PARANOID PERSONALITY DISORDER
Paranoid personality disorder is characterized by per-vasive mistrust and suspiciousness of others. Clients with this disorder interpret others’ actions as poten-tially harmful. During periods of stress, they may develop transient psychotic symptoms. Incidence is estimated to be 0.5% to 2.5% of the general population; the disorder is more common in men than in women. Data about prognosis and long-term outcomes are lim-ited because most people with paranoid personality disorder do not readily seek or remain in treatment (APA, 2000).
Clients appear aloof and withdrawn and may remain a considerable physical distance from the nurse; they view this as necessary for their protection. Clients also may appear guarded or hypervigilant; they may survey the room and its contents, look behind furniture or doors, and generally appear alert to any impending danger. They may choose to sit near the door to have ready access to an exit or with their backs against the wall to prevent anyone from sneaking up behind them. They may have a restricted affect and may be unable to demonstrate warm or empathic emotional responses such as “You look nice today” or “I’m sorry you’re having a bad day.” Mood may be labile, quickly changing from quietly suspicious to angry or hostile. Responses may become sarcastic for no apparent reason. The constant mistrust and suspicion that clients feel toward others and the environment distorts thoughts, thought processing, and content. Clients frequently see malevolence in the actions of others when none exists. They may spend disproportionate time examining and analyzing the behavior and motives of others to discover hidden and threatening meanings. Clients often feel attacked by others and may devise elaborate plans or fan-tasies for protection.
These clients use the defense mechanism of projec-tion, which is blaming other people, institutions, or events for their own difficulties. It is common for such clients to blame the government for personal problems. For example, a client who gets a parking ticket may say it is part of a plot by the police to drive him out of the neighborhood. He may engage in fantasies of retribution or devise elaborate and sometimes violent plans to get even. Although most clients do not carry out such plans, there is a potential danger.
Conflict with authority figures on the job is common; clients may even resent being given directions from a supervisor. Paranoia may extend to feelings of being sin-gled out for menial tasks, treated as stupid, or more closely monitored than other employees.
Forming an effective working relationship with paranoid or suspicious clients is difficult. The nurse must remember that these clients take everything seriously and are partic-ularly sensitive to the reactions and motivations of others. Therefore, the nurse must approach these clients in a for-mal, business-like manner and refrain from social chitchat or jokes. Being on time, keeping commitments, and being particularly straightforward are essential to the success of the nurse–client relationship.
Because these clients need to feel in control, it is impor-tant to involve them in formulating their plans of care. The nurse asks what the client would like to accomplish in concrete terms, such as minimizing problems at work or getting along with others. Clients are more likely to engage in the therapeutic process if they believe they have some-thing to gain. One of the most effective interventions is helping clients to learn to validate ideas before taking action; however, this requires the ability to trust and to listen to one person. The rationale for this intervention is that clients can avoid problems if they can refrain from taking action until they have validated their ideas with another person. This helps prevent clients from acting on paranoid ideas or beliefs. It also assists them to start basing decisions and actions on reality.