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

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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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How does therapy help people?

By David Joel Miller.

People ask just how it is that therapy or counseling works.

The short answer is that there are many ways, not just one way in which therapy may work to help someone. Professionals all have their own preferred theory of therapy which is the basis of their practice. What they do is highly influenced by the theory they use, though the truth be told most of us borrow from other theories if we see a procedure that might help a client.

The way counseling might help also varies with the problem the client brings to the office. In the early days, there was one profession that largely dealt with problems of the mind, psychiatrists. Today there are many specialties that work to help people with their problems of living. A caveat here, I have my preferred way of trying to be helpful. This is my opinion so I won’t pretend to fully explain all the procedures.

Therapists are empathetic, nonjudgmental listeners.

There are some things people don’t feel comfortable talking to their families and friends about. One school of therapists, Rogerians, believe that most of us have the answers to life’s problems we just need to talk them out. Being able to talk through urges and fantasies helps people to understand themselves and may lead to an improved ability to control their behavior. Clients sometimes say their therapist just sat there, listened and didn’t tell them anything. If you want or need more than listening, discuss that with your counselor.

Therapy can be a corrective emotional experience.

Many clients tell me they have trust issues. Often this is because there has been no one in their lives they could trust or because they were not trustworthy themselves. If their family was never very affirming, a positive therapist can help them to learn to affirm themselves. Group therapy is especially good at teaching people how to deal with interpersonal problems by allowing them to experiment with new behaviors.

The counselor can provide reality testing.

Clients may come to therapy with incorrect perceptions. People think they are fat when they are normal or below in weight. They think of themselves as too old or too dumb when they are in fact at a normal developmental point in their life. People make plans that they do not have the skills or resources for, they have expectations of others that are not realistic. Having someone to “bounced ideas off” can help ground plans in the real world.

Counselors help people change life stories.

Many people have a “story” about themselves that started in early life and which they have been unable to alter. People with call themselves “a loser.” This personal story, saturated with problems, may keep them from trying new things because they expect to fail at any new effort.  Narrative therapists help people create a new story.  Cognitive therapists would call this a “thinking distortion” and use various methods to get the client to challenge this belief and create a new belief about themselves that was more adaptive. Instead of thinking of themselves as a “loser” the client may begin to see themselves as a “survivor” who has continued to try in spite of obstacles.

Counselors teach clients new skills.

A substance abuse counselor would teach a client refusal skills. A career counselor might teach his client how to use online career inventories, interviewing skills or resources to use to conduct a job search. Marriage counselors may teach couples communications skills. Family counselors may teach parenting skills. Skills-based approaches may involve recommendations for books to read and real-life homework to increase skills. School counselors primarily work on academic issues, what classes to take and how to succeed in school.

Counselors help clients get in touch with themselves.

Exploration of the self, personal growth and discovery are all legitimate reasons to see a counselor. Counselors don’t make decisions for clients, but they can teach clients decision-making skills and encourage clients to practice these skills. Therapy can help clarify values and assist clients in evaluating choices. People may come to counseling confused and in need help in gaining clarity.

Psychotherapy can assist in changing personality.

Psychotherapists often focus on basic personality characteristics. Psychologists can give and administer personality tests while psychotherapists can spend time working through personality characteristics the client may wish to change.  Changing an underlying personality characteristic takes more time and effort than the crisis-driven techniques but it can result in long-term changes in coping skills. Psychodynamic therapists work on the unconscious. More cognitive therapists would approach personality issues by trying to help the client gain a new worldview. “Getting a new pair of glasses” results in seeing the world and problems differently.

There are sure to be more ways in which counseling is helpful. What do you think? Are you a client who has been helped? What was helpful? If you are a therapist, what do you think helps clients?

This post was featured in “Best of Blog – May 2012

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.

 

Mindfulness on a full brain

By David Joel Miller.

What is all this mindfulness stuff?

And how can I possibly include that in with my cognitive behavior therapy?

Problem-solving in mental health as in life has always been pretty straightforward for me. If we are applying the wrong formula to a problem then we keep getting the wrong answer. Once we learn an improved formula all we need to do is turn the crank and out comes an answer.  Get a head change, a new way of seeing things and the problem changes from unsolvable to a manageable size. So we work on core schemas, automatic thoughts, irrational or dysfunctional beliefs. And we work on acceptance – radical acceptance. So the whole mindfulness thing troubled me—until-

There have been a lot of articles recently on mindfulness. Now I feel that this has its uses. Religious and spiritual practices have their place. And I am as much in favor of candles and herbal scents as the next person. All this has its time and place. And we know that if the client believes in something it will probably help. But do mindfulness techniques have a place in modern scientific, best practices, forms of treatment. Then I read some things that made me think.

Siegal has written and talked about mindfulness and recently I happened to read some things he had written on the subject. They made sense to me from a logical rational perspective.  Let me try to explain this as I get it and hope not to do too much violence to the science.

Scientists have discovered mirror neurons in the brain. Now if all they did was see someone else doing something and result in us knowing how to do the same thing that would be the end of it, one more way to learn stuff.  But these mirror neurons detect patterns that allow us to infer why someone is doing what they are doing. Learning these patterns makes our world a more secure and predictable place. This has a lot to do with understanding attachment theory.

If when we reach for more food at the table we get slapped – we learn to not reach but ask which may be a valuable learning experience for a young unsocialized child. But if the response varies depending on the amount of alcohol mom has consumed, what we may learn is the pattern that the world is a scary and inconsistent place. The pattern of asking may be adaptive and is quickly forgotten if we encounter a situation where it is not expected. The pattern of seeing the world as a frightening place is likely to last a lifetime.

So the mirror neurons help to explain how we learn basic core ways of relating to the world.

But there is more.

Mindfulness teaches the practice of paying attention to how we feel inside. As we come to recognize how we are feeling it becomes easier to recognize feelings in others. This is sometimes called the “expert” effect. If you are an expert on antiques you will spot them and probably will notice the cheap reproductions also. If you are not an antique expert you will see things you like or don’t like but lots of stuff will go unnoticed in the piles of other stuff. Same thing with feelings and empathy.

Seeing people express love will teach you the pattern of love.  But if the people you live with don’t show love or show it inconsistently then you may be unable to recognize the pattern and to replicate it. This does not mean that people whose early caregiver did not love them as much as they wanted will be unable to love. What it does mean is that it may be harder to recognize and express love in later life.

Lots of people in recovery, from drugs, alcohol, mental illness or dysfunctional caregivers report they have difficulty with trust issues. Most came from situations where it was not safe to trust on a regular basis so they never learned the pattern.  Some recovering people have spent so much time being deceitful to cover up and continue their addiction they no longer recognize the truth when they hear it. Their mirror circuits have not had trust images to reflect back and incorporate into their catalog of patterns.

So how will mindfulness techniques help someone who has trust issues, attachment problems or dysfunctional behaviors? How might these approaches help counselors in helping clients?

By becoming aware of our inner feelings and thoughts we can begin to dispute dysfunctional beliefs. We can learn new more functional patterns of meaning in life. We can recognize our feelings of anger, mistrust, and fear and test these feelings to see if they have a basis in reality. And we can learn from recognizing our own feelings to have empathy for others.

Counselors can especially benefit from mindfulness techniques by becoming better able to present an empathetic other who can participate in a corrective emotional experience with the client.

More to come as I research for that book I am writing on resilience.

Wishing you all the mindfulness you care to have. Hope to hear from some of you.

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.