PARANOID PERSONALITY DISORDER

Recipient

KEZIA MATHEW
11C

PARANOID PERSONALITY DISORDER

 ACKNOWLEDGMENT
I express my deep sense of gratitude to all those who have been
instrumental in preparation of this project.

I had been immeasurably enriched to be working under Ms.

Nazneen, Psychology teacher, who has a great level of knowledge
and has an art of encouraging, correcting and directing me in
every situation possible.

To all friends, relatives, my parents and others, who in one way or

the other shared their support, either morally or physically.

I acknowledge to all the people who have involved and supported

me in making this project.

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 TABLE OF CONTENTS
SECTION TOPIC PAGE
NUMBER

1 INTRODUCTION 4-5

2 HISTORY OF PARANORIA AND PARANOID PERSONALITY 6

DISORDER

3 DETAILS OF PARANOID PERSONALITY DISORDER 7

4 RISK FACTORS 8

5 CAUSES OF PARANOID PERSONALITY DISORDER 9

6 SIGNS AND SYMTOMS 10

7 DIAGNOSIS AND TESTS 11-13

8 OTHER 14-15

9 MANAGEMENT AND TREATMENT 16-20

10 HOW PARANOID PERSONALITY DISORDER EFFECTS 21-22

RELATIONSHIP

11 CASE HISTORY OF CLIENT 23-30

12 ASSESSMENT USING PSYCHOMETRIC TEST 31-35

13 CONCLUSION 36

14 BIBLIOGRAPHY 37

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 1.INTRODUCTION
Paranoid personality disorder is a psychiatric diagnosis assigned to individuals who
persistently perceive interpersonal threats and danger without sufficient evidence or
cause. Individuals with this diagnosis constantly monitor their social environments for
signs of danger, believing that other people are plotting against them; minor
hardships occurring over the course of the day that most people would dismiss are taken
by the paranoid individual to be evidence in support of their conclusion that others are
“out to get them.” Because of this, individuals with this diagnosis remain vigilant in
scanning their environment for potential threat, feeling mistrustful of friendly
gestures or any situation that may be ambiguous (e.g., co-workers engaged in
conversation across the room are suddenly perceived to be talking about and plotting
against the paranoid individual, consistent with what Garety and Freeman (1999) have
labelled as a “personalizing bias” in paranoid delusional thinking).

They often keep to themselves and have

difficulty in social activities or settings;
those who are involved in romantic relationships
often have trouble sustaining them without
accusing the other person of being
disloyal. In contrast to paranoid thoughts
occurring at the psychotic level (as in paranoid
schizophrenia), the suspicious beliefs of the
paranoid personality disorder are typically at least somewhat plausible, and an individual
diagnosed with paranoid personality disorder retains some degree of reality testing
albites.

The prevalence of paranoid personality disorder in the general population is estimated to

be approximately 1.5%, while in outpatient clinical populations it may be as high as
25%. It is more often diagnosed in men and in individuals of cultural minority status.
Paranoid thinking, however, is believed to occur much more commonly in the general
population than the prevalence rates for paranoid personality disorder might suggest;

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with some estimating that up to 15% of the general population may experience
symptoms of paranoia on a regular basis.

The ability to focus attention on identifying and avoiding danger and risk, and to be
discerning in who to trust and believe, gives a clear survival advantage to paranoid
individuals in comparison to those who are overly trusting or who ignore signs of danger
and threat. Some theorists have argued that epistemic vigilance (i.e., the natural
suspicion towards information coming from others that can be harmful to the self)
diminishes over time through the establishment of a secure attachment with an attuned
caregiver; individuals experiencing paranoia, in contrast, may retain a heightened level of
vigilance that protects them against potential danger (though with a high interpersonal
cost). Despite convincing arguments that adopting a suspicious, mildly hypervigilant
stance may be both adaptive and normal in some situations, there is general agreement
that at a certain level of severity such traits become maladaptive and disruptive to daily
functioning.

Paranoid personality disorder has appeared as a formal diagnosis in every edition of the
Diagnostic and Statistical Manual of Mental Disorders and is one of only three personality
disorders to carry this distinction (the others include antisocial personality disorder and
schizoid personality disorder.

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 2. HISTORY OF PARANOIA AND PARANOID PERSONALITY DISORDER

Paranoia has a long history in the field of psychiatry and mental health, and paranoid
personality disorder has appeared in every edition of the Diagnostic and Statistical
Manual of Mental Disorders (Coolidge and Segal 1998). References to “paranoia,”
translated from an ancient Greek term literally meaning “out of one’s mind,” have existed
in medical literature for over two thousand years. Emil Kraepelin (1856–1926), a German
psychiatrist who contributed to early classification systems for mental disorders, adjusted
the definition of paranoia from a general term for madness to a specific term for
“delusional” thinking. Kraepelin asserted that the phenomenon of paranoia exists along a
continuum of severity, with more extreme presentations 4 occurring in individuals with
schizophrenia and milder forms occurring in individuals with character disorders.
Descriptions of paranoid processes in the early twentieth century focused on the
symptoms of chronic mistrust, frequent misinterpretation of life events, isolation from
others, and a tendency to overvalue ideas that occur during moments of high emotion.

Sigmund Freud (1856–1939) first explored paranoid processes in his paper

Psychoanalytic notes upon an autobiographical account of a case of paranoia (Dementia
paranoids) (1911), which presented a psychoanalytic theory of paranoia based on a first-
person account of the illness written by Daniel Paul Schreber. Schreber was a successful
judge who was hospitalized multiple times for psychiatric symptoms in the later part of
his life; in 1903, he published a narrative account of his illness that included reflections
on his elaborate paranoid delusional system, which was analysed by Freud and published
in the year of Schreber’s death. Freud identified the primary role played by the defence
mechanism of projection, or the unconscious disavowal and externalization of distressing
internal thoughts and feelings, as a central mechanism underlying the emergence and
maintenance of paranoid ideation.

While Freud’s early writings on the subject

asserted that paranoia was a defence against
disavowed homosexual urges, later
psychoanalytic writers focused instead on the
more general, systematic use of projection as an
unconscious defence against deeply rooted,
unsettling feelings about the self.

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3.DETAILS OF PARANOID PERSONALITY DISORDER
 What age does paranoid personality disorder begin?

People with paranoid personality disorder typically start experiencing symptoms and showing
signs of the condition by their late teens or early adult years.

 Who does paranoid personality disorder affect?

Overall, research reveals higher rates of paranoid personality disorder (PPD) in people
assigned female at birth (AFAB), while samples from hospital records reveal higher rates of
PPD in people assigned male at birth (AMAB).

People with PPD are more likely to:

❖ Live in low-income households.

❖ Be Black, Native American or Hispanic.
❖ Be widowed, divorced or separated or never married.

More research is needed to learn more about why these risk factors are associated with PPD
and how stress and trauma play a role in its development.

 How common is paranoid personality disorder?

Paranoid personality disorder is relatively rare. Researchers estimate that it affects 0.5% to
4.5% of the general population.

Are other medical conditions associated with paranoid personality disorder?

Yes, approximately 75% of people with paranoid personality disorder (PPD) have another
personality disorder. The most common personality disorders to co-occur with PPD include:

❖ Avoidant personality disorder.

❖ Borderline personality disorder (BPD).
❖ Antisocial personality disorder (ASPD).

People with PPD are also more likely to have substance use disorder and panic disorder than
the general U.S. population

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 4.RISK FACTORS
Childhood trauma has consistently been identified as a risk factor for PPD, in at least 4 cross-
sectional studies and one longitudinal study. The longitudinal study found that childhood
emotional neglect, physical neglect, and supervision neglect predicted PPD symptom levels in
adolescence and early adulthood. In adolescence, PPD has been cross-sectionally associated
with elevated physical abuse in childhood and adolescence, but not sexual abuse. In this
study, patients with PPD were also more likely to have PTSD. In a study of psychiatric adult
outpatients, PPD was found to associated with both sexual and physical abuse. These
relationships were found with other personality disorders as well, and were not specific to
PPD. Childhood abuse was also related to PPD symptom level, suggesting a dose-response
relationship, even when PPD symptoms were subthreshold for the diagnosis. Although these
studies have focused on chronic trauma from caregivers, acute physical trauma in the form
of childhood burn injury has also found to be a risk factor for adult PPD traits.

Brain trauma has been hypothesized to be a risk factor for paranoia. Empirical, cross-
sectional research finds that between 8.3 – 26% of brain injury patients meet PPD criteria.
PPD was the second most common PD following TBI. Longitudinal studies in this area are
lacking, but are needed to establish the temporal sequence of the association. Another
important question regarding the associating with brain injury and PPD is if the relationship is
due to neural circuit dysfunction, or if a change in function as result of the injury alters social
interactions. As an example of this, persons who are hard of hearing are more likely to
develop paranoia, likely through increased difficulty with and stress from communication with
others.

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 5.CAUSES OF PARANOID PERSONALITY DISORDER
A genetic contribution to paranoid traits and a possible genetic link between this personality
disorder and schizophrenia exist. A large long-term Norwegian twin study found paranoid
personality disorder to be modestly heritable and to share a portion of its genetic and
environmental risk factors with the other cluster A personality disorders, schizoid and
schizotypal.

Psychosocial theories implicate projection of negative internal feelings and parental

modelling. Cognitive theorists believe the disorder to be a result of an underlying belief that
other people are unfriendly in combination with a lack of self-awareness.

Researchers have found that childhood emotional neglect, physical neglect and supervision
neglect play a significant role in the development of PPD in adolescence and early adulthood.

Researchers have also identified other factors that may predict PPD symptoms in
adolescence and adulthood. These include:

❖ emotional neglect
❖ physical neglect
❖ supervisory neglect
❖ extreme or unfounded parental rage

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6.SINGS AND SYMTOMS
 What are the symptoms of paranoid personality disorder?
Often, people with paranoid personality disorder don’t believe that their behavior is
abnormal. It may seem completely rational to a person with PPD to be suspicious of others.
However, those around them may believe this distrust is unwarranted and offensive. The
person with PPD may behave in a hostile or stubborn manner. They may be sarcastic, which
often elicits a hostile response from others, which may seem to confirm their original
suspicions.
Someone with PPD may have other conditions that can feed into their PPD. For
example, depression and anxiety can affect a person’s mood. Mood changes can make
someone with PPD more likely to feel paranoid and isolated.
Other symptoms include:
❖ believing that others have hidden motives or are out to harm them
❖ doubting the loyalty of others
❖ being hypersensitive to criticism
❖ having trouble working with others
❖ being quick to become angry and hostile
❖ becoming detached or socially isolated
❖ being argumentative and defensive
❖ having trouble seeing their own problems
❖ having trouble relaxing
Some symptoms of PPD can be similar to symptoms of other
disorders. Schizophrenia and borderline personality disorder are two disorders with
symptoms similar to PPD. It can be difficult to clearly diagnose these disorders.

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 7. DIAGNOSIS AND TESTS
 How is paranoid personality disorder diagnosed?
Personality continues to evolve throughout child and adolescent development. Because of this,
healthcare providers don’t typically diagnose someone with paranoid personality disorder (PPD)
until after the age of 18.
Personality disorders, including PPD, can be difficult to diagnose, as most people with a
personality disorder doesn’t think there’s a problem with their behaviour or way of thinking.
When they do seek help, it’s often related to conditions such as anxiety or depression due to the
problems created by their personality disorder, such as divorce or lost relationships, not the
disorder itself.
When a mental health professional, such as a psychologist or psychiatrist, suspects someone
might have paranoid personality disorder, they often ask broad, general questions that won’t
create a defensive response or hostile environment. They ask questions that will shed light on:
❖ Past history.
❖ Relationships.
❖ Previous work history.
❖ Reality testing.
❖ Impulse control.
Mental health providers base a diagnosis of paranoid personality disorder on the criteria for the
condition in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental
Disorders.

 ICD-10
The World Health Organization's ICD-10 lists paranoid personality disorder under (F60.0). It is a
requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of
general personality disorder criteria. It is also pointed out that for different cultures it may be
necessary to develop specific sets of criteria with regard to social norms, rules and other
obligations.
PPD is characterized by at least three of the following symptoms:
1. excessive sensitivity to setbacks and rebuffs;
2. tendency to bear grudges persistently (i.e., refusal to forgive insults and injuries or
slights);
3. suspiciousness and a pervasive tendency to distort experience by misconstruing the
neutral or friendly actions of others as hostile or contemptuous;

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 4. a combative and tenacious sense of self-righteousness out of keeping with the actual
situation;
5. recurrent suspicions, without justification, regarding sexual fidelity of spouse or sexual
partner;
6. tendency to experience excessive self-aggrandizing, manifest in a persistent self-
referential attitude;
7. Preoccupation with unsubstantiated "conspiratorial" explanations of events both
immediate to the patient and in the world at large.
Includes: expansive paranoid, fanatic, querulant and sensitive paranoid personality disorder.
Excludes: delusional disorder and schizophrenia.

 DSM-5
The American Psychiatric Association's DSM-5 has similar criteria for paranoid personality
disorder. They require in general the presence of lasting distrust and suspicion of others,
interpreting their motives as malevolent, from an early adult age, occurring in a range of
situations. Four of seven specific issues must be present, which include different types of
suspicions or doubt (such as of being exploited, or that remarks have a subtle threatening
meaning), in some cases regarding others in general or specifically friends or partners, and in
some cases referring to a response of holding grudges or reacting angrily.
PPD is characterized by a pervasive distrust and suspiciousness of others such that their
motives are interpreted as malevolent, beginning by early adulthood and present in a variety
of contexts.
To qualify for a diagnosis, the patient must meet at least four out of the following
criteria:
1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them.
2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or
associates.
3. Is reluctant to confide in others because of unwarranted fear that the information will be
used maliciously against them.
4. Reads hidden demeaning or threatening meanings into benign remarks or events.
5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
6. Perceives attacks on their character or reputation that are not apparent to others and is
quick to react angrily or to counterattack.
7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual
partner.

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The DSM-5 lists paranoid personality disorder essentially unchanged from the DSM-IV-
TR version and lists associated features that describe it in a more quotidian way. These features
include suspiciousness, intimacy avoidance, hostility and unusual beliefs/experience.

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 8.OTHER
Various researchers and clinicians may propose varieties and subsets or dimensions of

personality related to the official diagnoses. Psychologist Theodore Millon has proposed five

subtypes of paranoid personality:

 Obdurate paranoid (including compulsive features)

Self-assertive, unyielding, stubborn, steely, implacable,

unrelenting, dyspeptic, peevish, and cranky stance;

legalistic and self-righteous; discharges previously

restrained hostility; renounces self-other conflict.

 Fanatic paranoid (including narcissistic features)

Grandiose delusions are irrational and flimsy;

pretentious, expensive supercilious contempt and

arrogance toward others; lost pride re-established with

extravagant claims and fantasies.

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  Querulous paranoid (including negativistic features)

Contentious, cavilling, fractious, argumentative,

fault finding, unaccommodating, resentful, choleric,

jealous, peevish, sullen, endless wrangles, whiny,

waspish, snappish.

 Insular paranoid (including avoidant features)

Reclusive, self-sequestered, hermitical; self-protectively

secluded from omnipresent threats and destructive

forces; hyper vigilant and defensive against imagined

dangers.

 Malignant paranoid (including sadistic features)

Belligerent, cantankerous, intimidating, vengeful,

callous, and tyrannical; hostility vented primarily in

fantasy; projects own venomous outlook onto others;

persecutory delusions.

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 9.MANAGEMENT AND TREATMENT
 How is paranoid personality disorder treated?
The prognosis for paranoid personality disorder depends on the individual. For someone
willing to accept help, treatment can reduce feelings of paranoia and minimize the impact the
condition has on the ability to function normally at home, at work, or in relationships.
Individuals who resist treatment have a worse prognosis, but for anyone with this condition it
is life-long and requires ongoing management and support. Most people with PPD need to be
pushed and encouraged by loved ones to get diagnosed and to accept treatment.
Treatment for PPD centers on therapy and medication where appropriate. Behavioral
therapies can be helpful, but also challenging because of the inherent distrust an individual
with this condition has of others. It can take time and a lot of patience to establish a good
relationship with a therapist. With that established, therapy can help an individual learn to
recognize that paranoid thoughts are flawed and to take steps to change their resulting
behaviors. A therapist works with an individual to learn coping skills, develop trust, build
better relationships, and learn how to communicate and engage with others in appropriate
ways.

 Therapy Options for Paranoid Personality Disorder

People with paranoid personality disorder are more likely to establish trust with a therapist
who is plain-spoken and more focused on facts than emotional expression. Therapists can
play important supportive roles for people with paranoid personality disorder, modelling
positive and trustworthy interactions and helping their clients be more accepting of and
engaged in treatment.
Psychotherapy for paranoid personality disorder is most effective when therapists use
techniques focused on problem-solving and rational insight. People with paranoid personality
disorder usually have a hard time forming intimate emotional connections with others and
withdraw when they feel like someone else is being too intrusive. Many people have a hard
time connecting with a therapist on an emotional level or responding to emotional cues. They
respond better to therapists who make direct statements and avoid emotional appeals.

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  Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is a practical choice for people with paranoid personality
disorder. Nearly all of the traits associated with paranoid personality disorder are rooted in
distorted cognitive patterns that emphasize and magnify potential interpersonal threats and
attribute malice to neutral people or events. People with paranoid personality disorder can
experience a significant improvement in their symptoms when they learn how to identify and
challenge irrational or distorted beliefs in CBT.

 Individual Therapy
Whether a therapist uses CBT or another related approach, individual therapy for paranoid
personality disorder typically focuses on the cognitive aspects of the disorder, or paranoid
thought patterns and belief systems. People who participate in individual therapy receive
support and encouragement from therapists who help them learn and practice different ways
of thinking and behaving.
While individual therapy can be useful on its own, people with paranoid personality disorder
usually have better outcomes when they participate in integrated services that are coordinated
to target different symptoms. For example, many people with paranoid personality disorder
will pair individual therapy with support groups and family therapy.

 Group Therapy
For people with disorders that affect their functioning in relationships, group therapy can be
an efficient and effective treatment option. This format allows therapists to provide some of
the same interventions and education they would participate in individual therapy while
helping a person explore and challenge beliefs about other people in real time.
Treatment groups allow people to learn from other people with similar symptoms or

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disorders. People receiving group treatment for paranoid personality disorder might be able to
see how another person’s paranoid thoughts are delusional and start to question their beliefs.
Therapy groups can also make people feel less alone and give them a safe space to talk about
their challenges in a stigma-free environment.

 Family Therapy
Family therapy can help individuals recover while helping family members learn how to
support them in their recovery. Family therapists help individuals reflect on their roles in
conflicts and practice calmer, more effective ways of communicating with each other. When a
person with paranoid personality disorder is actively living with family members, family
therapy can be particularly useful.

 Nutrition Counselling
In severe cases, people with paranoid personality disorder may severely restrict their diet
due to not trusting entire categories of food or the people who sell the food. More
typically, people with thought or Cluster A personality disorders suffer nutritional deficits
due to the effects of medications or a lack of awareness of how nutrition affects mood
and cognition. A nutrition counsellor can help people with paranoid personality disorder
establish a well- rounded diet with necessary minerals for mental health like Omega-3
fatty acids, B vitamins and magnesium.

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 9.1 Medications
The Food and Drug Administration (FDA) have not yet approved any drug treatments for PPD.

Some people have suggested treating PPD with the same drugs that healthcare professionals use
to treat borderline personality disorder (BPD). The premise for this is that the two conditions
share similar diagnostic features, such as hostility and aggression toward others.

Although the FDA have not approved any drugs for BPD either, healthcare professionals may
prescribe the following medications to reduce aggression:

 Anti-Anxiety Medications
There are two types of medications commonly used to treat anxiety symptoms: sedatives and
selective serotonin reuptake inhibitors (SSRIs).
Sedative medications like benzodiazepines can be helpful for people with severe anxiety
symptoms but have many dangerous side effects and a high risk of addiction. For this reason,
they are less typically prescribed to people who are at an elevated risk of harming themselves
or who have co-occurring substance use disorders.
For many people, SSRIs reduce anxiety symptoms just as effectively and are a safer option
with fewer side effects. These five SSRIs are the ones most commonly prescribed for anxiety:
❖ Paroxetine (Paxil)
❖ Citalopram (Celexa)
❖ Escitalopram (Lexapro)
❖ Sertraline (Zoloft)
❖ Fluoxetine (Prozac)
People with paranoid personality disorder and co-occurring anxiety require evaluation by a
clinician to determine which anti-anxiety medication, if any, is recommended.

 Antidepressants
Selective serotonin reuptake inhibitors are the most researched and most commonly used
antidepressant medications. They can help the brain regulate levels of serotonin, form new
connections and build new nerve cells, reducing levels of both depression and anxiety. Studies
show that commonly prescribed SSRIs like Prozac and Zoloft are safe for most people with co-
occurring depression.

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  Antipsychotics
Psychiatrists have not historically used antipsychotic medications to treat personality disorders,
even Cluster A disorders like paranoid personality disorder that resemble psychotic disorders.
More recently, however, researchers have found that atypical antipsychotics like risperidone
(Risperdal) and olanzapine (Zyprexa) can alleviate symptoms of paranoid personality disorder.

Still, these medications do not appear to have as pronounced an effect on people with paranoid
personality disorder as they do on people with schizophrenia. For this reason, they are usually
only recommended when severe aggressive or delusional symptoms put a person with paranoid
personality disorder at risk of harm or impede their ability to participate in psychotherapy.

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 10.HOW PARANOID PERSONALITY DISORDER AFFECTS RELATIONSHIPS

If you have a relationship with someone with paranoid personality disorder you already know
how stressful and emotionally turbulent it can be. Whether you’re dealing with a spouse, partner,
or family member, the suspicion, finger-pointing, and twisting of your words to mean something
else can take a heavy toll. The verbal insults, lack of sensitivity to your feelings, and stubborn
belief that they’re always right can make you feel like you’re walking on eggshells around them.
And their jealousy and controlling behavior can make it difficult for you to maintain other
relationships and social ties, leaving you feeling isolated and alone.

You probably feel like the person with PPD doesn’t ever see you for who you really are. They’re
so guarded about their feelings and paranoid about revealing anything personal about
themselves, it can be difficult to ever feel close.

In healthy relationships, trust tends to deepen over time as two people get to know each other
better. But in a relationship with someone with paranoid personality disorder, the opposite often
occurs. The longer you’re in the relationship, the less the person with PPD trusts you and the
more suspicious of you they become.

While it’s easy to become overwhelmed or lose hope, it is possible to stabilize your relationship
by encouraging your loved one to get treatment and taking steps to establish healthy boundaries.

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 10.1. COPING WITH AN LOVED ONE’S PARANOIA
As hurtful and confusing as a person with PPD’s behavior can be, try to remember that your
loved one’s paranoid beliefs and disordered thinking stem from fear. Even though their beliefs
may be totally unfounded, the fear, anxiety, and distress they’re experiencing are very real.

Recognize their pain. While you don’t need to agree with your loved one’s groundless beliefs,
you can recognize and offer comfort for the feelings that are fueling these beliefs. Acknowledging
their pain can help them feel more secure and diffuse their anger and hostility.

Don’t argue about their mistaken beliefs or instantly dismiss them. A person with PPD
misinterprets events as threatening and trying to argue rationally with them will only reinforce
their belief that you’re out to deceive them. Instead, respect their beliefs but focus on the fears
behind their claims. Talking openly about what they’re feeling, without validating their paranoid
thinking, can help to reduce their stress and anxiety.

Set boundaries. No matter how much pain your loved one is in, that doesn’t make it okay for
them to take it out on you. Setting clear boundaries can help the person with PPD see the
damaging effects of their behavior, which in turn may encourage them to seek treatment. For
example, you could make it clear that if they accuse you of cheating or prevent you from seeing
friends, you’ll leave until they begin treatment. Make the rules and consequences clear—but only
if you’re prepared to follow through with them.

Simplify how you communicate. Try to use clear, unambiguous language to reduce the
chance of your loved one misinterpreting what you’re saying. If your loved one starts to twist
your words, try to offer clarification without becoming defensive.

Encourage exercise. Regular physical activity releases endorphins that can relieve tension,
boost your loved one’s mood, and help manage symptoms of stress, anxiety, and depression.
Adding a mindfulness element—really focusing on how the body feels while exercising—may also
help your loved one interrupt the flow of negative thoughts running through their head.

Promote relaxation. People with paranoid personality disorder often have difficulty relaxing.
You can help by encouraging a regular relaxation practice such as yoga or meditation.

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 11.CASE HISTORY OF CLIENT
Client’s Profile
Name: Joe
Age: 49
Gender: Male
Primary Diagnosis: Paranoid Personality Disorder

Social History
Joe was the third of four children. He had two older brothers and a younger sister. His father was
a steamfitter, and his mother was a homemaker. The family lived in a lower-middle-class
neighborhood in a large, north-eastern city. Joe’s grandmother also lived with them, beginning
when Joe was 11 years old. She was an invalid and could not care for herself after Joe’s
grandfather died.

Our first information about Joe comes from his high school years. Unlike his older brothers, Joe
was an exceptionally bright student. On the basis of his performance in elementary school and
entrance examinations, he was admitted to a prestigious public high school. The school was
widely recognized for academic excellence.

The school was also known as a “pressure cooker.” All of the students were expected to meet
very high standards; those who failed were denigrated by their peers. Joe thrived in this
intellectually competitive environment. He usually received the highest test scores in his classes,
particularly in science. These achievements were based on a combination of intelligence and hard
work. Joe was clearly very bright, but so were most of the other students in this school. Joe was
a serious student who seemed to be driven by a desire to succeed. Although many of the other
students worried about examinations and talked to one another about their fear of failure, Joe
exuded self-confidence. He knew that the teachers and other students viewed him as one of the
best students; he often made jokes about people who “couldn’t make the grade.” This critical
attitude was not reserved for other students alone. Whenever a teacher made a mistake in class,
Joe was always the first to laugh and make a snide comment. His classmates usually laughed
along with him, but they also noticed a sneering, condescending quality in Joe’s humor that set
him apart from themselves.

Joe was a classic example of the critic who could “dish it out but couldn’t take it.” He was
extremely sensitive to criticism. It did not seem to matter whether the criticism was accurate or

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justified; Joe was ready to retaliate at the slightest provocation. He argued endlessly about
examinations, particularly in mathematics and science classes. If he lost points on any of his
answers, even if he had gotten an “A” on the exam, he would insist that his answer was correct,
the question was poorly written, or the teacher had not adequately explained the topic prior to
the exam. He never admitted that he was wrong.

His sensitivity was also evident in interpersonal relationships. His family background was a
particularly sore spot. Many of the other students in his school were from wealthy homes. Their
parents were mostly professionals with advanced degrees. Joe seemed to be self-conscious about
his father’s lack of formal education and the fact that his family did not live in a large, modern
house. He never admitted it openly, but the topic led to frequent arguments.

Joe did not participate in organized sports or student organizations, and he tended to avoid
group activities. He did have a small circle of friends and was particularly close to two other boys.
They were people whom he had judged to be his intellectual equals, and they were the only
people in whom he could confide. He was interested in women, but his attitude toward them and
his interactions with them struck his friends as being somewhat odd. The issues of dependence
and control seemed to be of central importance to Joe. Whenever one of his friends spent a lot of
time with a girlfriend or went out with her instead of a group of guys, Joe accused him of being
spineless or “on a tight leash.”

After graduating from high school, Joe enrolled at an Ivy League university, where he majored in
chemistry and maintained a straight-A average throughout his first 2 years. He seemed to study
all the time; his friends described him as a workaholic. Everything he did became a
preoccupation. If he was studying for a particular course, he concentrated on that topic day and
night, 7 days a week. If he was involved in a laboratory project, he practically lived in the
laboratory. Relaxation and recreation were not included in his schedule.

Later Adjustment
After receiving his B.S. degree, Joe stayed on at the same university to do graduate work in
biochemistry. He continued to work very hard and was considered one of the most promising
students in the department. His best work was done in the laboratory, where he was allowed to
pursue independent research. Classroom performance was more of a problem. Joe resented
being told what to do and what to read. He believed that most faculty members were envious of
his intellect. Highly structured reading lists and laboratory assignments, which were often time
consuming, were taken by Joe to be efforts to interfere with his professional advancement.

24
In his second year of graduate school, Joe began dating an undergraduate woman in one of his
study sections. Ruth was unremarkable in every way. His friends described her as plain, bland,
and mousy. They were surprised that Joe was even interested in her, but in retrospect, she had
one general feature that made her perfect for Joe—she was not at all threatening. He made all
the decisions in the relationship, and she acquiesced to his every whim and fancy. Other men
were not interested in her. In fact, they seldom noticed her, so Joe did not have to remain
constantly alert to the possibility of desertion. They were perfect complements to each other and
were married within a year.

Joe admired Dr. Daniels, a distinguished senior investigator and wanted to impress him. He did
not think much of his young colleagues and particularly resented the supervisors, whom he
considered to be his intellectual inferiors. He believed that they had been promoted because they
were “yes-men,” not because they were competent scientists. He often complained about them
to his peers and occasionally laughed openly about their mistakes. When they asked him to
perform a specific experiment, particularly if the task was tedious, he was arrogant and resentful,
but he usually complied with the request. He hoped that the quality of his work would be noticed
by Dr. Daniels, who would then allow him to work more independently. He also worried,
however, that the others would notice that he was being subservient in an effort to gain Dr.
Daniel’s favor. He became more and more self-conscious and was constantly alert to signs of
disdain and rejection from the others in the laboratory. The others gradually came to see him as
rigid and defensive, and he eventually became isolated from the rest of the group. He interpreted
their rejection as evidence of professional jealousy.

Joe’s response to criticism was openly hostile. He complained bitterly about the imbeciles in
company management and swore that he would no longer tolerate their jealousy and stupidity.
He was certain that someone had learned about his ideas and that Dr. Daniels and the others
were trying to force him out of the company so that they could then publish the theory without
giving him credit. Their insistence that he discontinue his work and return to more menial tasks
was clear proof, from Joe’s point of view, that they wanted to slow down his progress so that
they could complete the most important experiments themselves. His paranoid ideas attracted
considerable attention. Other people began to avoid him, and he sometimes noticed that they
gave him apprehensive glances. It did not occur to him that these responses were provoked by
his own hostile behavior. He took their behavior as further evidence that the whole laboratory
was plotting against him. As the tension mounted, Joe began to fear for his life.

The situation soon became intolerable. After 3 years with the firm, Joe was told that he would
have to resign. Dr. Daniels agreed to write him a letter of reference so that he could obtain

25
another position as long as he did not contest his termination. Joe considered hiring a lawyer to
help him fight for his job, but he became convinced that the plot against him was too pervasive
for him to win. He also had serious doubts about being able to find a lawyer he could trust. He
therefore decided to apply for other positions and eventually took a job as a research associate
working with a faculty member at a large state university.

Joe did not like the new job, partly because he thought it was beneath him and also because his
activity was even more highly structured than it had been at the drug company. He was working
on a research grant in which all the experiments had been planned in advance. Although he
complained a good deal about the people who had ruined his career and expressed a lack of
interest in the new line of work, he did high-quality work and was tolerated by the others in the
laboratory.

Things did not work out the way Joe had planned. After he had been working at the university
for 1 year, Dr. Willner asked him to curtail his independent research. He explained that these
outside experiments were becoming too expensive and that the main research funded by the
grant would require more of the laboratory’s time. Joe did not accept this explanation, which he
considered to be an obvious excuse to interfere with his personal work. He believed that Dr.
Willner had pretended to be disinterested in Joe’s work while he actually kept careful tabs on his
progress. Several weeks after, Dr. Willner hired another research associate and asked Joe to
share his office with the new person. Joe, of course, believed that the new person was hired and
placed in his office solely to spy on his research.

As the tension mounted at work, Joe’s relationship with Ruth became severely strained. They had
never had a close or affectionate relationship and now seemed on the verge of open conflict.
Ruth recognized that Joe was overreacting to minor events. She did not want him to lose another
job. She often tried to talk rationally with him in an effort to help him view these events from a
more objective perspective. These talks led to arguments, and Joe finally accused her of
collaborating with his enemies. He suggested that the people from the drug company and from
the university had persuaded her to help them steal his ideas and then get rid of him. As Joe
became more paranoid and belligerent, Ruth became fearful for her own safety and for that of
her daughter. She eventually took their daughter with her to live with Ruth’s parents and began
divorce proceedings. Her desertion, as Joe viewed it, provided more evidence that she had been
part of the plot all along.

Two weeks after Ruth left, Joe began to experience panic attacks. The first one occurred while
he was driving home from work. He was alone in the car, the road was familiar, and the traffic

26
pattern was not particularly congested. Although the temperature was cool, Joe noticed that he
was perspiring profusely. His hands and feet began to tingle, and his heart seemed to be beating
irregularly. When he began to feel dizzy and faint, he had to pull the car off the road and stop.
His shirt was now completely soaked with perspiration, and his breathing was rapid and labored.
At the time, he thought that he was going to smother. All in all, it was a terrifying experience.
The symptoms disappeared as quickly as they had appeared; within 10 minutes, he was able to
get back on the road and drive home. He experienced three such incidents within a 2-week
period and became so concerned about his health that he overcame his distrust of physicians and
made an appointment for a physical examination.

The physician was unable to discover any medical disorder and recommended that Joe consult a
psychiatrist about his anxiety. Joe reluctantly agreed that a psychiatrist might be of help and
arranged an appointment with Dr. Fein. The issue of Joe’s paranoid thinking did not come up
during his conversations with Dr. Fein because Joe did not consider it to be a problem.
Furthermore, he knew that other people thought that he was overly suspicious and that some
people would consider him to be mentally ill. He therefore, carefully avoided talking about the
efforts to steal his ideas and did not mention the plot involving his wife and former colleagues.
He simply wanted to know what was causing the panic attacks and how he could control them.
At the end of his second session, Dr. Fein suggested that Joe begin taking imipramine (Tofranil),
an antidepressant drug that has also been effective in treating panic anxiety. This suggestion
precipitated an extended conversation about the physiological action of mood- stabilizing drugs
that escalated into a heated argument.

Joe had been disappointed with Dr. Fein. He did not believe that Dr. Fein understood his problem
(i.e., the panic attacks) and resented the many open- ended, probing questions that he asked
about Joe’s personal life. Dr. Fein believed that he was trying to complete a thorough assessment
that would allow him to place this specific problem in an appropriate context, but Joe considered
this line of inquiry an invasion of privacy regarding matters for which he had not sought advice.
The prospect of taking antidepressant drugs further aroused Joe’s suspicions. He began asking
Dr. Fein about the neurological mechanisms affected by this drug—a topic with which he was
intimately familiar because of his own research at the drug company. He was obviously better
versed on this subject than Dr. Fein and concluded that Dr. Fein was therefore incompetent
because he recommended a treatment that he could not explain completely. Joe finally ended the
conversation by telling Dr. Fein that he thought he was a quack. He stormed out of the office and
did not return.

27
Fifteen-Year Follow-Up
Joe had found an occupational and social niche in which he was able to function on a relatively
stable basis. He continued to live in the same community, working as a cab driver. Still convinced
that Ruth had betrayed him, Joe never tried to contact her again. He had no further contact with
his daughter. He remained grandiose, suspicious, and frequently contemptuous of others, but his
condition did not deteriorate any further. In fact, he functioned relatively well, given his
maladaptive personality traits. His small and rather loose-knit circle of friends afforded him some
support and enough companionship to suit his modest needs. Because he did not see himself as
having any psychological problems, Joe did not seek additional treatment after his brief
encounter with Dr. Fein.

Joe’s paranoid thoughts were suddenly rekindled by an unexpected news event. One day, while
driving his cab, he heard on the radio that the Nobel Prize in chemistry had been awarded to a
professor at the university where he had received his bachelor’s and doctoral degrees. The
recipient, a faculty member in that department for 35 years, had been a member of Joe’s
dissertation committee when he was in graduate school. Although the man was only trying to be
helpful, Joe had felt enormous anger and embarrassment. Since that incident, Joe had always
described this professor as “a simple-minded, unimaginative charlatan.” No one else shared this
view, but others hadn’t been able to change Joe’s bizarre opinion.

The most shocking aspect of this news story, from Joe’s point of view, was the topic of the work
for which the prize was awarded: atmospheric chemistry. This subject had been of great interest
to Joe for many years. In fact, he had written two lengthy theoretical papers about it while he
was still working for the drug company. Joe had presumably developed a revolutionary new
theory regarding the ozone layer and the future of the Earth’s atmosphere. He believed that, if
only anyone would listen, his ideas would dramatically affect the future of the human race.
Unfortunately (from his point of view), most other scientists were too stupid to appreciate his
ideas.

Ruminating about the prize, Joe remembered that he had mailed copies of these papers to the
chemistry department at his alma mater when he was leaving his job at the drug company and
had been desperate for employment. He had applied for a postdoctoral position in another
laboratory. Although he was always reluctant to share his ideas with others in the field, he had
mailed copies of these papers in the hope of impressing the head of the lab. He hadn’t gotten the
job. Surely, he reasoned, this other professor (who had now won the Nobel Prize) had obtained
the papers, stolen Joe’s ideas, and gone on to conduct brilliant research while pretending that

28
the ideas were his own. Once again, Joe believed that he had been cheated—this time out of the
world’s most prestigious scientific award.

Unfortunately, little could be done. Joe complained bitterly and continuously. He knew that he
couldn’t complain to any of his peers from graduate school or his former colleagues at the
university. They hadn’t believed him before, and he was certain that they would not support him
now. Joe wisely chose not to file any formal complaints with the university. He was quite upset
about this story for several weeks, but he also had enough perspective on his own suspicions to
know that other people thought he was irrational. He resigned himself once again to living the
life of an exile from the scientific community.

The principal features of a paranoid personality are unwarranted suspicion and mistrust of other
people. People with this PD are often seen by others as cold, guarded, and defensive; they refuse
to accept blame, even if it is justified, and they tend to retaliate at the slightest provocation.
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; APA, 2000, p. 694) lists the
following criteria for paranoid PD:

1. A pervasive distrust and suspiciousness of others such that their motives are
interpreted as malevolent, beginning by early adulthood and present in a
variety of contexts, as indicated by four (or more) of the following:
▪ Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or
her
▪ Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or
associates
▪ Is reluctant to confide in others because of unwarranted fear that the information will be
used maliciously against him or her
▪ Reads hidden demeaning or threatening meanings into benign remarks or events
▪ Persistently bears grudges (e.g., is unforgiving of insults, injuries, or slights)
▪ Perceives attacks on his or her character or reputation that are not apparent to others
and is quick to react angrily or to counterattack
▪ Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual
partner

2. Does not occur exclusively during the course of schizophrenia, a mood disorder
with psychotic features, or another psychotic disorder

29
11.1. DISCUSSION
Joe’s case illustrates the overlap among different types of PDs. In addition to
paranoid PD, Joe also met the DSM-IV-TR (APA, 2000, p. 717) criteria for narcissistic
PD, which requires that the person exhibit five (or more) of the following features:
1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and
talents, expects to be recognized as superior without commensurate
achievements)
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty,
or ideal love
3. Believes that he or she is “special” and unique, and can only be under- stood
by, or should associate with, other special or high-status people (or
institutions)
4. Requires excessive admiration
5. Has a sense of entitlement (i.e., unreasonable expectations of especially
favourable treatment or automatic compliance with his or her expectations)
6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his
or her own ends)
7. Lacks empathy: is unwilling to recognize or identify with the feelings and
needs of others
8. Is often envious of others or believes that others are envious of him or her
9. Shows arrogant, haughty behaviours or attitudes

Joe’s inflated sense of his own intellectual abilities and scientific accomplishments clearly fits the
pattern for narcissistic PD. He also exhibited the lack of empathy and feelings of entitlement that
are described in these criteria. In addition to these characteristics, his behaviour was arrogant
and occasionally exploitative.
At least two aspects of Joe’s case might be consistent with this psychodynamic model. He
occasionally made comments about other men’s sexual orientation, particularly when he was
trying to embarrass them. We might infer from these remarks that he was concerned about his
own sexual desires, but we do not have any direct evidence to validate this conclusion. His only
sexual experiences had been with women, and he did not express ambivalence about his interest
in women. Joe’s panic attacks might also fit into Freud’s model, which suggests that Joe was
using the defence mechanism of projection to avoid the anxiety associated with unconscious
homosexual impulses.

30
12.ASSESSMENT USING PSYCHOMETRIC TEST
Clinical Interview
A Structural Clinical Interview from the DSM-IV-TR Axis II was conducted with the client. The treatment
phase consisted of six months of twice weekly Cognitive Behavioral Therapy (CBT). Joe took a Structural
Clinical Interview for DSM-IV-TR Axis II Personality Disorder. His results are as follows:

EVALUATOR POSSIBLE VALUES

1= Absent or False
Trained mental health
2=Subthreshold
professional
3=Threshold or True

SERIAL POSSIBLE
QUESTION
NUMBER VALUES

1 Often keeps an eye out to stop people from hurting him 1

2 Keeps thinking about how bad things have happened in the past 3

3 Wonders if he can trust others a lot 1

4 Does not let others know a lot about him 1

5 Feels that he can make things happen just by wishing for them 3

6 Often detects hidden threats or insults in things people do/say 1

7 Almost always expects things to turn out badly 2

8 Thinks it is not fair others have more than he does 2

9 Holds grudges or takes a long time to forgive people 1

10 Gets angry when someone criticizes him 1

11 Has very high standards about what is right and wrong 2

12 Suspects partner has been unfaithful 1

 Joe’s results on Structural Clinical Interview for DSM-IV-TR Axis II Personality Disorder

31
 12.1. PARANOID DISORDER TEST
The following question were asked to Joe and these are his responses.

Question 1

Others are talking about me behind my back, trying to put me down unfairly.

QUESTION 2

I often feel suspicious of people, even after they’ve acted loyally toward me.

QUESTION 3

I often hesitate to confide in others.

32
QUESTION 4

I am usually suspicious of other people and/or their motives.

QUESTION 5

Many of the people in my life secretly want to harm, exploit, or deceive me.

QUESTION 6

I am often eaten up by jealousy on the inside.

QUESTION 7

People deliberately do and say things to provoke me.

33
QUESTION 8

I believe that others are conspiring to harm me.

QUESTION 9

I monitor my romantic partner, friends, and/or family members intensely to find out who is being
unfaithful.

QUESTION 10

People around me want to destroy my reputation.

34
Joe’s Paranoid Disorder Test results

♦ Joe’s Paranoid Disorder Test Results

35
 13.CONCLUSION
Despite high prevalence rates in both clinical and community populations, paranoid personality
disorder has remained a significantly understudied and poorly understood diagnosis. Substantial
difficulties exist in recruiting individuals with the disorder into large-scale research studies or
even adequately referring them to psychiatric treatment; these difficulties may be due in large
part to the characteristic symptoms of avoidance and wariness of interpersonal situations and
relationships that are the hallmarks of the disorder.

Many areas of ambiguity remain in need of empirical investigation, including the relationship of
paranoia as a personality diagnosis to similar symptoms seen in delusional or psychotic-spectrum
disorders. At least one author has called for the removal of paranoid personality disorder from
future editions of the DSM, if its unique contribution to clinical understanding of paranoid and
delusional processes over and above conditions such as delusional disorder or schizophrenia
cannot be demonstrated through empirical evaluations (Triebwasser et al. 2013).

Despite a lack of sufficient empirical attention in both clinical and research realms, it remains
clear that paranoid ideation, in general, and paranoid personality disorder, in particular,
continues to pose important challenges to mental health professionals across a broad range of
clinical settings and contexts, and further knowledge is 16 strongly needed that can aid in
effective treatment and improved outcomes for individuals meeting criteria for this diagnosis.

36
 14.BIBLIOGRAPHY
➢ en.wikipedia.org/

➢ courses.lumenlearning.com/

➢ my.clevelandclinic.org/

➢ www.medicalnewstoday.com/

➢ www.helpguide.org/

➢ www.researchgate.net/

➢ psychiatryonline.org/

➢ www.idrlabs.com/

➢ scholar.google.ae/

➢ www.studocu.com/

➢ www.pitt.edu/

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