The term “paranoid schizophrenia” is no longer used diagnostically, but historically was used to describe schizophrenia with paranoia as a prominent symptom. Paranoia is defined as perturbing beliefs of mistrust and suspicion, despite the presence of reasonable evidence to the contrary. Regardless, there are treatment options available to help those who suffer from severe paranoia as a part of their schizophrenia diagnosis.
What Is Schizophrenia Paranoid Type?
Previous versions of the DSM distinguished between various schizophrenia subtypes, with “paranoid schizophrenia” being one of them. However, the DSM-5 no longer differentiates subtypes. Thus, the phenomena of paranoia is now subsumed under the category of delusions, usually of the persecutory type.1
Paranoid Schizophrenia Symptoms
Like many other aspects of thought and behavior, paranoia in schizophrenia exists on a spectrum. It is not uncommon for regular individuals to experience mild expressions of it, such as fears that others may be talking poorly of them.2 However, as with other aspects of behavior, paranoia can become extreme–when this happens, it crosses into the category of delusional beliefs.
Although it’s not always clear when the line has been crossed from normal concerns to psychotic delusion, a mental health professional can usually make this distinction. Although the difference can sometimes be subtle, severe paranoia often leads to extreme actions and reactions–this may include cutting off one’s family, stockpiling weapons, performing surgery on oneself to remove a chip implanted by the government, among others.
Symptoms of schizophrenia include:
Delusions
Diagnostically, delusions (along with hallucinations and disorganized thinking/speech) are typically categorized among the positive symptoms of schizophrenia. More specifically, delusions are distorted beliefs that are not supported by most typical observers.
Common delusions experienced by those with schizophrenia include:
- Delusions of persecution: Persecutory delusions are unshakeable beliefs that one is in danger of being harmed by another person, group, organization. These beliefs can range from elaborate, conspiratorial plots to more mundane suspicions.
- Delusions of grandeur: Grandiose delusions, also called delusions of grandeur, are beliefs that one is significantly more important than they really are. These inaccurate self-assessments might concern one’s abilities, but they may also relate to being wealthy and famous, despite clear evidence to the contrary.
- Delusions of control: Control delusions are beliefs that one can control outcomes, or the thoughts and behavior of others, in a way that most typical observers would reject. Some examples may include extreme forms of superstitious beliefs or extreme forms of religious thinking.
- Delusions of reference: Referential delusions, which often co-occur with paranoia, are beliefs that one is the intended recipient of certain cues, signs, and gestures from external sources, especially in media.
- Erotomanic: Erotomanic delusions are one’s inaccurate beliefs that another person, often one of great renown, is in love with them.
- Nihilistic: Nihilistic delusions are fixed beliefs that a major catastrophe will occur imminently, despite a lack of valid evidence.
- Somatic: Somatic delusions are unshakable ideas about one’s health or body, despite a lack of medical evidence.
Hallucinations
A hallucination is a false perception of something without an external cause. These faulty sensory experiences can form within any modality, including hearing (which is the most common), vision, touch, taste, and smell. Hallucinations are often vivid and real, and they can provoke unusual behaviors, like speaking to someone who is not there.
Those who experience hallucinations may or may not feel paranoid, depending on whether the hallucination evokes feelings of fear, worry, or suspicion in the individual. A hallucination that can elicit paranoia might be seeing a (fictional) person show up in various places, giving the person the sense they are being followed for some nefarious purpose.
Negative Symptoms
Negative symptoms, which refer to the absence of a typical behavior, include deficits of expression, motivation, and interest. These can manifest in several different behaviors and may overlap with symptoms of other diagnoses, like depression. Though there’s no longer an official distinction between paranoid and non-paranoid schizophrenia, research has shown that individuals with schizophrenia who have paranoia tend to have fewer negative symptoms.3
Negative symptoms of schizophrenia include:
- Flat affect: A minimal emotional response to positive or negative events.
- Anhedonia: The inability to experience pleasure (a.k.a., “hedonism”) when engaging in activities that usually bring joy, like sex or playing video games.
- Alogia: The lack of making logical sense in one’s arguments.
- Avolition: A lack of motivation to voluntarily complete one’s regular tasks.
- Diminished Activities of Daily Living (ADLs): Avoidance of bathing, oral hygiene, changing clothes, shaving, doing laundry, etc.
Disorganized Behavior
As with other features of schizophrenia, motor disturbances tend to highlight a disconnect between an individual and societal norms of appropriateness. These positive symptoms may present as repetitive actions, such as pacing or rocking, or inappropriate emotional responses, like shouting or grimacing. They can range from atypical ways of performing routine activities to a bizarre mismatch of behavior and location.
Paranoia in schizophrenia is often frightening and can lead to reactive behaviors that may seem odd to others. As such, paranoia can be the cause of one’s disorganized behavior. For example, an individual with persecutory delusions keeps looking behind them or engages in other “safety behaviors” that are out-of-place.2
Disorganized Speech
While hallucinations and delusions concern the content of thought, disorganized thinking (also known as formal thought disorder or disorganized speech) refers to a problem with how thoughts are organized or communicated. Though disorganized thinking is most easily assessed in speech, it may also be apparent in writing.4 A person with this feature may struggle to maintain a coherent, relevant train of thought while communicating with others, which can be frustrating for both the individual with schizophrenia and the listener.
How is Paranoid Schizophrenia Diagnosed?
What used to be diagnosed as the paranoid-type of schizophrenia is now diagnosed simply as schizophrenia. Paranoia is not a formal symptom of schizophrenia described in the DSM-5, even though it may often accompany certain positive symptoms like delusions. There are often signs or mild symptoms that precede the full psychotic expression of schizophrenia, and this initial period is referred to as the prodromal phase. Recognizing these early signs can improve the prognosis and secondary problems that schizophrenia can cause.
Despite the decision to not formally distinguish between diagnostic subtypes of schizophrenia, the distinction of paranoid versus non-paranoid features present in schizophrenia is still relevant from a research perspective. Further, it is accompanied by notable neuropsychological differences that might give rise to this symptom cluster. Schizophrenia with paranoia delusions is accompanied by fewer negative symptoms, better executive functioning, better memory, faster processing speed, more depressive symptoms, and better digit sequencing than schizophrenia without paranoia.3,5,6
The DSM-5 criteria for diagnosing schizophrenia include:
- The presence of at least two symptoms, with at least one being a positive symptom.
- Negative symptoms can be among the symptoms to meet criteria, as long as a positive symptom is present.
- Key symptoms must last for a period of at least one month. The condition’s effects must also last for at least six months.
- Social or occupational dysfunction must also be present during the period of dysfunction.
Diagnosing schizophrenia with paranoia as a symptom may include:
- Meeting with family members: Individuals with schizophrenia may be unaware of certain symptoms or the degree to which they interfere with daily functioning. Family members can provide additional information that may be key in diagnosis.
- Medical history review: Given the highly heritable nature of schizophrenia, reviewing medical history of relatives can be useful in determining whether certain ambiguous behaviors.
- Neuropsychological testing: Though the presence of cognitive symptoms are not formally required for diagnosing schizophrenia, the disease is often accompanied by certain cognitive deficits that can help elucidate a diagnosis and differentiate between schizophrenia and other neuropsychological disorders or personality disorders.
What Causes Paranoid Schizophrenia?
The onset of schizophrenia with paranoia, along with any other mental health condition, is influenced by a variety of different factors.
Schizophrenia with paranoia as a symptom may be caused by a combination of:
- Genetics: Schizophrenia is believed to have a genetic component, as having a first degree relative (parent or sibling) with the disorder increases one’s risk for developing the condition.7
- Brain structure: The symptoms of schizophrenia are broad and likely stem from dysfunction in various parts of the brain and the connectivity between areas. The circuitry connecting the prefrontal cortex and limbic system with midbrain areas, like the striatum, are of particular interest to researchers trying to understand this disorder.8
- Neurotransmitters: The dopamine circuit seems to play a significant role in many psychotic symptoms. Other neurotransmitters, like GABA (gamma aminobutyric acid), glutamate and serotonin (5-HT), also seem to work in concert with dopamine.
- Psychological & environmental factors: Numerous factors can impose immense stress on an individual, which can either lead to the gradual development of schizophrenia or trigger its sudden onset. Among the most common are sexual or physical abuse, trauma, social disadvantage, urbanicity, migration, and separation from loved ones.
- Substance use: Some drugs are thought to increase vulnerability to schizophrenia, especially substances affecting dopamine, as well as cannabis.9
- Autoimmune & inflammation: Individuals with certain autoimmune diseases are between two and five times more likely to develop schizophrenia, possibly through a mechanism involving cytokines.10,11
- Infection: Research suggests that prenatal exposure to certain viral or parasitic infections increases the risk of developing schizophrenia later in life.10
Some researchers have even suggested a possible link between prenatal exposure to COVID-19 and schizophrenia.12
Treatment for Schizophrenia with Paranoid Features
In general, a combination of treatment methods is the best way to manage symptoms of schizophrenia. If positive symptoms are present, medication is often a first line of treatment. Therapy, social skills training, and support groups also play an important role in long term treatment and management of the illness.
Depending on the nature of the paranoia, treatment may be challenging due to suspicion of the clinician, intervention, etc. As such, patients tend to respond better to clinicians with whom a good rapport has been established.
Medication
Pharmaceutical treatment is often the first and most effective means of alleviating schizophrenia’s most challenging symptoms–especially psychotic symptoms. However, finding the right medication can be difficult. A skilled psychiatrist can help figure out the best pharmaceutical regimen for the individual.
Medications used to treat schizophrenia include:
- Typical antipsychotics: First-generation or typical antipsychotics work by reducing dopamine levels. Typical antipsychotic medications have numerous serious side effects such as tardive dyskinesia.
- Atypical Antipsychotics: Second-generation or atypical antipsychotics work by modulating both serotonin and dopamine. Though atypical medications have a reduced propensity to cause certain side effects, they come with their own set of adverse effects, including severe weight gain and other metabolic issues.13
- Antidepressants & anti-anxiety medications: Other medications commonly used for depression and anxiety may also be used to treat specific negative symptoms of schizophrenia, or to preempt positive symptoms that may be triggered by intense anxiety. They may also be useful in helping the depression and anxiety that commonly occurs with schizophrenia.
- Injectables: Since antipsychotic medication often comes with unpleasant side effects, compliance is often a problem. Longer-acting doses injected by medical professionals eliminate the need for one to rely on regular daily adherence.10
- Cannabidiol (CBD): There has been considerable optimism recently for the use of CBD as a relatively safe and tolerable therapeutic to treat schizophrenia symptoms. In fact, a number of studies have shown CBD to be as effective as some antipsychotic drugs (e.g., amisulpride) and without as many adverse side effects.14,15
Therapy Options
Psychotherapy with individuals who have schizophrenia, either with or without paranoia, is generally less effective than for those with other mental illnesses. However, a combination of individual and family therapy is most helpful.
Individual therapy from a BT or CBT perspective often focuses on setting concrete goals, like reality testing of one’s hallucinations and delusions, verbal skills enhancement, maintenance of ADLs, and medication compliance. Family therapy often focuses on the ways an individual’s family system can better prevent the afflicted individual from undue anxiety, frustration or confusion.
While finding the right therapist can be daunting, there are resources that can help, such as an online therapist directory.
Therapy options for schizophrenia with symptoms of paranoia may include:
- Behavior therapy (BT): BT can offer patients concrete rewards for concrete behavior successes, like achieving hygiene goals.
- Cognitive behavioral therapy (CBT): CBT can help individuals learn to perform reality testing on their hallucinations and delusions, particularly paranoid delusions.
- Family therapy: Family therapy can help family members create an environment of support and positivity that reduces anxiety, anger, and confusion, thus preventing symptoms before they arise.
- Group therapy: Regardless of whether or not someone has schizophrenia, realizing that you are not alone in feeling paranoid can help one feel more comfortable. Also recognizing and identifying paranoid thoughts in others may bring perspective to one’s own thoughts of paranoia.
- Psychodynamic therapy: while not typical for schizophrenia, it can sometimes be helpful with patients who have good insight to recognize how their psychotic symptoms may be related to past traumas that haven’t been fully examined or acknowledged.
- Social skills training (SST): SST can be particularly useful, especially in conjunction with psychotherapy and medication, to help an individual develop skills that are often deficient in schizophrenia.
Medical Procedures
In severe cases of schizophrenia where medication and therapy are ineffective, neuromodulation interventions may be used such as electroconvulsive therapy (ECT) or transcranial magnetic stimulation (TMS). There are mixed research findings regarding the efficacy of these treatments for schizophrenia, and they are usually only pursued in extreme cases.
Hospitalization
Often, the need for hospitalization is the first indication that one’s increasingly aberrant behavior and confusing internal experiences have crossed the line to a psychotic disorder, like schizophrenia. In fortunate situations, a doctor, friend, or family member may point out privately that one’s logic or behavior is acutely concerning, prompting a trip to a psychiatric ER. In less fortunate situations, individuals may behave bizarrely or violently in public, leading the police or an EMS team to have a patient involuntarily hospitalized.
In either case, hospitalizations can be brief (sometimes just a few days to re-stabilize an individual on the right medication), or they can lead to long term care, where patients may live in community treatment residences for years. Though psychotherapy is provided during hospitalizations for schizophrenia, treatment is very basic and usually limited to group therapy, covering only the most superficial aspects of the disorder. Hospitalization primarily aims at stabilizing patients on the right medication(s) in a supportive environment with maximum supervision.
How to Cope With Paranoid Symptoms of Schizophrenia
Paranoia is experienced by non-clinical and clinical people alike; it is not exclusive to psychosis. Reality checking can be helpful in general, but this is often accomplished through conversation with others. Unfortunately, paranoia causes significant distress in individuals with schizophrenia, and can thus be an impediment to social interaction. While medication and therapy can be helpful with paranoia and the delusions that it may accompany, there are strategies that may help one cope with paranoid ideation.
Healthy coping skills that may help in the management of paranoid ideation in schizophrenia include:
- Journaling: Journaling can be a great way for individuals experiencing paranoia or other positive symptoms to express in words or pictures what they’re experiencing. In addition to serving as a creative outlet, if shared with a therapist, it can be helpful in guiding psychotherapy.
- Family support: Having family members join for therapy appointments can make a big difference in the treatment outcome for individuals with schizophrenia, as they may be unaware of certain symptoms. Moreover, coping strategies work best when relatives are involved, educated about the illness, and equipped with coping strategies themselves.15
- Stress management: Avoiding stressful situations is not always possible and learning techniques to manage stress is important. This might include mindfulness techniques or reframing one’s thoughts.
- Stay social: Individuals with schizophrenia tend to isolate in response to their symptoms, which can lead to a vicious cycle of loneliness and alienation. The best antidote to breaking this cycle is maintaining many healthy relationships and increasing socialization as much as possible.
- Maintain self-care: Engaging in activities that one finds enjoyable holds considerable therapeutic value. Activities that reduce stress and distract one from paranoia and other delusions are ideal, like playing sports or games, watching a movie, reading a book, cooking, going to a bookstore, or shopping.
- Maintain hygiene: Maintaining good hygiene is important in order to avoid other complicating health issues and encourage positive social interactions.
- Seek structure: Trying to establish structure into one’s daily schedule can be more helpful than one realizes. Paranoid delusions can often impede daily functioning, and the structure routine provides can be useful in protecting against derailment.
- Pay attention to nutrition, diet, and exercise: Poor nutrition can be a stress factor, rendering an individual who is already at risk for schizophrenia even more vulnerable. Regular exercise is also important for mental health and can reduce anxiety, which is associated with feelings of paranoia.
- Avoid drugs and alcohol: The same brain structures that are implicated in schizophrenia also play a role in drug use and addiction.16
- Plan ahead: Individuals with schizophrenia and paranoia would be wise to have an emergency plan in place, if they start to notice themselves withdrawing or experiencing other negative symptoms.
Final Thoughts
Though paranoid schizophrenia is no longer a formal diagnosis in DSM-5, paranoia is still a common symptom to be aware of. Paranoia can be distressing for people in general, but when combined with psychotic symptoms, negative symptoms, and reduced insight into one’s symptoms, it can be downright debilitating. Symptom relief is possible with integrated treatment. Early intervention, in particular, is key to slowing the progression of the disease and maintaining social connectedness, as isolation can lead to a vicious cycle that can exacerbate both positive and negative symptoms of schizophrenia.
For Further Reading
Paranoid Schizophrenia Infographics
