People with PPD (Panic Personality Disorder) do not trust other people. In fact, the central characteristic of people with PPD is a high degree of mistrustfulness and suspicion when interacting with others.
Even friendly gestures are often interpreted as being manipulative or malevolent. Whether the patterns of distrust and suspicion begin in childhood or in early adulthood, they quickly come to dominate the lives of those suffering from PPD. Such people are unable or afraid to form close relationships with others.
They suspect strangers, and even people they know, of planning to harm or exploit them when there is no good evidence to support this belief. As a result of their constant concern about the lack of trustworthiness of others, patients with this disorder often have few intimate friends or close human contacts.
They do not fit in and they do not make good "team players". Interactions with others are characterized by wariness and not infrequently by hostility. If they marry or become otherwise attached to someone, the relationship is often characterized by pathological jealousy and attempts to control their partner. They often assume their sexual partner is "cheating" on them.
People suffering from PPD are very difficult to deal with. They never seem to let down their defenses. They are always looking for and finding evidence that others are against them. Their fear, and the threats they perceive in the innocent statements and actions of others, often contributes to frequent complaining or unfriendly withdrawal or aloofness.
They can be confrontational, aggressive and disputatious. It is not unusual for them to sue people they feel have wronged them. In addition, patients with this disorder are known for their tendency to become violent.
Despite all the unpleasant aspects of a paranoid lifestyle, however, it is still not sufficient to drive many people with PPD to seek therapy. They do not usually walk into a therapist's office on their own. They distrust mental health care providers just as they distrust nearly everyone else. If a life crisis, a family member or the judicial system succeeds in getting a patient with PPD to seek help, therapy is often a challenge. Individual counseling seems to work best but it requires a great deal of patience and skill on the part of the therapist.
It is not unusual for patients to leave therapy when they perceive some malicious intent on the therapist's part. If the patient can be persuaded to cooperate — something that is not easy to achieve — low-dose medications are recommended for treating such specific problems as anxiety, but only for limited periods of time.
If a mental health care provider is able to gain the trust of a patient with PPD, it may be possible to help the patient deal with the threats that they perceive. The disorder, however, usually lasts a lifetime.
A core symptom of PPD is a generalized distrust of other people. Comments and actions that healthy people would not notice come across as full of insults and threats to someone with the disorder. Yet, generally, patients with PPD remain in touch with reality; they don't have any of the hallucinations or delusions seen in patients with psychoses.
Nevertheless, their suspicions that others are intent on harming or exploiting them are so pervasive and intense that people with PPD often become very isolated. They avoid normal social interactions.
And because they feel so insecure in what is a very threatening world for them, patients with PPD are capable of becoming violent. Innocuous comments, harmless jokes and other day-to-day communications are often perceived as insults.
Paranoid suspicions carry over into all realms of life. Those burdened with PPD are frequently convinced that their sexual partners are unfaithful. They may misinterpret compliments offered by employers or coworkers as hidden criticisms or attempts to get them to work harder.
Complimenting a person with PPD on their clothing or car, for example, could easily be taken as an attack on their materialism or selfishness.
Because they persistently question the motivations and trustworthiness of others, patients with PPD are not inclined to share intimacies. They fear such information might be used against them. As a result, they become hostile and unfriendly, argumentative or aloof. Their unpleasantness often draws negative responses from those around them.
These rebuffs become "proof" in the patient's mind that others are, indeed, hostile to them. They have little insight into the effects of their attitude and behavior on their generally unsuccessful interactions with others. Asked if they might be responsible for negative interactions that fill their lives, people with PPD are likely to place all the blame on others.
A brief summary of the typical symptoms of PPD includes:
- suspiciousness and distrust of others.
- questioning hidden motives in others.
- feelings of certainty, without justification or proof, that others are intent on harming or exploiting them.
- social isolation.
- aggressiveness and hostility.
- little or no sense of humor.
No one knows what causes paranoid personality disorder, although there are hints that familial factors may influence the development of the disorder in some cases. There seem to be more cases of PPD in families that have one or more members who suffer from such psychotic disorders as schizophrenia or delusional disorder.
Other possible interpersonal causes have been proposed. For example, some therapists believe that the behavior that characterizes PPD might be learned. They suggest that such behavior might be traced back to childhood experiences.
According to this view, children who are exposed to adult anger and rage with no way to predict the outbursts and no way to escape or control them develop paranoid ways of thinking in an effort to cope with the stress. PPD would emerge when this type of thinking becomes part of the individual's personality as adulthood approaches.
Studies of identical (or monozygotic) and fraternal (or dizygotic) twins suggest that genetic factors may also play an important role in causing the disorder. Twin studies indicate that genes contribute to the development of childhood personality disorders, including PPD.
Furthermore, estimates of the degree of genetic contribution to the development of childhood personality disorders are similar to estimates of the genetic contribution to adult versions of the disorders.
Because they are suspicious and untrusting, patients with PPD are not likely to seek therapy on their own. A particularly disturbing development or life crisis may prompt them to get help. More often, however, the legal system or the patient's relatives order or encourage him or her to seek professional treatment. But even after a patient finally agrees or is forced to seek treatment, the nature of the disorder poses very serious challenges to therapists.
The primary approach to treatment for such personality disorders as PPD is psychotherapy. The problem is that patients with PPD do not readily offer therapists the trust that is needed for successful treatment. As a result, it has been difficult to gather data that would indicate what kind of psychotherapy would work best.
Therapists face the challenge of developing rapport with someone who is, by the nature of his personality disorder, distrustful and suspicious; someone who often sees malicious intent in the innocuous actions and statements of others. The patient may actively resist or refuse to cooperate with others who are trying to help.
Mental health workers treating patients with PPD must guard against any show of hostility on their part in response to hostility from the patient, which is a common occurrence in people with this disorder. Instead, clinicians are advised to develop trust by persistently demonstrating a nonjudgmental attitude and a professional desire to assist the patient.
It is usually up to the therapist alone to overcome a patient's resistance. Group therapy that includes family members or other psychiatric patients, not surprisingly, isn't useful in the treatment of PPD due to the mistrust people with PPD feel towards others.
This characteristic also explains why there are no significant self-help groups dedicated to recovery from this disorder. It has been suggested, however, that some people with PPD might join cults or extremist groups whose members might share their suspicions.
To gain the trust of PPD patients, therapists must be careful to hide as little as possible from their patients. This transparency should include note taking; details of administrative tasks concerning the patient; correspondence; and medications. Any indication of what the patient would consider "deception" or covert operation can, and often does, lead the patient to drop out of treatment.
Patients with paranoid tendencies often don't have a well-developed sense of humor; those who must interact with people with PPD probably should not make jokes in their presence. Attempts at humor may seem like ridicule to people who feel so easily threatened.
With some patients, the most attainable goal may be to help them to learn to analyze their problems in dealing with other people. This approach amounts to supportive therapy and is preferable to psychotherapeutic approaches that attempt to analyze the patient's motivations and possible sources of paranoid traits.
Asking about a patient's past can undermine the treatment of PPD patients. Concentrating on the specific issues that are troubling the patient with PPD is usually the wisest course.
With time and a skilled therapist, the patient with PPD who remains in therapy may develop a measure of trust. But as the patient reveals more of his paranoid thoughts, the clinician will continue to face the difficult task of balancing the need for objectivity about the paranoid ideas and the maintenance of a good rapport with the patient.
The therapist thus walks a tightrope with this type of patient. If the therapist is not straightforward enough, the patient may feel deceived. If the therapist challenges paranoid thoughts too directly, the patient will be threatened and probably drop out of treatment.
While individual supportive psychotherapy is the treatment of choice for PPD, medications are sometimes used on a limited basis to treat related symptoms. If, for example, the patient is very anxious, anti-anxiety drugs may be prescribed. In addition, during periods of extreme agitation and high stress that produce delusional states, the patient may be given low doses of antipsychotic medications.
Some clinicians have suggested that low doses of neuroleptics should be used in this group of patients; however, medications are not normally part of long-term treatment for PPD.
One reason is that no medication has been proven to relieve effectively the long-term symptoms of the disorder, although the selective serotonin reuptake inhibitors such as fluoxetine (Prozac) have been reported to make patients less angry, irritable and suspicious.
Antidepressants may even make symptoms worse. A second reason is that people with PPD are suspicious of medications. They fear that others might try to control them through the use of drugs.
It can therefore be very difficult to persuade them to take medications unless the potential for relief from another threat, such as extreme anxiety, makes the medications seem relatively appealing. The best use of medication may be for specific complaints, when the patient trusts the therapist enough to ask for relief from particular symptoms.
Paranoid personality disorder is often a chronic, lifelong condition; the long-term prognosis is usually not encouraging. Feelings of paranoia, however, can be controlled to a degree with successful therapy. Unfortunately, many patients suffer the major symptoms of the disorder throughout their lives.
With little or no understanding of the cause of PPD, it is not possible to prevent the disorder.