Paranoia: Prevalence and Correlates

Clinicians dealing with psychiatric disorders commonly encounter patients with paranoia in their clinical practices.  However, it is important for clinicians to understand the relatively frequency of paranoia endorsement by people in the general population.  Whether paranoia is a pathological phenomenon commonly depends on the degree of paranoia, associated signs and symptoms and presence (or absence) of a formal psychiatric diagnosis.  Freeman and colleagues from the Institute of Psychiatry other colleagues in London published an important paper to address this issue.

Their data and research stems from a general population study of over 7,000 general population survey respondent in England.  To assess paranoia in the general population, subjects were asked three questions where positive responses reflected increasing severity of paranoia.  The three questions in the survery (and the general population rate of endorsement) were:

• Paranoia level 1. ‘Over the past year, have there been times when you felt that people were against you?  (18.6%)
• Paranoia level 2. ‘In the past year, have there been times when you felt that people were deliberately acting to harm you or your interests ? (8.2%)
• Paranoia level 3. ‘In the past year, have there been times you felt that a group of people was plotting to cause you serious harm or injury?  (1.8%)

I found it interesting the relatively high rate of endorsement of paranoia level 1 in the general population.  Nearly one in five endorsed feeling times in the last year when they felt that people were against them.  As the severity of paranoia increased, the prevalence rates decreased to less than 2% of the population fealing a good of people was plotting to cause them harm or injury.

The research also looked at some of the correlates of paranoia.  Those endorsing each level of paranoia were compared to those with no endorsement of paranoia.  The paper is packed with data but here are some of the things that stood out for me:

• Level 1 paranoia was more likely to be endorsed by women while level 3 paranoia was more likely to be endorsed by men
• Paranoia rates were higher in populations with a variety of medical conditions including: diabetes, hearing or visual problems, recent heart attack/angina.  There was a trend for increased level 3 paranoia in those with obesity (BMI greater than 30 kg/m2)
• Paranoia rates were higher in a variety variables indicating social isolation, i.e. separated, divorced or single marital status, fewer number of close family members or friends, fewer supportive relationships
• Paranoia rates were higher along with a variety of other psychiatric symptoms/disorders, i.e. insomnia, depression,worry, anxiety, panic and PTSD
• Paranoia rates were increased in those endorsing suicidal thoughts in past year, history of a suicide attempt, anxiolytic and antidepressant drug use and not surprisingly antipsychotic medication use
• Paranoia rates were strongly and progressively associated with cannabis use and less strongly associated with heavy drinking

In summary, this research manuscript provides a valuable overview of paranoia.  Elements of paranoia are relatively common in the general population.  Paranoia is a marker for many other psychiatric syndromes and cannabis abuse.  Clinicians should include screening questions for paranoia in routine clinical assessment.

Photo of Japanese Maple Courtesy of Yates Photography

Freeman, D., McManus, S., Brugha, T., Meltzer, H., Jenkins, R., & Bebbington, P. (2010). Concomitants of paranoia in the general population Psychological Medicine, 41 (05), 923-936 DOI: 10.1017/S0033291710001546

Gabapentin Improves Outcome in Alcoholism

Molecular Model of GABA

Improving abstinence rates in alcoholism continues to be a goal of treatment research. Several novel drug treatment strategies in alcoholism have targeted the neurotransmitter gamma-aminobutryic acid or GABA. GABA is the major inhibitor neurotransmitter in the brain.  Alcohol has effects through the GABA receptor.  Alcohol withdrawal is typically treated with the sedative drug class of benzodiazepines known to have effects on GABA receptors.  There are two main types of CNS GABA receptors GABA(A) and GABA(B).

Here is summary of drugs known to have effects through GABA and the GABA receptor:
GABA analogues: gabapentin, pregabalin
GABA(A) agonists (activators): alcohol, benzodiazepines, barbiturates,carisoprodol (SOMA), propofol, kava, valerian
GABA (A) antagonists (inhibitors):  flumazenil
GABA(B) agonists: baclofen
GABA(B) antagonists:phaclofen
GABA reuptake inhibitors (activators): tiagabine

Naltrexone (an opioid receptor antagonist) has an FDA indication for alcohol dependence in the United States.  However, a significant number of patients taking naltrexone for alcohol dependence do relapse, so successful augmentation strategies are necessary. A recent randomized clinical has been published online at the American Journal of Psychiatry looking at augmentation of naltrexone with gabapentin in alcohol dependence.  Here are the key elements of the study design:

Molecular Model of Gabapentin

Inclusion criteria: DSM-IV alcohol dependence, consuming 5 or more drinks per day (4 for women), able to enter study with a minimum of 4 days of abstinence
Exclusion criteria: current suicidal or homicidal ideation, no drug dependence, use of illicit drugs in last 30 days, positive urine drug screen, psychotropic or anticonvulsant drug use, medical problems including elevated liver enzymes
Random drug assignments: placebo, naltrexone 50 mg, naltrexone 50 mg plus gabapentin up to 1200 mg daily

The study found that the combined medication group was less likely to relapse to at least one heavy drinking day through six weeks (33% vs about 50% for both placebo and naltrexone alone).  Biomarkers of drinking also favored the combined group suggesting validity to the self-reported drinking history finding.  Interestingly, the combined gabapentin/naltrexone group reported the fewest complaints about sleep during the study.  Sleep complaints correlated with number of heavy drinking days. Additionally, gabapentin augmentation appeared to also be most beneficial in subjects with a history of alcohol withdrawal.

Gabapentin was withdrawn after six weeks and the drinking outcome improvement in the combined group waned in the ensuing 10 weeks of follow up.   This suggests that longer term treatment with gabapentin may be necessary to sustain the original superior reponse.

Although, this study is not large enough to change practice guidelines the results are encouraging and need replication.  Gabapentin is currently available (and in generic form) and approved for the treatment of seizures. If confirmed effective in alcoholism gabapentin could provide clinicians with another safe medication option.

Molecular Model of GABA From Creative Commons file--source Wikipedia author Ben Mills
Molecular Model of Gabapentin From Creative Commons file--source Wikipedia, author Fvasconellos

Anton RF, Myrick H, Wright TM, Latham PK, Baros AM, Waid LR, & Randall PK (2011). Gabapentin Combined With Naltrexone for the Treatment of Alcohol Dependence. The American journal of psychiatry PMID: 21454917