Objectives

• What are the DSM-IV criteria for the paranoid personality?

• The vigilant personality is a normal variant of the paranoid. Describe its characteristics and relate them to the more disordered criteria of the DSM-IV.

• Explain how different personality styles combine to form each of the subtypes of the paranoid personality.

• Is there a genetic connection among paranoid personality, delusional disorder, and schizophrenia?

• Explain Freud's contention that paranoia is a defense against unconscious homosexual urges?

• How does splitting work in paranoid functioning according to object-relations theorists?

• Explain how megalomania and omnipotence relate to the paranoid's extremely low self-esteem.

• How does early abuse lead to the development of paranoid tendencies?

• Explain why the central cognitive problem of the paranoid is not perceptual but interpretive.

• How can signal detection theory help us understand paranoid thinking?

• What are the core beliefs of the paranoid?

• Lack of trust is the hallmark of the paranoid's thinking. Explain how that lack of trust affects their interpersonal world.

• Paranoids share characteristics with other personality disorders. List these other disorders and explain the distinction between each and the paranoid.

• Are paranoids prone to substance abuse?

• Therapy is very threatening to paranoids and equally difficult for the therapist. List some of the major pitfalls that the therapist must avoid.

• List therapeutic goals for the paranoid personality.

Undoubtedly, you have encountered people who question the integrity of everything said to them. Often, they are fearful that they will be taken advantage of and have no qualms expressing this fear. Distrust fills their lives to the extent that even family members and others who may be considered closest to them (if they have allowed any) are not excluded from this equation. Yet trust and self-determination are fundamental to existence. We trust others to have our best interest at heart, to come to our assistance in time of need, to provide helpful advice, to anticipate dire outcomes that might escape us, to inform us tactfully when our judgment is wrong, and to help keep our lives running smoothly. We may, at times, argue vehemently with our family and close friends, but when the chips are down, there is an understanding that those we love will "be there" to protect us and fight by our side, at a moment's notice, if necessary.

Among paranoid personalities, the focus of this chapter, the basic capacity for trust has somehow been destroyed. Most people see some fundamental goodness in human nature. Paranoids, however, usually view sincerity as a danger sign, a "Trojan Horse" sent to conceal evil schemes and nefarious intentions. Others are the enemy, waiting to rush in, strip them of their already-questionable safety and security, expose their precious vulnerabilities, and ultimately devour them with sadistic delight. For protection, paranoids wall themselves in to keep others out. Never letting their guard down, they watch vigilantly for any sign of impending onslaught from the deep recesses of their fortress. Nothing must escape their scrutiny. From the perspective of others, they are guarded, hostile, self-righteous, rigid, black-and-white thinkers, unwilling to consider the objective evidence and draw rational conclusions. Instead, they misread consensual social reality, attribute hidden motives to others, and even accuse lifelong friends of heinous betrayals. Standing alone against the world at the very precipice of destruction, paranoids bandage themselves with righteous indignation and self-pity, further fueling their anger.

To protect themselves against hidden assaults, paranoids search for information that corroborates their suspicions. Even the most incidental fact may become a huge brush stroke and subsequently be used to support sweeping conclusions. Gradually, unconnected facts are drawn together into a fabric that reveals the outcroppings of a dark conspiracy. Eventually, paranoids fabricate a "pseudocommunity" (Cameron, 1963) in which the objective attributes and intentions of real people have been lost, replaced instead by sinister traits and motives imposed by the paranoid mind. By creating a reality that confirms their fears, their anxious desperation grows ever more intense, fueling circles ever more vicious, leading to retreat behind ever stronger and higher walls, still greater vigilance, and finally, the discovery of new layers of intrigue, which function to keep the cycle going.

Reflect on the case of Ron (Case 13.1). Ron has been forced to seek counseling by the court, and he is not at all happy about it. Defensiveness and a thinly concealed aggression are part and parcel of the paranoid personality. Ron crosses his arms and never breaks eye contact. He is invested in letting others know that he is on his guard, he "knows" what is happening, and he is tired of what he regards as a thin façade of social propriety, when others really just want to exploit him. He refuses to share anything

Forced to seek counseling by the court, Ron was resistant from the very start, even though assured that confidentiality is an important part of the therapeutic relationship.1 He postures himself defensively, crosses his arms tightly across his chest, taps his foot furiously in endless circles, and glares at the interviewer, never breaking eye contact. An aggressive stance is firmly in place.

For almost a year now, Ron has refused to pay child support to his former wife. Although he states openly that his position is "deplorable," he nevertheless answers specific questions only reluctantly. Sometimes, he challenges the therapist by asking, "Why would you need to know that? I just don't see the relevance." Otherwise, he deflects questions or gives only marginally useful information. When asked why he is evasive, he pauses, makes piercing eye contact, and says, "Because you never know when something might come back to haunt you." Obviously, he suspects that the therapist and the court have ulterior motives. What he does answer paints him in the role of the victim.

Eventually, he states that his wife has been unfaithful to him, and that he suspects even his children, ages 7 and 12, are not his own. He becomes more defensive when asked why he believes his wife has been unfaithful. He offers no direct substantiation, but believes that she and his former best friend have been carrying on an affair. "I can see it in their eyes when we're together," he says. Apparently, the belief itself suffices for proof. Although he admits his children do resemble him, he also asserts indignantly that both his children and his friend have brown hair. The fact that his wife has brown hair is unimportant. He maintains that he should not be ordered to support a woman who has betrayed him and made his life intolerable.

Ron is also having trouble at work. He notes that his coworkers have been manipulating the time clock so that he is cheated out of pay, while adding it to their own checks. "I can't prove it yet, but I know they'll slip up. I'm keeping my eyes wide open for them. They're trying to humiliate me in front of society by making it impossible for me to provide for a family. They want to tarnish my good name before the community." He admits that the family is having problems with money, which he attributes to his coworkers.

When asked why he believes these things, Ron becomes very agitated, interpreting a simple request for information as blatant and insulting skepticism. Each subsequent gesture and inflection is viewed with suspicion. He continues with a fusillade of remarks that malign his wife, and now, the motivations of the therapist and the court. He states that he believes that he is the victim of a well-conceived plan. Even his putative children are perhaps coconspirators with all those involved. Moreover, he asserts, "I'll never forgive the injustices that have been done to me, and I'll never forget them, either. My memory is long, and I'll see that those who have wronged me are made to pay. You can count on that." He glares at the interviewer one last time before leaving.

1 Numbers mark aspects of the case most consistent with DSM criteria, and do not necessarily indicate that the case "meets" diagnostic criteria in this respect.

Paranoid Personality Disorder DSM-IV Criteria

A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

(1) suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her

(2) is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates

(3) is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her

(4) reads hidden demeaning or threatening meanings into benign remarks or events

(5) persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights

(6) perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack

(7) has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner

B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic Features, or another Psychotic Disorder and is not due to the direct physiological effects of a general medical condition.

Note: If criteria are met prior to the onset of Schizophrenia, add "Premorbid," e.g. "Paranoid Personality Disorder (Premorbid)."

Reproduced with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association.

substantial with the therapist because he "knows" that such information might be used against him. For Ron, others are on a need-to-know basis, and even then, he is reluctant to reveal much of anything (see criterion 3).

Ron has his reasons. Because trust and loyalty are such fundamental issues for paranoids, many become obsessed with the notion that their spouse or lover has been unfaithful. Ron has accused his wife of cheating, though he has no solid evidence, and even suspects that his children are not his own, although their ages would require an ongoing affair stretching 12 years into the past (see criterion 7). Strangely, Ron is tormented by the fact that both his children and his best friend have brown hair, even though his wife also has brown hair. He neglects the obvious in favor of data that support his own misinterpretation of reality. Moreover, he deeply fears and resents the possibility that he might be forced by the legal system to supply funds that will be used to raise someone else's children, and he is determined not to let this happen. Ironically, the more he is pushed to take responsibility for his children, the more aggressively certain he will become that they are not his at all.

Like other paranoid personalities, Ron's concern with deceit is easily generalized beyond a single forum or relationship. He could reconstruct reality in any number of ways, but he has chosen a path in which he is the victim and others are the beneficiaries. For example, he believes that his coworkers are manipulating the time clock (see criterion 2). He suspects that they not only cheat him out of pay but also add that money to their own checks, thus allowing them to enjoy the fruits of Ron's toil behind his back. Therefore, his indignation is doubly justified: His deficit is their surplus; his agony, their joy. The case does not elaborate, but we can easily imagine Ron lying awake at night, recycling the injustices done to him again and again, becoming angrier and angrier and more and more determined to avenge himself or at least catch them in the act. Like other paranoids, Ron holds grudges and seldom forgives an injury (see criterion 5). He can't, because he is always reconstructing reality so that others have self-consciously exploited or attacked him. Nothing is accidental.

Moreover, the putative attacks on Ron made through the time clock go beyond simple exploitation. Instead, they are attacks on his character (see criterion 6). If successful, they will prove something to the world: Ron is a person of low moral quality, and he is unable to provide for a family, apparently a characteristic essential to his self-respect and one he believes is essential to the respect of others. Thus, in addition to deceiving Ron, his enemies are now waging war on another, even more malicious front: They are attempting to deceive the public about him. Of the two forms of attack, Ron may fear the second even more than the first. He can potentially thwart attacks against his person, but he cannot as easily control the perceptions of others. Such distortions of reality could give way to further, more severe paranoid developments—perhaps the notion that others are talking about failures and inadequacies behind his back even though they may have no foundation in truth. In Ron's mind, others might be saying, "Yeah, I heard his take-home pay was so embarrassing his wife couldn't take it anymore and started screwing his best friend."

Given the portrait of Ron, we are now in a position to approach additional issues that form the plan of this chapter. First, we compare normality and abnormality; then we move on to variations on the basic paranoid pattern. After that, biological, psycho-dynamic, interpersonal, and cognitive perspectives on the paranoid personality are described. These sections form the core of what is scientific in personality. By seeking to explain what we observe in character sketches like Ron's, the goal is to move beyond literary anecdote and enter the domain of theory. As always, we present history and description side by side, noting the contributions of past thinkers, each of whom tends to bring into focus a different aspect of the disorder. Developmental hypotheses are also reviewed but are tentative for all personality disorders. Next, the Evolutionary Neurodevelopmental Perspective section presents a theory of how the existence of this personality pattern follows from the laws of evolution. Also included are a comparison between the paranoid and other theory-derived constructs and a discussion of how paranoid personalities tend to develop Axis I disorders. Finally, we survey how the disorder might be treated through psychotherapy, again organizing our material in terms of classical approaches to the field: the interpersonal, cognitive, and psychodynamic perspectives.

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