Paranoid personality disorder (paranoia)

If we talk about personality typology, according to “Psychoanalytic Diagnostics” by Nancy McWilliams, she identifies several leading types. In this article we will look at the paranoid personality type. The article is structured on the principle of gradually illuminating the main features of the type, its characteristics, signs, and peculiarities of how a psychologist works with it. The reader who is interested in issues of self-development, self-knowledge, and the study of psychology will find in this note information about one of the personality types.

Psychological characteristics of the paranoid personality type

The leading characteristics of the paranoid personality type are suspicion, wariness, absence or a dull sense of humor.

A paranoid person treats his qualities as negative, projecting them externally. And then they are perceived as an external threat. We can say that everything that this person worries and worries about is within herself. For example, such a person may not realize that in some of his manifestations he is quite aggressive and, projecting this quality onto other people, notes these traits in them.

Also often in paranoids one can observe a consciousness of their own greatness.

A paranoid person must suffer greatly in order to seek psychological help; they are not inclined to trust strangers. And in this regard, they tend to avoid consultations with psychologists and trust few people.

Paranoid individuals often play political roles where their projective traits may be opposed to existing views. They can “climb onto an armored car” to prove something to someone. True, it is important to note that such people do not always exaggerate the real danger. However, they can also be ironic and suspicious.

Treatment and therapy

Psychoanalytic

Psychoanalytic therapy of paranoid individuals is a rather labor-intensive task that requires the therapist to have high professional qualities and, above all, the ability to tolerate negative emotions directed at themselves. A paranoid client tends to project his negative (in the client’s opinion) qualities onto the therapist, suspect the therapist of all mortal sins and actively seek evidence of his fantasies, including provoking the therapist to have a negative attitude towards himself (the so-called “projective identification”).

Another tendency the therapist may encounter is temporary idealization. Typically, a paranoid client, denying those qualities of his that seem negative to him, perceives himself as a victim of external aggression, and sees those around him (including the therapist) as aggressive carriers of many vices. However, in the initial stages of therapy, he may identify with the therapist and idealize him along with himself. The more painful it will be for the therapist to face the inevitable wave of negativity when the period of idealization ends.

Successful psychoanalytic therapy requires the client to recognize that the qualities and desires that he does not like in others are his own qualities and desires. One of the main means of achieving this awareness is through transference analysis, during which the client can see that his fantasies about the therapist have no objective basis. To do this, the therapist needs to actually not give such reasons - to successfully withstand the client's provocations and to cope well with his feelings, especially negative ones.

Paranoid clients' reliance on denial has a significant impact on the speed of therapy. This defense mechanism works by categorically refusing to acknowledge something (and not by forgetting, as with repression). Direct interpretations of transference run into even greater denial. It takes considerable time and support from the client's observing position for him to begin to accept the very possibility that what he sees in others may come from within himself.

Despite all these difficulties, Nancy McWilliams, in her book, notes that the therapy process turns out to be extremely significant for such clients who, despite the fact that they express a huge number of reproaches and complaints to their therapists, stubbornly continue to attend sessions. McWilliams suggests that for a person with a paranoid personality type, who sees the whole world in dark, anxious tones, psychotherapy sessions in which someone listens to his negativity without responding with retaliatory attacks are a rare and very valuable outlet.

Drives, affects and temperament of paranoid personalities

It can be said about paranoid individuals that they are less suicidal than depressed ones. They are often unfriendly. They have a high degree of internal aggression and irritability.

It is difficult for a child to control their reactions; they may have an internal feeling that they are being persecuted.

In social interactions, paranoids may not be adaptive. Hyperexcitability is also noted. They struggle with hostile feelings and have many different fears.

Most often, paranoids experience a combination of fear and shame. This can lead to resourcefulness. Such people vigilantly monitor all interactions of other people among themselves and with them.

Narcissistic individuals may be subject to feelings of shame if the mask is somehow removed from them. Attempts are made to make such an impression on others that the devalued self will not be noticed by them. Paranoid individuals, on the contrary, use denial and projection. Shame remains completely unattainable within one's own self. Therefore, a paranoid person rushes headlong at those who are trying to shame and humiliate them. At the same time, narcissistic individuals are afraid of discovering their own inconsistency with some standards, and paranoid individuals are afraid of being judged by other people.

Paranoids can be noted to focus on the motives of other people, instead of focusing on their own “I”. They love to discuss possible motivations and consequences of other people's actions.

Paronoid individuals are vulnerable to envy. They cope with it through projection, believing that they envy them. In essence, we can say that they can project and deny those qualities of other people that they have in themselves. For example, the fact that they were betrayed.

Paranoid individuals project qualities that they may not notice or deny in themselves. For example, an office employee who is constantly late may make comments about this to other employees.

Paranoid individuals are not always aware of the guilt that is projected in the same way as shame. They believe that the psychologist, having learned about their sins, will reject them. They transform any feeling of guilt into a threat coming from outside. The fear of being exposed pushes them to recognize them earlier than others, thereby preventing evil intentions towards them.

Diagnostics

ICD-10

According to ICD-10, this mental disorder is diagnosed if the general diagnostic criteria for personality disorder are met, plus three or more of the following signs:

• a) excessive sensitivity to failures and refusals;
• b) the tendency to constantly be dissatisfied with someone, that is, to refuse to forgive insults, damage and arrogant attitudes;
• c) suspicion and a general tendency to distort facts by misinterpreting neutral or friendly actions of other people as hostile or contemptuous;
• d) a militantly scrupulous attitude towards issues related to individual rights that is not adequate to the actual situation;
• e) renewed unjustified suspicions of sexual infidelity of a spouse or sexual partner;
• f) the tendency to experience one’s increased significance, manifested in the constant attribution of what is happening to one’s own account;
• g) being covered by insignificant “conspiracy” interpretations of events occurring with a given person or in the world in general.

Included:

• fanatical disorder;
• fanatical personality;
• expansive-paranoid disorder;
• expansive-paranoid personality;
• sensitive paranoid disorder;
• sensitive-paranoid personality;
• paranoid personality;
• paranoid personality disorder;
• paranoid personality;
• touchy-paranoid personality;
• Querulant personality disorder.

Excluded:

• schizophrenia (F20.);
• delusional disorder (F22.0);
• paranoia (F22.01);
• querulant paranoia (F22.88);
• paranoid psychosis (F22.08);
• paranoid schizophrenia (F20.0);
• paranoid state (F20.08);
• organic delusional disorder (F06.2);
• paranoids caused by the use of psychoactive substances, including alcoholic delusions of jealousy, alcoholic paranoid (F10. - F19.).

DSM-IV and DSM-5

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), paranoid personality disorder is classified as Cluster A (unusual or bizarre disorders). A person with this disorder is characterized by a global mistrust and suspicion of others, which leads to the interpretation of people's motives as malicious. The following manifestations of such a personality begin to be detected in early adulthood, in a wide variety of situations. To make a diagnosis, in addition to the general criteria for a personality disorder, four or more of them are necessary.

1. Suspicions, without sufficient reason, that others are exploiting, harming, or deceiving him or her.
2. Preoccupation with unreasonable doubts about the loyalty and reliability of friends or companions.
3. Reluctance to open up to others due to an unjustified fear that it will be used against him (her).
4. Detecting hidden derogatory or threatening meanings in favorable words or events.
5. Persistent hostility towards others, including refusal to forgive insults, disrespect or harm caused.
6. Recognizing subtle attacks on his or her reputation, with quick retaliatory attacks or anger.
7. Repeated, unfounded suspicions of infidelity of a spouse or sexual partner.

To make a diagnosis, these manifestations must be recorded not only during the course of schizophrenia, a mood disorder with psychotic symptoms, another psychotic disorder, or generally a direct consequence of some other illness or general physical condition.

The latest edition of DSM-5 retains the same criteria as DSM-IV.

Defense and adaptation processes in paranoia

The degree of projection in paranoids can be borderline or neurotic.

In a disturbed personality, the Ego is completely projected and external, no matter how much these projections may appear to other people.

Individuals with a preserved “I” still have the opportunity to test reality.

Borderlines act in ways that make their projections suitable for the target of the projection. For example, a woman who does not admit her hatred and envy may tell her psychologist that he is jealous of her. And she interprets the psychologist’s empathic manifestations as a desire to control.

In neurotic paranoids, their feelings are projected in a way potentially alien to the ego. Such a person projects, but at the same time a part of his own “I” remains, which, when forming a trusting working alliance between the client and the psychologist, can reach the level of awareness.

Paranoid individuals project their feelings externally, including in order not to recognize unbalancing relationships.

Psychologist Karen, exploring paranoid dynamics, summarized the basic psychological defense mechanisms of the individual. For example, how can a person with delusions cope with the desire for intimacy with a person of the same sex. At the same time, the person seeks to refute “I love him!” through a number of ways:

• Megalomania: “I don’t love him, I love myself!”
• Erotomania: “I don’t love him, I love her!”
• Delusional jealousy: “I don’t love him, she loves him!”
• Projection of homosexuality: “I don’t love him, he loves me!”
• Reactive formation: “I don’t like him, I hate him!”
• What allows me to hate him: “He hates me! If I hate him, I don’t love him!”

Description

Three different disorders are characterized by a “paranoid” approach to life. The DSM-III-R diagnoses of paranoid schizophrenia (formerly paranoid schizophrenia) and delusional (paranoid) disorder (formerly paranoid disorder) are characterized by persistent paranoid ideation, while paranoid personality disorder (BPD) is characterized by an unreasonable tendency to perceive the actions of others as intentionally threatening or humiliating. , but at the same time it is free from persistent psychotic symptoms (APA, 1987). Schizophrenia, paranoid type and delusional disorder have attracted great theoretical interest and have been the object of many empirical studies; however, there is no clear agreement regarding the relationship between BPD and these two psychoses, which are characterized by paranoia (Turkat, 1985). Thus, it is unclear whether the results of studies conducted on psychotic samples can be applied to BPD. Because BPD has not received much attention until recently, clinicians lack experience to draw upon when working with clients who have paranoid but not psychotic symptoms.

In recent years, behavioral and cognitive-behavioral research has focused on the treatment of people diagnosed with personality disorders (Fleming & Pretzer, in press; Pretzer & Fleming, 1989). There are now several cognitive-behavioral perspectives on BPD; they can provide the clinician with a framework for understanding the disorder and for effective interventions.

Interpersonal relationships with paranoia

A child who grows up paranoid suffers from feelings of his own reality. He was subjected to periodic suppression and humiliation. The family can convey to the child that they are the only ones who can be trusted. This creates suspicion in the child towards other people.

Borderline or neurotic paranoid individuals come from a family system where criticism and ridicule predominate. The child may be a scapegoat.

Uncontrollable anxiety can trigger the development of paranoia in children. When a child came to such a parent with a problem, he either presented this situation as catastrophic, since he could not bear the child’s anxiety, or devalued it, since he could not condense it. Such an adult conveyed to the child that thoughts are equivalent to actions. And the child perceived that his personal feelings had dangerous power.

As children, paranoid individuals did not have the opportunity to express their feelings naturally and safely. In a psychologist’s office with such clients, a specialist teaches paranoid individuals to do this.

We can also say that paranoid individuals are capable of deep attachment and relationships.

Causes of paranoid disorder

As with other personality disorders, their formation is influenced by a combination of factors (genetic, psychogenic, biological), but paranoid disorder also has its own differences.

The disorder is initiated in childhood, with childhood complexes and problems. The child is suspicious, straightforward, and has an inflated opinion of his own capabilities. Such children neglect the interests of others, often take offense, and are distinguished by rancor and vindictiveness. With age, the features are fixed and become more pronounced. The disorder begins to fully manifest itself after 20-25 years.

Paranoid disorder is more common in men than in women. The reasons for its occurrence are not fully understood. Risk factors are the presence of other mental illnesses - schizophrenia and delusional disorders in family members, unhealthy family relationships. Manifestation of cruelty on the part of parents, overprotection, totalitarianism, great detachment or demandingness towards the child; as a result of such relationships, the child becomes distrustful of the people around him. The disorder may be a variant of a kind of “self-preservation instinct,” for example, if in childhood the child often had to defend himself. Such people are characterized by negative stereotypes and dividing everyone into “friends and foes.”

Paranoid Self

The paranoid client despises his own humiliated personality. He has a high degree of fear, which leads to the fact that he constantly “monitors those around him,” observes their reactions, “keeps his finger on the pulse.” Paranoids believe that they are the target of everyone around them, that people think and talk only about them.

It is also important to note that paranoids have a high sense of guilt.

Statistically, a connection has been found between thoughts about homosexuality and paranoid personalities, this has been confirmed by some studies.

Paranoids can fight against existing authorities. Revenge and triumph provide a temporary and shallow sense of security and moral clarity.

Transference and countertransference with paranoid individuals

Transference in paranoid clients is rapid and intense. The psychologist is the recipient of the projection of the image of the rescuer. But more often the psychologist is seen as an unsupportive, humiliating type. Such clients believe that the psychologist is trying to save them or, conversely, is focused on causing suffering. They evaluate a psychological assessment, believing that the psychologist wants to feel his own superiority.

Paranoid individuals may look closely at a psychologist. This can create a feeling of vulnerability and total protection. Transference here can be hostile and less often benevolent.

Countertransference may look like an opportunity to directly point out to the client that what the person perceives as a danger is unrealistic.

What to do?

Diagnosing yourself on your own is a stupid decision; a person can rarely “examine” himself rationally; it is best to turn to professional psychologists who, using their experience, can help you. Remember that the specialists of the Narkozdrav clinic are always happy to help and will be happy to find time to talk with you.

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Therapeutic recommendations when diagnosing paranoia

The first requirement is the establishment of a stable working alliance with the psychologist. This is necessary to build trust, which will make it possible to build effective interaction.

If the paranoid client trusts the psychologist, then the work can be considered completed.

The main task for the specialist will be to increase the paranoid person’s access to the client’s inner world.

Jokes within reason can safely defuse aggression. They may relate to those topics within which the work is being carried out at a given time. For example, to a client who is overly worried about how he will look on a date, you can say something like this: “If you think that you will be examined under a microscope, take blood and urine tests, then rest assured that your your partner is also worried.” This, of course, is only possible after basic trust has been built in a psychological session.

If paranoids feel that their opinions are valued, they will become more open. You can find a way to demonstrate this to them. In addition, it is important to give the opportunity to talk.

Together with a psychologist, explore what led to such reactions. This stimulates separation, which will eliminate carryover.

It is important to teach paranoid clients to identify what triggers their paranoia. Starting from observing your own body and reactions to external factors that can trigger alarming symptoms.

It is also very important with paranoids to consider other reasons besides those used by paranoid individuals. Give me the opportunity to think about it for myself. There are clients who want ready-made, and even better, quick solutions to their problems. But at the same time, they do not always understand that instead of getting a fishing rod and then independently solving pressing problems that will arise in their lives, they want to immediately get a fish.

Emphasize the differences between thoughts and actions. “Just enjoy your fantasies!” Thinking about something does not mean doing it.

A psychologist should be very careful about boundaries. This may affect the paranoid's feelings of security. May cause anxiety. Something can be done with psychological boundaries if it is possible to identify them. And their identification is realistic only after identifying oneself.

Story

In general, paranoia has been the object of close attention of representatives of the psychodynamic approach from Freud to the present day. A typical view of this disorder is presented by Shapiro (1965, pp. 54-107). After a detailed discussion of the paranoid cognitive style, he argues that the disorder is the result of the “projection” of unacceptable feelings and impulses onto other people. Theoretically, attributing inappropriate urges to others reduces or eliminates blame for those urges and thus serves as a defense against internal conflict. The view of psychoanalysis is essentially that a person missees in others what is factually true for himself, and as a result experiences less suffering than if he took a more realistic view of himself and others.

A cognitive-behavioral model of paranoia similar to this traditional view was presented by Colby and his colleagues (Colby, 1981; Colby, Faught, & Parkinson, 1979). These researchers developed a method of computer modeling the responses of a paranoid client in a psychiatric interview that is so realistic that experienced interviewers are unable to detect the difference between the responses of the computer and the paranoid client if the interview is sufficiently limited (Kochen, 1981). Colby's model is based on the assumption that paranoia is actually a set of strategies aimed at minimizing or preventing shame and humiliation. It is assumed that a paranoid person has a strong belief that he is inadequate, imperfect, and flawed. This is believed to lead to the experience of intolerable shame and humiliation in situations where the person is the object of ridicule, falsely accused, or suffers from a physical disability.

Colby hypothesizes that when there is an “abusive” situation, a person may avoid taking the blame and the resulting feelings of shame and humiliation by blaming someone else for what happened and claiming that they were treated unfairly. The anger and/or anxiety that results from attributing problems to persecution by ill-wishers is assumed to be more acceptable than the shame and humiliation that arises when a person is held accountable for what happens. Colby (1981) also notes that a paranoid person's attributions have a major impact on interpersonal interactions. If a paranoid person takes action against people to whom they attribute bad intentions, they may take retaliatory measures that include actions that are potentially offensive. Thus, in reality, paranoid behavior may indirectly increase the shame and humiliation that it was intended to reduce. Although Colby's model is interesting, it should be noted that his computer program simulates a patient who is delusional and thus does not meet the diagnosis of BPD.

Actually, BPD has been the object of attention of many authors. Cameron (1963,1974) views this disorder as arising from a lack of trust that results from parental abuse and lack of parental love. The child begins to expect sadistic treatment from others, be vigilant to signs of danger, and act quickly to protect himself. A person's alertness leads to the fact that he detects subtle signs of negative reactions of other people, then reacts intensely to them and at the same time is poorly aware of the impact of his own hostile attitudes on others.

Millon (1981) argues that BPD almost always co-occurs with other personality disorders and discusses each of the five major subtypes separately. The "paranoid-narcissistic" subtype is seen as developing as a result of a strong belief in self-worth coupled with a lack of social skills. Millon hypothesizes that when these people are faced with an environment that does not share their beliefs in their worth, they will indulge in fantasies of their own omnipotence rather than admit their shortcomings. The “paranoid-antisocial” personality is seen as developing as a result of parental persecution and hostility, which led to a perception of a harsh world and to rebellious, hostile behavior that provoked rejection from others. “Paranoid-compulsive” people are seen as having learned to strive to completely obey rigid parental rules and, as a result, remain overly controlling, perfectionistic, withdrawn, and self-critical. Paranoia occurs when the hostility inherent in their harsh self-criticism is attributed to others. Millon hypothesizes that constitutional factors contribute to the development of the "paranoid-passive-aggressive" personality, provided that the infant's responses to the parents elicit conflicting parental responses. Subsequently, they lead to the fact that the child grows up to be an irritable, negative person who is unable to maintain stable relationships. This leads to social isolation and the development of delusions of jealousy. Finally, the “decompensated paranoid” personality is seen as one predisposed to developing psychotic episodes in response to stress and possibly being a link between BPD and psychosis. Millon (1981) does not provide a general theoretical model of BPD or discuss possible interventions.

Turkat (1985, 1986, 1987; Turkat & Maisto, 1985) recently presented a cognitive-behavioral model of the development and maintenance of BPD that is based on detailed case studies. According to Turkat, early interactions with parents teach the child: “You should be wary of making mistakes” and “You are different from others.” It is hypothesized that these two beliefs result in a person who is highly concerned about the evaluations of others, but also has to live up to parental expectations that prevent him from being accepted by his peers. This ultimately results in such a person being ostracized and humiliated by his peers, but lacking the interpersonal skills needed to overcome the ostracism. Consequently, the person spends a lot of time thinking about his loneliness and mistreatment by his peers and eventually comes to the conclusion that the reason for the persecution is because he is special and others are jealous of him. This “rational” explanation is supposed to alleviate the suffering that results from social exclusion. It is proved that the resulting paranoid idea of ​​others strengthens a person’s isolation, which is due to two reasons. First, a person's anticipation of rejection causes social interactions to generate significant anxiety. Second, acceptance by others will threaten this explanatory system.

Differential diagnosis

Paranoid versus psychopathic client: If a paranoid person notes that you share their values ​​with them, then they are capable of loyalty and generosity. Projection is a psychological defense mechanism in psychopathic and paranoid individuals. However, the former are not empathic, and paranoid individuals are deeply connected to the object (for example, another person). The experience of betrayal can be a threat. They perceive any violations of morality in their partner as a vice in themselves that should be eradicated.

Paranoid personalities in comparison with absessive ones: the latter are sensitive to little things, they are afraid of control, but do not experience the fear of physical harm, moral humiliation, which is typical of paranoid personalities. Absessive clients try to cooperate with the psychologist, although they may have alternative positions. A violent reaction to clarification at work may indicate that the client has dominant paranoid qualities.

Paranoid versus dissociative personality: Paranoid traits may be present in dissocial personalities.

Next, let's look at the depressive personality type.