Dr F B McManus MB BS FRCPsych RAF, Consultant Psychiatrist,
Scope of Paper
In this paper I beg in by looking at some early history relating to unusually persistent litigants before focusing upon the specific mental health aspects relating to this group of individuals. Some comments on aspects of management are included.
A variety of descriptive terms have been used to describe a group of individuals who are unusually persistent in their litigation. Such terms include querulant litigants, paranoid litigants, litigious paranoia, morbid querulousness and unusually persistent complainants. This group of individuals attracted the attention of some famous names in the early history of psychiatry. Krafft-Ebing wrote in 1886 “Their constantly more voluminous recriminations, requests and denunciations are filled with invectives and insults to officials which attract the attention of the law……they use up their property, insult the courts and disturb public order”. In 1905, Kraepelin described the syndrome of persistent litigation and commented on the style of correspondence of such people. He felt that they wrote their letters like legal documents and often referred to themselves as the plaintiff or defendant. Their written pages were completely covered with writing which extended even to the margins and they frequently underlined words and phrases. Their case was repeated numerous times in different ways.
The problems of such individuals for the legal profession was highlighted in the Vexatious Action Act of 1896 with the first vexatious litigant being found guilty under the Act in 1897. This individual had started 48 legal actions in the preceding 5 yrs and had attempted to sue, amongst others, the Prince of Wales and the Lord Chancellor. It is still a relatively uncommon finding with approximately 6 individuals per year being named as vexatious litigants in the English courts. Historically, such individuals were felt to inhabit the borderland between “sane but obsessed” and “frankly deluded and psychotic”. However, after early writings on the subject, the literature greatly diminished and some modern textbooks of psychiatry make no mention of the topic at all. However, interest may now be reviving in this topic for reasons to be examined later.
A more modern author (Rowlands in 1988) described “a condition in which there is an overvalued idea of having being wronged, that dominates the mental life, and results in behaviour directed to the attainment of justice, and which causes significant problems in the individual’s social and personal life. It usually, but not always, involves petitioning in the courts or other agencies of administration”. He also described in a neat and elegant way “a small group of people who persist in litigation over real or imagined grievances, regardless of cost or consequences”.
I have already mentioned that the psychiatric literature on this topic is relatively sparse. I suspect that this is because it is unusual for such people to be seen by psychiatrists except in very small numbers. Such individuals are highly unlikely to regard themselves as having a psychiatric problem and even if this is suggested to them by others they are not likely to voluntarily seek psychiatric consultation. Even should they go along to seek advice they would probably resist any suggestion that they might require help. Another factor in the relative paucity of literature on the subject was the rise of the anti-psychiatry movement in the 1960’s and 1970’s, largely as a result of the influence of a psychiatrist Thomas Szasz. Szasz became famous for stating his view that psychiatric disorders did not exist. He saw psychiatric diagnoses as a labelling of individuals in a way that meant that psychiatry was serving the interests of societal control rather than any advancement of mental science. Following on in time from this anti-psychiatry movement, there was the development of Equal Opportunities Legislation, the Human Rights Act, the Freedom of Information Act and an increased accountability of public institutions and private companies to the general public. The social climate, particularly in America and Northwest Europe has been described as a “rights culture” or a “culture of complaint” where customers, clients or patients are encouraged by the system and by legislation to pursue any complaint they might have. As a defence against such increased freedom to pursue complaints, it is not surprising that many organisations, wittingly or unwittingly, put many bureaucratic barriers in the way of individuals seeking redress which only served to add fuel to the litigious flames. Before looking at the psychiatry behind morbid querulousness I think it should be acknowledged that there is a whole range of behaviours from that of individuals making a reasonable complaint or initiating litigation right through the spectrum to those individuals who virtually anyone would regard as either being significantly mentally disturbed or else morbidly obsessed with their complaint or litigation. In other words, I do not believe we are looking at an homogenous group of people who can be subsumed under a single label of the “morbidly querulous” – the situation is much more complex than this.
Classification of Associated Mental Health Problems
A variety of psychiatric conditions might explain at least some of the behaviour of the morbidly
querulous. Table 1 lists those conditions in the tenth version of the World Health Organisation’s
International Classification of Diseases (ICD 10) that might underpin morbidly querulant behaviour.
Table 1 Relevant Psychiatric Conditions from ICD 10
Schizophrenia and Delusional Disorders
•Persistent Delusional Disorder
It can be seen from the conditions listed in Table 1 that the words “paranoid” or “paranoia” feature in many of them and this requires further examination. However, in order to understand the relevance of the psychiatric diagnoses we first need to look a little more closely at the underlying psychopathology.
The most serious mental disorders are called psychoses and these are conditions characterised by delusions, hallucinations and other forms of disordered thinking. A delusion is “a belief, firmly held on inadequate grounds, not affected by rational argument or evidence to the contrary and out of keeping with the individual’s educational, cultural or religious background”. An hallucination is a false perception e.g. hearing voices talking to you which can have no basis in reality. An overvalued idea is “an isolated, preoccupying belief, which comes to dominate a person’s life and actions, often indefinitely. The belief is usually more understandable to others and is less rigidly held to than a delusion and the person may be able to express doubt about its truth”.The boundary between a delusion and an overvalued idea is often unclear but McKenna in 1984 stated that he felt that the querulous paranoid state remains the standard clinical example of an overvalued idea. The word “paranoid” was originally used synonymously with “delusional” though in more recent times it is a description applied to a person who is suspicious, mistrustful and who feels persecuted by others. It is interesting to note that psychoanalytic theory sees paranoid individuals as being,fundamentally, people with low self-esteem who feel weak and powerless in dealing with others but who project their own self self-loathing on to others around them, thus coming to feel that they are disliked and badly treated by other people. The psychodynamic defence of “reaction formation” can lead to individuals with marked feelings of inferiority to develop an external mask of arrogance and self assurance, something often seen in paranoid people.
Psychiatric Syndromes of Relevance.
Of the various conditions listed in Table 1, it is the group of paranoid-related conditions that most authors feel to be the key to morbid querulousness and we will focus on this more carefully now. Munro in 1982 proposed a paranoid spectrum of disorders using a dimensional view of the conditions rather than a categorical one.
The paranoid spectrum is found below at Table 2.
Paranoid Ideation Paranoid Personality
It should be noted that Munro did not include Paranoid Ideation in his spectrum but I believe that there is merit in including it for our purposes. As one reads the spectrum from left to right there is an increasing level of severity of disorder and an increasing disintegration of personality and rationality. I will say a little more shortly about paranoid ideation in the general population and so we can first look at Paranoid Personality Disorder.
Table 3 below details the features of Paranoid Personality Disorder
• Excessive sensitivity to setbacks and rebuffs.
• Tendency to bear grudges persistently; a refusal to forgive insults or slights.
• Suspiciousness; tendency to view neutral or friendly actions of others as hostile
• Combative sense of personal rights.
• Recurrent suspicions regarding sexual fidelity of partner.
• Tendency to experience excessive self-importance.
• Pre-occupation with “conspiratorial” explanations of personal and world events.
It is not difficult to see how such a personality could become morbidly querulant. Many observers note that such behaviour begins after a perceived injustice which assumes a special meaning for the individual and goes on to unlock litigious behaviour. Many such individuals will not initially arouse suspicions as they will often be very friendly towards those whom they believe are helping them in their litigation. It is only when their demands become more and more intense and they become less able to be pleased that the individual’s true personality starts to emerge.
Persistent Delusional Disorders
This is a group of disorders in which long-standing delusions constitute the only or the most
conspicuous clinical characteristic. The relative importance of genetic factors, personality
characteristics and life circumstances in their genesis is uncertain and probably variable. Not all delusional disorders are linked to excessive litigation. Some delusions will result in litigious
behaviour while others will not. The condition entitled “Paranoia Querulans” probably represents the archetypical form of delusional disorder linked to excessive litigiousness.
This is the commonest type of schizophrenia in most parts of the world. The clinical picture is
dominated by relatively stable paranoid delusions but is usually accompanied by hallucinations particularly of the auditory variety. While the nature of the delusions or hallucinations might lead one to predict that the person will become excessively litigious, the individual will often have become so disorganised and so lacking drive and motivation by his illness that he is unlikely to become morbidly querulant.
Paranoid Thinking in the General Population.
How common are paranoid thoughts and ideas in a non-clinical population? Freeman et al in a
2005 study carried out an internet survey of 1200 individuals who completed a 20 item self report paranoid check list. This study found that approximately 1/3rd of the group admitted to paranoid thoughts occurring regularly (at least weekly). These thoughts and feelings included a perception of hostility in others, feelings of being watched and criticised and suspiciousness regarding the motivation and behaviour of other people. An increased level of paranoid thinking was seen in individuals who had an avoidant coping strategy, a negative attitude to emotional expression, submissive behaviour, lower social rank and a feeling of lack of control over their lives. Thus, this survey suggests that there is a significant level of paranoid thinking in the general population which, under certain circumstances, could quite understandably progress to litigious behaviour and perhaps even morbidly querulant behaviour.
It is quoted that the age of onset of morbidly querulous behaviour is generally between 40 and 60 years of age. The number of males and females indulging in this behaviour is equal. Astrup in 1984 suggested that 10% of such individuals spontaneously recovered but it is felt by many other observers that the condition runs a chronic course with periods of quiescence followed by outbursts of litigation but with a generally poor lifetime prognosis. It is a widely held view that the morbidly querulant are treatment resistant but this is based more on clinical impression rather than on any systematic study. I have already said that it would probably be very difficult to study psychiatrically a cohort of such individuals as they do not view themselves as ill and would not see a psychiatrist.
If the individual has a mental illness then this might be treated but we come back again to the
problem of getting such individuals to view themselves as being mentally ill and persuading them to seek treatment. Personality disorders are traditionally viewed as being very difficult to treat and paranoid personalities are highly unlikely to engage in any psychotherapeutic process.
The morbidly querulant often focus on personal vindication and retribution and this fits badly with court-based litigation which is geared to provide reparation and compensation. Such people are searching for outcomes that court procedures simply cannot deliver.
There are some study findings which suggest those factors which are usually present from the outset of excessively litigious behaviour and which potentially provide an early warning sign but this does not greatly help in suggesting how such disastrous cases can be aborted early.
It has been suggested that litigants might be inducted into the legal process to identify and counter unrealistic goals. There is debate about whether such individuals should have a single point of contact in their litigation or whether a mutually supportive team approach in the relevant legal department would be better. Individuals facing the morbidly querulous need to maintain a real interest and attentiveness to the litigant yet stay relaxed and detached – doing their best not to get drawn into the individual’s more aberrant behaviour. Judgement should be suspended i.e. “I cannot accept your view but I respect it”. Some of the above measures may help but much further study is required into managing this complex problem.