Essential Feature

The essential feature of the paranoid personality disorder (PPD) is a pattern of pervasive distrust and suspiciousness of others; the motives of others are interpreted as malevolent. The suspiciousness may be expressed by overt argumentativeness, recurrent complaining, or hostile aloofness. While individuals with a paranoid personality disorder may appear "e;cold,"e; objective, and rational, they more frequently display hostile, stubborn, and sarcastic affect. They may form negative stereotypes of others and join cults or groups with others who share their paranoid beliefs (DSM IV™, 1994, pp. 634-635).

The ICD-!0 (1994, pp. 224-225) describes the paranoid personality disorder as characterized by:

• excessive sensitivity to setbacks;
  
  
• unwillingness to forgive perceived insults;
  
  
• suspiciousness;
  
  
• inclination to distort experience by interpreting neutral actions as hostile;
  
  
• suspiciousness of sexual infidelity of partners; and,
  
  
• a combative and tenacious adherence to personal rights.

There may also be excessive self-importance and self-reference.

The rigidity of beliefs found in individuals with PPD isolates them from corrective environmental feedback; they are vulnerable to increasing distortion of reality, hypersensitivity to misinterpreted events, and an inflated view of self that results in tumultuous struggles with others who are bewildered by the entire situation.

Paranoid personality disorder may first appear in childhood and adolescence with solitariness, poor peer relationships, hypersensitivity, peculiar thoughts, and idiosyncratic fantasies. There is some evidence of increased prevalence of PPD in individuals with relatives who have a delusional disorder. The prevalence of PPD is estimated to be 2% to 10% in outpatient mental health clinics. In clinical samples, this personality disorder appears to be more common in males. PPD must be distinguished from symptoms developed in association with chronic substance use, e.g. cocaine (DSM-IV™, 1994, pp. 636-637).

It has been suggested that paranoia be seen as existing on a continuum that goes from normal vigilance toward potential threat in the environment to transitory paranoid behavior and interpersonal suspiciousness (paranoid personality disorder) to delusional states to full paranoid schizophrenia. The paranoid personality disorder is distinguished from psychosis by the lack of delusions or hallucinations (Sperry, 1995, p. 154). It appears that having the word paranoia in the name may contribute to the possible underdiagnosis of the personality disorder in outpatient mental health and substance abuse treatment settings. It has been suggested that it be called the "e;vigilant"e; personality disorder to make the personality disorder variant of the paranoia disorders more readily recognizable.

Paranoia or paranoid ideation is not limited to those disorders with paranoia in the name. Rawlings and Freeman (Claridge, editor, 1997, p. 39) note that there are at least five mental disorders that contain paranoia constructs in the DSM-IV™: paranoid personality disorder, schizotypal personality disorder (with suspiciousness or paranoid ideation), borderline personality disorder (with transient, stress-related, paranoid ideation), the paranoid type of schizophrenia, and the persecutory type of delusional disorder. Symptoms of paranoia can also be associated with substance abuse; with abstinence these symptoms will subside.

Self-Image

Individuals with PPD experience a polarity in their self-image; even though their behavior may be grandiose and arrogant, they are vulnerable to shame and will alternate between the impotent, despised self and the omnipotent, vindicated self (McWilliams, 1994, p. 214). Stone (1993, p. 210) suggests that defenses are activated by individuals with PPD in the service of warding off shame and humiliation. These individuals view themselves as righteous and mistreated (Beck, 1990, p. 48) and will attempt to enhance their self-esteem through exerting power over others. They fight "e;on the side of the angels."e; Other people are wrong; they are pure. They are vengeful and pursue conflict with great tenacity, never seeming to tire in their quest for self-vindication; they acquire an inordinate fondness for righteous causes (Kantor, 1992, pp. 113-119). People with PPD often feel that their own hurt feelings provide sufficient cause for justifying almost any retaliation (Richards, 1993, p. 284).

Kantor (1992, pp. 113-119) suggests that individuals with PPD exhibit six core beliefs (which would necessarily influence how they view themselves):

• Disaster is on the horizon (a continuing sense of foreboding).
  
  
• The world is full of enemies.
  
  
• Accidents are doubtful; negative events are initiated by others with hostile intent.
  
  
• All events relate to self.
  
  
• Individuals with PPD are never to blame or guilty (others are).
  
  
• Individuals with PPD are different from the rest of humanity, often with pretensions of having unique awareness or insight.

View of Others

Individuals with paranoid personality disorder assume others will exploit, harm, or deceive them; they are preoccupied with doubts about the loyalty of others. They may feel they have been deeply and irreversibly injured by others even when there is little objective evidence that this is the case (DSM-IV™, 1994, p. 634). People are seen as devious, treacherous, and manipulative; care must be taken to not be demeaned, controlled, or discriminated against (Beck, 1990, pp. 48-49).

These individuals are consumed by their mistrust and their anticipation of betrayal. They expect the worst of others and are, accordingly, apprehensive, suspicious, uncompromising, and argumentative. They are on guard against a hostile world (Oldham, 1990, p. 167). When a friend or associate shows loyalty to individuals with PPD, they are so surprised that they cannot believe it; if they get into trouble, they expect others to attack or ignore them (DSM-IV™, 1994, p. 634). These individuals often misinterpret compliments as hidden criticism or coercion to do even better. They may see an offer to help as an implication that they are not doing well enough on their own (DSM-IV™, 1994, p. 634).

Individuals with PPD are reluctant to confide in others because they fear the information will be used against them; they often withhold personal information for self-protection (DSM-IV™, 1994, p. 634). These are individuals who, in the intake process of mental health or alcohol & drug clinics, refuse to answer questions, ask what is being written about them, and are adamant that certain information is personal and should not be sought by the treating agency. They may well refuse to sign release of information forms for other agencies, service providers, or family members.

Relationships

The DSM-IV™ (1994, p. 635) notes that individuals with PPD are generally difficult to get along with and have consistent trouble within relationships. They are distrustful and hostile; their interpersonal behavior may involve overt argumentativeness, complaining, or aloofness. They can be guarded, secretive, or devious; they appear to lack tender feelings and engage in stubborn and sarcastic exchanges with others. It can be difficult to elicit the behaviors suggestive of PPD from individuals in treatment. PPD characteristics tend to be manifested in interpersonal conflicts with close or significant others, e.g. spouses, supervisors, colleagues, and relatives (Joseph, 1997, p. 31).

Individuals with PPD tend to provoke hostility in others. They engage in "e;hair trigger"e; responses to trivial behavior from others (Kantor, 1992, p. 118). Matano and Locke (1995, p. 62) suggest that these individuals repeatedly enact guarded and domineering interpersonal patterns. Meissner (1994, pp. 221-223) describes people with PPD as distrustful, secretive, and isolative; they will direct hate and rage at those who betray or disappoint them. They are concerned with the issues of power and powerlessness and fear domination. They are inordinately quick to take offense, slow to forgive, and ever willing to counterattack (Fenigstein, 1996, pp. 245-246). They want to get even (Kantor, 1992, p. 118). Individuals with PPD struggle with anger, resentment, vindictiveness, and hostility. They live in fear of harm and malevolence from others and maintain extraordinary vigilance. Accordingly, the more disturbed they are, the more dangerous they are (McWilliams, 1994, p. 207).

However, the range of dysfunction within the diagnosis of paranoid personality disorder is sufficient to allow many of these individuals to be sufficiently interpersonally functional to preserve relatively cohesive relationships. Many authors note the possibility of individuals with PPD whose symptoms manifest at a level of subtlety that allows them to function within a marriage and maintain adequate work relationships. This appears to be in conflict with Theodore Millon's idea that PPD is a structurally deficient and, by definition, a more severe and impaired personality disorder than those that are functionally impaired only. This position does not appear to be supported by the client population served in an outpatient program in a large local community mental health system. Individuals with PPD certainly pose a serious challenge to therapists, but can often develop enough trust to work successfully within the therapeutic process.

Issues With Authority

McWilliams (1994, pp. 211-216) states that individuals with PPD are vulnerable to shame and humiliation as a result of criticism, punishment, and adults who could not be pleased in their families of origin. Accordingly, adults with PPD have recurrent conflict with authority figures. They fear domination, enslavement, and loss of autonomy. They will attempt to exert interpersonal power to avoid the anticipated destructive consequences coming from interaction with people in authority (Meissner, 1994, p. 223). Benjamin (1993, p. 236) considers deferential behavior with authorities to be an exclusionary criterion for the diagnosis of paranoid personality disorder.

These individuals counterattack when they feel threatened. Consequently, they are inclined to be litigious and involved in legal disputes (DSM-IV™, 1994, p. 635). One client in an outpatient mental health center was a non-practicing attorney that had not been able to pass the bar exam. He lived with his wife and child in severe financial straits but none of his economic concerns deterred him from spending nearly all of his time in self-generated and self-maintained litigation with various companies or individuals with whom he had contact. He was not looking for employment when he came to the mental health center on a referral from Child Protective Services (for his difficulty in managing his anger with both his wife and his daughter). He considered his various lawsuits to be his "e;work."e; He was not particularly intimidated by CPS involvement with his family; he was hoping to be able to sue that agency as well.

Individuals with PPD will fight "e;the good fight"e; no matter what the cost may be. They will welcome opportunities to force others (particularly those in power) to admit they have been wrong. They will accept negative consequences that arise from their own actions as further proof that those around them are malicious and corrupt.

Behavior

Paranoid traits may be manifested in some degree in a significant portion of the normal population. Indications of a paranoid style are frequently quite subtle; the paranoid features may form a latent portion of the personality that emerges under stress (Meissner, 1994, pp. 220-221).

As noted above, individuals with a paranoid personality disorder retain many areas of intact functioning. McWilliams (1994, p. 205) writes that individuals with PPD can have any level of ego strength, identity integration, reality testing and object relations. Many individuals with PPD can function well enough to avoid coming to the attention of professionals (Fenigstein, 1996, pp. 245-252).

However, individuals with PPD may also be argumentative and easily aroused to agitated contentiousness. They can appear tense, anxious, guarded, devious, sensitive, and ready to counterattack. They are inclined to criticize and devalue others -- while any criticism of them is unacceptable. They are often seen as energetic, ambitious, hard-working, and competent. They tend to be intelligent and intellectual as well as hostile, stubborn, and rigid. They are inclined to be inflexible and unwilling to compromise. They have an excessive need to be self-sufficient along with an exaggerated sense of their own self-importance (Meissner, 1994, pp. 220-221).

Millon (1996, p. 701) describes people with PPD as always on guard, mobilized, and ready for threat. They are edgy, tense, abrasive, irritable, distant, and vigilant. However, while individuals with PPD anticipate betrayal and deceit from others, they may well be deceptive, hostile, disloyal, and malicious themselves (Beck, 1990, p. 100).

The PPD style is to displace responsibility from self to others via an inclination to project and to blame. They also tend to understand problems in terms of external circumstances, forces, events, persons, etc. rather than in terms of internal difficulties, problems, or limitations. They will scan the environment for minimal clues that validate their preconceived ideas (Meissner, 1994, pp. 220-221).

Fenigstein (1996, pp. 245-252) describes eleven dimensions associated with paranoid personality disorder: vindictiveness, suspiciousness, hypervigilance, hypersensitivity, reluctance to confide in others, avoidance of blame or responsibility, attribution of problems to the external world, a fixed, rigid cognitive style, readiness to anger, resentfulness of authority, and fear of humiliation. Stone (1993, p. 202) adds arrogance, self-righteousness, feelings of inferiority and envy, sexual anxiety, moralism, and an inner readiness to lie and distort.

Kantor (1992, pp. 122-124) describes paranoid personality disordered behavior with the following: blamelessness (with aggression legitimized as a counterattack), passive-aggressiveness, superciliousness (haughty, arrogant, and superior behavior intended to defend against anticipated or perceived criticism), seeking trouble for the purpose of self-vindication, exaggerated competitiveness, vengefulness (unremitting), verbal malice, manipulativeness, grandiosity, a fondness for righteous causes, and grandiose rescue fantasies.

Beck (1990, p. 100) describes the following as clinical indicators of paranoid personality disorder: vigilance, exaggerated concern about confidentiality, inclination to blame others, seeing self as mistreated and abused, recurrent conflict with authority figures, unusually strong beliefs about the motives of others, a tendency to give small events great significance, an inclination to counterattack, contentiousness and litigiousness, a tendency to provoke hostility in others, seeking evidence that confirms negative expectations, inability to relax, inability to see the humor in a situation, an unusually strong need to be self-sufficient and independent, disdain for the weak and needy, difficulty expressing warm, tender feelings, and pathological jealousy.

Affective Issues

PPD affect can serve as an assist in differential diagnosis. Underlying arrogant behavior in the narcissistic personality is a comfortable assumption of superiority; underneath the antisocial personality arrogance is indifference and aggression. Individuals with PPD also behave in an arrogant and abrasive manner. However, the dominant affect accompanying the behavior is fear. These individuals struggle with intense dread of abuse, exploitation, or harm from others. At times they may feel able to protect themselves, but often they are afraid and unsure. Their world is a hostile place filled with danger; they rarely can relax into a sense of safety and contentment. In fact, the more they have of what they want in life, the more vigilant they must be to ward off the (sometimes real, sometimes projected) envy and malicious intent of others to take away anything of value.

The self-righteous rage covers the same fear and an abiding sense of inferiority. Abrasive behavior warns others that individuals with PPD are formidable enemies and people with ill intent would be well-advised to stay away.

The intensity of the fear, rage, envy, and dread for individuals with PPD is a factor in the tirelessness with which they fight "e;the good fight."e; Only when they believe that they are vindicated and others are controlled is an element of safety introduced into their affective experience. This is a powerful motivator and should be considered in any attempt to confront these individuals in the treatment process.

Defensive Structure

Individuals with PPD are uncomfortable with dependency with its implied weakness. They also become quite anxious when coerced by external authority. Their defensive structure requires an ongoing experience of independence, superiority, and autonomy. They seek self-determination and acquire an active fantasy life wherein they create a self-enhanced image and a rewarding existence apart from others (Millon & Davis, 1996, p. 700).

These individuals actively disown undesirable personal traits and motives by projecting them onto or attributing them to others. Even while people with PPD avoid awareness of their own unattractive behaviors and characteristics, they remain extraordinarily alert to, and hypercritical of, similar features in others (Millon & Davis, 1996, p. 702).

Individuals with PPD maintain their sense of balance, internal and external, through rigid adherence to an inelastic set of defenses and methods of need gratification. Either extreme or unanticipated stress can precipitate a crisis that appears, to others, out of proportion to the situation at hand (Millon & Davis, 1996, p. 702).