Atlanta Medical Psychology
The clinical practice of Dr. David B. Adams


Psychotic disorders are characterized by a difficulty with reality testing - differentiating what is real from what is imagined, and the disorders may be characterized by false belief systems referred to as delusions and often by auditory and/or visual hallucinations. The individuals capacity to deal with their work is severely impaired during the occurrence of their disorders. While extreme environmental situations may produce psychotic symptoms, it is generally accepted that many of the psychotic disorders are attributable to a defect in brain chemistry and the way in which the brain processes its electrochemical impulses.

Delusional Disorder involves potentially real life situations that are, however, unreal in the life of the patient. Thus, a person may, indeed, be poisoned, famous or followed, but this is not reality for the patient. These patients are not odd, eccentric or bizarre as we see in schizophrenia but instead falsely believe that important people are in love with them (Erotomanic Type) or that they (the patients) themselves are powerful, knowledgeable, or wealthy (Grandiose Type), that the person is being malevolently treated (Persecutory Type), that their sexual partner is unfaithful (Jealous Type), that they have a physical defect or medical condition (Somatic Type) or that they have symptoms of two or more of these subtypes (Mixed Type). Outside of their delusional beliefs, the individual may have an overall appearance of being functional with minimal impairment.

In Shared Psychotic Disorder (also called Folie a Deux) a delusion or false belief system develops in an individual who is closely involved with another individual who is demonstrably delusional. The second individual's delusion is similar, if not identical, to that of the individual with whom they are involved. They essentially share the same delusional system. This can apply to couples, and it can apply to groups of individuals. This must be differentiated from those who are abusing similar psychoactive substances and.or who were, for example, schizophrenic before entering the relationship with the delusional individual.


Author: Jason Bennett, MD, Consulting Staff, Department of Psychiatry, Camp Pendleton Medical Center

Historically, the concept of delusional disorder is derived from the classic Greek concept of paranoia or paranous, meaning beside (para) mind (nous). With the historical absence of a unified and rigorous diagnostic system, the term paranoia has been used to describe a multitude of observed phenomena, some of which are now associated with the category of delusional disorder. Delirium associated with fever, delusional jealousy, generalized suspiciousness, and even poor decision-making have been labeled as paranoia. Other labels, including morbid jealousy, conjugal paranoia or Othello syndrome, erotomania or Clerambault syndrome, folie à deux, and late paraphrenia, also have been attached to syndromes in which delusions are the central feature.

Early conceptualizations of paranoia preceded Emil Kraepelin (1856-1926), but Kraepelin is credited with defining paranoia in a rigorous way. Interestingly, his definition most closely parallels the modern definition of delusional disorder.

Kraepelin described paranoia as the presence of a fixed delusional system with the absence of hallucinations and personality deterioration. He also observed various subtypes of paranoia, including persecutory, grandiose, erotomanic, and jealous. Kraepelin also concluded that paranoia was primarily a disorder of personality and judgment influenced largely by environmental factors.

Various people contributed to the concept of paranoia, including Ernst Kretschmer, who described sensitive, pessimistic, narcissistic, and depressive personality traits that were thought to relate to the presence of the condition. In his analysis of the memoirs of Judge Daniel Paul Schreber, Sigmund Freud recognized the presence of delusions and circumscribed paranoia in the absence of deterioration of personality. However, rather than focus on “the character of the products of the delusion (and) an estimate of their general influence on the patient’s behavior,” Freud chose to analyze how “structures so extraordinary . . . (are) derived from the most general and comprehensible of human impulses.” In concert with his drive-conflict model of psychology, Freud attributed Schreber’s delusional symptoms to repressed homosexual impulses, providing one of the first psychological explanations of delusions and paranoia.

The concept of paranoia was largely lost under the influence of Eugen Bleuler (1857-1939) and his description of schizophrenia. Bleuler paid little attention to paranoia, believing it too rare to consider as a separate diagnosis. DSM-I (1952), DSM-II (1968), and DSM-III (1980) refocused attention on the concept of paranoid disorders, describing acute and chronic versions along with persecutory and grandiose delusional content as defining characteristics.

The DSM-III-R (1987) authors sought to clarify the boundaries and presented the currently used concept of delusional disorder. No longer was paranoia the central feature but, rather, the circumscribed presence of nonbizarre delusions. The definition adopted in the DSM-III-R was very close to Kraepelin’s original classification system. Subtyping based on content was expanded and included erotomanic, grandiose, jealous, persecutory, somatic, mixed, and unspecified categories. Unlike Kraepelin, hallucinatory symptoms were allowed into the diagnostic grouping. DSM-IV (1994) and DSM-IV-TR (1999) largely preserve DSM III-R definitions.

The cause per se is unknown. Delusional disorder theoretically represents a heterogeneous group of conditions that seems distinct from mood disorders and schizophrenia. Family studies show increased prevalence of delusional disorder and paranoid personality traits in relatives of delusional disorder probands but no association with mood disorders or schizophrenia. Longitudinal studies suggest that the disorder is stable and reclassified as a mood disorder or other psychotic disorder only 10-25% of the time.


Delusions can be a feature of a number of biological conditions, suggesting possibly biologic underpinnings for the disorder. Most commonly, neurological lesions associated with the temporal lobe, limbic system, and basal ganglia are implicated in delusional syndromes. Neurological observations indicate that delusional content is influenced by the extent and location of brain injury. Prominent cortical damage often leads to simple, poorly formed, persecutory delusions. Lesions of the basal ganglia elicit less cognitive disturbance and more complex delusional content. Right posterior cerebellar lesions are associated with misidentification syndromes. Excessive dopaminergic and reduced acetyl cholinergic activity have been linked to the formation of delusional symptoms.


Psychological explanations of delusions present 3 ways of viewing the phenomena of delusions.


Norman Cameron defined social situations with the following characteristics as contributing to the development of delusional disorder: expectations of receiving sadistic treatment, distrust and suspicion, social isolation, jealousy, lowered self-esteem, people seeing their own defects in others, and rumination over meaning and motivation.

Associated risk factors that suggest other avenues in the pathogenesis of delusions include advanced age, social isolation, group delusions (eg, in the McCarthy era), low socioeconomic status, premorbid personality disorder, sensory isolation (particularly deafness), recent immigration, family transmission, head injury, and substance abuse disorders.

January Newsletter of the Schizophrenia Help Home Page

III. Delusional (Paranoid) Disorder (475-481)

In delusional disorder, in which schizophrenic
disorganization seems not to be a significant factor, the
paranoid individual harbors ideas of persecution and
grandiosity. The person, however, is entirely functional in
areas that do not impinge on the delusional thought. Shared
psychotic disorder involves two or more people who develop
persistent, interlocking, delusional ideas. DSM-IV types of
delusional disorder include: persecutory, jealous,
erotomanic. somatic, grandiose, and mixed type.

A. The Clinical Picture in Delusional Disorder

A paranoid or delusional individual feels singled out and
taken advantage of, mistreated, plotted against, stolen from,
spied on, ignored, or otherwise mistreated by "enemies." The
delusional system usually centers around one major theme.
Some paranoid individuals develop delusions of grandeur.
Aside from the delusional system, such individuals may appear
perfectly normal in conversation, emotionally and

B. Causal Factors in Delusional Disorder

Most delusionally disordered persons have a history of being
aloof, suspicious, seclusive, secretive, stubborn, and
resentful of punishment as children. They tend to both trust
and mistrust inappropriately, and to overreact when others
are perceived as betraying the trust. This disorder
develops as mounting failures and seeming betrayals force
these individuals to elaborate their defensive structures.
To avoid self devaluation they search for "logical" reasons
for their lack of success, using highly selective information
processing in the development of delusional systems.

Delusional Disorder

Non-bizarre delusions (such as those involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease). Characteristics include a grossly disorganized or catatonic behavior negative symptoms.

Antisocial Personality

A pervasive pattern of disregard for and violation of the rights of others. Most significant is the substantial lack of remorse for the crimes that they commit. They also often exhibit an inability to control their violent impulses. They erupt without warning.

Mind Change

A phrase tossed about these pages is psychodynamic psychology. Psychodynamic is a general term going back some 100 years and reflecting concepts drawn from diverse schools of thought. Note the two components:

Psycho—having to do with the human mind.

Dynamic—having to do with change.


The "dynamic" element was first used to stand in opposition to "static". Very quickly it was taken up to define "functional" rather than "organic". It's a way of thinking—not only about a patient but also about the relationship between patient and therapist. Psychodynamic psychology is a tributary to the psychiatric community that puts a great deal of attention, not to mention credence, on the product of conflict and deficit. The individual suffers from a deficiency and conflict in their psychological framework.

In essence, modern psychodynamic psychotherapy focuses on three areas of development:

The inter-psychic conflict of the patient.

The difficulties in maintaining a cohesive self.

The impact of early primary relationships.

For many psychodynamic psychologists the inter-psychic world is one of internal conflict between the ego, the id and the superego. The ego can be defined as the part of our personality that helps us make decisions, integrate reality and maintain our psychological defenses. The id is the unconscious aspect of us assigned to discharge tensions between our sexual drives (libido) and our aggressive drives. The superego represents our moral values and our internalization of our societal and parental values. When all three aspects of our personalities battle amongst themselves the results will often times be anxiety. In order to cope with this anxious state the individual may then develop psychological defenses. Some of the more prominent defenses include repression (the expulsion of unacceptable thoughts into the unconscious), displacement (undesirable wishes and thoughts that are attached to one source are displaced onto another), and somatization (painful feelings are communicated through physical ailments). As an individual matures he attempts to gain mastery over his drives and integration of various aspects of his personality.

The reduction of tension can also be viewed in the context of relationships (infant-mother dyad). As children develop they learn that drive reduction and integration can also be achieved by seeking relationships. How the child then internalizes these early relationships will have a major impact on their adult development. If a primary caregiver was experienced as hostile and non-loving, a child may then experience most intimate relationships with a sense of paranoia and trepidation. On the other hand, if the atmosphere of child rearing was one of love and nurture the child may then develop into an adult that is capable of having mature loving relationships.

In order to manage difficult childhood rearing situations the child may also develop defense mechanisms in addition to some of the ones mentioned above. One of the most prominent defense mechanism developed in early childhood development is splitting. The world may become polarized into good and bad. This defense is based on a need for safety. The world must be divided into all good and bad experiences in order to integrate the good parts of the early maternal relationship and ward off the bad aspects of those same relationships. Unfortunately, the end results are usually one where the person is weakened and growth is difficult.

In addition to developing a theoretical model for understanding inter-psychic conflicts and maternal relationships, the psychodynamic psychologist will look at the external world of the individual and how external relationships help them in developing a sense of self-esteem and self-respect. Many times our responses to individuals in our environment will aid us in maintaining a sense of happiness. Our environment may either validate us or we may have a dissimilar experience. If validation does not occur on a consistent basis our ego may experience a disintegrative quality that will fill us with anxiety. Many times an individual's hunger for drugs or alcohol will be an emergency attempt to ward off the disintegration of their sense of self. This fragmentation can occur on a continuum from anxiety to severe paranoia and panic.

Furthermore, the psychodynamic psychologist will attempt to understand a patient's life story by listening to their dreams, fantasies, fears, hopes, impulses, wishes, self-images, and perception of others. Similar to the creative artist, the psychologist must learn what is unique about each patient if they are to develop a comprehensive understanding of character.

Psychic Determinism

An important factor in psychotherapy as well as storytelling is psychic determinism. This is a principle that states that symptoms and behaviors are external manifestations of unconscious processes. Although most of us prefer to think that we go through our daily lives as we wish, the basic psychodynamic principle is that each of us is a character living out a script written by our unconscious minds. Our major choices in life—our relationships, our careers—are not random chance or luck. Unconscious forces fundamentally shape them. Luke Skywalker of Star Wars was not simply a bored teenager stuck in an isolated-galaxy-far-far-away-farm life for a kid. There was a destiny tied to great psychological machinations. So much so that millions of fans never saw the forest through the trees (as presented by the prequels Parts I, II, III, Luke Skywalker is revealed to not even be the central character of the story being told). When human behavior becomes markedly symptomatic—when psychopaths eat their victims' hearts, when extra-marital one night stands "won't be ignored"—the limits of free will become quickly apparent.

By delving into the character's early childhood experiences, you can establish a template—a strong foundation from which you can chart a character's evolution. Choice of career, types of relationships, and communication styles can all be traced back to a character's development during his formative years.

This concept—that the past is tied to the future—can not be stressed enough. Within the psychological community's diagnostic criteria of the personality disorders presented in this book, most of those definitions include the phrase,"…and present from early adulthood." These personality disorders are honed and refined over many years. They are experts in the nature and manner of their behavior.

Corner Stones

The sphere of the neonate's perception is a tight one and the development into a viable and distinguishable person is unmatched in both quantity and quality in the whole of a human's lifetime. The universe of an infant can be as small as a mother's nipple, and the feelings toward it, then, fill the whole universe. These first perceptions—as trite as they may seem to a fully formed adult who has to worry about mortgages, the intricacies of the stock market, and the incomprehensibility of, say, love—are the lode stones of our awareness and stick with us throughout life. Without question, all that comes after—the ability to integrate into society, the strength of our egos—is laid atop these primitive corner stones.

The reason these corner stones are so crucial is that all humans are born prematurely, that the gestation period of a baby human is 21 months. This gestation period is due to an evolutionary give and take—we can't have both the big brain of a Homo sapiens and pass through a female human birth canal. So, ingeniously, a compromise was reached—we're born helpless and still gestating. The relationships with the outside world—the tiny universe of the nipple—are as vital to proper growth as nutrition. Our arms wouldn't form correctly in utero without the adequate nutrients, and nor do our personalities without the adequate nurturing during the vital first years of life outside the womb.

Developmental theory addresses human growth as the complex process that it is. Growth is a series of transformations, similar to a primordial cell dividing to create new life forms. Each stage of development is viewed as evolutionary and each stage becomes increasingly more complex. With each stage there is a sensible order—no stage can be skipped and the preceding stage most often determines the next one. Evolution demands that new cells must take on a new responsibility to gain the next rung of the ladder, the stages of personality development must also exhibit growth in a new direction (i.e., maturity).

For the creative artist, attempting to understand the evolution of their characters over time, developmental theories provide sophisticated insight into character psychology. The understanding of human development is essential for the creative artist if he is to understand how characters may change over time, as well as how and why they remain the same. Many psychodynamic theorists have centered on the first years of childhood development in order to differentiate between normalcy and psychosis.

Perhaps of greatest importance, the theories and very name of Sigmund Freud have entered the modern argot. His body of work has been extremely influential in all spheres of life. His ideas have shaped modern literature, music, drama, cinema, and art. The concept of the unconscious mind has proven to be one of the emblematic ideas of the Twentieth Century.

Freud used the metaphor of a cave in his original formulation of his theory of the unconscious mind. Outside the cave is the conscious mind. This is the realm of everyday consciousness and thoughts—where everything, seemingly, is relatively accessible to constant awareness. When you first enter the cave, you encounter the preconscious mind—the part of the mind where thoughts are below the surface of immediate awareness—yet with little trouble the individual can access them. But deep within the cave lies the unconscious mind, the region of our soul that harbors thoughts that are unacceptable or incomprehensible to the individual. These thoughts are not easily brought into awareness. The unconscious, the preconscious, and the conscious systems of the mind compose what Freud termed the topographic model.

Psychological illness, or psychopathology, is often believed to be the result of repressed memories of distant, early (and usually disturbing) events. The unconscious selectively forgets the things that are too painful or objectionable for the conscious mind to acknowledge. This is especially true with the repression of sexuality, Freud believed, and this repression was connected with the development of neuroses. The banishment to the dark recesses of the back of the cave of these highly troubling or inappropriate feelings can be a tremendous battle. When a character has a great deal of repressed material, the battle to keep those terrible things safely hidden and cordoned off with defense mechanisms can lead to complex, irrational, and even seemingly insane behaviors. Anyone familiar with Jungian archetypes or the insights of Joseph Campbell and The Hero of a Thousand Faces will recognize this cave business and its relationship to film and storytelling.

The Past As Prologue

The past always serves as prologue. William Wordsworth's statement that, "the child is the father of the man" describes it aptly and succinctly. Childhood experiences play the central role in the formation of adult personality. While the process of personality development always involves the subtle and ongoing interplay between an individual's inherited traits and the environmental factors that shape those traits, it is impossible to overestimate the effect of early childhood relationships on psychological well-being later on in adult life. It is also hard to overestimate the effect of a flawed childhood on adult psychopathology. Psychiatric illness can often be traced to just how good (or how bad) the relationship between the child's temperament and that of the parenting figure was during the early phases of life.

In the movie Shine, young David Helfgott is alternately encouraged and upbraided by his overbearing father. He can never be quite sure if he'll be thrown against a wall or be drawn up into the old man's ursine arms for a crushing embrace. The father is a survivor of the Nazi camps and is ruled by survivor guilt. He pushes his son to limits that horrify David's teachers, yet when David wants to strike out and pursue unquestionable success, the father refuses to let him go. When David insists, he is excommunicated. Throughout the film, the father has a constant litany for David; "no one will ever love you as much as I do." David believes this—he has to—but what he hears and what he experiences is very different. He winds up institutionalized, unable to fathom the intricacies of a mature, adult relationship.

The psychologist is trained to see that through the way the patient relates to him, his behavior and responses actually symbolize some deeper processes. He must ask himself what the patient's relationships really symbolize, what aspects of the past are being replayed in the present. The creative artist must go through a similar process, though working the other way around—creating a puzzle as opposed to solving one. Whereas the psychologist has a fully formed "character" with whom he must get to the roots, the creative artist needs to start from the roots, establish a clear understanding of what motivates the character, and what behaviors will spring from this basis. He must constantly ask himself what the character's behavior actually represents...

When Adolf Hitler moved to Vienna in 1907 at the age of eighteen, he reported in Mein Kampf, he haunted the prostitutes' district, fuming at the "Jews and foreigners" who directed the "revolting vice traffic" which "defiled our inexperienced young blond girls" and injected "poison" into the bloodstream of Germany.1

Months before this blood poison delusion was formed, Hitler had the only romantic infatuation of his youth, with a young girl, Stefanie.2 Hitler imagined that Stefanie was in love with him (although in reality she had never met him) and thought he could communicate with her via mental telepathy. He was so afraid of approaching her that he made plans to kidnap her and then murder her and commit suicide in order to join with her in death.

Hitler's childhood had been so abusive-his father regularly beat him "with a hippopotamus whip," once enduring 230 blows of his father's cane and another time nearly killed by his father's whipping3 that he was full of rage toward the world. When he grew up, his sexual feelings were so mixed up with his revenge fantasies that he believed his sperm was poisonous and might enter the woman's bloodstream during sexual intercourse and poison her.4

Hitler's rage against "Jewish blood-poisoners" was, therefore, a projection of his own fears that he might become a blood-poisoner. Faced with the temptation of the more permissive sexuality of Vienna, he wanted to have sex with women, but was afraid his sperm would poison their blood. He then projected his own sexual desires into Jews- "The black-haired Jewboy lies in wait for hours, satanic joy in his face, for the unsuspecting girl"5 and ended up accusing Jews of being "world blood-poisoners" who "introduced foreign blood into our people's body."6

As is usually the case with delusional systems, Hitler's projection of his fears of his own poisonous sexuality into Jews and foreigners helped him avoid a psychotic breakdown and allowed him to function during his later life. He admitted this quite specifically in Mein Kampf, saying that when he "recognized the Jew as the cold-hearted, shameless, and calculating director of this revolting traffic in the scum of the big city, a cold shudder ran down my back . . . the scales dropped from my eyes. A long soul struggle had reached its conclusion."7 From that moment on, Hitler became a professional anti-Semite, ordering Nazi doctors to find out how Jewish blood differed from Aryan blood, having his own blood regularly sucked by leeches to try to get rid of its "poison,"8 giving speeches full of metaphors of blood poisoning and of Jews sucking people's blood out and, eventually, ordering the extermination of all "world blood-poisoners" in the worst genocide and the most destructive war ever experienced by mankind

The success of Hitler's ability to use anti-Semitism to save his sanity was dependent, of course, upon there being millions of followers who shared his fantasies about poisonous enemies infecting the body of Europe. Much of Europe at that time shared Hitler's experience of a severely abusive childhood,9 and many shared his fantasy that the ills of the modern world were caused by the poisonous nature of Jews.10 When he used metaphors of blood in his speeches, saying the world was a constant warfare of one people against another, where "one creature drinks the blood of another," and that Jews were spiders that "sucked the people's blood out," he was cheered on by millions who shared his fantasies.11