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the first step in finding the right
treatment is ensuring the right
diagnosis in this session dr. Romani
walks through the key 7 symptoms used to
diagnose paranoid personality disorder
trauma 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 it
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 pretty much if we're
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 but the DSM still seems
to be what is used and it gives 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 yeah 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 you are
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 right 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 an
T too
persons in there 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 you know good
treatments for every mental illness we
have them for many but not all all right
so the DSM lays out seven criterias for
PPD let's go through them one by one
what's the first so what you 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 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 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 you know
it's not like abandonment but it's not
no there 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 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 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
was paranoid personality disorder thinks
his loyalty is almost like this
absolutely blind unquestioning devotion
which is actually not a very healthy
state frankly to be in you're not going
to get a lot 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
they're students graduating they have to
go get a job they're not going to say
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
they're paranoid mentor will view it as
a as not being loyal does the paranoid
I'm just fascinated by this does the
paranoid mentor know they have paranoid
personality this or this is one of those
doesn't matter mental health
professionals okay and have a whole
spate of mental illnesses absolutely
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 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 try to get me before you try to
you were out to you trot 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 all 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 even a period in the wrong place
in that text or a word used the wrong
way or a misplaced capitalization
they're gonna say wasn't this important
to you and it'll literally because
you're just knocking the text off okay
so the the producer of the series 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 horse
so finally I just approached her I said
hey I'm sure I'm reading into this but
is you're sure like sure I'll get to it
I'm irritated with you or is it sure of
course cuz I just ya know 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 at work where you cared about
saying I confronted her about it in in a
respectful way it's not every single
message but no the hidden and demeaning
message could be in an email it could be
in a thank you know it could be the
absence of the thank you no thank you no
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
come
am I not valuable like why white you
know I can't believe you you couldn't
even talk to me you know I I worked so
hard I drove all the way here and it's
just this you you know it can its a
hypersensitivity so you could imagine
you know no matter how many emojis I
mean you could be James Joyce with your
texting you're still gonna get it wrong
I don't what to James Joyce with your
tow James Joyce like that were the
greatest writer of English literature
you know like you really I mean the two
so you could be Hemingway you could be
Shakespeare the perfect writer yeah it's
not gonna be right because it's not
about how you write it it's how they
interpret it and they read these hidden
meanings in and they're looking at
everything and they're looking for them
I know
King for them yeah 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
say 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 you are not only their list you
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 well 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 I think someone didn't get
seated at the right table as at a
wedding that was grounds for divorce
there was no divorce like I'm not going
to be married to you anymore because I
wasn't at table 1 at your cousin's
wedding no yes
stop somebody got into voice yeah yeah
yeah like it because your family
disrespects me that means you disrespect
me and and the your voice all been out
to get me not putting me a table and
went to the wedding said move all these
cards you know the carpets around I'd
have to be at table 1 table 1 that's
where the best people are and they got a
divorce filed
that shocks me I've heard multiple cases
like this is not only one they can't
always weddings where there's a 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 let's say oh diamonds are more
precious than rubies right you put me at
ruby I need to be at diamond so like you
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 sexy yeah I want to be
in red
you know so you know no weddings and
table placement I've heard of people
stopping friendships filing for divorce
cutting people out of Wills I mean like
a ticket and all three were weddings
yeah there's nothing I wasn't there
wedding it wasn't things right but
there's nothing I could do for that
person I don't think which is hard for
me too yeah that's hard for me to come
to translate 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 uh-huh and they're still gonna
ask for a divorce yeah and everyone's
really angry at me here because I met
table one okay I I just needed a minute
to process that's a lot it's a lot like
a divorces the biggest thing people
could go yeah well that's it yeah and
they're voluntarily deciding to do that
because of truly nothing not to them and
not to them I understand that but isn't
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 that you see that
it's like I'm gonna look terrible you
know this is ruining my reputation it
was like don't see it and then they
counter-attack so they perceive that
somebody's attacking their character
attacking their reputation and they
counter-attack but there's no attack
so that person who's being counter
attacked it's just a lie infected yeah
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 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 why did your kids make
that and then you as a person fences
she's a single mom you just called her a
single mom
dude that 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 she's
trying to say I think you're so tough to
do and she said and then we'll then take
her friend aside 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 she'll
just be like that dude 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 whisk it's
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 a very contemptuous
very arrogant sigh you know there
it's nothing who cares don't even mean
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 as 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
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 spouses 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 gonna 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 grocery drama on the frozen
food aisle that's it that's that could
be the title of your next book
what here's my question I've it or my
statement rather I've never met this
person it's good it's pretty rare it's
one person it's pretty rare yeah I mean
you've seen them in your Pratt's have
you ever met them out and about anyone
like this out and about probably not
full-blown I've met people were
definitely teetering towards full
diagnostic but not full-on I have to
tell you nothing that's jumping out and
mine but I've definitely met people who
are strongly I can think of one or two
people who were strongly like this and
really was not an Isis a it was a family
member of someone close to me
yeah dude they have to have all seven of
these no I think I believe it's four out
of the seven okay yeah and any for any
for and for a specific period of time
it's consistent and pervasive like
they've had it since throughout
adulthood you got yeah okay it's not
that your wake you would not like this
and then you wake up at 30 in your life
yes you just develop 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
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you