Paranoid Personality Disorder

When interacting with a paranoid patient, the physician typically reacts with fear, mistrust, and a sense of danger. The physician may also feel blamed or accused. The patients may have a similar fear of being hurt, exploited, or invaded. Patients often react to suggestions for medical care with mistrust, excessive fault finding, sensitivity to criticism, or hypervigi-lance. They may collect small insults as proof of the world's injustices. When invasive medical procedures are performed, the paranoid patient may react with full-blown panic and anxiety; many paranoid patients unconsciously experience a body invasion as a homosexual assault. Patients with paranoid personality disorder rely most heavily on projection as their main defense. Using projection, they accuse the physician of hurts that reflect their own aggressive style of hurting others.

A physician working with the paranoid patient needs to empathize with the patient's mistrust and hypersensitivity. The physician should avoid arguing or attempting to reason the patient out of the paranoid worldview. It is extremely important to use confrontations and clarifications to help correct the patient's distorted perceptions about his medical care. Unfortunately, direct confrontation of a delusion or hallucinations (the most troubling deficits in reality testing) often has the paradoxical effect of making these patients more suspicious of the physician.

Acknowledging that the patient's suspicion has an emotional reality can be helpful. Rather than confronting mistrust or suspicions directly, the physician can acknowledge responsibility for any actions that the patient might have perceived as mistakes. For example, the physician could say, "I did not appreciate how it might hurt you when I ordered that lab test." It may also help to express understanding and concern for the patient's rights. If there is a medical need for special testing of which the patient is suspicious, acknowledge the patient's fears, and describe openly and honestly the details of the procedures, potential for pain, and likely risks and benefits. If the patient still refuses to comply, do not use direct persuasion. Ask the patient, "Is it all right with you if we have different opinions?" With the patient's consent to hearing a different opinion, openly discuss the medical necessity of the testing without trying to resolve the problem. At future office visits, attempt new and ongoing discussions of the patient's fears of complying with the request for specialized testing. It may take months for the paranoid patient to trust enough to consent to the appropriate treatment. Counterpro-jective statements by the physician can diffuse the projections and distortions directed at the physician. The physician can use counterprojective remarks to help the patient access her feelings while focusing angry or suspicious feelings away from the physician toward others who are not present. For example, a physician harassed by an angry, suspicious, or blaming patient could use a counterprojective statement such as, "You felt angry and hurt when the lab technician drew your blood. You must be fearful of the results of these tests."

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