The Cognitive Perspective

Cognitively, paranoids have much in common with the compulsive personality. Both are keen observers, with an outstanding attention to detail motivated by fear. Compulsives, however, sublimate their interpersonal conflicts in an effort to satisfy their internalized objects, their condemning parents, who have taken up residence in a carping superego. In contrast, paranoids are perpetually under attack from their internalized objects but project these attacks, which are then experienced as coming from external sources. After having been pushed all his life to satisfy the expectations of his parents, for example, we can imagine the self-condemnation that Stephen must feel.

Furthermore, both the compulsive and the paranoid have superego pathologies that take the joy out of life. Compulsives, however, become "hyperadjusted," whereas paranoids become keen observers who are extremely suspicious of the motives of others. A constant fear that danger might go undetected compels them toward scrutiny of the smallest details of their interactions. All communications are analyzed for nuance, double meaning, and their implications for power, status, and threat to autonomy. Because the abstract is inherently slippery, everything must be concretized. Ambiguity becomes intolerable.

As noted by Shapiro (1965), suspiciousness goes beyond a contextual trait to an active mode of cognition—not just a consequence but also a cause, a "preoccupying expectation" (p. 56), of which hypervigilance is an important part. Suspiciousness is not the detached curiosity of the scientist. Instead, it is energy invested with a bias toward discovering anything that confirms the original suspicion. Paranoids do not seek to test reality; they seek an empirical foundation that validates self-referential constructions that they are being conspired against and influenced, for example. From the very beginning, their mission is one of discovery, not hypothesis testing. Ron is not interested in proving whether his coworkers are cheating him out of his pay; rather, he is interested only in proving that they are cheating him.

The central cognitive problem of the paranoid, then, is not perceptual but interpretive. The same basic stimulus inputs are received fine, but the information is processed with the explicit goal of identifying plots, persecutions, slights, and criticisms. Stephen, for example, is not interested in discovering the limitations of his ideas and how they might be better adapted to their purpose. When faced with constructive criticism, he sees only the "criticism" and never the "constructive." Suspicion is thus a central mechanism in perpetuating the disorder. Every discovery of additional evidence simultaneously fuels anxiety, indignation, and resentment, which justifies the need for ongoing scrutiny in turn.

Because paranoid thinking is different from normal thinking, it has its own criteria for success. We all bring our own filter to the facts, but we nevertheless do test reality with some degree of scientific detachment. When inconsistencies arise, they become the object of intense interest. Eventually, they are approached logically and either solved or tolerated as not yet explainable. Most of us would agree that few things are either one way or the other and that a tolerance for ambiguity and complexity is necessary in contemporary life.

Paranoid thinking, however, is neither disinterestedly inductive nor logically deductive. Instead, it is a search process, and its success depends on its ability to see through external appearances and uncover concealed truths. Unless surface realities are somehow penetrated, paranoids remain convinced that the truth is concealed—they are in the dark while others are aware. For this reason, paranoids cannot let themselves be swayed by the interpretations of others, who would only deceive them or feed them misinformation. Instead, they are self-contained, impervious to external influence or correction.

As noted by Shapiro (1965, p. 64), the paranoid style ultimately ends in a "loss of reality" similar to that experienced by the compulsive, but much more severe. By this, Shapiro does not mean that suspicion as a mode of cognition necessarily eventuates in a psychotic break, but instead, that the wholeness of social reality, its fabric and feel, is simply lost. The search for clues is guided by an attention that magnifies every small detail, as if paranoids were asking again and again, "Is this all? Is this all? Here's something, there must be more." Each tiny feature must be compulsively put under a microscope.

Shapiro (1965) uses the difference between hearing and listening as an example. A sound technician, he notes, hears the technical aspects of the audio, not the music. The same is true for the paranoid. By zeroing in on the tiniest detail, the ability to make holistic appraisals is lost. The pleasant atmosphere of a party, the ambiance of a nice restaurant—such things are simply not appreciated. As noted by Akhtar (1992), discussed previously, even aesthetic appreciation becomes impossible. Unable to understand the overall tone of a social engagement, for example, paranoids lack the sense of proportion necessary to appraise the details of interpersonal interactions. The eventual outcome is a strange autism of detail, a new world fabricated completely from decon-textualized detail. Shorn of context, the paranoid is now free to entertain hypotheses of dubious probability and to imbue these details with idiosyncratic meanings that are consistent with their dark suspicions. This accounts for the paradoxical fact that both a paranoid and a normal person can agree on the objective course of events but not on their interpretation.

Elaborating on Shapiro, there is yet another important reason that paranoids are always groping for clues: The evidence that might conclusively prove their case simply does not exist. Undoubtedly, paranoids do discover coincidences that are strange and convincing, at least to them. However, their construction of the world is simply wrong. There is no proof because there is no proof. Perhaps this explains why paranoids feel that things are kept from them, others are hiding something, and surface appearances conceal dark secrets. Once such a conviction develops, objective support must seem strangely inaccessible. Ever searching for insight into an illusory level of reality, paranoid cognition disintegrates into indicators and frequencies. Anything that occurs too often is suspect, as is anything that does not occur often enough or otherwise seems out of the ordinary. And because life is rich with thousands of elements that might be monitored, some of them will inevitably be found to be out of bounds. These fabricated clues keep the search going.

Consider the case of Marcus, the paranoid professor (see Case 13.3). Marcus has taught chemistry for more than 20 years. Just as molecules can be broken down into atoms, Marcus is used to looking at the world in an analytic way. He has a history lacking in close, personal relationships, in part due to frequent family moves but also due to his strict, regimented childhood. With his parents now dead and minimal contact with his brother, he has made sure that no one will get close enough to gather information that might be used against him. Presenting problems reflect his increasing preoccupation with the idea that students, fellow faculty, and the department chair are plotting against him. For evidence, Marcus has managed to tie together the animosity of his fellow faculty with the complaints of the students that he is rude and rigid.

From the holistic perspective of everyday life, that is, what people value and how they really behave, Marcus's assertion is absurd. For one thing, it requires some hidden mechanism whereby bad and good students can be secretly divided up and the bad ones exclusively shunted to Marcus. When the slackers run into the strong headwind of taskmaster Marcus, he makes sure they quickly learn that they cannot take advantage of him by

Marcus, a professor at the university, has taught chemistry for over 20 years. Never an overly friendly man, in recent years he has become increasingly alienated from his colleagues.1 Students now regularly complain about his rude behavior during office hours. He has been known to pause during lectures, look at the class, and say, "I know what you're doing." After gentle suggestions from the department chair that he seek therapy were ignored, a firmer recommendation was made in writing. Several appointments were made and then cancelled, until Marcus finally learned that he would otherwise be taken off the teaching schedule.

Marcus refers to himself as a "military brat." His family moved 11 times by his eighteenth year. His parents are now deceased, and he has little contact with his older brother. He describes his early years as an extension of military life. He and his brother were expected to follow the rules of the home without discussion or emotion. As a slight, thin child, Marcus was an easy target for bullies at each new school. He learned to fend off attacks by keeping his distance, excelling in school, and becoming vigilant.

At the beginning of the session, Marcus maintains that there is nothing wrong with him. "The system allows mediocrity," he states, "but I will not allow it in my classroom. The students think they can just breeze through my classes without working. By the end of the first week, they know they are mistaken." At this, Marcus pauses and seems to smile to himself.

As the interview continues, Marcus maintains that the student's complaints are part of a larger plot involving other instructors and even the department chair. To upset their plans, he has resolved to rule his classes "with an iron fist." He lays traps for the cheaters, and states that several have now been caught and brought up on charges of academic dishonesty. "I have no use for the other faculty," he states boldly. "They are jealous of my intelligence. They want me out of the department because I make them look bad. They had their chance, and now, we are at an impasse, and I will never give in or trust them again." He concedes that it is possible that he is wrong, but "highly unlikely." "The faculty make sure that every semester I get the bad students," he continues. "That way, when they complain about their low grades, it looks like I'm a lousy teacher."

Marcus is firm in his beliefs. He states that he has always done things his way, and that he has always been right in the past. He has known for some time that he would need to fight for his position at the university. In anticipation of a court battle, he has kept careful records of all his activities as an educator. He seems to relish the coming battle. "There is not a single blemish on my record," he says proudly. "I have followed the rules to the letter, and I have the goods on those who haven't." He concludes by saying that he will comply with the order to continue therapy, because he knows that he was referred because the department is looking for an excuse for his dismissal.

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.

breezing through his class. However, they also complain to the department, and it is these complaints that Marcus knows will be used as evidence to dismiss him. Marcus has lost perspective on the situation. Convinced of an inevitable court battle with the university over his faculty position, he has gone to great lengths to document his unblemished record. At many levels, Marcus is convinced he is under attack. To defend himself, he lays traps for cheaters and brings them up on charges of academic dishonesty.

Signal detection theory provides another way of understanding paranoid thinking. A signal is detected on the basis of an indicator, a blip on a radar screen, for example. Some blips are real, and some are not. Those that are real are said to be true positives: positive because the indicator detects a signal or signature; true because the signature reflects objective reality. Conversely, when a signature is detected that turns out wrong, it is said to be a false positive: The signal was detected, but it does not correspond to objective reality. A true negative refers to the absence of a signature when no signal is present. A false negative refers to failure to detect a signature when something in fact exists that should produce a signal; the indicator reads negatively, but falsely so.

In warfare, survival often depends on the ability to detect an enemy, even if many false positives are generated as a result. In this sense, the life of the paranoid resembles submarine warfare. If an enemy submarine can seize the element of surprise, it launches torpedoes. The other sub is often sunk before it even had a chance to react. Paranoids are caught in a kind of submarine warfare because survival depends on never allowing a false negative, that is, never missing the presence of a threat, even if a large number of false positives are generated thereby. Paranoids by definition distort reality, so they never really know which positives are false positives and which positives are true positives. Paranoids never know exactly where the truth lies. The enemy is there; this they believe with certainty, but how close and how deeply infiltrated are impossible to answer.

Struggling to unravel the threads of plots that do not exist, paranoids push themselves into a chronic state of emergency. With the barbarians at the gate, their apocalyptic visions of engulfment verge on realization. Because the cost of a false negative is checkmate, no cloaked sub must ever go undetected, no matter how many phantoms are created in the process. When a single false negative means annihilation, a thousand false positives have survival value, no matter how frightening. Trust leads only to a "Trojan Horse" scenario, and everyone becomes the enemy. Worse, because the enemy often seems to escape the best detection efforts, they must be very stealthy and highly intelligent and, therefore, all the more dangerous. The only protection is total fear of everyone. Obviously, the natural tendency is toward delusional generalization into a worldwide conspiracy.

Consider Ron again, who is convinced that his coworkers are skimming his paycheck. Ron hasn't yet found the evidence he needs as proof. He never will, because no one is skimming him (although he may discover something that he can misconstrue as proof). As convinced as he is, objective support must seem strangely inaccessible. Ron cannot question his own hypothesis, however, because he began with certainty, and his self-esteem will not support an iota of self-doubt. Ron's therapist asked him why he believes these things about his coworkers. He reads this request for information as apparent skepticism, and his radar immediately engages into a mode of hypersensitivity. Now, the therapist is suddenly a threat and, as such, has joined the coalition against him. Better to assume such, than to trust someone who would pass confidential information on to your enemies. In his position, Ron can't afford the risk.

The paranoid personality has also been analyzed within the cognitive therapy movement. Not unlike paranoids themselves, cognitive theorists hold that traits are only surface realities. Traits refer to consistencies in behavior, and behind every behavioral consistency lies a cognitive consistency. Whether explicitly articulated or not, every personality trait expresses a belief, and it is beliefs that determine behavior. Core beliefs, which may be either conscious or unconscious, are held to be true regardless of time, place, or circumstance. Conditional beliefs express the interactive role between person and situation: If such-and-such occurs, then such-and-such will result. In turn, conditional beliefs feed into instrumental beliefs, which concern what the person can or cannot do to affect the surrounding world.

According to Beck et al. (1990), paranoids carry a posture of mistrust beyond what is adaptive. They see themselves as righteous and mistreated and view others as devious, deceptive, and secretly manipulative. To counteract the threat of being controlled or demeaned under a guise of innocence, he states, they become guarded, hypervigi-lant, and suspicious. Beck et al. (p. 48) note a number of core beliefs, paraphrased here as, "I am vulnerable," and "Others cannot be trusted." Conditional beliefs include variations of, "I must be careful not to let others take advantage of me," and "If a person is friendly, he or she must be out to use you." Instrumental beliefs include, "I must always be on my guard," and "I must be alert to hidden motives."

In addition to these, many other beliefs can be generated (see Table 13.1). Almost any trait, especially an interpersonal trait, can be turned into a statement of belief. For example, cynicism might be cast as, "The universe is an unfair place," and hypervigi-lance might be portrayed as, "I need to be aware of everything that goes on around me if I am not to get hurt." Similarly, hypersensitivity to perceived slights might be cast as, "I must defend myself strongly against the slightest attack." The traits of being convicted and of dichotomous thinking might be portrayed as, "I must not let others influence my views in the slightest," and "Things become clearer when viewed in their purest form."

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