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The first step in finding the right treatment is ensuring the right diagnosis. In this session, Dr. Ramani walks through the key seven symptoms used to diagnose paranoid personality disorder. Dr. Ramani, for our members who don't know, what is the DSM? The DSM is the Diagnostic and Statistical Manual of Mental Disorders, and we're in the fifth edition. It's published by the American Psychiatric Association, and basically it's a list of nearly 200 separate mental disorders and all of the symptoms and the criteria a person needs to meet in order to receive that diagnosis. Is it perfect? Absolutely not. And in fact, the other manual that's used to diagnose mental illness is called the International Classification of Diseases.
We're in version 10, and that book is put out by the World Health Organization. Do you have a preference? The ICD-10 is what we're required to use to generate diagnoses for clients' billing. So that's what the insurers use, interestingly. The diagnostic criteria, at least for mental illness, pretty well mirror between the two manuals. It can sometimes be a few little tweaks. They'll categorize the subcategories a little bit differently. The DSM still seems to be what is used, and it can be its own episode on the amount of controversy about the DSM and how we use it. To me, it's a guide. It's a rubric. It's not perfect.
We should always get as much data as we can on a client and understand that all of our diagnoses are always hypotheses, and hypotheses that can be revised based on getting more data. So I think we get so caught up in labels that if you have borderline personality, you might spend more time and say, you know, this is post-traumatic stress disorder. And it almost doesn't matter except for treatment. If there's something that's better suited to PTSD than borderline personality, you should be using that treatment. So I think it's very much about what is happening.
For example, I've run into this where we think a person has major depressive disorder, but it turns out they have narcissistic personality, and they're very dejected because life isn't going the way they want. So they're getting antidepressants, and they're getting cognitive behavioral therapy, and nothing's happening. And so you see what I'm saying? So it's really, it's not meant to be a value judgment. It's really meant to drive treatment in the most accurate way possible. That's presuming we have good treatments for every mental illness. We have them for many, but not all. So the DSM lays out seven criteria for PPD. Let's go through them one by one.
What's the first one? So to start with, always remember that the overarching theme of paranoid personality disorder as laid out in the DSM is that the person has a pervasive pattern of suspiciousness, of mistrust, and hypersensitivity. That's the overall sort of rubric. When we think about the diagnosis more specifically than there's these seven criteria, the first criteria is that they suspect with no real basis that other people are harming them or deceiving them. So that they think people are doing things that are causing them problems or causing them money or causing them harm in public or lying to them in some ways. But there's really no substantiation for this. It's just a suspicion they have. Okay.
What about number two? The second is that they're preoccupied about the loyalty of their friends and their associates. So they believe, they really are constantly testing people for their loyalty. They think that people aren't loyal, that if something better comes along they'll just turn on a dime. They'll leave them. They will. . . Now it's not like abandonment, but it's more like, no, no, no, no. They won't be loyal to them. That they won't keep their secrets. That they won't stand behind this business no matter what. They won't stand behind their friendship no matter what.
And so they're like, who else are you spending time with? Who else are you talking with? So there's always this obsession with loyalty. People who work in these situations with maybe a boss or someone like that who has paranoid personality, their boss will always be keeping very close tabs on people, making sure they're not going off to take another job. And people in those situations who are trying to find other jobs to get out of the situation often have to do it under tremendous secrecy because they're such an over-focus on loyalty.
And even the word loyalty is sort of not a good word here because what the person with paranoid personality disorder thinks is loyalty is almost like this absolutely blind, unquestioning devotion, which is actually not a very healthy state for anyone to be in. You're not going to get a letter of recommendation from a boss with PPD. You would get a letter of recommendation from that boss or supervisor if they had no more use for you. You see what I'm saying? And if they felt that what you were going on to do was consistent with their rubric of loyalty. Let's say you're a teacher. Students graduating. They have to go get a job.
They're not going to stay a student forever. But there have been people, I can say this from being in academia, who will keep their best performing scholars at the postdoctoral level around and really kind of almost clip their career because they want their talent around. And when that poor postdoc after six years says, yeah, I want to go and get my own independent career, their paranoid mentor will view it as not being loyal. Does the paranoid. . . I'm just fascinated by this. Does the paranoid mentor know they have paranoid personality disorder? This is one of those disorders. They're so educated. Doesn't matter. Doesn't matter. No, no.
Mental health professionals can have a whole spate of mental illnesses and actually not be aware of it. That makes me feel better, actually. Absolutely. Yeah, no, no. This is a very low insight. This is a very low insight pattern. Okay. So that was number two. Number three. They're reluctant to ever confide in other people because they believe that information will be used against them. And it is for this reason that it's almost impossible to engage these folks in therapy because they're not going to confide in the therapist because they're convinced that this is going to be used against them. They won't confide in anyone because they believe that. . .
Because remember, the person with paranoid personality accumulates grievances. They have vaults and vaults full of grievances that they're constantly pulling out and saying, see, you tried to get me before. You tried to. . . You were out to. . . You broke my trust before. They're constantly pushing back on what they think of people letting them down. So they won't confide in people because they believe someone will use that against them because they do the same thing to other people. Right. Number four. They tend to read hidden meaning and sort of threatening meaning in messages and communication from other people.
So never, ever, ever, ever text a person who has paranoid personality disorder because there's even a period in the wrong place in that text or a word used the wrong way or a misplaced capitalization. They're going to say, wasn't this important to you? And it'll literally because you're just knocking the text off. OK, so the producer of the series, for months I would text her and I would ask her a question and she would respond with, sure. There was no period, no exclamation mark, no. . . And it was sure. It wasn't yes or of course. So finally I just approach her.
I said, hey, I'm sure I'm reading into this, but is your sure like, sure, I'll get to it. I'm irritated with you. Or is it sure? Of course. Because I just need to know. She goes, oh, it's just a yes. And I go, OK, great. So I had that. Right. With one person. With one person. Where you cared about something. And I confronted her about it. In a respectful way. But it's not every single message. But the hidden and demeaning message could be in an email. It could be in a thank you note. It could be the absence of the thank you note. It could be in a text.
It could be in how you speak to them. It could be, hey, give me a second. And you're actually, am I not valuable? I can't believe you couldn't even talk to me. I work so hard. I drove all the way here. And it's just this, it's a hypersensitivity. So you could imagine, no matter how many emojis, I mean, you could be James Joyce with your texting. You're still going to get it wrong. I don't, what's a James Joyce with your texting? Oh, James Joyce, like the greatest writer of English literature. You know, like you really, I mean, seriously, you could be Hemingway, you could be Shakespeare. Perfect writer. It's not going to be right.
Because it's not about how you write it. It's how they interpret it. And they read these hidden meanings in to everything. And they're looking for them. And they're looking for them. Okay. What about number five? They're very unforgiving and they persistently bear grudges. They if you, if you, if you do end up on the wrong side of them, that they really do think that you're out to get them. Or maybe you, you did write that message with the wrong language or you did say something accusatory. God forbid it was actually blatant. They will never forgive you. Never.
If I go to somebody who does have paranoid personality disorder and said you are acting out of control, you are making people feel uncomfortable and you're really lowering the quality of work around here, I am now on their list for that. You are not only on their list, you're probably on their hit list. I wouldn't be surprised if they went to HR about you. If you got like registered letters from attorneys. I mean, they, they go, they go big. Whoa. They go big. These grudges are huge. They will be the kind of thing where they will never go to a family wedding again.
Um, I, you know, I was recently talking with someone and I think someone didn't get seated at the right table as at a wedding. That was grounds for divorce. There wasn't her wedding divorce. Like I'm not, I'm not going to be married to you anymore because I wasn't at table one at your cousin's wedding. No. Yes. Stop. Somebody got divorced. Yeah, yeah, yeah. Like because your family disrespects me. That means you disrespect me and, and you, you, you've always all been out to get me, not putting me at table one to the wedding said, move all these cards, you know, the cards around. I have to be at table one table. One is where the best people are.
And they got a divorce filed. That shocks me. I've heard multiple cases like this. This is not only one. Like it's always weddings where there's a, what is that table? The head table, you know, the tables are numbered or I think this is why people should name with their tables. But even then they'll say, oh, diamonds are more precious than rubies. You put me at Ruby. I need to be at diamond. So like you have to have to really be like apple, banana, orange. You wouldn't want to go into the tropical fruits because that might seem a little bit more sassy.
Yeah, that's too, I want to be in mango, you know, so no, no, no, no, no, no weddings and table placement. I've heard of people stopping friendships, filing for divorce, cutting people out of I mean like big ticket and all three were weddings. Yeah, there's nothing. It wasn't their wedding. It wasn't someone else's right. But there's nothing I could do for that person. I don't think which is hard for me to know. That's hard for me to come to terms with. Yeah. I mean, I guess you could then move table one around, but then all night they'll say you know, I don't think you really want me at table one, even though it's where I belong.
And they're still going to ask for a divorce. Yeah. And everyone's really angry at me here because I'm at table one. Okay. I just needed a minute to process that. It's a lot. It's a lot like divorce is the biggest thing people could go through. Well, that's it. Yeah. And they're they're voluntarily deciding to do that because of truly nothing. Not to them. Not to them. I understand that. But to the rest of us, nothing. Wow. Okay. Yeah. What about number six? Number six is that they perceive that people are attacking their character or their reputation and others don't see it.
So in other words, they're like, don't you don't do you see how there's do you see that they like I'm going to look terrible. You know, this is ruining my reputation. Everyone's like, don't see it. And then they counterattack. So they perceive that somebody is attacking their character, attacking their reputation, and they counterattack. But there's no attack. So that person is being counterattacked is just is just blindsided. Yeah. Like, oh, what are you talking about? So the person who sat them at table two and not table one then gets attacked. It might be the kind of thing where I'll give you an example.
Somebody introduces someone to someone and says, hey, I want you to meet my friend. They're having conversation. And maybe the new person says, oh, you know, I saw that you have a little necklace. Did your kids make that? And then you as a person friend says, yeah, she's a single mom. You just called her a single mom. That to her might feel like you just you just besmirched her character instead of it being an honor, an honor, which absolutely is. Right. Or she takes it. Because she's trying to say, I think you're so tough to do this.
And she said and then will then take her friend aside and said, how dare you? How dare you out me like that? How dare you make me look like something less than to the world? Why can't I just be a mother? And then that will then and then it'll just be like that. Do they ever reach a point where they have moments of, oh, thanks for saying that or that was really nice? No, no. And here's where it gets very interesting. And I've seen this happen in a few cases. When you finally do compliment them, that's amazing. What? Why didn't you tell me you do this amazing thing? They'll say, it's absolutely nothing. They're very contemptuous, very arrogant. You know, it's nothing.
Who cares? Don't even make you know what? I don't even want you to view me through that way because it's almost as though once you start dismantling the apparatus of the paranoia, that's a bigger threat. So they will minimize that praise. So to say it's not that big a deal. You don't even notice that because if you do that, then the whole the whole framework collapses. So they'll often be, again, dismissive, arrogant and contemptuous when you genuinely they'll say it's nothing. Don't be silly. Anyone could do that. Oh, please don't even bring that up. I feel ridiculous that you're even complimenting me for that. OK, let's get to the last one. Then I have a question.
What is the last criteria? The last one is that they have recurrent suspicions about their partner or spouse's fidelity. They always assume that their partner is cheating. They work late. They go on a business trip. They don't answer a text immediately. They run into it all together. They're out and they happen to coincidentally run into one of the old partners in a grocery store or something. You planned this. You knew they were going to be here. You knew this. You timed it. You did it to humiliate me and make me have to see this.
And like it's a drama on the frozen food aisle when all you did was try to get your groceries and drama on the frozen food aisle. That could be the title of your next book. What? Here's my question. I've or my statement rather. I've never met this person. It's good. It's pretty rare. It's 1%. It's pretty rare. I mean, you've seen them in your practice. Have you ever met them out and about? I met anyone like this out and about. Probably not full blown. I've met people who are definitely teetering towards full diagnostic but not full on. I have to tell you nothing that's jumping out. But I've definitely met people who are strongly.
I can think of one or two people who are strongly like this and really was not a nice. It was a family member of someone close to me. Do they have to have all seven of these? No. I believe it's four out of the seven. And any four? Any four. And for a specific period of time? It's consistent and pervasive. They've had it throughout adulthood. It's not that you wake up at 30 and you're like this. Yes, you just developed that. All right. Well, this is all good to know. In our next episode, we're going to look at the screening process of someone with paranoid personality disorder.
What happens when they finally make their way into therapy and what does that process look like so that they actually get the right diagnosis? All that and more when we come back. .