July 1, 2025 • 29 mins
In this episode of The Personality Couch Podcast, we (licensed clinical psychologists Doc Bok and Doc Fish) unpack how paranoia, paranoid personalities, and psychotic disorders overlap. We explore the line between personality disorders and psychosis; misuse of the term schizophrenia; and introduce the concept of paraphrenia as it relates to psychosis in the paranoid personality. We also explore the historical context of paranoia, the nuances between paranoia and delusions, and how the terms became so intertwined in history. We end with our own unfiltered thoughts about limitations to DSM diagnostic categories and how paranoia became so confusing!
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Chapters 00:00 Introduction to Paranoia and Psychosis 02:14 Defining Paranoia 03:15 Sociocultural Paranoia: The Salem Witch Trials 04:22 How Paranoia Leads to Psychosis: A Train Metaphor 06:51 Defining Delusions 08:21 Persecutory Delusions 08:55 Delusions of Grandeur 09:32 Jealous Delusions 10:01 Erotomanic Delusions 12:01 When Paranoia Becomes a Diagnosis 13:14 Paranoia in Personality Disorders 14:34 Wait- Paranoid Schizophrenia is NOT a Diagnosis?! 16:03 Defining Paraphrenia 16:43 Defining Schizophrenia 17:54 How is Paranoid Personality Disorder Different from Schizophrenia? 22:50 The Difference Between Schizophrenia and Paraphrenia 23:11 Confusion in Definitions and DSM Limitations 27:24 Closing
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Welcome to the Personality Couch podcast,
where we discuss all thingspersonality and
clinical practice. I'm yourhost, Doc Bok,
and I'm here with my co-host,Doc Fish. We
are both licensed clinicalpsychologists in
private practice, and todaywe answer important
questions about paranoia, paranoid
(00:22):
personalities, and psychosis. Like,if someone is delusional,
does it mean they're schizophrenic? If
someone has paranoia, did theygo off the deep end?
And what is paranoia anyway? And where's theline between personality pathology and
psychosis? We've got a lot of things tounpack, so let's jump right in.
(00:46):
All right, Doc Fish, to startanswering all
of these deep questions aboutthe psyche and
psychosis, we need to define some terms. Solet's start with paranoia. What is it?
Well, historically, it's kindof been a trash
can term that we've actuallybeen using for over
2,000 years, believe it ornot. It was used
(01:08):
for all kinds of things, basicallyanything and
everything in the DSM thatwe use today to
diagnose. Now, it disappeared forseveral hundred years,
though, before resurfacing in the 1800s.
Oh, this is super interestingbecause as we've
hypothesized before, paranoiaand paranoid
personalities seem to followa cultural pattern.
(01:29):
So like, what's happeningon the global and
political stage can absolutelyinfluence how
much paranoia pops up. Super interesting,yes. So in the 1800s,
paranoia was used to describeintellectual
disorders and emotional disorders.Before being
used to describe delusionalstates in the mid to
late 1800s. Despite Freud'ssignificant influence
(01:53):
in describing paranoia asa unique defense
mechanism, Creplin was actuallythe first one
to start using the conceptof paranoia most
similar to what we use today.Ooh, he was also
a major contributor to theconcept of paranoid
personalities and schizophrenia.But we'll get
to that more later. What isparanoia exactly?
(02:17):
The narrow definition that Ilike is that paranoia
includes a hostile attributionbias. So that
means there's an inclinationto view others'
behavior as arising fromhostility towards
oneself. So like, in otherwords, it's basically
reading neutral statements and events is
threatening because othersare thought of as
(02:38):
dangerous. Okay, so like othersare out to get
me, I need to watch my back,the world is dangerous.
Right. And paranoia as a standalonedescriptor
is just kind of like an outof bounds thought
that someone or somethingis after you in some
type of way. Hmm. Okay, so paranoiadoesn't always
(02:58):
mean that someone's delusional, right? It
doesn't always mean that the personis psychotic. And
paranoia doesn't always leadto a diagnosis.
Sometimes it just stays asparanoia, nothing
more than an out of boundsthought. Mm hmm.
So paranoia can also havestrong cultural or
(03:18):
social roots. Like let'sthink back to the
Salem witch trials. That allstarted with paranoia,
which then led to a folia do 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 strongcultural aspects to
(03:40):
paranoia. Definitely given the right
environment. Paranoia can almostbe contagious. Mm hmm. This
is where it gets really interesting.Because
paranoia, even in its purestform, can kind of
metastasize and become somethingmuch more serious
when it enters into delusionalterritory, like it
(04:02):
did with the Salem witch trials.And then when
you add cultural fuel to thatfire, you are on the
road to disaster, right withthe Salem witch
trials, like we were actually killingpeople. And it was
culturally acceptable withthe shared paranoia
and shared delusion. Yes. Soa helpful metaphor
(04:23):
to think about this, you'rehaving an out of
bounds paranoid thought, andyou board the paranoia
train. The paranoia traincan just idle there.
Like it doesn't have to goanywhere. You can get
off the train, the thoughtcan stop, or the
train can start moving as thethoughts start growing.
(04:44):
So then the next stop on this train is
delusional paranoia. Yes, here iswhere the out of bounds
thought can't be reasonedwith, even given new
data that runs contrary tothe belief. It may
start to pick up other similarthoughts and form
a cluster of thoughts. Mm hmm.This stop on the
(05:04):
paranoia train means we aredeparting from the
land of reality. Yeah. So thenthe next stop on
this train is diagnosis. Butthis is interesting
because the doors don't reallyopen reliably on
this stop. Sometimes theystick, or the person
just doesn't get off the paranoiatrain and actually
(05:26):
get the help that they need.But then also the
doors may not open if theparanoid delusion is
culturally acceptable. Like,are we really able
to diagnose a whole societyas being cuckoo for
Cocoa puffs? Yeah, well, technicallynot, but I
kind of wish we could sometimes.Like, could you
(05:48):
imagine trying to do thatduring the Salem
witch trials? Oh, my goodness,that would have been
really interesting in historyin the making
as well. But continuing downthis train, okay,
so we have multiple stopswith the last stop
of this paranoia line is goingto be full blown
psychosis. So at this stop,the person is far
(06:12):
from the land of reality, likethe 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, itreally depends on the
individual psyche as towhere the train is
going to head. So stayingin paranoia only,
(06:35):
becoming delusional, becoming
diagnostically problematic, orbecoming psychotic. Yeah,
right on. Yeah. So let's camp here at the delusionalstop on the paranoia train. So
firstly, what is a delusion?According to the
DSM five delusions are fixedbeliefs that are
(06:58):
not amenable to change inlight of conflicting
evidence. So a different waybehavior becomes
a delusion when an unwarrantedsuspicion becomes
a belief. So basic suspiciousnessis not the same
thing. But suspiciousness canlead to delusions.
(07:18):
Yeah. So if I'm initially suspiciousthat someone
put something in my coffee this morning,
because it smelled funny, like,that's not a delusion,
right? It could be that thecreamer was off.
But if I consistently believethat someone has
poisoned my coffee, despite other people
drinking it and not dying, thatwould be a delusion.
(07:41):
Mm hmm. Part of a delusionis that a false
belief has emotional significanceto the person,
which is held in defiance ofevidence at hand. So
it's significant to the person,but blatantly false.
Mm hmm. Yes. So there can be emotional
reactions when the world does notwholeheartedly accept
(08:03):
that delusion with you, becausethat belief runs
deep. So what does the DSMsay about delusions?
They group together commonthemes that delusions
fall under. So we won't getinto all of them for
the sake of time. There's somecommon ones include
persecutory, which is the mostcommon actually. So
(08:26):
that means like someone isout to harm me or
kill me. But also this reallyincludes anything that
someone might dread. So likeincluding humiliation,
rejection, being victimizedor excluded, betrayed.
Mm hmm. You can see where thisgoes hand in hand
with paranoia, right? Like,it's not that far of a
(08:46):
stretch to go from paranoid,suspicious thoughts
to persecutory delusions. Anothercommon one is
grandiose delusions or delusionsof grandeur.
It's the false belief thatone has exceptional
abilities, wealth, fame, etc. So for
example, a belief like I amGod, I am all knowing.
(09:10):
Mm hmm. Yeah, these are actuallypretty common
too. And this level of grandiositycan show up in
narcissistic personality disorderor borderline
personality disorder, and inhypomania sometimes,
but it may not reach thatlike full delusional
status, but there's going tobe some similarities
(09:30):
and it's close. Another oneis jealous delusions.
So that's the thought or thebelief that a lover
or spouse is unfaithful andacting out in extreme
ways based on that belief. Mmhmm. So for example,
like following the spouse toher GYN appointment
thinking she's meeting a lover.And this is based
(09:52):
on the time she took groomingin the bathroom
and the clothes she's wearing.Yeah, kind of along
those lines is a rhodomanicdelusions, which is
an unrealistic belief thatanother person is in
love with you. Yeah. So believingthat Justin
Bieber is in love with me andI am doing everything
(10:15):
in my power to track himdown. Some put this
under grandiose because of thespecialness that's
assumed though. Mm hmm. Yeah.So the person
cannot accept that the other persondoesn't love them.
So Justin Bieber actually doesnot love me, but
if I think that he does, there'ssome grandiose
thinking in that. And interestingly,these are
(10:38):
rhodomanic delusions often doinvolve famous people
or people of like higher socialstatus or financial
status, which has a grandioseelement to it as well,
where we're kind of wantingto associate with the
some buddies of society. Mm hmm.Now it's important
to note that delusions, soincluding paranoid
(11:00):
ones are also seen in medicalconditions. So one
study found like at least70, most notably
senile dementia as an Alzheimer's.Yes, that's a great
point. So it's importantto note that if you
have delusions, it doesn't necessarilymean you have
severe mental illness, paranoidpersonality
(11:21):
disorder or schizophrenia.Like there's a lot
of things that it could be even a medical
condition. So with this, we'rehammering in that
point, not all things on theoutskirts of reality
equals schizophrenia. So important.Yes. Mm hmm.
Okay, so let's keep movingdown the paranoia
(11:42):
train line. We've just stoppedat delusions.
The next stop is diagnosis.So remember, this
is the stop with the unreliabledoors that stick
and you know, people don't getoff that stop. And
then, you know, when societygoes mad as a group,
it doesn't really work either.But Doc Fish, what
does it look like when paranoiabecomes a diagnosis?
(12:04):
So we don't really have a diagnosisof paranoia
in the DSM five TR. However,multiple diagnoses
do include it. So conceptsof paranoia are
included in delusional disorder,though it's not
overtly stated as paranoia.delusional disorder
encompasses persecutory andjealous types of this
(12:26):
disorder. Yeah, so we just talkedabout these types
of delusions. So like, othersare out to harm you,
or, you know, others areout for your lover,
or someone loves you, andthey really don't.
Correct. So someone would have a
delusional disorder, when thosejealous delusions or
persecutory delusions standalone. And the
(12:46):
person is otherwise functional.Yeah, okay,
so they wouldn't necessarilybe maybe in an
inpatient facility, becauseother functioning
has not declined here, likethey're fairly
functional in society, exceptthis one super
duper bizarre belief thattheir life revolves
around. Right. It's like kindof thoughts only
(13:09):
not personality functioning.But there are also
personality disorders thatinclude elements of
paranoia, of course, like borderline
personality, and of course, paranoidpersonality. But for
borderline, it's fleetingparanoia, the others
are out to get them or rejectthem. And it does not
(13:30):
last. And then for paranoidpersonality, as
we've been talking about inthis whole series,
the paranoia is like all encompassing, so
much so that it's a definingcharacter trait.
And then we get into darker personality
stuff outside the DSM, likemalignant narcissism,
(13:51):
psychopathy, sadism, allof which can have
elements of paranoia as part ofthe personality makeup.
These are the scary types.Yeah. So aside from
the personality disorders,all we really have is
delusional disorder in the DSMthat captures when
(14:11):
pure paranoia becomes delusional.You got it. So
I want to go back to somethingthat you said
earlier about delusional disorder,encompassing
persecutory and jealous delusions. So
interestingly, these paranoidand jealous delusions
used to be part of the classification,paranoid
(14:32):
schizophrenia, but they'renot anymore. Hold on.
Are you saying that paranoidschizophrenia is no
longer a thing? Yeah, that'scorrect. Okay. So the
last stop of the paranoid train is not
schizophrenia. Correct. Yes. Thepsychosis stop on the
(14:52):
paranoia train line does notend 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 schizophreniaanymore. And
(15:15):
we actually haven't since theDSM five came out in
2013. When it comes to psychopathology,understanding symptoms on a continuum
with a range of possibilitiesis more useful
than using boxes or categories.Always. And so
researchers found that subtypes just
weren't helpful. Yes. So unlikeother categories,
(15:37):
the schizophrenia subtype didn'treally tell us
about how the person wouldrespond to treatment
and across time, researchers actually
couldn't tell the differenceamong all the different
subtypes because the paranoiaelement is not
really part of schizophreniaand schizophrenia
is not the only diagnosisfor individuals who
(15:59):
are psychotic. Yes. Yes. Soon the paranoia train,
plain old paranoia can becomea hallmark part of
the paranoid personality orparanoid personality
disorder. And then that personalitydisorder can
further disintegrate into psychosis.And when it
(16:22):
does, paranoia becomes paraphernia.Okay. So for
more info on paraphernia andthe severe types of
paranoid personalities, youhave to check out
our last episode on the subtypesof paranoid
personality, which I'll linkon YouTube and in
the show notes. So let's talkabout schizophrenia
(16:42):
though. Paranoid personalities cousin in
cluster a the schizotypal personalitycan fully fall
apart into the psychotic level,which would be
schizophrenia, but not paranoidpersonalities.
That is a completely different train of
disintegration. Yes. So paranoidfalls apart
(17:03):
into paraphronic schizotypalfalls apart into
schizophrenia. Yes. They aredifferent train lines
leading to different psychotic
destinations. So true. Okay. Andthis concept though,
has been much debated backand forth among
personality researchers. SoCrapelin himself,
(17:26):
so he's the guy that coined the term
paraphernia and came up with theidea for schizophrenia.
He even went back and forth as to whetherschizophrenics and paraphrenics actually
come from the same personalityplace. Right.
And we still use the termsincorrectly today.
Yeah. Paranoid schizophreniais being used
(17:47):
regularly, even though it'sno longer a diagnosis.
Yes. So true. Yeah. Okay. But help me
understand how is paranoid personalitydisorder different
from a delusional disorder or even from schizophrenia.Let's start with the DSM.
The DSM basically tells us that paranoid
(18:07):
personality disorder does nothave any criteria
involving psychosis. So likehallucinations
or delusions, it can thus bedistinguished from
other diagnoses that do have a psychotic
component, like the persecutory typeof delusional disorder,
like schizophrenia, like bipolaror depressive
(18:28):
disorder with psychotic features.Yes. So what
this means is that paranoid personality disorderdoes not involve actual psychosis,
but they can tow that line ofreality, but they're
not going to have a long lastingpsychotic break.
But what is long lastingand consistent is
(18:49):
they're towing that line of realityand non-reality with
these frequent paranoid fears.In fact, echo
berry 2009 wrote, individualswith paranoid
personality disorders createand sustain an
altered reality that althoughnot psychotic,
(19:10):
sustains their beliefs aboutthemselves and
others. Oh, wow. Yeah. That'sa 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 insociety within his
paranoid personality structure. So he was
the first director of theFBI and within his
(19:32):
personality, he kept lockedfiles filled with
dirt and blackmail on politiciansand celebrities
so that he could use it to bendthem to his will.
Holy cow. So corrupt. Yes,absolutely. But
technically adaptive forhis position. One
(19:53):
could argue like he was still in reality andwas able to keep a high profile job,
making his paranoia work forhim. Right. So some
examples, echo berry providedregarding the non
psychotic, but altered reality includes
beliefs such as being on the sideof the angels gives
(20:16):
them the right to fight corruptedauthority.
Uh huh. So this is like thevigilante flavor.
Or no one can surprise you ifyou see him coming.
Like people have to be watchedor they'll exploit
and deceive you if they'renot stopped. Okay,
that's the hyper vigilanceflavor. Like always
be on alert or like neverlet them see you
(20:37):
bleed is good advice or trustingothers is a way to
self destruct. Yeah. So inother words, like
never show your vulnerabilitylest it be exploited.
People will respect what theyfear being soft
only lets people do what theywant and take what they
want. Aha. And this speaksto how paranoid
(20:59):
project their anger and aggressionon the world
as a way to counteract theirown fear, like hurt
others before they hurt you.Right. So like all of
these core thoughts are notreally psychotic.
They're not helpful. Yeah,technically they're
maladaptive and not necessarilytrue across
(21:19):
context, but they're not completelyout of reality.
Yeah, exactly. But paranoidpersonalities can
fall apart into parapherniaand become dangerous.
Yeah. So decompensated paranoid types or
paraffrenics are much morelikely to be seen in
forensic settings like hospitalsor jails.
(21:41):
Yeah, yeah. So paranoid at thepsychotic level or
paraffrenics operate withthat core paranoid
personality component, whichis seeing the world
as dangerous. And so thenin the throes of
psychosis, paraffrenics arehostile and then see
everyone as a threat. And thenthey're more prone
to take their anger out onthe world in dramatic
(22:04):
and irrational ways. So they'regoing to be
like the dog that you don'tmove towards because
they're going to attack you.Whatever neutral
move you make will be interpretedas an attack.
And so they attack first.Yes. Yeah. But we
don't have a DSM definition ofthese types at their
(22:25):
unhealthiest level, likelybecause the DSM
tends to stop at pathologythat's not common in
outpatient treatment. So kindof on that note,
in addition to being found injails and hospitals,
these individuals also mayend up homeless.
And when they do, they're oftenalongside their
(22:47):
schizophrenic neighbors.It's important to
note here that the differencebetween paraffrenic
and schizophrenic is thatparaffrenics use
projection to protect themselves,making them
more dangerous. While schizophrenicsuse fantasy
to protect themselves, makingthem more likely to
hide or run. That is yes, a very helpful
(23:08):
thing to distinguish. Okay.But why is all of this
so confusing? I know, I wishit wasn't. But
the first thing that I thinkabout is that
paranoid and paranoia are notwell defined, like
stemming all the way back fromhistory when the
terms were basically trashcan diagnoses that
(23:31):
were used to describe everything.I think that's my
biggest disappointment withthe psychological
understanding of paranoia,paranoid personality,
and the historic paranoid schizophrenia.There's
no clear cut definition. We'vebeen researching
and theorizing, but we've been using the samewords to describe different concepts.
Yes, we tend to do thatas shrinks because
(23:53):
we're not original. And it'sa pet peeve of mine.
I think it's simply not helpful.I personally
like the term vigilant or hypervigilantthat was
proposed to describe paranoidpersonality. It
differentiates it from paranoiaand those other
psychotic paranoid concepts.Yeah, I agree. And
then, you know, all these conceptshave confused
(24:16):
theorists and shrinks basicallysince schizophrenia
and paraphernia were first discovered,and we still
can't get it straight. Butthe other thing that
I'm thinking about, like fora reason for confusion
is just the limitations ofthe DSM, which we've
alluded to already. But I justwant to say I fully
respect the DSM for whatit is, but it's not
(24:39):
super helpful when it comes tothe more severe end of
the spectrum. So the disordersfound in more
forensic settings or inpatienthospital settings,
like the DSM really is incompletewith its
diagnostic categories. Ohmy goodness. Don't
even get me started on theDSM. Okay. The DSM
(25:00):
is a book defining pathology.So first of all,
it's only a little picture of human
functioning. There's no inclusionof 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 overlapand individuality. For
(25:24):
example, like no borderline paranoid,narcissistic,
etc. Individual looks the same.Yeah. And my point
really is that the DSM doeshave some benefits,
but it's only a small piece ofthe puzzle involving
personality disorders, which is why other
conceptualizations and perspectivesare helpful,
like psychoanalytic, Milan,young. Yeah, yeah,
(25:46):
exactly. Kind of expandingour knowledge base.
But still, I mean, the DSMhas research backing.
We have to use it. And forwhat it is, it does a
great job, but it does havelimitations beyond
the outpatient setting. I'm justthinking of another
reason. And that's just, I personallydon't think
we have enough emphasis onpersonality disorders
(26:08):
in our training outside of borderline
personality disorder. Our traininghas moved from the
understanding of human natureand complexities to
fixing symptoms. So maybe likeinsurance doesn't
have to pay as much money.We're focused on
empirically supported, manualizedtreatments that
(26:29):
can be replicated in a lab,but it doesn't mean
it translates to real complexindividuals. There's
definitely not an emphasis onpersonality disorders
and trainings. Maybe unless yougo to a psychoanalytic
institute. Right. Yeah, yeah.And I think that
insurance piece and the focuson like, let's use
the manualized treatments.That's why we don't
(26:52):
focus as much on the personalitydisorders. And
that's in large part why the personality
disorders were put on a differentaxis in earlier editions
of the DSM is because you'renot as easily able to
check the box basically is whatI'm trying to say.
But yes, insurance has madeall the things
(27:13):
messy. And unfortunately, oncethat gets involved and
kind of tangled up in ourfield, it just kind
of makes things complicated,not for the better.
But that said, we've covereda lot of ground
as always. And this is confusingstuff. Like it
confuses us, especially aswe're going back and
(27:33):
researching and seeing thesame stinking terms
used over and over and tryingto figure out,
okay, which version of the termsare people using.
But distinguishing all these things in
general can be so tricky. Andespecially in clinical
practice, which is why DocFish and I are here
to help if you're a clinician,and you're stuck on
a case and you're in a sidepacked state, we do
(27:55):
provide consultations to helpyou figure out what
you're working with. So Iwill add our contact
information in the show notesbelow. And on that
note, that is a wrap for today.So thank you for
joining us today on this episodeof the personality
couch. Make sure to checkout our blogs that
coincide with these episodes atwww.personalitycouch.com.
(28:19):
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app. And on YouTube, hit that bell so you
don't miss a single episode ofour paranoid series.
Be well, be kind, and we'll see you nexttime on the personality couch.
Shh. This podcast is for informational
(28:40):
purposes only and does not constitutea professional
relationship. If you're inneed of professional
help, please seek out appropriateresources in
your area. Information aboutclinical trends or
diagnoses are discussed inbroad and universal
terms and do not refer to anyspecific person or case.
Welcome to the Personality Couch podcast,
where we discuss all thingspersonality and
clinical practice. I'm yourhost, Doc Bok,
and I'm here with my co-host,Doc Fish. We
are both licensed clinicalpsychologists in
private practice, and todaywe answer important
questions about paranoia, paranoid
(00:22):
personalities, and psychosis. Like,if someone is delusional,
does it mean they're schizophrenic? If
someone has paranoia, did theygo off the deep end?
And what is paranoia anyway? And where's theline between personality pathology and
psychosis? We've got a lot of things tounpack, so let's jump right in.
(00:46):
All right, Doc Fish, to startanswering all
of these deep questions aboutthe psyche and
psychosis, we need to define some terms. Solet's start with paranoia. What is it?
Well, historically, it's kindof been a trash
can term that we've actuallybeen using for over
2,000 years, believe it ornot. It was used
(01:08):
for all kinds of things, basicallyanything and
everything in the DSM thatwe use today to
diagnose. Now, it disappeared forseveral hundred years,
though, before resurfacing in the 1800s.
Oh, this is super interestingbecause as we've
hypothesized before, paranoiaand paranoid
personalities seem to followa cultural pattern.
(01:29):
So like, what's happeningon the global and
political stage can absolutelyinfluence how
much paranoia pops up. Super interesting,yes. So in the 1800s,
paranoia was used to describeintellectual
disorders and emotional disorders.Before being
used to describe delusionalstates in the mid to
late 1800s. Despite Freud'ssignificant influence
(01:53):
in describing paranoia asa unique defense
mechanism, Creplin was actuallythe first one
to start using the conceptof paranoia most
similar to what we use today.Ooh, he was also
a major contributor to theconcept of paranoid
personalities and schizophrenia.But we'll get
to that more later. What isparanoia exactly?
(02:17):
The narrow definition that Ilike is that paranoia
includes a hostile attributionbias. So that
means there's an inclinationto view others'
behavior as arising fromhostility towards
oneself. So like, in otherwords, it's basically
reading neutral statements and events is
threatening because othersare thought of as
(02:38):
dangerous. Okay, so like othersare out to get
me, I need to watch my back,the world is dangerous.
Right. And paranoia as a standalonedescriptor
is just kind of like an outof bounds thought
that someone or somethingis after you in some
type of way. Hmm. Okay, so paranoiadoesn't always
(02:58):
mean that someone's delusional, right? It
doesn't always mean that the personis psychotic. And
paranoia doesn't always leadto a diagnosis.
Sometimes it just stays asparanoia, nothing
more than an out of boundsthought. Mm hmm.
So paranoia can also havestrong cultural or
(03:18):
social roots. Like let'sthink back to the
Salem witch trials. That allstarted with paranoia,
which then led to a folia do 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 strongcultural aspects to
(03:40):
paranoia. Definitely given the right
environment. Paranoia can almostbe contagious. Mm hmm. This
is where it gets really interesting.Because
paranoia, even in its purestform, can kind of
metastasize and become somethingmuch more serious
when it enters into delusionalterritory, like it
(04:02):
did with the Salem witch trials.And then when
you add cultural fuel to thatfire, you are on the
road to disaster, right withthe Salem witch
trials, like we were actually killingpeople. And it was
culturally acceptable withthe shared paranoia
and shared delusion. Yes. Soa helpful metaphor
(04:23):
to think about this, you'rehaving an out of
bounds paranoid thought, andyou board the paranoia
train. The paranoia traincan just idle there.
Like it doesn't have to goanywhere. You can get
off the train, the thoughtcan stop, or the
train can start moving as thethoughts start growing.
(04:44):
So then the next stop on this train is
delusional paranoia. Yes, here iswhere the out of bounds
thought can't be reasonedwith, even given new
data that runs contrary tothe belief. It may
start to pick up other similarthoughts and form
a cluster of thoughts. Mm hmm.This stop on the
(05:04):
paranoia train means we aredeparting from the
land of reality. Yeah. So thenthe next stop on
this train is diagnosis. Butthis is interesting
because the doors don't reallyopen reliably on
this stop. Sometimes theystick, or the person
just doesn't get off the paranoiatrain and actually
(05:26):
get the help that they need.But then also the
doors may not open if theparanoid delusion is
culturally acceptable. Like,are we really able
to diagnose a whole societyas being cuckoo for
Cocoa puffs? Yeah, well, technicallynot, but I
kind of wish we could sometimes.Like, could you
(05:48):
imagine trying to do thatduring the Salem
witch trials? Oh, my goodness,that would have been
really interesting in historyin the making
as well. But continuing downthis train, okay,
so we have multiple stopswith the last stop
of this paranoia line is goingto be full blown
psychosis. So at this stop,the person is far
(06:12):
from the land of reality, likethe 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, itreally depends on the
individual psyche as towhere the train is
going to head. So stayingin paranoia only,
(06:35):
becoming delusional, becoming
diagnostically problematic, orbecoming psychotic. Yeah,
right on. Yeah. So let's camp here at the delusionalstop on the paranoia train. So
firstly, what is a delusion?According to the
DSM five delusions are fixedbeliefs that are
(06:58):
not amenable to change inlight of conflicting
evidence. So a different waybehavior becomes
a delusion when an unwarrantedsuspicion becomes
a belief. So basic suspiciousnessis not the same
thing. But suspiciousness canlead to delusions.
(07:18):
Yeah. So if I'm initially suspiciousthat someone
put something in my coffee this morning,
because it smelled funny, like,that's not a delusion,
right? It could be that thecreamer was off.
But if I consistently believethat someone has
poisoned my coffee, despite other people
drinking it and not dying, thatwould be a delusion.
(07:41):
Mm hmm. Part of a delusionis that a false
belief has emotional significanceto the person,
which is held in defiance ofevidence at hand. So
it's significant to the person,but blatantly false.
Mm hmm. Yes. So there can be emotional
reactions when the world does notwholeheartedly accept
(08:03):
that delusion with you, becausethat belief runs
deep. So what does the DSMsay about delusions?
They group together commonthemes that delusions
fall under. So we won't getinto all of them for
the sake of time. There's somecommon ones include
persecutory, which is the mostcommon actually. So
(08:26):
that means like someone isout to harm me or
kill me. But also this reallyincludes anything that
someone might dread. So likeincluding humiliation,
rejection, being victimizedor excluded, betrayed.
Mm hmm. You can see where thisgoes hand in hand
with paranoia, right? Like,it's not that far of a
(08:46):
stretch to go from paranoid,suspicious thoughts
to persecutory delusions. Anothercommon one is
grandiose delusions or delusionsof grandeur.
It's the false belief thatone has exceptional
abilities, wealth, fame, etc. So for
example, a belief like I amGod, I am all knowing.
(09:10):
Mm hmm. Yeah, these are actuallypretty common
too. And this level of grandiositycan show up in
narcissistic personality disorderor borderline
personality disorder, and inhypomania sometimes,
but it may not reach thatlike full delusional
status, but there's going tobe some similarities
(09:30):
and it's close. Another oneis jealous delusions.
So that's the thought or thebelief that a lover
or spouse is unfaithful andacting out in extreme
ways based on that belief. Mmhmm. So for example,
like following the spouse toher GYN appointment
thinking she's meeting a lover.And this is based
(09:52):
on the time she took groomingin the bathroom
and the clothes she's wearing.Yeah, kind of along
those lines is a rhodomanicdelusions, which is
an unrealistic belief thatanother person is in
love with you. Yeah. So believingthat Justin
Bieber is in love with me andI am doing everything
(10:15):
in my power to track himdown. Some put this
under grandiose because of thespecialness that's
assumed though. Mm hmm. Yeah.So the person
cannot accept that the other persondoesn't love them.
So Justin Bieber actually doesnot love me, but
if I think that he does, there'ssome grandiose
thinking in that. And interestingly,these are
(10:38):
rhodomanic delusions often doinvolve famous people
or people of like higher socialstatus or financial
status, which has a grandioseelement to it as well,
where we're kind of wantingto associate with the
some buddies of society. Mm hmm.Now it's important
to note that delusions, soincluding paranoid
(11:00):
ones are also seen in medicalconditions. So one
study found like at least70, most notably
senile dementia as an Alzheimer's.Yes, that's a great
point. So it's importantto note that if you
have delusions, it doesn't necessarilymean you have
severe mental illness, paranoidpersonality
(11:21):
disorder or schizophrenia.Like there's a lot
of things that it could be even a medical
condition. So with this, we'rehammering in that
point, not all things on theoutskirts of reality
equals schizophrenia. So important.Yes. Mm hmm.
Okay, so let's keep movingdown the paranoia
(11:42):
train line. We've just stoppedat delusions.
The next stop is diagnosis.So remember, this
is the stop with the unreliabledoors that stick
and you know, people don't getoff that stop. And
then, you know, when societygoes mad as a group,
it doesn't really work either.But Doc Fish, what
does it look like when paranoiabecomes a diagnosis?
(12:04):
So we don't really have a diagnosisof paranoia
in the DSM five TR. However,multiple diagnoses
do include it. So conceptsof paranoia are
included in delusional disorder,though it's not
overtly stated as paranoia.delusional disorder
encompasses persecutory andjealous types of this
(12:26):
disorder. Yeah, so we just talkedabout these types
of delusions. So like, othersare out to harm you,
or, you know, others areout for your lover,
or someone loves you, andthey really don't.
Correct. So someone would have a
delusional disorder, when thosejealous delusions or
persecutory delusions standalone. And the
(12:46):
person is otherwise functional.Yeah, okay,
so they wouldn't necessarilybe maybe in an
inpatient facility, becauseother functioning
has not declined here, likethey're fairly
functional in society, exceptthis one super
duper bizarre belief thattheir life revolves
around. Right. It's like kindof thoughts only
(13:09):
not personality functioning.But there are also
personality disorders thatinclude elements of
paranoia, of course, like borderline
personality, and of course, paranoidpersonality. But for
borderline, it's fleetingparanoia, the others
are out to get them or rejectthem. And it does not
(13:30):
last. And then for paranoidpersonality, as
we've been talking about inthis whole series,
the paranoia is like all encompassing, so
much so that it's a definingcharacter trait.
And then we get into darker personality
stuff outside the DSM, likemalignant narcissism,
(13:51):
psychopathy, sadism, allof which can have
elements of paranoia as part ofthe personality makeup.
These are the scary types.Yeah. So aside from
the personality disorders,all we really have is
delusional disorder in the DSMthat captures when
(14:11):
pure paranoia becomes delusional.You got it. So
I want to go back to somethingthat you said
earlier about delusional disorder,encompassing
persecutory and jealous delusions. So
interestingly, these paranoidand jealous delusions
used to be part of the classification,paranoid
(14:32):
schizophrenia, but they'renot anymore. Hold on.
Are you saying that paranoidschizophrenia is no
longer a thing? Yeah, that'scorrect. Okay. So the
last stop of the paranoid train is not
schizophrenia. Correct. Yes. Thepsychosis stop on the
(14:52):
paranoia train line does notend 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 schizophreniaanymore. And
(15:15):
we actually haven't since theDSM five came out in
2013. When it comes to psychopathology,understanding symptoms on a continuum
with a range of possibilitiesis more useful
than using boxes or categories.Always. And so
researchers found that subtypes just
weren't helpful. Yes. So unlikeother categories,
(15:37):
the schizophrenia subtype didn'treally tell us
about how the person wouldrespond to treatment
and across time, researchers actually
couldn't tell the differenceamong all the different
subtypes because the paranoiaelement is not
really part of schizophreniaand schizophrenia
is not the only diagnosisfor individuals who
(15:59):
are psychotic. Yes. Yes. Soon the paranoia train,
plain old paranoia can becomea hallmark part of
the paranoid personality orparanoid personality
disorder. And then that personalitydisorder can
further disintegrate into psychosis.And when it
(16:22):
does, paranoia becomes paraphernia.Okay. So for
more info on paraphernia andthe severe types of
paranoid personalities, youhave to check out
our last episode on the subtypesof paranoid
personality, which I'll linkon YouTube and in
the show notes. So let's talkabout schizophrenia
(16:42):
though. Paranoid personalities cousin in
cluster a the schizotypal personalitycan fully fall
apart into the psychotic level,which would be
schizophrenia, but not paranoidpersonalities.
That is a completely different train of
disintegration. Yes. So paranoidfalls apart
(17:03):
into paraphronic schizotypalfalls apart into
schizophrenia. Yes. They aredifferent train lines
leading to different psychotic
destinations. So true. Okay. Andthis concept though,
has been much debated backand forth among
personality researchers. SoCrapelin himself,
(17:26):
so he's the guy that coined the term
paraphernia and came up with theidea for schizophrenia.
He even went back and forth as to whetherschizophrenics and paraphrenics actually
come from the same personalityplace. Right.
And we still use the termsincorrectly today.
Yeah. Paranoid schizophreniais being used
(17:47):
regularly, even though it'sno longer a diagnosis.
Yes. So true. Yeah. Okay. But help me
understand how is paranoid personalitydisorder different
from a delusional disorder or even from schizophrenia.Let's start with the DSM.
The DSM basically tells us that paranoid
(18:07):
personality disorder does nothave any criteria
involving psychosis. So likehallucinations
or delusions, it can thus bedistinguished from
other diagnoses that do have a psychotic
component, like the persecutory typeof delusional disorder,
like schizophrenia, like bipolaror depressive
(18:28):
disorder with psychotic features.Yes. So what
this means is that paranoid personality disorderdoes not involve actual psychosis,
but they can tow that line ofreality, but they're
not going to have a long lastingpsychotic break.
But what is long lastingand consistent is
(18:49):
they're towing that line of realityand non-reality with
these frequent paranoid fears.In fact, echo
berry 2009 wrote, individualswith paranoid
personality disorders createand sustain an
altered reality that althoughnot psychotic,
(19:10):
sustains their beliefs aboutthemselves and
others. Oh, wow. Yeah. That'sa 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 insociety within his
paranoid personality structure. So he was
the first director of theFBI and within his
(19:32):
personality, he kept lockedfiles filled with
dirt and blackmail on politiciansand celebrities
so that he could use it to bendthem to his will.
Holy cow. So corrupt. Yes,absolutely. But
technically adaptive forhis position. One
(19:53):
could argue like he was still in reality andwas able to keep a high profile job,
making his paranoia work forhim. Right. So some
examples, echo berry providedregarding the non
psychotic, but altered reality includes
beliefs such as being on the sideof the angels gives
(20:16):
them the right to fight corruptedauthority.
Uh huh. So this is like thevigilante flavor.
Or no one can surprise you ifyou see him coming.
Like people have to be watchedor they'll exploit
and deceive you if they'renot stopped. Okay,
that's the hyper vigilanceflavor. Like always
be on alert or like neverlet them see you
(20:37):
bleed is good advice or trustingothers is a way to
self destruct. Yeah. So inother words, like
never show your vulnerabilitylest it be exploited.
People will respect what theyfear being soft
only lets people do what theywant and take what they
want. Aha. And this speaksto how paranoid
(20:59):
project their anger and aggressionon the world
as a way to counteract theirown fear, like hurt
others before they hurt you.Right. So like all of
these core thoughts are notreally psychotic.
They're not helpful. Yeah,technically they're
maladaptive and not necessarilytrue across
(21:19):
context, but they're not completelyout of reality.
Yeah, exactly. But paranoidpersonalities can
fall apart into parapherniaand become dangerous.
Yeah. So decompensated paranoid types or
paraffrenics are much morelikely to be seen in
forensic settings like hospitalsor jails.
(21:41):
Yeah, yeah. So paranoid at thepsychotic level or
paraffrenics operate withthat core paranoid
personality component, whichis seeing the world
as dangerous. And so thenin the throes of
psychosis, paraffrenics arehostile and then see
everyone as a threat. And thenthey're more prone
to take their anger out onthe world in dramatic
(22:04):
and irrational ways. So they'regoing to be
like the dog that you don'tmove towards because
they're going to attack you.Whatever neutral
move you make will be interpretedas an attack.
And so they attack first.Yes. Yeah. But we
don't have a DSM definition ofthese types at their
(22:25):
unhealthiest level, likelybecause the DSM
tends to stop at pathologythat's not common in
outpatient treatment. So kindof on that note,
in addition to being found injails and hospitals,
these individuals also mayend up homeless.
And when they do, they're oftenalongside their
(22:47):
schizophrenic neighbors.It's important to
note here that the differencebetween paraffrenic
and schizophrenic is thatparaffrenics use
projection to protect themselves,making them
more dangerous. While schizophrenicsuse fantasy
to protect themselves, makingthem more likely to
hide or run. That is yes, a very helpful
(23:08):
thing to distinguish. Okay.But why is all of this
so confusing? I know, I wishit wasn't. But
the first thing that I thinkabout is that
paranoid and paranoia are notwell defined, like
stemming all the way back fromhistory when the
terms were basically trashcan diagnoses that
(23:31):
were used to describe everything.I think that's my
biggest disappointment withthe psychological
understanding of paranoia,paranoid personality,
and the historic paranoid schizophrenia.There's
no clear cut definition. We'vebeen researching
and theorizing, but we've been using the samewords to describe different concepts.
Yes, we tend to do thatas shrinks because
(23:53):
we're not original. And it'sa pet peeve of mine.
I think it's simply not helpful.I personally
like the term vigilant or hypervigilantthat was
proposed to describe paranoidpersonality. It
differentiates it from paranoiaand those other
psychotic paranoid concepts.Yeah, I agree. And
then, you know, all these conceptshave confused
(24:16):
theorists and shrinks basicallysince schizophrenia
and paraphernia were first discovered,and we still
can't get it straight. Butthe other thing that
I'm thinking about, like fora reason for confusion
is just the limitations ofthe DSM, which we've
alluded to already. But I justwant to say I fully
respect the DSM for whatit is, but it's not
(24:39):
super helpful when it comes tothe more severe end of
the spectrum. So the disordersfound in more
forensic settings or inpatienthospital settings,
like the DSM really is incompletewith its
diagnostic categories. Ohmy goodness. Don't
even get me started on theDSM. Okay. The DSM
(25:00):
is a book defining pathology.So first of all,
it's only a little picture of human
functioning. There's no inclusionof 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 overlapand individuality. For
(25:24):
example, like no borderline paranoid,narcissistic,
etc. Individual looks the same.Yeah. And my point
really is that the DSM doeshave some benefits,
but it's only a small piece ofthe puzzle involving
personality disorders, which is why other
conceptualizations and perspectivesare helpful,
like psychoanalytic, Milan,young. Yeah, yeah,
(25:46):
exactly. Kind of expandingour knowledge base.
But still, I mean, the DSMhas research backing.
We have to use it. And forwhat it is, it does a
great job, but it does havelimitations beyond
the outpatient setting. I'm justthinking of another
reason. And that's just, I personallydon't think
we have enough emphasis onpersonality disorders
(26:08):
in our training outside of borderline
personality disorder. Our traininghas moved from the
understanding of human natureand complexities to
fixing symptoms. So maybe likeinsurance doesn't
have to pay as much money.We're focused on
empirically supported, manualizedtreatments that
(26:29):
can be replicated in a lab,but it doesn't mean
it translates to real complexindividuals. There's
definitely not an emphasis onpersonality disorders
and trainings. Maybe unless yougo to a psychoanalytic
institute. Right. Yeah, yeah.And I think that
insurance piece and the focuson like, let's use
the manualized treatments.That's why we don't
(26:52):
focus as much on the personalitydisorders. And
that's in large part why the personality
disorders were put on a differentaxis in earlier editions
of the DSM is because you'renot as easily able to
check the box basically is whatI'm trying to say.
But yes, insurance has madeall the things
(27:13):
messy. And unfortunately, oncethat gets involved and
kind of tangled up in ourfield, it just kind
of makes things complicated,not for the better.
But that said, we've covereda lot of ground
as always. And this is confusingstuff. Like it
confuses us, especially aswe're going back and
(27:33):
researching and seeing thesame stinking terms
used over and over and tryingto figure out,
okay, which version of the termsare people using.
But distinguishing all these things in
general can be so tricky. Andespecially in clinical
practice, which is why DocFish and I are here
to help if you're a clinician,and you're stuck on
a case and you're in a sidepacked state, we do
(27:55):
provide consultations to helpyou figure out what
you're working with. So Iwill add our contact
information in the show notesbelow. And on that
note, that is a wrap for today.So thank you for
joining us today on this episodeof the personality
couch. Make sure to checkout our blogs that
coincide with these episodes atwww.personalitycouch.com.
(28:19):
And as always, don't forgetto give us a thumbs
up or rate and review us onyour favorite podcast
app. And on YouTube, hit that bell so you
don't miss a single episode ofour paranoid series.
Be well, be kind, and we'll see you nexttime on the personality couch.
Shh. This podcast is for informational
(28:40):
purposes only and does not constitutea professional
relationship. If you're inneed of professional
help, please seek out appropriateresources in
your area. Information aboutclinical trends or
diagnoses are discussed inbroad and universal
terms and do not refer to anyspecific person or case.
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