(gentle music) - 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 client's billing. So that's what the
insurers use interestingly. The diagnostic criteria, pretty much if for at
least for mental illness, pretty well mirror between the two manuals there can sometimes be
a few little tweaks. They'll categorize the sub categories a little bit differently, but the DSM still seems to be
what is used and it gives it, it can be its own episode on
the amount of controversy about the DSM and how we use it. And
to me, it's a, it's a guide. It's a, 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 hypothesis. And hypothesis that can be revised based on getting more data. So I think we get so caught
up in labels that you have borderline personality. You
might spend more time and say, you know, this is
post-traumatic stress disorder. Like what, what, and it almost doesn't
matter except for treatment. If there's something that's
better suited to PTSD than borderline personality, should
be using that treatment. You know? So I think it's very
much about what is happening. For example, I 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, 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 yeah, not at all. - All right. 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 hype,
of, of suspiciousness, of mistrust and hypersensitivity. That's the overall sort of rubric. When we think about the
diagnosis more specifically, then 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 costing them money
or doing them, you know, 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, 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 not, it's not like abandonment,
but it's more like, - 'Cause that sounds like borderline. - No, 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? You know, 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 there's 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,
you, the students graduating, they have to go get a job. They're not going to stay student forever, but there have been people. I can say this from being an
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 a, as not being loyal. - Does the paranoia, I'm
just fascinated by this. Does the paranoid mentor know they have paranoid personality disorder? - This is one of those concerns, right? - Because they're so educated. - It doesn't matter. - It doesn't matter. - No, no mental health
professionals, okay, had to have a whole spade 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. - Right. - Because they not going to
confide in the therapist. - Right. - Because they're convinced
that this is going to be used against them. They won't confide in anyone
because they believe that that, because remember the person
with paranoid personality, accumulates grievances,
they have vaults and vaults full of grievances that they're
constantly put, pulling out and saying, see, you
tried to get me before you tried to, you were out to, you tried, you broke my trust before.
They're constantly, you know, pushing back on what they think
is 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. Cause 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 a literally, because you're just knocking the text off. - Okay. So the producer of the series, I, for months I would text
her and I would ask her, you know, a question and
she would respond with sure. And there was no period,
no exclamation mark. No. And it was sure, it
wasn't yes or of course. So finally I just
approached 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, I just need to know. And
she goes, oh, it's just, it's just a yes. And I go, okay, great. So. I had that. - Right. - Yeah. - With one person. - With one person. - At work. -At work. - Where you cared about - And I confronted her about it and in a respectful way I hope. - But it's not every single message. - No - But the hidden and demeaning
message could be in an email. It could be in a thank you note. - Yeah - It could be the
absence of the thank you. - In 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, and
how am I not valuable? Like why, why? You know, I can't believe you. You couldn't even talk to me.
You know, I, I worked so hard. I, I drove all the way here
and it's just this, you, you know, it can, it's a hypersensitivity. So you could imagine, you know,
no matter how many emojis, how, I mean, you could be
James Joyce with your texting, you're still gonna 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 didn't mean to, seriously, you can be Hemingway, you
can be Shakespeare. - Yeah. - Perfect writer. - Yeah. - 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 into everything - and they're looking for them. - and they're looking for them. - Yeah. - 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. - So 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 that 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. They go big. These grudges are huge. It will be the kind of thing where they will never go to
a family wedding again. I, you know, I was recently
talking with someone and I think someone didn't
get seated at the right table at a wedding that was grounds for divorce. - What do you mean 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 because - Yeah, yeah, yeah. Your family disrespects me.
That means you disrespect me and you, your, you've
always been out to get me not putting me at table one, went 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 these people are. - And they got a divorce? - Filed. - That shocks me. - I've heard multiple cases
like this. It's not only one. Like it's always weddings
where there's a table, what is that table? The head table? You know, the tables are numbered. Or I think this is what people
should name their tables. But even then they'd
say, oh, - It's better. - diamonds are more precious
than rubies. - Right - You put me at Ruby. I
need to be at diamond. So like, you have to
answer to really be like apple, banana, orange. - Right. - You wouldn't want to go into
the tropical fruits because that might seem a little bit more sassy. - Yeah that's too, too rare. - I want to be a 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 wills. I mean like big ticket and
all three were wedding. - Yeah. There's nothing I could do. - It wasn't their wedding. It
wasn't someone else's wedding. - Right. But nothing. I
could do for that person I don't think. Which is hard for me to, that's hard for me to come to terms with. - Yeah. Yeah. I mean, I guess you could
then move table one around, but then all night
they'll say you, 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 - Because divorced is the biggest thing people could go through - Yeah it's, it's yeah. - And they're, they're,
they're voluntarily deciding to do that
because of truly nothing. - Not to them it's not. - 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 you see that? Like, I'm going to look terrible. You know, this is ruining my reputation. Everyone's like, don't see it.
And then they counter attack. So they perceive that somebody
is attacking their character, attacking their reputation
and they counter attack, but there's no attack. So
that person who is being counterattacked is just blindsided. - Is just being attacked. Yeah. Like 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. And they're having a conversation. And maybe the new person
says, oh, you know, I saw that you have a little
necklace around your neck, did your kids make that?
And then you, as a person, friend says, yeah, she's a single mom. You're just called her a single mom. That, that, that to her
might feel like you just, you just besmirched her character. - Instead of it being an honor. - An honor, which is absolutely is. - Right. She takes it as a negative. - or just, because she's trying to say, I think you're so tough to do this. - Yes - And she said, and then will
then take her friend aside and say 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 she'll, 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. - 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 did this amazing thing. They'll say it's absolutely nothing. A very contemptuous, very arrogant. You know, it's nothing who cares. Don't even ma, 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 it's to say, it's not that big a deal. 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. - Okay. Let's get to the last one. And then I have a question. What is the last criteria? - The last 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, 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 in
the frozen food aisle. When all you did was try
to get your groceries. - Drama on the frozen
food aisle. That that's That could be the title of your next book. Drama on the frozen food aisle. What, here's my question I
have, or my statement rather, I've never met this person. - That's good, it's pretty rare. It's 1%. - It's pretty rare. - Yeah. I mean, you've seen them in your practice. - I have, yeah. - Have you ever met them out and about? - Have I met anyone
like this out and about? Probably not full blown. I've met people who were definitely teetering
towards full diagnostic, but not full on. I have
to tell you nothing that's jumping out at me, 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, it was a family member of
someone close to me. Yeah. - Okay. Do they have to
have all seven of these? - No, I think I believe
it's four out of the seven. - Okay. And any four? - Any four. - And for a specific period of time? - It's consistent and pervasive. Like they've had it some
throughout adulthood. - Got it. - Yeah. - Okay. It's not like you were,
you're not like this and then you wake up at
30 in your like this. - Yes. You just developed that. Right? Okay. 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. (gentle music)
