The paranoid individual

Introduction

The cornerstone on which we have grounded this book, the central axis, is the concept of " paranoid behavior ", derived from psychiatric diagnoses (paranoia, paranoid constitution, paranoid personality…) that date back to the late 19th and early 20th centuries. However, in speaking of paranoid behavior we wish to reflect a reality that, beyond the field of Psychiatry and mental illness, enters fully into the realm of the psychology of normality and social psychology.

The conceptual landscape of paranoia and the paranoid spectrum has been the subject of debate for a long time, and the proposal of Kraepelin has constituted a fundamental point of reference. The sections that follow trace the evolution of these ideas, from rigid nosologies to a broader understanding encompassing delusional systems, fixed ideas, personality patterns, and interpersonal dynamics.

In short, this introduction situates paranoia not only as a medical category, but also as a widespread pattern observable in delusions, in the stable personality traits and in transitory states frequently triggered by context.

In other words: the hypothesis introduced in this first chapter asserts that paranoia, paranoid personality, obstinations, and states of transitory paranoidization share a common substrate. To understand this proposal it is worth beginning with the history of the concept of paranoia.

Paranoia

Kraepelin

First, a terminological clarification is necessary. In accordance with the proposal by Winokur, who in 1977 suggested the substitution of the term paranoia with "delusional disorder" (54), the two major international psychiatric classifications gradually replaced the old "paranoia" with this new expression.

The DSM-5 (4) defines delusional disorder with five operational criteria, of which we highlight two:

A Presence of one (or more) delusions with a duration of one month or more.

C Apart from the impact of the delusion or its ramifications, functioning is not markedly impaired, and behavior is not manifestly bizarre.

The conception of paranoia / delusional disorder in modern classifications stems fundamentally from Kraepelin. It is the unavoidable starting point:

Paranoia. Kraepelin

"Insidious development, determined by internal causes and following a continuous evolution, of a lasting, unshakeable delusional system, alongside the absolute preservation of clarity and order in thought, will, and action" (30).

In thisdefinition, the two decisive elements already appear: the delusional system and the relative preservation of the rest of the personality.

Thus, in the sixth edition of his treatise (1899), Kraepelin presented for the first time a definition of paranoia (in essence, "the illness of delusion"), a clear nosological delimitation (above all from schizophrenia), and a meticulous clinical description that, despite the passage of time, retains its full validity. More than a century later, modern classifications of mental disorders have not introduced any substantial change.

The Kraepelinian conception of paranoia distinguishes two poles in the patient:

On the one hand, the delusional idea, of a morbid character, which arises inexplicably and, necessarily, as the consequence of some type of cerebral disease.

On the other, the "intact remainder of the personality."

It must be insisted upon: this bipolar structure constitutes the very core of the Kraepelinian concept of paranoia.

Now, between these two poles lies an intermediate zone, that of "behaviors derived from delusion". These are behaviors that, taking into account the presence of the delusion, are reasonable or understandable, but only on the basis of the delusional conviction. Thus, for example, patients with persecutory delusions make sudden changes of residence, inexplicably attack those they believe to be their enemies, or tend to hide and go unnoticed, and jealous patients follow, spy on and interrogate their wives and put their sexual desire to the test.

Obviously the new clinical entity was not discovered by the German psychiatrist out of nowhere, based on mere observation, compilation and analysis of the symptoms and words of his patients, but rather his concept of paranoia culminated a progressive process that unfolded mainly in Germany and France during the nineteenth century. It is not our objective to present the succession of ideas that would end up crystallizing in the sixth edition of his Treatise, and we will simply limit ourselves to recalling a few milestones.

The word paranoia was coined in ancient Greece by joining the roots para (to the side, parallel) and noia (spirit, thought) and was used to refer to mental illnesses in general, and especially to those that ran their course with greater deterioration and loss of reason. Little in common, then, with its modern meaning. As is repeatedly claimed, the term was already used by Hippocrates and by Plato.

Antecedents in Germany

It was precisely in Germany where the term paranoia, after several centuries of disuse, was rescued by Vogel (1764), who maintained the original meaning of "madness".

Heinroth (1818), in his Textbook on the Disorders of Mental Life (32), defined paranoia as a disturbance of the intellect without affectation of feelings or volition, while he termed paranoia ecstasia the disturbances of feeling.

The term fell into disuse again until it was rescued by Kahlbaum in 1863. It is often claimed that this author already gave it the meaning of progressive systematized delusion. As Berrios sets out (8), Kahlbaum divided mental illnesses into three broad groups; one of them, the vecordias, included the group of illnesses with onset after puberty, unknown etiology, and more or less specific symptoms. In turn, the vecordias were divided among disorders of thought (paranoia), of volition (diatrophia), and of the emotions (dysthymia).

In the following decades, clinical descriptions and alternative denominations proliferated in Germany (Verrückheit, secondary paranoia, acute paranoia, primitive paranoia, paranoia querulans, paranoia inventoria, paranoia combinatoria, paranoia simplex chronica), each of them with its own nuances (46).

It was certainly affirmed that, in some cases, delusional ideas were not accompanied by any hallucinatory activity, but no one before Kraepelin had proposed considering the patients with chronic delusions without hallucinations as affected by a differentiated morbid entity. None of these developments crystallized into a clinically delimited entity with such precision as Kraepelinian paranoia.

Antecedents in France

In France, the term paranoia was imported and adopted belatedly, already associated with the meaning that Kraepelin had definitively assigned to it. However, throughout the nineteenth century, French Psychiatry had also traveled its own tortuous path, riddled with successive denominations and classifications, which, slowly and through other terms, had brought it closer to the Kraepelinian conception of the disease.

The "arrangeurs" François Leuret (1834)

Our first milestone on the road to paranoia is constituted by the arrangeurs (solvers, those who resolve, straighteners of wrongs, as opposed to the incohérents) of François Leuret (1834), to whom he refers as a particular type of madmen. The following quotations allow us to verify to what extent this group of patients constituted an early anticipation of future paranoia.

"It has not been possible for me, whatever I did, to distinguish a mad idea from a reasonable idea solely by its nature. I searched in Charenton, in Bicêtre, in the Salpêtrière, for the idea that seemed maddest to me; then, comparing it with a good number of those that circulate in the world, I was surprised and almost ashamed to find no difference whatsoever […] Being a physician, I took as objects of comparison the humoral theories, the strictum and laxum of Themison, the reactions of Paracelsus, the archeus of van Helmont, asthenia, contro-stimulism, nervous fluid, irritation…; I saw that all these theories, based on a small number of facts, often poorly observed, and from which general conclusions were drawn, had no more reason to exist than the ideas with which I had confronted them" (34).

"I have the utmost respect for scholars […] but I shall be permitted to say it, since it is true; sometimes they have mad ideas, as mad as those of the insane" (34).

"(…) Thus deprived, on account of the numerous usurpations committed by reasonable persons, of a character [falseness] which, at first, I believed belonged exclusively to madness, I was compelled to look elsewhere for the element I needed. To the falseness of ideas I had to add their fixedness and their abnormal cohesion. A man takes stones for precious metals: false idea; nothing can turn him away from this belief: fixed idea; every time he sees a stone, the idea he holds about it returns necessarily: abnormal cohesion" (34).

Arrangeurs. Leuret

"Often the arrangeur is skillful and possesses a particular talent for giving an appearance of reality to his conceptions. Everything serves him as long as it demonstrates what he has in mind; no evidence to the contrary dissuades him or discomforts him" (34).

Arrangeurs. Leuret

"The arrangeur has no hallucinations, visions, inspirations, or perverse inclinations; he has an idea, one of those ideas that come to all of us, but to which we give no more importance than they deserve and which we know how to dismiss when they do not seem reasonable to us or become inopportune. The arrangeur cannot rid himself of his idea, he is its slave, he has nothing but it, he identifies with it" (34).

Arrangeurs. Leuret

"The arrangeur is considerably more skillful; to begin with, he does not necessarily have what is called a mad idea; his idea, if not true, is at least deceptive, and he supports it with reasoning. He does not demand to be believed from the outset, he offers explanations readily and in a very sound manner […] it is not uncommon for the patient to gain the upper hand over the doctor in the discussion" (34).

The concrete examples he provides correspond essentially to persecutory delusions.

Arrangeurs. Leuret

"He claimed to be persecuted, and he linked everything to that supposed persecution which, devoid of any real foundation, nonetheless had something deceptive about it when he spoke of it" (34).

The arrangeurs were unjustly forgotten and nothing more was ever heard of them.

Intellectual monomania (1838)

With Esquirol we encounter a formulation surprisingly close to the bipolar structure of Kraepelin's paranoia.

Faithful to the theory of mental alienation as a single illness, Esquirol defended the existence of five forms of the same. These variants were not mutually exclusive and could succeed one another and even overlap in a single individual. The one that most directly concerns us is monomania, "in which the delirium is limited to a single object or to a small number of objects with excitement and predominance of a joyful and expansive passion" (19). It is worth noting that the délire of Esquirol (as befits French psychiatry of the era) is far more diffuse than its current counterpart and includes almost any psychopathological phenomenon. In turn, according to the author, there would be three types of monomania, namely:

The instinctive (monomanias of drunkenness, arson, and homicide).

The affective (erotic monomania)

The intellectual (reasoning monomania). This last is defined as that in which

"(…) the intellectual disturbance is concentrated on a single object or series of objects; the patients set out from a false principle which they follow without deviating from logical principles, and from which they draw legitimate consequences that modify their affections and their acts of will; outside of this partial delirium, they feel, reason, and act like everyone else" (19).

The parallels with Kraepelin's definition of paranoia are obvious, and Esquirol's definition seems to lead us directly to it. However, the specific cases that the author presented correspond to a considerably wider range of diagnoses, with current criteria.

The delusion of persecution

We owe to Lasègue (1852) the delusion of persecution (33), which the author split off from the excessively broad and diffuse field of classical mental alienation.

The delusion of persecution is characterizedby two phases. In the first, the patient feels overcome upon perceiving hidden meanings in what is happening around them. In the second, they find an explanation: everything happens because of a persecutor or enemy. The condition could run its course with or without hallucinations.

In the decades that followed, this diagnosis was the most common among inmates of psychiatric asylums. The majority were probably schizophrenics. That said, Lasègue's description also contains elements that refer us to delusional disorders, especially persecutory delusions.

Lucid and reasoning madmen

In 1861, Trélat (49) published his work La Folie lucide, étudiée et considerée au point de vue de la famille et de la societé. His lucid madmen did not constitute any specific diagnostic group or chapter, but would simply be alienated individuals, belonging to any of the categories thereof, who share some common elements: 1) they are not admitted to asylums, and 2) their madness becomes evident more in their behavior than in their words, which seem absolutely reasonable. Often, those acts in which madness manifests itself are known only to the family.

The fous lucides could belong to any of the following pathological types: imbeciles and the mentally feeble, satyrs and nymphomaniacs, monomaniacs, inventor monomaniacs, erotomaniacs, the jealous, dipsomaniacs, spendthrifts and adventurers, the proud, the wicked, kleptomaniacs, the suicidal, the inert, and lucid maniacs. Some of these types clearly anticipate future variants of paranoia.

In 1857, Morel (39) set forth his theory of degeneration, which for several decades would enjoy extremely wide acceptance in Francophone psychiatry. Magnan offers us a simple summary of it:

"You are already acquainted, gentlemen, with Morel's doctrine. For him the general fact is the transmission of mental afflictions through the progressive worsening of the illness in descendants. Thus, ancestors who made themselves known for their nervous temperament give rise to hysterics, epileptics, and hypochondriacs (subjects affected by the great neuroses). These — the hysterics, the epileptics, and the hypochondriacs — will beget the alienated, and these latter will have as descendants imbeciles and idiots, who will, in the end, be sterile" (35).

Throughout the following decade, passionate debates took place at the Societé médico-psychologique on folie raisonnante (the old reasoning monomania of Esquirol), debates in which heated and opposing opinions were often expressed.

Some, following Morel, moved the folie raisonannte (the lucid madmen) from the field of monomania, or that of the delusion of persecution, to that of degeneration, in which they would constitute the penultimate rung.

"It is under the varied names of moral insanity, reasoning madness, madness of acts, litigious mania (querulant madness of the Germans), etc. that one must look in the various authors for the observations linked to this morbid form. Engaging in this scholarly inquiry […] one comes to be convinced that patients of this kind, rather than being assigned to classical delusion of persecution, as it is observed in asylums, in reality belong to another morbid species, namely, to the still poorly defined great family of the hereditary, of the reasoning alienated, or of the lucid madmen" (43).

Others maintained that it was a mistake to individualize the folie raisonnante as a diagnostic entity in its own right, outside the field of classical alienation or the delusion of persecution.

Jules Falret (21), for his part, considered that the folie raisonnante was nothing more than a completely artificial aggregation of up to nine varieties of patients who had little to do with one another. He thus distanced himself from the two preceding positions.

"I have tried to demonstrate that the folie raisonnante does not exist, as a distinct form or variety of mental illness, and that it is nothing more than an arbitrary and artificial grouping of disparate facts.

[…] I myself have committed an analogous confusion, by describing, in my last address, as forming part of the folie raisonnante, five varieties of mental illnesses that legitimately should not belong to it, leaving in the shadows those that represent the most common type (…) I have identified four other categories that would also need to be studied in order to complete the set of facts of diverse orders that are today arbitrarily gathered under the vague and overly broad name of folie raisonnante" (20).

The theoretical disquisitions surrounding the folie raisonnante were vibrant, and an endless succession of proposals ensued. In the memoir presented by Dr. Campagne for the André prize, the alienist set forth a curious theory on the genesis of the illness, summarized by Falret at the session of the Societé in February 1867.

"It is an illness of defect, rather than of excess and perversion of human faculties; it is an anomaly, a mental deformity, a monstrosity, rather than a disturbance or an illness in the proper sense. It is a flaw in the primordial organization, which exists from childhood […] a partial idiocy, that is, a native absence of certain faculties, a gap in the psychic organization. The reasoning madmen are incomplete beings, ill-born, defective, rather than properly ill in the true sense of the word" (21).

The opposition –with multiple nuances– between the delusion of persecution of Lasègue and the reasoning madnesses already prefigured the clear Kraepelinian separation between dementia praecox and paranoia, the latter characterized by the absence of hallucinations and the great weight acquired by logical argumentation, capable of disconcerting the professionals themselves.

Descriptive contributions

The jumble of diagnoses, taxonomies, clinical presentations, terminologies and etiological theories that traversed French Psychiatry in the second half of the nineteenth century was not sterile. Beyond the denominations and classifications chosen by each author, concrete clinical observations abound that clearly contributed each of the bricks with which the definitive paranoia (as well as the paranoid personality) would be constructed.

For example, we can easily verify that some of the fous lucides of Trélat (such as the jealous or the monomaniac inventors) anticipated what would end up becoming typical contents of delusional disorder. If, furthermore, we confine ourselves to the description of the general characteristics of the fous lucides as a whole, we find assertions that, with the passage of time, would end up being attributed specifically to paranoid pathology.

"Among them there are those who possess an uncommon strength in discussion, who have the gift of repartee and who constantly seek the occasion to make their wit shine" (49).

"It is their background that leads us to know that they are mad, rather than their conversation, in which they do not put a foot wrong" (49).

The following clinical description corresponds to the first of the nine "categories" to which Falret referred; it contains abundant observations that, years later, would be incorporated into the clinical descriptions of delusional disorder of the persecutory type.

"I will first mention certain delusions of persecution, barely systematized, or in a state of evolution, which patients manage to conceal, whose development is entirely internal and which manifest themselves outwardly only through the eccentricity of their acts, the alterations of their feelings and the disturbances of their behavior. These alienated individuals, who in reality belong to partial delusion with a predominance of ideas of persecution, make themselves the center of everything around them; they withdraw into their pride and believe themselves to be the object of general animosity and attention. They see the most insignificant events occurring around them as directed against themselves, and believe themselves to be victims of ill will, hatred, or persecution on the part of those with whom they live. But this system of persecution, which has not yet taken on a definite form in their minds, persists for years at a degree of vague apprehension, and remains entirely enclosed within their inner self. This exceedingly slow work of systematization takes place in a latent state and does not crystallize into sharply defined series of ideas. The patient does not make it known to anyone, concentrates everything within himself, and rarely allows any outline of it to escape outwardly. Nevertheless, their feelings, their tendencies, and their behavior in general are evidently affected by this persistent inner workings of their diseased mind; they flee from the world, which strikes and wounds them in a thousand ways; they abandon their parents and their closest friends; affectionate feelings are extinguished and transformed into feelings of hatred and repulsion; they take refuge in solitude, they lock everything within themselves and only momentarily emerge from this habitual isolation and withdrawal in order to give themselves over to certain disorderly, bizarre, violent, or harmful acts, which are at once proof and measure of the alteration that exists in their intellect and their feelings. Now then, these patients, whom one encounters more often in civil practice than in asylums for the alienated, and whose mental state is often difficult to diagnose, are often mistaken for alienated individuals with folie raisonnante, given that their illness manifests itself less through intellectual alteration — which they manage to conceal even from the most seasoned observers — than through the alterations of their feelings and tendencies and through the strangeness of their acts" (20).

Paranoias

In addition to the definitive delimitation of the illness with respect to other pathologies, there is another facet of Kraepelin's work worth highlighting. We refer to the description he provided, detailed and with abundant examples, of the main subjects of delusions, those themes that tend to recur in patients. Because the truth is that delusional patients do not simply come up with any false idea resistant to logical argumentation, but rather confine themselves to a relatively limited repertoire of contents.

Let us specify the themes most characteristic (some of which were included after Kraepelin):

The infinite variants of persecution and harm, in which the patient feels and believes themselves to be followed, spied upon, the object of antipathies and comments, and the victim of all kinds of traps, deceits and malicious acts. Those who harm them or would wish to harm them (if they could) are specific individuals, groups of people conspiring with one another, organizations or, in the worst of cases, almost everyone.

Jealousy. The patient is convinced that their partner is being unfaithful to them (or wishes to be so, or desires it even without attempting it). They also see dangerous rivals everywhere, ready to seduce those they should not.

Hypochondriac delusions. The patient believes themselves to be the victim of some illness (always serious).

In dysmorphic delusion the patient finds themselves distressed by the belief that they suffer from a significant deformity that is clearly visible to others, most often on the face (asymmetry, a prominent nose, enormous ears, etc.). It is of no use to repeatedly tell them that their appearance is normal, since they notice it in the gazes of others. Also included in this chapter are pathological ideas relating to the quantity or quality of hair, skin abnormalities, or the mistaken perception of insufficient muscular mass development (scrawniness). From a theoretical standpoint, anorexia could likewise be included in this section.

Delusional infestation with dermatozoans. It affects primarily middle-aged women of lower social class who claim to have parasites moving beneath their skin. They sense them, feel them through touch and even see them, extract them and hoard them.

Patients with olfactory reference syndrome perceive an exaggerated foul odor from their own body and are convinced that whoever approaches them will also notice it.

In erotomanic delusion, patients, almost always women, find obvious signs that a particular figure, whom they usually do not know personally but whom they love, loves them. Almost without exception, the supposed lover possesses a superior estatus in society. In their delusion, therefore, the patient is not only passionately loved but also rises in her position in society through her romantic relationship and future marriage. Erotomania does not belong exclusively to women; in clinical practice I have attended various cases of erotomanic delusion in men. The difference from those of women was twofold: 1) those who fell in love with them had been many, one after another, and 2) the question of estatus was of no concern to them. By another path, we witness one and the same megalomania: what makes the patient an extraordinary being is, in the male erotomaniac, his great capacity for seduction.

In grandiose delusions, the patient is convinced of possessing some talent or knowledge that makes him a unique, special being. A good example is healers. Some believe themselves endowed with special, highly exclusive powers that enable them to achieve cures. Others possess knowledge that serves them to restore health to the sick; they have at their disposal for that purpose simple methods, of universal validity and not grounded in experimentation but in irrefutable arguments. Others are mere intermediaries between the patient and the world of spiritual beings from whom the healing of diseases originates. Among grandiose delusions are likewise included inventors (whose protagonists exhibit surprising scientific theories and contraptions, often destined to resolve great problems of Humanity), those who are convinced of having a special relationship with God (they may see themselves as his spokespeople on Earth), and those who believe that their biological parents are in reality others, always of superior rank (delusions of filiation).

Certainly, delusions of grandiosity are uncommon in psychiatric practice, far less so, in any case, than those associated with harm and persecution. But this disproportion perhaps does not reflect a lower prevalence of these delusions in the general population, but rather a lesser inclination to come into conflict with one's surroundings. For example, a hypochondriac patient seeks contact with doctors on their own initiative, insistently, and will easily end up being referred to a Psychiatry clinic. The patient, despite lacking insight into their illness, may accept the referral because they feel depressed or insomniac. A healer endowed with powers, on the other hand, will rather avoid it. It is even possible that they find themselves integrated into an environment of individuals with beliefs similar to their own, or that they receive those who seek their help and even pay for it. The fact that often megalomanic delusions run their course with a certain exaltation of mood, with a certain subjective sense of well-being, also contributes to keepingthem away from clinics.

A good part of the topics we have mentioned were previously scattered throughout the literature, with no connection to one another. However, despite their integration into a single illness, each thematic variant has maintained its own identity, now in the capacity of a subtype of paranoia. The different subtypes differ from one another not only in the content of the delusions but, quite logically, in the behaviors that derive from them.

The subtypes of paranoia should not be regarded as entirely independent from one another. They may succeed one another, coexist, and even combine; such is the case, for example, of the patient convinced of suffering from a serious illness (hypochondriac delusion) resulting from poisoning through coffee (delusion of harm).

Acute delusional episodes

Once paranoia had been identified and isolated, it soon became evident that there were also patients in whom the delusion was of limited duration and subsided without leaving any sequelae. It was possible to verify that some patients repeatedly suffered episodes of this type throughout their lives, while in other cases it was a single episode. The delusions, according to numerous observations, would often respond to situations of tension, and especially to certain particular ones, such as (prison) isolation or emigration.

Benign paranoia

"From 1905 onwards, Friedmann drew attention to a certain number of cases with which he created a subgroup of Kraepelin's paranoia. In these cases, the delusion appears clearly as a reaction to a specific experienced event and the evolution is relatively favorable. He designates them with the name of benign paranoia…" (32).

Subsequently, different designations were used, such as "paranoid reaction," to refer to these brief delusional episodes. Since the publication of the DSM-III, they are usually included in the broad chapter on acute psychoses, alongside conditions in which delusional ideas occur together with other psychotic symptoms (hallucinations, behavioral disorganization…).

The Obstinate

With this designation we wish to delineate a heterogeneous group of people with manifestly pathological behaviors who, nevertheless, lack a proper place in modern psychiatric nosologies. In many cases these are marginal, eccentric, maladjusted individuals, who only occasionally come into contact with psychiatry professionals and, when they do, it is in a fleeting manner. Other obstinate individuals, the minority, manage to obtain a certain recognition and even social leadership.

Common characteristics

What are the elements that allow us to bring together this disparate group of individuals under a single heading?

Without any doubt the main characteristic is the presence of a fixed, persistent idea, which can be catalogued neither as obsessive nor as delusional. The fixed idea lacks the egodystonic, stereotyped, and manifestly absurd character of the obsessive idea. On the other hand, although the fixed idea is as irreducible as a delusion and equally resistant to any attempt at persuasion, it cannot be assigned the character of falseness proper to the delusional idea.

The fixed idea is primordial, central, and the obstinate person's life seems to revolve, gradually more and more, around it. Little by little they develop an argumentative repertoire of increasing depth to support it. Other interests fade away. They have no time for other matters.

The obstinate person asserts their fixed idea with tenacity and, unlike the obsessive, demands the recognition of others, their acquiescence. To this end they apply enormous, tireless energy, and a great combativeness which, in many cases, manifests in violent behavior and harassment of specific individuals (or institutions).

Their monoideism works to the detriment of the remaining facets of their life. The obstinate person, if they do not entirely forget their work, their family, or their social life, nonetheless devotes less interest, attention, and energy to them. The foreseeable consequence is the gradual deterioration of their material and social situation.

Another common element among our obstinate individuals is the exaltation of mood. This is an exaltation that we must distinguish from the manic kind, in which the euphoric, playful component and the dispersal of ideas and activities predominate. In the obstinate person, on the contrary, the racing thoughts and hyperactivity point obstinately toward a single end.

Types of obstinate individuals

Obstinate seekers of justice. Querulants

Litigious. adj. Said of a person: Quarrelsome, and who with little cause stirs up and occasions disputes and lawsuits. Also used as n. (44).

Complainant. adj. Law. One who files a complaint. Also used as n. (44).

The barbarism "querulants" is the term used in Psychiatry to refer to a particular type of repeat complainants.

"There is a small number of people who insist on litigating, over real or imaginary injustices, regardless of the cost and consequences. Members of this group are rarely seen in a formal psychiatric evaluation. The complaints usually stem from a legal offense or injustice, which acquires a special meaning for the individual and triggers the litigious behavior. These individuals use the courts to correct an injustice, but are never able to accept a ruling that goes against them. There is a constant process of appeals against adverse judgments, which usually lasts many years" (44).

Once they have filed their first complaint, querulant patients behave like the rest of the obstinate.

Querulant disorder. Cullerre (1888)

"(…) the passion becomes exalted and immediately reaches its paroxysm; the querulant sacrifices everything — wellbeing, patrimony, and family — to the need to restore their rights […] they will never accept that they have lost a case because it was unfounded; they consider themselves a martyr or a victim of deceit; the judges are corrupt and scoundrels…" (13).

The querulant hyperactivity of these patients has a twofold root: the predisposition to react with complaints before the judiciary over minor offenses, over relatively everyday matters, and, second, the systematic filing of appeals when — as tends to happen — the rulings are not in their favor.

"Querulant mania" had been extensively discussed by Kraepelin as yet another form of paranoia (except in the final edition of his treatise, in which he relocated it to the psychogenic psychoses), but its classification within this illness has always encountered a significant difficulty, namely: that a good number of litigious patients cannot be categorized as delusional patients simply because they are not delusional. The grievance over which they litigate is not always imagined, and it is not uncommon for them to have good reason on their side.

But dividing querulous patients into two pathologies (as several authors propose), based on the presence or absence of delusional ideation, is somewhat artificial, since clinically both respond to the same pattern, and the behavioral disorders and conflicts arising from litigious activity are the same and equally serious, whether or not delusions are present.

Obstinate resentful individuals. Harassers ("persécuteurs")

These are patients who have been victims of a harm or an affront by someone. The accusation may be truthful or mistaken, but in any case it is not without foundation and cannot be considered a delusional attribution of guilt.

Among the harms suffered, the following stand out:

financial ruin or impoverishment,

the loss of status social or occupational,

illness,

loneliness, loss of reputation, and the loss of attention from those who are abandoned by their partners.

Unable to forget (neither the offender nor the offense), they cling to a memory that cannot be erased and around which everything revolves. They typically tend to become obsessed with a specific person.

"[…] hatred toward a man whom they consider to be the immediate cause of their personal misfortunes, of their incessant miseries, of the loss of their position, their credit, or their health" (15).

"[…] they start from an affective judgment that presents to them a powerful man as the cause of their misfortunes, a doctor as the origin of their incurability…" (15).

The resentful harassers seek revenge for the harms suffered, or compensation or reparation for them.

Persecuted-persecutors. Pottier (1886)

"He [the victim] encounters him at every turn, and is ceaselessly disturbed and threatened by him. He receives letter after letter, each more injurious and threatening than the last, and this tiresome ongoing correspondence, always repeating the same facts and accusations. The letters are followed by visits; in vain does he shut the door, in vain does he protect himself in a thousand ways — the persecutor finds a means of reaching the one whom his delusion has designated. He waits for him for long hours, he stalks him, he seeks him out wherever he goes, he follows him, clings to his footsteps and appears before him when least expected. He seizes him in passing, in public places, to insult him, threaten him and verbally repeat all the grievances and accusations he had already conveyed in his letters and writings. Finally, having exhausted all these means of moral pressure, the persecutor often resorts to violence, hurling himself at his enemy to strike him, or watching him intently, revolver in hand, to cross his path."43).

Harassment manifests in various ways: prolonged stalking, exhortations, threats, acts of aggression, and so forth. We somewhat artificially exclude those who opt above all for the legal route. They often employ every means at their disposal, from simple placards to the media, to make their recriminations and claims known. Today, the telephone, email and social media open up new spaces for the deployment of harassing behaviors.

On the other hand, classical literature distinguishes several specific types of harassers:

hypochondriac harassers

scorned husbands

aggrieved heirs ("revendicateurs").

While not belonging to the group of persécuteurs, I do not wish to omit mention of another group of equally resentful patients who, however, do not strike back but instead confine themselves to brooding and dwelling on fantasies of revenge, or of well-deserved misfortunes befalling those they hate, without themselves becoming the agents of such misfortunes. They detest their offender, yet undertake no form of vengeful or punitive action. Conversation with those around them becomes monotematic. Sleepless, anxious and despairing, incapable of releasing themselves from their fixed idea or directing their attention to anything else, they sink into indolence, self-neglect and self-destruction. Often years pass before a slow improvement begins.

Obstinate lovers. Those in love

The "love idealists" (15) and the "erotomanic stalkers" (46) constitute a group of patients who experience a prolonged state of infatuation (ignored or unrequited by the other party) that is clearly abnormal in its manifestations. If Dide placed these patients among the "passionate idealists" and Sérieux and Capgras mentioned them among their "delusions of recrimination," Esquirol, many years before, had situated erotomania or "erotic monomania" alongside the rest of the monomanias.

Erotic monomania. Esquirol (1838)

"Erotomania is, for medicine, a chronic cerebral affection, characterized by an excessive love, whether for a known object or for an imaginary one (…). It is a mental affection in which amorous ideas are fixed and dominant, just as religious ideas are fixed and dominant in theomania or in religious lipemania.

Erotomania differs fundamentally from nymphomania and satyriasis. In these, the illness arises from the reproductive organs, whose irritation acts upon the brain (…) the erotomaniac neither desires, nor even dreams of the favors he might receive from the object of his mad tenderness…" (19).

Erotic monomania. Esquirol (1838)

"In erotomania the eyes are lively, animated, the gaze passionate, the words tender, the actions expansive, but erotomaniacs never overstep the bounds of decency. In a certain way they forget themselves; they devote to the object of their love a pure, often secret worship; they make themselves its slaves, carrying out its orders with puerility; they find themselves in ecstasy, in a state of contemplation before its often imaginary perfections; desperate in its absence, the gaze becomes downcast, the complexion pale, their features are altered, sleep and appetite are lost. These unfortunate individuals appear restless, dreamy, desperate, agitated, irritable, choleric, etc." (19).

Erotic monomania. Esquirol (1838)

"These patients are generally of an inexhaustible loquacity, always speaking of their love (…)

Like all monomaniacs, the same ideas pursue them day and night, the same affections, all the more disordered in that they are concentrated or exasperated by adversity: fear, hope, jealousy, fury, etc., seem to converge all at once or one after another to make the torment of these ill-fated souls more cruel. They prove negligent, they abandon and finally flee from their relatives and friends; they scorn fortune, they disregard social conventions, they are capable of the most extraordinary, most difficult, most painful and most bizarre actions" (19).

In his work, Esquirol presented a good number of cases, and in those individual descriptions he mentioned several further characteristics: "erotic fever", epigastric pains, suicide, frequent mood swings, the unfounded belief of being loved, the systematic pursuit of the object of love, and even death…

A century later, the term erotomania acquired a more limited meaning when Clérambault defined it as the delusion, particular to women, characterized by the patient's delusional conviction of being loved by another person. What for Esquirol was no more than an occasional symptom of erotomania, later became, much later,the defining element of a distinct diagnostic entity (despite retaining the same name).

Our group of the obstinate lovers coincides almost entirely with Esquirol's erotic monomania, albeit excluding those patients with delusional symptoms. Stalkers with jealous delusions or with a Clérambault delusion should be diagnosed as suffering from paranoia (or delusional disorder).

The description of erotomania by Ulysse Trélat –similar to that of Esquirol– clearly places classical erotomania within the group of the obstinate: a fixed, all-absorbing idea that ultimately affects the subject's behavior with the consequent general deterioration of vital functioning.

Erotomania. Trélat (1861)

"Erotomaniacs are tormented lovers…

[…] they spend day and night obsessed with the same ideas, with the same worries […] They set aside, abandon and then distance themselves from their parents and their friends… they scorn fortune, disregard social conventions, are capable of the strangest actions, the most difficult, most painful and most unusual ones" (49).

The pathological nature of falling in love manifests itself, in the first place, in the excess of the feeling and of the reactions it provokes, in the exaggeration.

Erotomania. Trélat (1861)

"[…] she speaks with contempt of her husband, she grumbles that she is forced to live with him, she ends up feeling aversion towards him, as well as towards her close ones, who strive in vain to bring her out of her delusion. The affliction grows worse and Madame X must be separated from her husband; she goes to live with her paternal family, with whom she speaks incessantly of the object of her passion, and she becomes difficult, capricious and irascible; she has fits of nerves; she escapes from her parents' home to run after him, she sees him everywhere, she calls out to him through passionate songs […]" (49).

Also anomalous is the path that leads to the choice of the "object": they tend to be people with whom there has never been any dealings or personal contact, they may even be distant and inaccessible figures of whom the patient has knowledge only through the media. Falling in love almost never arises in a natural way from empathy within an interpersonal relationship, but rather emerges unilaterally in a single individual.

Persecutors-persecuted. Pottier (1886)

"As for the mentally deranged of predominantly amorous disposition, it is usually possible to pinpoint the day on which they suddenly caught sight, for the first time, of the unknown person who from that moment on would be, without any motive whatsoever, the constant object of their preoccupations and anxieties, of their obsessions or of their amorous persecutions" (43).

Erotomania. Trélat (1861)

"[…] a very young woman who, shortly after her marriage, crosses paths with a young man of higher rank than her husband and immediately falls in love with him" (49).

Dide (like Esquirol) thinks that idealistic love is chaste and barely contains elements of genitality. Erotomania was likewise associated with ecstatic experiences.

Erotomania. Trélat (1861)

"Sometimes the patient is caught in a kind of ecstasy, of enchantment. She remains motionless, her gaze fixed and a smile on her lips" (49).

Obstinate utopians. Reformers

Reformers. Case of Eduardo V

"For the alienist this is interesting from more than one point of view; to begin with, this patient who has been admitted for more than ten years shows not the shadow of a delusional interpretation: outside of his humanitarian and religious conception, he reasons as well as anyone in the world; his tendencies are purely abstract, and he feels no hatred toward any priest, whoever they may be; he holds the clergy in contempt as a whole, but admits that among them one can find people of worth. The current representatives of authority apply false, disastrous, demoralizing principles, but he does not hold them individually responsible for the errors or crimes they commit: they are the unconscious agents of a nefarious system, and the insults he directs at them go beyond the individuals to address authority itself. He does not consider himself persecuted by anyone, and, after his long internment, he is found without bitterness and without sadness. His misfortune is an unavoidable necessity; he suffers with pride for a just cause and is certain that the force of his ideas will triumph in spite of the confinement to which he finds himself subjected" (15).

The lives of reformers revolve exclusively around a sociopolitical or religious ideal, around a utopia that they themselves construct. These are always unrealizable, impossible dreams, insofar as they idealize human nature and refuse to acknowledge its darker side. Nevertheless, they display a strangely confident attitude toward the prospects of success of their projects and hold a disproportionate view of themselves and of their own role in History. The extreme puerility and naivety of their expositions reveal a notable departure from the thinking patterns of the majority. Simplistic, they attribute the cause of all evils to a single person or group of persons, to a ideology, to a stratum or sector of society, and they believe that its eradication will resolve all problems. Some attempt this through political assassination. Others propose the extermination of some particular group. For this reason, Arnaud placed them among the persecutors.

Persecuted-persecutors. Arnaud (1903)

"Finally, some of these persecutors may be described as political. These are, more clearly than the others, ambitious from the outset. They consider themselves capable of playing a role in the world, of reforming society through their personal activity. They are perhaps more dangerous than the rest, first because they often find supporters who accept their ideas, lend them active assistance and defend them in the difficult situations to which their delusion leads them. Then and above all because, deeply convinced of the greatness of their mission, imbued with the importance of the interests they believe themselves to be watching over, they do not hesitate to resort to the worst means in order to make their cause triumph — which is the cause of the people" (5).

Reformers may gather groups of followers equally blinded by a shared vision of the utopia. They may even attempt to set their dream in motion, always with catastrophic results.

Dide (15) established a curious distinction between two types of reformers. On one hand, the genuinely altruistic ones, who "systematically and tirelessly pursue the realization of a dream in which utopia plays an important part". Others, "[…] are today reformers, tomorrow financiers, then inventors, always unstable, restless souls, exalted and vain. If they sometimes seem to harbor altruistic intentions, it is nothing more than an appearance; they pursue their personal aggrandizement under the guise of benefactors of humanity, and an inextinguishable thirst for admiration prevails over the desire to do good: these latter deserve the title vindicators because what they want above all is to be given their due, for humanity to know of their discoveries, their benevolent works, their highly disinterested character, their powerful intelligence […] they are the pseudo-altruistic vindicators".

Cullerre (who used the term "fanatics") underlined the parallels existing between these patients and the "mystics", especially in the grandiose conception that both have of themselves.

Fanatics. Cullerre (1888)

"The fanatic is a mystic in action. Not only does he believe himself inspired, charged with a divine mission, not only does he have ecstasies and visions, but he places at the service of this disposition a blind zeal that does not shrink from any consequence

[…] the fanatic sins in the moral sense. It is something he does not have […] he believes himself invested with the monopoly of what is right, the representative of morality, the sole authority to dictate the laws; from that point on, he does not stop at the most odious or criminal acts in order to fulfill what he considers his duty" (13).

Those obstinate about contact with nature

"Some men of today fully realize the life dreamed of by Rousseau; they are unstable migrants, incapable of settling in any one place, and who, having developed a hatred toward society with its obligations and its laws, travel Europe on foot seeking the only intense sensations they know, those provided by vast open spaces and nature outside the cities.

'[…] Under these conditions, it is better to leave a society where there are so many vices and faults, to become a vagabond and be free.

[…] 'This ideal equality is realized for vagabonds, all consider themselves equal'

Our patient, as can be appreciated, is a libertarian, but his naturism bursts forth with fervor amid his resentments. He spends hours of delicious happiness when, having reached the summit of a mountain, he turns around and sees among the valleys the flourishing nature bathed in light, he has intense visions of the places through which he has passed, and his capacity to remember and evoke are proof of the strength of his capacity for admiration" (15).

The agoraphytes, or agoraphilics, or wanderers by naturist idealism (15) are individuals hostile to the civilized world and to society, who find all their happiness in the contemplation of natural spaces and who characteristically wandered "along the roads of Europe."

One must acknowledge that the profile of "nature fanatics" presented to us by Dide seems a thing of the past and not a current reality. However, the underlying drive has not disappeared. In some subjects, the enthusiastic search for contact with Nature seems to serve the need for a schizoid isolation from the rest of human beings.

A decade later, Genil-Perrin (24) spoke of the love of Nature as one of the traits associated with the paranoid constitution. Subsequently, this association would fall into oblivion.

Up to this point we have presented each one of our obstinate individuals: those of justice, of redress, of love, of social utopia, and of immersion in nature. Almost all of them were described between the second half of the 19th century and the first half of the 20th, without any of them ever acquiring a place in modern psychiatric nosologies.

Historical approaches

The group of the obstinate (I refer now to the group as a whole and not to each of its members), with common traits that place it halfway between delusional disorder and paranoid personality, was already sketched out by several classical authors, albeit under different names, different conceptualizations, and with important differences in the specific elements encompassed within each category. With all these caveats, we have found eight designations that, to a greater or lesser extent, foreshadowed our obstinate individuals.

Persecuted-persecutors

Cullerre: persecutors and mystics

Overvalued ideas

Delusions of grievance

Passionate idealisms

Passionate delusions

Fanatic personality

All these diagnostic attempts emerged in the late nineteenth century and in the first half of the twentieth century, only to fall into oblivion shortly thereafter (with the exception of French Psychiatry). Some later authors sought to rescue the "overvalued ideas disorder", but with no success.

However, in recent decades a new line of research has emerged, led by forensic psychiatrists, oriented toward the psychiatric study of convicted stalkers. These investigations offer unexpected parallels with what was written by the classical authors and have made it possible to rescue and dust off old ideas that seemed definitively abandoned. Although the designation obsessive followers was initially proposed for the academic sphere, the term that has ultimately become established in the literature is the one used in journalism and, in some jurisdictions, in law:

Stalkers

Let us begin with the first of the classical diagnoses.

1 The persecuted-persecutors of Jules Falret

The delusion of persecution of Lasègue (1852)

"He established the important fact that persecuted lunatics should be subdivided into two categories, from the point of view of their actions: passive persecuted and active persecuted; those who passively endure all the physical and moral tortures to which they believe themselves subjected and those who, on the contrary, react against these tortures, seeking by all means to take revenge on the supposed authors of their imaginary ills, and from persecuted they transform into persecutors" (43).

This early distinction was the seed of a fruitful line of thought that extended over several decades. Various authors took a particular interest in "persecution," with different approaches. Thus, in 1878, M. Bourdin gave an interesting talk at the "Societé médico-psychologique" on persecution (harassment, in current terms).

"Persecution considered in itself presents itself in two main forms. Either it is relatively harmless and consists of simple importunities, or in vexations that only become distressing as a result of their persistent tenacity, or, on the contrary, the persecution is violent, aggressive, merciless, driving the enemy down every path, with no regard for honesty or justice" (9).

The author distinguished between mentally deranged persecutors, sane persecutors, and a third group.

"Between the lunatics and the mentally sound men we place persons who, while preserving, at least in appearance, the more or less complete integrity of their intellectual and moral faculties, are nonetheless possessed by the infernal genius of persecution. For these individuals we reserve the designation of anomalians persecutors" (9).

The group of anomalians, however, aroused little enthusiasm and did not outlive its discoverer.

The complete opposite of what would happen with the "reasoning persecuted, and persecutors" that a month later –in February of 1878– Falret presented at one of the sessions of the Societé médico-psychologique. The author applied to the folies raisonnantes (an entity that, despite its initial rejection, he had ended up admitting) with ideas of persecution the same division that Lasègue had established in his delirium of persecutions: the passive and the active (persecutors).

Consequently, there would exist two types of persecutors: the patients of the classic "delirium of persecutions" of Lasègue and the fous raisonnants –whom nineteenth-century French psychiatry attributed to the field of degenerates and hereditaries–. His student Pottier explained it clearly.

Persecuted-persecutors. Pottier (1886)

"Dr. J Falret, in his addresses to the Societé psychologique and in his courses at the Salpêtrière, laid the foundations of this distinction, describing in parallel two orders of the persecuted, and showing how they differed essentially in their symptoms and in the course of their illness […]

Our aim is to demonstrate that there truly exist two species of persecutors that must be described separately; some belong particularly to melancholy or to monomania, others to reasoning or hereditary insanities; some follow a determined morbid evolution passing through successive periods susceptible of description, while others preserve, during almost their entire lives, the same morbid characteristics, with simple differences of degree according to the moment; some experience numerous hallucinations of hearing or of general sensibility, while others, on the contrary, do not present throughout their existence this most important symptom of mental illness" (43).

For several decades the persecuted-persecutors were unanimously accepted in French psychiatry as two diagnosises independent and well-founded .

Persecuted-persecutors. Arnaud (1903)

"Gentlemen, the persecuted-persecutors are divided into two great types which I shall call the Lasègue type and the Falret type" (5).

The characterization of this second group by its discoverer was summarized in eight points:

Persecuted-persecutors. Falret (1878)

"1. They are hereditary.

2. They have physical symptoms of degeneration and congestions.

3. They write worse than they speak and produce memoirs.

4. They personify the persecution in a single person and harass them through blackmail, obsessions, etc.

5. They have no auditory hallucinations or hallucinations of general sensibility, and they do not progress toward further periods of chronicity.

6. They are ill throughout their entire lives with paroxysms, but they remain the same at an advanced age and do not move toward dementia.

7. Like the hereditary and reasoning ones, they die from congestive episodes or sudden cerebral accidents […].

8. They have an incomparable pride, are sterile inventors, consider themselves degraded and misunderstood, possess notable faculties, immense gaps in intelligence and above all in morality. They lack moral sense" (22).

The illness of the persecuted-persecutors, as described by Pottier years later, was characterized by three successive stages.

A peculiar premorbid personality, which departs from commonly accepted patterns and is marked by an irregular and hazardous existence.

A triggering event.

A wholly disproportionate response to it, with persecution as the central axis, which from that moment on conditions the patient's life.

Persecuted-persecutors. Pottier (1886)

"(…) who has led a bizarre, agitated, irregular existence, unlike that of the majority; who has always been strange and singular in his ideas and in his actions; who, even before the events that constitute the starting point of his illness occurred, had already displayed in his intelligence and in his character the general dispositions we have described; who at the moment when the circumstances to which the patient makes continual allusion in his delirium came to pass, reacted, in word and in deed, in a manner completely different from that observed in other persons faced with those same circumstances; who from that moment on his conduct and his actions have been entirely directed by his delusional ideas [in the broadest sense that the French gave to the term], which have absorbed his entire existence and have made him negligent, in order to satisfy this exclusive preoccupation, with regard to all his family and professional duties, his interests, his tastes and his former habits..." (43).

Well, the group of the persecuted-persecutors is, historically, the first precursor of our obstinate ones. It is true that Pottier speaks of the "delirium" of his persecuted-persecutors, but the délire of the French authors still included a wide range of psychopathological phenomena.

Persecuted-persecutors. Pottier (1886)

"(…) it is notable, as we have already said, that it is almost always after a real event, having occurred during their existence, that the delirium takes shape and leads them into the particular path of preoccupations that will dominate their existence" (43).

For Pottier, the starting point of ideas of grievance (and of the subsequent harassment) is often a real occurrence, an event that certainly took place, and not the product of the patient's fantasy; the illness develops gradually at a second stage after the event. In contrast, in the future paranoia kraepeliniana that precipitating event would simply have been imagined by the patient. No one has done anything to him.

The persecuted-persecutors also prefigured our obstinate ones in a second respect, namely the identification of specific types: threatening or homicidal persecutors, hypochondriacal persecutors, litigious persecutors, as well as a group of persecutors who were never persecuted, the erotomaniacs. With some variations, this typology was maintained in the subsequent clinical descriptions that followed that of the persecuted-persecutors.

Arnaud added a new subtype of persecuted-persecutors.

Persecuted-persecutors. Arnaud (1903)

"The family persecutors are characterized by that false idea that the family to which they seem to belong is not in reality their true family, that those who have raised them are not their true parents. From there to believing that their current lot is unworthy of them, and that a higher destiny awaits them, there is but one step […]" (5).

He also referred to the political persecutors, within which category fall the regicides and those reformers who embark on violent and harassing behaviors.

2 Cullerre: persecutors and mystics

In his book Les frontières de la folie (13), Cullerre includes some of our obstinate individuals, albeit in two completely independent chapters; the Harassers (persécuteurs) are described in chapter V while the Mystics are presented in chapter VI.

The first group, in turn, includes the persecuted-persecutors, the querulants, and the jealous. Harassment is the element common to all three. It is born of resentment, of the pain of having been betrayed, and always seeks revenge, redress, the conclusive demonstration of the truth and the acknowledgment of guilt on the part of the culpable party.

The group of mystics includes the mystics properly speaking, the fanatics (reformers), and the erotoманics (those in love). The element common to all of them is immoderate, overflowing love. What distinguishes them is the object of that love: God, another person, a social ideal. Nature fanatics might also have found a place here.

3 Overvalued ideas disorder

In the history of overvalued ideas, three names stand out: Wernicke, Jaspers, and McKenna.

The first one is credited with having coined the expression to refer to a group of pathological ideas that, however, could be considered neither delusional nor obsessive (52). What would give these fixed ideas their pathological character is the disproportionate way in which they condition behavior, but not the distortion of reality. The morbid idea, according to Wernicke, revolves around an experience charged with emotion (any emotion) and whose memory the subject is incapable of letting go of. The overvalued idea is experienced as something entirely one's own, and not as a foreign body in psychic life, in the manner of the obsessive idea. The range of possible triggers is extremely wide (the suicide of a friend, the death of a spouse, the observation of the washing of a person covered in lice…). Among these situations that constitute the starting point, Wernicke mentions two cases that clearly correspond to our obstinate individuals: that of those who suffer an injustice in the equitable distribution of an inheritance, and that of those who are victims of a judicial ruling that seems to them unjust.

The new psychopathological concept was completely ignored until Jaspers (27) rescued it, placing it, alongside "transient errors provoked by deceptive perceptions" and "melancholic and manic ideas," in the field of delusion-like ideas. These would be convictions consolidated by a "strong affective state" and understandable when taking into account the personality and biography of the subject. Qualitatively, according to Jaspers, they would differ in no way from a passionate political conviction. Among overvalued ideas, Jaspers included the ideas of inventors, ideas of jealousy, and the ideas of claimants.

Veale (50) synthesized the main characteristics that various authors have attributed to overvalued ideas; they are as follows:

They are held firmly, without reaching delusional conviction.

They are ego-syntonic ideas, unlike obsessions.

They often emerge in pathological personalities.

They are often understandable when taking into consideration the circumstances and the personality of the subject.

The content will normally be considered as abnormal taking into account general opinion.

They alter functioning and are a cause of distress for the patient and others.

They are associated with a significant emotional component.

They lead to obstinate behaviors.

They may evolve into delusion.

Patients may appear at the consultation more as a consequence of the intervention of third parties than on their own initiative.

There are similarities with passionate political or religious convictions.

For Wernicke, the overvalued idea had to be clearly distinguished from the delusional idea and the obsessive idea. Jaspers, likewise, radically opposed the delusional idea to the delusion-like idea; despite appearances, the two had nothing to do with each other.

However, in clinical practice the term would end up having a much more diffuse meaning and would be used to refer to those ideas that "fall short" of constituting a delusion. Between the overvalued idea and the obsessive idea there would be a qualitative difference, whereas with the delusional idea the leap would be merely quantitative, a matter of degree of severity. This is also the position adopted by the DSM-5 (4).

McKenna (36) suggested a new diagnostic class, that of "disorders with overvalued ideas," which would group together those conditions in which the overvalued idea is the most relevant feature of the clinical presentation. Under this new heading it would be necessary to include querulous paranoid states, morbid jealousy, hypochondriasis, dysmorphophobia, parasitophobia, and anorexia nervosa.

4 Delusion of grievance (1909)

In 1895, Pailhas published several cases (42) of patients who had been dispossessed of their lands (due to unpaid debts) and who had obstinately refused to abandon them, to not return to them, and to recognize the new owners. Unable to understand the reasons that led to the expropriation, all of them entered into repeated conflicts with the new owners and with the forces of public order who, after several arrests and trials, would end up bringing them to the hospital alongside the rest of the insane. The author proposed calling them "conservative degenerates of property".

A year later, Régis, having acknowledged Pailhas's contribution, presented a case that he himself had evaluated. He proposed the designation of "délire raisonnant de dépossession", and considered it a modality of paranoia querulens and of the persecuted-persecutors.

In 1897, Cullerre (13) presented two cases of a particular form of persecuted-persecutors, which he called "delusion of claim." These were two patients in whom the condition originated at the moment they expressed disagreement with the lands they had each received in separate inheritances; their frenetic activity was directed at obtaining what they believed was rightfully theirs, that is, more land. The term used —claim— belonged at the time to the legal domain and meant "to reclaim what belongs to oneself but is in the hands of another."

Sérieux and Capgras reclaimed the designation but gave it a broader meaning. They divided "what in Germany is called paranoia" into "delusions of interpretation" and "delusions of claim," based on a supposedly differentiated mechanism in the genesis of each.

In this way:

Delusion of interpretation. Sérieux and Capgras (1909)

"[…] it is a chronic systematized psychosis characterized by: 1st the multiplicity and organization of delusional interpretations; 2nd the absence or scarcity of hallucinations, their contingency; 3rd the persistence of lucidity and psychic activity; 4th the evolution through progressive extension of the interpretations; 5th incurability without terminal dementia" (46).

Delusion of claim. Sérieux and Capgras (1909)

"The delusion of querulance can be defined as a chronic systematized psychosis characterized by the exclusive predominance of a fixed idea that imposes itself on the mind in an obsessive manner; it alone completely orients all activity in a manifestly pathological direction and exalts it by reason of the obstacles encountered. This state of monoideism […]" (46).

Delusion of querulance. Sérieux and Capgras (1909)

"[…] those who, under the sway of an obsessive idea, employ all their intelligence and all their abnormal activity not for the construction of a delusional novel [as in the delusion of interpretation], but for the satisfaction of a morbid passion" (46).

Both. Sérieux and Capgras (1909)

"The delusion of querulance has as its starting point a fixed idea; in the delusion of interpretation, one arrives at a fixed idea after a long preparatory phase. From the very beginning, the querulant has his system established, his sole objective consists in making his obsessive idea triumph. The interpreter, on the contrary, begins by making false judgments without a determined plan, and only subsequently will he coordinate them around a principal idea" (46).

In turn, and according to these same authors, the delusions of querulance were divided into two groups: those of an egocentric character and those of an altruistic character. Among the former they included litigants, "hypochondriac persecutors" and certain "amorous persecutors," as well as the category of "misunderstood artists and writers." For their part, the majority of altruistic delusions of querulance would currently be classified among megalomanic delusions: inventors, prophets, thaumaturges… with the exception of reformers, whose ideas, which do not typically conform to the concept of delusion, do not permit the diagnosis of a delusional disorder.

Thus, the delusion of querulance includes several of our obstinate individuals alongside other patients who today would be classified predominantly under delusional disorder.

5 Passionate idealists (1914)

Les idéalistes passionnés was the principal work of the French neurologist and alienist Maurice Dide (15).

"We propose the grouping of a certain number of abnormals under the heading of Passionate Idealists. We do not claim to have discovered these exceptional beings, who were recognized before us; we simply wish to group them by their psychological affinities […] better than their study scattered across different chapters of Psychiatry" (15).

"By idealism we understand all psychological activity linked to the special aspirations of the human species (abstract love —mystical or profane—, aspirations toward goodness, beauty, and justice)" (15).

"We have seen the close architectural analogy (if we may use the expression) that exists between the delusion of interpretation and the affective systematization of the idealists. The difference is above all psychological; the deviation is intellectual in the first case, affective in the second" (15).

Throughout his book, Dide maintained the thesis that idealism and the delusion of interpretation are two radically distinct phenomena, which must not be confused. If they sometimes coexist in the same patients, it is solely because degeneration predisposes to both psychopathological manifestations.

"Since all men offer us a small degree of idealism, it is the ardor brought to the realization of the ideal that may come to be abnormal" (15).

Dide divides the idealists of love into two groups depending on whether the love in question is profane or mystical. Although the majority of them would fall within the field of delusional disorders, there remains a group that, having not developed delusional ideas, could be included among our "obstinate lovers."

The idealists of goodness include in their ranks, first and foremost, the "utopians of communism" who might correspond to the "reformers" of other authors. The examples provided by Dide correspond to historical leaders (mainly Anabaptists and utopian socialists), who were at once charismatic and markedly disturbed, as well as examples drawn from clinical practice (also disturbed, to the point of being admitted to hospital, but without charisma or followers).

A third and heterogeneous group is the one characterized by the idealism of beauty and justice conducive to cruelty. What –following the author– distinguishes this group is absolute selfishness, as opposed to the altruism of the previous two.

In this third group we find those individuals in whom the ideal of beauty "is felt in an almost exclusive manner". Their "affective reasoning", completely biased and distorted, leads them to consider that they, and only they, embody the ideal of beauty and are, ultimately, the center of the world. The rest of humanity appears to them despicable and of inferior nature. Consequently, they scorn reason and sentimentalism and consider themselves above any principle or moral that might impose some limitation upon them. Nothing can stand in the way of their "artistic or moral personality powerfully illuminated by their affective judgments". Dide presents Gabriele d'Annunzio as a paradigmatic example of this category. He provides no clinical examples. The most extreme cases of this "egocentric inversion of the object of love" lead to sadism, exemplified by the Marquis de Sade. Nor does he offer examples drawn from clinical practice.

The idealists of justice of an egocentric character (the fourth group) include in turn two subgroups:

The first is that of the "claimants whose idealism of justice has a pessimistic or hypochondriac character" and corresponds to the group we have dubbed "obstinate seekers of redress", as well as to the querulants.

Idealists of justice with an egocentric character

"After a more or less lengthy period of meditation, the personalization of the system suddenly bursts forth one day; we find ourselves faced with a phenomenon analogous to that of the revelation of the altruistic avengers. What we have here is a blow to one's self-esteem, the disillusionment brought about by the failure of a supposed business venture, the loss of a lawsuit, the reappearance of an illness once cured. Indeed, sometimes the choice of victim may be triggered by a truly trivial cause.

From that moment on, the persecution of whoever appears to be the cause of all ills takes on a character that has been described as obsessive…" (15).

In contrast to this egotistic group, the group of "idealists of justice with an altruistic character" is defined, which in turn is subdivided into two types. The first of these is that of "synthetic tendencies," for which three examples are offered: Torquemada, Calvin, and Robespierre.

Idealists of justice with an altruistic character

"History provides us with figures, whose traits are strongly marked, of a somewhat dry character, of a rigid austerity, but of an incontestable strength, who stand in contrast to the dreamers we have encountered in previous chapters. They are also reformers, but devoid of any feeling of love […] Their cold passion for justice develops with a rigor they believe to be mathematical, and in order to attain their ideal they break down all resistance, destroy all obstacles, and regard any opinion contrary to their doctrine as a harmful, dangerous, even criminal manifestation, deserving of death" (15).

All of them share certain traits: austerity in their private lives, mystical tendencies, pride or "hypertrophy of the personality," they are "somber and harsh"…

The second type is that of the "idealists of justice with individualistic tendencies (the assassins of heads of state)." Dide does not include in this section all those who assassinate heads of state, but only those who act out of a deeply refined sense of justice. The most notable common characteristics are the following:

family background of mysticism,

personal history of mystical exaltation,

studious and austere childhood,

chastity and idealistic loves,

experience of revelation and

pride without reaching megalomania.

6 Passionate Delusions (1921)

The influential psychiatrist G. G. Clérambault (12) also maintained, in essence, the opposition between delusions of interpretation and those of recrimination, with two minor differences.

The delusions of recrimination were included in a broader group, that of passionate psychoses; it is in passion that the origin of the condition was to be sought.

Under the new heading he brought together the recriminators of Sérieux and Capgras with the jealous and the erotomanias, a condition to the study of which he devoted much of his effort. Following Kraepelin, the erotomanias were exclusively those patients with a delusion of being loved, setting aside the far broader meaning the concept had carried since Esquirol (11).

On the other hand, he detailed the elements of the differential diagnosis between delusions of interpretation and those of revendication/passion. For the author, interpretive delusions stem from the paranoiac character, passionate ones do not. In the former, the subject's entire personality is at stake; in the latter, it is not. Excitement and even hypomania are characteristic only of passionate delusions. The delusion of interpretation spreads "by circular irradiation," it can encompass everything, the concepts are multiple and shifting. That of revendication advances like a circular sector, with a limited aperture and a single aim, a guiding concept. Willpower and vehemence in the pursuit of the single objective characterize revendication delusions. The paranoiac's distrust comes from afar, from an imprecise moment; the passion of the erotomania sufferer or the revendicator begins on a specific date. The interpreters live in a state of expectation; the passionate delusionals, of effort.

The interpretive delusional is affected by everything that happens around him, seeks an explanation for everything, and the delusional system grows in all directions like a web at whose center he finds himself. The passionate one is only affected by what relates to his preoccupations, and the delusional system, the interpretations, progress as in a circular sector, in which the length of the radius grows but not the opening of the angle. For the interpreter, the entire world tends to revolve around him (either because he is the center of persecutions or because of the extraordinary nature of his being); this megalomania does not occur in the revendicator. The interpreter seeks past explanations; the passionate one is oriented toward the future.

7 Fanatic Personality (1946)

Fanatic Personality. Kurt Schneider (1946)

"Psychopathic fanatics are individuals dominated by sets of thoughts —personal or idea-related— that are overvalued. And certainly the true fanatic is a markedly active, expansive personality. The personal fanatic, as is the case with the querulant, fights for his real or supposed right; the fanatic of ideas fights or manifests himself for a program" (46).

Kurt Schneider's psychopathic personalities constitute a milestone fundamental in the history of personality disorders and their classification by psychiatry. Among them, the author included a fanatic type characterized by:

The overvaluation of certain complexes (or sets of closely associated and interrelated ideas). This is equivalent to saying that a particular complex displaces all others and dominates the subject's psychic life.

The type of complexes, qualitatively distinct from those presented by depressives and the insecure.

The fact that these are complexes that drive toward action, combat, and external struggle.

On other occasions, however, fanatics remain silent, inactive and isolated in their fantasies (which, that said, may include significant activity). Although the term fanatics fits better with the former, the author was in favor of applying it as well to this second group, in the absence of a better one.

Kurt Schneider also spoke likewise of two types of overvalued ideas held by fanatics: the personal ones (characteristic of the aggrieved, who tend toward querulousness) and the not so personal ones of the sectarians. In turn, the former can be divided between single litigants (who fight for a single issue) and multiple ones. Of the sectarians –he provides abundant examples–he underlined above all their extravagance.

In his classification, the author clearly separated clearly the fanatic personality (characterized by the predominance of certain overvalued ideas) from the paranoid one (characterized above all by generalized distrust). Even so, there would be points of overlap:

Fanatic Personality. Kurt Schneider (1946)

"Sometimes paranoid developments also occur in them that exceed the usual distrust…" (46).

On the other hand, in the DSM-III and subsequent editions, fanaticism has already disappeared as an independent type and, if it is mentioned briefly, it is as one of the traits that make up the paranoid personality.

Paranoid personality

"They may be seen as 'fanatics' [...]" (3).

Stalkers (harassers)

"Stalking (stalking) refers to a set of behaviors that include repeated and persistent attempts to impose unwanted communication and/or contact on another person. Communication may occur through phone calls, letters, e-mail and graffiti, and contact through approaching the victim and following and maintaining surveillance […] Threats, property damage and assault may accompany stalking" (40).

The modern psychiatric literature on stalkers began in the 1990s and has since grown very gradually, generating a relatively limited number of articles. From reading it, one can conclude that the patients included in the group of stalkers resurrect with considerable accuracy the persécuteurs françaises. Studies that use quantitative methods to identify which specific behaviors stalkers display coincide with the colorful nineteenth-century descriptions: letters, covert surveillance, gifts, phone calls, approaches, aggressions (ranging from shoves and pushes to homicides) … these are behaviors that (out of love or hatred) persist for months or even years. In 70-80% of cases the victim is a single individual, which also coincides with the classic descriptions.

Equally striking is the similarity in the type of victims identified. They may be acquaintances, people "simply seen on the street," or notable public figures present in the media. When the subjects involved are those with whom a prior relationship existed, they may be mere acquaintances, neighbors, professional contacts, partners, etc., but half of all victims had a prior professional or work-related relationship. In a population of 200 victims (37), three of them were healthcare professionals who had previously treated those who would later become their stalkers.

Different authors have proposed different classifications of stalkers, using one or more variables for this purpose: delusional versus non-delusional, affective/enamored versus persecutory/angry, classifications based on the nature of the victims, etc. But, without doubt, the classification that has garnered the most acceptance is that of Mullen (40):

The first group is that of the rejected (by their ex-partners but also by their mother, by a friend, by an employer…). Some of these patients would have a delusional disorder (such as delusions of jealousy) and the supposed rejection would not actually have occurred, but the majority of them would not suffer from any type of psychosis.

The second is that of the "intimacy seekers," convinced that the victim is their true love. This group includes both Clérambault's delusions and "morbid infatuations." Frequently associated phenomena are jealousy and anger, at not finding their feelings reciprocated.

In third place, the "incompetent stalkers" are individuals with intellectual limitations or deficiencies in social relationships, who neither believe themselves to be loved nor idealize their victims as those in the previous group do.

The so-called "resentful stalkers" display more aggressive behavior toward their victims than the previous groups. Some pursue personal revenge against a specific person while others have a general sense of grievance and randomly choose a person on whom to seek redress.

The "predatory stalkers" are those who act in preparation for a sexual assault (rape, exhibitionism…) and constitute a clearly distinct group from the previous ones.

The psychiatric diagnosis of stalkers also offers us another interesting parallel with the old descriptions of French psychiatry. Approximately 10% of stalkers (the intimacy seekers) coincide completely with the old erotic monomania. Of these, only a quarter can be ascribed to the delusion of Clérambault. As for the rest, the authors acknowledge the insufficiency of current nosology and suggest, precisely, recovering Esquirol's original erotomania:

"A nosological difficulty is posed by those who do not believe that their love is reciprocated but are entirely preoccupied and insist, with delusional intensity, on both the legitimacy and the eventual success of their actions. This group does not correspond to the DSM-IV criteria for delusional disorder of the erotomanic type […] the much older tradition of considering erotomania as the morbid exaggeration of love in all its aspects" (40).

To encompass this broad group of non-delusional stalkers in love, Meloy (37) proposed "borderline erotomania" as a diagnostic entity. Other authors spoke of "love obsessives," "obsessive erotomanias," etc. These are stalkers in love who, however, do not nurture the fantasy that the other person is also in love with them. There would be, in any case, a certain pre-delusional distortion of reality in the full conviction with which they expect to succeed in their conquest. As in Esquirol's cases, the beloved person may also be, for the patient, a stranger.

Thus, stalkers refer us unequivocally to classical erotomania and to the lovesick pursuers of the late nineteenth century. In more general terms, and with the exception of the incompetent and the predators, the bulk of stalkers would have some type of connection with the pathology of the paranoid spectrum.

"As for diagnosis, stalkers often fit within the spectrum of those with paranoid disorders. Intimacy-seeking stalkers include those with erotomanic delusions, both secondary to pre-existing schizophrenia and within the framework of a delusional disorder. True delusional disorders, common among intimacy seekers, overlap imperceptibly with overvalued ideas and the fanatical obsessiveness of those with personality disorders, with the boundaries often uncertain and shifting. With rejected stalkers, there is a spectrum in which the inadequate fixation on a relationship in inadequate individuals merges with the assertive assertion of the narcissist's own rights and the persistent jealousy of the paranoid. Resentful stalkers, in contrast, present an almost pure culture of persecution, with paranoid personalities, paranoid-type delusional disorders, and paranoid schizophrenia" (40).

The paranoid personality

By personality we understand that set of behavioral characteristics which, for any given individual, remain relatively stable over time. These individual tendencies (referred to as traits) are what, together with physical constitution, make each of us different from one another. Miserliness, generosity, likability, antipathy, a predisposition to helping others, or concern or indifference toward one's health, are examples of some personality traits from among the hundreds we could select.

For decades, Psychiatry has accepted the idea that pathological or disordered personalities exist. These are individuals whose way of being prevents them from adequately adapting to and integrating into their environment, predisposing them to distress and conflict.

the unstable personality

Let us return to the lucid madmen: they were described by Trélat in 1861 (49) and, subsequently, would come to constitute the penultimate rung in the transgenerational evolution of degenerates toward idiocy, imbecility, and sterility.

In 1903 Gilbert Ballet published an extensive Traité de pathologie mentale, comprising several volumes. We are particularly interested in the one drafted by Arnaud.

"Book IV is devoted to constitutional psychoses. We thus designate those mental conditions, of varying physiognomy and severity of progression, independent of the action of harmful elements foreign to the organism, and which are due to an original defect or to the defective development of the brain [which are due, in the final analysis, to the heredity of degeneration]" (5).

Psychosis, then, did not yet mean loss of contact with reality, but rather referred to mental illness in general. What are, according to Arnaud, these constitutional psychoses?

"In a certain number of cases the predisposition [hereditary] is minimal; the illness requires, in order to develop, the adjuvant action of occasional causes of a powerful nature: various intoxications and infections, intense or prolonged emotions, cerebral trauma, overexertion of all kinds, etc. […] these are the toxic psychoses, febrile deliriums, mania and melancholia simple, general paralysis, etc.

In other circumstances, on the contrary, the morbid predisposition is at its maximum, and the most insignificant and banal causes suffice to awaken it, causes whose action is inseparable from the veryconditions of existence, which cannot be avoided. In this case, the onset of a mental illness is no longer an accident but rather the normal culmination of a strong predisposition [which derives from inherited degeneration], or like the flowering of a seed deposited in favorable soil.The mental illnesses that develop under such conditions, the result of the subject's own constitution, are rightly calledconstitutional psychoses.They are the most numerous and most important psychoses. They encompass the varioussystematized delusions, theintermittent orperiodic madnesses,the innumerable moral,reasoning andinstinctive madnesses of thehereditaries, of thedegenerates, etc." (5).

It is at this point that Arnaud introduces a personality pattern, prior to the onset of psychosis proper, which would characterize a good portion of those degenerates. We have christened it theunstable.

"[…] constitutional psychoses can be divided quite naturally into two classes main ones.

In the first, the predisposing influence, however powerful it may be, does not manifest itself clearly before the onset of the psychosis […] Before the beginning of the specific mental disorder, the subject was neither ill nor even unstable […] in this group the predisposition has remained latent […].

In a second class, the predisposition is more pronounced, more severe and its action is apparent and permanent, often from the earliest years of life […] unstable […] Undisciplinable, unsociable, their capricious and shifting instincts, often perverted, drive them into all manner of adventures […] eccentricities that draw attention to them and cause them to be regarded as crackpots or originals […] lack of balance, disharmony of the cerebral functions. Their intelligence may be highly developed but they lack moderation and judgment […] at once abulic and pigheaded to the point of absurdity, often impulsive […] To this second class belong the reasoning alienated, the mad moralists, the obsessed, the impulsive, all those patients from whom the groups of the hereditarily insane and of mental degeneration have been constituted" (5).

As can be verified, the author states that, even before the onset of the illness, degeneration can manifest in the form of character traits, highlighting instability, imbalance, deficiencies in the moral sphere, etc. Alongside physical stigmata, these manifestations were considered the expression of the degenerative taint inherited from one's progenitors.

This unstable personality, however, would very soon be relegated to the great catalogue of failed diagnostic proposals.

the paranoid constitution

In 1919 Dupré (15) proposed the denomination paranoid constitution, to refer to a personality pattern radically different from the unstable one of the degenerationists. The choice of the term constitution implied that this set of closely associated traits was congenital, deeply rooted, and unmodifiable. The term paranoid, for its part, reflected the growing weight of Kraepelin in French psychiatry and, more specifically, the general acceptance of his paranoia.

For Dupré, the paranoid constitution was the fertile ground in which paranoia could end up flourishing, just as the mythomaniac constitution is the one that would predispose to its fantastic delirium.

The paranoid constitution was grounded in three pillars:

Hypertrophy of the ego: pride and feelings of superiority.

Distrust.

Falseness of judgment, characterized by rigidity and paralogic.

The importance of the paranoid constitution in French psychiatry lies not so much in the fact that it contributed novel descriptive elements, but rather in that it assembled those elements into a simple schema of great utility in clinical practice. We might say that, although the building blocks were given to it, its merit consisted in using them to construct a morbid entity.

Later French authors maintained this diagnostic approach based on three pillars, refining the description of each of them and adding other secondary components such as morbid proselytism and altruism, fanaticism, autodidacticism, pathological love of nature, etc. (25).

With the passage of time, however, the term constitution would eventually disappear from psychiatric terminology and paranoid/paranoid became identified with delusional disorder, while paranoid would end up being associated solely with the disorder and with personality traits. From the paranoid constitution, there was a definitive transition to the paranoid personality.

Antecedents of the paranoid constitution

It is clinical reality itself that was bound to make evident that the premorbid personality of a good number of paranoid patients did not coincide with the "unstable pattern" (described by the proponents of the theory of degeneration), but rather with a different one.

The birth of the new diagnostic entity was facilitated by the fact that most of its constituent elements had already been identified and isolated previously, albeit in a slow, scattered, and disconnected manner.

Bourdin

For example, Bourdin's description of the anomalian persecutors already represented an early approximation to some of the traits of the future paranoid personality, such as cruelty and insensitivity toward the suffering of others.

Anomalians. Bourdin (1878)

"From the tenderest age to extreme old age, they are the torment of those around them" (9).

Or like the energy and ardor with which they devote themselves to their objectives.

Anomalians. Bourdin (1878)

"Man or woman, they bring the same ardor to the pursuit of those they regard as their enemies" (9).

Anomalians. Bourdin (1878)

"[…] full of audacity…" (9).

Some of the paranoid personality profiles appear not in the general description of persecutory anomalians, but in the presentations of some specific clinical cases.

Anomalians. Bourdin (1878)

"Envious of authority and markedly ambitious…" (9).

Anomalians. Bourdin (1878)

"For anything, he is in the opposition" (9).

Even some of the characteristics of the paranoid cognitive style can be glimpsed.

Anomalians. Bourdin (1878)

"[…] a series of intellectual faculties that constantly slumber for good, but which become active, and even ardent, for evil. Devoured by the instinct of persecution, M. puts at the service of this instinct faculties whose very existence was not even suspected" (9).

According to Kretschmer, however, the first sketches of the paranoid personality derived from two specific diagnostic entities.

Paranoid personality. Kretschmer (1918).

"In the old bibliography on paranoia, these descriptions of the paranoid character predominated, whose hard and sthenic coloring [as opposed to the asthenic of the psychasthenics] came from the types of the litigant and the persecuted-persecutor" (31).

In both clinical pictures, those elements that would later be incorporated into the paranoid constitution appear subsumed within the clinical description itself. No distinction was established yet between symptoms and traits, nor between the illness and the personality that precedes it.

Persecuted-persecutors

Persecuted-persecutors. Arnaud (1903)

"[…] completely devoid of moral and altruistic feelings, holding a high opinion of themselves, they soon come into conflict with their equals and above all with their superiors. Incapable, at once through vanity and through a native incorrectness of judgment, of acknowledging that they may be wrong, they persist in the path they have embarked upon and apply their stubbornness and their great intellectual activity to making their way of seeing things prevail against and before everyone. The inevitable failures irritate them. Ever more defiant and aggressive, they soon find themselves exposed to malevolence and defend themselves preemptively by attacking. It is in this that they are at once persecuted and persecutors" (5).

In the case of the persecutors-persecuted, it is already the very name of the illness that pointed toward the future paranoid personality. Persecution (harassment, in more current terms) would have a twofold dimension: passive and active, as victims or as agents.

The feeling of superiority characteristic of the paranoid personality was also present in the descriptions of the persecuted-persecutors.

Persecuted-persecutors. Falret (1867)

"They have an incomparable pride, they are sterile inventors, rejected, misunderstood, they have notable faculties […]" (20).

Persecuted-persecutors. Cullerre

"[…] shows an immense pride and begins to position himself as a victim and persecuted" (13).

Persecuted-persecutors. Ball (1890)

"The third characteristic is the exaltation of the personality. More than the rest of the persecuted, they are proud, vain and deeply selfish. They are always right, they never admit their mistakes and they are completely devoid of any feeling of altruism" (5).

The peculiar cognitive style of the paranoid personality would also have previously been attributed to the persecuted-persecutors.

Persecuted-persecutors. Ball (1890)

"The fourth character is the abuse of logic. They live in a perpetual monologue, they do not listen to their interlocutors and when they want to listen to them it is to give their arguments, to reply and to argue; their life is a continuous pleading" (5).

Clinical descriptions included other elements that, in the same way, would end up converging in the future paranoid personality: eccentricity/originality, persuasive capacity, the application of an inexhaustible energy to the achievement of their objectives, selfishness, insensitivity to the suffering of others…

Persecuted-persecutors. Cullerre (1888)

"As soon as he reaches adulthood, he acquires the air of the eccentric reasoner" (13).

Persecuted-persecutors. Cullerre (1888)

"[…] they are capable of convincing enlightened spirits" (13).

Persecuted-persecutors. Ball (1890)

"Let us also recall that there are general characteristics that are common to all persecuted-persecutors.

The first is activity. Endowed with great vigor of spirit, these individuals manifest their agitation through writings, speeches, innumerable reasonings and, finally, through violent attacks.

In second place, tenacity. Once they have chosen their victim, they never abandon her, tormenting her for long years. Nevertheless, substitutions may occur and, above all, additions. The persecutors lash out against those who contradict their delusion and even against those who, having taken an interest in their cause, have failed to fulfill their hopes. It goes without saying that one must add the doctors who have treated them and the judges who have condemned them.

[…]

They view everything in relation to themselves, they think of no one else. A persecutor of this type kills his wife. He regrets it, as he told me, because, confined to a sanatorium after having gone through a criminal court, he is prevented from managing his fortune, which greatly concerns him.

[…]

The fifth character they share is intellectual and often physical longevity. They are vigorous types. Their intelligence does not falter and their life often extends over many long years. It must be added that they are subject to alternations of excitement and remission that sometimes lead one to believe they are cured, when they are doing nothing more than concealing their delusion" (5).

Querulants

Querulant disorder. Cullerre (1888)

"[…] they are prematurely immoral, insubordinate, little scrupulous with the property of others. The notion of right exists for them only insofar as it grants power over others; it is a legal weapon to achieve their ends. Filled with egotism, incapable of the slightest concession, the slightest sacrifice, anything that causes them harm drives them out of their minds. Stubborn, grumbling, prone to arguing over trifles and presumptuous […] Let us also note an alteration of the imagination, which distorts facts and presents them to the conscience deformed and altered […] Satisfied with themselves and their infallibility, they tolerate no contradiction and hence the permanent conflicts with their surroundings" (13).

The anomalians, the persecuted-persecutors and the querulants provided the pieces of the puzzle. To assemble them, one needed only to listen to the patients —paranoiacs— and their families, and to take note of the facts. Some had already begun the task before Dupré proposed his paranoid constitution; it is possible that they also served him as a source of inspiration.

Paranoid Personality. Kretschmer (1918)

"Thus, for example, in the attempt at characterological grouping carried out by Tiling, the paranoid individual appears above all as a proud, contemptuous, stubborn, arrogant man, with great combative resolve, vindictive, resentful and ambitious. Friedman highlights the paranoid individual's capacity for decision-making, his premature, passionate, obtusely fixed thinking, and his decisive difference with respect to the neurotic-obsessive personality" (31).

Subsequent evolution of the paranoid personality

Let us examine the operational diagnostic criteria and additional clinical information proposed by the DSM-IV (1).

Operational criteria:

General distrust and suspiciousness from the beginning of adulthood, such that the intentions of others are interpreted as malicious, appearing in various contexts, as indicated by four (or more) of the following points:

Suspects, without sufficient basis, that others will take advantage of, harm, or deceive him or her.

Preoccupation with unjustified doubts about the loyalty or fidelity of friends and associates.

Reluctance to confide in others due to unjustified fear that the information shared will be used against him or her.

Discerns hidden meanings in the most innocent remarks or events that are demeaning or threatening.

Bears grudges for a long time, for example, does not forget insults, injuries, or slights.

Perceives attacks on their person or reputation that are not apparent to others and is predisposed to react with anger or to counterattack.

Suspects repeatedly and unjustifiably that their spouse or partner is unfaithful to them.

Other features of the DSM-IV clinical description:

Tendency toward the establishment of conflictive interpersonal relationships that produce a hostile reaction in the surrounding environment, which tends to confirm the suspicions.

Recurrent protests and complaints.

Silent withdrawal.

Appearance of coldness and absence of compassionate feelings.

Stubbornness, combative nature.

Sarcasm.

Self-sufficiency.

Propensity to control the people in their environment.

Rigid thinking.

Hypercritical toward others, hypertolerant toward themselves.

Litigious.

Grandiosity fantasies.

They attach great importance to power and hierarchy.

Using a sophisticated personality assessment method and multivariate analysis, Westen (53) obtained several pathological personality profiles, mostly coinciding with the traditional ones. The following items, ordered from highest to lowest "weight," are those that, in his research, clustered together in the paranoid dimension:

Tends to hold grudges, to brood over insults and slights for prolonged periods of time.

Tends to feel misunderstood, mistreated, or like a victim.

Easily suspects that others want to harm him or take advantage of him; tends to perceive malevolent intentions in the words and actions of others.

Tends to express intense and inappropriate anger, disproportionate to the situation that provokes it.

Tends to be critical of others.

Tends to engage in power struggles.

Consciously or unconsciously, tends to be angry and to behave in a hostile manner.

Tends to see some people as "completely bad," losing the ability to perceive their positive qualities.

Tends to be moralistic and to claim moral superiority.

Reacts to criticism with feelings of rage or humiliation.

Tends to blame others for his own failures or shortcomings; tends to think that his problems are caused by external factors.

Tends to be oppositional, to adopt contrary attitudes, and to disagree readily.

Tends to see in others his own unacceptable impulses or feelings.

Tends to lose rationality when strong emotions come into play, potentially showing a notable impairment of his usual level of functioning.

Tends to "catastrophize", seeing problems as disastrous, irresolvable, etc.

In others, tends to produce disgust and animosity.

Emotions tend to spiral out of control, leading to extreme degrees of anxiety, sadness, rage, excitement.

Has difficulty understanding the meaning of others' behavior, often misinterprets or misunderstands, the actions and reactions of others often leave them feeling confused.

Tends to be controlling.

Tends to provoke extreme reactions or strong feelings in others.

Tends to avoid trusting others out of fear of betrayal; fears that what they say or do may be used against them.

Reasoning processes and perceptual experiences seem strange and idiosyncratic.

Under stress, the perception of reality can become severely altered.

As can easily be verified, these items make up a type of individual very close to the paranoid personality of the DSM-IV, albeit with a greater depth of description. It is worth noting that the item that weighs most heavily in the paranoid dimension is not distrust, but resentment.

Type versus trait

The traditional psychiatric classification of personality disorders was typological: a patient could be assigned to a particular personality disorder and, theoretically, that diagnosis ruled out the others, since the types are mutually exclusive.

There exists a completely different approach to personality disorders that comes from Psychology departments and the use of multiple-choice tests. This approach produces a series of dimensions, each and every one of them applicable to any individual. On each scale, a score is obtained that falls between extreme maximum and minimum values.

If the paranoid personality of traditional psychiatry is something one either has or does not have, something one either is or is not, the trait-paranoidism of psychometry is a dimension on which every individual scores to a greater or lesser degree. It is worth noting that the majority of psychometric tests used in clinical settings (the MMPI, the Millon test, and the 16PF) each contain their corresponding paranoid scale.

In the case of the 16PF, the protension (derived from paranoid trend) reflects traits such as suspiciousness and touchiness, hypervigilance, skepticism, and oppositionalism. Protension aggregates into two "second-order factors." The first of these corresponds to a neurotic personality. The second, called QIV, Independence (in which protension combines with scales that measure the tendency to dominate, rebelliousness, radicalism, self-sufficiency, and original thinking focused on abstract topics), leads us unequivocally to the paranoid constitution (28).

In addition to the scales derived from multiple-choice tests, there is a well-established tradition of assessing paranoid personality traits through projective tests, and most especially through the Rorschach test

Experimental assessment methods with great potential are also being developed. In an interesting study, Freeman et al. (23) subjected one hundred men and one hundred women to a four-minute walk through the subway, using a virtual reality device, during which they encountered various passersby. As it turned out, compared to a slight majority who described their interactions with the other travelers as positive or neutral, no fewer than 40% of the subjects experienced paranoid-type thoughts: hostile people, or people who laugh at you, or who make contemptuous gestures, who stare you down, who want to start arguments…

Theodore Millon's subtypes

In one of his works on personality disorders (38), this author isolated a series of variants of the paranoid personality. They have not achieved general acceptance, but they hold —for our purposes— a great deal of interest. They are as follows:

Let us look at what characteristics the author attributes to each of them.

According to the author, these subtypes arise from the intersection, each of them, with another personality disorder. That is, they combine the properly paranoid traits with those of another disorder.

Numerous objections could be raised regarding the choice of the specific items that identify each variant, items that largely overlap. However, the great merit of this typology is to highlight that there are different ways in which the same personality disorder can present itself, at least in appearance.

Nor does it seem accurate to suggest that each of these variants arises from the intersection between the paranoid personality (distrustful and self-referential) and another specific personality disorder. Our way of seeing it, which is very different, is as follows: each of the subtypes is produced by the relative accentuation of certain specific traits of paranoidism. The variants arise from the description of what appears in the foreground and draws the most attention. Nevertheless, a deeper, more prolonged, case-by-case evaluation tends to reveal the presence of the full set of elements identified by the French classicists, although some of them in a less immediately obvious way.

The variants do not constitute perfect and mutually exclusive types, but rather overlap with one another as well, with a wide range of intermediate situations. Moreover, if instead of a fixed snapshot we were to take a longitudinal perspective, one that took into account the subject's entire biography, we could appreciate to what extent they can succeed one another at different moments in the life of the same individual.

Even accepting these qualifications, Millon's variants are valid and prove useful, even more so than he himself thought. Indeed, beyond paranoid personality, they constitute equally effective prototypes for approaching delusional disorders, obstinations, or states of transitory paranoidism. The variants are the most common and identifiable faces of paranoid behavior in general, and not only of paranoid personality.

To the obdurate we will dedicate an entire chapter in the last part of this book. We will attempt to demonstrate that it does not derive from any overlap with obsessive or anankastic traits, although it may appear to do so. This variant, that of the pigheaded person, also refers us to work dependency (workaholism) and to certain delusions such as those of inventors, tireless and ever engrossed in their grand projects.

Fanatic. In the DSMs, fanaticism is mentioned as a trait that can appear in paranoid personality. The possibility is also mentioned that some delusional patients or those with a paranoid personality may create or lead pseudoscientific, quasi-political, mystical or esoteric religions, cults…: precisely the type of groups we immediately associate with fanaticism. The reformers of French psychiatry —let us not forget them— would represent more than anyone else the quintessence of the fanatic. And if we turn to the classic paranoid tripod, the fanatic is one who tends to live fighting against a group of enemies (dehumanized and demonized), displays a cognitive style completely closed to any evidence or argumentation, and feels that he is part of an elite: that of those who are in possession of the truth. Pride, distrust, and rigidity also distinguish the fanatic

Querulous. Between (a) that querulous patient, completely out of touch with reality, who has made lawsuits (which are always, necessarily, against someone) the epicenter of his life and whose sole activity is the study and preparation of his court appearances, and (b) the neighbor obsessed with compliance with rules (official or customary), as well as with the state of cleanliness and upkeep of common areas… we find the spectrum of individuals to be included in this third variant.

Insular. There is no doubt that the tendency toward a solitary life, or even to domestic seclusion, is a common trait in many paranoid conditions. From individuals with persecutory delusions or delusions of ugliness, to unsociable people who, due to their character and lack of empathy, cannot live with anyone, the range of insular types is variopinted.

Malignant. Here we should include those paranoiacs whose repeated critical comments, persistent anger, and hostile and defiant attitudes are what draws the most attention. If this subtype really exists, Falret's description of his Persecutor-persecuted (22) is, without doubt, its best exemplar.

State

Clinicians always think of paranoidism as something pathological that affects only our patients. However, paranoid behavior constitutes a universal human potentiality that, to a greater or lesser extent, everyone can manifest at some point. Paranoid behavior is comparable to hunger, laughter, or anger: all three can be activated and can be deactivated. In fact, something resonates within us in response to the paranoid experiences of our patients, something that even allows us to understand them. By contrast, the experiences of schizophrenic patients produce in us a greater degree of bewilderment.

Even though we always associate the paranoid with the field of mental illness or personality disorders, our colloquial language inadvertently reflects a less restrictive view. This is the case, for instance, when we use the informal expression "ponerse parana" to refer to people who are not our patients and whom we assume to be healthy (or even when speaking about ourselves).

Psychoanalysts too have described states of paranoidization transitory during the process of psychoanalytic therapy, as well as the emergence of schizo-paranoid dynamics in the course of group therapy.

The common substrate

We have ascribed three diseases and a personality disorder to the paranoid universe, and we have taken for granted the existence of a common substrate to all of them. The thesis that a single behavioral pattern underlies several pathologies and personality disorders is a guiding thread of this work, and we will insist on it time and again. JL Tizón's "paranoid relational organization" adopts an even broader view than our own.

The paranoid relationship. Tizón

"In psychiatric and psychopathological practice, this structure, pattern, or relational organization predominates in people with a paranoid personality disorder, with a paranoid delusional disorder or chronic paranoid delusion (erotomanic, jealous, grandiose, persecutory, somatic...), in hypochondria, in dementias with paranoid features, in schizophreniform disorders, in paranoid schizophrenic disorders, in brief reactive psychoses, in induced psychotic disorders, in some adaptive disorders and post-traumatic stress disorder […]" (48).

However, the idea of the common substrate is by no means the majority view.

Unitary model and dichotomous model

The central question is that of the relationship between paranoid personality and paranoia, the two core diagnoses within the set of pathologies of the paranoid spectrum. Two extreme positions are possible in this regard:

Paranoia and paranoid personality are exactly the same thing, the only difference being one of severity.

Paranoia and paranoid personality are two completely independent phenomena, with little or nothing to do with each other.

The unitary approach, characteristic of French Psychiatry at the beginning of the last century, asserts that delusions are nothing but an extreme manifestation of the paranoiac constitution both in terms of "form" (delusions as a way of pushing to the limit the rigidity, the obstination, and the tendency toward paralogy of the paranoiac constitution) and in terms of content, which would do nothing but deepen tendencies already present in the aforementioned constitution (pride-superiority and grievance-persecution).

"For these authors, a unique type of premorbid personality predisposes to the onset of psychosis" (25).

Delusion of interpretation

"[...] constitutional psychoses that do not modify the personality, of which they are an exaggeration" (46).

Delusion of interpretation

"The delusion is linked to the previous state of the personality by a period of meditative incubation, and, even if it seems to be triggered suddenly, it reveals a long preparation in the ancient tendencies of the character.

Also, our authors say 'in the delusion of interpretation the importance of this paranoid constitution is capital, since contrary to what occurs in dementive psychoses, there is, as we know, neither radical modification, nor dissolution of character, but rather a hypertrophied and unilateral development of some pre-existing tendencies. No rupture between the subject's previous personality and the personality of the interpreter. The latter is nothing more than the flowering of the former […]" (32).

In summary, the unitary model of the paranoid constitution postulated the existence of a single disorder, characterized by pride, distrust and rigidity. Only in the most severe cases, and with the passage of years, would delusional ideas appear, as a consequence of a progression of these three characteristics, but without any genuine break in continuity between the moments before and after the emergence of the delusion.

On the opposite side are those who believe that paranoid personality and delusional disorder are two diagnoses completely independent of each other and, therefore, two conditions between which there is no substantial relationship. The dichotomous approach –it must be acknowledged– responds to unquestionable objective facts:

in clinical practice, the vast majority of subjects with a paranoid personality disorder do not end up developing a delusional system

and a good number of delusional patients do not have a paranoid personality prior to the onset of the illness.

Elaborating further on the dichotomous approach, delusion has been addressed with a basically medical model, as the symptom of an organic disease that at a given moment affects the brain, invades it and alters its functioning. The disease would give rise to a set of absurd assertions, which are what we classify as delusions, for which no explanation other than a biological dysfunction is conceivable. It does not seem very plausible that a simple way of being of the individual, their personality, could predispose them to a particular brain disease. In the dichotomous perspective, the psychic life of the delusional subject is divided between a healthy part, an extension of the premorbid personality, and a sick part in which the morbid phenomenon holds sway. The following example, referring to a specific variant of delusional disorder, illustrates this.

Monosymptomatic delusional hypochondriacal disorder

"The rest of the personality is notably well preserved, but the delusional system, despite its encapsulation, dominates a large part of the subject's way of life. Profound and surprising secondary changes occur in affect, attitude and logic when the patient shifts from the normal mode to the delusional one or vice versa" (41).

At most, some authors were able to accept the possibility that the prior personality might influence the choice of theme of the delusion.

"Thus we see for example how a previously distrustful, withdrawn, solitude-loving individual one day imagines himself persecuted, how a brutal, selfish man, with mistaken views about his rights, produces a querulant, how a religious eccentric falls into mystical paranoia" (Krafft-Ebbing. Lehrbuch der Psychiatrie, 3 Aufl. 1888, p. 436, cited in 32).

The dichotomous approach is clear-cut and practical. It is likewise consistent with that opinion dating back to Jaspers, which has had such an impact on psychiatry, that leads to drawing a sharp distinction between understandable phenomena (and among these would be the extreme variants of personality) and those others (such as delusions and hallucinations) that have no other explanation than an organic affectation.

Nevertheless, some research suggests that this radical division between a) the healthy part of the patient and b) the delusional part, which includes the delusion and the behavioral repercussions that derive from it, could be somewhat simplistic.

Paranoia

"[…] is associated with violent actions even when the victims do not appear to have been incorporated into the delusions" (29).

For our part, while defending the advisability of using multiple diagnoses, we believe that the existence of this substrate should not be forgotten — that common element which, at least in part, dissolves the boundaries between all of them.

The paranoid substrate manifests itself in at least three respects, which we will develop below.

First. The ambiguity of boundaries

First point. At least conceptually, there exists a very precise boundary between, on the one hand, delusional disorder, characterized by the presence of a persistent delusion and, on the other hand, overvalued ideas and personality traits. Indeed, the diagnosis of delusional ideas has a high inter-rater concordance or reliability. Despite the ethereal nature of the definition, clinicians generally agree on whether a given idea in a given patient has a delusional character or does not. However, this clarity arises with the most common delusional contents in clinical practice (persecutory and jealousy delusions). In others, such as hypochondriacal ones, the boundaries between the delusional idea and the non-delusional one are somewhat more diffuse. In the case of certain ideas of grandiosity, the distinction is lost entirely. When we venture into the entertaining world of healers, clairvoyants, ufologists, occultists, gurus, illuminati of all kinds, messiahs, prophets, people with paranormal powers, santeros, masters, shamans, magicians, and other exceptional beings, the delusion, or its absence, is far less evident.

"[…] He was obsessed with the idea of hydrotherapy as a panacea, and wrote a book about it, maintaining that 'water, both inside and out' can preserve good health. He would habitually make his daughters, despite their protests, wrap themselves in damp sheets to spend the night, with the result that they grew impatient to grow up, marry, and escape their father's deranged experiments" (51).

For example. A subject professes great faith in a certain extreme diet. He believes wholeheartedly in the cure-all potential of his garlic-based diet, and insistently makes this known to whoever approaches him. The clinical evaluation, individual and out of context, could easily lead the psychiatrist to conclude that he holds "a false idea resistant to logical argument."

However, the DSM-5 (4) also requires that the delusional idea –in order for it to be classified as such– be rejected by the people of the patient's culture or subculture. And, quite to the contrary, it turns out that several thousand more people also believe in that diet, forming a single "interest group" (a set of people drawn to the same subject who tend to read the same books, attend the same talks, and form, to a certain extent, a subculture). Although their dietary beliefs might be considered absurd and delusional, the truth is that they are entirely acceptable within their particular social sphere.

Moreover, the individual in question may be integrated into an organized group that vehemently advocates said diet and may even lead it.

Paranoid personality

"[...] It seems reasonable that individuals with this disturbance should be widely represented among the leaders of mystical or esoteric religions and in pseudoscientific and quasi-political groups" (1).

Depending on who, how, when and why evaluates them, our healer will be catalogued as someone with a simple eccentricity, as a delusional patient, or even, often, as a swindler with psychopathic tendencies who takes advantage of the suffering of others with their deceptions. This disparity is a recurring phenomenon when different people offer opinions about the same cult leader.

Insisting on the diagnostic ambiguity, self-referential interpretations are quite frequent in the paranoid personality, often held with conviction in their reality, which means one could speak of a delusional activity secondary to the interpretations. However, these are delusions without systematization, with little behavioral impact and little clinical relevance, which is why the clinician avoids diagnosing delusional disorder in patients who are, in reality, delusional…

Second point. Clinical association

Although it does not always occur, it is nonetheless common for delusional disorders to arise in subjects with prior paranoid-type personality traits. This is a gradual evolution, without breaks in continuity, in which a "general" paranoid functioning tends to focus on a single matter around which the subject's life increasingly begins to revolve. In this gradual process, it is also common to pass through an initial stage in which the conviction does not yet reach a delusional consistency and should be labelled (merely) as an overvalued idea.

Third. Similarity

Finally, and in third place, the main argument in favor of a common substrate is the existence of a shared clinical phenomenology. While we could be more exhaustive, we will limit ourselves for now to the classic diagnostic triad of the French authors –pride, distrust and rigidity–, applicable equally to paranoid personality, to chronic delusional disorders and to the rest of the illnesses within the paranoid spectrum.

Let us begin with the last of the three elements: rigidity. Any experienced clinician is capable of identifying a peculiar way of thinking –obtuse, obstinate, and resistant to change– and of expressing oneself that is characteristic of patients with a paranoid personality disorder. As for the delusions of paranoid patients, we know that inflexibility forms part of the very definition of delusion. Stubbornness, impermeability to outside influence, the tendency toward black-and-white thinking and the rejection of nuance… are characteristics common to the delusions of paranoid patients and to the cognitive style of paranoid personalities.

And what can be said of the other two great characteristics of the paranoid constitution, pride and suspicion-distrust?

It is not without curiosity that absolutely all recurring delusional themes refer us back to one or the other: megalomaniacal delusions (pride) and persecutory delusions (distrust). However, it is necessary to employ a broad concept of suspicion-distrust in which the inability to trust refers not only to human beings but extends also to microorganisms or parts of one's own body (hypochondriacal delusions), immaterial beings (witches and demons), and even to social and natural circumstances (delusions of catastrophe, which are frequently accompanied by messianic ideas). The objects feared by paranoid patients are the same ones that, on a non-delusional and less focused level, are feared by patients with a paranoid personality disorder.

But a more unhurried analysis makes it plain that both—superiority and harm-persecution—coexist within the delusion itself. To divide delusions into persecutory and megalomaniacal is to remain on their surface, given that both –persecution and megalomania– are present, simultaneously, in all delusional contents. Kraepelin noted that patients with persecutory delusions feel themselves to be, at the same time as they are persecuted, extraordinary beings, given that it is precisely they, and not others, who are the victims of the most important conspiracies and plots. If they find themselves in the crosshairs of ETA or the CIA, it is solely to the extent that they possess some special knowledge or ability that, of course, not everyone has.

Paranoia. Kraepelin

"Delusions of grandiosity always occur simultaneously with persecution mania. Sometimes they do not exceed the limits of a considerable increase in self-confidence. Already the enormity of the means that the patient believes are being employed against him points to a considerable overestimation of his own personality, the supposed target of those efforts" (30).

Patients with erotomanic delusions love and know themselves to be loved by some notable figure, which entails a certain megalomania. But if that love does not materialize into a true union, it is always because other people, hostile to the couple, place insurmountable obstacles to prevent it.

Patients with messianic religious delusions feel a special bond with God, with whom they are in communication, their destiny being to act as intermediary between Him and humanity. But it is no less true that, in general, they experience with equal intensity the presence and the siege of the devil, who tempts them, places stones in their path, and even goes so far as to take on flesh and blood in actual persons with the aim of harming them.

Jealous husbands fear the infidelity of their spouses or are convinced that it has already taken place. But the preoccupation with betrayal is almost always associated with a peculiar type of pride of millenary tradition: that of the macho.

It is possible to break down the two poles of distrust and grandiosity into several themes that are somewhat more concrete and widely shared. These themes are expressed both in the personality traits, and in the delusions, as well as in the fixed ideas of the obstinate.

Narrow paranoia

We cannot help but recall that today the concept of paranoid-paranoiac is not associated with the classic triad (suspicion, grandiosity, and rigidity) but rather exclusively with the first of the components, distrust (and only with that experienced toward other human beings). The tripod of the French authors, rather than being rejected, is simply unknown: it fell into oblivion.

This reductionist approach is evident both in the way delusional disorders are understood and in the way the paranoid personality is viewed.

Although Kraepelinian paranoia included all chronic delusions, the truth is that subsequently, as we have already noted, there has been a marked tendency to reserve the term paranoia exclusively for persecutory and prejudicial delusions, giving the remaining delusional themes a specific designation. The official classifications maintain the nosological unity of paranoia, but by opting for the denomination "delusional disorder" instead of "paranoia," they also reinforce this limited way of using the term. Inadvertently, the new terminology implies that only one type of delusion, the persecutory kind, bears any relationship to the paranoid personality.

The equation paranoid = suspicion-prejudice is also evident in the definition that DSM-III and its successors give of the paranoid personality

Paranoid personality

"General distrust and suspiciousness from the beginning of adulthood, such that the intentions of others are interpreted as malicious…" (1).

In accordance with this definition, the diagnostic criteria used to diagnose paranoid personality are conceived as mere manifestations of distrust.

However, the clinical description that precedes the exposition of the official diagnostic criteria reveals a tacit conception of paranoid personality much closer to the old "paranoid constitution"; not all of the characteristics of paranoid personality included in the text derive from distrust. In this way, the description that the DSM-5 (4) gives of paranoid personality differs from the definition by means of operative criteria provided by the same manual.

In summary, the restrictive clinical view is made manifest in:

the fact of reserving the term paranoia solely for delusions whose subject matter is most closely related to persecution and distrust and

in a way of conceiving paranoid personality that does away with pride, with rigidity and with the rest of the characteristics that do not derive directly from distrust toward other people. At best, it limits itself to granting them a lesser importance.

The bias of the words paranoia-paranoid toward distrust, suspicion and persecution is also present in their popular usage. The following quote, taken from the autobiographical account of the kidnapping of Patty Hearst, serves as an example:

Sectarian-Leninist splinter group. SLA

"Paranoia must be contagious, for in that house everyone had caught it. When Cin addressed me one day and told me that the newspapers were reporting that my father had hired fortune tellers to find out where the SLA was keeping me, I was paralyzed with fear. 'Don't think about any fortune teller right now, don't communicate with them,' he told me. 'Keep your mind fixed on something else at all times.' I did as I was told. I didn't want any fortune teller or anyone else to point the FBI in my direction. To protect themselves, and through strict discipline, the members of the SLA had learned to speak in low voices, almost a whisper. They could even shout in a whispering voice. Their leader was convinced that the FBI had super-listening devices that could be aimed at that house from a car parked in the neighborhood. Every day they eagerly clipped news items from the San Francisco newspapers, including the absurd filler lines and paragraphs at the foot of the news columns. Cin was convinced that these fillers were actually secret coded messages between CIA agents operating in the area. On one occasion he informed me that whenever the SLA met they always turned the television set to face the wall to prevent the government from being able to spy on the SLA through the television screen" (25).

Paranoid activation

One can speak of the existence of a paranoid behavior pattern that, like other behavior patterns in the ethological sense of the term, becomes abnormally intensified in certain situations or individuals.

The various clinical presentations and circumstances in which paranoid activation occurs differ from one another in:

chronology (permanent state versus transitory states),

the intensity,

whether the paranoid behavior has a generalized or focused character around some theme (and in this second case, around which one),

the degree of association with other symptoms (hallucinatory and affective, above all, also dissociative),

the presence or absence of delusional ideation or fixed ideas and, finally,

the reactive or non-reactive character in relation to conflictive situations or stress.

Furthermore, in some individuals, paranoid activation tends to occur specifically within a particular domain (family, work, neighborhood), diminishing or ceasing in other contexts.

Paranoid behavior should not be considered solely as the manifestation of a disease that one day affects some brain structure or some neurotransmitter, nor solely as the expression of an abnormal development of personality, but also as an entirely normal behavior incorporated into the repertoire of biologically transmitted behaviors. In other words, the paranoid can be a disease that one has, something that one is (a personality) or a state in which the subject –healthy– finds himself for a limited period of time.

Henceforth, we will use the term " paranoid behavior " (or "paranoidism") to refer to that common substrate whose components we have attempted to isolate, define, describe and exemplify, and "paranoid individual" (PI) to refer, interchangeably, to the paranoiac, the individual with paranoid personality traits, or the person who finds himself in a transitory state of paranoidization.

The truth is that psychiatric diagnoses, absolutely indispensable in clinical practice and for research, often mask a much more diffuse reality, in which character traits, chronic delusional activity –with changes in content–, transitory decompensations and various fixed ideas, intermingle, become confused, overlap and succeed one another in a manner considerably more disorderly than what the literature suggests.