The Paranoid Patient: Perils and Pitfalls

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1 The Paranoid Patient: Perils and Pitfalls Phillip J. Resnick, MD Professor of Psychiatry Case Western Reserve University Director of Forensic Psychiatry University Hospitals Case Medical Center Cleveland, Ohio Did the psychiatrist fall below the standard of care by allowing the steelworker to go home?

2 Teaching Points Psychosis and Homicide A building crescendo of paranoid fear creates a high risk of violence A clinician should not surrender professional judgment to family Posing a threat is different from making a threat The rate of homicide during first-episode psychosis is 15 times greater than the annual rate after treatment. Nielssen O, et al. Schizophr Bull. 2011;37(3): First-Episode Psychosis Overview One-third of patients commit violence before receiving treatment The longer the symptoms are untreated, the more the serious violence Delusions and violence Paranoia and violence Motives for paranoid violence Paranoid safety behaviors Evaluation of violence risk Large MM, et al. Schizophr Res. 2011;125(2-3): Violent Behavior in the Last Year Psychosis and Violence Diagnosis % No disorder 2 Major depression 12 Mania or bipolar disorder 11 Schizophrenia 13 Alcohol abuse or dependence 25 Other drug abuse or dependence 35 Swanson JW, et al. Hosp Community Psychiatry. 1990;41(7):

SMI = serious mental illness. Junginger J, et al. Schizophr Bull. 2004;30(1):21-30. Junginger J, et al. Schizophr Bull. 2004;30(1):21-30. Thomas Theorem Dangerous Delusions If people define situations as real, they are real in their consequences.

risk to love object and person seen standing in the way Capgras syndrome Persons replaced by imposters Threat by imposter violence American Psychiatric Association.

3 SMI = serious mental illness. Junginger J, et al. Schizophr Bull. 2004;30(1): Junginger J, et al. Schizophr Bull. 2004;30(1): Thomas Theorem Dangerous Delusions If people define situations as real, they are real in their consequences. Erotomania Misidentification Threat/Control-Override Persecutory Erotomania Misidentification Delusions A delusional belief that one is loved It is usually toward a person of higher status Violence risk to love object and person seen standing in the way Capgras syndrome Persons replaced by imposters Threat by imposter violence American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.

Threat and Control-Override Symptoms Non-Violent Delusions Mind feels dominated by external forces Thoughts are being put into head Feeling that people wish you harm Feeling dead or not existing

Borum R, et al. Journal Practical Psychiatry & Behavioral Health. 1996;2(4):205-215.

4 Threat and Control-Override Symptoms Non-Violent Delusions Mind feels dominated by external forces Thoughts are being put into head Feeling that people wish you harm Feeling dead or not existing Thoughts are broadcast Thoughts are removed Borum R, et al. Journal Practical Psychiatry & Behavioral Health. 1996;2(4): Borum R, et al. Journal Practical Psychiatry & Behavioral Health. 1996;2(4): Alexis Paranoid Delusions Threat Anticipation Model of Paranoia Schizophrenia 50% Psychotic depression 44% Dementia 31% Mania 28% Patient attempts to make sense of odd feelings Patient interprets ambiguous experiences negatively Anxiety concerns about the anticipation of threats Ideas become persecutory when attribute intention to perpetrators Freeman D. Clin Psychol Rev. 2007;27(4): Freeman D. Clin Psychol Rev. 2007;27(4):

5 Paranoid Persons Paranoid Delusions 20 times more likely to have a history of receiving threats Excessive sensitivity to others negative emotions Attend selectively to threat stimuli Most dangerous Well planned violence Usually preemptive strike Occasionally vengeance Harris T. In: Cooper B (Ed). Psychiatric Epidemiology: Progress and Prospects. London: Croom Helm; 1987: Bentall RP, et al. Clin Psychol Rev. 2001;21(8): Krakowski M, et al. Compr Psychiatry. 1986;27(2): Gender Response to Threats Increased Violence in Paranoid Delusions Men respond with violence Fight or flight Become aggressive Women respond without violence Tend and befriend Seek nurturing relationships Systematized delusions Anxiety and distress Anger and fear Teasdale B, et al. Law Hum Behav. 2006;30(6): Bjorkly S. Aggression and Violent Behavior. 2002;7(6): Paranoid Violence Delusions, Violence, and Anger Occurs when there is a high degree of perceived threat Mediated by anger Severe dysfunction impedes violence Delusions of persecution Delusions of conspiracy Delusions of being spied on Gardner W, et al. J Consult Clin Psychol. 1996;64(3): Taylor JL. In: Freeman D, et al (Eds). Persecutory Delusions: Assessment, Theory, and Treatment. New York, NY: Oxford University Press; Coid, JW, et al. JAMA Psychiatry. 2013;70(5):

Paranoid Violence Motives Paranoia Formulation Self-defense

you. I hate you. You hate me. Resnick PJ.

2016;15(2):24. Freud S, et al. The Schreber Case.

6 Paranoid Violence Motives Paranoia Formulation Self-defense Defense of manhood Defense of children Defense of the world I love you. I hate you. You hate me. Resnick PJ. From paranoid fear to completed homicide. Current Psychiatry. 2016;15(2):24. Freud S, et al. The Schreber Case. Penguin Books; Paranoid Violence Motives Self-defense Defense of manhood Defense of children Defense of the world

Paranoid Violence Motives Self-defense Defense of

7 Paranoid Violence Motives Self-defense Defense of manhood Defense of children Defense of the world Paranoid Violence Motives Self-defense Defense of manhood Defense of children Defense of the world Responses to Paranoid Fear Resnick PJ. From paranoid fear to completed homicide. Current Psychiatry. 2016;15(2):24.

8 Safety Behaviors Evidence of Paranoid Fear Avoidance Protection Decrease visibility Enhance vigilance Changes of residence Long trips to evade persecutors Barricading their rooms Carrying weapons for protection Asking police for protection Freeman D, et al. Behav Res Ther. 2007;45(1): Strategies for Paranoid Patients Evaluation of the Paranoid Patient for Risk of Violence Therapeutic alliance Hear full paranoid story Maintain some distance Be nonjudgmental Yang S. Dangerously Paranoid? Overview Strategies for a Psychiatric Evaluation of a Highly Prevalent Syndrome. Psychiatric Times. 2008;25(14). Assaults Against Residents Violence Risk Assessment Psychiatry 54% Surgery 38% Internal medicine 28% Emergency medicine 26% Pediatrics 7% Confront with persecutor Perceived intentionality Substance abuse Weapons available Kwok S, et al. J Grad Med Educ. 2012;4(3):

9 Stimulants and Violence Violence Prevention Plan Risk Factor Management/Treatment Status Disinhibition Grandiosity Paranoia Brecher M, et al. J Clin Psychopharmacol. 1988;8(6): Evaluation of Risk after Paranoid Violence Timing of Violence Prodromal symptoms Warning behaviors Quickness of onset The median length of time between the onset of an acute psychotic episode and violence is 30 days. Hodgins S. Arch Gen Psychiatry. 1992;49(6): Summary Paranoia can lead to severe violence Assess how the patient is responding to paranoia Threats may or may not precede paranoid violence

Alcohol abuse or dependence ) 25 Other drug abuse or dependence 35

Alcohol abuse or dependence ) 25 Other drug abuse or dependence 35 RISK ASSESSMENT FOR VIOLENCE Phillip J. Resnick, M.D. vj I. Demographics of Violence in General A. Age - violence peaks in late teens and early 20s. B. Sex - males more than females. C. Social class -