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Paranoid personality disorder 

Persons with paranoid personality disorder are hypersensitive. They expect trickery and disloyalty from other people. And then they try to avoid all surprises by anticipating them. In an interview people will be intense and guarded and overly serious. They have difficulty expressing warm emotions and tolerating feeling anything that is being dependent on another person. Including feelings of being dependent on the clinician. They are keenly aware of power and rank. They will often seize upon irrelevant details to confirm suspicions. And what happens is that they paranoid people generally do not see the forest for the trees. They will do this about their treatment as well as other aspects of their life. They have very poor judgment in matters relating to their specific fears. Often their judgment is not so impaired in other areas and so can be quite misleading. Itís often only when you get the paranoid person to talk about his or her fears you begin to see the disordered thinking and errors in judgment.

People with paranoid personality disorder may become delusional under stress, but most of the time people are not frankly delusional. Their reality testing is within the bounds of the non-psychotic. Certainly the basic defense mechanism of paranoid personality disorder is projection. This is essentially attributing ones own motives and feelings and desires to someone else because you find them unacceptable in yourself. So in this way people make their inner world safe by making the outside world unsafe. Paranoid people often bear a striking resemblance to the demons that they identify in the outside world. Another defense mechanism that goes with projection is projected identification. And this is essentially where you identify a trait in yourself that you donít want to know about in somebody else, and then make strenuous efforts to control the trait in that other person. So, for example, the woman who believes that all men are out to rape her but is completely unaware of her own sexual desire may structure her life around preventing rape and yet be unaware of her own repressed sexual needs. This is not to be confused with people who have had sexual trauma before.

DSM IV talks about a pervasive and unwarranted tendency to interpret the actions of other people as deliberately demeaning or threatening, and so you can see that you need four out of the seven criteria - you expect to be exploited or harmed being able to bear grudges. Quite a few people who are violent towards spouses in particular, fulfill the criteria for paranoid personality disorder.

The etiology of the paranoid personality disorder is unknown. Some psychoanalytic theorists have suggested that people who would be objects of irrational and unpredictable parental rage may adopt paranoia as a realistic stance in childhood but then be unable to modify that stance in adulthood. The incidence of paranoid personality disorder is unknown because many of these people never present for treatment. The diagnosis is made more frequently in men than in women, and it is more frequently made in biological relatives of schizophrenics.

In terms of differential diagnosis, here are basically four disorders that you want to think about. One is the paranoid disorders in DSM IV. The paranoid disorders essentially involve persistent psychotic symptoms. So if you are frankly delusional, you no longer qualify for paranoid personality disorder. You have a paranoid disorder. Thatís one of the main distinguishing factors. Schizophrenia also needs to be distinguished from paranoid personality disorder. Again, schizophrenia is marked by persistent psychosis and also other positive and negative symptoms that we know so well. Borderline personality disorder also needs to be established because many borderline patients have strong paranoid traits. But borderline individuals are generally involved, over-involved, in chaotic relationships and paranoid individuals are more likely to be distant and under-involved in relationships.

Another disorder to think about is antisocial personality disorder because both antisocial and paranoid personality involve difficulty with intimacy, but paranoid individuals donít have the life-long histories of antisocial behavior.

Treatment. It is important initially to be as open and straightforward as you can in your dealings with paranoid individuals. Use humor quite sparingly because it is so easily misunderstood. It is important to maintain a very professional manner, not to be overly warm, because this can exacerbate someoneís paranoid fears about intrusion. Individual support of psychotherapy is probably the most widely used modality. And it seems to be the best in terms of helping people to think through interpersonal situations and possibly offering an individual alternatives to their paranoid constructions of what is going on in life. Although this is extremely difficult. For example one of the paranoid patients that I treated found that when he did see me in supportive psychotherapy weekly, his life got much better. He came in because his co-workers were plotting against him and doing bad things to him at work. They stopped doing that, but then my paranoid patient thought that they stopped doing it because I told them to stop it and that I was now in control of his life. He became more and more frightened of me and needed to leave the treatment.