Transcription
Welcome to the Personality Couch podcast, where we discuss all things personality and clinical practice. I'm your host, Doc Bach, and I'm here with my co-host, Doc Fish. We are both licensed clinical psychologists in private practice, and today we continue our series on paranoid personality disorder.
In this episode, we unpack the six subtypes of paranoid personalities according to the greatest personality shrink of all time, Dr. Theodore Milan. So, we discuss the instability central to these types while further exploring their characteristics at mild levels, moderate levels, and at the most severe level, where they enter into psychotic thought processes. If you think you have a paranoid personality in your life, you don't want to miss this discussion. So, let's jump right in.
Duckfish, in our research on paranoid personality, there's really not a lot there. It's grossly underresearched, but Milan, of course, came to the rescue and became a major contributing force to the literature on paranoid personalities. But overall, the research is still pretty old that we found, like prior to the 1980s. You're right about that. Not many care to look at it in depth. Even still, paranoid as a personality disorder has remained in the DSM since its first edition in 1952. The ICD 8th edition picked it up in the next decade, like in 1965. It's even in the psychoanalytic diagnostic manual. So, it's like researchers and shrinks have been able to spot this trend of personality, character, structure, but we really haven't gone much beyond that. That's what I'm seeing, too. Yeah, it's so interesting because I'm guessing that even the pros really don't understand it. I agree. Yeah.
So, paranoid personality disorder is definitely a thing, though it's actually been proposed it should be removed from the DSM. What? No. No. While it's been severely underresearched, a forensic psychiatrist, Michael Stone, contributed to some of the thoughts of paranoid personality, but his focus was mostly in forensic settings. So, capturing severe mental illness in the criminal population. Right. Right. And I think it's important to highlight that a lot of the textbook cases of paranoid personality disorders are more severe because, like, the less severe paranoid personalities are not coming to treatment or to the research studies. Like, they're hiding, typically, which means that we don't really have the opportunity to understand them, like, really understand them. So, while a paranoid personality can be dangerous and is prone to aggression, it doesn't mean that every case is murderous. Like, paranoid personality can look like bitterness and hostility, but without fighting others. But on the other hand, paranoids can start fights with others. And many who are in prison for mass murder are paranoid personalities, according to Stone. So, how they present is vast. Yeah, we just want to take a minute to acknowledge that each case is different. But with any paranoid personality, you do want to be mindful and watch your back. None of that negates our empathy and treatment for how their personality developed and the sheer terror that they live in every day. Yeah. Yeah, that's an excellent point.
Okay, but before we jump into the different flavors and shades that paranoid personality disorder comes in, let's quickly review what paranoid personality disorder is. Okay, so if we remember, paranoid personalities are in cluster A of the DSM, meaning the odd and eccentric disorders. So, these types, while their language can be quite dramatic, they are not going to demand a crowd. They would rather hide and withdraw. So, with that, they're going to overlap more with schizoid and schizotypal types in cluster A. Mhm. Paranoid personalities are very mistrustful of other people's loyalty and they fear confiding in others because they don't want the information to be used against them. That's correct. Yeah. They are super suspicious of other people harming them, which is unwarranted, but then they find neutral things threatening, and they're going to be hypervigilant, constantly scanning every surrounding, no matter how benign, for threats. Mhm. Because of all of this, they're quick to attack any perceived slight or threat. Yeah. So, they're not going to be warm, fuzzy people. Like, they have difficulty expressing warmth and can actually be irritable and abrasive. There tends to be like an exaggerated competitiveness because they're self-righteous and arrogant, and with that, they have a fondness for righteous causes and they can have grandiose rescue fantasies. Yes. So, we might actually find these types in politics, in emergency services, in law enforcement, or in other settings like with threat assessments, or kind of that would elicit a vigilante response. Very much so. And they also have an unusually strong need to be self-sufficient and independent, having resentment towards authority and very strong reactions to humiliation. Mhm. Yeah. And a really big part of this type is that they are vindictive, like taking their anger out on the world around them, especially as they hold grudges forever. Mhm. Yes.
So, some examples of paranoid personalities in history, these are going to be more extreme, but they do include Timothy McVeigh and his sidekick Terry Nichols, who joined forces with a shared paranoia and desire to retaliate against the government. With both of these individuals, they took their vengeance out on a government building in what we now know as the Oklahoma City bombings in 1995. And they were likely that disordered level or beyond, paranoid duo. Mhm. Very much. Another example, which is forensic, more extreme. Stone talked about Richard Farlay. So, this story highlights pathological jealousy in a paranoid stalker turned mass murderer. So, Richard stalked a girl who refused to date him, and eventually she filed a restraining order, which he did not respect. Uh-oh. So, he threatened to kill her if she didn't go out with him, which also led to him getting fired. Two years later, he killed seven people and wounded four, including that girl, at his old workplace. Oh my goodness. This is what we're talking about. Like, that grudge holding is long and serious, which can make these types dangerous because they see everything and everyone as a threat, and they have a high need for vengeance. So, this means that they often take their anger out on the world in the form of harming others, or as with these more extreme examples, even killing other people. Yeah. And it is important to note that not all paranoid types kill. There is high risk giving their unstable, irritable, and vindictive personality structure, but there are more like mild forms of paranoid personality types. Yeah, agreed. Agreed.
So, with that, why don't we talk about Milan's different levels of paranoid personality severity? Absolutely. So, with subtypes, we actually have six to unpack, each increasing in pathology. Milan differentiates three levels of severity. The first is the mild level, that's closer to normal functioning. He just calls those like mistrustful personalities. The second is the middle level, the borderline functioning. He calls that actual paranoid personalities. Makes sense. This is where we would find the actual paranoid personality disorder. Right? Then the third, that last level that has completely fallen apart out of reality, can't function well, is what he labels paraphrenic personalities. Oh yes, this is where it gets really interesting. So, paranoid personality structures occur along a continuum with a range of severity levels, but any level can disintegrate and become worse. Correct. Yeah. So, it's tricky kind of using the word mild to describe any personality structure of the paranoid variety. But since these types disintegrate quickly and can go from mild to disorder with minor stressors and setbacks, we have to be really careful in how we talk about that. And I think this is especially true in today's post-pandemic world and conspiracy theory culture. Oh wow. Yes. Very much so. Very much so.
Okay, but with that, let's go ahead and jump into level one, the mistrustful types. So, starting at that first level, we have that mistrustful style. So, while having some unhealthy traits similar to paranoid personalities, they likely still have other useful traits that help them blend into society and possibly even be successful, right? Yeah. So, in these types, there's something off about them, like, but they're still functioning, and you're not consistently questioning your safety around them, right? So, this, like, mild category includes a self-righteous style and an obdurate style of paranoid personalities. Ooh, we will unpack those big words too. Thank you, Milan. Yes. So, let's start with that self-righteous subtype, which seems to be like a more pure flavor of paranoid, as they're mistrustful of others with a high need for independence. These types can disintegrate into paranoid personality disorder easily if they start to fall apart. That's right. Yeah. Okay. But tell me, like, what do these types look like? How do we spot them? Yes. So, in those self-righteous mistrustfuls, self-sufficiency is extremely important, with possible fantasies of fascism. Their excessive need for control means that they control their close inner circle very tightly. If they don't keep a tight reign on their functioning, their cover's blown. Yes. Okay. So, an example might be a professor who's ruling the classroom like with an iron fist, like no surprises, no jokes, really no real connection to the students either. And he might fear that the students are actually colluding, especially after there were complaints about his more rigid and authoritarian way of teaching. But the interesting thing is that these types may own their own businesses to protect themselves from the threats of the world. So, this allows them to create policies and procedures to ward off those attacks and threats. So, they make it work for them. They're functional. They're a professor, maybe a business owner, but, right, the professor may be overly concerned about his tenure or somebody being out for his job. The business owner may think like others are trying to steal his ideas, which might be like technically helpful because then no one can actually steal the ideas. Sure. Sure. And in a chapter by Milan, he noted that J. Edgar Hoover was said to be a paranoid type. Uh, not sure where exactly he would fit in with Milan's theory, but I think it's helpful to bring up here because he adaptively used his skills as the FBI's first director. And this is where functioning is really important. Like, Hoover functioned and was successful because his personality was paranoid. But if you take him out of that paranoid role as a director, then would he be a more severe type? Maybe. It's hard to say. And this is where it gets really tricky with paranoid personalities because you never really know them, and therefore never really know how severe they are or could be. So, while they can technically be functional, they can still make others' lives miserable, and people often fear them at all levels of severity. Yeah, that's so true. So, with all paranoid types, you likely feel some type of countertransference of fear or hostility. So, essentially, you feel their fear of you. Mhm. These self-righteous types are still hypervigilant and fear being annihilated. Woo! They cannot let their guard down, even for a quick joke. Oh my goodness. Wow. That's the rigidity again. And this makes me think that we're going to probably see some overlap with this type and obsessive-compulsive personality disorder, since that compulsive part can be adaptive. Like, they're functional but odd, fearful, chilly, and very rule-bound. And again, J. Edgar Hoover was said to have some obsessive features himself. Well, as Milan says to the self-righteous type, the enemy is there. This they believe with certainty, but how close and how deeply infiltrated are impossible to answer. So, essentially, they feel they cannot miss any negative attribution or threat, less they perish. Their biggest fear. Yes. So, this can be adaptive and make someone a functional, like, political leader, maybe, or maybe a law enforcement lead, or even a spy. Mhm. Yeah.
Okay. So, the other mistrustful type, or mild personality, is called the obdurate subtype. Oh my goodness. Here we are with Milan's, and his vast vocabulary again. But obdurate is essentially extreme and rigid stubbornness. Mhm. While they can also be self-righteous, suspicious, and humorless, the obdurate type holds a conflict similar to the compulsives of trying to restrain their anger and hostility by deferring and depending on others. However, they can't restrain it. So, they end up rejecting their own dependency and then, like, discharging their hostility. So, basically, they actively rebel against any external or outside constraint so they can feel in control. Right? So, here we see that they project their hostility, meaning it's put on others. So, because they can't handle their dependency or their need for others, they constantly push others away. It's, it's a conflict, like, I need people, but I can't get too close. Like, I need to be independent so I am not destroyed. Mhm. Right? Because if they're independent, there's less need for vulnerability, which could lead to them being destroyed. They can be very moody, cranky, tense, and unrelenting. Yes. And Milan notes that they may appear to function normally much of the time, but possess tightly compartmentalized persecutory delusions. So, these tendencies go largely unnoticed, but the individual's hypersensitive antennae are perpetually in alert mode, noticing any unusual twitch, remark, or facial expression emanating from nearby others. Right? And if the antenna sensitive nerve is touched, their normal functioning is hindered, and then all those hidden beliefs come to the surface. Mhm. I have seen this so much. So, like, "Are you mad at me? Are you mad at me now? Are you mad at me?" All because a facial expression was actually confused or tired or surprised, but there's that major hypersensitivity to any anger, conflict, threats, danger. Like, the little hungry caterpillar always has those antennae ready. Oh, he does. Yes. But I mean, can you imagine what that feels like? Like, spending so much energy running around with your antennas up all the time, like, being anxious all the time, like, no wonder these people are cranky. Like, that takes up so much energy. Yeah. It's extremely draining, and it's really scary. Absolutely. Yeah.
Okay. Well, this brings us to level two of paranoid subtypes. So, these are in the borderline range of functioning, meaning that individuals mostly stay in reality but can dip their toe into the psychotic range for brief periods of time, like hours or days, but definitely not weeks or more. So, paranoid personality disorder lives in this space. So, in that paranoid personality disorder range, we have the querulous paranoid, which is a paranoid personality core with features of negativistic personality. That negativistic piece includes discontentment, pessimism, stubbornness, vacillation, vengefulness. Mmm. They are the bitter chip on the shoulder type, as they are overtly hostile, argumentative, fault-finding, unaccommodating, resentful, like whiny and snappish. Okay. Wow. Yes. So, going back to querulous. So, querulous actually means complaining or fretting, even whining in a high-pitched voice. Okay. So, these types are rarely in a consistent and healthy relationship since they usually reject their need for connection and focus on their independence with vengeful fury. Mhm. So, there's actually a conflict here, though. They're not content being alone, and they don't like this about themselves. But then they also don't like, like, their indecisiveness and being with others. So, they swing between desiring others and being repulsed by others. Oh my goodness. Wow. So, I can also imagine, like, because they want affection, but then they refuse it. So, then they're going to project that need for affection onto others. Like, for example, it's others who maybe want me erotically, not me who wants them, right? And this is where it can turn into erotic delusions with this type. Uh, so, for example, like, I'm not attracted to them, like, they made advances at me. They are stalking me. They love me. It's twisted. They often accuse others of cheating, lying, and betraying them, or even of making suggestive comments towards them, or even molesting them. So, they can be super jealous. Wow. This actually reminds me of cases that I've seen with reports of severe sexual trauma history. But something doesn't quite add up in that narrative. We have to be careful with that because obviously severe sexual trauma histories exist. Like, this is something different. It feels different. Something is like off, and it just, it does not make sense. Right. Yeah. So, in the cases that I've seen, something feels off in the storytelling, like it doesn't add up, or maybe in the way that they've told the story, or maybe I'm feeling like they're trying to get a reaction from me, or maybe are projecting something onto me, like, there's something about it that feels inauthentic, right? And we still meet it with empathy. Absolutely. Um, but there's like a clinical skepticism that's helpful for treatment purposes. Very much so. Yeah.
All right. So, going back to querulous. So, unsurprisingly, with these types, their envy can easily turn into complaints about things not being fair, which is then turned into anger and spite. So, can you take a guess where they go to make their complaints heard? The courts, of course. Mhm. They can be very litigious types. Mhm. They can also have frank delusions when they slip into those quick psychotic episodes, but emphasis on quick. They are not at the psychotic level. Right? Right. But they'll pop over to psychosis land for a minute. Mhm. All right. But I think we have another one in this, like, moderate or borderline range. Mhm. Another subtype that Milan described in the moderate severity level or borderline level is the insular paranoid. It's a paranoid personality at the disorder level who has avoidant personality features, being extra hypersensitive to criticism, like an avoidant personality might be, especially criticism involving, like, achievement and their own worth. Mhm. So, going back to insular, insular means insulated or isolating, or like on an island or in a cocoon. Mhm. I like to think of it as the paranoid who likes to hide in, like, an insulated cooler to stay safe. It's hilarious. That's very true. Yeah. So, they're more reclusive, withdrawn, and sometimes even hermit-like, focusing on isolating themselves from any threats or destructive forces. They still have the hypervigilance and defensiveness against imagined dangers, but their self-protection is self-focused. Mhm. They also have a very, very, very strong fear of being controlled, which means they're extra unwilling to take in any outside data to check themselves. Thus, they can fall out of reality more easily. So, they are hostile against new data. They need to read it or feel it through those antennas themselves. Mhm. Now, what really pulls my empathy here is that their internal thoughts without that outside check are terrifying and painful, and their anger too. It can become out of control, right? So, they can turn that anger inward towards themselves, resulting in self-mutilation, suicide, or even self-destruction. And in this way, they overlap some with borderline personality disorder. But they are not the same. Not the same. So, the piece that also can distinguish this type from borderline is that they can turn their anger outward onto others and project it. So, this is going to result in rageful and brutal attacks. And again, this may apply to Stone's reference of paranoid personality disorders being more likely to commit mass murders. Right. Right. Project the pain onto the masses. Yeah.
Okay. I think we have one last subtype level, level three of paranoid personality. Okay. So, sometimes paranoids in the borderline or that middle level of severity can fall apart and become even less healthy. When this happens, Milan says they often end up in, like, inpatient care where they get regulated with medications or therapy or treatment, right? They go back to functioning, but then it happens again. So, paranoids in decompensation, that falling apart, can have increasingly frequent inpatient stays, recovering until they can't. Oh boy. So, at that point, they're in psychotic land, which for the paranoid personality is called paraphrenic, according to Milan. Wow. Milan says the paraphrenic area is essentially parallel to schizophrenic territory, but it's not schizophrenia. More on that later. Exactly. More on that later. Yeah. This, this is so fascinating. But this again speaks to how fragile the paranoid structure really is. Like, it's already on the fritz of falling apart, which means they can quickly deteriorate to the next level of severity, possibly even becoming fully psychotic. But as you said, this psychotic range is not schizophrenia. But it's confusing because we still use the term paranoid schizophrenia today, even though it was removed from the DSM-5 in 2013 and in the ICD-11 fairly recently. So, from this, I think we can kind of gather that we have a really hard time as clinicians understanding this paranoid structure, which has only contributed to more confusion and misdiagnosis. Yeah. But shall we start with the first subtype in this severe level? Sure thing. We have that fanatic subtype, that is a decompensated paranoid personality at that paraphrenic level with narcissistic features. Ooh. So, this is interesting because a researcher in 1973 actually suggested that paranoid personality disorder was a subtype of narcissistic personality disorder. Oh, no way. That is so interesting. And yeah, there's certainly a heavy dose of narcissism in paranoid personality, but they're not the same thing. But Kernberg actually made a very important note that narcissistic personality disorder and paranoid personality disorder can coexist, but the paranoid individual is cold, aloof, and suspicious, but not exploitative and envious like the narcissistic individual. So, this also supports why and how some individuals with paranoid personality disorder are often labeled as narcissists, right? Okay. So, the fanatic paraphrenic has the arrogance, exaggerated self-importance, and, like, disrespectful, disapproving superiority that the narcissistic personality disorder displays. But they have grandiose delusions that are flimsy and irrational. They're making up for lost pride through extravagant grandiose fantasies and delusions. Okay. Okay. So, this is the piece that separates them from narcissistic personality disorder. And that's that the delusions here really don't make sense. Like, someone with paranoid personality disorder, narcissistic personality disorder usually has a linear way of thinking. Like, for example, maybe a grandiose narcissist might think that they're the best. End of story. Like, everything they do is for the ego. But someone who is a fanatic paraphrenic is out of touch with reality in bizarro ways. Like, you can't follow their logic. So, for example, someone proclaiming that they are the Messiah and that they are being persecuted by unholy and unseen forces. Yeah. So, they can actually present themselves as, like, a holy saint, inspired leader, or talented genius. But eventually, others see through this. Of course. Yeah. So, then the fanatic paraphrenic projects to protect themselves from humiliation. Of course. Of course they do. Yeah. So, they believe that they are all-powerful against an evil world, like a superhero, even. So, a great example is we've mentioned this multiple times for different types of pathology, but a great example here is the Jonestown cult leader. Like, he was the helpful messiah, but towards the end, he started falling apart and saying that the CIA was after him, and he was afraid that the world would drop a nuclear bomb, which resulted in him moving himself and his followers to a remote location in Guyana. Right. So, Milan literally wrote that fanatic paraphrenics project their stuff. Like, it's not their own power that's insufficient. It's that there's this secret government agents that are conspiring against them. Like, they really lean into that all-powerful part that paranoids have. Yeah, this is so interesting. Like, it's not me that's incompetent. I'm not the one that lacks the power. These forces here are destroying me and my greatness. Like, you can see that overlap with narcissistic personality here. And interestingly, like some types of narcissists, these fanatic paraphrenics had overindulgent parents who let them believe that their existence was sufficient without effort. So, their grandiose fantasies didn't have any boundaries. Wow. But later, the world gave them a big reality check, and they couldn't handle it. So, they turn to fantasy, primarily coping with all of this with those grandiose delusions. Yeah. Again, another fascinating point is that fanatic paraphrenics are out of touch with reality. They're often grandiose, and they can position themselves as godlike figures in an evil society. But then they can also flip that script and become victimy, taking on, like, a, "Oh, woe is me. Everyone's out to get me." Or even, like, "Oh, no one recognizes my great talents and abilities. I guess I'm just too brilliant to be understood," right? And that's a perfect place to put that reminder again that not all paranoid personalities are going to kill you. Mhm. But also, like, dramatically, this next subtype is probably more at risk to hurt you because they have a sadistic flavor. Oh no. Rut. All right, so we better pull up a seat. This one is going to be fascinating. Yes.
So, the second subtype in the severe paraphrenic range that Milan describes is a malignant paraphrenic. So, a paranoid personality core with sadistic features. Oh my. To summarize these subtypes, Milan stated, "These paranoids are characterized best by their power orientation, their mistrust and resentment of others, and by their belligerent and intimidating manner." Wow. And their strategy is to dominate you before you can dominate them. So, as you can imagine, temperamentally, these types come across as callous, belligerent, argumentative, vengeful, and even tyrannical. Like, they will fight you. And these types are hypersensitive to power dynamics, believing that others are only capable of aggression and hostility towards them. Mmm. Which then results in persecutory delusions, which this aligns with the theorist who proposed that those with paranoid personalities experience a sadistic parent in childhood. And it pulls my empathy here because they're literally fighting against that sadistic parent. Right. Right. Which then gets projected onto the larger world as they grow up. But yeah, so they project their own sadistic impulses onto other people, saying, "They are trying to intimidate me. They are trying to control my thoughts. They are trying to weaken me." Mhm. Which totally makes sense because that's probably what they expected from their sadistic parent. Yeah. Yeah. And at this severity, these types really can't function in society with their sadistic impulses and will eventually end up in a forensic setting or in an institution. Right? So, someone who ends up, like, in prison might be there for assault or murder because they're acting out those sadistic urges. Someone who ends up in, like, a state hospital, maybe, might be hallucinating the people that they believe are persecuting them. That is so fascinating. Yeah. Yeah. So, Milan provides a case in his book explaining how basically a man who was a childhood bully who was influenced by his sadistic father ended up beating his father severely in adolescence. He later joined the Navy, drank excessively, and flew off the handle at the drop of a hat. So, he was discharged early for psychiatric reasons due to the bizarre features of his episodes. So, a lot happened in his 20s and 30s, but he eventually was elected into a political position and then, of course, forced to resign. Uhoh. Then later, a romantic partner sold his business and kept the proceeds, which just confirmed his lack of trust in others. So, he became even more violent and was institutionalized for two years. Then he got out. He began drinking again and attempted to assault his wife multiple times. And he was unsuccessful since his teenage sons intervened. So, my goodness, after four years of this, he disappeared for 18 months and was found destitute. He returned to a state hospital for over a decade, where he experienced unrealistic psychotic persecutory delusions and hallucinations. That's what we're talking about. Yeah. Oh my goodness. So, in this case, we can definitely track the decompensation, like, that falling apart. Oh yes. So, that paraphrenic level of falling apart started around the time that he left his family and disappeared. Right. So, like, before that, we can see, like, he's, he's kind of functioning, maybe a little bit. It's not good, but, like, he's functioning. After that, he disintegrated into that paraphrenic level. Absolutely. Mhm. Interestingly, I think if his own teenage sons did not, like, win the fights, probably more likely he would have ended up in, like, jail or prison. Right. Right. So, there's where there's like that, which way are you going to take in terms of decompensation and where are you going to end up? Mhm. Mhm. So, with these malignant paraphrenic types, they try to actually avenge themselves by hurting others. And of course, it backfires. It doesn't work. So, then, as a result, they direct their hostility towards fantasy much more than through behaviors. That is what separates them from a sadistic personality. Mmm. The malignant paraphrenic goes that fantasy route because their brutality has backfired, right? And that fantasy route leads to psychosis. So, all of those hallucinations and bizarre delusions, right? Because if you're already prone to fantasies and you can't distinguish between what's real and what's in your head, that's going to lead to problems with reality testing, which is the vehicle to psychotic or paraphrenic land. Mhm.
My goodness. Okay, so we learned a lot about paranoid personality and the varying severity levels that give way to subtypes. Paranoid personalities overall can decompensate quickly under stress, which means that this instability can actually make them dangerous. However, the dangerous cases are also more likely to find themselves in textbooks as they're in settings where they can be studied, like a state hospital or a prison. And then others are just hiding. So, we know less about those types, the more mild forms of paranoid personality. But that said, as we've noted before in this series, this post-pandemic landscape has meant that paranoid personalities are disintegrating because they are afraid. And this means that they've been coming to treatment more as a result. And we believe that you may also be seeing these types pop up in your circles, which is why we're doing this whole series, so you can know what to be on the lookout for. And on that note, that's a wrap. Thank you for joining us today on this episode of the Personality Couch. Make sure to check out our blogs that coincide with these episodes at www.personalitycouch.com. And as always, don't forget to give us a thumbs up or rate and review us on your favorite podcast app. And on YouTube, hit that bell so you don't miss a single episode in our paranoid personality series. Be well, be kind, and we'll see you next time on the Personality Couch.
This podcast is for informational purposes only and does not constitute a professional relationship. If you're in need of professional help, please seek out appropriate resources in your area. Information about clinical trends or diagnoses are discussed in broad and universal terms and do not refer to any specific person or case.