Nancy McWilliams on Psychoanalytic Diagnoses, Part 1: Personality, Defenses, Themes, Paranoid Personality

Nancy McWilliams

Vittorio Ninciardi.

Nancy McWilliams

And it's a psychodynamic diagnostic name. Okay, correct.

Nancy McWilliams

Very nice. Thank you.

Nancy McWilliams

Well, that's asking a lot of questions. Sorry, sorry. But my background was in personality. My PhD is in personality and social psychology, and I became a clinician. So I'm technically a clinical psychologist, but my background is studying personality. And the personality types that are in my book preexisted the DSM. pre-existed the 1980 edition, which is what I was reacting to when I first wrote the diagnosis book, because the DSM in 1980, the framers of it, were being very influenced by certain groups of researchers, by the drug companies, and by certain problems that had arisen in the field.

For example, there were different theoretical orientations, and they needed a way of describing psychological problems so that you didn't have to have psychoanalytic training to diagnose them. And if you were behaviorally trained, you could still talk about the same phenomena. You could agree across theoretical orientations. But what was most important was researchers were having a lot of trouble with clinical diagnosis as it was actually practiced naturalistically, which was more that you sit down and you try to get to know a person and pretty soon you get a sense of their personality.

And it may not be a disordered personality at all. Everybody's got a personality style or type. or a combination of styles and types, and it's not necessarily a disorder. So that was the atmosphere in which I was originally trained. But when the DSM made its paradigm shift in 1980, it decided, for various reasons that were very well-intentioned, that it wanted to make a categorical nosology or categorical taxonomy, meaning that you'd have present versus absent criteria, and they would be discrete criteria.

They didn't want dimensionality, a little of this, a little of that. They wanted to talk about specific entities, and that was partly for researchers. Because researchers need to figure out, you mentioned narcissistic personality disorder. If they went to therapists before 1980 and said, well, how do you diagnose narcissistic personality disorder? Therapists would have said, Well, you take the person into treatment, and you see what the transference is like.

And if it's a self-object transference, presumably the person has mostly narcissistic dynamics. And that's no help at all for researchers. They wanted present versus absent categories. So the DSM tried to be neokreplinian, meaning that clinical psychiatry and psychology and social work had all gone in the direction of dimensionality, complexity, seeing people in context, inferring meaning. If you're going to try to do research on specific things, like specific kinds of depression, you have to have rule-outs so that you're not mixing things up.

And that created a lot of problems. One problem was the most common kind of personality type that existed in the literature, including the empirical literature before 1980, was depressive personality. But people on the mood disorders task force didn't want to have depressive personality in there. They thought it was too muddy a concept compared to depressive illness. And the drug companies who were funding a lot of these people also didn't want depressive personality in there because it was already known that antidepressant medication isn't very helpful if you've got the personality problem rather than just a discreet personality.

So they eliminated depressive personality disorder from the DSM. In fact, the whole personality section of DSM-III and subsequent DSMs, until the most recent one, which has an alternative classification system, was an afterthought. They were more interested in anxiety disorders, depressive disorders, addiction disorders, and so forth. And that's why it's at the end. And what they did at the end was only add personality disorders on which there was an empirical literature.

That meant getting rid of some, like, inadequate personality on which there wasn't an empirical literature. It also meant they got rid of the idea of dimensionality, and that was a problem because borderline... originated as the idea of a kind of personality organization, not crazy enough to be psychotic, but crazier than neurotic. So in other words, it was a mid-level kind of level of severity of personality problems.

And you could have a schizoid personality at the borderline level, an obsessional personality at the borderline level, and so on. But the empirical literature that had been done had mostly been done on people who had more histrionic versions of borderline personality, and so they took those criteria, mostly from John Gunderson's work, and made it a category so then there was borderline personality disorder and it was described as you know self-dramatizing and having trouble with affect regulation and all the things that we're familiar with but that's really only one version of of being organized at a borderline level and then they got upset because If you meet the criteria for borderline personality disorder in the DSM, you probably meet the criteria for histrionic personality disorder, too.

And they said, we can't have that. Well, there's a perfectly good reason they have that. Gunderson was the head of a hospital, and he was most interested in... borderline patients who were causing trouble. He wasn't that interested in the schizoid borderline patient who spends all of his day in the room playing video games and doesn't ever see people and is not self-dramatizing and doesn't cut himself and so forth.

So they were trying to solve some problems by making the DSM from 1980 on neo-Kreplinian, categorical, non-dimensional, non-inferential. The previous DSMs had been heavily influenced by psychoanalytic ideas, and there were plenty of people that didn't want to be fed psychoanalytic ideas with their diagnostic categories. They were quite well-intentioned, but it created certain kinds of clinical problems that they didn't fully foresee. Even in the language of the DSM, you you can find places where the authors say these categories don't substitute for clinical judgment or a good case formulation and things are really a lot more dimensional and complex than this but And they didn't intend it to be used as the Bible for everything.

Gotten to be that, and I think that's quite a problem. And my concern has been to, the reason I wrote the diagnosis book was I was finding that certain knowledge that we had as practicing therapists was getting lost. because the DSM was treated as the be-all, end-all of understanding people, and that's really a shame. It wasn't intended to be that. It's useful for certain kinds of research, but other kinds of research like on personality differences on attachment, on neuroscience, on development, things that don't lend themselves to the test of a particular technique for a particular set of symptoms are, as a result, kind of devalued in general.

And I've seen the difference clinically. I mean, it used to be people would come and they'd say to me something like, I'm very shy. I need help getting more comfortable around other people. I'm an introvert. And now they come and they say, I have social phobia. What do you think I should, what medicine should I be taking? Or give me a skill set for that. And it's a very different mental set that has been the result of the DSM.

The drug companies love the DSM because if you have discrete categories, you can market drugs for them. And certain researchers like the DSM because it makes their research cleaner to eliminate any comorbidities, so-called. In fact, some of the evidence-based treatments have eliminated so many comorbidities when they study a particular disorder that the patients represent the healthiest people in that category and not the kind of people who come into our offices.

And it's served the interests of government cost cutters, too, and insurance companies that say, well, you know, if these are the disorders that we cover and we don't cover these more complicated things like complex post-traumatic states or personality disorders. It's interesting. The insurance companies marketed their managed care policies to corporations, saying that they gave comprehensive mental health care. And then they very quickly said, oh, but we don't cover personality disorders.

That's not comprehensive mental health care. Whereas we have plenty of empirical data that most people who come for therapy have some involvement with their lifelong patterns of relatedness, their personality. not just with a one-shot anxiety disorder or eating disorder or other disorder category, but it's in the interest of cost-cutters, whether they're private or public, to see it as, oh, you got rid of the immediate symptoms? Fine.

We don't do that in the rest of medicine. You don't lower a fever and say, okay, problem solved. or cure a skin rash and not be interested in what it's telling you about what's going on in the body. And you can describe a limp in terms of present versus absent criteria, but you're not you're not saying that it is the disorder. You can limp for any one of a number of reasons, and in the rest of medicine you try to figure out what those reasons are.

So we've done a peculiar thing in psychiatry where we're substituting symptoms that tend to cohere together for an idea about what's really the problem here that the person needs to work on. This is probably more information than you wanted, but that's what What made me feel, it wasn't exactly like I took the DSM categories and then switched the paradigm. It was that the DSM categories to a certain extent reflected our understanding prior to the switch in 1980.

of what the different personality disorder possibilities were. With some omissions, for example, there's no sadistic personality in the DSM, even though everybody knows that there are a very small number of people who are organized around sadistic dynamics. They don't tend to volunteer happily to be research subjects, so you can't say there's an empirical basis for the category. So they just omitted that. We don't have the hypomanic personality type in there.

There are some people who are stably hypomanic who do not have diagnosable bipolar illness, but they have disappeared from the DSM because they do not tend to be very constant about cooperating with researchers. It is kind of a mess. What I was trying to do was keep alive clinical knowledge that came from scholarship and clinical experience that had gone on for quite a while by 1980 and has gone on since 1980.

That is what I was trying to do. I was trying to be useful to my students. It was my students that pushed me to write that book. They got sick of hearing me bitch that there should be a book like that.

Nancy McWilliams

Yeah, that comes originally from the work of Otto Kernberg, who was noticing, like any experienced clinician, that personality problems run on a continuum from healthy versions of a kind of psychology through neurotic versions of it, through really more troubled versions of it that we would think are more diagnosable as personality disorders, to... psychotic versions of it. For example, and I don't mean necessarily schizophrenia, there was before, in the 1960s, there was a diagnosis of hysterical psychosis, for example, and I think that it's a loss.

We don't have that now. At any rate, the first person to write about this was Elizabeth Zetzel. She wrote an article called The So-Called Good Hysteric, because psychoanalytic treatment was invented with people with what were then called hysterical disorders. We've now mostly diagnosed those as post-traumatic or histrionic or dissociative. But she talked about how high-functioning people with hysterical disorders psychologies are very easy to work with you know they make a a very easy connection with the therapist they understand that they're working on themselves they experience themselves as having internal conflicts that they could work on you know they can be pretty neurotic but if they can have kind of sense of self-constancy and make a good relationship with another person and see the problem as internal they would be in the neurotic range of personality disorder.

If they're getting into trouble a lot with their dynamics, you'd still call them a personality disorder, but at the neurotic range. Zetzel didn't use those terms, but she had four categories of levels of hysterical psychology. There are a couple of levels we've now diagnosed as borderline, where there's much more self-dramatizing, much more enactment outside the self, much more creating disasters. The same internal preoccupations in the case of hysteria with issues of gender and power and fear of impingement and fear of other people In the other gender, usually, they think in very binary ways, dominating them.

Those dynamics will run through the whole level, but at the borderline level, it could be enacted as people having a series of horrible relationships that all end up coming to a bad end, involving domination, sexuality being a problem, and so on. And then at the psychotic level, you see people who are... so chronically creating crises all the time and believing their own fabrications in certain ways. I tend to think of Munchausen's as at the psychotic end of the hysterical continuum because the whole...

drive for people with Munchausen seems to be to matter to the medical establishment, to matter to doctors. If Munchausen is by proxy, it's to get this drama going where their child is a death's door and somebody saves them and it's a wonderful outcome and then they have to repeat it. That's a crazy level. of enacting the same dynamics. So she was the first one to write about it.

Kernberg in 1984 talked about how it's much more important to know what level the person is at than what their dynamics are. So for example, in the obsessive compulsive dimension, a healthy obsessive compulsive person is just somebody who's very well organized kind of type A has pretty strong moral principles, is interested in issues of control, maybe a little bit wooden, but in general a good citizen all around.

The neurotic range of obsessive-compulsive would be somebody who has ritualistic practices that they know are crazy. They know it involves internal anxiety that they have to do something about. They can make a good relationship with a therapist. They can see that the problem is internal. They're easy to work with. They would respond well to any of the short-term therapies, especially exposure therapy. At the borderline level, you see obsessive-compulsive people who are, for example, hoarding or crazily involved with their rituals and they kind of know they're crazy but they have to do them and they have a much harder time making a relationship with a therapist or thinking a therapist could really help them.

At the psychotic level, it's pretty hard to, you know, there's a kind of very soft category between, or soft boundary between being extremely obsessive and being paranoid. And at the psychotic level, you get people who firmly believe that if they don't do their rituals, they will be destroyed. And if a therapist tries to get them to use exposure therapy, for example, or to question their rituals, they simply believe the therapist has turned into a persecutor now and doesn't get how dangerous everything is.

So you can see how it would be easy to work with the healthy or the neurotic version of obsessive compulsive. It would be more challenging to work with a more borderline and with the more psychotic person with the same dynamics which involve issues of control and discontrol, neatness and messiness, promptness and lateness, cooperation and resistance, all those dyadic struggles are the kind of core of obsessional psychology.

You can see that at the borderline and psychotic levels, it would be really rough going. You'd have to spend, especially at the psychotic level, you'd have to spend months or years becoming a safe enough other to the person who's suffering. For that person to be able to imagine, maybe I could try something that this therapist is suggesting to expose myself to what I think are going to be the disasters that accompany my not doing my rituals.

So that really came from Kernberg's work. There's now considerable empirical work supporting the idea of dimensionality. Carla Sharpe's work, for example, is I think a very powerful empirical demonstration of the value of thinking this way. Patrick Leuton has done some work on this as well, Ken Levy. Most practicing therapists have always seen it this way. So it matters clinically, not just what kind of nuts, but how nuts the person is.

Or maybe they're not nuts at all, but you want to take into consideration what their personality is. There are plenty of introverted people who see themselves as on the schizoid side, who don't have significant psychological problems, might come to a therapist for a depression or an anxiety or an eating disorder or something. If the therapist appreciates that they have a schizoid psychology, you don't necessarily try to modify that, but it helps you to understand that that's the kind of patient that will do better if you give them a lot of space, rather than if you move in on them, in contrast to somebody who's more let's say, depressive or hysterical in their organization where they move toward people and if you give them a lot of space, they feel abandoned.

So even at the highest functioning levels, to know something about personality differences, even if there's no disorder, helps you orient therapy to make a person comfortable enough to get into their stuff with you, to show the disowned parts of themselves to you, to move ahead with their work.

Nancy McWilliams

Well, that's a big question, because I'm not sure I buy into the idea that there is such a thing as schizophrenia. I think there is psychotic experience, and certain things map onto what we've called schizophrenia. But let me put that aside, but say that if you use the term psychotic in the way that it was originally meant, namely... there's a problem with joining with consensual notions of reality.

Then you see a number of people who aren't diagnosably schizophrenic but who are struggling to stay in reality or who have some really crazy ideas. For example, one man I worked with who was on the paranoid side but never had had a psychotic break. He was in his 50s or 60s when I worked with him. I noticed a few sessions into our work that when he started feeling sad, he would cut himself off and change the subject.

So I brought that to his attention. I said something like, I think I'm noticing that when you start to feel sad, you change the subject. And he said, oh yeah, I know I do that. And I said, well, what's going on when you do that? And I think I expected him to say something like, well, I don't want to start crying or I'm not ready to go there yet or something like that.

And he said, well, I can see I'm hurting you. So he kind of thought he could read my mind. He thought it was his job to keep me safe. He couldn't imagine another person showing sadness. He would see sadness on my face and he would feel he was destroying me and he had to stop. And that's crazy in the sense of not having a good boundary between self and other.

And that's really usually what's going on in what we call psychosis. You're hallucinating things that you think are outside you when they're really expressions of dynamics that are inside you. Or I had a woman who was telling me about how she had a particular kind of urinary problem And she said something about the urethra being like a tube. And I said, well, you know, the urethra flattens out.

It closes up against. It's not mine. It's a tube. And she looked at me as if I was dangerous. Or another patient who, she came late one day, and I said, it's not like it. It comes late. She said, oh, yeah, it took me longer than usual to boil all the sheets and towels. And I said, you boil all your sheets and towels? And she immediately looked at me with distrust.

I'd seen her for several years by this time. And she said, of course I boil all my sheets and towels. Haven't you ever heard of germs? What good mother doesn't boil all the sheets and towels every morning? And she was looking at me like I was a contaminant all of a sudden. Now that's a crazy level of obsessive neatness. It goes beyond just borderline. there's a terrible anxiety that the world will fall apart if you don't control it somehow in that kind of psychology.

That's how people used to use the term psychosis. When the DSM in 1980 decided we're going to label the handful of psychotic conditions that we know about, I think they made some rather arbitrary choices. For example, I think extreme anorexia is a psychotic condition. Because when a person weighs 82 pounds and is starving themselves and tells you that they're too fat and sees an obese person in the mirror, that's completely crazy.

It goes beyond neurotic or borderline. But we don't think of extreme versions of anorexia as a psychotic illness and I wonder why not because there's a loss of touch with reality there. In certain post-traumatic states people believe you are the Viet Cong right now. They can be sitting with you in a session and all of a sudden the therapist is the rapist and they will act as if you're just about to attack them or just did attack them and it takes a while before they can come back to now, and that's a post-traumatic phenomenon, but in the moment they're psychotic.

So I'm using the term in the general way that clinicians have used it, because I think these discrete categories blind us to the ways in which we all have the And we could all go mad in one way or another. Maybe we don't all have the biological predisposition to be diagnosably schizophrenic at any point, but different people's minds fracture along different patterns, but we can all be really damaged.

And if we separate out these few symptomatic constellations and say, well, that's other, we lose the capacity to empathize with what it's like to go there. And if you lose that empathy, you're not going to be experienced by the patient as respectful.

Nancy McWilliams

Pretty much, yeah.

Nancy McWilliams

Well, first of all, we all have primitive defenses. It's not just the sick patient. The primitive defenses, and I'm using primitive not in a way to try to pathologize them, but just to descriptively say they come up early in our experience. They're the way young children deal with the world, and those ways of dealing with the world never die in any of us. They include withdrawal, if you are overstimulated.

An infant will withdraw and go to sleep sometimes. Denial, which is, it is not happening. Tell anybody that somebody has just died and the first thing they will say is, oh, no. That is the residue of denial. I do not want this to be true. It is not true. There are primitive forms of idealization and devaluation. There are primitive forms of dissociation, where you literally become somebody else.

Splitting is a very important primitive reaction. It's where you organize experience as all bad or all good. And we all do that, especially under stress. On 9-11, People weren't going around saying, gee, we're so curious why people in certain Arab countries would hate us so much. What do we represent to them that they would want to kill themselves in order to get back at us? We were going completely to, they're evil.

They're the evil empire. There are three parties in the evil empire. We're the good guys. So we shift into good and bad rather than complex understandings. And that's the way very young kids organize the world. Good, bad, big, little. And sometimes male, female are the binaries that they tend to generate starting around age one and a half or two. And those remain with us, and they come up under stress.

If your partner breaks up with you, you don't immediately go to, gee, I can understand why, given his history, he wouldn't have found me the right partner. You go to, he's a bastard, I hate him. So that's splitting. And primitive forms of projection where we can't quite know the difference between inside and outside. We think the infant has to learn the difference between inside and outside. They get more of it than we used to think because studies of infants have now shown that they have pretty good capacity to see another, but they do kind of treat the mother and father as parts of themselves until they're a little bit older.

And they tend to impute all kinds of power to us, too. Omnipotent control is a primitive defense. So is somatization, where you get Very young children, if they don't have the words for what they're feeling, they'll tend to act out or get sick. So acting out and getting sick are primitive defenses too. They're just processes that become defensive later on when people are struck with a lot of stress.

What makes a difference as to whether you're able to be more adaptive in the world is not that you have primitive defenses, but it's more that you don't have adaptive higher order defenses, like repression is a higher order defense than denial, to allow something to exist, to acknowledge that it's true, and then to, for motivational reasons, forget it, means you didn't fully deny it. Rationalization, most people think of as a higher order defense, certainly intellectualization.

And there are some defenses that are so adaptive generally that we consider them the kind of good defenses, like using a sense of humor to deal with things, sublimating things, like if you have a, a primitive wish to exhibit yourself, you could become a singer or an artist and do some social good with your wish. Or if you have fantasies of statistically cutting people, you can turn that into becoming a surgeon and do the world a great deal of good.

And it may have been based in early childhood experiences where you wanted to hurt somebody, but it's turned into a positive. So there's a whole range of what we call defenses, which may not be the best word, but we're stuck with it, because we've observed these processes mostly in their defensive function. And there's a long list of them. They've been studied empirically by people like Phoebe Kramer and Chris Perry and George Valiant.

So we know something about when they emerge and how people get better defenses as they get older. For example, a four-year-old or five-year-old kid... If they are displaced by a sibling, you can see reaction formation in that kid. But a two-year-old displaced by a sibling, you won't see that. Reaction formation is, oh, you're so cute. I'm determined to love you. And I really am pinching your cheek in a way that...

You can kind of see leaking through the hostility. But they're trying to feel positive about the new baby. And younger kids aren't capable of that.

Nancy McWilliams

I'm good.

Nancy McWilliams

No.

Nancy McWilliams

Okay.

Nancy McWilliams

Because what we mean by personality... The DSM tried to describe personality based on traits. The presence or absence of traits. And I think that's highly problematic because... What really organizes personality is something more like themes and stories. What's the primary narrative of the person, or what some of the cognitive folks call schemas? So you'll see traits that aren't... It's not wrong to say, for example, using paranoid as an exemplar, that paranoid people have the traits of suspicion and distrust.

It's not wrong, but it's incomplete. It doesn't capture the fact that paranoid people also can be pathologically over-trusting. A paranoid person can tell you their cult leader is flawless. They can believe fervently that somebody is totally trustable. Sullivan said they don't have a medium and realistic capacity to deal with trust and distrust. They're all organized around the issue of trust and betrayal. That's their theme. That's their issue.

So it's not just that they have certain traits, but that you can see behaviors on both ends of the continuum of ways of dealing with that theme of who can I trust and who's going to betray me and how am I going to get hurt here, the kind of basic insecurity that runs. through paranoia.

Nancy McWilliams

Yes.

Nancy McWilliams

Yeah, I mean, And in a way, it sounds paradoxical, but it's also kind of common sense. Like obsessive compulsive people tend to be organized about neatness. Everything is organized, but they also tend to have a mess somewhere. They have a dirty drawer somewhere. They can't organize certain things. You see an oscillation between neatness, messiness, control, discontrol, obedience, rebellion, submission, provocation. Promptness, lateness, all the dyadic issues that they get organized around.

Or you mentioned narcissistic. There's the arrogant version of feeling better than other people, which is a compensation for the fact that you feel worse than other people. And you see both sides of that in every narcissistic person I've ever met. worked with. If they run into a narcissistic injury, you'll see the side of them that feels desperate and empty and lonely and not good enough and shamed as opposed to contemptuous and arrogant and grandiose and so forth.

That's true with all the personality types. They cluster together mostly because of the story that illuminates the person's thinking about life than any particular traits. The DSM alternative personality classification is a big improvement on the regular DSM personality categories. But unfortunately, from my perspective, it's dimensional. That's why it's a big improvement. But they tried to do it based on traits, and you can measure some traits, and there is a very robust empirical literature on the so-called big five personality traits, but they're not as clinically relevant as these stories that I think practicing clinicians can spot in any given patient.

Oh, okay. This is the third time they've talked about how somebody got too much under their skin and they were overstimulated. I think I'm dealing with a person with a schizoid psychology here. or I'm sitting with a woman who's constantly telling me how bad men are or how wonderful men are, so she seems to be very organized around gender differences and very binary in her orientation. There's stuff in her history that makes me think she felt defensive about being female, and she was the recipient of a certain amount of sexism, and so her issue is issues of gender and power.

And you can see, again, There are some very self-dramatizing versions of hysterical personality and very inhibited versions of hysterical personality, but the dynamics are the same. That's sort of what I wanted to say before I talk about the specific personality types.

Nancy McWilliams

Yeah, that's true.

Nancy McWilliams

But very relevant. I think it's true. We objectify people in the DSM and then we think that those reifications correspond to reality or we have to make them correspond to clinical realities when in fact, you know, to really get a feel for a person, you have to Let their story impact you, feel what it stirs up in you, hear the themes, the music behind, just the notes.

Nancy McWilliams

Yeah.

Nancy McWilliams

Yeah. Okay.

Nancy McWilliams

Yeah.

Nancy McWilliams

Well, since you mentioned the fear system, let me take on the DSM in one other way. One of the problems of what they were trying to do, namely describe symptoms by... present versus absent observable phenomena. It meant that anxiety, for example, was treated as one thing. If you have sweaty palms and rapid heartbeat and you describe a feeling of apprehension, you have an anxiety disorder. It doesn't invite you to ask what kind of anxiety.

Up until we started diagnosing that way, There was, in the clinical literature, the notion that there were several different kinds of anxiety. Most dominantly, separation anxiety was very different from annihilation anxiety. But there was also anxiety about the integrity of the body. Some people called that castration anxiety, but it could involve any body damage. Moral anxiety, when you're afraid you're going to break your moral code. Signal anxiety, when in the past this has meant danger.

So, I'm keeping an eye out now. Post-traumatic anxiety, oh my god, this is just like Vietnam or whatever. So, we wanted to know the meaning of anxiety. It turns out that it's really bad to just define anxiety disorders based on externally observable stuff because there are two different anxiety centers in the brain. One of them is Panksepp's fear system, and the other is what he calls the panic-grief system, which is the attachment system.

In any young mammal, if you separate them from the parent and usually the mother mammal, they emit a particular separation cry. The same part of their brain lights up on an fMRI as lights up in the mother animal. If you insist on keeping them separate, you see, first of all, a great deal of anxiety in the child, also in the mother, by the way. And eventually... you see the searching kind of behavior.

You can see it in monkeys, you can see it in rats, you can see it in dogs, every mammal that's been studied. And then you see depression, that it finally, the animal begins to look like there's no hope. That's the attachment system. And that is mediated, among other things, by serotonin. So the SSRIs are helpful with anxiety and depression that results from separation anxiety and depression. But there's also in the brain the fear system.

It's in a different part of the brain. It's not mediated by serotonin. Unfortunately, what calms it are the benzos and the downer drugs. which is why people with paranoid personality, which is dominated much more by annihilation anxiety, the fear of being destroyed, than it is by separation anxiety, the fear of being alone. If you're afraid of being destroyed, this system in the brain seems to be the legacy of our evolutionary worry about predation, that some predator is going to eat us.

That system is calmable by alcohol and the benzos and the downer drugs, and that's why I think a lot of our patients with paranoid personality styles have secondarily substance use disorders with the barbiturates and other drugs that calm that system. So that has implications even for medicating patients, not just for psychotherapy, to try to understand the meanings of anxiety, not just the manifestations of anxiety. So end of that sermon.

But back to paranoia. Paranoia is very much about fear and also shame and humiliation. And it involves often ways of trying to manage fear by figuring out where the danger comes from and to avoid humiliation. There's usually a fair amount of shaming in the history of People with paranoid tendencies, their strengths involve being very acutely aware of their environment, often picking up stuff before the rest of us do.

There's usually a grain of truth in even crazy paranoid ideas. They often get the affect right in other people, but the meaning wrong. So, for example, if a paranoid patient sees me frown, they'll assume I'm angry at them. I may have just remembered that I owe my taxes and I forgot that I have to work on them tonight. So they'll say, you're mad at me. But they've got the affect right.

They read the face right. Having a streak of paranoia is very adaptive in certain professions, and those professions attract people with some paranoid tendencies. Police work, detective work, some elements of military work where you have to worry about where the danger is coming from next. The defenses that they use are disavowal of something in the self and seeing it as coming from outside. So it's not like there's some kind of ordinary badness in me.

I think that they feel too much, they've been shamed too much to own that. So instead, they feel like it's going to come at them from outside. So persecutory paranoia is, I'm not the person who's hostile or aggressive. I'm in danger of being treated with hostility and aggression. Or erotomania, which is a paranoid phenomenon. disorder where you believe that some celebrity or somebody who is idealizable is really in love with you.

It's a disavowal of your own need and desire and seeing it as, well, you behaved so seductively. You wanted me. Jodie Foster wanted John Hinckley to try to assassinate the president because she was really in love with him. That's a paranoid disavowal of a different set of things or paranoid hatred. where you hate parts of yourself, you can't acknowledge that they are parts of yourself, and you attribute them to an out-group or another person.

It's black people who are shiftless and lazy. I'm never shiftless and lazy. Or it's women who are always trying to control. I have no needs to control. The outgroups are infinite, and this is a time-honored way of handling things that we don't want to see in ourselves, is to figure out who to blame. That's essentially a paranoid attitude. I like working with paranoid people in psychotherapy. They're very sensitive people.

They've often suffered a great deal, but it's also delicate work because you can't say to them, do you think you're projecting? You can't interpret the defenses. What the therapy has to consist of is trying to help them be more comfortable with parts of the self that they need to disown and project rather than to just show them how they're dealing with those parts of the self. So I think with paranoid patients, I tend to be more self-disclosing because I want to model somebody who's okay with being wrong, being flawed, being needy, being angry, being tearful, and so forth.

And there's something very poignant about their struggle, because they tend to have both separation anxiety and annihilation anxiety. And when they are by themselves, they don't quite know who they are. They tend to have been treated, and paranoia runs in families like many things. If you've got a parent who had to disavow badness and put it in the kid, or picked one kid to be the bad kid in the family and is always telling the kid, you're jealous, you're stupid, all the things the parent doesn't want to admit in the self, they put in the kid.

The kid ends up feeling, my parent is always critical of me. I'm just bad. But I'm very important to them. If you need somebody to be a bad object, you need them a lot. So parents of paranoid people tend to discourage separation and individuation because they need the kid to be the receptacle of all the stuff they're disowning. If you've ever worked with parents to try to help them with their kids who have behavior problems, most parents are happy for you to suggest that.

some way of dealing with the kid that might elicit better behavior. But a certain minority of parents will say, you don't get it. He's bad. He's incorrigible. And you get the sense of their investment in this kid being bad. So paranoid people have been fused with in a toxic way. and not encouraged to be separate. In fact, they've often been told that the only people you can trust are your family, when in fact the family members aren't very trustable at all.

So they feel scared to be alone, but they're also afraid of being destroyed. So they suffer more than many people. And of course, in psychotic versions of paranoia, they suffer terribly. One of the reasons that the neuroleptics help psychotic people is that they are huge anti-anxiety drugs. They reduce terror and sometimes allow for more clear-headedness. Anything else you want me to say about paranoia?

Nancy McWilliams

Well, the same dynamics in a family that would create a paranoid child of the parents being arbitrary, unreliable, not treating you like a separate person, treating you more like an object or something. If those are operating in your culture, it creates a paranoiogenic atmosphere. Most of us can probably recall some organization we were in at one point where we felt the authorities were too distant, too arbitrary, too capricious, or had a shtick against us because of some reason we couldn't understand.

And it makes you paranoid. You begin looking for, how are they going to get me next? And Otto Kernberg wrote a rather funny article about paranoia atmospheres in psychoanalytic institutes. Because when you feel like everybody's evaluating you in a small community to see whether you're good enough and they're going to find every flaw that you have, that... That's a recipe for paranoia. So under those circumstances, anybody becomes paranoid.

That's another objection to diagnosing people based on externally observable features. If I'm an immigrant and I'm undocumented and I'm working for a boss who tells me I get paid well below the minimum wage and if I complain to anybody they're going to report me to... The immigration authorities, I'm going to get pretty paranoid, but it's not because I have a paranoid personality. It's because I'm in a situation where it's paranoiogenic.