What is Paranoid Personality Disorder (F60.0)?

By David Joel Miller.

There’s more than one kind of paranoia.

Fearfulness

Paranoia.
Photo courtesy of Pixabay.com

When you hear the word paranoid, most people think of the expression “paranoid schizophrenic.” Paranoia can be a part of several mental illnesses. Among the mental illnesses that include paranoia as a symptom Paranoid Personality Disorder is the most common. According to the DSM-5, estimates for the prevalence of Paranoid Personality Disorder range between 2.3% and 4.4 %. The estimate for all types of schizophrenia is between 0.3% and 0.7%. Since there are several types of schizophrenia, my rough estimate tells me Paranoid Personality Disorder is probably 10 times as common as paranoid schizophrenia.

Paranoia can also be a part of several other mental illnesses including, depression, bipolar disorder with psychotic features, other psychotic disorders, delusional disorder persecutory type. Suspicion and even paranoia may also be features cognitive dementia and substance use disorders.

There is also a condition known as “Subclinical paranoia” in which the person has milder forms of trust issues, suspicion, or paranoia. Symptoms that may cause them problems, but doesn’t quite meet all the criteria to be diagnosed as a specific mental illness. Professionals are beginning to believe that paranoia can exist on a continuum from occasional mild symptoms to the more persistent and serious symptoms that we see in those people diagnosed with Paranoid Personality Disorder.

Many cases of paranoid personality disorder do not get diagnosed. People with this disorder, whether in a mild form or more serious one, distrust others and believe people are out to harm them. As a result of these beliefs, they tend to avoid others, professionals in particular. Those with paranoid personality disorder are likely to only be diagnosed when they are involuntarily hospitalized for mental health issues or forced to be seen by professional because of criminal or legal issues.

How is Paranoid Personality Disorder diagnosed?

To receive the diagnosis of Paranoid Personality Disorder someone would need to exhibit the presence of at least four symptoms from a list of 7 possible symptoms. These symptoms involve suspiciousness, trust issues, beliefs that others are deliberately trying to harm them. The DSM calls for the symptoms to begin by early adulthood and happen in multiple contexts. This leaves us with a gray area in diagnosing paranoid symptoms which develop in senior citizens.

It’s easy to see that there can be a large mathematical number of combinations of having or not having the seven symptoms. My math tells me that there are over 5000 possible combinations of these symptoms with 840 of those combinations meeting criteria for a diagnosis of Paranoid Personality Disorder. Since we don’t have laboratory tests such as blood tests or x-rays to detect the symptoms, they are evaluated using symptom check-lists either from the patient’s reports or observations by others. Depending on how the client describes their feelings and the mood of the therapist’s that day it’s easy to call a particular symptom either in or out resulting in fuzzy diagnoses.

Many of these possible symptoms can vary in intensity. Deciding if someone has 3, 4, or 5 symptoms present can be very much a judgment call. Using more objective screening tools and checklists result in a large number of people who show some symptoms, but not enough to make the cut off for having Paranoid Personality Disorder. One commonly used instrument is the 20-question questionnaire, Paranoia Scale by Fenigstein and Vanable. Results from this scale vary from very low, occasional, symptoms of paranoid to extremely high and constant levels. In future posts, I want to talk about those people who fall in the middle of the score range on the paranoid scale, enough that they frequently experience trust issues and suspicion but don’t quite meet the cut off to be diagnosed with Paranoid Personality Disorder.

What are the 7 symptoms that may be present in Paranoid Personality Disorder?

  1. Being suspicious without good reason that others are trying to harm them, lie to them or take advantage of them. The presumption here is that the person can’t accurately perceive the actions of others. It can be difficult for the professional to determine whether these beliefs about others actions are accurate.
  2. They spend a lot of time thinking about their beliefs that others are not trustworthy, disloyal or have bad intentions.
  3. They do not trust anyone and avoid talking about their fears because of a belief that others will use what they say against them.
  4. They interpret normal, everyday events as threats or personal attacks.
  5. Holds onto the perceived attacks, may have grudges and be unwilling to forgive even accidental injuries because they believe others are deliberately trying to harm them.
  6. Gets angry and fights back because they believe others are attacking their character or reputation. The things they’re angry about most other observers don’t see as intentional attacks.
  7. Have unjustified suspicions that their regular sexual partner is unfaithful.

How does Paranoid Personality Disorder disrupt lives?

People with Paranoid Personality Disorder assume that others are out to get them. Sometimes these thoughts are totally unreasonable but other times there a matter of opinion or even experience. If someone has harmed you in the past, it’s not unreasonable to be on the lookout for other people seeking to harm you.

If your partner has cheated on you before, it’s hard to trust them again. Sometimes the mistrust makes sense but other times the injured spouse develops a persistent sort of paranoid jealousy, and no amount of checking will convince them that their partner is faithful.

People with varying levels of paranoid thoughts spend a lot of time doubting and worrying about whether the people around them are trustworthy and loyal. When you’re high in paranoia, you find it difficult to believe you can trust anyone.

Paranoia makes it harder to trust others and makes you reluctant to share personal information with others for fear they will use that information against you. They may be reluctant to answer personal questions and when asked to fill out forms may refuse to give answers to some questions saying that these things are “nobody’s business.” This high level of distrust leads them to believe that accidents were deliberate and that routine jokes were meant as personal criticism. The paranoid person is likely to take compliments as veiled insults.

There are some other characteristics of paranoia which aren’t included in the diagnostic criteria but are listed as associated features. It’s really hard to get along with people who have even moderate levels of suspicion and distrust. People who are high in paranoia are likely to be control freaks and have difficulty getting along with others.

Paranoid Personality Disorder is part of the “Cluster A Personality Disorders.” It’s common for people who are diagnosed with one of the Cluster A personality disorders to also have symptoms of several other personality disorders from this group.

Not everyone with trust issues gets diagnosed with Paranoid Personality Disorder.

As with the other things we are calling a mental illness this needs to interfere with your ability to work or go to school, your relationships, your enjoyable activities or cause you personal distress. Otherwise, you may have the issues, but you will not get the diagnoses if this is not causing you a problem. If the only time this happens is when you are under the influence of drugs or medicines, or because of some other physical or medical problem, this fear needs to be more than your situation would warrant. These other issue needs treating first; then if you still have symptoms, you could get this diagnosis.

In upcoming posts, we will look at the overlap between paranoia and substance use disorders, some possible causes for paranoia, some of the milder variations of fearfulness and trust issues as well as ways to reduce the impact of your trust issues on your ability to have a satisfactory life.

FYI These “What is” sometimes “What are” posts are my efforts to explain terms commonly used in Mental Health, Clinical Counseling, Substance Use Disorder Counseling, Psychology, Life Coaching and related disciplines in a plain language way. Many are based on the new DSM-5; some of the older posts were based on the DSM-IV-TR, both published by the APA. For the more technical versions, please consult the DSM or other appropriate references.

See Recommended Books.     More “What is” posts will be found at “What is.”

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life.

You can recover. You are cruising along the road of life and then wham, something knocks you in the ditch. If you have gone through a divorce, breakup, or lost a job, your life may have gotten off track. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel that explores the world of a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

Other books are due out soon; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on my writing projects, speaking and teaching, along with comments on recent news in the field of counseling – sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse and Co-occurring disorders see the about the author page or my Facebook author’s page, David Joel Miller. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

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Reasons to get mental health help now!

By David Joel Miller.

Some emotional problems need immediate attention.

Mental Health or Mental Illness

Mental Health or Mental Illness?
Photo courtesy of Pixabay.com

There are some mental and emotional problems that shouldn’t be ignored.  Sometimes people think that if they’d just wait, the problem will go away all on its own.  Other people believe that by asking for help and let the problem get control of them. Unfortunately, many serious emotional problems get worse if they’re not attended to.  When should you wait to see if the problem resolves itself?  Which are the times that you need to take immediate action?

Here is my list of the times when you shouldn’t wait to see if a mental or emotional problem will get better. If you or someone you know is having any of the problems listed below don’t wait, seek help immediately.

Suicidal thoughts.

When someone is having thoughts of killing themselves, you should take immediate action.  Some people believe that when a person talks about suicide they won’t really do it.  That just is not true.  If someone you know has mentioned their thoughts of suicide, now is the time to take action.  If you are having these thoughts reach out for help immediately. One good resource is:

National Suicide Prevention Lifeline at: 1-800-273-8255.

Paranoia.

Paranoia is defined as an unreasonable fear.  When someone is becoming more and more afraid of situations or people around them they are at risk.  Paranoid people may take actions that put themselves or others at risk.

Hallucinations.

There are lots of reasons people might have hallucinations.  Hallucinations are a lot more complicated than just hearing voices or seeing things.  In another post, I wrote about other types of hallucinations. Hallucinations can be caused by a mental illness.  They can also be caused by drugs, both street drugs, and prescription medications.  Some other types of hallucinations may indicate a medical emergency.  When someone is hearing voices or other sounds, seeing things, feeling things crawling on their skin, or having another perceptual distortion, there’s no time to lose in getting them help.

Self-harm.

Besides suicidal behavior, there are other types of Self-harm.  Some people do self-injurious behavior, like cutting or burning themselves as a way to regulate emotions.  The Self-harming behaviors can get out of hand.  By Self-harm, I am not talking about everyone who does something dangerous or disturbing to their families.  If someone is doing things to themselves with the clear intention of hurting themselves, they need help.

Racing thoughts.

Many people have episodes racing thoughts.  Most of that time these turn out to be worry or excitement over upcoming events.  But when someone begins to experienced racing thoughts on a recurring basis this needs to be looked at by a professional.

Impulsive behavior that is out of character.

Many people have times in their life when they do something impulsively.  But if this impulsive behavior is dangerous, reckless, and completely out of character for that person, this is the time that they need help.

Need to punish yourself.

Someone who develops a need to punish themselves is at risk.  It’s not uncommon for someone to make a mistake and then continue to beat themselves up, at least mentally about that mistake.  But if this self-punishment moves from being upset and reminding themselves not to do this act again, to active self-injurious self-punishing behavior, this person needs help.

Sudden unexplained changes in sleep and appetite.

Changes in sleep and changes in appetite are two of the diagnostic criteria for depressive disorders.  There can also be changes in sleep and or appetite in a number of other mental illnesses.  But when someone suddenly develops unexplained changes in sleep or their appetite they need to seek professional assistance.

Overwhelming fear or anxiety.

A certain amount of fear or anxiety when you are in a risky or dangerous situation is normal.  Many people experience overwhelming, uncontrollable fear and intense anxiety about the future.  These kinds of fears or anxieties can interfere with people’s ability to live life.  Anxiety disorders rarely go away on their own.

Serious loss of motivation.

Serious loss of motivation is likely to be a symptom of a developing or worsening mental illness.  When someone loses their motivation it’s time to seek assistance.

Extreme loss of pleasure.

Extreme loss of pleasure, sometimes called anhedonia, is one of the symptoms of a serious depressive disorder.  People who were unable to feel any happiness or pleasure are at higher risk to develop depression or another serious mental illness.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life.

You can recover. Your cruising along the road of life and then wham, something knocks you in the ditch. If you have gone through a divorce, break up, or lost a job your life may have gotten off track. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel that explores the world of a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

Other books are due out soon; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on my writing projects, speaking and teaching, along with comments on recent news in the field of counseling – sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse and Co-occurring disorders see the about the author page or my Facebook author’s page, David Joel Miller. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

Delusions are a leading cause of homicides; if you were delusional would you know?

By David Joel Miller.

What exactly is a delusion and why are they so hard to recognize beforehand?

One particular delusion has been implicated as a leading cause of homicides. Related delusions may also play a major role in other violent acts even though professionals have such a hard time recognizing them.

Delusions are one of those things like art or pornography we have a great difficulty in defining but we all think we will recognize it when we see it. Unfortunately, it often goes unrecognized until way too late.

While not necessarily a particular mental illness, Delusions are a symptom of a number of mental illnesses. In practice professionals rarely seem to pick out the delusion first. The person gets diagnosed with a particular mental illness and then the descriptor with delusions gets tossed in later like that tells us much about what is going on.

Some mental status exam forms and assessment forms include checkboxes to mark off delusions. Since deciding if someone is delusional is such an extreme judgment call, this decision often comes after the diagnosis not before. Also, note that the one delusion that results in many homicides is not usually included in the list of delusions that we are presented to check off.

The commonly considered delusions are, Paranoid, Grandiose, Religious, and Persecutory. Let’s look at these one at a time and see why they can be problematic. Some of these examples are slightly exaggerated and embroidered for effect. Can you tell which are which?

When paranoia is not a delusion.

A client told me that he was being followed; that the police were out to get him and that it was not safe to walk the streets. Clearly, he was sounding paranoid. On Monday I learned that he had been arrested after the police responded to a shooting at his house. The police were quick to respond as they were only a couple of blocks down. They had been watching his house. He was found in possession of a large quantity of drugs.

Was he paranoid? As I tell students in the substance abuse counseling program, if the client thinks people are watching him and he has a kilo of dope in the trunk of his car this is not paranoia, it is common sense.

How Grandiose is Grandiose.

If I told you that an African-American though he could run for president and have a chance of winning in this the 21 century that would sound Grandiose wouldn’t it?  And if that Black man was a first-term Senator from the mid-west – any psychiatrist worth his salt would know right off that this person was Grandiose.

Thank goodness no one told President Obama those things. Or if they did, it is a good thing that he did not listen. Whatever your political affiliation, it is clear that President Obama ought not to be diagnosed as Grandiose, not since he won anyway.

So it is not grandiosity if you are actually able to do something. This makes me nervous when I put down that someone is having grandiose delusions. How do I know for a fact that they are delusional? In my mind, any doubt goes to the client.

Your religion is delusional mine is doing what God wants.

All religions are based on Beliefs. They customarily urge you to act on faith and have belief. Unfortunately, they all seem to have a different group of these essential beliefs.

In mental health, if something occurs to you and most of the other people in your community think this is correct, we do not diagnose this as a mental illness.

If a Catholic believes that they see the Virgin Mary we let that go.
Where this becomes a problem is if you move to a country where no one believes in the Virgin Mary and now if you keep seeing her they can lock you up as delusional. That whole community values thing is a rabbit hole down which the truth can disappear in an instant.

If you are now thinking of sending me a nasty comment or e-mail about how far off I am about your religious beliefs please read the next section before hitting send.

Persecutory Delusions.

It is not persecutory if people are after you. Like paranoid this one is a matter of degree and judgment.

If you think that people are out to get you and then you start getting written death threats, that is probably not a persecution delusion.

This like all the others is a matter of fact and judgment.

Which major delusion is not on a lot of forms?

We don’t like to look for and may miss jealousy delusions. People who believe that their partner is cheating on them can and do frequently get violent. Sometimes after they shot or kill someone they discover that their partner was not in fact cheating on them but at the time the evidence looked to them like that partner was clearly cheating.

One article I read recently reported that someone killed a man he believed was cheating with the client’s wife. He was arrested. The victim now dead was clearly not having an affair with the client’s wife. This belief was called a delusion.

Later it came out that the wife was, in fact, having an affair, the client just got the identity of the man she was cheating with wrong.

Was he delusional? I let you decide that.

Certain groups are far more likely than others to be described as delusional. I worry that if you do not agree with the assessor you will get called delusional.

Say you are sent for an evaluation and the assessor is a member of the Church of the Religious Egg. They teach that you should cover yourself with plastic and surround yourself with plastic objects three times a day to meditate. You report that this whole idea is crazy. The assessor reports that you are having religious delusions because you believe in some other deity.

At this point who are we thinking is delusional?

Please do not misunderstand here. I do believe that people, with or without mental illness, can and do have delusions, some more bizarre than others. My point is that we need to be careful about what we call a delusion and what we let go.

So in some future posts, we will need to talk about the research on delusions and why certain groups get that label more often than other groups.

Until next time, stay happy.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life.

You can recover. You are cruising along the road of life and then wham, something knocks you in the ditch. If you have gone through a divorce, break up, or lost a job your life may have gotten off track. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel that explores the world of a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

Other books are due out soon; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on my writing projects, speaking and teaching, along with comments on recent news in the field of counseling – sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse and Co-occurring disorders see the about the author page or my Facebook author’s page, David Joel Miller. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

How to turn anxiety into paranoia

By David Joel Miller.

Some days it is a short trip from anxiety to paranoia.

The higher the volume is turned up on your anxiety control the greater the risk that this could lead to paranoia.

Some caveats here. In this context, I am not talking about one of the paranoia’s that are currently diagnosable as a mental illness. Most people say Paranoid-schizophrenia as if it was all one word. There are lots of people with schizophrenia that are not paranoid. There are also people who suffer from paranoid personality disorder who do not have schizophrenia.

This discussion is about people without those two diagnosable illnesses who have some feeling that looks like paranoia during the course of another illness or even without meeting criteria for a diagnosis. In other words, this is about the dictionary definition of paranoia not the DSM definition of a paranoid mental illness.

Yes, in my opinion, you can have paranoid thoughts and not have a mental illness with the word paranoia in it.

One definition of Paranoia is an unfounded, exaggerated or unreasonable distrust of others not based on facts. This is fear based and makes you question others motives.

Here is how a case of paranoia might begin.

You are very fearful, sensitive and worried about what others think of you. You have “trust issues” and are not sure if people are really your friends or might want to harm you.

People who have been victimized in the past are especially at risk for these kinds of trust issues and for good reason. They have been harmed by someone in the past and may feel that they were too trusting.

One day this anxious person, let’s call her Annid. This is one of those made up names contracted from her mother’s name Ann and her father’s name, David. I don’t know an Annid or an Ann and David combination so I think I am safe here.

One day Annid is walking down the street and she hears footsteps behind her. She walks faster but the footsteps are still there. She looks over her shoulder and there is someone there. Let’s make this person a man. She is afraid of men because she was attacked by a man in an alley. This would be even worse if the man who attacked her was a member of a particular race and the man behind her was the same race.

At the corner, she decides to cross the street to get away from this man. She notices out of the corner of her eye he stops at the corner to talk to another man. She is becoming more anxious.

When the light changes the second man turns and follows her across the street. She walks faster but every time she looks back there is a man back there. She is not sure if this is either of the two men she saw before but there is always one behind her.

Eventually, she ducks into a coffee place and has some coffee. She decides to wait a bit to get rid of those men who are following her. But when she leaves the coffee place there across the street are 5 or 6, men all standing together and one of them looks like that man who was following her. Same sports team shirt and everything.

At this point, convinced she is being followed by a gang of men she ducks back into the coffee place and calls a friend who comes to pick her up and take her home.

Unchecked this fear that men are following her can grow until she is unable to leave the house.

One problem for this woman is that no matter where in this town she may walk there may be a man walking behind her.

Is this an irrational fear? Maybe, maybe not. Having been the victim of an assault once there is proof that a man could assault her. Is this fear excessive? Probably. The chances that every man on the street is following her and plans to assault her are very low, most of the time.

The challenge for this person and other people with paranoid symptoms is to reasonably evaluate the situation, assess for danger and still keep this fear of another assault from keeping her a prisoner in her home.

Now so far in this example, I have said that Annid has a history of being a victim. What if she has never been victimized?

She might have had a friend who was assaulted or heard a story on T. V. about assaults in her town. If she had a preexisting anxiety disorder even if nothing had ever happened to her she might keep looking over her shoulder believing that constant vigilance will keep her safe. And if you keep looking for something you will begin to see it.

See how easy it is to turn a fear in your mind into a belief that there is a real danger. We have even had cases where someone believing they were in danger pulled out a gun and shot a person who just happened to be going in the same direction they were. Family members have killed other family members in the mistaken belief that there was an intruder in the house.

High levels of fear can create the situation in which everything becomes scary.

If you have anxiety issues or feel threatened and unsafe, consider getting professional assistance both in determining if this is a real threat and in learning to manage your anxiety or other issues before that emotional problem turns you into a paranoid person.

Two David Joel Miller Books are available now!

Bumps on the Road of Life.

Bumps on the Road of Life.

Your cruising along the road of life and then wham, something knocks you in the ditch. If you have gone through a divorce, break up or lost a job you may have found your life off track. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel that explores the world of a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

Other books are due out soon; please visit my Amazon Author Page – David Joel Miller

Staying connected with David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on my writing projects, speaking and teaching, along with comments on recent news in the field of counseling – sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse and Co-occurring disorders see the about the author page or my Facebook author’s page, David Joel Miller. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.