confusion and obscurityhas been introduced into the nomenclature ofmental alienation.' Maudsley at about the sametime (1895) wrote, rather petulantly, that thesystematic insanities 'used to be described underthe name of Monomania or Partial Mania; butas these names were thought to limit the area ofdisorder too strictly, the tendency now is toabandon them in favour of a still worse-con-ceived name—Paranoia—which means properlynothing less than general insanity. Because

monomania expressed too little, though itmarked well an essential feature of the disorder,those who are in love with a new term, withoutunderstanding it, and run gladly after a newthing because it is new, would supersede it by aname which marks not any special character ofthe disease, but really means just what it is not—general madness. To christen it mental derange-ment would appear plain nonsense: to call it soin Greek passes for scientific nomenclature.Thereupon in accordance with precedent, theinvention of the new name is supposed to be thediscovery or discrimination of a new disease.'He proposed for the condition the name 'primarysystematised mania'.

Conolly Norman did not object to the wordand treated it (1899) as an exact synonym for'systematizeddelusional insanity': 'Thepeculiaritywhich has been called the "systematization oforganization of delusions", together with fixityof the morbid idea and usually slow develop-ment, forms the characteristic note of paranoia.'His account shows familiarity with the mainGerman and French writings on the subject sincethe middle of the century.

Clouston (who had used the term withoutcomment in 1890) became ill-disposed towards it(1904), partly because different authors meantdifferent things by it, but partly because, bysome undisclosed reasoning, he had evidentlycome to regard it as obscene. Citing Ludwig ofBavaria as a typical paranoiac, Cloustonremarks on his 'sexual perversion of the mostabominable kind' and digresses to say that this'unsavoury subject, i.e. sexual perversion, hasbeen too fully dealt with by German psychia-trists' and that 'the whole subject of paranoia isallied to the "degeneracy" and the "hysteria"which Max Nordau so vividly describes asinfluencing our present-day literature and art'.In spite, however, of Clouston's and Maudsley'sobjections, paranoia made its way into Britishtextbooks until a later turn of the wheel reducedthe disease-concept to a 'subject of purelyhistorical interest'.

IN THE UNITED STATES

In the United States a less conservative spiritwas abroad. Spitzka adopted the term (1883),and from 1901 onwards Adolf Meyer educated

Paranoia and paranoid: a historical perspective

American psychiatrists by his erudite and criticalreports of relevant studies in Europe, as well asby his own contributions towards defining theconcept and reviewing the psychopathology andtreatment. He was greatly impressed—'conceptsequally suggestive and helpful'—by Freud'sexplanation of the dynamics of paranoia.

FREUD

In 1896 Freud had published a contrast betweenthe mechanisms of obsessional neurosis andparanoia, the latter based on his analysis of awoman whom he referred to as suffering fromparanoia, though he later recognized thatdementia paranoides would have been a morecorrect diagnosis. In 1911 his lengthy expositionof the Schreber case appeared. The impact ofthe Schreber analysis has been great and is notdiminished by the emendation of Freud'sdiagnosis which is now generally agreed upon.As Macalpine and Hunter have pointed out,Freud was not at pains to be consistent in theuse of diagnostic terms (although he wrote that'paranoia' should be kept distinct from 'dementiapraecox') and there can be no question thatSchreber's illness conformed much more to theclinical picture of schizophrenia than to any ofthe prevailing notions of paranoia. For thelimited purpose of this review it does not callfor detailed consideration since it did not affectdiagnostic practice or clinical delimitation.What it did affect were the more fundamentalquestions of the relation between paranoidpsychoses and the personality of those whodeveloped such an illness: Lacan's monograph isan instance, as was Bleuler's monograph onAffeclivity and Paranoia, and Kretschmer's onBeziehungswahn.

A number of compound words of Greekorigin have been used to refer to mental disorder—paraphrenitis, paraphrosyne, parergasia, para-frenesie, paraphrenia; but only the last of thesehas survived, by the skin of its teeth. Kraepelinapplied it to the uncertain group between his'dementia praecox' and his 'paranoia'; Freudproposed to substitute it for 'dementia praecox'or 'schizophrenia'; and Leonhard calls one ofthe atypical schizophrenic psychoses affektvoUeParaphrenia, equating it with Kleist's progressiveBeziehungspsychose. It might be a good thing

for psychiatry if coining names for diseases adlihilwn were made as serious an offence ascoining money without authority. Leonhard'sjustification lay in his painstaking clinical andgenetic studies and the continuity of the theo-retical position that had originated with Wern-icke and been elaborated by Kleist. Thisresulted in a self-contained parallel nosologicalsystem (which included Kleist's 'involutionalparanoia').

Although the rarity of paranoia in the strictKraepelinian form is constantly referred to andconfirmed, few if any writers go so far as todeny that it occurs at all. Moreover the interestin pragmatically justified and clinically correctclassification of diseases and syndromes haswaned—in America because of the preoccupationwith psychoanalytic dynamics, in Europe largelybecause of the concern with existential analysis.It is now common to find intricate expositionsof the psychopathology of paranoid states whicheither by their silence on the matter take it forgranted that everybody knows what is a paranoidstate, or indicate that they regard all paranoidstates as varieties of schizophrenia. There ismuch looseness in the use of the noun 'paranoia'and the related adjectives 'paranoiac', 'paranoic',and 'paranoid': obviously what is 'paranoid'should be like paranoia, but with a difference:if there is no difference it is paranoiac. 'Paranoiac'as a noun designating the patient who hasparanoia has no substantive counterpart, todenote the patient who has a paranoid disorder.The literary and vernacular use of 'paranoid' asmeaning 'resentfully distrustful' is as inexact asthe corresponding use of 'hysterical'.

CURRENT CONTINENTAL VIEWS

Current German (and Swiss) practice is to viewparanoid conditions as reactions or 'develop-ments', arising out of a psychopathic constitutionsubjected to the strains of daily life. Binder, forexample, has extended this (1960) to includecatathymic delusional formation. Others—forexample, Conrad—stress the paranoid-hal-lucinatory pattern which may develop in thesymptomatic psychoses. Weitbrecht, while re-garding paranoid psychosis as a personalityreaction, maintains the distinction betweenparanoiacs whose delusions have grown out of

10 Aubrey Lewis

overvalued ideas and paranoid schizophrenicswhose personality is intact.

French psychiatrists have been strikinglyconservative in this linguistic matter. They eitheradvocate dropping the terms 'paranoia' and'paranoid' altogether, or they adhere to thetraditional classification; chronic delusionalpsychoses are divided into those in whichprogressive deterioration occurs (paranoid schizo-phrenia) and the non-progressive forms of whichthere are three—namely, systematized (para-noia), hallucinatory, and fantastic. Within thesystematized chronic delusional psychoses theycontinue to distinguish on de Clerambault's linesdelire de revendication (which includes thequerulants, the cranky inventors, and theideological extremists), delire passionel (jealousyand erotomania), delire de relation (sensitiverBeziehungswahn) and delire d'interpretation (thefolie raisonnante of Serieux and Capgras). Alongwith this evidence of respect for classical Frenchterminology and subdivisions, there is a reluc-tance to impute causal importance to past orpresent events and an emphasis on hereditarydeterminants which derives from another tra-dition. 'Ces delirants se montrent en effetprofondement perturbes dans leur vie instinctive(caractere endogene de l'affection) par lesexperiences delirantes aigues (moments feconds)qu'ils presentent, par leurs antecedents heredi-taires assez frequents, ils imposent bien l'ideeque le delire n'est chez eux ni reductible a l'actiondes evenements passes ou actuels, ni a desphenomenes mecaniques cerebraux localises'(Ey, Bernard, and Brisset, 1960).

CONTEMPORARY BRITISH AND AMERICAN USAGE

British psychiatrists differ a good deal in theiruse of the term 'paranoid': 'paranoia' is almostentirely given up. At one end of the spectrum it ismaintained that paranoid states are not dis-orders of the same nosological rank as schizo-phrenia but are to be distributed according tothe symptoms and other characteristics of aparticular major disorder which may accom-pany them; at the other end of the spectrum it isheld that the terms 'paraphrenia' and 'paranoidschizophrenia' must be discarded, and the dis-tinction between schizophrenia, on the one hand,and the paranoid states on the other must be

sharpened. A very recent textbook treatsparanoid conditions solely as a variety ofschizophrenia, while another textbook includesthe paranoid development, as Weitbrecht,Kehrer, Kahn, and other German writers do,among the morbid reactions which may occur inpersons of psychopathic constitution (though theauthors reject any separation of the paranoidgroup of psychoses from the main body ofschizophrenia). In the main British psychiatristseschew the term paranoia, seldom use the term'paraphrenia' and apply the non-committaladjective 'paranoid' to delusions or delusionalstates in which the false beliefs include ideas ofself-reference that cannot be adequately derivedfrom the prevailing morbid mood (as delusionsof impending punishment can be derived, forinstance, from self-reproachful depression).

Contemporary usage in America seems toavoid a clear demarcation between paranoia,paraphrenia, and paranoid schizophrenia infavour of a continuum which would makeclassification and definition of these diagnosticterms a rather superfluous exercise. In the mostrecent and thoughtful American contribution tothe topic, Norman Cameron (1967) expresses theopinion that paranoid states 'are, in effect, mildforms of paranoia that are actually static. Theyoften begin as active paranoid reactions, losetheir vigour and progression, and leave the personchronically paranoid'. He also puts forward aview commonly held in the United States that'biological inheritance appears to play no part inthe development of paranoid reactions', andtherefore it cannot be declared an endogenousdisorder.

It would be informative to survey the usageof these terms in many other countries, but itwould call for a wider command of languages,and might reveal only minor variations fromwhat has been evident in the countries referredto above. It might also add to existing causes ofconfusion. There is at least one Scandinaviancentre where 'paranoid' is applied to mild formsof the disorder ('in analogy with schizoid'), and'paranoia' is used for psychotic forms of thedisorder.

There are other aspects of the paranoid statewhich are more or less implied in the subject ofthis review—/o//e a deux, for example; alcoholicparanoia; amphetamine psychosis; megalo-

Paranoia and paranoid: a historical perspective 11

mania; senile paraphrenia; and institutionalizedparanoia in other cultures, such as among theDobu of New Guinea whom Fortune studied.But their relevance to the theme of this survey isnot direct and close enough to warrant inclusion.

HOW SHOULD 'PARANOID' BE DEFINED?

How, then, is 'paranoid' to be defined so that ithas the least subjectivity and the most tenablebasis possible (assuming that we should notaccept Kretschmer's dictum that definitionsprevent us from getting a clear insight intoconditions 'die weder logisch noch symptoma-tisch sondern nur lebendig sind')?

A paranoid syndrome is one in which thereare delusions of self-reference which may beconcerned with persecution, grandeur, litiga-tion, jealousy, love, envy, hate, honour, or thesupernatural (the list is Kolle's) and which can-not be immediately derived from a prevailingmorbid mood such as mania or depression. Itmay be a symptomatic condition, a toxiccondition, or a part of a schizophrenic disorder.The adjective 'paranoid* should not be applied topersons, but may be applied to a psychopathicpersonality characterized by the same featuresas a paranoid syndrome except that 'dominantideas' must be substituted for delusions. Unlike'paranoiac' it is a descriptive term carrying noimplications about chronicity, permanence, cura-bility, presence of hallucinations, integrity ofpersonality, or aetiology. 'Paraphrenia' can becomprehended within 'paranoid'. Recognition ofa paranoid syndrome is not a diagnostic act but apreliminary to diagnosis, as would be therecognition of a stupor, or depersonalization.The syndrome will eventually be classifiable inone of the major categories of mental disorder.

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