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Hypochondriasis and paranoia are common psychopathologies of aging. The former may be secondary to depression or organic brain syndrome, whereas the latter may be secondary to sensory impairment or organic brain syndrome. Paranoid schizophrenia, with delusions of grandeur, is rare in later life. The authors classified 273 institutionalized geriatric patients by means of staff ratings into categories such as lucid and alert, confused, hypochondriacal, paranoid, etc. Among confused patients there was a correlation of .45 (p less than .001) between hypochondriasis and paranoia. Even among nonconfused patients, there was a slight positive correlation. The authors concluded that geriatric paranoia and hypochrondriasis have similar structure (delusion) and functions (safeguarding self-esteem and manipulating others). An interpersonal perspective can also provide guidelines for when to treat these conditions.
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PMID:Hypochondriasis and paranoia: similar delusional systems in an institutionalized geriatric population. 43 93

The extremes of drug compliance were studied in two groups of schizophrenics: 29 habitual drug-refusers who invariably discontinued medication only to be readmitted several months later, and 30 drug-complier patients who habitually came in for their refills or injections of antipsychotic medication. The drug-refusers experienced the resurgence of an ego-syntonic grandiose psychosis after they discontinued medication. The habitual compliers, in contrast, developed decompensations characterized by such dysphoric affects as depression, anxiety, virtual absence of grandiosity, and some awareness of illness. The refusal of these chronic schizophrenics to take their medication could not be attributed to social isolation, paranoid diagnosis, or secondary gain. A discriminant function analysis showed grandiosity to be the most powerful discriminating variable between the two groups. We interpret these findings to mean that some schizophrenics may prefer an ego-syntonic grandiose psychosis to a relative drug-induced normality.
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PMID:Drug refusal in schizophrenia and the wish to be crazy. 99 48

During five years of self-medication with Prednisone, a forty-one-year old asthmatic businessman experienced periods of euphoria, psychomotor hyperactivity, and poor judgement; a period of depression and anxiety during temporary steroid withdrawal; and finally, with resumption of Prednisone, episodes of grandiosity and bizarre fugue-like behavior, with adoption of a second identity and culminating in an irrational crime. Steroids were then withdrawn, and the patient resumed his premorbid personality, but had amnesia for much of his previous behavior. The literature on hysterical fugues and corticosteroid-induced mental disturbance is reviewed. The patient's reactions are analyzed in terms of his premorbid neurotic conflicts, the psychological stresses acting upon him, and the effects of Prednisone on his central nervous system.
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PMID:An unusual adverse reaction to self-medication with prednisone: an irrational crime during a fugue-state. 105 90

Plasma levels of 3-methoxy-4-hydroxyphenylglycol (MHPG) were found to be significantly higher in manic patients than in age- and sex-matched normal controls (n = 22). In 18 manic patients plasma MHPG correlated with manic symptoms but not with anxiety, depression, motor behaviour, acute psychosis, schizophrenia and severity of illness. A positive correlation between MHPG and grandiosity items on rating scales suggests a link with cognitive contents and therefore a relationship with central factors.
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PMID:Plasma 3-methoxy-4-hydroxyphenylglycol in manic patients: relationships with clinical variables. 233 Aug 23

Why, one might reasonably query, do some narcissistic characters serve time as seemingly successful presidents of corporations while others serve time as seemingly impaired inpatients on psychiatric units? I will offer some observations on this unusual clinical phenomenon and suggest that it is useful to distinguish between two clinical presentations of narcissistic character psychopathology, which I will call, for the sake of expedience, Level 1 and Level 2. I will then examine 1) how an understanding of the dimensions of empathic abilities, paranoia, levels of depression, grandiosity, and defensive uses of denial and disavowal can lend a broad explanatory range to the understanding of these levels, and 2) how we can assess both successful and unsuccessful adaptation to the outer world and the inner world in narcissistic disorders. Moreover, it is important to distinguish between being well adapted and being emotionally healthy, which are quite different in meaning and intent. I use the term Level 1 to refer to the more poorly adapted presentation, and the term Level 2 to refer to the more successfully adapted narcissistic presentation. Characteristics of Level 1 narcissistic pathology dispose a patient to an adaptation that is similar to the description of the narcissistic patient who is often described as borderline; characteristics of Level 2 narcissistic pathology dispose a patient to a high-flying and superficially successful adaptation in which the patient can competently navigate the occupational and social demands of an external world despite the presence of severe object relational impairments. While a difference in adaptation is highlighted, emotional well-being is not within the exclusive province of either's characteristic adaptive skills.
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PMID:Levels of adaptation and narcissistic psychopathology. 273 21

Risk of relapse and recidivism makes the failure to take antipsychotic medication as prescribed a significant issue in forensic psychiatry. This question may arise in such contexts as the setting of bail, plea bargaining, the insanity defense, and sentencing. We have reviewed the literature on medication noncompliance in schizophrenia and present here the results, organized by topics relevant for the work of forensic mental health experts. Reported rates of noncompliance vary widely, reflecting major differences in the populations studied and the methods used as well as the complexities involved in defining noncompliant behavior. A noncompliance rate of 50 percent has been attributed globally to chronic patients, both medical and psychiatric. The tendency of significant factors to interact precludes a simple typology of noncompliance. However, environmental security and supportiveness correlate positively with adherence; whereas anxiety, paranoia, grandiosity, depression, and side effects correlate negatively. Clinicians' assessments of whether medication is being taken have proven to be unreliable. Although monitoring by chemical measurement, particularly a radioreceptor assay for urine samples, can be useful, depot injection ensures that prescribed medication is being taken. Less invasive means of promoting compliance are described; psychodynamic and ethical issues to be considered in the monitoring and promotion of compliance over extended time periods are presented. We also probe the link between medication noncompliance and behavioral relapse. The time between default and relapse is most often measured in weeks. Whether due to medication withdrawal or not, the relapse pattern of each individual tends to repeat, allowing its recognition before recidivism occurs. Restarting medication at this stage, especially with a dosage increase, is usually effective. In sum, the forensic mental health expert can now readily use a large and diverse literature to assist with a variety of significant issues.
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PMID:Medication noncompliance in schizophrenia: codification and update. 287 51

The differences in the psychopathologic status of 26 complaint and 32 noncomplaint schizophrenic patients were evaluated on the basis of rating scales used at discharge. Noncomplaint patients had significantly higher scores for grandiosity, lack of feeling of illness and insight into it. Their score for global psychopathological state and disturbance in social adjustment was also significantly higher. The compliant patients had significantly higher score for self-rated depression.
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PMID:Clinical symptomatology and drug compliance in schizophrenic patients. 289 46

The growth of object relationships may be studied along either the developmental line of the discharge-object or that of the reflexive-object. The former is the well-known line of development from the need-satisfying object to the constant object and is a study of id-ego relationships. The developmental line of the reflexive-object, on the other hand, follows the history of the introjects and is a study of either ego-superego or ego-ego ideal relationships. It is the latter which constitutes the study of narcissism. The development of the ideal ego out of the ego nuclei leads eventually to the child's struggle to maintain a sense of omnipotence and to the narcissistic crisis. Out of this struggle the introjection of the idealized mother occurs which, as the ego ideal, continues the systemic line of development of narcissism. Various narcissistic states and affects such as shame, humiliation, depression, grandiosity, pomposity, arrogance, adoration and enthralment are the result of either hypercathexis of the introjects of the ego ideal (or of persisting remnants of the ideal ego) and the resulting conflict with the ego, or hypocathexis of the introjects and resulting dormancy of the system ego ideal.
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PMID:Narcissism: its structures, systems and affects. 401 39

Affective symptoms were evaluated in chronic alcoholics during a 2-week period following detoxification from alcohol. Increased ratings were apparent both on the Manic State Rating Scale (MSRS) and on the Ma Scale of the Minnesota Multiphasic Personality Inventory (MMPI) in a subgroup of these patients. Primary symptoms included grandiosity, irritability, and mildly increased psychomotor activity. Alcoholics who had been detoxified for several months or hospitalized medical patients did not show similar symptoms. Measurements of urinary 3-methoxy-4-hydroxyphenylethylene glycol (MHPG), a metabolite of norepinephrine which has been associated with manic-depressive illness, also showed increased excretion in a subpopulation of recently detoxified patients. The coexistence of depressed mood in these patients may have led to symptoms of hypomania being previously overlooked, although signs of depression are common in mania itself.
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PMID:Altered mood and norepinephrine metabolism following withdrawal from alcohol. 664 96

In this article I have elucidated the diagnostic entity of the grandiose character, primary type. The concept of the primary grandiose character has been around for a long time but has not been formally elucidated. The primary grandiose character is contrasted to the reactive grandiose character, which is the type normally considered in the literature. The primary grandiose character is someone who was treated with such anticipation and succor by the parents that he learned to feel no way but good and to demand succor when he did not feel good. The reactive grandiose character is someone who originally moderated his primary grandiosity but re-intensified it in order to defend against later appearing pain, particularly of a narcissistic sort. The primary grandiose character develops a large array of fears and depressions as he learns little developmentally except how to demand. In the face of these increasing anxieties and depressions, he simply demands more and more. When he appears in treatment, he shows himself as an anxiety- and depression-ridden individual, with a strong need for help (succor). The analyst tries to help with the anxieties and depressions but the treatment goes round and round because the patient does not cathect the observing function of his own ego, only that of the analyst's ego: the analyst is to know what is wrong (observe it) and fix it. When the analyst does not fix it (although he might, for a while, observe it), the analysand's grandiose rage breaks through and he shows himself for what he is, a grandiose character, primary type. Now the task is clear but the treatment formidable. The analysand must come to observe that he is grandiose and that he has foresworn the observing function. This process, which comprises a major portion of the working through, is replete with grandiose rage, working through, grandiose rage, and working through. Ultimately the patient discovers the great strength that comes from decreased reliance on the observing ego of others and increased reliance on his own observing ego. A number of diagnostic entities and clinical behaviors are shown to have a primary grandiose base. And rather than some of these depending upon repression as the basic defense, it would seem that they depend on a pre-stage of repression, akin to the concept of biological irritability. The concepts of secondary grandiosity, partial grandiosity, and developmental grandiosity are natural corollaries to the concept of primary grandiosity.
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PMID:The grandiose character, primary type. 764 1


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