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.