I have a friend who is generally very sensible, holds down a job, says she has loyal friends and is devoted to her son and extended family. She is very generous. She describes her work as very satisfying with a good relationship with her colleagues and I am certain she is extremely good at it.
Part of a description under the heading of paranoid personality disorder, however, describes her other side very well — a preoccupation with unsubstantiated “conspiratorial” explanations of events both immediate to her and in the world at large. She has, for a lot longer than I have known her, been determined that she is being targeted personally by people (probably belonging to some criminal-backed gang) who seem to follow her to wherever she moves, gaining access to her house and garden and changing or tampering with things when she is out. She is also attracted to some rather dubious websites that would make anyone paranoid if you believed them.
I realise it is probably best for me just to sympathise with her and refrain from trying to point out the impossibility of some of her concerns. She says no one is going to wear her down and she will just get on with living. I just feel concerned she has to deal with this in her otherwise down-to-earth life. I also do not feel, despite her opening up to me, that I am the right person to suggest help. I do not know if she has gone down this route.
Anne-Marie
A. You describe your friend as having a paranoid personality disorder (PPD), given her longstanding belief that “she is being targeted personally by people”. Your compassionate letter also highlights your concern that these beliefs will be a burden on her despite “her otherwise down-to-earth life”.
As a clinical psychologist I work less from a diagnosis and more from a holistic understanding of why a person is struggling with their mental health. Diagnoses describe a cluster of symptoms, and while they can be helpful in terms of targeted, evidence-based intervention, they can be reductionist and too simplistic, leading to stereotypes and ignoring individual differences, circumstances and other variables contributing to an individual’s difficulties. However, I can understand, how, due to your concern, you have landed on the possibility of a PPD.
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The diagnosis of a personality disorder is used to describe a person’s significant difficulties with mood and how they think and feel about themselves and others, leading to a deterioration in mental health and relationships. About one in twenty people in the UK is thought to have a personality disorder — a diagnosis that also carries unhelpful stigma and can feel a judgmental assessment of personality rather than a consideration of what the individual is actually struggling with.
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A PPD, usually emerging in early adulthood, causes long-term distrust and suspicion of others with no rational basis, causing extreme fears of, for example, being targeted by others intent on harm, and so causing substantial difficulties with the ability to form close relationships. Causes are complex and not fully understood, and generally thought to come from a combination of factors, including childhood trauma and/or neglect, and genes.
We can all feel paranoid from time to time, holding irrational suspicion or mistrust of others that cause us anxiety. However, a key consideration is whether the paranoid beliefs impact on daily life and functioning; with your friend, who can make and maintain healthy relationships and cope well with life, this does not seem to be the case. Instead, it sounds more like your friend struggles with delusions — an unshakeable belief in something that’s untrue, such as believing that people are trying to harm her. These can often be what are called non-bizarre delusions, involving situations that could possibly occur in real life (such as being followed), usually involving the misinterpretation of perceptions or experiences, making the belief completely untrue or highly exaggerated. However, people with delusional disorder function well, despite the delusion they hold, whereas people with PPD tend not to.
To this last point, while the belief held by your friend sounds irrational, it is not beyond the realms of rational possibility. There have been cases where people who are being targeted (for example, being stalked) have been dismissed as being delusional with tragic consequences. If, however, your friend is delusional, then her not being able to recognise this fact is called anosognosia. This is different to being in denial (rejecting reality to avoid distress), and instead describes an inability to recognise the mental health issue at all. Indeed, as you fear for your friend, this inability to rationalise what is probably irrational can cause levels of distress that are not rooted in reality and are really distressing for the person experiencing them.
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There are evidence-based treatments that can be helpful for people who suffer with paranoia and delusional beliefs. Dialectical behavioural therapy (DBT) enables understanding and management of difficult feelings by learning emotional and interpersonal coping skills; mentalisation-based therapy (MBT) enables understanding of and reflection on thoughts and feelings of the self and others, helping to manage impulses and behaviours and improve relationships; and cognitive behavioural therapy (CBT) and cognitive analytic therapy (CAT) can show good outcomes. Medication can also be effective for people whose delusions come with mental health difficulties (for example depression, anxiety or psychosis).
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Confronting your friend with the irrationality of her belief (if indeed they are irrational) will not help. Her beliefs are real to her, and it would be kind and reassuring to let her know that you recognise the feelings that must be evoked by the delusions. I imagine she must feel frightened and perhaps also alone (it is lonely to believe something that others dismiss), and the best approach would be to acknowledge these underlying feelings and discuss them rather than the content of the delusion. It’s possible to listen and try to understand without colluding with the thoughts and the underlying belief that generates them. Additionally, what she expresses via the delusion could reflect actual lived experience of trauma that has led to chronic post-traumatic stress disorder (PTSD), therefore talking about feelings could lead to a causal experience that your friend has never had the support to process, and so still feels alive for her.
If you do challenge her belief, then do so sensitively from the position of the possibility that she is misinterpreting some of her experiences, and how that would be a heavy burden for her to carry and so worth exploring. You could balance this with the idea that exploring this belief could also enable her to be safe if her belief is grounded in reality. This doesn’t mean she needs to engage with mental health services in a formal way (many people, already anxious and suspicious, will find this idea terrifying), but she could talk to others who may be able to support her. Encouraging your friend to reach out to her GP and mental health charities would enable her to find support for the stress, distress and possible anxiety or low mood that she may be experiencing. You could also explore with her how, while looking for reassurance online, it is possible to get locked into echo chambers that reinforce fears rather than alleviate them — again, not directly indicating that her belief is irrational, but more thinking about balancing perspectives to support her mental health.
I admire your concern and compassion — that is the hallmark of a good friend. Often when we see a loved one in distress, our instinct is to “fix” the problem by tackling the issue(s) head on. In this case I advise patience, and caution you against directly confronting the possible/probable irrationality of her belief, because if you do you risk losing your friend, entrenching her further in her belief, and potentially escalating a decline in her mental health. I wish you both well.
