By: THEODORE MILLON
et al.
Among paranoid
personalities, the capacity for trust has been destroyed. While it is part of our normal, human development to have some
mistrust of others, especially when we are young (stranger anxiety) or if we live in
life-threatening situations, a persistent and extreme mistrust of others is
maladaptive. Within the normal range of personality styles that include
paranoid characteristics are Oldham and Morris’s (1995) vigilant style, who are highly
independent and valuing of their independence. Normal paranoid styles can also
be viewed as simply normalizing the DSM-IV criteria, such as valuing honesty and fidelity without alienating
friends and family instead of suspecting close friends of being disloyal
without evidence.
Several variants
exist of the paranoid personality that combine paranoid traits with other personalities. The fanatical paranoid is a mix
with the narcissistic personality who has had a serious narcissistic wound. The
malignant paranoid combines the paranoid with the sadistic personality and is
hypersensitive to issues of power and domination. The obdurate paranoid shares
traits with the compulsive personality and may function more normally in
society than most paranoids. The querulous paranoid is a paranoid with negativistic
traits who feels perpetually as though he or she has been cheated in life. Last, the
insular paranoid shares characteristics with the avoidant personality, tending
to be the most isolated of the paranoids.
While
biologically, there does not appear to be a paranoid temperament, most likely the same irritable and
aggressive temperament that may also lead to antisocial, sadistic, or borderline
personality plays a role in the paranoid, with early environmental factors playing a great role in
determining the ultimate path of development. Limited empirical research conducted on
the heritability of a paranoid personality has been inconclusive as have been studies that
try to link paranoid personality to schizophrenia and delusional disorder.
The classical
psychodynamic perspective offers an interesting insight into the paranoid,
namely their overdependence on the defense mechanism of projection. Strict Freudian interpretation of the paranoid personality
holds that the paranoia is a defense against homosexual urges that
are unacceptable to the individual. Later in the century, object-representation lists began to see the paranoid
as polarizing life into categories of all good and all bad. By using projection to
eliminate any of the bad in the self, they become all good; hence
anything external becomes all bad. Because the negative thoughts are within the
paranoid, they follow the paranoid wherever they go in life. Later dynamicists proposed
secondary defense mechanisms such as using isolation, indignation, and
megalomania or extreme overvaluation of the self as well as early abuse
in the development of
the paranoid personality.
Paranoids closely
resemble compulsives in their cognitive style. Both are keen observers,
attending to every detail and nuance of a situation; and both are intolerant of ambiguity. For the paranoid, suspiciousness becomes
the entire mode of thinking where all of their energy is spent discovering not if people
are cheating them, but how they are cheating them. Their self-statements may include, “I
must always be on my guard,” and “I must be alert to hidden motives.”
Interpersonally,
Sullivan proposed that paranoids not only have an extreme insecurity related to a feeling of inferiority but also blame
others instead of themselves for these perceived shortcomings. Paranoids treat others as the
enemy, which precludes the development of any attachments. Occasionally,
paranoids surround themselves with loyal persons who can act as the eyes and ears of the
paranoid, routing out evil plots being planned against them.
Developmentally,
Benjamin describes an environment of harsh punishment
in childhood that leads the paranoid to expect that the world is going to
attack. The paranoid might have also been used as a scapegoat for the family.
The biopsychosocial
evolutionary perspective adds yet another angle to understanding the paranoid
personality. Paranoid traits act as “danger detectors” from impending
attacks and serve a useful
purpose of saving the life of the individual. Thus, the potential for paranoid
fear is probably an inevitable outcome of evolution and, expressed in
moderation, is highly
beneficial to the organism.
Paranoid traits
are expressed by all of the severe personality disorders but also in avoidants, narcissists, sadists, antisocials, and
compulsives. They also often overlap with delusional disorder; anxiety disorders; mood
disorders, particularly depression and perhaps bipolar disorder; somatization disorders
in an effort to escape the shame of not being able to engage the world effectively; and
substance abuse, especially when the paranoid is experiencing symptoms of anxiety.
Therapy seems to
be most successful with paranoids closer to normal on the spectrum. Numerous traps must be avoided when working with the
paranoid. The most dangerous is directly confronting the paranoid’s semidelusional
notions, which will be construed by the client as proof of another attack. Benjamin
proposes a soothing empathy as an antidote to earlier abuse to increase the
intimacy between the client and therapist. Cognitive techniques should focus on
modifying the assumption that others are not to be trusted and improving their sense of
self-efficacy. Behaviorally, coping skills training may be effective, as well
as anxiety-reducing exercises such as gradual exposure to an anxiety
hierarchy paired with a
cognitive relaxation method. Object-relations therapy may also be useful as a first step to
get paranoids to convert their paranoid symptoms into an acknowledged
depression; then they can be treated with traditional methods.
References
Personality Disorders in Modern Life, second edition, 2000,
2004 by John Wiley & Sons, Inc.
Read Also
Paranoid Personality Disorder, Case vignette (2)Paranoid Personality Disorder, Case vignette (3)
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