Clinical features
The combination of sensitive personality and an experience perceived as humiliating are the starting point for the emergence of delusional ideas. E. KRETSCHMER classified these disorders into 4 different groups, all belonging to the same disease
- sensitive delusions of reference
- acute dissociative delusions
- paranoid neurosis
- brief psychotic disorder related to obsessions
E. Kretschmer said that various associations and exchanges could be observed between these states.
1. Sensitive delusions of reference
This type of delusion, by far the most frequent, has the systematized symptomatic form of paranoia. It consists of systematized delusions presenting a mode fairly similar to that of obsession with obsessive ruminations that are very often repeated. It is “non-dissociative”, i.e. the delusional mechanism is mainly interpretive: the subject with sensitive paranoia perceives the events correctly but interprets them incorrectly. Consequently, these delusions do not belong to the group of schizophrenia. For example, the words or acts of other people are interpreted as a sign of contempt or a threat. The subject with sensitive paranoia subtly constructs delusional ideas in ramified and ingenious combinations, interpreting everyday conversations, snippets from newspapers, unusual attitudes of family or friends.
According to E. KRETSCHMER, delusions of reference are organized by a psychopathological mechanism of “conscious retention of a group of strongly emotionally charged representations”, for example concerning ethical and sexual or work conflicts. This retention maintains a state of physical tension “isolated from consciousness”, which induces affective slowing like “a parasitic body”.
Sensitive paranoia is very different from the other forms of paranoia (passionate or interpretative) in terms of its rapid reaction to easily detectable adjacent events, its asthenic nature and the absence of querulousness.
The themes of the delusions are mainly recurrent and can comprise:
- ideas of persecution, contempt, humiliation or the belief of being watched
- insults to the subject’s moral or religious values
- conflicts of conscience between the subject’s moral or religious values and sexual practices
- subjects with a depressive connotation
In contrast with schizophrenia, sensitive paranoia described by E. KRETSCHMER comprises little or no auditory or visual hallucinations. However, as we have seen, patients with the “unstable delusions” described by J.M. SUTTER and J.C. SCOTTO can present this type of hallucination.
2. Acute dissociative delusions
This is the extreme form of sensitive delusions of reference. The delusions are said to be dissociative because there is no logical connection between the patient’s delusional ideas.
E. KRETSCHMER defined these delusions as follows in the 3rd edition of its book “Paranoia and Sensitivity” :
“Delusions of reference reach their most severe form when the paranoid state is transformed into acute dissociative delusions. Acute dissociative delusions occur as a brief, critical phase at the paroxysm of the most severe forms of sensitive psychosis. It is characterized psychologically by extreme tensions of affects and their content by the appearance of groups of catatoniform representation, with a physical influence, thought transmission and feelings of strangeness. It is also characterized by loosening of associative links and a tendency to transform despair into delusions of grandeur. Its clinical features are also distinguished from schizophrenic states, according to the limited definition of this term, by the absence of immediate conscious awareness of the delusional experience, by constant fluctuation of the sense of reality, by the absence of autistic attitude, by an easily approachable natural affective attitude and by sociability.
This form of acute delusions of sensitive paranoia is particularly dangerous for the patient, as the patient is not aware of the delusional experience and has only a fluctuating sense of reality. The patient must therefore be hospitalized immediately.
3. Sensitive neurosis
Kretschmer used this term to describe “all states in which the value of the reality of ideas of reference remains below the psychotic limit.”
This type “can constitute an initial phase, which is prolonged by subsequent mental disorders, but secondary paranoid neuroses are especially important because, after resolution of sensitive delusions of reference, they can leave persistent residual symptoms… These states predispose to psychotic relapses”.
In another passage, Kretschmer wrote: “in relation to neurosis, it should be stressed that, in a specifically predisposed individual, an urgent reason for onset of neurosis is only necessary for the first episode. Subsequently, minor reasons derived from everyday life are sufficient to set off the obsessive mechanisms.”
It is as if the sensitive subject’s mental state becomes accustomed to the emergence of neurosis. We have noticed that this is also true for delusions of reference and even for acute delusional state. It is therefore important to optimize drug treatment while the disorders remains relatively minor.
4. Brief psychotic disorder related to obsessions
Marked forms of this type are rare: E. Kretschmer said that he had encountered this form only once. The basis for this brief psychotic disorder is intense nervousness, abruptly resulting in delusional ideas at brief intervals. This form resembles obsessive neuroses.