Last Saturday, on May 17, 2025, the second workshop of Module III in the one-year training program “Personality Disorders” led by Dr. Otto Kernberg took place.
This session was dedicated to paranoid personality disorder—a foundational topic that lays the groundwork for understanding the entire borderline level of personality organization.
The following is a brief outline of the main points covered during the workshop::
The workshop was divided into three sections, which included:
1. Theoretical Section – Two lectures with a total duration of 2 hours and 30 minutes. Key topics included:
First Lecture:
- Definition and prevalence of paranoid personality disorder
- Key features of paranoid personality disorder
- Social life of individuals with paranoid personality disorder
- Reality testing in paranoid personality as a basis for differential diagnosis of levels of personality organization
- Paranoid personality disorder in modern diagnostic classifications (including DSM-5)
- Depressive-masochistic, sadomasochistic, and paranoid personalities
- Paranoid personality vs. paranoid psychosis: essence and key features
- Differential diagnosis of paranoid personality disorder with:
* Narcissistic personality disorder
* Malignant narcissism
* Antisocial personality disorder
Specific syndromes associated with paranoid personality (with clinical examples):
– Persecutory behavior (stalking)
– Erotomania
– Pathological jealousy
- The role of psychological testing in confirming psychosis
- Cultural specifics of paranoid personality disorder (with clinical examples)
- Course, treatment, and prognosis of paranoid personality disorder
- Perspectives on paranoia in the works of Freud and Melanie Klein
- Therapeutic approaches to paranoid personality disorder, including clinical cases from Otto Kernberg’s practice
- Overview of Michael Garrett’s method for treating psychosis
- Other related topics
Second Lecture:
- Envy:
- As a component of the normal aggressive affective system
- a pathological envy
- Jealousy as a complication in paranoid personality disorder: nature and differential features of pathological jealousy, with clinical illustrations
- Sadistic personality as defined by Michael Stone and its differentiation from paranoid personality disorder
- Treatment prognosis for paranoid personality disorder
- Negative prognostic factors that may be identified early in treatment or during the pre-treatment assessment phase
- Working with paranoid transference and resistance
- Other related topics
Dr. Otto Kernberg offered participants a deep and precise understanding of paranoid personality structure, emphasizing the key diagnostic features that distinguish it from other psychopathologies. Clinical case material added valuable practical insight into the full spectrum of paranoid personality presentations.
2.Practical Section – Public Clinical Supervision with a total duration of 1 hour and 30 minutes:
What is the nature of boredom and devaluation as observed in patients? Are these phenomena interconnected? What do they signify about the patient’s internal dynamics?
These questions were explored in depth during the supervision segment led by Dr. Otto Kernberg.
He paid particular attention to working with boredom and devaluation in narcissistic patients and provided recommendations on how to explore these dynamics. Dr. Kernberg offered targeted, in-depth interventions to support therapeutic work with such presentations.
The second part of the supervision focused on analyzing manifestations of negative transference, particularly when patients perceive the therapist as a hostile, mocking, or threatening figure—one who seeks to harm or belittle them, or toward whom they feel a sense of superiority.
Dr. Kernberg shared his recommendations for working with such transference reactions and suggested ways to respond to provocative questions and statements arising in the therapeutic relationship.
3.Question and Answer Session:
This part of the workshop brings together the most interesting and diverse questions from participants, along with thorough responses from Dr. Otto Kernberg, who often enriches his answers with clinical examples from his over 70 years of practice.
This time, the participants asked Dr. Otto Kernberg the following questions:
- Rigid paranoid traits can be present in various individuals at the borderline level of personality organization. How can we differentiate between a patient with paranoid personality disorder and one who simply exhibits rigid paranoid character traits?
- Consider a patient who presents with a fear that their social media accounts may be hacked, has not left their home for two years, and reports anxiety about being attacked. Yet, this patient readily accepts the suggestion to change psychiatrists and easily transitions between therapists. Can we interpret this as the patient using paranoid symptoms to attract attention? In other words, is it appropriate to speak of pseudoparanoia in this case?
- Could you share your perspective on the etiology of paranoid personality disorder?
- You mentioned that physical unattractiveness is a negative prognostic factor. Could you elaborate on how and to what extent unattractiveness influences prognosis?
- The literature describes therapist-centered interpretations (following John Steiner) as an effective approach that allows patients to become aware of internal representations they have difficulty integrating into their sense of self. How effective are therapist-centered interpretations when working with negative transference, especially with patients diagnosed with narcissistic or paranoid personality disorders?
What is the main danger or difficulty for a therapist at the start of his career when working with each of the personality disorders? What is the most common rookie mistake in each case?
Both the antisocial personality and the sadomasochistic personality take pleasure in harming others? How can we distinguish between these two structures by using a structural interview?
- To what extent are internal conflicts foundational to bipolar disorder, versus it being primarily a neurophysiological condition?
- and other questions.
Supervision-related questions:
- We observe that the patient strongly devalues his wife.
In your view, is it realistic to expect that, through working through this devaluation, the wife could once again become a desirable or emotionally significant figure in the patient’s perception? Or are these relationships essentially doomed, such that only future sexual relationships—after the devaluation has been addressed—could become satisfactory?
- How should therapists work with narcissistic defenses, particularly in cases where the therapist is perceived as the patient's primary adversary, as in the case presented for supervision? How should the therapist respond when the patient seeks to offer acceptable answers rather than engaging in genuine free association?
- and other questions.
This time, there were an exceptionally large number of questions, but this did not prevent Otto Kernberg from providing deep and structured answers to each of them.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy