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Paranoia, although originally referring (in Greek) to almost any kind of mental aberration or bizarre thinking, is currently used to describe a disordered mode of thought that is dominated by an intense, irrational, but persistent mistrust or suspicion of people and a corresponding tendency to interpret the actions of others as deliberately threatening or demeaning. Because of the general expectation that others are against them or are somehow trying to exploit them, paranoid persons tend to be guarded, secretive, and ever vigilant, constantly looking for signs of disloyalty or malevolence in their associates. These expectations are easily confirmed: the hypersensitivity of paranoids turns minor slights into major insults, and even innocuous events are misinterpreted as harmful or vindictive. As a result, a pernicious cycle is set in motion whereby expectations of treachery and hostility often serve to elicit such reactions from others, thus confirming and justifying the paranoid’s initial suspicion and animosity. Of all psychological disturbances, paranoia is among the least understood and most difficult to treat.
I. Paranoid Syndromes
A. Delusional (Paranoid) Disorder
B. Paranoid Personality Disorder
C. Paranoid Schizophrenia
D. Other Paranoid Disorders
III. Causes of Paranoia
A. Biological Bases
1. Genetic Contribution
B. Psychological Bases
1. Psychodynamic Theory
2. Faulty Development
3. The Paranoid “Illumination” and the Paranoid Pseudo-Community
4. Anomalous Perceptions
6. Biases in Information Processing
a. Paranoia and Self-Focus
b. Personalism and Intent
IV. Treatment of Paranoia
I. PARANOID SYNDROMES
Paranoid features are found in a variety of different psychological conditions. Although these conditions are often regarded as distinct, the criteria for distinction are not entirely clear and the practical utility of the distinction, in terms of etiology or treatment implications, has not been established. Thus, it may be useful to consider the different paranoid disorders as related syndromes existing along a continuum which varies in terms of the frequency and severity of paranoid thoughts, the degree to which reality is allowed to influence perceptions, and the extent to which functioning is impaired. The continuum extends from paranoid personality disorder, which is nondelusional, but where suspicion and its sequelae occur so regularly that work and family life are often disrupted; to delusional (paranoid) disorder, involving a chronic, dysfunctional delusional system, although apart from the delusion, reality testing is good and behavior is not obviously odd; and finally, to paranoid schizophrenia, a severe, incapacitating psychosis, involving a serious loss of contact with reality in which all thought is affected by the delusion.
A. Delusional (Paranoid) Disorder
The cardinal feature of this disorder is the presence of a delusion that is so systematic, logically developed, well-organized, and resistant to contradictory evidence, that others are often convinced by it. Delusions are faulty interpretations of reality that cannot be shaken, despite clear evidence to the contrary. Although the delusions in this disorder are nonbizarre (unlike those found in paranoid schizophrenia) and involve situations that may occur in real life, in fact they have no basis in reality, and are not shared by others in the culture. Delusional systems are usually idiosyncratic, but some themes or combination of themes are more frequently seen than others, and psychiatric diagnosis of this disorder is now specified by the predominant theme of the delusions present.
Delusions of persecution, in which the paranoid believes that “others are out to get me,” are the most common form of this disorder. While those with a paranoid personality disorder may be suspicious that colleagues are talking about them behind their backs, persons with delusional disorder may go one step further and suspect others of participating in elaborate master plots to persecute them. They often believe that they are being poisoned, drugged, spied upon, or are the targets of conspiracies to ruin their reputations. Many of them tend to be inveterate “injusticedetectors,” inclined to take retributive actions of one sort or another, and are constantly embroiled in litigation or letter writing campaigns, in an attempt to redress imagined injustices.
Persons with delusions of grandiosity have an exaggerated sense of their own importance. In some cases, these beliefs are related to persecutory delusions, in that the paranoid eventually comes to feel that all the attention he’s receiving is indicative of his superiority or unique abilities. Such exalted ideas usually center around messianic missions, extremist political movements, or remarkable inventions. Persons suffering from delusions of grandeur often feel that they have been endowed with special gifts or powers and, if allowed to exercise these abilities, they could cure diseases, banish poverty, or ensure world peace. When these efforts are ignored or thwarted, as they almost inevitably are, the paranoid may become convinced of a conspiracy directed against him.
Another theme frequently seen is that of delusional jealousy, in which any sign~even an apparent wrong number on the phone or a short delay in returning home–is summoned up as evidence that a spouse is being unfaithful. When the jealousy becomes irrationally pathological, and the paranoid becomes convinced beyond all reason that his spouse is cheating and plotting against him in an attempt to humiliate him, he may become violently dangerous.
An erotic delusion (also known as erotomania) is based on the belief that one is romantically loved by another, usually someone of higher status or a well-known public figure, although the other, presumably, cannot acknowledge it openly. Because of unrealistic expectations about the likelihood of living with the celebrity, these delusions often result in stalking or harassment of famous persons through incessant phone calls, letters, visits, and surveillance. When their love is not returned, these delusional individuals feel a sense of betrayal that may turn to rage and hatred. Although this disorder has been reported most often in women, it occurs in men as well (perhaps the best example being John Hinckley, whose erotomanic delusions involving the actress Jodie Foster led to his attempted assassination of then-President Ronald Reagan).
Those with somatic delusions are convinced that there is something very wrong with their bodies—-that they emit foul odors, or have bugs crawling inside of them, or are misshapen. These delusions often result in an avoidance of others, except for physicians who, despite being accused of conspiring to deny the problem, are consulted continuously regarding the imagined condition.
The thinking and behavior of these individuals tend to become organized around the delusional theme in the form of a pathological “paranoid construction” that, for all its distortion of reality and loss of critical judgment, provides a sense of identity, importance, and meaning not otherwise available. The meaningfulness of delusions is also suggested by the fact that they often reflect the person’s position in the social universe: Women and married men are most likely to have delusions with sexual content; foreign immigrants are most prone to have persecutory delusions; and people from higher socioeconomic levels are the most likely to have delusions of grandeur.
Once the basic delusion is accepted, other aspects of behavior, including emotional responses, may be described as appropriate and more or less conventional. Delusionally disordered persons do not suffer hallucinations or indications of other mental disorders, and their personalities do not change drastically; there are few exacerbations or remissions. There is a relatively high level of cognitive integration skills in areas that do not impinge on the delusional thought structure. Despite their mistrust, defensiveness, and fear of being exploited, they can sometimes function adequately, especially when their suspicions are limited to one specific area; for example, if they suspect poisoners everywhere, they may be satisfied if they can prepare all their own food. Their lives may be very limited and isolated, but they are just as likely to be regarded as harmless cranks than as someone requiring the help of a mental health professional.
Sometimes, however, the consequences of the delusions are debilitating and not so easy to manage; for example, a person suffering from delusions of persecution may assault an imagined persecutor or spend a fortune fleeing enemies and pursuing redress for imagined wrongs. In other instances, the disorder may be dangerous. In particular, paranoid delusional disorder may be overrepresented among fanatical reformers and self-styled prophets and cult leaders. These individuals may be especially attracted to an enterprise that encourages blaming others, regarding themselves as a victim, and putting themselves at the center of things. Especially in times of social cataclysm or uncertainty, their grandiosity and moralistic tendencies, as well as the logical and compelling presentation of their messianic or political delusions, can often attract disciples. In addition, their garrison mentality is quite capable of provoking events which then serve to confirm their apocalyptic prophecies.
Much of the difficulty involved in diagnosing paranoid disorders is because of the slipperiness of the concept of delusion. Even in the real world, it is not always possible to determine the truth or falsity of an idea: Does the government keep track of unsuspecting individuals? Is our air and water filled with unseen toxins? Does our boss really have our best interests in mind? Some ideas that are patently false are held with sincere conviction by many; and even when an idea is held as preposterous by the majority, that majority may be wrong. How, then, do we evaluate the irrationality of an idea, or decide whether clearly eccentric and convoluted thinking merits the designation “delusional?” Although it may be difficult to distinguish reality from illusion, particularly when the belief system develops around a potentially real injustice, other indications may be diagnostically helpful. An inability to see facts in any other light or to place them in an appropriate context, a glaring lack of evidence for far-reaching conclusions, and a hostile, suspicious, and uncommunicative attitude when delusional ideas are questioned usually provides clues of pathology.
B. Paranoid Personality Disorder
Anyone starting in a new situation or relationship may be cautious and somewhat guarded until they learn that their fears are unwarranted. Those with paranoid personality disorder cannot abandon those concerns. Although not of sufficient severity to be considered delusional, theirs is a rigid and maladaptive pattern of thinking, feeling, and behavior, usually beginning by early adulthood, that is built upon mistrust, vigilance, and hostility. The conviction that others “have it in for them” represents their most basic and unrelenting belief; they feel constantly mistreated, and have a high capacity for annoying and provoking others.
Seeing the world as a threatening place, these individuals are preoccupied with hidden motives and the fear that someone may deceive or exploit them. They are inordinately quick to take offense, slow to forgive, and ready to counterattack at the first sign of imagined criticism, even in their personal relationships. Disordered paranoid personalities see references to themselves in everything that happens. If people are seen talking, the paranoid knows they are talking about him. If someone else gets a promotion, that person’s advancement is seen as a deliberate attempt to humiliate him and downgrade his achievements. Even offers of help and concern are taken as implied criticisms of weakness or as subtle manipulations of indebtedness. The constant suspicions and accusations eventually strain interpersonal relations to the point where these individuals are in continual conflict with spouses, friends, and legal authorities.
Given their hypersensitivity, any speck of evidence that seems to confirm their suspicions is blown out of proportion, and any indication to the contrary is ignored or misinterpreted. Trivial incidents become accumulated and unconnected “facts” are fit together to create false, but unshakeable beliefs regarding their mistreatment. Because of their conviction that others are undermining their efforts or ruining their achievements, they tend to see themselves as blameless, instead finding fault for their own mistakes and failures in others, even to the point of ascribing evil motives to others.
Those with disordered paranoid personalities also tend to overvalue their abilities, and have an inflated sense of their rationality and objectivity, making it extraordinarily difficult for them either to question their own beliefs or to accept or even appreciate another’s point of view. Unable to recognize the possibility of genuine dissent, simple disagreement by others becomes a sign of disloyalty. The resulting obstinacy, defensiveness, and self-righteousness exasperates and infuriates others, and elicits responses that exacerbate the conflict and confirm the original paranoid expectations.
In addition to being argumentative and uncompromising, paranoids appear cold and aloof, and emotionally cut off from others. They avoid intimacy, partly because they fear betrayal, partly in an attempt to maintain total control over their affairs, and partly because of profound deficits in their capacity for joy, warmth, and nurturance. The resulting social isolation, by limiting the opportunity to check social reality and learn from others, only reinforces their egocentric perspective.
Compared to some other paranoid pathologies, those with disordered personalities tend not to progressively worsen, but rather reach a certain level of severity and stay there. They show considerably less disorganization of personality, and they do not develop the kind of systematic and well-defined delusions found in delusional disorders. However, the proverbial kernel of truth is often greater in the suspicions of disordered paranoid personalities than in those with delusional disorders; their accusations have more plausibility and their paranoid attitudes are more diffuse. Because of the complexity and pervasiveness of personality disorders, these individuals may have more impoverished lives, although some do manage to function adequately in society, often by carving out a social niche in which a moralistic and punitive style is acceptable or at least tolerated.
C. Paranoid Schizophrenia
This major mental illness is one of the most common types of psychotic disorders. Paranoid schizophrenics may be distinguished from those with delusional disorder on the basis of the extreme bizarreness of their paranoid delusions, such as the belief that their thoughts or actions are being controlled by external forces, and by the presence of hallucinations (e.g., hearing voices) and other indications of a serious break with reality. The delusions of schizophrenics are not organized and systematic, but fragmentary and unconnected. Although these individuals may be suspicious and very much threatened by outside influences, their reaction, unlike that of the disordered paranoid personality, is usually hesitant and confused; their anger has no concentrated intensity. The behavioral, cognitive, and perceptual disorders of paranoid schizophrenics are so dysfunctional that performance on the job or at home almost invariably deteriorates, and emotional expressiveness becomes severely diminished.
These individuals commonly suffer from delusions of persecution, wherein they are convinced that they are constantly being watched or followed, and that strangers or government operatives or even alien beings are plotting against them with fantastic machines, undetectable poisons, or extraordinary mental powers. Of course, given the exceptional cunning and duplicity of these diabolical forces, virtually anything–a look, a sound, a bodily sensation, for that matter, even the absence of anything, a particularly shrewd maneuver–is seen as confirmation of one’s suspicions. When the schizophrenic experiences the “paranoid illumination,” and recognizes that all this overwhelming evidence fits together, the sense of his own visibility and vulnerability is profoundly increased, as is the tendency to misperceive himself as the target of other people’s stares, comments, and laughter. In some cases, persecutory beliefs are accompanied by delusions of grandeur: that they are the target of these forces is only because they are special or powerful or dangerous. They may recognize that others reject them and their message, but they interpret these negative reactions as persecution based on jealousy, hostility, or enemy conspiracies.
Some paranoid schizophrenics avoid detection for long periods because their extreme suspiciousness encourages them to keep their “precious knowledge” secret. Moreover, although these individuals are deeply disturbed and are subject to intense panic (given their sense of imminent danger) and extreme excitement (over their irrational “discoveries”), many of them are not overtly bizarre or belligerent.
D. Other Paranoid Disorders
Some paranoid thinking manifests itself in a less persistent form. Acute paranoid disorder, in which delusions develop quickly and last only a few months, sometimes appear after a sudden, stressful social change, such as emigration, prison, induction into military service, or even leaving a family home. Although these conditions are multifaceted, they all are associated with extreme social isolation, unfamiliarity with the appropriate customs and rules of behavior, a sense of vulnerability to exploitation, and a general loss of control over life, psychological factors which may play an important, albeit temporary, role in inducing episodes of paranoia.
Paranoid symptoms may also be a byproduct of physical illness, organic brain disease, or drug intoxication. Among organic illnesses, hypothyroidism, multiple sclerosis, Huntington’s disease, and epileptic disorders, as well as Alzheimer’s disease and other forms of dementia, are common causes of paranoia. In some people, alcohol stimulates a paranoid reaction even in small doses, and paranoia is a common feature of alcohol hallucinosis and alcohol withdrawal delirium. Chronic abuse of drugs, such as amphetamines, cocaine, marijuana, PCP, LSD, or other stimulants or psychedelic compounds, may produce some of the symptoms of paranoid personality disorder, and in high doses, may cause an acute psychosis that is almost indistinguishable from paranoid schizophrenia. These drugs may also exacerbate symptoms in persons already suffering from a paranoid disorder.
It is difficult to estimate the frequency of paranoia in the general population because many paranoids function well enough in society to avoid coming to the attention of professionals, and because their suspiciousness and intellectual arrogance usually prevent them from volunteering for treatment. While clinical diagnoses of paranoid disorders are rare, a more realistic picture of its actual occurrence is suggested by the many exploited inventors, morbidly jealous spouses, persecuted workers, fanatic reformers, and self-styled prophets who are often able to maintain themselves in the community without their paranoid condition being formally recognized.
Estimates of prevalence are further complicated by the fact that almost everyone engages in paranoid thinking at one time or another. Most people can think of an occasion when they thought that they were being watched or talked about, or felt as if everything was going against them, or were suspicious of someone else’s motives without adequate proof that such things had actually occurred. Recent studies have shown that for a significant number of people, these paranoid beliefs represent a relatively stable personality pattern. Such paranoid personalities–although characterized by suspiciousness, self-centeredness, scapegoating tendencies, and a generally hostile attitude–apparently are capable of functioning reasonably well in society.
III. CAUSES OF PARANOIA
A. Biological Bases
1. Genetic Contribution
Although there is little research on the role of heredity in causing paranoia, there is some evidence from twin studies indicating that paranoid symptoms in schizophrenia may be genetically influenced. In addition, family studies suggest that features of the paranoid personality disorder occur disproportionately more often in families with members who have either delusional disorders or paranoid schizophrenia, suggesting that these syndromes may be genetically related.
No identifiable biochemical substrate or demonstrable neuropathology relates specifically to paranoid thought or delusions; that is, there is no brain system whose dysfunction would specifically produce the psychological characteristics associated with paranoia. Although the abuse of drugs, such as amphetamines, may lead to paranoid symptoms, thus suggesting a possible biochemical pathway, no such pathway has been identified; whatever drug effects have been found may be psychologically, and not biochemically, mediated.
B. Psychological Bases
In the absence of a clear organic basis or effective drug treatment for paranoia, most researchers have sought to identify the psychological mechanisms that explain how paranoid ideas become fixed in the mind.
1. Psychodynamic Theory
Of all psychological theories, Freud’s is perhaps the best known, although it is increasingly challenged. He believed that paranoia was a form of repressed homosexual love. According to Freud, paranoia arises, at least in men, when a child’s homosexual feelings for his father are preserved but driven into the unconscious, from which they re-emerge during an adult emotional crisis, converted into suspicions and delusions by projection~the attribution of one’s own unacknowledged wishes and impulses to another person.
That is, before reaching consciousness, the impulses undergo some kind of transformation that disguise their homosexual origin; for example, a man suffering from paranoid jealousy, unable to acknowledge that he himself loves another man, projects that feeling onto his wife and becomes convinced that it is his wife who loves the man.
Although Freud’s theory of unconscious homosexuality has been largely discredited, projection is still recognized as a basic mechanism used by paranoids to defend against their feelings. Paranoids will explain their sense of helplessness by pointing to the control exerted by others; or self-critical ideas are transformed into the belief that others are criticizing them. Viewing others as hostile not only justifies the paranoid’s feeling of being threatened, it may actually elicit the other’s anger, thus confirming the paranoid’s original assumption. As a result, paranoids are left feeling weakly vulnerable, but morally righteous.
2. Faulty Development
Rather than emphasizing unconscious dynamics, other approaches have viewed paranoid thinking as the outcome of a complex interaction of personality traits, social skills, and environmental events, some of which may be traced to early family dynamics. Paranoids, even as children; were often described as aloof, suspicious, secretive, stubborn, and resentful of punishment. Rarely was there a history of normal play with other children, or good socialization with warm, affectionate relationships. Their family background was often authoritarian, and excessively dominating and critical. Paranoid persons may dread being watched and judged because, it has been suggested, that reminds them of their parents, who were distant, demanding, and capricious.
This inadequate socialization may have kept them from learning to understand others’ motives and points of view which, in turn, may have led to a pattern of suspicious misinterpretation of unintentional slights. Social relationships tended to be suffused with hostile, domineering attitudes that drove others away. These inevitable social failures further undermined self-esteem and led to deeper social isolation and mistrust. In essence, these individuals emerged from childhood with deeply internalized struggles involving issues of hostility, victimization, power, submission, weakness, and humiliation. In later development, these early trends merged to create self-important, egocentric, and arrogant individuals, who maintained their unrealistic self-image and a sense of control by projecting blame for their problems onto others, and seeing weaknesses in others that they could not acknowledge in themselves. Their suspicion and hypersensitivity were made even more problematic by their utter inability to see things from any viewpoint but their own.
3. The Paranoid “Illumination” and the Paranoid Pseudo-Community
Other theorists have focused, not on early family history, but on the later emergence of a fixed, unyielding paranoid belief system. Given the paranoid’s rigidity, self-importance, and suspiciousness, he is likely to become a target of actual discrimination and mistreatment; and ever alert to such occurrences, the paranoid is likely to find abundant “proof,” both real and imagined, of persecution. The cycle of misunderstanding is then perpetuated by the paranoid’s subsequent responses. The belief that others are plotting against him results in hostile, defensive behavior. This in turn elicits the others’ anger and irritability in response to the paranoid’s apparently unprovoked hostility, thus confirming the paranoid’s original suspicion that they are out to get him. This cycle of aggression and counteraggression has also been offered as one explanation for the greater prevalence of paranoia among males than females. The paranoid’s inability to consider the others’ perspective–that the other may be operating out of defensiveness against the paranoid’s antagonism and belligerence–only exacerbates the conflict.
As failures and seeming betrayals mount, the paranoid, to avoid self-devaluation, searches for “logical” explanations. He becomes more vigilant in his scrutiny of the environment, looking for hidden meanings and asking leading questions. Eventually, a meaningful picture, in the form of the “paranoid illumination,” crystallizes and everything begins to make sense: he has been singled out for some obscure reason, and others are working against him. Failure is not because of any inferiority on his part, but rather because of some conspiracy or plot directed at him. With this as his fundamental defensive premise, he proceeds to distort and falsify the facts to fit the premise, and gradually develops a logical, fixed delusional system, referred to as the “pseudocommunity,” in which the paranoid organizes surrounding people (real and imaginary) into a structured group whose purpose is centered on his victimization. As each additional experience is misconstrued and interpreted in light of the delusional idea, more and more events, persons, and experiences become effectively incorporated into the delusional system. Because the delusion meaningfully integrates all the vague, disturbing, amorphous, and unrelated “facts” of his existence, the paranoid is unwilling to accept any other explanation and is impervious to reason or logic; any questioning of the delusion only convinces him that the interrogator has sold out to the enemy.
4. Anomalous Perceptions
Another theory offers the intriguing hypothesis that delusions are the result of a cognitive attempt to account for aberrant or anomalous sensory experiences. For example, research has shown that persons with visual or hearing loss–because of both heightened suspiciousness and an attempt to deny the loss–may conclude that others are conspiring to conceal things from them. The experience of many elderly people, who are a high risk group for paranoia, provides a particularly good example of this phenomena. These individuals, because of physical disability or social isolation, often feel especially vulnerable. These realistic feelings may be converted to paranoia by an unacknowledged loss of hearing. That is, an awareness of oneself as a potential victim of greedy relatives or petty criminals, together with an increased sense that others are whispering, may contribute to a growing suspicion that others are whispering about them, or harassing them, or perhaps planning to steal from them. When the others angrily deny the accusation, that only reinforces the conspiratorial delusion, and intensifies the cycle of hostility and suspicion.
The occurrence of paranoia in those with degenerative brain disorders, such as Alzheimer’s disease, may be explained through a similar process. These diseases commonly involve a disruption of memory that victims may be unwilling to acknowledge. As a result, failures of memory become an anomalous experience that needs to be explained. For example, not being able to locate one’s keys is transformed into the belief that someone else has stolen or misplaced them. This suspicion may then be incorporated with actual perceptions, such as seeing one’s child speaking to the doctor, to produce the conviction that others are conspiring to confuse the patient in order to put them away.
The general hypothesis that anomalous experience may be the basis for paranoia assumes that the process by which delusional beliefs are formed is very similar to the process that operates in the formation of normal beliefs; that is, delusions are not the result of a disturbed thought process, but arise because of abnormal sensory or perceptual experiences. Anomalous experiences demand an explanation, and in the course of developing hypotheses and testing them through observations, the delusional insight is confirmed through selective evidence. This explanation offers relief in the form of removing uncertainty, and the relief in turn works against abandonment of the explanation.
A related explanation may account for the often observed association between paranoia and stressors such as social isolation, economic deprivation, and abrupt situational changes. These conditions generally involve feelings of confusion, vulnerability, and a loss of control, suggesting that, in some ways, paranoid thought may serve to impose meaning and control in an otherwise uncertain and threatening environment. The paranoid belief that others are responsible for one’s own misfortune, although threatening and irrational, may still be preferable to the belief that one is responsible for one’s own misfortune or that such misfortune is a purely random event. In this regard, it is possible that the paranoid thinking which often develops as a result of acute drug intoxication (for example, amphetamine abuse), or aging (and its concomitant sensory loss and social isolation), or degenerative brain disorders (such as Alzheimer’s disease) may be mediated by the confusion and vulnerability often found in these conditions.
6. Biases in Information Processing
Some of the approaches discussed thus far have emphasized the fact that, apart from the paranoid construction itself, the cognitive functioning of paranoids is essentially intact. In fact, given their delusional system, paranoid reactions are not unlike the biased tendencies of many individuals with strong belief systems, who are likely to exaggerate, distort, or selectively focus on events which are consistent with their beliefs. Once the paranoid suspects that others are working against him, he starts carefully noting the slightest signs pointing in the direction of his suspicions, and ignores all evidence to the contrary. With this flame of reference, it is quite easy, especially in a highly competitive, somewhat ruthless world, for any event, no matter how innocuous, to be selectively incorporated into the delusion. This, in turn, leads to a vicious cycle: suspicion, distrust, and criticism of others drives people away, keeps them in continual friction with others, and generates new incidents for the paranoid to magnify.
Although these information processing biases serve to maintain the paranoid’s beliefs once they are established, they do not address the question of the origin of paranoid beliefs. The essence of paranoia is a malfunctioning of the capacity to assign meanings and understand causes for events. Ordinarily, these cognitive processes operate in a reasonably logical and objective fashion. In paranoia, such objective assessments are overwhelmed by judgments and interpretations that bear little relation to what actually happened, but instead are perverted in accord with the paranoid’s own concerns and interests. The persistent misperception of oneself as the target of others’ thoughts and actions, referred to as an idea or delusion of reference, is the hallmark characteristic of almost all forms of paranoid thought. Even when there is no basis for making any connection, paranoids tend to perceive others’ behavior as if it is more relevant to the self than is actually the case as, for example, when the laughter of others is assumed to be self-directed, or the appearance of a stranger on the street is taken to mean that one is being watched or plotted against. Why does the paranoid consistently feel singled out or targeted by others?
a. Paranoia and Self-Focus
Part of the answer may lie in the characterization of paranoia as a very self-focused style of functioning. Recent studies have suggested that self-awareness, or the ability of an individual to recognize itself as an object of attention, heightens the tendency to engage in paranoid inferences. In essence, to see oneself as an object of attention, particularly to others, leaves a person susceptible to the paranoid idea that he is being targeted by others. Apparently, as a result of recognizing the self as an object of attention, the self is more likely to be interjected into the interpretation of others’ behavior, thus transforming insignificant and irrelevant events into ones that appear to have personal relevance for the self. Self-focus not only relates directly to paranoid ideas of reference, it has important implications for other critical aspects of paranoid thought.
b. Personalism and Intent
Unfortunate things happen to everyone, and usually they are dismissed as random or chance events. But paranoids rarely accept the idea that bad things just happen; instead they are likely to believe that it is someone else’s doing. Why? Because events that are taken personally or are seen as uniquely targeted toward the self, are more likely to be understood in terms of others’ personal characteristics or intentions. For the paranoid, the negative event itself is evidence for others’ malevolent intentions toward them. Eventually, the accumulation of such events constitutes evidence for a fundamentally irrational view of the world as a hostile and threatening place. Once the assumption of ubiquitous danger is accepted, the other manifestations of paranoia become comprehensible: suspicion and guardedness; selective attention and memory for signs of trickery or exploitation; misinterpretation of apparently harmless events as malevolent; and blaming others for all of one’s difficulties. Moreover, when negative events are seen not as fortuitous occurrences, but as personally intended by others, hostilities become intensified and enemies are found everywhere.
One of the critical elements of paranoid thinking is the utter inability to understand the motivations and perspectives of others. Not only are paranoids more likely to misinterpret the other’s behavior, they are less likely to correct that misinterpretation by altering their point of view. The narrowness and rigidity of paranoid thought the failure to examine events critically or in a broader context, the ability to fit anything into one’s belief system, the unwillingness to consider ever changing one’s mind is, in large part, the result of being locked into one’s own perspective. Although social isolation may account, in part, for this deficit in role taking, self-focused attention may also contribute to the self-centeredness of paranoids. Attention directed toward the self interferes with the ability to take the role of another or appreciate the existence of alternative perspectives. As a result, paranoids are likely to assume that others share their own view of events, and fail to appreciate the way in which their own actions are viewed by others. Thus, in a typical encounter, they are unlikely to consider how their own behavior provokes the hostility of others, but instead are likely to see themselves as the innocent victim of the other’s hostility. Self-focus may also play a role in the egocentric tendency of paranoids to project their own characteristics onto others.
IV. TREATMENT OF PARANOIA
Treatment of paranoia is extraordinarily difficult for a number of reasons. First, little is known about the causes that presumably are to be treated. Second, it is difficult for the paranoid to recognize a problem when he is locked into his own perspective and is reluctant to accept another’s viewpoint. Finally, it is nearly impossible for therapists to penetrate the barrier of suspiciousness. For all these reasons, paranoids are generally unlikely and unwilling to enter therapy; and once in therapy, their wariness often leads them to sabotage treatment, or break it off prematurely. Paranoids also generally refuse to take responsibility for their treatment, because the only problems they see are those created by the people intent upon harming them. In addition, the disclosure of personal information or other aspects of therapy may represent a loss of control, especially to male paranoids.
Mistrust obviously serves to undermine the therapeutic relationship. Any expression of friendliness or concern by the therapist is likely to arouse suspicion or be taken as confirmation that others are trying to humiliate them. Any questions or suggestions are likely to be seen as criticisms or attacks. Even if therapy improves other aspects of the paranoid’s functioning, their delusional system is so strenuously defended, and so easily confirmed by “clues” detected in the therapeutic situation, that it often remains intact, yielding a highly unfavorable prognosis for complete recovery.
Because of the paranoid patient’s guardedness and insistence on their own correctness, an effective therapeutic approach usually focuses on trust building rather than direct confrontation of the delusional beliefs. Perhaps the most powerful strategy is to establish rapport by forming a “therapeutic alliance” in which the therapist recognizes whatever kernel of trust exists in a paranoid system, and acknowledges the delusional beliefs as powerful, convincing, and understandable. The therapist can then try to identify the ways in which these beliefs may interfere with the patient’s goals or create frustration for others as well as for the patient. The patient’s paranoid reactions have usually driven others away or incited them to counterattack, heightening the cycle of suspicion and hostility. The therapist can sometimes bring about change by providing a different, empathic response that serves as a model of nonparanoid behavior. The task is then to help the paranoid become more competent at discriminating real threats from perceived ones, and the final step is the development of more adaptive responses to real or even ambiguous threats.
Behavioral theory assumes that paranoids have learned to be hypersensitive to the judgments of others and, as a result, they behave in ways that invite just the sort of reaction they anticipate and fear. As others begin to avoid them, they become socially isolated and develop increasingly elaborate suspicions that maintain the isolation. Behavior therapy tries to break the cycle by first using relaxation and anxiety management to teach the patient to be less sensitive to criticism, and then improving social skills by training the patient to act in ways that will not invite attack or avoidance. The patient can also be given help with recognition and avoidance of situations that produce or increase delusions. Paranoid thinking can in some cases be altered by aversive conditioning or the removal of factors that reinforce maladaptive behavior.
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