|
For references, see the Bibliography page |
Essential Feature
The essential feature of the paranoid personality disorder (PPD) is a pattern of pervasive distrust and suspiciousness of others; the motives of others are interpreted as malevolent. The suspiciousness may be expressed by overt argumentativeness, recurrent complaining, or hostile aloofness. While individuals with a paranoid personality disorder may appear "e;cold,"e; objective, and rational, they more frequently display hostile, stubborn, and sarcastic affect. They may form negative stereotypes of others and join cults or groups with others who share their paranoid beliefs (DSM IV?, 1994, pp. 634-635).
The ICD-!0 (1994, pp. 224-225) describes the paranoid personality disorder as characterized by:
There may also be excessive self-importance and self-reference.
The rigidity of beliefs found in individuals with PPD isolates them from corrective environmental feedback; they are vulnerable to increasing distortion of reality, hypersensitivity to misinterpreted events, and an inflated view of self that results in tumultuous struggles with others who are bewildered by the entire situation.
Paranoid personality disorder may first appear in childhood and adolescence with solitariness, poor peer relationships, hypersensitivity, peculiar thoughts, and idiosyncratic fantasies. There is some evidence of increased prevalence of PPD in individuals with relatives who have a delusional disorder. The prevalence of PPD is estimated to be 2% to 10% in outpatient mental health clinics. In clinical samples, this personality disorder appears to be more common in males. PPD must be distinguished from symptoms developed in association with chronic substance use, e.g. cocaine (DSM-IV?, 1994, pp. 636-637).
It has been suggested that paranoia be seen as existing on a continuum that goes from normal vigilance toward potential threat in the environment to transitory paranoid behavior and interpersonal suspiciousness (paranoid personality disorder) to delusional states to full paranoid schizophrenia. The paranoid personality disorder is distinguished from psychosis by the lack of delusions or hallucinations (Sperry, 1995, p. 154). It appears that having the word paranoia in the name may contribute to the possible underdiagnosis of the personality disorder in outpatient mental health and substance abuse treatment settings. It has been suggested that it be called the "e;vigilant"e; personality disorder to make the personality disorder variant of the paranoia disorders more readily recognizable.
Paranoia or paranoid ideation is not limited to those disorders with paranoia in the name. Rawlings and Freeman (Claridge, editor, 1997, p. 39) note that there are at least five mental disorders that contain paranoia constructs in the DSM-IV?: paranoid personality disorder, schizotypal personality disorder (with suspiciousness or paranoid ideation), borderline personality disorder (with transient, stress-related, paranoid ideation), the paranoid type of schizophrenia, and the persecutory type of delusional disorder. Symptoms of paranoia can also be associated with substance abuse; with abstinence these symptoms will subside.
Self-Image
Individuals with PPD experience a polarity in their self-image; even though their behavior may be grandiose and arrogant, they are vulnerable to shame and will alternate between the impotent, despised self and the omnipotent, vindicated self (McWilliams, 1994, p. 214). Stone (1993, p. 210) suggests that defenses are activated by individuals with PPD in the service of warding off shame and humiliation. These individuals view themselves as righteous and mistreated (Beck, 1990, p. 48) and will attempt to enhance their self-esteem through exerting power over others. They fight "e;on the side of the angels."e; Other people are wrong; they are pure. They are vengeful and pursue conflict with great tenacity, never seeming to tire in their quest for self-vindication; they acquire an inordinate fondness for righteous causes (Kantor, 1992, pp. 113-119). People with PPD often feel that their own hurt feelings provide sufficient cause for justifying almost any retaliation (Richards, 1993, p. 284).
Kantor (1992, pp. 113-119) suggests that individuals with PPD exhibit six core beliefs (which would necessarily influence how they view themselves):
View of Others
Individuals with paranoid personality disorder assume others will exploit, harm, or deceive them; they are preoccupied with doubts about the loyalty of others. They may feel they have been deeply and irreversibly injured by others even when there is little objective evidence that this is the case (DSM-IV?, 1994, p. 634). People are seen as devious, treacherous, and manipulative; care must be taken to not be demeaned, controlled, or discriminated against (Beck, 1990, pp. 48-49).
These individuals are consumed by their mistrust and their anticipation of betrayal. They expect the worst of others and are, accordingly, apprehensive, suspicious, uncompromising, and argumentative. They are on guard against a hostile world (Oldham, 1990, p. 167). When a friend or associate shows loyalty to individuals with PPD, they are so surprised that they cannot believe it; if they get into trouble, they expect others to attack or ignore them (DSM-IV?, 1994, p. 634). These individuals often misinterpret compliments as hidden criticism or coercion to do even better. They may see an offer to help as an implication that they are not doing well enough on their own (DSM-IV?, 1994, p. 634).
Individuals with PPD are reluctant to confide in others because they fear the information will be used against them; they often withhold personal information for self-protection (DSM-IV?, 1994, p. 634). These are individuals who, in the intake process of mental health or alcohol & drug clinics, refuse to answer questions, ask what is being written about them, and are adamant that certain information is personal and should not be sought by the treating agency. They may well refuse to sign release of information forms for other agencies, service providers, or family members.
Relationships
The DSM-IV? (1994, p. 635) notes that individuals with PPD are generally difficult to get along with and have consistent trouble within relationships. They are distrustful and hostile; their interpersonal behavior may involve overt argumentativeness, complaining, or aloofness. They can be guarded, secretive, or devious; they appear to lack tender feelings and engage in stubborn and sarcastic exchanges with others. It can be difficult to elicit the behaviors suggestive of PPD from individuals in treatment. PPD characteristics tend to be manifested in interpersonal conflicts with close or significant others, e.g. spouses, supervisors, colleagues, and relatives (Joseph, 1997, p. 31).
Individuals with PPD tend to provoke hostility in others. They engage in "e;hair trigger"e; responses to trivial behavior from others (Kantor, 1992, p. 118). Matano and Locke (1995, p. 62) suggest that these individuals repeatedly enact guarded and domineering interpersonal patterns. Meissner (1994, pp. 221-223) describes people with PPD as distrustful, secretive, and isolative; they will direct hate and rage at those who betray or disappoint them. They are concerned with the issues of power and powerlessness and fear domination. They are inordinately quick to take offense, slow to forgive, and ever willing to counterattack (Fenigstein, 1996, pp. 245-246). They want to get even (Kantor, 1992, p. 118). Individuals with PPD struggle with anger, resentment, vindictiveness, and hostility. They live in fear of harm and malevolence from others and maintain extraordinary vigilance. Accordingly, the more disturbed they are, the more dangerous they are (McWilliams, 1994, p. 207).
However, the range of dysfunction within the diagnosis of paranoid personality disorder is sufficient to allow many of these individuals to be sufficiently interpersonally functional to preserve relatively cohesive relationships. Many authors note the possibility of individuals with PPD whose symptoms manifest at a level of subtlety that allows them to function within a marriage and maintain adequate work relationships. This appears to be in conflict with Theodore Millon's idea that PPD is a structurally deficient and, by definition, a more severe and impaired personality disorder than those that are functionally impaired only. This position does not appear to be supported by the client population served in an outpatient program in a large local community mental health system. Individuals with PPD certainly pose a serious challenge to therapists, but can often develop enough trust to work successfully within the therapeutic process.
Issues With Authority
McWilliams (1994, pp. 211-216) states that individuals with PPD are vulnerable to shame and humiliation as a result of criticism, punishment, and adults who could not be pleased in their families of origin. Accordingly, adults with PPD have recurrent conflict with authority figures. They fear domination, enslavement, and loss of autonomy. They will attempt to exert interpersonal power to avoid the anticipated destructive consequences coming from interaction with people in authority (Meissner, 1994, p. 223). Benjamin (1993, p. 236) considers deferential behavior with authorities to be an exclusionary criterion for the diagnosis of paranoid personality disorder.
These individuals counterattack when they feel threatened. Consequently, they are inclined to be litigious and involved in legal disputes (DSM-IV?, 1994, p. 635). One client in an outpatient mental health center was a non-practicing attorney that had not been able to pass the bar exam. He lived with his wife and child in severe financial straits but none of his economic concerns deterred him from spending nearly all of his time in self-generated and self-maintained litigation with various companies or individuals with whom he had contact. He was not looking for employment when he came to the mental health center on a referral from Child Protective Services (for his difficulty in managing his anger with both his wife and his daughter). He considered his various lawsuits to be his "e;work."e; He was not particularly intimidated by CPS involvement with his family; he was hoping to be able to sue that agency as well.
Individuals with PPD will fight "e;the good fight"e; no matter what the cost may be. They will welcome opportunities to force others (particularly those in power) to admit they have been wrong. They will accept negative consequences that arise from their own actions as further proof that those around them are malicious and corrupt.
Behavior
Paranoid traits may be manifested in some degree in a significant portion of the normal population. Indications of a paranoid style are frequently quite subtle; the paranoid features may form a latent portion of the personality that emerges under stress (Meissner, 1994, pp. 220-221).
As noted above, individuals with a paranoid personality disorder retain many areas of intact functioning. McWilliams (1994, p. 205) writes that individuals with PPD can have any level of ego strength, identity integration, reality testing and object relations. Many individuals with PPD can function well enough to avoid coming to the attention of professionals (Fenigstein, 1996, pp. 245-252).
However, individuals with PPD may also be argumentative and easily aroused to agitated contentiousness. They can appear tense, anxious, guarded, devious, sensitive, and ready to counterattack. They are inclined to criticize and devalue others -- while any criticism of them is unacceptable. They are often seen as energetic, ambitious, hard-working, and competent. They tend to be intelligent and intellectual as well as hostile, stubborn, and rigid. They are inclined to be inflexible and unwilling to compromise. They have an excessive need to be self-sufficient along with an exaggerated sense of their own self-importance (Meissner, 1994, pp. 220-221).
Millon (1996, p. 701) describes people with PPD as always on guard, mobilized, and ready for threat. They are edgy, tense, abrasive, irritable, distant, and vigilant. However, while individuals with PPD anticipate betrayal and deceit from others, they may well be deceptive, hostile, disloyal, and malicious themselves (Beck, 1990, p. 100).
The PPD style is to displace responsibility from self to others via an inclination to project and to blame. They also tend to understand problems in terms of external circumstances, forces, events, persons, etc. rather than in terms of internal difficulties, problems, or limitations. They will scan the environment for minimal clues that validate their preconceived ideas (Meissner, 1994, pp. 220-221).
Fenigstein (1996, pp. 245-252) describes eleven dimensions associated with paranoid personality disorder: vindictiveness, suspiciousness, hypervigilance, hypersensitivity, reluctance to confide in others, avoidance of blame or responsibility, attribution of problems to the external world, a fixed, rigid cognitive style, readiness to anger, resentfulness of authority, and fear of humiliation. Stone (1993, p. 202) adds arrogance, self-righteousness, feelings of inferiority and envy, sexual anxiety, moralism, and an inner readiness to lie and distort.
Kantor (1992, pp. 122-124) describes paranoid personality disordered behavior with the following: blamelessness (with aggression legitimized as a counterattack), passive-aggressiveness, superciliousness (haughty, arrogant, and superior behavior intended to defend against anticipated or perceived criticism), seeking trouble for the purpose of self-vindication, exaggerated competitiveness, vengefulness (unremitting), verbal malice, manipulativeness, grandiosity, a fondness for righteous causes, and grandiose rescue fantasies.
Beck (1990, p. 100) describes the following as clinical indicators of paranoid personality disorder: vigilance, exaggerated concern about confidentiality, inclination to blame others, seeing self as mistreated and abused, recurrent conflict with authority figures, unusually strong beliefs about the motives of others, a tendency to give small events great significance, an inclination to counterattack, contentiousness and litigiousness, a tendency to provoke hostility in others, seeking evidence that confirms negative expectations, inability to relax, inability to see the humor in a situation, an unusually strong need to be self-sufficient and independent, disdain for the weak and needy, difficulty expressing warm, tender feelings, and pathological jealousy.
Affective Issues
PPD affect can serve as an assist in differential diagnosis. Underlying arrogant behavior in the narcissistic personality is a comfortable assumption of superiority; underneath the antisocial personality arrogance is indifference and aggression. Individuals with PPD also behave in an arrogant and abrasive manner. However, the dominant affect accompanying the behavior is fear. These individuals struggle with intense dread of abuse, exploitation, or harm from others. At times they may feel able to protect themselves, but often they are afraid and unsure. Their world is a hostile place filled with danger; they rarely can relax into a sense of safety and contentment. In fact, the more they have of what they want in life, the more vigilant they must be to ward off the (sometimes real, sometimes projected) envy and malicious intent of others to take away anything of value.
The self-righteous rage covers the same fear and an abiding sense of inferiority. Abrasive behavior warns others that individuals with PPD are formidable enemies and people with ill intent would be well-advised to stay away.
The intensity of the fear, rage, envy, and dread for individuals with PPD is a factor in the tirelessness with which they fight "e;the good fight."e; Only when they believe that they are vindicated and others are controlled is an element of safety introduced into their affective experience. This is a powerful motivator and should be considered in any attempt to confront these individuals in the treatment process.
Defensive Structure
Individuals with PPD are uncomfortable with dependency with its implied weakness. They also become quite anxious when coerced by external authority. Their defensive structure requires an ongoing experience of independence, superiority, and autonomy. They seek self-determination and acquire an active fantasy life wherein they create a self-enhanced image and a rewarding existence apart from others (Millon & Davis, 1996, p. 700).
These individuals actively disown undesirable personal traits and motives by projecting them onto or attributing them to others. Even while people with PPD avoid awareness of their own unattractive behaviors and characteristics, they remain extraordinarily alert to, and hypercritical of, similar features in others (Millon & Davis, 1996, p. 702).
Individuals with PPD maintain their sense of balance, internal and external, through rigid adherence to an inelastic set of defenses and methods of need gratification. Either extreme or unanticipated stress can precipitate a crisis that appears, to others, out of proportion to the situation at hand (Millon & Davis, 1996, p. 702).
The Paranoid Personality Disorder Coming Into Treatment
Few individuals with a Cluster A personality disorder are particularly inclined to seek treatment. They are often forced into therapy by family or the legal system. However, life crises can precipitate self-referral. The challenge then is to engage clients with PPD in a collaborative working relationship based upon trust.
Medication Issues
Sperry (1993, pp. 171-172) noted that antipsychotic medications, particularly those selected for their impact on delusional disorders, may be helpful. Prozac, or other SSRIs, have been effective for the symptoms of suspiciousness and irritability.
Janicak, et.al. (1993, p. 518) states that there have been a few controlled studies and anecdotal information that low-dose antipsychotics may benefit individuals with PPD when used in conjunction with therapy.
S. Joseph, M.D., Ph.D., MPH (1997, pp. 27-30) suggests that successful use of neuroleptics for low-grade paranoia depends on dosage. Compliance is more likely when the dosage is low enough to minimize side effects. The recommended dosages are approximately one-tenth to one-fourth of those used with psychotic individuals. Medication given in the evening reduces daytime sedation. In the treatment of PPD, however, antipsychotic medication alone does not usually provide optimal benefit. Other symptoms may also require medication, e.g. obsessional features (SSRIs), vigilance, guardedness, and tension (low dose benzodiazepines for a short period of time), and anger and irritability (SSRIs). Kantor (1992, p. 133) suggests that antidepressant medication alone is contraindicated because it may make the symptoms of paranoia worse.
Overall, recommended medication for clients with PPD involves a combination of low-dose neuroleptics and SSRIs. However, since individuals with PPD will distrust medication, respond quite negatively to unpleasant side effects, and may well be offended by the suggestion that they take antipsychotic medication, it is likely to be more effective to delay considering medication until these clients ask about it for specific target symptoms. If other treatment modalities are intolerable to clients with PPD due to paranoid symptoms, a medication evaluation can be suggested. How service providers describe both the process of considering medication and the purpose of medication will largely determine if clients with PPD will cooperate or become defensive and incensed.
Treatment Provider Guidelines
Creating a working alliance is a challenge but many individuals with PPD are able to attach to and trust service providers when their testing behavior is met with honesty, openness, and a willingness to interpret anger without behaving with hostility. Service providers must be able to calmly accept these clients' powerful hostility, maintain strict boundaries, and allow their personal strength to be conveyed in the treatment process (McWilliams, 1994, pp. 217-223). Richards (1993, pp. 284-286) suggests that individuals with PPD, among all the personality disorders, need the most interpersonal distance from others because of their fear of the consequences and hidden motives of attachment. When considering the inclination these individuals have toward tireless litigation, service providers must adhere to strict boundaries and conservatively interpreted ethical behavior. The vigilance of these clients allows them to observe any fault or failure on the part of service providers and they are inclined to vindicate themselves through the search for retribution. Breaking or bending the rules, for whatever reason, could lead to serious consequences for those working with clients with PPD.
Transference/Countertransference Issues
McWilliams (1994, p. 216) notes that transference for individuals with PPD is often swift, intense, and negative; the service provider is not assumed to be trustworthy or benign.
Countertransference can also be intense and uncomfortable. Individuals with PPD are abrasive, arrogant, and self-important. Service providers may tire of the demand to be supportive without showing reactivity to the hostility. McWilliams (1994, p. 216) states that individuals with PPD miss nothing; no defect in service providers is safe from their scrutiny. Accordingly, countertransference response is often anxious hostility.
Peer supervision, supervision, or consultation can assist in maintaining balance toward and understanding of PPD dynamics. It can be beneficial to review the purpose and effectiveness of a non-reactive acceptance of PPD feelings. Non-reactivity, however, does not mean allowing individuals with PPD to behave abusively toward service providers. Limits should be set on PPD behavior and service providers may identify to these individuals their own responses to PPD aggression. Non-reactivity means not meeting harshness with harshness or aggression with aggression.
Treatment Techniques
Zimmerman (1994, pp. 87-89) suggests the following questions when assessing individuals for paranoid personality disorder:
Beck (1990, pp. 105-116) believes that the key issue in the treatment of PPD is mistrust and the fear of being manipulated, controlled, demeaned, or discriminated against. Any experience of mistreatment, particularly from others who are seen as powerful, will be seen as intentional and malicious -- and deserving of retaliation. Therefore, work with clients with PPD must involve the gradual development of trust in the service provider via the demonstration of trustworthiness through action. Benjamin (1993, pp. 332-337) notes that aggression must not be met with counteraggression, even though individuals with PPD are exceptionally able to provoke hostility from others. Moreover, the service provider will need to find a manageable method to call these clients' attention to their provocativeness or their ongoing interpersonal behavior will continue to validate their expectation of anger and abuse from others.
Individuals with PPD are likely to have grown up in an atmosphere charged with criticism, blame, and hostility. In treatment, rapport is hindered by their belief that others, including service providers, intend to harm and exploit them. In the treatment setting, these individuals tend to be resistant, provocative, and contentious (Sperry, 1995, pp. 158-167). Nevertheless direct confrontation and refutation of paranoid assertions are counterproductive. Rather, the clinician can introduce an element of doubt, e.g. half-agree, but half-wonder if a more benign interpretation of the world could be made (Stone, 1993, pp. 203-209). The agreeing but suggesting possible alternatives can also help the service provider avoid "e;knowing too much."e; Clients with PPD will not necessarily welcome skilled interpretation. They may well feel uncomfortably transparent and see the service provider as intrusive. Richards (1993, pp. 284-286) points out that too much insight may be seen as sadistic by individuals with PPD and result in retreat or retaliation toward the clinician.
Service providers should keep in mind that treatment is very stressful for individuals with PPD because of their difficulty with self-disclosure and fear of harm as a result of being open. Care must be taken not to move too quickly or to threaten these individuals within the treatment process. Challenging the paranoid thinking or the provocative interpersonal behavior too quickly can result in treatment failure (Will, Retzlaff, ed., 1995, p. 106).
Treatment Goals
Beck (1990, p. 108) identifies the primary strategy in treatment with PPD as working toward an increase in personal client efficacy; these individuals need to believe in their own ability to achieve positive changes. Stone (1993, p. 210) sees the reduction of feelings of inferiority in individuals with PPD as resulting in reduced activation of paranoid defenses to ward off shame and humiliation. Vulnerability to shame may well be impossible for individuals with PPD to acknowledge. It is more likely to be acceptable to them to form treatment goals to increase a sense of competence and effectiveness. It is important, however, that treatment goals be stated in terms of positive gains for these individuals rather than behaviors aimed against others, e.g. to stand up for self when others are unreasonable. This may seem like a good idea to these clients but the conceptualization of the goal invites paranoid interpretation of the behavior of others.
Goals of treatment do need to include increasing benignness of perception and interpretation of reality; clients with PPD experience accurate perceptions but misjudge what they mean. In particular, they need to learn to interpret interpersonal cues without distortion and preconceived conclusions (Sperry, 1993, pp. 349-351). Individuals with PPD need to learn that their expectation of abuse came from early experience and they have come to interpret their own interpersonal fear and tension as proof that others have an intent to attack. If they continue to use the defense of "e;anticipatory retaliation"e;, i.e. engaging in a preemptive strike, as adults, they will also continue to elicit hostility and counter-aggression (Benjamin, 1993, pp. 336-337).
Cluster A: Incidence of Co-Occurring Substance Abuse Disorders
The paranoid personality disorder is in Cluster A, the "e;odd or eccentric"e; personality disorders (DSM-IV, 1994, p. 629). Nace (1990, p. 184) indicates that Cluster A represents the lowest incidence of co-occurring substance abuse disorders.
One mitigating factor in this lower incidence of dual disorders involves the potential for individuals with PPD to fear the loss of control that accompanies the use of drugs. They may also resist drug involvement due the intensified sense of mistrust and vulnerability accompanying drug acquisition and use.
If addiction or substance abuse is present, the fact that many individuals with PPD enter treatment as a result of pressure from their families or involvement with the legal system may well serve as a potential tool for treatment. They may be inclined to accept substance abuse treatment to get free of and stay free of these external sources of constraint, i.e., the presence of probation officers, angry, potentially rejecting spouses, etc. The service provider can point out the loss of autonomy as negative consequences of drug and/or alcohol use escalate.
On the other hand, Meissner (1994, pp. 337-352) proposes that the more fragile the inner organization of the paranoid individual, the more need there is for stabilization from external sources. Drugs and alcohol can be the answer to the wish to be "e;someone,"e; get everything, and disregard boundaries and frustrations. Addiction can be a process of taking magical control over the uncontrollable. Individuals with PPD may turn to drugs and alcohol because their paranoid defenses begin to break down or become less effective. Meissner (1996, p. 223) suggests that these defenses protect against the direct experience of vulnerability, weakness, inferiority, and inadequacy which are connected with a defective sense of self. If alcohol or cocaine, for example, reinstate the paranoid defenses and these individuals can reliably control descent into feelings of despair and worthlessness, addiction becomes a substantial risk.
Drugs of Choice for the Paranoid Personality Disorder
Drugs that can reduce the constant pressure to be alert and vigilant, or conversely, heighten the individual's sense of being effectively alert and vigilant may be enticing enough to bypass initial hesitancy of these individuals to yield self-control. Beck, et.al. (1993, p. 278) note that individuals with PPD have beliefs that potentiate drug use -- they are looking for experiences that can be enjoyed in solitude and help them feel on their guard against intrusion or attack from others. In particular, people with PPD may be attracted to the sense of personal power provided by cocaine and amphetamines; these drugs may make them feel less vulnerable in a hostile world.
Drugs of choice for individuals with PPD which intensify the paranoid dynamic of self-aggrandizement include cocaine, marijuana, amphetamines, extreme alcohol intoxication, or chronic alcohol abuse. Another issue for these individuals is the attraction to drug use in settings where it is forbidden, thereby resisting an infringement on their "e;sacred autonomy"e; (Richards, 1993, p. 284).
Benjamin (1993, p. 322) also notes PPD attraction to the "e;dominance drugs,"e; e.g. alcohol, cocaine, and amphetamines -- because they give the user a sense of power and control. These drugs easily impart the longed-for sensations without requiring that the user demonstrate the social skills and awareness of social complexities that will implement interpersonal dominance in reality; they offer an illusory short-cut to power.
Dual Diagnosis Treatment for the Paranoid Personality Disorder
Clients with PPD may not stay in a treatment program long enough to be accurately diagnosed. They are so reactive to confrontation that they may leave treatment despite potential negative consequences, e.g., violation of probation. Direct and/or early confrontation will provoke hostility and escalation of dysfunctional defenses. It may be difficult to identify the intolerance and self-destructive response to confrontation in these clients as they can so easily confront others. They do not appear particularly fragile interpersonally. In fact, they have many narcissistic qualities and both personality disorders may be present. If the paranoid features are prominent, the underlying fear of malice and harm will become apparent. If the narcissistic features are prominent, the entitlement and assumption of personal superiority will become evident. This is an important differentiation as the individual with a paranoid personality disorder will respond very badly to direct confrontation (to the point of initiating litigation) and the individual with a narcissistic personality disorder will be indifferent to anything short of confrontation. Since substance abuse treatment requires some reflection, if not confrontation, of drug and alcohol use, assessing the individual's tolerance for seeing themselves in a negative light is important. Individuals with narcissistic personality disorder may be indignant and vulnerable to shame but will return happily to a psychological place of specialness if they are supported and reassured. People with PPD, on the other hand, may develop, in response to confrontation, an intractable view of the service provider(s) as being of malicious intent and impossible to trust. The damage can be considerable; a cautious approach with ongoing assessment of level of trust and receptivity is essential. Clients with PPD may well respond most immediately to a psychoeducational approach that does not contain personal data, or limits personal issues to self-reflection. To provide education regarding drugs and alcohol may well initiate a cognitive recognition and acceptance for individuals with PPD that they do not want these substances in their lives doing them harm--all without confrontation or igniting the paranoid defenses.
Matano and Locke (1995, p. 66) note that clients with PPD in alcoholism treatment have a hard time relinquishing autonomy and control to a treatment program or a higher power in AA. In contrast to reliance on an external source of strength, Richards (1993, p. 286) believes that individuals with PPD will be able to leverage considerable self-control against urges to use once engaged in recovery and stabilized. This may appear contradictory to the principles of drug and alcohol treatment, i.e., the importance of turning to a power greater than self within a program of recovery. However, if an individual with a paranoid personality disorder becomes too anxious to tolerate a sense of dependency or feels too crowded by attachment to groups, self-help or professional, self-generated strength may be enough, or may be the best that individual has to bring to a program of recovery.
Some treatment programs require abstinence as a prerequisite for treatment. Other programs are structured so that relapse, or use, results in termination from treatment. Both approaches are likely to be less than helpful for addicted paranoid personality disordered individuals. Abstinence as a prerequisite for treatment may well result in a failure to engage; individuals with PPD resist domination and such an ultimatum may send them into a flight toward autonomy, i.e., "e;You can't tell me what to do."e; Discharge for use is likely to be interpreted as an abuse of power and seriously interfere with the rapport needed for future successful engagement in the treatment process. Use must be addressed but, most effectively, in terms of the power the drugs and alcohol have and how much strength and resolve must be brought to the process of recovery to achieve freedom from addiction.
Sharon C. Ekleberry, 2000