A 48-year-old woman comes to the office with her sister for a preventive visit. Her sister says, "I got diagnosed with stage I breast cancer a year ago and want to make sure my sister is okay. It took a lot of convincing, but she finally agreed to come in for a checkup." The patient last saw a physician 10 years ago and says, "Doctors always try to find something wrong so that they can bill." She has no health issues and takes no medications. The patient does not use tobacco, alcohol, or illicit drugs. She lives alone and has never dated or married because she believes others may try to exploit her for the small inheritance she received from her parents. On physical examination, the patient appears older than her stated age; she is wearing baggy clothing, and her hair is unkempt. The patient agrees only to a breast examination and asks the physician, "Why would you need to examine anything else?" Throughout the examination, her gaze is fixated on the physician, and her affect is constricted. Which of the following best explains this patient's behavior?
Paranoid personality disorder | |
Clinical features |
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Differential diagnosis |
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This patient's long-standing suspicion and mistrust of others, including medical professionals and potential partners, is characteristic of paranoid personality disorder (PPD). Although these patients do not have specific paranoid delusions, they generally mistrust other people's intentions and typically believe that others want to exploit them (eg, doctors wanting to "find something wrong so they can bill," others exploiting her for her small inheritance). Other characteristics include oversensitivity to perceived criticism, reluctance to confide in others, and a tendency toward aggression or defensiveness in response to perceived attacks.
Patients' paranoid belief systems often result in social isolation and strained interpersonal relationships (as in this patient). In the physician-patient relationship, these can manifest as difficulty establishing rapport or creating a therapeutic alliance. Taking a nondefensive stance and carefully explaining things can be helpful.
(Choices A, D, and E) In avoidant personality disorder, avoidant behavior is due to fears of rejection and feelings of inadequacy rather than paranoia. Individuals with schizoid personality disorder display a pattern of social detachment and restricted emotional expression; they do not have a pervasive suspiciousness of others. Schizotypal personality disorder is characterized by odd beliefs and eccentric behaviors (eg, belief in telepathy, idiosyncratic speech), which this patient does not have.
(Choice B) In delusional disorder, persecutory type, individuals believe they are being conspired against, with symptoms lasting for ≥1 month. The belief is specific and held with delusional intensity (fixed, unshakable). Individuals with PPD have generalized suspicion but lack distinct delusions.
(Choice F) Individuals with social anxiety disorder avoid social situations due to fear of negative evaluation rather than suspicion of others.
Educational objective:
Paranoid personality disorder is characterized by a long-standing pattern of suspicion and mistrust of others' intentions. In the physician-patient relationship, it may manifest as difficulty establishing rapport and creating a therapeutic alliance.