582 CHAPTER 13
People with paranoid personality disorder are better able to evaluate whether
their suspicions are based on reality than are people with paranoid schizophrenia.
Moreover, the sources of their perceived threats are not likely to be strangers or
bizarre types of signals (such as radio waves), as is the case with paranoid schizo-
phrenia, but rather known individuals (Skodol, 2005). If the symptoms arise while
a person is using substances or during a psychotic episode of schizophrenia or a
mood disorder, then paranoid personality disorder is not diagnosed. As you’ll see
in Case 13.2, about Ms. X., it may not be immediately apparent from a patient’s
report what is “true” and what is a paranoid belief.As was the case with Ms. X.’s refusal to believe her sisters, people with para-
noid personality disorder cannot readily be persuaded that their paranoid beliefs
do not refl ect reality, although they can recognize that there are multiple ways to
interpret other people’s reactions and behaviors. Although less
obvious in the case of Ms. X., other common characteristics of
people with this personality disorder include a strong desire to
be self-suffi cient and in control, which stems from a distrust of
others, and a tendency to be critical of others and blame them for
problems that arise. People with this disorder may also be unable
to accept criticism from others. In response to stress, they may
become briefl y psychotic, with their paranoid beliefs reaching de-
lusional proportions.
In addition, people with paranoid personality disorder tend
to be diffi cult to get along with because their suspiciousness fre-
quently leads them to be secretive or “cold,” argumentative, or
complaining or to bear a grudge. These behaviors often elicit
hostility or anger in others, which then confi rms the individual’s
suspicious beliefs. Table 13.5 provides additional information
about paranoid personality disorder.CASE 13.2 • FROM THE OUTSIDE: Paranoid Personality Disorder
The Case of Ms. X. by Daphne C. Brazile, MD
Ms. X. is a middle-aged African-American woman who has lived in the area all of her life.
She began seeking treatment... after her family members had noted that, to them, she was
acting strangely. Ms. X. stated that she believed that her family members were out to make
her crazy and convince her neighbors of the same. She stated the reason for this was because
she was the “darkest one” in her family. Ms. X. was a fair-skinned black woman. She was born
to a dark-skinned black mother and a white father. She was the darkest sibling of her family.
Because of this, she felt that her family had treated her and her mother unjustly. She stated
that as a child, she was instructed to look after her lighter-skinned older sisters, whom the
family held in high regard. She stated that she did not complete high school because she had
to care for her older sister’s children. She described that she would be instructed to “cook
and clean” for them, as though she were their slave, and be available to them whenever they
needed her.... Because of this, [she claimed] she was not able to have a social life. After
Ms. X. married, she continued to receive the same treatment from her sisters. She stated that
her children were treated unfairly, because of their darker skin as well.... As she got older,
Ms. X. stated that her sisters, who were part of the elite society, would “embarrass” her while
around their socialite friends. She believed this to be due to her darker skin color. She stated
that her sisters convinced her neighbors that she was a “bad” person, and because of this,
her neighbors would do “evil” things to spite her.
Ms. X. met with her sisters to discuss this issue. When confronted, the sisters denied that
they were treating her negatively. They acknowledged that their skin was fairer than hers but
denied that they were treating her in such a way. They believed that their sister was “delu-
sional.” Ms. X. refused to believe her sisters, and when confronted with the idea that her fam-
ily was not in any way harming her, she would shift the conversation to another topic.
(Paniagua, 2001, pp. 135–136)People with paranoid personality disorder dis-
trust others and tend to interpret other people’s
remarks or behaviors as having malevolent intent.
They are likely to maintain these interpretations
despite evidence to the contrary.David Young-Wolff/Photo Edit