History: So much of our society works via a process of invoking fear. This is how a history of our smoking, drinking, eating and exercise habits are shaped. We are told of the horrific fates that will befall us if we do not do as we are told. This, of course, begins when we are young. Our parents structure our behavior around a series of “this will happen if you…(or)…if you don’t.”
While not ideal, it is likely harmless except when this approach is used with individuals who are frankly paranoid. I am not referring to those who are paranoid schizophrenic and believe that they are part of some greater and mystical plot. I am referring to those with paranoid personality or paranoid personality traits.
Paranoid Personality Disorder is characterized by a pervasive distrust and suspiciousness of others. The motives of others are seen as evil. There is not sufficient justification for their belief that they are being harmed, exploited or deceived. They are preoccupied with doubts of loyalty and trustworthiness of others and they are unlikely to confide in others because they believe data will be used against them. Such individuals, by adulthood, read critical or threatening meaning into benign events or remarks. They bear grudges for even minor insults and are quick to anger and counterattack. Not infrequently, they believe that they are being betrayed by their sexual partner. Most often such individuals do not perceive themselves as having a problem and that any suggestion that they need assistance is proof to then that they are, indeed, under attack.
TV commercials selling legal services, other patients in doctors offices, remarks by family members and neighbors all conspire to convince this patient that he (or she) will be manipulated and somehow harmed. Some of these fears may be well-founded in some cases (Eg. employers who do not wish to report an injury or an insurer who wants an injury minimized). But just as some music or video games will evoke bizarre behaviors in some individuals, it is better to know which patients are most vulnerable to these paranoia-evoking commercials and input from others.
The use of these fear-tactics in patients who have a history paranoid personality traits will be extremely destructive of any trust between doctor and patient. As with the compulsive patient, the solution lies in providing the patient with a sense of control where possible: “When do you want that appointment?” “What would you prefer to do?” “What would make you the most comfortable.”
You must work within the confines of a personality disorder that formed years earlier. Since you will not talk the patient out of his/her perceptions and beliefs, your best approach is to accept that this is the way the patient assesses the situation and what would provide him/her with at least some belief that the control is ultimately their own.