Transcription
Welcome to the Personality Couch podcast, where we discuss all things personality and clinical practice. I'm your host, Doc Boach, and I'm here with my co-host, Doc Fish. We are both licensed clinical psychologists in private practice, and today we are continuing our series on paranoid personality disorder.
So, these types can masquerade as having many different types of conditions, but especially borderline personality disorder. Many clinicians, not knowing what they're looking for, will diagnose the funky and frightening interpersonal dynamics as borderline, but it's not. Paranoid types are actually much, much more dangerous than individuals with BPD. They are dark, sinister, and of all the personality disorders, probably the most likely to sue you. The paranoid types that aren't behind bars for serious crimes are hiding in our closest circles and in our outpatient clinics. So, join us on this episode as we unpack paranoid and borderline personality disorder similarities, differences, and what you can be on the lookout for. Let's jump right in.
So, to start off, these types are very, very tricky to distinguish. Doc Bach and I even struggle with this distinction at times. Even Milan, the greatest of all time, in our opinion, says that sometimes the only way to differentiate between these two personality types is to understand their childhood attachment to parents and initial fears or drives. They're both unstable types that will often present themselves as victims or like falling apart, especially in clinical settings. Yes, that's a good point. Even our favorite personality theorist, Milan, says it's tricky. So, indeed it is. So, here we are. Let's start the conversation by discussing the concept of being an unstable personality structure. So, there's some deep research about this that really makes our head spin. So, we won't go into the weeds, but basically, any personality is capable of falling apart. Certain types are more prone to it than others, and certain types naturally live in a more unhealthy space than others. Even as far as disordered personalities go, borderline and paranoid personalities are especially fragile and more prone to falling apart. So, the way that these personalities are wired means they're going to likely have more mini psychotic episodes. Like, they're going to have extreme problems in relationships and just navigating the world in general. And they dip their toe out of reality frequently. And this is why they're so tricky to distinguish sometimes. And let's be honest, we have much more research about borderline than we do paranoid personality disorders. Oh, yeah. And there's major problems with the way we chose to categorize borderline personality in the DSM in the first place. Yes. For more information about that, check out episode 13 on borderline personality disorder history, the media, and the DSM symptoms. We also did a whole series on BPD, so we're not going to camp here, but I do think it's important to have a quick dialogue about the symptoms of each disorder before going deeper.
Okay, so borderline is part of the cluster B, so the erratic and dramatic types, but as we know, BPD can also appear as quiet or less dramatic. There's many different subtypes and flavors of BPD, but the core characteristics of borderline personality disorder are fear of abandonment. Yes, it's the hallmark feature differentiating it from other personality types. They feel empty. So, someone else has to fill that emptiness. Anxious attachment is also another key part. All of the other characteristics here revolve around this fear. Exactly. Yeah. Yeah. That fear of abandonment is the hub of all the other symptoms that revolve around it. Mhm. And that brings us to recurring suicidal or self-harm thoughts, gestures, or behavior secondary to the abandonment fear. Yes. Yeah. If there's even the possibility of a relationship ending, suicidal thoughts and gestures can increase, like if the therapist goes on vacation, if there's a relational breakup. But really, any personality type can exhibit suicidal thoughts. But the key piece of BPD is that it hinges on that fear of being abandoned in a relationship, hence the anxious attachment. So that's a common thread running through all of their major relationships, right? And there's also so much instability. Yes. So there's unstable sense of self. So how they experience the self and like pervasive emptiness, there's unstable moods. So extreme mood swings again out of that emptiness, there's unstable relationships with others. So there's constant ruptures or problems, especially in romantic relationships. Yeah. There's a constant push-pull in how they live their lives. Like all-in, not at all, love this person, hate this person, euphoric, depressed. There's emptiness when there's no external input like relational hobbies, etc. Because of that empty spot, there's also impulsivity. So, there's frantic efforts to soothe the self, especially when that fear of abandonment is triggered. So they might seek out quick fixes that could be risky to pacify themselves in extreme mood swings or if a relationship ends. Yeah. An example might be like recklessly speeding down the interstate after their lover who just left, or maybe impulsively buying a puppy after a relationship ends without thinking through how they could take care of it. Excessive spending, indiscriminate intimate partners, those types of things. Or things that destroy the self or make kind of a quick high to make themselves feel better. And this usually leads to immediate regret, low mood, and further self-punishment. Mhm.
So, the characteristics and symptoms that we just discussed can fit into a range of different personalities. Oh, yes. And a lot of paranoid personality features also fit here, including suicidality and anxious or ambivalent attachment dynamics. Yeah. But in contrast, paranoid types are part of the cluster A category and are withdrawn, odd, and eccentric. So their hallmark feature is not fear of abandonment, but instead, it is extreme suspiciousness or distrust because they fear others' malevolence or badness. And these characteristics, like suspiciousness, are not necessarily tied to fear of abandonment. They can be, but fear and mistrust are pervasive regardless of context. They could have no relationship with a person and think they're being like spied upon or invaded upon in some way. Oh, very true. Yeah. There's constant fear, no relationship necessary. And governing authorities are often where paranoids put that anxiety, like they don't really have a relationship, but there's the fear of, "Don't trust the government, don't trust the authorities," that type of thing. Um, but yes, this fear or suspicion can translate to being suspicious about a partner's fidelity, like, "Oh, yeah, I know they're cheating," or constantly looking for evidence despite there being none. Reading hidden meanings into benign conversations, even with strangers or people they don't know well, or perceiving others to be attacking their character, leading to lashing out and anger. And paranoids limit their self-disclosure. They hold grudges, and it's all about that fear. Fear and more fear. Absolutely. Yep.
So, let's start with notable overlaps here, and in that, we'll compare and contrast. Sound good? Sounds good. Yes. All right. So, this is tricky, so hang with us here. The first thing that they overlap in is anger. So, borderlines become angry when there's a fear of being abandoned. It's a protective mechanism to keep them from losing the attachment, and it's triggered by interpersonal stressors. Like, sure, they can lash out at a partner and spout off, but only if there's the threat of or perceived threat of a relationship changing, and they're generally not angry as like a core characteristic. They can be irritable, as we all can be, right? But typically, it's not part of that core personality makeup. It comes out if there's that threat to their relationship. Exactly. Yep. That's right. And they lack the hostile suspiciousness that paranoids have. They will walk straight into the arms of danger and not blink if it means they can stay attached. This makes them much more impulsive and self-destructive than paranoids. A paranoid does not trust in the first place. They sense danger in all situations at all times. So, they're not going to walk into the arms of someone that's dangerous unless it's to retaliate and get them back. That is something really helpful to distinguish. Exactly. Yep.
But conversely, paranoids are angry as a default in order to protect against the world that is out to get them. At the core, they have a chip on their shoulder and are negativistic and bitter anyway. That and that bitterness is likely to shine through most interactions, even if it's not directly bitter at you, but they can be. Oh, yeah. Yeah. They'll tell you stories upon stories of people they are angry towards. And sometimes, passive-aggressively, you find you fit those types of people they're describing. Like they have a vendetta against the world or certain types of people, like the trauma response of fighting to survive. Their two main emotions are anger and fear. But fear isn't really something they want you to see because it's too vulnerable. Yeah. So hostility and attacks are where they often sit. They have a level of contempt towards others that borderlines usually lack. Oh, exactly. Yeah. So, a therapist might feel that the paranoid patient is describing them in their attacks towards others, or they may directly attack you, like, "You're not good at your job, you're selfish." And typically, these are not triggered by abandonment, but they can be, but not typically. So, oppositely, it's often because you are getting too close to them. So they attack and push away against vulnerability or you potentially discovering them. So it can feel like in treatment you're hitting a wall. Like just when treatment is getting good and you feel like you're on to something, like, nope, too close. Zip it back up and push away with mean and aggressive statements. Mhm.
Okay. So, both types also struggle with shame. But borderlines consciously experience shame, and their core sense of self is like shame-filled. They don't feel like they're enough. It's essentially anger turned inward towards the self. They're mean to the self. They have low self-esteem. It's often fueled by depressive episodes. They sometimes like to sit in their shame because they're then a victim, a helpless, bad, sad person. Meanwhile, shame is a core feature of paranoid, but they don't actually experience it consciously. They use defenses to protect themselves against shame so strongly they can't even access it. They can't tolerate shame, which is why they either stay indifferent and chilly interpersonally or hostile, angry, and sadistic. Those are their two modes. Yes. Yes. So helpful. So, borderlines often authentically sit with their shame and their problems. Paranoids reject their shame and project their problems onto others. That's their core defense mechanism, projection. So that's another key piece is there's often something really sincere about borderline types and their pain, but there's often something inauthentic about paranoid types.
Now, both types also experience fear, and that can include fear of losing attachments. Borderlines are fearful of being abandoned, but also of being too close to someone. So if they are abandoned by an attachment, then they're alone and without an identity because they don't really know who they are. If they're too close to someone, they could be overtaken and lose whatever fragments of the self that they do have. But they're not scared of the world, and they don't think that like everyone's out to get them. Right. Right. So, paranoids' biggest fear is annihilation, or basically being scared of disappearing, being destroyed, or falling apart. Like they believe they are in constant danger, that the world is dangerous and out to get them. So that means that no one can really know them, lest they find their vulnerabilities to exploit. And while there may be some fear of abandonment, as we keep saying, most of that fear involves being close with someone. They don't want to be destroyed, which then they react against this fear with that irritability and aggression. Exactly.
Now, one of the criteria for borderline could be transient paranoia or psychotic episodes. Mhm. Borderline types' delusions are irrational, scattered, and unconvincing, only occurring when there's like lots of emotional distress. The delusions are fleeting, and they can have insight into them. Yeah. So, just make up an example. A borderline who's maybe having a fleeting episode of paranoia might think that their friend group is talking bad about them. So, they pack their bags and maybe flee the country. But then they quickly realize their mistake and get the next plane back. Right? So this example showcases the time-limited nature of their paranoia, that it's interpersonally triggered, and they are impulsive and sometimes not rational when distressed, but they can come back from it. But paranoid delusions are systemic, rational, and convincing because they're confident in their competence and superiority. Mhm. The delusions are long-lasting and often pervasive, and they cannot be challenged since they don't like to take in data from that outside world. Oh, yes. So, for example, a paranoid type might believe that this friend group is talking bad and then pick a different friend group without looking back, thinking, "I knew they were out for my job or out for my character anyway." Right? They're not going to impulsively flee the country and come back and apologize. They're just going to leave without a trace, without an apology, and they are not going to look back, right? Yep.
Okay. So, let's talk about the structure. Borderline personality structure is extraordinarily inconsistent and changeable. Yes. So, for example, "I feel this way now, I don't. I like this hobby, now I have a new one and a new one and a new one. Oh, now I have a new friend. Oh, friend is leaving. Come back, friend. I'll do anything for you, friend. Changed my hair. Bought a new car to win you back." Like, they're fluid like water, filling whatever relational container they need to in order to keep that attachment. In contrast, paranoids' structure is just inflexible and rigid. They can't take in any new information. "That world is unsafe and it will destroy me. I have to protect myself." That belief is stable, and all of their behaviors come back to that core fear and belief. Yeah. So maybe we can think of it as if like they are the water container, and everything in the world must fit their container, and most things don't. So they don't really collect any water at all, or really any data from the outside world, period, because they're not able to adapt. Like, they're not malleable, versus borderline is too malleable. They're too adaptable, morphing into whatever mold keeps that attachment secure.
Let's move to how we differentiate based on intuition, as I think we've definitely learned some key things in clinical practice. Yes, we indeed have. Okay, so the first thing that comes to mind for me is both have dramatic narratives, or at least they can. But those with BPD don't typically take you on what I call a wild goose chase with their symptoms. Like a borderline may overendorse things because everything hurts, but there's a sincerity to their pain, and usually we can feel that with them. And often, a borderline's life story will be filled with hurts that often include abuse and neglect. And then with that, you can see and feel their hypersensitivity to relationships and rejection. Like they don't typically want to project their pain onto you, usually, unless you threaten to leave, but generally no. It makes me think of a sensitive child in pain. Like, you know that kiddo hurts. They yell, they scream, they tell you they need a band-aid for that little tiny scratch, but they're hurt. It's dramatic. It's also genuine. Yeah. Yeah.
But then paranoids, on the other hand, overendorse symptoms, but it contradicts. Like, you might notice they say one thing about experiencing a trauma at age seven, and then in a different conversation, say that it happened in college. Like the narrative is all over the place with overendorsements, and their life story is just full of contradictions. It doesn't make sense. It doesn't add up. And then the kicker, a paranoid will project their pain onto you in most interactions. Like, "It's your fault." Exactly. You hear the pain, but it's so confusing. It makes you question what's real, what's not. Like, there's pain, but where? So maybe like a hurt child who doesn't want to or can't tell you where it hurts. Like you look all over their little bodies trying to find that one hair that's tied around their toe, but they're telling you maybe their arm might be broken. Maybe they burned their tongue in the hot cocoa. They don't want you to find the pain because they're afraid if you touch it, it's going to hurt worse. That makes so much sense. Yeah.
But then borderline types are going to swing back and forth between dependency and avoidance. So you might feel pulled to rescue someone with borderline. Or you may feel like you need to help them because they're in distress. And this feeling will be pervasive in the relationship. They need help, and they need their attachment to you to survive. Absolutely. There's a childlike quality to their need for you. And you'll often feel like you have the power and that you should use that power to help them. It's like, "Mama, mama, I need you, but also don't come too close." Mhm.
And then a paranoid, by contrast, rejects dependency. So dependency is too threatening and opens that door to possible humiliation or rejection. They can't trust, so they don't need you. If they do need you, it's a more detached neediness, like keeping the connection with you because maybe you can help them hide. They're not going to come across as smothering typically in a relationship. Likely, they're more cool and detached. There can be some anxious attachment though. So they might react poorly and maybe like borderliny when there's an attachment break or conflict. The difference is that the borderline needs you, while the paranoid has to keep you close and happy so like you don't destroy them. It's a surface-level connection, but definitely a connection that's needed for protection. You never really get that emotional closeness with them that you can get with a borderline. Oh, that is a really good point. Yeah, there can be an anxious attachment piece, but it's that surface level. Mhm.
And on that note, a borderline is probably going to be more favorable to relationships. Generally speaking, they likely have friends and social circles, but they get absorbed into those other relationships. And then they might find their identities in other groups or friends that they seek out, taking on their interests and hobbies again to secure those attachments. Like they genuinely want connection, but they're also scared of being hurt. Yeah, they are. But then a paranoid type may or may not have friend groups, or they might find someone who has the same type of bizarre way of believing that they do. That's an episode for another time. But they don't really get absorbed into their friend groups or really even need them. Like they utilize people to keep the camouflage and may take on their interests to hide or disguise themselves, but they're really more detached from those interests typically. Perhaps like a kiddo saying, "Mommy, I think I kind of need you, but are you going to destroy me today? What about tomorrow? Do I need to do something or shapeshift to avoid danger?" Yeah, that's a key thing here. A paranoid can shed his identities like snakeskin from one group to the next, unaffected and really indifferent about it. Versus a borderline may take on the identities of friend groups but lose a piece of themselves if those friendships fade. And borderlines need other people to tell them who they are and validate them. But you can see how like these things can look so similar on the surface, but the underlying motivations and drives are very, very different. Exactly. Borderlines are motivated by a desire to be close, but not too close, so they can have an identity. Paranoids are motivated by a desire to avoid any danger that could humiliate or destroy them. Mhm.
Another piece is countertransference. So, how do I feel with this person? Am I afraid for my safety? If so, likely a paranoid. Yeah. Am I afraid for the other person's safety? Likely a borderline. Mhm. This is a really big thing to distinguish, especially clinically. So, a paranoid personality will make you fearful seemingly out of nowhere. You might ask like, "Why do I feel afraid of this person?" Or maybe there seems to be like an innocence or an unassuming way about this person, which is maybe the mask that they wear to fit in, but like something feels off. Like my gut is telling me I'm afraid of them, and I'm not sure why. Oh, absolutely. I feel like there's a threat. I'm suspicious somehow and feel hypervigilant to their facial expressions and body language. Uh-huh. Like I don't understand them, and it's concerning, not intriguing. Something is off in a way where I do not like it. Yeah, I hear you. I'm more concerned about their safety. Like a borderline personality is more likely to harm themselves than others. They engage in self-harm and may make suicidal gestures or threats if there's the possibility of a change in a relationship. But you don't typically fear for your life with a borderline. Exactly. They might be angry with you and maybe even try to hurt you in like a childlike way. Yeah. And with a paranoid, they project that annihilation fear onto you. Like you feel it. You might think, "Oh my gosh, like am I even safe with this person? Like, do they want to harm me?" Then it makes you anxious or hostile with them. Mhm.
And borderlines are more likely to present to treatment, right? Because they're in touch with their pain. So paranoids can come to treatment, but typically only if there's a crisis, if forced, or if their cover is blown or about to be. Oh, absolutely. Borderlines are searching for help because they hurt. They legitimately hurt, and they will come to you with their pain. They'll tell you all about it, ask you to fix it, like a kiddo showing you their mess with like a puckered lip like, "Please help. Please help me. It's too much." Yeah. A paranoid's words will tell you that they're in pain and that they're a victim of the world, but you have to go find that mess. It's like a kiddo who was playing with a puzzle and they hid all the pieces all over the house. They're like, "Hey, you need to help me find all the pieces so I can clean up my mess." But holy moly, finding those pieces is a lot. Oh my goodness. This is my least favorite part about paranoid cases as a testing psychologist. The hunt for the puzzle pieces, like what is real and what is BS as they try to throw me off their scent. Yes.
Now, interestingly, both can have suicidality. Yeah. Usually, borderlines have a depressive component to their suicidal ideation. Paranoids, not so much. Suicidal gestures or threats, maybe so that someone else can hold their pain in death, not because of a relationship loss. Right. Right. And that's not to say that paranoids can't be depressed. They can be, but it's not always connected to the suicidal ideation. For example, like generally, you wouldn't hear someone with paranoid personality disorder say like, "I want to die" after a breakup. But a borderline, absolutely common. Yes. But after a breakup, a paranoid would likely say about their ex-lover, "I hope she dies." Especially if they know too much about the person, right? They go on the attack. Mhm.
And a few other things that I think are important to note here is that both types can have pretty significant trauma histories. And individuals with BPD specifically often report sexual trauma or trauma with a parent or attachment figure. Mhm. But individuals with paranoid personality disorder often experience humiliation and sadistic traumas, often from like a father figure, or overwhelming, unmanageable anxiety from a mother figure. Oh yeah, definitely still trauma there. It's often extremely humiliating for that young child, or their own anxiety can't be soothed because a parent's anxiety takes up all the space. Yes. Yes. And I think this is where, even though paranoid types typically are more dangerous than borderline types, where we can hold space for some empathy as how, yeah, like how people get here and how they express this pain to others, to the world. Um, but that doesn't mean that you have to let your guard down, especially with paranoids, but we can make space for empathy, right? Like imagine going through the entire world all the time, spending all of that energy, being so scared that you're going to be attacked. Yeah. Yeah. It would be hard to function. Yeah.
But I mean, from all this, I think the bottom line is that personality disorders are complex, as we always say, but these two types in particular are really hard to tease apart, which is where psychological testing comes in as well, because through that, we can really get in there and see what the drives are. And even with the games that sometimes paranoids play through the testing process, a game is still a game, and a game is still data. So, it's helpful, I think, with testing to really tease apart the different personality disorders, too. But it still can take you for a loop, as it has the both of us. Um, but yeah, again, it takes a professional who is well-versed also in personality dynamics, personality disorders, the games that they play. And it's taken Doc Fish and I years to understand personality disorders, and we're still learning, like constantly. We really haven't stopped. Like, it seems like with each new case, we learn like 10 more things. But I do want to say, if if you are a clinician, a licensed mental health professional who's stuck and you're in a stacked state, Doc Fish and I are happy to help you. We provide consultations. If you would like help with a challenging case, diagnosis, or case conceptualization, or maybe even teasing apart, is it borderline or paranoid, we'll add our contact information to the show notes below.
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.