Introduction

Paranoid personality disorder is an enduring pattern of maladaptive behavior, thinking, and personality traits. Patients with this disorder are not psychotic, but some evidence suggests a possible but weak genetic link to schizophrenic spectrum disorders. The characteristic personality traits may be well established by adolescence and may have been present in modified or precursory form even in childhood.

General Considerations

Diagnosis
DSM-IV (American Psychiatric Association 1994) describes paranoid personality as marked by pervasive and long-standing suspiciousness and general mistrust of others (see

Table 80-1 for DSM-IV diagnostic criteria for paranoid personality disorder). These patients are hypersensitive, are easily slighted, and habitually relate to the world by vigilant scanning of the environment for clues or suggestions to validate their prejudicial ideas or biases. They tend to be guarded and suspicious and have quite constricted emotional lives. Their incapacity for meaningful emotional involvement and the general pattern of isolated withdrawal often lend a quality of schizoid isolation to their life experience.

Often the hypervigilance, hypersensitivity, suspiciousness, and guardedness of these patients can be quite muted, so that their role in the patients’ difficulties is not readily apparent. In many psychoanalyses of patients with unrelated character diagnoses, paranoid traits, especially fears centered on passivity, issues of narcissistic injury and rage, and masochistic and projective defenses, come to the surface. These traits are often subtle and muted but at times can be surprisingly intense. In paranoid personalities, ideas of reference may be present, but without the degree of delusional conviction found in psychotic paranoid patients.

Characteristically, patients with paranoid personalities have difficulty accepting responsibility for themselves, their lives, and the consequences of their behavior. They are quick to blame others, even fate or the gods, for their misfortune or unhappiness. Constant blaming is a typical paranoid posture. Their general guardedness is often reflected in keeping their ideas to themselves and communicating them reluctantly even under the best of circumstances. Consequently, although difficulties characteristically arise in more intimate contexts (e.g., marital relationships or work situations, particularly in relation to authority figures), their external impairment and maladaptation often escape notice or are rationalized as minor eccentricities.

Common Difficulties
Paranoid personality disorder is well established in the catalogue of personality disorders, but even so, the clinical literature, not to mention research, on its specific treatment is rather sparse. Most discussions of treatment of paranoid pathology deal more or less exclusively with psychotic conditions. The dearth of careful study is striking but may be the result of a series of factors: 1) the personality disorder as such is rarely seen clinically; 2) the defensive organization is often ego-syntonic and does not give rise to symptoms or significant impairment - the impairment is more often interpersonal than intrapsychic and more disturbing or disruptive to those around the patients than to the patients themselves; 3) even when such individuals come to psychiatric attention, they often keep their emotional or interpersonal difficulties hidden because of their guardedness and mistrust; 4) for similar reasons, they are less likely to lend themselves to systematic investigation; 5) such patients tend to maintain a reasonably good level of functioning, coming to psychiatric attention only when their defenses have crumbled and they experience a regressive episode that may result in a more severe diagnostic evaluation; and finally, 6) often enough, the paranoid characteristics are mingled with other pathological personality features that allow the patient to be classified as narcissistic, borderline, antisocial, schizoid, or even depressed. The rigidity of paranoid defenses does not augur well for effective treatment, so that diagnosis should include assessment of the patient’s motivation and receptivity for psychotherapy as well as capacity to tolerate the therapeutic process.

The diagnosis of paranoid personality may be easy or difficult - easy when the paranoid characteristics can be identified but difficult when they cannot. The problem is that these traits are often not easily recognized. Even when recognition of traits is not complicated, mixed personality configurations and the potential overlap between paranoid personality characteristics and those of other personality disorders are persistent problems.

Paranoid Traits
The presence of paranoid traits may be muted and subtle. These “soft signs” of paranoia are continuous with a more normal range of personality characteristics and functioning and often are difficult to evaluate for this reason. They include the following:

• Centrality - Often these patients believe that they are somehow the center of other people’s interest or attention. This can reflect their sense of being passive recipients of external influences over which they may feel they have little or no control. In patients with personality disorder, this more commonly may take the form of ideas of reference, whereas in psychotic paranoid disorders, it takes a more extreme form, in which evil and often powerful external forces or influences are seen as directed against and threatening the patient.
• Self-sufficiency - Also characteristic is a facade of self-sufficiency, which may represent an attempt to defend against underlying narcissistic vulnerability. The self-sufficiency may involve a degree of grandiosity and isolation similar to that seen in patients with schizoid conditions.
• Concern over autonomy - A concern over autonomy is fragile and easily threatened. This can especially be a problem in therapy.
• Blaming - A tendency to blame others for any personal failures, shortcomings, or disappointments is often evident.
• Feelings of inadequacy - Patients’ feelings of inadequacy or deficiency may be reflected in concerns about being different or feeling like an outsider or often in a more diffuse concern with having values or beliefs different from those of associates.
• Concerns over power and powerlessness - Paranoid individuals typically have difficulty in relating to authority figures, taking orders, assuming appropriate responsibility, and generally fitting into preexisting social or group structures.