The Case Study - Paranoid Personality Disorder case PDF

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Paranoid Personality Disorder case ...

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Paranoid Personality Disorder This case study is based on personal, rather than clinical, experience. Joe Fuller was in treatment for a brief period of time, but he terminated the relationship well before a therapy plan was formulated. This pattern is, in fact, characteristic of this type of person; people who are paranoid seldom seek professional serv- ices and, when they do, are difficult to work with. One of the authors was well acquainted with Joe during high school and college and has stayed in contact with him throughout subsequent years.

Social History Joe was the third of four children. He had two older brothers and a younger sis- ter. His father was a steamfitter, and his mother was a homemaker. The family lived in a lowermiddle-class neighborhood in a large, northeastern city. Joe’s grandmother also lived with them, beginning when Joe was 11 years old. She was an invalid and could not care for herself after Joe’s grandfather died. Our first information about Joe comes from his high school years. Unlike his older brothers, Joe was an exceptionally bright student. On the basis of his performance in elementary school and entrance examinations, he was admitted to a prestigious public high school. The school was widely recognized for academic excellence. More than 90% of the graduating seniors went on to college; most went to Ivy League schools. The school was also known as a “pressure cooker.” All of the students were expected to meet very high standards; those who failed were denigrated by their peers. Joe thrived in this intellectually competitive environment. He usually received the highest test scores in his classes, particularly in science. These achievements were based on a combination of intelligence and hard work. Joe was clearly very bright, but so were most of the other students in this school. Joe was a serious student who seemed to be driven by a desire to succeed. Although many of the other students worried about examinations and talked to one another about their fear of failure, Joe exuded self-confidence. He knew that the teachers and other students viewed him as one of the best students; he often made jokes about people who “couldn’t make the grade.” This critical attitude was not reserved for other students alone. Whenever a teacher made a mistake in class, Joe was always the first to laugh and make a snide comment. His classmates usually laughed along with him, but they also noticed a sneering, condescending quality in Joe’s humor that set him apart from themselves. Joe was a classic example of the critic who could “dish it out but couldn’t take it.” He was extremely sensitive to criticism. It did not seem to matter whether the criticism was accurate or justified; Joe was ready to retaliate at the slightest provocation. He argued endlessly about examinations, particularly in mathematics and science classes. If he lost points on any of his answers, even if he had gotten an “A” on the exam, he would insist that his answer was correct, the question was poorly written, or the teacher had not adequately explained the topic prior to the exam. He never admitted that he was wrong.

His sensitivity was also evident in interpersonal relationships. Most people are able to laugh at themselves, but Joe could not. His family background was a particularly sore spot. Many of the other students in his school were from wealthy homes. Their parents were mostly professionals with advanced degrees. Joe seemed to be self-conscious about his father’s lack of formal education and the fact that his family did not live in a large, modern house. He never admitted it openly, but the topic led to frequent arguments. The following example was a typical instance of this sort. Joe had been arguing in class about his grade on a chemistry examination. After class, he overheard another student say to one of his friends, “I don’t know why some people have to work so hard for everything.” The other boy’s father happened to be a successful businessman. Joe took his comment to mean that Joe was trying to compensate for the fact that his family did not have a lot of money. This implied insult, which may or may not have been a simple comment about Joe’s aggressive behavior, infuriated him. Two nights later, while everyone else was watching a school basketball game, Joe sneaked out into the parking lot and poured sugar into the gas tank of the other boy’s car so that the engine would be ruined. Joe did not participate in organized sports or student organizations, and he tended to avoid group activities. He did have a small circle of friends and was particularly close to two other boys. They were people whom he had judged to be his intellectual equals, and they were the only people in whom he could confide. He was interested in women, but his attitude toward them and his interactions with them struck his friends as being somewhat odd. The issues of dependence and control seemed to be of central importance to Joe. Whenever one of his friends spent a lot of time with a girlfriend or went out with her instead of a group of guys, Joe accused him of being spineless or “on a tight leash.” Joe seldom dated the same woman twice. He usually insisted that she was weird or boring, but, if the truth were known, most of them would not have gone out on another date with him if he had asked. They found Joe to be rude and arrogant. He was not interested in being friends; his sole purpose was to make a sexual conquest. He often bragged about having sex with many women, but his closest friends suspected that he was still a virgin. In most respects, Joe’s relationship with his family was unremarkable. They were not a tight-knit family, but he respected his parents and got along well with his older brothers and his sister. His principal problem at home centered on his grandmother, whom he hated. He complained about her continuously to his friends, saying that she was old and crippled, and he wished that his par- ents would ship her off to a nursing home. Her inability to care for herself and her dependence on Joe’s parents seemed to be particularly annoying to him. He noted on several occasions that if he was ever in a similar situation, he hoped that someone would put him out of his misery. After graduating from high school, Joe enrolled at an Ivy League university, where he majored in chemistry and maintained a straight-A average through- out his first 2 years. He seemed to study all the time; his friends described him as a workaholic. Everything he did became a preoccupation. If he was study- ing for a particular course, he concentrated on that topic day and night, 7 days a week. If he was involved in a

laboratory project, he practically lived in the laboratory. Relaxation and recreation were not included in his schedule. Even if he had the time, there were few leisure activities that Joe enjoyed. He had never been particularly athletic and was, in fact, clumsy. He hated to lose at any- thing and was also afraid of being ridiculed for looking awkward, so he avoided sports altogether. Joe’s first steady relationship with a woman began during his sophomore year. Carla was a student at a small liberal arts college in upstate New York. They happened to meet at a small party while she was visiting friends in New York City. Several weeks later, Joe drove to spend the weekend with her. They continued to see each other once or twice a month throughout the spring semes- ter. From Joe’s point of view, this was an ideal relationship. He liked Carla; she shared his sarcastic, almost bitter, sense of humor, and they got along well sexu- ally. Perhaps most important, the fact that she was not in the same city meant that she could not demand a great deal of his time and could not try to control his schedule or activities. The relationship ended after a few months when Carla told Joe that she had another boyfriend. Although he was shocked and furious, he made every effort to seem calm and rational. He had always taken pride in his ability to avoid emo- tional reactions, particularly if they were expected. In discussing the situation with friends, Joe maintained that he had never really cared for Carla and said that he was interested only in her body. Nevertheless, he was clearly interested in revenge. His first plan was to win her back so that he could then turn the tables and drop her. Presumably this process would demonstrate to everyone that he, not Carla, had been in control of the relationship. When this effort failed, he set- tled for spreading rumors about Carla’s promiscuous sexual behavior. After his breakup with Carla, Joe became more deeply involved in his laboratory work. He would disappear for days at a time and seldom saw any of his friends. The experiments he was running were apparently based on his own ideas. His assigned work and routine studying were largely ignored; conse- quently, his academic performance began to deteriorate. The experience with Carla also contributed to an increase in Joe’s already cynical attitude toward women. He described her behavior as treacherous and deceitful and took the rejection as one more piece of evidence proving that he could not trust anyone, particularly a woman. He continued to go out on dates, but he was extremely suspicious of women’s intentions and obviously jealous of their attention to other men. On one occasion, he went to a party with a woman he met in one of his classes. They arrived together, but Joe chose to ignore her while he chatted with some male friends in the kitchen. When he later discov- ered his date talking with another man in the living room, he became rude and offensive. He insulted the woman, made jokes about her clothes and the makeup she was wearing, and suggested that her friend was gay. As might be expected, they never saw each other again. Another time, after he had dated a woman once, he sat in his parked car outside her apartment and watched the entrance for 2 nights to determine whether one of his friends was also seeing her.

Later Adjustment After receiving his B.S. degree, Joe stayed on at the same university to do grad- uate work in biochemistry. He continued to work very hard and was consid- ered one of the most promising students in the department. His best work was done in the laboratory, where he was allowed to pursue independent research. Classroom performance was more of a problem. Joe resented being told what to do and what to read. He believed that most faculty members were envious of his intellect. Highly structured reading lists and laboratory assignments, which were often time consuming, were taken by Joe to be efforts to interfere with his pro- fessional advancement. In his second year of graduate school, Joe began dating an undergraduate woman in one of his study sections. Ruth was unremarkable in every way. His friends described her as plain, bland, and mousy. They were surprised that Joe was even interested in her, but in retrospect, she had one general feature that made her perfect for Joe—she was not at all threatening. He made all the deci- sions in the relationship, and she acquiesced to his every whim and fancy. Other men were not interested in her. In fact, they seldom noticed her, so Joe did not have to remain constantly alert to the possibility of desertion. They were perfect complements to each other and were married within a year. Joe’s first job after getting his Ph.D. was as a research chemist for a major drug company. At the beginning, it seemed like an ideal position. He was expected to work somewhat independently doing basic biochemical research. There was no question that he was intellectually capable of the work, and his willingness to work long hours would be beneficial to his advancement, which was closely tied to productivity. Joe expected to be promoted rapidly and was confident that he would be the head of a division within 5 years. When Joe began working in the company laboratory, he quickly evaluated all the employees and their relationship to his own position. There were several young Ph.D.s like himself, three supervisors, and the head of the laboratory, Dr. Daniels, a distinguished senior investigator. Joe admired Dr. Daniels and wanted to impress him. He did not think much of his young colleagues and particularly resented the supervisors, whom he considered to be his intel- lectual inferiors. He believed that they had been promoted because they were “yes-men,” not because they were competent scientists. He often complained about them to his peers and occasionally laughed openly about their mistakes. When they asked him to perform a specific experiment, particularly if the task was tedious, he was arrogant and resentful, but he usually complied with the request. He hoped that the quality of his work would be noticed by Dr. Daniels, who would then allow him to work more independently. He also worried, how- ever, that the others would notice that he was being subservient in an effort to gain Dr. Daniel’s favor. He became more and more self-conscious and was con- stantly alert to signs of disdain and rejection from the others in the laboratory. The others gradually came to see him as rigid and defensive, and he eventually became isolated from the rest of the group. He interpreted their rejection as evi- dence of professional jealousy.

Joe’s initial work did gain some recognition, and he was given greater independence in his choice of projects. He was interested in the neurochemical basis of depression and spent several months pursuing a series of animal experiments aimed at specific details of his personal theory. Very few people knew what he was doing. He refused to discuss the research with anyone other than Dr. Daniels. Even then, he was careful to avoid the description of procedural details. His principal concern was that other people might get credit for his ideas. He wanted to impress Dr. Daniels, but he also wanted to take over Dr. Daniels’s job. The quickest way to do that was to make a major breakthrough in the laboratory, one for which he alone would receive credit. Dr. Daniels and the other supervisors recognized that Joe was exception- ally bright and a talented, dedicated scientist. They liked his early work at the company but were dissatisfied with the independent work that he was pursu- ing. There were no immediate, practical implications to this line of research, and it did not promise to lead to any commercial results in the near future. Consequently, Joe was told that his work was not acceptable and that he would have to return to doing work that was more closely supervised. Joe’s response to this criticism was openly hostile. He complained bit- terly about the imbeciles in company management and swore that he would no longer tolerate their jealousy and stupidity. He was certain that someone had learned about his ideas and that Dr. Daniels and the others were trying to force him out of the company so that they could then publish the theory without giving him credit. Their insistence that he discontinue his work and return to more menial tasks was clear proof, from Joe’s point of view, that they wanted to slow down his progress so that they could complete the most impor- tant experiments themselves. His paranoid ideas attracted considerable atten- tion. Other people began to avoid him, and he sometimes noticed that they gave him apprehensive glances. It did not occur to him that these responses were provoked by his own hostile behavior. He took their behavior as further evidence that the whole laboratory was plotting against him. As the tension mounted, Joe began to fear for his life. The situation soon became intolerable. After 3 years with the firm, Joe was told that he would have to resign. Dr. Daniels agreed to write him a letter of reference so that he could obtain another position as long as he did not contest his termination. Joe considered hiring a lawyer to help him fight for his job, but he became convinced that the plot against him was too pervasive for him to win. He also had serious doubts about being able to find a lawyer he could trust. He therefore decided to apply for other positions and eventually took a job as a research associate working with a faculty member at a large state university. ew position was a serious demotion. His salary was considerably less than it had been at the drug company, and the position carried much less prestige. Someone with Joe’s academic credentials and experience should have been able to do better, but he had not published any of his research. He was convinced that this lack of professional success could be attributed to interference from jealous, incompetent administrators at the drug company. A more plausible explanation was that his work had

never achieved publishable form. Although the ideas were interesting, and his laboratory techniques were technically skillful, Joe was not able to connect the two facets of his work to produce conclusive results. He was also a perfectionist. Never satisfied with the results of an experiment, he insisted on doing follow-up after follow-up and could not bring himself to consider a piece of work finished. The thought of sub- mitting an article and having it rejected by a professional journal was extremely anxiety provoking. Thus, despite his recognized brilliance and several years of careful research, Joe was not able to land anything better than this job as a research associate. Joe did not like the new job, partly because he thought it was beneath him and also because his activity was even more highly structured than it had been at the drug company. He was working on a research grant in which all the experi- ments had been planned in advance. Although he complained a good deal about the people who had ruined his career and expressed a lack of interest in the new line of work, he did highquality work and was tolerated by the others in the lab- oratory. The salary was extremely important to Joe and Ruth because they now had a young daughter, who was 2 years old. There were also some other features about the job that were attractive to Joe. Much of his work was planned, but he was allowed to use the laboratory in his spare time to pursue his own ideas. It was an active research program, and the department included a number of well-known faculty members. Joe believed that these people, particularly his boss, Dr. Willner, would soon recognize his talent and that he would eventually be able to move into a faculty position. Things did not work out the way Joe had planned. After he had been work- ing at the university for 1 year, Dr. Willner asked him to curtail his independ- ent research. He explained that these outside experiments were becoming too expensive and that the main research funded by the grant would require more of the laboratory’s time. Joe did not accept this explanation, which he consid- ered to be an obvious excuse to interfere with his personal work. He believed that Dr. Willner had pretended to be disinterested in Joe’s work while he actually kept careful tabs on his progress. In fact, he took this interference to indicate that Dr. Willner believed Joe’s research was on the verge of a breakthrough. Joe continued to work independently when he had the opportunity and became even more secretive about his ideas. Several weeks after these developments, Dr. Willner hired another research associate and asked Joe to share his office with the new person. Joe, of course, believed that the new person was hired and placed in his office solely to spy on his research. As the tension mounted at work, Joe’s relationship with Ruth became severely strained. They had never had a close or affectionate relationship and now seemed on the verge of open conflict. Ruth recognized that Joe was overre- acting to minor events. She did not want him to lose another job. She often tried to talk rationally with him in an effort to help him view these events from a more objective perspective. These talks led to arguments, and Joe finally accused her of collaborating with his enemies. He suggested that the people from the drug company and from the university had persuaded her to help them steal his ideas and then get rid of him. As Joe became more paranoid and belligerent, Ruth became fearful for her own safety and for that of her daughter. She

eventually to...