Childhood Precursors of the Paranoid-Depressive Disorder

CHILDHOOD PRECURSORS OF THE PARANOID-DEPRESSIVE DISORDER THOMAS P. MILLAR* The Paranoid Picture There is a tendency for psychiatric diagnostic terminology to be adopted by semiprofessionals and lay persons and used so loosely that items eventually lose their categorizing value; the term "learning disability " is now applied to any child any teacher has trouble teaching, and "anorexia" to any capricious adolescent eater. This has been happening to the category of paranoid disorder for a long time. Even so, experienced clinicians recognize a core constellation of characteristics that constitutes paranoid mentation whether this picture is associated with schizophrenia or paranoia or is part of a neurotic picture . What is this paranoid picture everybody knows? It has three characteristics about which few would argue. The paranoid person is suspicious. He feels no assurance of the goodwill of others toward himself. He is constantly on the alert for signs of malice toward him. His suspicion is pathological because it has a minimal reality base. Looking at suspicion from the other side, we may appropriately say that the paranoid lacks normal trust. Second, the paranoid regularly misinterprets events as having reference to himself. When persons smile, he wonders whether they are laughing at him. When the action of others causes him pain, he is sure this was their intent. He interprets events solely in terms of their effect on him. Though he develops an acute perceptivity with respect to the This paper was presented at the annual meeting of the North-Pacific Society of Neurology and Psychiatry, Seattle, March 28, 1987. *Address: Suite 23, 659 Clyde Avenue, West Vancouver, British Columbia V7T 1C8, Canada.©1989 by The University of Chicago. AU rights reserved. 0031-5982/89/3204-0645$01 .00 Perspectives in Biology and Medicine, 32, 4 ¦ Summer 1989 \ 539 actions of others, he has no capacity to empathize their motives and regularly misreads them in terms of self. Again, to approach the matter from the other side, the paranoid has retained the egocentricity normal in the three- or four-year-old, has somehow failed to acquire the capacity to shift his point of view temporarily to that of another and then back to self, in order to read the world as it is. He cannot decenter socially—to adapt Piaget's concept of cognitive decentering to the interpersonal arena [I]. The third regularly reported quality of the paranoid is his sometimes covert, sometimes up-front unrealistic conviction of his own superiority. Again, one must stress the unrealistic nature of this assessment of self. If Einstein believed he was a great intellect, such could hardly be deemed paranoid grandiosity. However, the paranoid has a secret; it is that he is somehow special, somehow better than or in some way superior to ordinary persons. He is determinedly lacking in humility and will not accept an ordinary humanity . The price he pays for his unreal appreciation of self is a deep alienation that renders him friendless in the world. These characteristics, unwarranted suspiciousness and lack of trust, self-centered arrogance coupled with ideas of reference and a more or less overt conviction of superiority, are the basic characteristics of the clinical pattern we call paranoid. If one is dealing with a psychotic individual, the picture is deepened and embroidered by the additional psychopathology. And, as those cases uncomplicated by psychosis become chronic, the picture is again embroidered by the individual's efforts to maintain his security in a world that he believes has no goodwill toward him. Much has been written about the paranoid condition, but surprisingly little attention has been paid to the childhood precursors of the disorder. The emphasis has been on an increasing dissatisfaction with the present state of dynamic understanding of these patients. Zigler and Glick [2] have recently provided us with a comprehensive review of this literature. While they primarily address themselves to providing a revised view of the nature of paranoid schizophrenia, they do review the adult literature extensively. Their survey reveals that, while Freud's attribution of paranoid disorder to repressed homosexuality has been widely discredited, little has been added to the essential picture of the adult nonpsychotic paranoid, with one exception— a number of observers have reported an...