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Understanding and caring for patients experiencing paranoia

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VOL: 103, ISSUE: 01, PAGE NO: 28

Lynne Walsh, MSc, BSc, RMN, RGN, RNT, is lecturer, School of Health Science, University of Wales, Swansea

WHAT IS PARANOIA?

In paranoia an individual mistakenly interprets others’ actions and motives as being of a threatening nature. It can establish itself through a personality disorder (Lippincott, 1992) and is also associated with schizophrenia, in which the individual becomes socially detached and shows little expression or emotion.

As well as unusual ideas and peculiar behaviour, people with paranoia may also experience delusions that are out of keeping with their normal culture and activities. This is an important consideration when nursing people who come from a variety of cultural backgrounds. Just because an individual displays behaviour different from the western norm it does not mean they are suffering from paranoia.

PERSONALITY DISORDERS

Personality disorders can cause a variety of inflexible and abnormal behaviour patterns that can impair normal functioning and relationships. The person often lacks insight into their behaviour and stress can often worsen symptoms.

Patients with paranoid personality disorder are suspicious and mistrusting, manifested as hypersensitivity and believing others will harm or exploit them. Such people often appear tense, cold and unemotional and find it hard to relax. Others may perceive them as hostile, stubborn and defensive (Aromando, 1989).

Signs of personality disorder

- Hypersensitivity;

- Distrust;

- Low self-esteem;

- Secretiveness;

- Pathologic jealousy;

- Coldness or aloofness;

- Suspiciousness;

- Fearfulness;

- Guardedness;

- Tenseness.

CAUSES

Paranoid states have been classified by Levi (1998) into different types which include:

- Simple paranoid state;

- Paranoia;

- Paraphrenia;

- Induced psychosis.

Simple paranoid state

This is not associated with any schizophrenic, organic or affective disorder. Symptoms of simple paranoid state include delusions of being persecuted or influenced. These are often fixed and the patient has consistent thoughts and beliefs.

Paranoia

This often occurs in middle or later life. The personality remains intact and the individual often continues to hold down a job and maintain a fairly normal social life. The delusions are permanent and hallucinations are absent.

Paraphrenia

This is also referred to as paranoid schizophrenia. The patient may experience well-developed persecutory and grandiose delusions and hallucinations. The personality and intellect are maintained but the patient experiences prominent hallucinations (false perceptions in the absence of any external stimulus, which affect all or some of the senses). They may appear normal until the abnormal beliefs are uncovered. This type of paranoia becomes more common as individuals get older.

Induced psychosis

Also called folie a deux. The patient suffers from paranoid delusions that appear to have developed as a result of a close relationship with another person who already has an established and similar delusional system.

ALCOHOL DEPENDENCE

Even though alcohol abuse affects all age groups, it is an increasing problem among younger people. In addition to liver disease and other physical and social problems, there is likely to be an increase in mental health problems. The Welsh Assembly Government (WAG, 2005) has addressed the implications of this in the adult mental health national service framework, with protocols and a substance misuse framework to ensure patients do not fall through the net.

Chronic alcohol abuse can result in alcoholic hallucinosis. The individual may experience auditory hallucinations, such as hearing voices uttering insults or threats. This may also be accompanied by delusions that cause restlessness and anxiety.

The patient may also experience delirium tremens as part of withdrawal from alcohol. Clinical features of this include:

- Clouding of consciousness;

- Disorientation in time and place;

- Impairment of recent memory;

- Hallucinations;

- Delusions;

- Agitation;

- Restlessness;

- Fear;

- Prolonged insomnia;

- Tremulous hands;

- Autonomic overactivity.

OTHELLO SYNDROME

This is a paranoid delusion, often associated with alcohol or drug abuse, where the person believes that their partner is being unfaithful. It may be accompanied by other delusions that the partner is plotting against them or trying to poison them. The paranoid person continues to look for evidence to substantiate the belief (Levi, 1998). The patient is usually male and becomes anxious and irritable. They may become aggressive and present a danger to their partner.

DRUG ABUSE

Drug abuse is increasing and affects all social classes, cultures and ages groups (Lippincott, 1992). Several drugs can cause behaviour changes and paranoid delusions.

An excessive or chronic use of amphetamines can induce a paranoid psychosis (Levi, 1998). This condition is barely distinguishable from paranoid schizophrenia. Nurses need to be aware that for people who have a mental illness and who also abuse drugs the affects can be devastating. Both amphetamine and cocaine dependence can cause delusions and hallucinations similar to those found in paranoid schizophrenia (Lippincott, 1992).

Dependence on hallucinogens can cause:

- Heightened sensory experience;

- Hallucinations;

- Unpredictable behaviour;

- Self-destructive behaviour;

- Poor judgement;

- Delusions;

- ‘Bad trips’ that mimic schizophrenia;

- Anxiety and fear.

Nurses need to understand the impact of alcohol and drug abuse on physical and mental health and its implications for families and wider society.

NURSING ASSESSMENT

Symptoms of paranoid disorders include:

- Suspiciousness or mistrust;

- Jealousy;

- Guardedness;

- Restricted affect, including lack of emotional expression and spontaneous behaviour;

- Projection of the patient’s own feelings and beliefs onto others.

Other aspects of schizophrenic disorder:

- Emotional aloofness;

- Social withdrawal;

- Peculiar mannerisms, oddities of thought, speech and behaviour;

- Detachment, including neglect of hygiene and social standards.

Nurses should also assess such patients for personality disorders by looking for signs such as impaired social and occupational functioning and cognitive impairment.

NURSING CARE

- Form a good nurse-patient relationship;

- Ensure clear and consistent verbal and nonverbal messages;

- Ensure a regular routine is established;

- Focus on low-stress topics of conversation;

- Gradually identify the patient’s feelings;

- Support the patient to take prescribed drugs;

- Monitor for alcohol or drug misuse;

- Encourage the patient to function in work or social surroundings;

- Observe for paranoid delusions.

TREATMENT

Physical symptoms may be relieved by antipsychotic medication. The choice of drug will be determined by the patient’s age, physical condition and previous response to medication (Levi, 1998). Because the patient may be suspicious about being poisoned, they may not take their medication and compliance needs to be monitored.

Nurses should provide support and encouragement and recognise that the patient’s experience of the delusion is real to them but take care not to concur with it.

Psychotherapy may help reduce tension between the patient and their partner and encourage both to ventilate their feelings.

Behavioural therapy may help the partner to understand their own behaviour and change it to reduce jealousy in the patient. It can also help the partner to diffuse aggressive behaviour by not arguing with the patient.

CONCLUSION

Improving knowledge about mental health can help improve care and reduce the stigma of mental illness (DH, 2001). Nurses need to be aware of the factors that can cause paranoid behaviour, its symptoms and the treatment options. This will help to provide a better quality experience for the very vulnerable patient.

LEARNING OBJECTIVES

- Recognise the causes of paranoia

- Identify the different types of paranoid state

- Understand the nurse’s role in caring for a paranoid person

- Have some knowledge of treatments available to people who are experiencing paranoia

GUIDED LEARNING

- Outline your place of work and why you were interested in this article

- Describe a situation where you encountered a patient exhibiting signs of paranoia

- Explain how you dealt with this particular situation

- Reflect on how you could improve your care for such patients in the future

- This article has been double-blind peer-reviewed.

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