Cluster A: Paranoid Personality Disorder

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29 March, 2000

Cluster A: PARANOID PERSONALITY DISORDER (PPD)

Mental Health Issues Treatment Issues PPD & Addiction:
Dual Diagnosis Treatment Issues

Essential Feature: A pattern of pervasive distrust and suspiciousness of others; the motives of others are interpreted as malevolent (DSM IV™, 1994).
Self-Image: Righteous and mistreated by others; "fights the good fight," they are right, others are wrong (Beck, Kantor).
View of Others: Assume others will exploit, harm, or deceive; preoccupied with doubts about the loyalty of others; will not forgive injuries; see others as devious, deceptive, treacherous, and manipulative (DSM IV™, Beck).
Relationships: Tend to provoke hostility in others; engage in "hair trigger" responses to trivial behavior from others; distrustful, secretive, and isolative (Beck, Benjamin, Millon, Sperry, Kantor).
Authority Issues: Recurrent conflict with authority figures; attempt to exert power against authorities; envy people in authority and have difficulty with supervisors (Beck, McWilliams, Oldham).
Behavior: Show edgy tension, abrasive irritability, arrogance, aggression, interpersonal antagonism, hyper-sensitivity, guardedness, enviousness, self-righteousness, and resistance to external influence. Inclined to be contentious and litigious (Millon, Stone, Beck, Sperry).
Affective Issues: Struggle with anger, resentment, vindictiveness, hostility, and overwhelming fear (McWilliams).
Defensive Structure: Uncomfortable with dependency; disowns unfavorable traits; rigid; vulnerable to stress or unexpected change (Millon & Davis).
The PPD Coming Into Treatment: No Cluster A personality disorder is particularly inclined to seek treatment although they may self-refer if paranoid defenses break down or they are experiencing a severe crisis. They are often forced into therapy by family or the legal system. A potential tool for treatment is to work with PPDs to get free of and stay free of the legal system.
Medication Issues: Antipsychotic medications may help; they may be used with PPDs who exhibit blaming, low frustration tolerance, and hypersensitivity to criticism. SSRIs have been effective for the symptoms of suspiciousness and irritability (Sperry). PPDs may distrust psychotropic medication and compliance could be a problem.
Treatment Provider Guidelines: Service providers must be able to calmly accept PPDs' powerful hostility, maintain strict boundaries, and allow their personal strength to be conveyed in the treatment process (McWilliams).
Countertransference Issues: PPDs are abrasive, arrogant, and self-important. Service providers may tire of the demand to be supportive without showing reactivity to the hostility. Countertransference with PPDs is usually anxious or hostile. PPDs miss nothing; no defect in the therapist is safe from their scrutiny (McWilliams).
Treatment Techniques: Be careful about "knowing too much" as PPDs fear transparency. Do not directly confront or try to refute PPD beliefs. Rather, introduce an element of doubt, e.g., half-agree, but half-wonder if a more benign interpretation of the world could be made (Stone). By calmly accepting PPDs' powerful hostility (though not abusive behavior), service providers allow these individuals to reduce their fear of retribution (McWilliams).
Treatment Goals: PPDs experience accurate perceptions but misjudge what they mean; they mold perceived data into their preconceptions (Sperry). PPDs need to learn that their fearfulness is not proof that others have an intent to attack (Benjamin). PPDs need to identify and reduce provocative behavior so that others are less inclined to be hostile (which reinforces the paranoid view) (Beck).
Incidence of Co-Occurring SA Disorders: Cluster A represents the lowest incidence of co-occurring substance abuse disorders of the three DSM-IV™ personality disorder clusters (Nace, 1990). Some individuals with PPD may fear loss of control and/or increased sense of vulnerability with use of drugs.
PPD Drugs of Choice: No single pattern of substance abuse can be identified for any of the personality disorders. PPDs may be attracted to the sense of personal power provided by cocaine and amphetamines; it makes them feel less vulnerable in a hostile world.
Dual Diagnosis Treatment: PPDs may turn to drugs when their paranoid defenses begin to break down. The more fragile they feel, the more external (drug) stabilization may be needed (Meissner). If drug use is ego-syntonic and augments the defenses already in place (i.e., does not escalate PPDs' sense of danger in a hostile world), treatment will not be welcome. Might be helpful to point out the "betrayal" of drugs as negative consequences escalate.
PPDs 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. PPDs may respond to confrontation with an intractable view of the service providers as being of malicious intent and impossible to trust.
PPDs in alcoholism treatment have a hard time relinquishing autonomy and control to a treatment program or a higher power in AA (Matano and Locke). They may have to rely on their own will, but that is a very strong force indeed.
PPDs may be attracted to drug use to defy authority and to protect their "sacred autonomy" (Richards). Demands from service providers for abstinence will not be interpreted as benevolent. It will be just one more demand from authority figures who can't be trusted.
Abstinence as a prerequisite of treatment may result in a failure-to-engage. PPDs would accept an ultimatum as an indication of abuse of power from an authority. Use must be addressed but should not result in termination from treatment.

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Cluster A: PARANOID PERSONALITY DISORDER (PPD)
Mental Health Issues	Treatment Issues	PPD & Addiction: Dual Diagnosis Treatment Issues
Essential Feature: A pattern of pervasive distrust and suspiciousness of others; the motives of others are interpreted as malevolent (DSM IV™, 1994). Self-Image: Righteous and mistreated by others; "fights the good fight," they are right, others are wrong (Beck, Kantor). View of Others: Assume others will exploit, harm, or deceive; preoccupied with doubts about the loyalty of others; will not forgive injuries; see others as devious, deceptive, treacherous, and manipulative (DSM IV™, Beck). Relationships: Tend to provoke hostility in others; engage in "hair trigger" responses to trivial behavior from others; distrustful, secretive, and isolative (Beck, Benjamin, Millon, Sperry, Kantor). Authority Issues: Recurrent conflict with authority figures; attempt to exert power against authorities; envy people in authority and have difficulty with supervisors (Beck, McWilliams, Oldham). Behavior: Show edgy tension, abrasive irritability, arrogance, aggression, interpersonal antagonism, hyper-sensitivity, guardedness, enviousness, self-righteousness, and resistance to external influence. Inclined to be contentious and litigious (Millon, Stone, Beck, Sperry). Affective Issues: Struggle with anger, resentment, vindictiveness, hostility, and overwhelming fear (McWilliams). Defensive Structure: Uncomfortable with dependency; disowns unfavorable traits; rigid; vulnerable to stress or unexpected change (Millon & Davis).	The PPD Coming Into Treatment: No Cluster A personality disorder is particularly inclined to seek treatment although they may self-refer if paranoid defenses break down or they are experiencing a severe crisis. They are often forced into therapy by family or the legal system. A potential tool for treatment is to work with PPDs to get free of and stay free of the legal system. Medication Issues: Antipsychotic medications may help; they may be used with PPDs who exhibit blaming, low frustration tolerance, and hypersensitivity to criticism. SSRIs have been effective for the symptoms of suspiciousness and irritability (Sperry). PPDs may distrust psychotropic medication and compliance could be a problem. Treatment Provider Guidelines: Service providers must be able to calmly accept PPDs' powerful hostility, maintain strict boundaries, and allow their personal strength to be conveyed in the treatment process (McWilliams). Countertransference Issues: PPDs are abrasive, arrogant, and self-important. Service providers may tire of the demand to be supportive without showing reactivity to the hostility. Countertransference with PPDs is usually anxious or hostile. PPDs miss nothing; no defect in the therapist is safe from their scrutiny (McWilliams). Treatment Techniques: Be careful about "knowing too much" as PPDs fear transparency. Do not directly confront or try to refute PPD beliefs. Rather, introduce an element of doubt, e.g., half-agree, but half-wonder if a more benign interpretation of the world could be made (Stone). By calmly accepting PPDs' powerful hostility (though not abusive behavior), service providers allow these individuals to reduce their fear of retribution (McWilliams). Treatment Goals: PPDs experience accurate perceptions but misjudge what they mean; they mold perceived data into their preconceptions (Sperry). PPDs need to learn that their fearfulness is not proof that others have an intent to attack (Benjamin). PPDs need to identify and reduce provocative behavior so that others are less inclined to be hostile (which reinforces the paranoid view) (Beck).	Incidence of Co-Occurring SA Disorders: Cluster A represents the lowest incidence of co-occurring substance abuse disorders of the three DSM-IV™ personality disorder clusters (Nace, 1990). Some individuals with PPD may fear loss of control and/or increased sense of vulnerability with use of drugs. PPD Drugs of Choice: No single pattern of substance abuse can be identified for any of the personality disorders. PPDs may be attracted to the sense of personal power provided by cocaine and amphetamines; it makes them feel less vulnerable in a hostile world. Dual Diagnosis Treatment: PPDs may turn to drugs when their paranoid defenses begin to break down. The more fragile they feel, the more external (drug) stabilization may be needed (Meissner). If drug use is ego-syntonic and augments the defenses already in place (i.e., does not escalate PPDs' sense of danger in a hostile world), treatment will not be welcome. Might be helpful to point out the "betrayal" of drugs as negative consequences escalate. PPDs 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. PPDs may respond to confrontation with an intractable view of the service providers as being of malicious intent and impossible to trust. PPDs in alcoholism treatment have a hard time relinquishing autonomy and control to a treatment program or a higher power in AA (Matano and Locke). They may have to rely on their own will, but that is a very strong force indeed. PPDs may be attracted to drug use to defy authority and to protect their "sacred autonomy" (Richards). Demands from service providers for abstinence will not be interpreted as benevolent. It will be just one more demand from authority figures who can't be trusted. Abstinence as a prerequisite of treatment may result in a failure-to-engage. PPDs would accept an ultimatum as an indication of abuse of power from an authority. Use must be addressed but should not result in termination from treatment.