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 answer important questions about paranoia, paranoid personalities, and psychosis. Like, if someone is delusional, does it mean they're schizophrenic? If someone has paranoia, did they go off the deep end? And what is paranoia, anyway? And where's the line between personality pathology and psychosis? We've got a lot of things to unpack, so let's jump right in.
All right, Doc Fish. To start answering all of these deep questions about the psyche and psychosis, we need to define some terms. So, let's start with paranoia. What is it? Well, historically, it's kind of been a trash can term that we've actually been using for over 2,000 years. Wow. Believe it or not, it was used for all kinds of things, basically anything and everything in the DSM that we use today to diagnose. Now, it disappeared for several hundred years, though, before resurfacing in the 1800s.
Ooh, this is super interesting because, as we've hypothesized before, paranoia and paranoid personalities seem to follow a cultural pattern. So, like, what's happening on the global and political stage can absolutely influence how much paranoia pops up. Super interesting. Yes. So, in the 1800s, paranoia was used to describe intellectual disorders and emotional disorders before being used to describe delusional states in the mid to late 1800s. Despite Freud's significant influence in describing paranoia as a unique defense mechanism, Kraepelin was actually the first one to start using the concept of paranoia most similar to what we use today. Ooh. He was also a major contributor to the concept of paranoid personalities and to schizophrenia, but we'll get to that more later.
What is paranoia, exactly? The narrow definition that I like is that paranoia includes a hostile attribution bias. So that means there's an inclination to view others' behavior as arising from hostility towards oneself. So, like, in other words, it's basically like reading neutral statements and events as threatening because others are thought of as dangerous. Okay? So, like, "Others are out to get me. I need to watch my back. The world is dangerous." Right? And paranoia as a standalone descriptor is just kind of like an out-of-bounds thought that someone or something is after you in some type of way. H. Okay. So, paranoia doesn't always mean that someone's delusional, right? It doesn't always mean that the person is psychotic, and paranoia doesn't always lead to a diagnosis. Sometimes it just stays as paranoia, nothing more than an out-of-bounds thought. Mhm.
So, paranoia can also have strong cultural or social roots. Like, let's think back to the Salem witch trials. That all started with paranoia, which then led to a folie à deux, or a shared delusion that people were witches. But paranoia was the first step to getting there. And this is where we can have really strong cultural aspects to paranoia. Definitely. Given the right environment, paranoia can almost be contagious. Mhm. This is where it gets really interesting because paranoia, even in its purest form, can kind of metastasize and become something much more serious when it enters into delusional territory, like it did with the Salem Witch Trials. And then when you add cultural fuel to that fire, you are on the road to disaster, right? With the Salem witch trials, like, we were actually killing people, and it was culturally acceptable with the shared paranoia and shared delusion. Yes.
So, a helpful metaphor to think about this: You're having an out-of-bounds paranoid thought, and you board the paranoia train. The paranoia train can just idle there. Like, it doesn't have to go anywhere. You can get off the train, the thought can stop, or the train can start moving as the thoughts start growing. So, then the next stop on this train is delusional paranoia. Yes. Here is where the out-of-bounds thought is reasoned with, even given new data that runs contrary to the belief. It may start to pick up other similar thoughts and form a cluster of thoughts. Mhm. This stop on the paranoia train means we are departing from the land of reality. Yeah.
So, then the next stop on this train is diagnosis. But this is interesting because the doors don't really open reliably on this stop. Sometimes they stick, or the person just doesn't get off the paranoia train and actually get the help that they need. But then also, the doors may not open if the paranoid delusion is culturally acceptable. Like, are we really able to diagnose a whole society as being "cuckoo for cocoa puffs"? Yeah. Well, technically not, but I kind of wish we could sometimes. Like, could you imagine trying to do that during the Salem witch trials? Oh my goodness. That would have been really interesting and history in the making as well. But continuing down this train. Okay, so we have multiple stops. The last stop of this paranoia line is going to be full-blown psychosis. So, at this stop, the person is far from the land of reality, like the furthest stop away from reality where they started, and they cannot be reasoned with, and in this space, other psychological functioning will also start to diminish. Yeah. It really depends on the individual's psyche as to where the train is going to head. So, staying in paranoia only, becoming delusional, becoming diagnostically problematic, or becoming psychotic. Yeah. Right on. Yeah.
So, let's camp here at the delusional stop on the paranoia train. So, firstly, what is a delusion? According to the DSM-5, delusions are fixed beliefs that are not amenable to change in light of conflicting evidence. Set a different way, behavior becomes a delusion when an unwarranted suspicion becomes a belief. So, basic suspiciousness is not the same thing, but suspiciousness can lead to delusions. Yeah. So, if I'm initially suspicious that someone put something in my coffee this morning because it smelled funny, like, that's not a delusion, right? It could be that the creamer was off. But if I consistently believe that someone has poisoned my coffee despite other people drinking it and not dying, that would be a delusion. Mhm. Part of a delusion is that a false belief has emotional significance to the person. Yes. Which is held in defiance of evidence at hand. So, it's significant to the person but blatantly false. Mhm. Yes. So, there can be emotional reactions when the world does not wholeheartedly accept that delusion with you because that belief runs deep.
So, what does the DSM say about delusions? They group together common themes that delusions fall under. So, we won't get into all of them for the sake of time, but some common ones include persecutory, which is the most common, actually. So, that means, like, "Someone is out to harm me or kill me," but also this really includes anything that someone might dread. So, like, including humiliation, rejection, being victimized or excluded, betrayed. Mhm. You can see where this goes hand-in-hand with paranoia, right? Like, it's not that far of a stretch to go from paranoid, suspicious thoughts to persecutory delusions. Mhm. Another common one is grandiose delusions, or delusions of grandeur. It's the false belief that one has exceptional abilities, wealth, fame, etc. So, for example, a belief like, "I am God. I am all-knowing." Mhm. Yeah. Uh, these are actually pretty common too. And this level of grandiosity can show up in, uh, narcissistic personality disorder or borderline personality disorder and in hypomania sometimes, but it may not reach that, like, full delusional status, but there's going to be some similarities and it's close. Mhm. Another one is jealous delusions. So, that's the thought or the belief that a lover or a spouse is unfaithful and acting out in extreme ways based on that belief. Mhm. So, for example, like following the spouse to her gyn appointment thinking she's meeting a lover, and this is based on the time she took grooming in the bathroom and the clothes she's wearing. Uh, yeah, kind of along those lines is erotomanic delusions, which is an unrealistic belief that another person is in love with you. Yes. So, believing that Justin Bieber is in love with me, and I am doing everything in my power to track him down. Some put this under grandiose because of the specialness that is assumed, though. Mhm. Yeah. So, the person cannot accept that the other person doesn't love them. So, Justin Bieber actually does not love me. But if I think that he does, there's some grandiose thinking in that. And interestingly, these erotomanic delusions often do involve famous people or people of like higher social status or financial status, which has a grandiose element to it as well, where we're kind of wanting to associate with the somebody's society. Mhm.
Now, it's important to note that delusions, so including paranoid ones, are also seen in medical conditions. So, one study found, like, at least 70, most notably senile dementia, as in Alzheimer's. Yes, that's a great point. So, it's important to note that if you have delusions, it doesn't necessarily mean you have severe mental illness, paranoid personality disorder, or schizophrenia. Like, there's a lot of things that it could be, even a medical condition. So, with this, we're hammering in that point: not all things on the outskirts of reality equal schizophrenia. So, important. Yes. Mhm.
Okay. So, let's keep moving down the paranoia train line. We've just stopped at delusions. The next stop is diagnosis. So, remember, this is the stop with the unreliable doors that stick, and you know, people don't get off that stop. And then, you know, when society goes mad as a group, it doesn't really work either. But Doc Fish, what does it look like when paranoia becomes a diagnosis? So, we don't really have a diagnosis of paranoia in the DSM-5-TR. However, multiple diagnoses do include it. So, concepts of paranoia are included in delusional disorder, though it's not overtly stated as paranoia. Delusional disorder encompasses persecutory and jealous types of this disorder. Mhm. Yeah. So, we just talked about these types of delusions. So, like, "Others are out to harm you," or, you know, "Others are out for your lover," or "Someone loves you and they really don't." Correct? So, someone would have a delusional disorder when those jealous delusions or persecutory delusions stand alone, and the person is otherwise functional. Yeah. Okay. So, they wouldn't necessarily be, maybe, in an inpatient facility because other functioning has not declined here. Like, they're fairly functional in society except this one super duper bizarre belief that their life revolves around. Mhm. Right. It's like, kind of thoughts only, not personality functioning. Mhm. But there are also personality disorders that include elements of paranoia, of course, like borderline and, of course, paranoid personality. Mhm. But for borderline, it's fleeting paranoia that others are out to get them or reject them, and it does not last. And then for paranoid personality, as we've been talking about in this whole series, the paranoia is like all-encompassing, so much so that it's a defining character trait. Mhm. And then we get into darker personality stuff outside the DSM, like malignant narcissism, psychopathy, sadism, all of which can have elements of paranoia as part of the personality makeup. Mhm. These are the scary types. Yeah. So, aside from the personality disorders, all we really have is delusional disorder in the DSM that captures when pure paranoia becomes delusional. You got it.
So, I want to go back to something that you said earlier about delusional disorder encompassing persecutory and jealous delusions. So, interestingly, these paranoid and jealous delusions used to be part of the classification paranoid schizophrenia, but they're not anymore. Hold on. Are you saying that paranoid schizophrenia is no longer a thing? Yeah, that's correct. Okay. So, the last stop of the paranoid train is not schizophrenia. Correct. Yes. The psychosis stop on the paranoia train line does not end in schizophrenia land. Let's go there next.
Okay, so for a while, we had subtypes of schizophrenia, which included a paranoid category, but we do not have the subtype of paranoid schizophrenia anymore, and we actually haven't since the DSM-5 came out in 2013. When it comes to psychopathology, understanding symptoms on a continuum with a range of possibilities is more useful than using boxes or categories always. And so researchers found that subtypes just weren't helpful. Yes. So, unlike other categories, the schizophrenia subtype didn't really tell us about how the person would respond to treatment. And across time, researchers actually couldn't tell the difference among all the different subtypes because the paranoia element is not really part of schizophrenia, and schizophrenia is not the only diagnosis for individuals who are psychotic. Mhm. Yes. Yes. So, on the paranoia train, plain old paranoia can become a hallmark part of the paranoid personality or paranoid personality disorder. And then that personality disorder can further disintegrate into psychosis. And when it does, paranoia becomes paraphrenia. Okay. So, for more info on paraphrenia and the severe types of paranoid personalities, you have to check out our last episode on the subtypes of paranoid personality, which I'll link on YouTube and in the show notes. Mhm.
So, let's talk about schizophrenia, though. Paranoid personality's cousin in Cluster A, the schizotypal personality, can fully fall apart into the psychotic level, which would be schizophrenia, but not paranoid personalities. That is a completely different train of disintegration. Yes. So, paranoid falls apart into paraphrenia. Schizotypal falls apart into schizophrenia. Yes. They are different train lines leading to different psychotic destinations. So true. Okay. And this concept, though, has been much debated back and forth among personality researchers. So, Kraepelin himself, so he's the guy that coined the term paraphrenia and came up with the idea for schizophrenia, he even went back and forth as to whether schizophrenics and paraphrenics actually come from the same personality place. Right. And we still use the terms incorrectly today. Yeah. Paranoid schizophrenia is being used regularly, even though it's no longer a diagnosis. Yes. So true. Yeah. Okay.
But help me understand, how is paranoid personality disorder different from a delusional disorder or even from schizophrenia? Let's start with the DSM. The DSM basically tells us that paranoid personality disorder does not have any criteria involving psychosis. So, like, hallucinations or delusions. It can thus be distinguished from other diagnoses that do have a psychotic component, like the persecutory type of delusional disorder, like schizophrenia, like bipolar or depressive disorder with psychotic features. Yes. So, what this means is that paranoid personality disorder does not involve actual psychosis, but they can tow that line of reality, but they're not going to have a long-lasting psychotic break. But what is long-lasting and consistent is they're towing that line of reality and non-reality with these frequent paranoid fears. In fact, Echeverria, 2009, wrote, "Individuals with paranoid personality disorders create and sustain an altered reality that, although not psychotic, sustains their beliefs about themselves and others." Oh, wow. Yeah, that's a great quote, and it actually makes me think of J. Edgar Hoover. So, he's a great example of how he was able to function in society within his paranoid personality structure. So, he was the first director of the FBI, and within his personality, he kept locked files filled with dirt and blackmail on politicians and celebrities so that he could use it to bend them to his will. Holy cow. So corrupt. Yes, absolutely. But technically adaptive for his position. One could argue, like, he was still in reality and was able to keep a high-profile job, making his paranoia work for him. Right.
So, some examples Echeverria provided regarding the non-psychotic but altered reality includes beliefs such as: "Being on the side of the angels gives them the right to fight corrupted authority." Uh-huh. So, this is like the vigilante flavor. Or, "No one can surprise you if you see them coming." Like, "People have to be watched or they'll exploit and deceive you if they're not stopped." Okay, that's the hypervigilance flavor. Like, "Always be on alert," or like, "Never let them see you bleed" is good advice, or "Trusting others is a way to self-destruct." Yeah. So, in other words, like, "Never show your vulnerability lest it be exploited." Mhm. "People will respect what they fear." "Being soft only lets people do what they want and take what they want." Aha. And this speaks to how paranoids project their anger and aggression on the world as a way to counteract their own fear, like, "Hurt others before they hurt you." Right? So, like, all of these core thoughts are not really psychotic. They're not helpful. Technically, they're maladaptive and not necessarily true across context, but they're not completely out of reality. Yeah. Exactly.
But paranoid personalities can fall apart into paraphrenia and become dangerous. Yeah. So, decompensated paranoid types, or paraphrenics, are much more likely to be seen in forensic settings, like hospitals or jails. Yeah. Yeah. So, paranoids at the psychotic level, or paraphrenics, operate with that core paranoid personality component, which is seeing the world as dangerous. And so then, in the throes of psychosis, paraphrenics are hostile and then see everyone as a threat, and then they're more prone to take their anger out on the world in dramatic and irrational ways. Mhm. So, they're going to be like the dog that you don't move towards because they're going to attack you. Whatever neutral move you make will be interpreted as an attack, and so they attack first. Yes. Yeah. But we don't have a DSM definition of these types at their unhealthiest level, likely because the DSM tends to stop at pathology that's not common in outpatient treatment. So, kind of on that note, in addition to being found in jails and hospitals, these individuals also may end up homeless. And when they do, they are often alongside their schizophrenic neighbors. It's important to note here that the difference between paraphrenic and schizophrenic is that paraphrenics use projection to protect themselves, making them more dangerous, while schizophrenics use fantasy to protect themselves, making them more likely to hide or run. That is, yes, a very helpful thing to distinguish. Mhm.
Okay. But why is all of this so confusing? I know. I wish it wasn't. But the first thing that I think about is that paranoid and paranoia are not well-defined. Like, stemming all the way back from history when the terms were basically trash can diagnoses that were used to describe everything. I think that's my biggest disappointment with the psychological understanding of paranoia, paranoid personality, and the historic paranoid schizophrenia. There's no clear-cut definition. We've been researching and theorizing, but we've been using the same words to describe different concepts. Yes. We tend to do that as shrinks because we're not original. And it's a pet peeve of mine. Mhm. Like, it's simply not helpful. I personally like the term vigilant or hypervigilant that was proposed to describe paranoid personality. It differentiates it from paranoia and those other psychotic paranoid concepts. Yeah, I agree. And then, you know, all these concepts have confused theorists and shrinks basically since schizophrenia and paraphrenia were first discovered, and we still can't get it straight. But the other thing that I'm thinking about, like, for a reason for confusion is just the limitations of the DSM, which we've alluded to already, but I just want to say I fully respect the DSM for what it is, but it's not super helpful when it comes to the more severe end of the spectrum. So, the disorders found in more forensic settings or inpatient hospital settings, like the DSM really is incomplete with its diagnostic categories. Oh my goodness, don't even get me started on the DSM. Okay, the DSM is a book defining pathology. So, first of all, it's only a little picture of human functioning. There's no inclusion of normal or just, like, a little problematic personalities, only the disorder-level functioning. Yeah. So, we're trying to fit personalities into a box. And to me, that's silly. There's too much overlap and individuality. For example, like, no borderline, paranoid, narcissistic, etc., individual looks the same. Yeah. And my point really is that the DSM does have some benefits, but it's only a small piece of the puzzle involving personality disorders, which is why other conceptualizations and perspectives are helpful, like psychoanalytic, Milan, Jung. Yeah. Yeah. Exactly. Kind of expanding our knowledge base. But still, I mean, the DSM has research backing. We have to use it. And for what it is, it does a great job, but it does have limitations beyond the outpatient setting. I'm just thinking of another reason, and that's just I personally don't think we have enough emphasis on personality disorders in our training outside of borderline personality disorder. Our training has moved from the understanding of human nature and complexities to fixing symptoms. So, maybe like insurance doesn't have to pay as much money. Like, we're focused on empirically supported manualized treatments that can be replicated in a lab, but it doesn't mean it translates to real, complex individuals. There's definitely not an emphasis on personality disorders in training, maybe unless you go to a psychoanalytic institute, right? Yeah. Yeah. And I think that insurance piece and the focus on, like, let's use the manualized treatments, that's why we don't focus as much on the personality disorders, and that's in large part why the personality disorders were put on a different axis in earlier editions of the DSM, is because you're not as easily able to check the box, basically, is what I'm trying to say. But yes, insurance has made all the things messy, and unfortunately, once that gets involved and kind of tangled up in our field, it just kind of makes things complicated, not for the better.
But that said, we've covered a lot of ground, as always. And this is confusing stuff. Like, it confuses us, especially as we're going back and researching and seeing the same stinking terms used over and over and trying to figure out, okay, which version of the terms are people using? Um, but distinguishing all these things in general can be so tricky, and especially in clinical practice, which is why Doc Fish and I are here to help. If you're a clinician and you're stuck on a case and you're in a "scacked" state, we do provide consultations to help you figure out what you're working with. So, I will add our contact information in the show notes below. And on that note, that is a wrap for today. So, 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 of our paranoid 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.