Why Diagnose Psychoanalytic Diagnosis

Paranoid Personalities

Most of us have a clear mental image of a paranoid person and recognize the type when it is portrayed fictionally. Peter Sellers's brilliant performance in the classic movie Doctor Strangelove, for example, captures the suspiciousness, humorlessness, and grandiosity that strike familiar chords in any of us who have paranoid acquaintances, or who recognize the comic elaboration of the paranoid streak we can all find in ourselves. Identifying less flagrant paranoid presentations requires a more disciplined sensibility. The essence of paranoid personality organization is the habit of dealing with one's felt negative qualities by disavowing and projecting them; the disowned attributes then feel like external threats. The projective process may or may not be accompanied by a consciously megalomanic sense of self.

The diagnosis of paranoid personality structure implies to many people a serious disturbance in mental health, yet as with other dynamics that infuse personality, this type of organization exists on a continuum of severity from psychotic to normal. As with the personality types in the preceding chapters, the defense that defines paranoia may derive from a time before the child had clarity about internal versus external events, where self and object were thus confused. Paranoia intrinsically involves experiencing what is inside as if it were outside the self. It may be that "healthier" paranoid people are rarer than "sicker" ones, but someone can have a paranoid character at any level of ego strength, identity integration, reality testing, and object relations.

The trait-based descriptions of paranoid personality disorder in DSM-Four are from a clinician's perspective rather superficial, but the manual is accurate in noting that our knowledge of this personality type may be limited. A paranoid person has to be in fairly deep trouble before he or she seeks (or is brought for) psychological help. In contrast to depressive, hysterical, or masochistic people, for example, higher-functioning paranoid individuals tend to avoid psychotherapy unless they are in severe emotional pain or are causing significant upset to others. Because they are not disposed to trust strangers, paranoid people are also unlikely to volunteer to be research subjects.

People with normal-level paranoid characters often seek out political roles, where their disposition to oppose themselves to forces they see as evil or threatening can find ready expression. Reporters and satirists have often portrayed Dick Cheney as paranoid, but even if they hate his politics, they have seldom questioned his capacity to cope efficaciously in the world. At the other end of the continuum, some serial murderers who killed their victims out of the conviction that the victims were trying to murder them exemplify the destructiveness of projection gone mad; that is, paranoia operating without the moderating effects of more mature ego processes and without a solid grounding in reality. Several recent notorious murders seem to have had a paranoid basis.

I want to emphasize again as I did in Chapter Five that attributions of paranoia should not be made on the basis of an interviewer's belief that a person seeking help is wrong about the danger he or she is in. Some people who look paranoid are actually being stalked or persecuted by members of a cult they have left, for example, or by a rejected lover or a disaffected relative. Some people who are diagnosably paranoid are also realistically imperiled; in fact, the off-putting qualities of many paranoid people make them natural magnets for mistreatment. Some people who are not characterologically paranoid become temporarily so in paranoiagenic situations that are humiliating and entrapping. When interviewing for diagnostic purposes, one should not reject out of hand the possibility that the interviewee is legitimately frightened, or that those who are urging him or her to seek therapy have a personal stake in making the client look crazy.

Contrastingly, some individuals who are in fact paranoid do not appear to be. Nonparanoid associates in their social group-and the interviewer for that matter-may share their beliefs about the dangers of certain people, forces, or institutions (terrorists, capitalists, religious authorities, pornographers, the media, the government, patriarchy, racists-whatever is seen as the obstacle to the triumph of good) and may therefore fail to discern that there is something internally generated and driven about their preoccupations. If Congressman Allard Lowenstein had fathomed the paranoid character of Dennis Sweeney, one of his protégés in the student movements of the nineteen sixties and the man who later assassinated him in the grip of a delusion, he might have known better than to behave in a way that was interpretable as sexually seductive, and he might still be alive. But Lowenstein and Sweeney had similar beliefs about what social evils required confrontation, and where Lowenstein's were not primarily projections, Sweeney's were.

There are also people whose perceptions turn out to be prescient, who are nevertheless paranoid. Howard Hughes had a consuming terror of the consequences of atomic testing in Nevada at a time when few others were concerned with nuclear contamination of the environment. Years later, as the toll exacted by radiation became clearer, he looked a lot less crazy. But the eventual vindications of his point of view do not make his psychology less paranoid; the events of his later life speak for the extent to which his own projections were the source of his suffering. My aim in bringing up all these possibilities is to stress the importance of making informed, reflective diagnostic judgments instead of automatic, a priori assumptions-especially with clients whose grim, suspicious qualities may make them hard to warm up to.

DRIVE, AFFECT, AND TEMPERAMENT IN PARANOIA

Because they see the sources of their suffering as outside themselves, paranoid people in the more disturbed range are likely to be more dangerous to others than to themselves. They are much less suicidal than equally disturbed depressives, although they have been known to kill themselves to preempt someone else's expected destruction of them. The angry, threatening qualities of many paranoid people have prompted speculations that one contributant to a paranoid psychology is a high degree of innate aggression or irritability. It stands to reason that high levels of aggressive energy would be hard for a young child to manage and integrate into a positively valued sense of self, and that the negative responses of caregivers to an obstreperous, demanding infant or toddler would reinforce the child's sense that outsiders are persecutory. There has not been much recent research relating paranoia to temperament; in nineteen seventy-eight Meissner marshalled empirical evidence connecting it with an "active" symptomatic style in infancy (irregularity, nonadaptability, intensity of reaction, and negative mood) and with a thin stimulus barrier and consequent hyperexcitability.

Affectively, paranoid people struggle not only with anger, resentment, vindictiveness, and other visibly hostile feelings, they also suffer overwhelmingly from fear. Silvan Tomkins regarded the paranoid stance as a combination of fear and shame. The downward-left eye movements common in paranoid people (the "shifty" quality that even nonprofessionals notice) are physically a compromise between the horizontal-left direction specific to the affect of pure fear and the straight-down direction of uncontaminated shame. Even the most grandiose paranoid person lives with the terror of harm from others and monitors each human interaction with extreme vigilance.

Analysts have long referred to the kind of fear suffered by paranoid clients as "annihilation anxiety"; that is, the terror of falling apart, being destroyed, disappearing from the earth. Anyone who has experienced this level of dread knows how terrifying it is. The research of Jaak Panksepp into mammalian affect has identified this kind of anxiety as part of the FEAR system that evolved evolutionarily to cope with the possibility of predation. Panksepp differentiates it from attachment/separation anxiety that belongs neurobiologically to the PANIC system and is mediated by serotonin. Paranoid anxiety tends not to be quelled by serotonin reuptake inhibitors, but is instead responsive to benzodiazepines, alcohol, and other "downer" drugs, which may be why paranoid patients often struggle with addiction to those chemical agents.

As for shame, that affect is as great a menace to paranoid people as to narcissistic ones, but paranoid people experience the danger differently. Narcissistic individuals, even arrogant ones, suffer conscious feelings of shame if they feel unmasked. Their energies go into efforts to impress others so that the devalued self will not be exposed. Paranoid people, contrastingly, may use denial and projection so powerfully that no sense of shame remains accessible within the self. The energies of the paranoid person are therefore spent on foiling the efforts of those who are seen as bent on shaming and humiliating them. People with narcissistic character structures are afraid of revealing their inadequacies; those with paranoid personalities are afraid of other people's malevolence. This focus on the assumed motives of others rather than on what is happening internally can be, as anyone experienced with paranoid patients can testify, a formidable obstacle to therapy.

Also like narcissistic people, paranoid individuals are vulnerable to envy. Unlike them, they handle it projectively. The degree of anger and intensity they have to manage may account for some of the difference. Resentment and jealousy, sometimes of delusional proportions, darken their lives. These attitudes may be directly projected (the conviction that "others are out to get me because of the things about me that they envy"); more often, they are ancillary to the denial and projection of other affects and impulses, as when a paranoid husband, oblivious to his own normal fantasies of infidelity, becomes convinced his wife is dangerously attracted to other men. Frequently involved in this kind of jealousy is an unconscious yearning for closeness with a person of the same sex. Because such longings may be unconsciously confused with erotic homosexuality, which can frighten heterosexual males, the wishes are abhorred and denied. These desires for care from a man then resurface as the conviction that it is, for example, one's girlfriend rather than oneself who wants to be more intimate with a mutual male friend.

Finally, paranoid people are profoundly burdened with guilt, a feeling that may be unacknowledged and projected in the same way that shame is. Some reasons for their deep sense of badness will be suggested below, along with ways of trying to relieve it therapeutically. Their unbearable burden of unconscious guilt is another feature of their psychology that makes paranoid clients so hard to help: They live in terror that when the therapist really gets to know them, he or she will be shocked by all their sins and depravities, and will reject or punish them for their crimes. They are chronically warding off this humiliation, transforming any sense of culpability in the self into dangers that threaten from outside. They unconsciously expect to be found out, and they transform this fear into constant, exhausting efforts to discern the "real" evil intent behind anyone else's behavior toward them.