Consult-Liaison Education Medicine

Personality Disorders (III): Paranoid.

Now that we are familiar with the three clusters of personality disorders, let us begin with cluster A. The first is paranoid personality disorder.

A few things to keep in mind when discussing paranoid personality disorder:

  1. Medical professionals seldom see people with this condition in clinical settings. Individuals with paranoid personality disorder generally don’t want to see us, so we have few opportunities to learn about and from them. Because of this, there is limited data on this condition and what interventions (if any) are useful.
  2. Paranoid personality disorder (as with most personality disorders) is considered “egosyntonic”. This is the fancy way of saying that people with this condition don’t find their thoughts, behaviors, or emotions distressing. No conflict exists between who they believe they “should be” and who they actually “are”.
  3. DSM adopts a fairly behavioral approach when describing symptoms of this condition. The authors make no attempt to explain why certain thoughts and behaviors came to be.[1. To be clear, there are many psychiatrists (most of whom have a psychodynamic perspective) who have attempted to explain the underpinnings of personality disorders, though these explanations are difficult to validate. It is difficult to apply the scientific method to the “unconscious”.] Again, this explains why the diagnostic criteria are something like “ordering from a Chinese menu”.

Here are the verbatim DSM-4 diagnostic criteria for paranoid personality disorder:

A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

You can already see why these individuals often lead solitary lives.

(1) suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her

These suspicions are generally within the realm of possibility. For example, someone with this condition might worry, “I don’t trust my boss—he says everything is fine, but I know he’s looking for reasons to fire me. I do my work like I should and he knows it. He just wants me out of here.”

Contrast that with someone who says, “I don’t trust my boss—he says everything is fine, but I know he’s trying to steal all of my bones. Every payday, I see how he looks at me. He thinks he’s God: He wants to use one of my ribs so he can create something new.”

(2) is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates

“You got me a birthday gift? Why? What am I supposed to do with this restaurant gift certificate? Are you regifting? Did the health department give this place a low rating? You don’t even like sushi—are you hoping that I’ll get sick?”

(3) is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her

“When is your birthday?”

“Why do you need to know that?”

“So I can send you a gift.”

“Or so you can steal my identity. I’m onto you.”

(4) reads hidden demeaning or threatening meanings into benign remarks or events

“I hope you have a happy birthday.”

“What do you mean by that? Is something going to happen the next day that will make me unhappy?”

(5) persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights

“He calls himself my ‘friend’. It’s convenient how he forgot that my stomach didn’t feel good after that meal at the sushi restaurant three years ago.”

(6) perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack

“I hope you have a happy birthday.”

“Are you saying that I’m not a happy person? Who are you to judge? I don’t see you smiling all the time—you got pretty pissed off the other day when that bird crapped on your car. Don’t tell me to be happy when you get bent out of shape over how your car looks.”

(7) has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner

“My boss invited me and my girlfriend to the holiday party. Why did he invite her? What is she going to do with him?”

DSM also inserts a (long) caveat about cultural differences:

Some behaviors that are influenced by sociocultural contexts or specific life circumstances may be erroneously labeled paranoid and may even be reinforced by the process of clinical evaluation. Members of minority groups, immigrants, political and economic refugees, or individuals of different ethnic backgrounds may display guarded or defensive behaviors due to unfamiliarity (e.g., language barriers or lack of knowledge of rules and regulations) or in response to the perceived neglect or indifference of the majority society. These behaviors can, in turn, generate anger and frustration in those who deal with these individuals, thus setting up a vicious cycle of mutual mistrust, which should not be confused with Paranoid Personality Disorder. Some ethnic groups also display culturally related behaviors that can be misinterpreted as paranoid.

Every individual, however, has his own individual culture. It’s not difficult to imagine that someone of the cultural “majority” who experienced chronic trauma and mistreatment could still demonstrate behaviors consistent with paranoid personality disorder.

Certain conditions must be ruled out before one receives a diagnosis of paranoid personality disorder. These include paranoia due to drugs (like methamphetamine), medical conditions, or schizophrenia. Personality disorders are uncommon conditions and should be “diagnoses of exclusion”.

According to DSM-4, somewhere between 0.5% and 2.5% of the general population meet criteria for a diagnosis of paranoid personality disorder. According to this article, 4.4% of adults in the US meet criteria for paranoid personality disorder. (Please recall that personality disorders should not be diagnosed from a single meeting… like a survey.) Many sources indicate that men are more likely to meet criteria for paranoid personality disorder, though I have not seen any research data to support this.

Paranoid personality disorder is one of the few diagnoses that has been listed in DSM since its first version (1952), though my understanding is that it is not in DSM-5. Hopefully DSM-5 will explain this omission (though I suspect it is due to the dearth of research data about this condition).

When I actually present this topic formally, I anticipate I will only superficially cover cluster A personality disorders (with the possible exception of schizotypal personality disorder). In many ways, these conditions are not relevant to the work of the audience.

Consult-Liaison Education Medicine

Personality Disorders (II).

Now that we know how personality disorders are defined, we can discuss specific types of personality disorders.

DSM-4 divides personality disorders into three “clusters”: A, B, and C. These clusters are based on “descriptive similarities”. The authors make an important comment:

It should be noted that this clustering system, although useful in some research and educational situations, has serious limitations and has not been consistently validated.

This means that these “clusters” can be useful in theory, but may be irrelevant, illogical, and a bunch of hooey in application.

Furthermore, DSM comments:

… individuals frequently present with co-occurring Personality Disorders from different clusters.

(The world of cookies would be easier to understand if there were only butter, fruit, and nut cookies, but sometimes you end up with a platter of apricot and pistachio cookies, hamantash cookies, and shortbread and chocolate chip cookies.)

The language used to describe the clusters of personality disorders (and the personality disorders themselves) can be interpreted as criticism. Instead of recognizing the clustering system as a heuristic, people might overlook its “serious limitations” and assume that the clustering system provides definitions.

This can lead to the unfortunate practice of people saying things like, “He’s definitely personality disordered,” or “She’s such a borderline,” when, in fact, no personality disorder is present and people actually mean, “I’m getting so annoyed with that person”.[1. You feel what you feel. Own it. That will make you a more effective clinician. If you don’t acknowledge your own emotions, they will come out in some other way that might affect your behavior in ways you don’t like.]

You can see how this starts upon reading how most medical students learn about the three clusters of personality disorders:

“Here’s a mnemonic for the personality disorders. Remember the three ‘W’s: Weird, Wacky, and Worried. Cluster A is ‘weird’, cluster B is ‘wacky’, and cluster C is ‘worried’. That’ll help you keep the personality disorders straight on your shelf exam.”

So, after that entire preamble, here are the verbatim DSM definitions of the three clusters of personality disorders:

Cluster A includes the Paranoid, Schizoid, and Schizotypal Personality Disorders. Individuals with these disorders often appear odd or eccentric.

That’s where the “weird” comes from.

Cluster B includes the Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders. Individuals with these disorders often appear dramatic, emotional, or erratic.

And that’s where the “wacky” comes from.

Individuals with “cluster B traits” or personality disorders within this cluster most commonly come to clinical attention because their behaviors often cause distress both to themselves and those around them.

Cluster C includes the Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders. Individuals with these disorders often appear anxious or fearful.

And there’s “worried”.

I’m not a linguist, but it is easy to see here how the use of language can greatly affect the way we think about events, behavior, people, etc. When we distill personality disorders down to single words, we forget the other criteria for personality disorders (the “enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment”).

That mental shortcut can significantly affect how we treat patients with these conditions. This is why I try to remain vigilant in what words I use to describe patients both to myself and others.

Next: We’ll start going through the specific personality disorders and interesting data associated with them as I review the literature.

Consult-Liaison Education Medicine

Personality Disorders (I).

I’ve been asked to give a talk about personality disorders.[1. Writing about personality disorders here, I hope, will help me organize my talk and post more frequently.]

It’s akin to being asked to give a talk about cookies. (Do I discuss the distinctions between bar, drop, and sandwich cookies? Do people want to hear about the varieties of butter, fruit, and nut cookies? Should I compare cookies with other confections? What about the term “biscuit”?)

I suspect that part of the reason why I find the breadth of the subject daunting is because I’ve never given a talk on personality disorders. (I also prefer teaching certain topics, such as schizophrenia and suicide risk assessment. My training in dialectical behavior therapy (DBT), though, has helped me craft talks about difficult interactions with clinical settings and borderline personality disorder. DBT has also significantly influenced my clinical practice; I am grateful for the opportunity to learn about this early in my training.)

DSM-4[2. Yes, DSM-5 is now out—I am already behind.] provides the following criteria to define a personality disorder:

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture.

Personality disorders account for culture. This is why, in the United States, it is not considered aberrant when someone goes to church every Sunday because he believes that a crucified man was resurrected from the dead after three days in a tomb.

This pattern is manifested in two (or more) of the following areas:

Someone once commented that these diagnostic criteria are something like “ordering from a Chinese menu”. (No comment.)

(1) cognition (i.e., ways of perceiving and interpreting self, other people, and events)

“Cognition” can be summarized as “thoughts”.

(2) affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)

“Affectivity” can be summarized as “emotions”.

(3) interpersonal functioning

This refers to relationships (both “deep” and “not so deep”).

(4) impulse control

… or, “What someone does when they feel an urge: can he sit with it? does she feel compelled to react immediately? if she does react, what is the reaction?”

To be clear, just because someone waits a while before demonstrating a reaction to an event does not necessarily mean that his impulse control is “good” (consider someone who reacts by planning and then executing a murder).

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

This is how one of my teachers impressed this criterion upon me: Most of us have all of the personality disorders, not just one of them. This means that we have a variety of ways (thoughts and behaviors) of coping with stress. This suggests healthy coping.

If, for example, I hear bad news, I might go for a walk, spend time with friends, or eat a sack of cookies.

If my sole coping skill consisted of eating sacks of cookies at home, at work, with friends, and by myself, that could suggest an inflexible and pervasive pattern.

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The act of eating sacks of cookies probably won’t get me into too much trouble. If, however, I only talked about cookies, kept five sacks of cookies underneath my pillow “just in case”, insisted that my employer pay me in sacks of cookies, and refused to go out with my friends unless they took me to a bakery, that would probably lead to “significant impairment” in multiple areas of my life.

D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.

This is why we generally avoid a diagnosis of a personality disorder until someone is at least 18 years old, though brain “maturity” may not actually occur until someone is closer to age 25.

Some psychiatrists insist that they can diagnose a personality disorder after meeting someone once. I disagree.

E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.

If someone’s thoughts and behaviors are most consistent with a diagnosis of schizophrenia, then diagnoses of schizoid, paranoid, and schizotypal personality disorders do not apply.

F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).

A psychiatrist’s primary job is to rule out medical causes of a condition that appears psychiatric. (That is often easier said than done.)

If that is the general definition of a personality disorder, what about specific personality disorders? Should I discuss personality disorders discussed in ICD-10? What about the personality disorders described in previous editions of the DSM? (Only four have been present across all four editions of the DSM.) Where is the balance between theory (what the conditions are) and application (the function of the behaviors and how to work with people who have these conditions)?