Schizophrenia With Paranoia

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Schizophrenia is a chronic psychotic disorder that affects how a person thinks, feels and behaves. Paranoia is one of the most commonly reported symptoms among people diagnosed with schizophrenia. According to some studies, almost 50% of individuals seeking help for a psychotic disorder have paranoia.

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However, not everyone who is diagnosed with schizophrenia will have paranoia as a symptom. People with schizophrenia can experience a number of symptoms and not everyone will experience the same ones.

You may have heard of "paranoid schizophrenia" but it is no longer classified as a subtype of schizophrenia. This is because the American Psychiatric Association (APA) determined that classifying schizophrenia into different subtypes was not helpful when diagnosing the disorder. 

Symptoms and Signs

The symptoms of schizophrenia usually start to develop during young adulthood, between late adolescence, around 16 years old, and early 30s. It tends to emerge slightly earlier in males than in females. Worldwide, it is estimated that around 20 million people live with schizophrenia, about 0.25%.

Schizophrenia is a progressive disorder, meaning that symptoms will get worse over time without treatment. Early diagnosis and treatment of schizophrenia increases the chance of successful recovery.

The symptoms of schizophrenia are broadly separated into either positive symptoms, negative symptoms, or cognitive symptoms. Paranoia—also referred to as paranoid delusions—belongs to the group called positive symptoms.

Positive Symptoms

These symptoms—sometimes referred to as psychotic symptoms—are characterized by altered perceptions, including changes in vision, hearing, smell, and taste.

They are not called positive because they are "good" but because they are the development of symptoms a person without schizophrenia would not experience.

 Positive symptoms include:

  • Delusions: These are firmly held beliefs that are not supported by objective fact, including paranoia but also other delusions such as the belief that the television, radio, or internet are broadcasting messages that need to be responded to.
  • Hallucinations: These are experiences of things that are not real. For example, seeing or hearing things, such as voices, that are not there. 
  • Disorganized thoughts and speech: These are ways of thinking of speaking that seem odd or illogical. 

Paranoia is characterized by the presence of persecutory beliefs, such as the belief that others are out to get them, and the perception that they are at risk. Someone with paranoid delusions may fear that others are plotting to harm or control them or that others can read their minds.

Paranoia is strongly associated with low self-esteem, high levels of depression and anxiety, and the assumption that the causes of negative events will be pervasive and persistent.

It is also associated with impaired cognitive performance, including a tendency to jump to conclusions, and difficulty understanding the mental states of others. For example, people with schizophrenia who experience paranoia have a tendency to inaccurately identify neutral facial expressions as anger.

Schizophrenia is typically diagnosed during the first severe episode when an individual displays positive symptoms, such as paranoia, delusions and hallucinations, for the first time. This is also referred to as an episode of psychosis.

Negative Symptoms

These symptoms are characterized by social withdrawal as well as a difficulty with functioning normally and showing emotions. They are referred to as negative because they refer to the absence of normal emotional responses or thought processes, not because they are "bad" symptoms. 

Negative symptoms typically include:

  • Decreased interest in, or motivation for, forming close relationships with others.
  • A reduced ability to experience pleasant emotions
  • A reduction in expression of emotion, including showing no facial expressions, such as smiles or frowns or talking in a flat voice. 

Cognitive Symptoms

Almost all patients with schizophrenia demonstrate some cognitive deficits, meaning they experience challenges in the way they think and understand the world around them. For example, someone experiencing cognitive symptoms might have difficulty processing information or trouble paying attention. 

Cognitive symptoms are not used to diagnose schizophrenia in the same way as negative and positive symptoms. However, they are core features of the disorder and are typically the earliest signs of schizophrenia, often preceding the onset of the first severe episode.  

Causes

It is not known exactly what causes schizophrenia but a number of factors have been linked to the risk of developing the disorder. These include:

  • Genetics: Schizophrenia can run in families. This does not mean that if one member of a family has schizophrenia others will too. 
  • Environment: Factors that may increase the risk of schizophrenia include living in poverty, stressful surroundings, and exposure to viruses or nutritional problems before birth. 
  • Brain structure and function: It is thought that differences in the way the brain is structured and how it works may contribute to the development of schizophrenia. 

Certain factors can trigger schizophrenia and its symptoms, such as paranoia, in those already at risk. These factors do not cause schizophrenia but may provoke a severe episode.

Psychological stress from difficult experiences is considered a trigger of schizophrenia. These experiences include abuse (physical, sexual, or emotional), bereavement, and the end of a serious relationship. For those with paranoid delusions, going into crowded areas, such as busy streets, may also trigger paranoid thoughts.

It is known that certain drugs, though they do not directly cause schizophrenia, can increase the risk of developing the disorder or similar illnesses. Drugs, such as cocaine and amphetamines, have been shown to lead to psychosis and can cause a relapse for those recovering from an earlier episode.

Diagnosis

A diagnosis of schizophrenia will be made clinically by a mental health practitioner using the "Diagnostic and Statistical Manual of Mental Disorders” (DSM–5).

According to DSM-5, a diagnosis of schizophrenia requires two, or more, of the following symptoms to be exhibited for a significant portion of time during a one-month period. At least one of the symptoms must be among the first three—delusions, hallucinations, or disorganized speech. 

The symptoms are:

  • Delusions
  • Hallucinations
  • Disorganized speech (e.g if someone frequently derails from their train of thought or is incoherent)
  • Grossly disorganized or catatonic behavior
  • Diminished emotional expression or avolition, also called negative symptoms

As well as the significant portion of time that two or more symptoms are present over a one-month period, symptoms must also have persisted for at least six months. The DSM-5 also requires there be significant problems with functioning in areas such as self-care, relationships, and/or at work.

A diagnosis of schizophrenia will only be made once it has been established symptoms are not caused by the effects of substance abuse, medication, or are due to another medical condition. 

Treatment

Effective treatments are available for schizophrenia and successful treatment will likely be a combination of different approaches over the long-term.

As the exact cause of schizophrenia is not fully understood, current treatments focus on managing symptoms and helping with day-to-day life. Treatments include:

  • Antipsychotic medications: These can help reduce the intensity and frequency of positive symptoms, including paranoid delusions.
  • Psychosocial treatments: Treatments such as cognitive behavioral therapy (CBT), behavioral skills training, and cognitive remediation interventions may help address negative and cognitive symptoms, which do not improve with antipsychotic medication.

It can sometimes take time to find the right antipsychotic medication. Your doctor will help you find the right antipsychotic medication and treatment plan for you.

Antipsychotic medication may cause side effects so talk to your doctor if you experience any side effects due to your medication. You should not stop taking antipsychotic medication without talking to your doctor first.

There is growing evidence that interventions, such as cognitive behavioral therapy (CBT), that target factors that can make paranoid delusions worse, such as a negative family atmosphere, might also be able to improve this symptom.  

Certain factors can negatively impact your recovery. These include substance use disorders, such as illicit drug or alcohol dependence. For those affected, a plan which includes treatment for substance abuse disorder is important. 

If you or someone you love are at risk of self-harm or at risk of harming others you should get help right away. Call 911 for emergency services or go to the nearest emergency room. 

Coping

Experiencing paranoid delusions and living with schizophrenia can be very challenging and you may find it difficult to reach out for support. Those experiencing paranoid delusions may believe family members or friends are trying to hurt them and so find it difficult to trust others and maintain relationships.

Remember that with a comprehensive treatment plan, symptoms, including challenging ones such as paranoia, can be managed. 

Self-care can support your treatment plan and help reduce anxiety, depression, and fatigue. This can help you have a better quality of life and be more active and independent.

Self-care includes:

  • Eating a healthy diet
  • Exercising regularly
  • Getting enough sleep
  • Effectively dealing with minor illnesses and conditions

Supporting a Loved One

It can be difficult to know how to support a loved one with schizophrenia who experiences paranoid delusions. If your loved one is experiencing this symptom it may be scary or confusing and you may find it challenging to help them, especially if they believe that others are trying to harm them or are extremely withdrawn.

It is important to understand that schizophrenia is a biological illness and that a long-term treatment plan is essential to a successful recovery. Be aware that paranoid delusions will seem very real to those experiencing them. 

You can support your loved one by encouraging them to stay in treatment, which should help them to manage their symptoms and recover sufficiently to lead a happy and healthy life. 

Educational programs and support groups can help you understand positive symptoms such as paranoia. These programs can increase your ability to cope with your loved one's illness and strengthen your capacity to help them effectively.

The National Institute of Mental Health has information on family-based services.

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