Resnick in forensic conferences emphasizes that "a building crescendo of paranoia" in and of itself is grounds to have someone held in a psych facility for further evaluation and cites several cases where people were new in their first-break psychosis, had a building crescendo of paranoia, and the clinician discharged the patient only to have that patient kill someone within the next few days.
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Based on what Resnick stated I have placed people in the hospital when detecting this building crescendo of paranoia and have often times quoted him in court when these cases graduated from the hold phase to the involuntary commitment phase.
IMHO suspected psychosis and homicidal thinking is enough for a hold and from there it should be considered. A building crescendo of paranoia too should be in and of itself grounds for at least a hold. The risk is hurting the therapeutic alliance.
Whopper - thanks so much for your informative post! I'm just responding - not disagreeing. I've seen Resnick talk about mounting paranoia. But do you think there are actually any US states where "a building crescendo of paranoia" is grounds for more than say, a 72 hour hold? A 72 hour hold sounds great until you realize that, unlike Resnick, you actually treat lots of general psychiatry patients, and those patients are yours even after the 72 hour hold expires. (Or else you've just passed the liability onto someone else - an inpatient doc, or a judge somewhere - ok fine. Is psychiatry about passing on liability? Is that all we do? We put people on holds even though we don't have cures for their problems?)
Is it even helpful to put people on 72 hour holds on the basis of a single diagnostic feature, i.e. paranoia? Psychiatry is not Beethoven, after all. A crescendo is not naturally followed by anything in psychiatry. None of us knows when or where a crescendo of paranoia will peak. And people can be paranoid over all manner of things, including neighborhood disputes, marital infidelity, politics, etc.
If you compare paranoia to chest pain, you can see the problem. Many if not most fatal MIs are preceded by mounting chest pain. The diagnosis is aided if there are related quantifiable features such as elevated BP, cholesterol levels, a family or smoking history, etc. But certainly not all mounting chest pain is indicative of a coming MI. Chest pain can be musculoskeletal, or a PE, or GI related. If everyone with mounting chest pain were subjected to catheterization, many people would be harmed unnecessarily. The parallel in Resnick's paranoia model is that many people will be unnecessarily detained (which damages their personal and family lives and professional reputations even if we tend to ignore this ugly fact about 72 hour holds.) See my point? What would Resnick say about that basic problem of predictive probability which exists throughout all medicine? Does he accept that it's ok for us in psychiatry to have a lower level of predictive probability? Because I'm pretty sure we do.
As far as quoting him in court - I'm impressed that you do that. In my opinion, he is not the standard of care in general psychiatry - he is the standard of excellence in the forensic world. Most probate court judges I've encountered wouldn't even know who he is!
