Paranoid disorders have a concrete and pervasive delusional system, usually persecutory. Projection is a chief defense mechanism of this disorder.

1. CONCEPTS AND PRINCIPLES RELATED TO PARANOID DISORDERS:
1. Delusions are attempts to cope with stresses and problems.
2. May be a means of allegorical or symbolic communication and of testing others for their trustworthiness.
3. Interactions with others and activities interrupt delusional thinking.
4. To establish a rational therapeutic relationship, gross distortions, misorientation, misinterpretation, and misidentification need to be overcome.
5. People with delusions have extreme need to maintain self-esteem.
6. False beliefs cannot be changed without first changing experiences.
7. A delusion is held because it performs a function.
8. When people who are experiencing delusions become at ease and comfortable with people, delusions will not be needed.
9. Delusions are misjudgments of reality based on a series of mental mechanisms: (a) denial, followed by (b) projection and (c) rationalization.
10. There is a kernel of truth in delusions.
11. Behind the anger and suspicion in a person who is paranoid, there is a person who is lonely and terrified and who feels vulnerable and inadequate.
2. ASSESSMENT of paranoid disorders:
1. Chronically suspicious, distrustful (thinks "people are out to get me").
2. Distant, but not withdrawn.
3. Poor insight; blames others (projects).
4. Misinterprets and distorts reality.
5. Difficulty in admitting own errors; takes pride in intelligence and in being correct (superiority).
6. Maintains false persecutory belief despite evidence or proof (may refuse food and medicine, insisting he or she is poisoned).
7. Literal thinking (rigid).
8. Dominating and provocative.
9. Hypercritical and intolerant of others; hostile, quarrelsome, and aggressive.
10. Very sensitive in perceiving minor injustices, errors, and contradictions.
11. Evasive.
3. ANALYSIS/NURSING DIAGNOSIS:
1. Altered thought processes related to lack of insight, conflict, increased fear and anxiety.
2. Severe anxiety related to projection of threatening, aggressive impulses and misinterpretation of stimuli.
3. Ineffective individual coping (misuse of power and force) related to lack of trust, fear of close human contact.
4. Impaired cognitive functioning related to rigidity of thought.
5. Chronic low self-esteem related to feelings of inadequacy, powerlessness.
6. Impaired social interaction related to lack of tender, kind feelings, feelings of grandiosity or persecution.
4. NURSING CARE PLAN/IMPLEMENTATION in paranoid disorders:
1. Long-term goals: gain clear, correct perceptions and interpretations through corrective experiences.
2. Short-term goals:
1. Help client recognize distortions, misinterpretations.
2. Help client feel safe in exploring reality.
3. Help client learn to trust self; help to develop self-confidence and ego assets through positive reinforcement.
4. Help to trust others.
1. Be consistent and honest at all times.
2. Do not whisper, act secretive, or laugh with others in client's presence when he or she cannot hear what is said.
3. Do not mix medicines with food.
4. Keep promises.
5. Let client know ahead of time what he or she can expect from others.
6. Give reasons and careful, complete, and repetitive explanations.
7. Ask permission to contact others.
8. Consult client first about all decisions concerning him or her.
5. Help to test reality.
1. Present and repeat reality of the situation.
2. Do not confirm or approve distortions.
3. Help client accept responsibility for own behavior rather than project.
4. Divert from delusions to reality-centered focus.
5. Let client know when behavior does not seem appropriate.
6. Assume nothing and leave no room for assumptions.
7. Structure time and activities to limit delusional thought, behavior.
8. Set limit for not discussing delusional content.
9. Look for underlying needs expressed in delusional content.
6. Provide outlets for anger and aggressive drives.
1. Listen matter-of-factly to angry outbursts.
2. Accept rebuffs and abusive talk as symptoms.
3. Do not argue, disagree, or debate.
4. Allow expression of negative feelings without fear of punishment.
7. Provide successful group experience.
1. Avoid competitive sports involving close physical contact.
2. Give recognition to skills and work well done.
3. Use managerial talents.
4. Respect client's intellect and engage him or her in activities with others requiring intellect (e.g., chess, puzzles, Scrabble).
8. Limit physical contact.
9. Health teaching: teach a more rational basis for deciding whom to trust by identifying behaviors characteristic of trusting and people who are trustworthy.
5. EVALUATION/OUTCOME CRITERIA: able to differentiate people who are trustworthy from untrustworthy; growing self-awareness, and able to share this awareness with others; accepting of others without need to criticize or change them; is open to new experiences; able to delay gratification.