Can an individual be considered paranoid solely because they experience a sense of threat or danger directed toward themselves? To answer this question, we must first examine the essential characteristics of the paranoid personality structure:
The diagnosis of paranoid personality structure implies to many people a serious disturbance in mental health, yet as with other dynamics that infuse personality, this type of organization exists on
a continuum of severity from psychotic to normal.
The defense that defines paranoia may derive from a time before the child had clarity about internal versus external events, where self and object were thus confused.
Paranoia intrinsically involves experiencing what is inside as if it were outside the self. It may be that “healthier” paranoid people are rarer than “sicker” ones, but someone can have a paranoid character at any level of ego strength, identity integration, reality testing, and object relations.
What is the etiology of paranoid personality?
Clinical experience suggests that children who grow up paranoid have suffered severe insults to their sense of efficacy, they have repeatedly felt overpowered and humiliated.
Criticism, capricious punishment, adults who cannot be pleased, and utter mortification are common in the backgrounds of paranoid people. Those who rear children who become paranoid also frequently teach by example. A child may observe suspicious, condemnatory attitudes in parents, who emphasize—paradoxically, in view of their abusive qualities and the objectively kinder worlds of school and community—that family members are the only people one can trust. Paranoid people in the borderline and psychotic ranges may come from homes where criticism and ridicule dominated familial relationships, or where one child, the future sufferer of paranoia, was the scapegoat—the target of the family members’ hated and projected attributes, especially those in the general category of “weakness.”
How is Paranoid Personality Disorder described in the DSM-5?
In the DSM-V the essential feature of paranoid personality disorder is a pattern of pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent. This pattern begins by early adulthood and is present in a variety of contexts.
Individuals with this disorder assume that other people will exploit, harm, or deceive them, even if no evidence exists to support this expectation. They suspect on the basis of little or no evidence that others are plotting against them and may attack them suddenly, at any time and without reason.
Individuals with paranoid personality disorder are reluctant to confide in or become close to others because they fear that the information they share will be used against them.
Individuals with this disorder persistently bear grudges and are unwilling to forgive the insults, injuries, or slights that they think they have received. Minor slights arouse major hostility, and the hostile feelings persist for a long time.
Is Paranoid Personality Disorder accurately described in the DSM-5?
The trait-based descriptions of paranoid personality disorder in DSM-IV are from a clinician’s perspective rather superficial, but the manual is accurate in noting that our knowledge of this personality type may be limited.
What challenges do psychotherapists face when diagnosing Paranoid Personality Disorder?
A paranoid person has to be in fairly deep trouble before he or she seeks (or is brought for) psychological help. In contrast to depressive, hysterical, or masochistic people, for example, higher-functioning paranoid individuals tend to avoid psychotherapy unless they are in severe emotional pain or are causing significant upset to others.
Because they are not disposed to trust strangers, paranoid people are also unlikely to volunteer to be research subjects.
An attributions of paranoia should not be made on the basis of an interviewer’s belief that a person seeking help is wrong about the danger he or she is in. Some people who look paranoid are actually being stalked or persecuted—by members of a cult they have left, for example, or by a rejected lover or a disaffected relative. Some people
who are diagnosably paranoid are also realistically imperiled; in fact, the off-putting qualities of many paranoid people make them natural magnets for mistreatment.
Some people who are not characterologically paranoid become temporarily so in paranoiagenic situations that are humiliating and entrapping.
When interviewing for diagnostic purposes, one should not reject out of hand the possibility that the interviewee is legitimately frightened, or that those who are urging him or her to seek therapy have a personal stake in making the client look crazy.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy