This article originally appeared in the December 2004 Harvard Mental Health Letter and is provided courtesy of Harvard Health Publications.

Paranoia

“…the patient imagines that everything happening around him is a veiled reference to his personality and existence. Clouds in the staring sky transmit to one another, by means of slow signs, incredibly detailed information regarding him. His innermost thoughts are discussed at nightfall, in manual alphabet, by darkly gesticulating trees. Pebbles or stains or sun flecks form patterns representing in some awful way messages which he must interpret. Everything is a cipher and of everything he is the theme. He must always be on guard and devote every minute and module of life to the decoding of the undulation of things.”

This strange vision from the fiction of Vladimir Nabokov conveys through exaggeration and poetic heightening some features of paranoia. The word is derived from Greek roots meaning something like “mind beside itself,” and the ancient Greeks used it to refer to almost any mental aberration or bizarre thinking. Since then, it has been applied to many disorders that involve delusions. Today it is mainly reserved in official psychiatric terminology for two conditions: paranoid personality and paranoid schizophrenia.

Mistrust as a personality trait
The identifying mark of paranoid personality is fear (and expectation) of attack and betrayal. Paranoid personalities are suspicious, touchy, humorless, quick to take offense and slow to forgive, self-righteous, argumentative, often litigious. They seldom show tenderness and may avoid intimacy; often they seem tense and brusque. Paranoid personalities find causal connections everywhere; nothing is coincidental. They think that others are taking special notice of them and see references to themselves in innocuous behavior and irrelevant events. They are constantly on guard, searching for hidden motives and meetings.

Once they fix on an idea or explanation, they look for evidence to validate their prejudices, and it is almost impossible to change their minds. When something goes wrong in their lives, they believe that another person is to blame. Some are arrogant, but others may be secretive because they fear that anything they say or do will be used against them. That can be a self-fulfilling prophecy because apparent coldness and arrogance make others uneasy, and mistrust provokes mistrust. According to the familiar saying, even paranoids have enemies. In fact, it is especially paranoids who have enemies because their attitudes and behavior provoke real hostility, further feeding their suspicions.

By the official definition, paranoid personality is rare, occurring in about 1% of the population, but paranoid symptoms are common in other personality disorders as well. Paranoid personality is usually classified as one of the odd or eccentric personality disorders, along with schizoid personality (emotional coldness, lack of close friends) and schizotypal personality (peculiar beliefs, suspiciousness, and social isolation). Paranoid characteristics are also found in antisocial personality (belligerence, arrogance, blaming others); in compulsive personality (small-mindedness, stubbornness, rigidity, and self-righteousness); and in narcissistic personality (arrogance, self-importance, self-centeredness).

Delusions
Paranoid schizophrenia is identified by prominent delusions or hallucinations in a person whose reasoning and emotional responses are relatively well preserved. Some believe it is a distinct type of schizophrenia; others regard it as one form or stage of an underlying schizophrenic condition that produces different symptoms at different times. Like paranoid personalities, schizophrenic patients in a paranoid state are angry, rigid, and argumentative, but unlike paranoid personalities, they have delusions — false beliefs about external reality that persist in contradiction to the beliefs of others and despite obvious and irrefutable evidence to the contrary. They hear abusive and threatening voices, believe others can read their thoughts, or claim that they are under the control of mysterious alien powers. Paranoid personality disorder may be genetically related to schizophrenia, although the evidence is uncertain.

As a symptom, paranoia also occurs in many other psychiatric disorders and medical illnesses, including mania, psychotic depression, epilepsy, Alzheimer’s disease, and alcohol intoxication and withdrawal. Abusers of stimulant drugs may develop symptoms that resemble paranoid personality, and high doses of stimulants can cause a psychosis that resembles paranoid schizophrenia. When deafness, isolation, or a degenerative brain condition interferes with their understanding, older people may begin to suspect that others are whispering about them, spying on them, or stealing from them.

Paranoia can also be a symptom of an adjustment disorder, especially one that results from a sudden change in environment. The classic case is the culture shock experienced by immigrants thrust into an unfamiliar world among strangers with customs and a language they do not understand.
Delusional disorders are another source of paranoid thinking. These include somatic delusions (the false belief that you are ill or dying); erotomania (the false belief that someone is in love with you); grandiose delusions (the belief that you are a misunderstood saint or genius); and delusions of persecution (the false belief that you are the object of spying, poisoning, insults, harassment, or conspiratorial betrayal).

Definition of paranoid personality disorder Pervasive distrust and suspicion that cause a person to misinterpret the motives of others as malevolent. It includes at least four of the following: A belief that others are exploiting, harming, or deceiving you. Preoccupation with unjustified doubts about the loyalty or trustworthiness of people around you. Reluctance to confide in others for fear of betrayal. Reading hidden threats and insults into harmless remarks or events. Bearing grudges. Perceiving attacks on one’s character or reputation that others do not notice — and quickly counterattacking. Unjustified jealousy. Adapted from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised.

The nature of paranoia
Paranoid symptoms arise from many different kinds of intellectual, emotional, and organic breakdown because they are a byproduct of the human capacity to find connections, assign meanings, and give reasons. The tendency to mistake coincidences for causes and blame persons rather than circumstances is universal. Within limits, everyone has to be on guard against deceit and betrayal. In everyday speech, the word “paranoid” has partly lost the connotation of error or delusion. People who describe themselves as paranoid usually mean they are justifiably fearful and suspicious. Normal vigilance may turn into genuine paranoia because of external circumstances (the immigrant suffering culture shock) or organic illness, and some people may simply be congenitally hypersensitive to signs of hostility.

As an explanation for paranoia without an obvious organic cause, Freud’s is the best-known theory. He suggested that paranoia is a psychological defense that arises when repressed childhood impulses reemerge in an adult crisis, converted into suspicions and delusions by projection — the process of attributing one’s own unacknowledged wishes to another person. For example, a man who feels violently angry at someone may deny his own rage but insist that the other person is going to attack him.

Projection is still considered central to paranoia. Paranoid persons cannot acknowledge that they feel unworthy, so they say others are criticizing them. Feeling guilty, they decide that others are making false accusations. Feeling helpless, they say that others are trying to entrap them. They are constantly thinking about their alleged persecutors, so the persecutors must be constantly thinking about them.

Paranoid delusions may develop in a susceptible person because of an accident, a minor injustice, a misunderstanding, even heightened intimacy or increased responsibility — any change that causes anxiety. Delusional explanations provide the comfort of knowing where the threat is coming from and what to be on guard against.

Treatment
Treating people with paranoid tendencies is difficult. When the paranoia reaches the level of delusions, antipsychotic medication is useful, although helping the patient acknowledge the problem can be a challenge. And even with psychopharmacological treatment, paranoia may persist.

Often, paranoid persons are coping well enough on their own terms, and their behavior troubles others more than themselves. They dread being dependent on anyone because they trust no one. They may seek help if projection and other paranoid defenses fail and they begin to feel depressed and anxious. But even then, they may go into therapy unwillingly and break it off prematurely. With a therapist, they tend to be at best irritable and guarded, at worst contemptuous, hostile, or even threatening.

Therapists who want to maintain a working alliance with a paranoid patient must avoid becoming the object of projection. They should provide models of non-paranoid behavior, and not allow themselves to become either an aggressor or a victim. The therapist must build trust gradually, without trying to be too friendly, and avoid showing of anger or defensiveness. Complete honesty is essential because people with paranoid tendencies are highly sensitive to deception and holding back.

Disputing or otherwise directly confronting paranoid beliefs is ineffective, and interpretations will be regarded mainly as accusations. Instead, the therapist must help patients acknowledge the feelings they have been defending themselves against. Some say depression is a good sign because it suggests that the patient is abandoning projection and realizes his or her own vulnerability. It helps to learn the details — what causes the paranoid thoughts, how they make the patient feel, when and why they come and go. Cognitive behavioral therapy may reduce sensitivity to criticism by improving social skills or anxiety. If therapy goes well, projection will gradually subside. Even if the patient does not eventually reject all suspicious ideas, paranoid feelings may become less intense and the paranoid thoughts less absorbing, giving way to better functioning and more comfort.