Paranoid Personality Disorder

Paranoid personality disorder (PPD) is characterized by a pervasive mistrust of other people. The behavioral tendencies of individuals with paranoid personality disorder are summarized under the following headings:

1. Overly circumspect, evasive individuals

As overly circumspect, persons with this trait do not readily show their hand because they feel that to do so would compromise their safety in what they believe to be a world full of wickedness and danger. If you ask them a question, they feel that you are trying to probe into their deepest secrets. So they do everything in their capacity to throw you off the scent. They might say “I do not know”, which is very often one of their favorite diversions.

1. Highly suspicious individuals

These are untrusting individuals who regularly feel that others are plotting against or are otherwise out to get them. A woman believes that her neighbor’s “polar” tree (she really means poplar tree) was deliberately put there for two reasons: to grow tall and fall over onto her house, and to hide in its shadow the bad things that her neighbors are doing.

1. Blaming individuals

These individuals consider themselves completely blameless after blaming others for things that go wrong in their own lives. As a result, they develop an overly positive view of themselves based on the formulas “I am not responsible for anything; you are responsible for everything” and “All my troubles in life can be attributed to you.” The resultant self-view, a self-view that Munro (1999) describes as full of hauteur and grandiosity (p. 35), is one of their most off-putting qualities. Victims do not usually like to be blamed for something that they did not or to be told that they are responsible for everything that happens to someone else. In a typical sequence they first feel guilty though they are innocent and afterwards feel resentful about having been falsely accused. They next do a slow burn and then become overtly angry and may even drop the person permanently.

1. Excessive guilt associated with a paradoxical inability/refusal to feel guilty protractedly

One reason individuals with a paranoid personality disorder find it difficult to accept blame is that they tend to become extremely, painfully, guilty, even or especially about small things. As Shapiro (1994) says, their “shame or weakness” (p. 54) exacerbates their problems. However, at the same time these individuals are unable or unwilling to feel guilty in a serious, meaningful, sustained, and productive way. So they employ several mechanisms for evading their guilt, chief of which involves turning a guilty self-accusation into a perceived unwarranted accusation or criticism from others, in effect blaming their bad behavior on some form of devil.

1. Tendency to collect injustices

They also collect injustices and traumata to give themselves reasons, or further reasons, to criticize and condemn others. As they perceive it, theirs now becomes not a case of misinterpretation of reality but a natural, expected response to the real, personal lack of consideration, antagonism, or malice implied in others’ negligence. The injustices they collect tend to revolve around someone having hurt them physically, taken advantage of them sexually, or scammed or otherwise used them financially. With injustice-collectors you cannot win. If you say hello you are trying to seduce them, but if you do not say hello you are ignoring and rejecting them. For them, all advice, however well-intended, is an unwelcome sales pitch, and all offers of help not an admirable attempt to assist but an unwelcome attempt to control them or a selfish manipulation meant to enrich you at their expense.

1. Tendency to feud

As part of their injustice and trauma collecting they continually embroil themselves in feuds. Their memories are especially long and their attitudes especially unforgiving when it comes to any issue that can conceivably give them the reason they need to feel injured. Unlike most people who soon lose interest in the battle, they have an ongoing mission. Therefore, they not only deliberately provoke feuds, they also purposely prolong them and refuse to back off.

1. Extreme pessimism

Patients with a paranoid personality disorder are worrisome pessimists who every day see the possibility of injustices, scams, and physical assaults, regularly anticipate the worst, and find unfaithful spouses, potential kidnappers, and leering sexual predators everywhere they look. Theirs is a deep sense of foreboding associated with the belief that disaster is always on the horizon and tomorrow will bring even worse news than yesterday, in the form of new revelations about more hostile, malignant enemies planning dangerous cabals and life-threatening conspiracies—further proof that “These days they’re all out to get you.”

They justify their pessimism by citing the things that actually go wrong in their lives, as if they do not go wrong in the lives of everybody. They then say, “I told you so,” as if they were right all along. But their predictions in fact remain invalid because they view trivial events as important and unusual circumstances as completely validating their usual fears, or because they make so many pessimistic predictions that some are bound to come true by chance alone.

1. Aloofness and withdrawal

Patients with paranoid personality disorder tend to be shy, cold, aloof loners. They withdraw from relationships because they believe that isolation protects them from others who might corner, attack, devour, and mutilate them, and, moving into their space, take over their lives, control them, and cause them to lose their individuality. They therefore often have a negative reaction to others who attempt to get too close to them, one that ranges from discomfort to counterattack. If they form relationships at all they tend to be loose, distant ones with others who themselves have problems with getting close—typically fanatics from fringe groups such as cults and militaristic, often Nazi-style organizations, that is, people who form bonds that are more ideational than interpersonal.

However, not all individuals with a paranoid personality disorder are cold and remote loners. Some actually dislike being alone because they fear that when they are by themselves they have no protection from dangerous outside forces. Those who are pathologically jealous are in some ways the opposite of loners: too intense and too involved for their own good and for the good of those they have incorporated into their delusional systems. Some swing between being related and unrelated and as a result appear to have a sort of split personality as they alternate between extreme dependency and a fear of being rejected on the one hand and extreme independence and a fear of beign devoured on the other. Such individuals tend to be diagnosed not as paranoid but as having borderline personality disorder with paranoid features.

1. Sadomasochistic tendencies

Some patients with paranoid personality disorder are openly sadistic. That would include the straight man who told a gay neighbor who was in fact a good citizen to get out of here and go back to where he came from—and added that all of the neighbors on the block agree that that is a good idea.

Sadistic paranoid individuals like him quest unremittingly for satisfaction in the ominous sense of triumph and vengeance. If they back in cyberspace it is not (as they often claim in their rationalizations) to demonstrate that computers are vulnerable to being compromised as a basis for improving the system. Rather it is to destroy those whom they believe have it all and more than they do—particularly members of the hated establishment as symbolized by the big business interests of the very rich. Focused on turning the tables on their supposed persecutors they make the formulation “an eye for an eye” holy writ. While obsessionals justify the code of “an eye for an eye” as upholding the principle of desirable balance, entropy, and the notion that every reaction must be followed by an equal and opposite reaction, the “eye for an eye” of paranoid individuals express the notion that sin has its wages and that he who calls the tune must pay the piper. These people call not for balance but for atonement for sins and punishment for crimes. Unlike obsessionals who need symmetry and balance to make even, paranoid individuals need symmetry and balance to get even.

A number of observers, including Bone and Oldham (1994), have noted that individuals with paranoid personality disorders are, being sadomasochists, as masochistic as they are sadistic (p. 3). In their masochistic mode these paranoid individuals are embroiled in self-destructive interpersonal interactions whose main goal appears to be to almost deliberately antagonize people—part of their plan to arrange for others to hurt them and make them suffer, so that they can now say, “Look at what they are doing to me, just like I told you.”

1. Grandiosity

Grandiosity in individuals with a paranoid personality disorder is at least partly an attempt to overcome a fear of being a big nobody. As such it has a palpable reactive quality to it. Individuals with a paranoid personality disorder deal with their fear that no one loves them by convincing themselves that everyone does. They deal with their fear of being demolished by convincing themselves that they are invincible. They deal with their fear of becoming big nonentities with smirking self-congratulations meant to cope with low self-esteem and to deny the effect of imagined put-downs. For example, one such individual dealt with the feeling that others were criticizing him for being uneducated by becoming a know-it-all who shamelessly debated with anyone, no matter how expert, on any topic whatsoever.

As noted throughout, some, plagued by the idea that they are sinners, deal with that self-perception by considering themselves saintly spokespersons of divine authority put here on Earth for the righteous cause of rescuing sinners from themselves, with the emphasis less on helping the sinner than on magically casting out their own sins by cleansing the very same sins in others. this righteousness even extends to the most antisocial of their actions, lending these an air of guiltlessness that in turn allows them to view their even truly horrific behavior in an entirely favorable light. They become like a pilot who crashes his plane to kill himself and those aboard for a higher cause: so that all can join a beneficent God in a better world.

1. Personalization tendencies

Patients with paranoid personality disorders tend to personalize the actions of others to the point that they come to believe that others play a central role in their lives, even when those others’ thoughts and actions in fact have little or nothing to do with them. They believe that they are the sole or principal target of actions just because those actions affect them. Just as they relate impersonal events to themselves, they impute personal motives—usually hostile, and where there are no reasonable grounds—to others. Thus the neighbors would be quieter if they didn’t hate the individual so much. In their view there is no such thing as an accident. Instead all adverse developments possibly caused or influenced by nonhuman or human agency, however random, are personally meaningful. What to a normal observer would be an error they construe as intentional. They feel that the police simply by virtue of being imperfect have it in for them. Loss of a job is attributed to enemies in high places. Neighborhood noise is attributed to a gang with a grudge. The failure to receive a check is attributed to thieving neighbors. In this tendency we find echoes of the atavistic need to animate or personify causative forces and transform them into persecuting demons.

1. The tendency to think illogically

Paranoids often distort logic in order to defend their favored philosophical or pseudophilosophical positions and in order to justify their negative reactions to other people and to external events. A favored form of illogic involves comparing apples with oranges, as in the pornographer’s defense that “Yes, but violence is worse, and the real sin.” They often use the logic disorder of von Domarus to justify their persecutory beliefs (The classic example of which is, “I am a virgin; the Virgin Mary is a virgin; therefore, I am the Virgin Mary). For example, one patient thought, “I am a foreigner, everyone hates foreigners, therefore all people hate me.” Their polemics depend on their using selective abstraction to omit facts that go contrary to, and might disprove, their often angry assertions. These individuals so much seek or demand consensual validation for their illogical thinking. They ask others to agree with them, hoping that the others will validate their invalid premises. Often they seek this agreement for practical as well as for emotional reasons.

Their use, really misuse, of logic, is often impressive and convincing. They are not necessarily smarter than other people. Rather they are more highly motivated to prove that they are right—more so than other people are motivated to prove them wrong. They want to prove themselves right so that they can convince people that they have the word, and so that they can defend themselves against those who would call them misguided. Also their illogic, being a product of their illness, comes as second nature to them, much as rituals come as second nature to obsessive-compulsives or as a fear of heights comes as second nature to phobics.

1. The tendency to get depressed

Individuals with paranoid personality disorders often appear to be clinically depressed for the following reasons. First, some deliberately revise their case presentations so that they can come across not as paranoid but as depressed. They want to avoid being thought of as paranoid, and to do so they change “I fear that people hate me” to “I fear that no one likes me.” As Ansar M. Haroun (1999) says, “It is ‘okay’ to be depressed’ (p. 335), but being paranoid means being angry, which is not okay (p.335).

Second, individuals with paranoid personality disorders are often truly moody people whose sadness and withdrawal are real. But in paranoids the sadness and withdrawal occur in the context of, and are a product of, an adversarial relationship less, as with depressives, with themselves, and more with others. Unlike depressives, who feel that all is lost because they made so many mistakes in life, paranoid individuals feel that all is lost because others have made so many mistakes with them. Another differential point is that while the affect in depression is anguished, sad, painted, and contrite, in paranoid individuals the affect is flattened or, when the hostility is intense, piercing. Also, while depressives look like tragic figures who suffer a great deal, paranoids look like antagonists always ready to strike out at others and to make them suffer.

1. A desire to look intact

Inherent in paranoid personality disorder is a desire to be able to continue to function effectively. This function is of course impaired, but the deficit may not apply equally to all parameters. It often leaves the capacity to work intact, while interfering with the capacity to love. It is quite common for individuals to accept being paranoid with their husbands or wives but to be “paranoid about being paranoid” with their boss or with strangers.

From these arise that need for marked emotional dependence upon others, as also do the exaggerated demands for attention and affection.

The traits foster furthermore the craving by this personality to be accepted by others as being something far greater than it really is.

Lacking an adequate central stability, the hysterical personality is liable to display a chameleon-like versatility.

Role after role may be switched or rejected to capitalize on the advantages of the moment. Affective response is typically forced, artificial and shallow.

In the sexual field, an outward display of enticement and encouragement contrasts markedly with a limited or absent capacity for performance.

In so many aspects, the hysterical personality inhabits a world of childish make-believe and utilizes the unreal values appropriate to childhood.

• Like the thwarted child, resenting its lack of independence, it seeks to impress others with its own importance;
• like the over-indulged child, frustrated at not gaining its own way, it revels in dramatic scenes of histrionic behavior so reminiscent of a childish tantrum.

• The hysterical personality employs many and devious means to attain its ends.
• Threats of suicide are extremely common.

Though frequently empty, they can never be taken lightly for the hysteric is notoriously liable to overplay his or her hand and what was intended as a suicide gesture may well end as the consummated act.

The involved manipulations of the hysterical personality are characteristically bids for dominance from a position of natural weakness.

Diagnosis

Hysterical symptoms may take innumerable forms:

1. There may be disturbances of sensation such as anesthesia (anaesthesia) or paresthesia (paraesthesia) or other neurological symptoms such as ataxia; spastic or flaccid paralysis; choreiform or athetoid movements and tremor.
2. Other manifestations include loss of vision, gynaecological complaints, difficulty in breathing or in swallowing, abdominal pains and peculiar dermatoses.
3. Mental disturbances include double or multiple personality. In some cases, a hysterical fugue or trance follows a traumatic experience but in others it is an escape from a disagreeable situation.

The differential diagnosis of hysteria is full of difficulty, not least the necessity to make certain that no organic lesion is present.

It should be possible to show that the symptom is a response to some conscious experience which has a strong personal significance to the patient.

Even so, it may sometimes be very difficult to decide between symptoms due to organic disease and those of hysterical states, particularly in later life when there may be a hysterical overlay on pre-existing organic lesion.

Management

No simple formula can be advanced for the treatment of hysteria. Each case will obviously be assessed on its highly individual merits and therapy devised accordingly.

A detailed case history will be taken and a careful physical examination must be made to exclude an underlying and contributing organic illness.

The personality of the doctor for better or worse will play a vital part in the attainment of any degree of success.

It is for this reason that unskilled and unqualified persons may achieve outstanding success in the treatment of this neurosis where eminently qualified persons may fail.

There is a possibility of curing an acute hysterical reaction by simple suggestion and a heavy dose of a sedative.

A chronic hysterical condition is, however, one which may demand all the resources of psychiatric therapy to effect any permanent improvement.

The basis of successful treatment is suggestion and this may be done either over a long period or in single intensive association under hypnosis or under light anesthesia (anaesthesia) Opens in new window.

Abreactive methods may also be used. It is thus clear that the management of hysteria requires the attention of a physician skilled in the use of these particular techniques and referral is therefore advised.

Apart from the use of mild sedatives to secure reasonable sleep and tranquilizers to ally anxiety, drugs are of little benefit in the hysterical states.