These posts explore the themes developed in my monograph, Narcisso-Fascism, which is itself a real-world test of the central concepts of the Biocognitive Model of Mind for psychiatry.
If you like what you read, please click the “like” button at the bottom of the text, it helps spread the posts to new readers. If you want to comment, please use the link at the end rather than email me as they get lost and nobody sees them.
****
A fairly lengthy article in reputable journal a few years ago looked at the much-neglected topic of paranoid thinking in personality disorders [1] (as much as I don’t like the abbreviation PD, I have to use it otherwise this would be too long). This was a “scoping review” which, unfortunately, used the term ‘paranoia,’ which had been dumped even when I was training. A scoping review sounds impressive but it means only a preliminary study of a field to try to work out what’s what and where to go. There’s now an established procedure to follow [2] and, in this paper, they kept to the procedure but seemed to miss a singularly important point. Just for context, the other types of reviews are literature reviews, which are often regularly updated as new material emerges, and systematic reviews, which survey the professional literature to answer one or a few specific questions, e.g. does drug X work?
The authors are psychologists, which means they come at the topic from a particular point of view but, as is often complained, psychology seems to be very much under the thumb of institutional psychiatry these days. They use the classification of personality disorders from the DSM system, i.e. they accept that personality disorder falls into distinct categories. There is a brief mention of the Alternative Model for Personality Disorders (p1216) but this wasn’t accepted in DSM-5 so they left it alone. Their preliminary survey of databases pulled up 4,433 papers which talked about paranoid symptoms in personality disorders but they quickly screened out nearly 99% of them, which tells us something.
The remaining 47 papers were analysed and showed that paranoid symptoms are common in, unsurprisingly, paranoid (PPD), but also in borderline (BPD) and schizotypal (STPD) personality types. What they described as “milder forms of paranoia” are quite common in avoidant (APD), narcissitic (NPD) and antisocial (ASPD) types but are almost never mentioned in schizoid (SPD), histrionic (HPD), dependent (DPD) or obsessive-compulsive (OCPD) personalities. To set the scene, they asked “What defines paranoia?” Oddly enough, they used the Freudian concept of projection, which is exactly what the DSM system was intended to replace. However, they qualify this by pointing out that we are all, to some extent, paranoid in the sense that we have to learn early to keep out wits about us because not everybody can be trusted: “... paranoid thoughts are quite common in the general population, with prevalence rates ranging from about 2% to 42%” (p1216), ranging from mild to severe and all-pervasive. I’d say that’s a major understatement caused by not asking the right questions but points out that it’s OK to be paranoid, just learn to keep it under control. After a foray into the mechanics of selecting their papers, they describe four “dimensions of paranoia”:
Doubts about others’ intentions (i.e. suspicion and mistrust);
Ideas of reference, i.e. attaching special significance to random or irrelevant events (for some reason, they included “the feeling of being observed by others”);
Paranoid beliefs (essentially, that other people have malign intentions); and
Persecutory delusions and beliefs.
This is a bit strange. A delusion is a belief, but it’s a psychotic belief. It’s not clear why they included it in a paper on non-psychotic states but we’ll come back to this point. Suspicion and ideas of reference go hand-in-hand; you can’t claim the TV is talking about you without suspecting some sort of malice somewhere. Now they get to the nitty-gritty: being good psychogists, they worked out the incidence of each of the four “dimensions” in each of a dozen personality types, giving pages of statistical analysis that only the determined would bother reading. After further pages of minute discussion, they conclude that paranoid thinking is most common in paranoid personalities, followed by schizotypal and then borderline types but, they warn...
This gap makes it difficult to set the boundary between paranoia as a symptom, a personality trait, a personality structure or a syndrome ... Where is the threshold between psychotic and nonpsychotic paranoid expressions remains open to scientific debate and may broadly depend on distress, conviction and frequency of paranoid manifestations, as well as cultural factors ... it is possible that suspiciousness may arise from these trauma-related mechanisms... (p1225). This is a bit alarming, admitting that they have no cut-off points for normal vs. abnormal, but they continue:
As to the remaining PDs, our synthesis suggests either negligible associations with paranoia (e.g., as for histrionic, dependent, obsessive-compulsive and schizoid personalities) or a serious lack of empirical interest in their relationship with paranoid presentations (p1225) ... It is worth mentioning that most studies used measures of paranoia whose validity and reliability have been questioned ... The present review suggests a lack of systematic studies on the link between personality disorders and paranoid presentations (p1228).
We had to wait until practically the last line to get to the juicy bit but we’ll try to be methodical. First, they assume that the DSM system of separate categories of personality disorder is valid, which is unexpected for psychologists because the entire history of psychology says it’s not. Second, they clearly have no concept of what personality actually is, which is fairly elementary, e.g. if you’re going to talk about traffic accidents, you need to know what traffic is. This is why they say (p1225) they can’t distinguish between normal paranoid thinking, a trait, a personality structure, a culture, a traumatic state or a disease syndrome. It’s not a strong start.
Next, why talk about delusions? Delusions mean psychosis, which means “not personality disorder.” That’s just further evidence that they’re floundering. Then, having said that some degree of paranoid thinking is normal, they are forced to admit that they can’t find evidence for it in many types of PD. Does that mean it doesn’t happen? But if it’s part of the normal personality, it must, so the only conclusion is that nobody’s interested enough to bother asking, and we know why: there’s no money in it. Finally, they point out that most of the studies used unreliable measures “whose validity and reliability have been questioned,” which suggests this is a case of GIGO: garbage in, garbage out.
All this points to the singularly important error hidden in the verbiage and stats of their “scoping study,” namely, the fact that they really don’t know what they’re talking about. That’s not entirely their fault, because if they’d said openly and honestly: “The whole field of personality and personality disorder in psychiatry is a cock-up,” which it is, they wouldn’t get published. Similarly, they have no control over the quality of the studies that are available, many of which are quite old and sub-standard. They could have said: “We need to start all this again,” but that wouldn’t work because it would only be more of the same: more money spent on dim-witted surveys by people who are only doing it because they need to publish something to get up the academic ladder.
The problem is psychiatry, its total failure to do the hard work of developing a theory of mind and a theory of personality, then using these to build models of mental disorder and personality disorder. Psychiatry has locked itself into a biological approach, in the mistaken belief that “science” can’t talk about minds and mental events. They want all mental disorder to be brain disorder but where does that leave personality disorder? As the study authors concede right at the beginning, some degree of paranoid thinking is normal. It can be pushed to extremes by a neglectful childhood or by traumatic events at any age, by culture, by drugs and by alcohol. Complicating matters, it gets worse under pressure or even through lack of sleep, further evidence it’s not a brain disease. Psychiatry’s way of fudging around this question was to write the criteria for each PD so that they seem separate and distinct when they certainly are not [3].
To make sense of it, they need a theory that sees beliefs as real things, able to work on the real, physical world, but without slipping into fantasy or magical thinking. The biocognitive model says the mind is real and everything we do or feel comes from the interaction of our belief state with external reality. There is no such thing as a free-floating belief, every belief we have is nested in a prior belief, and that in an even more basic belief, all the way back to the most fundamental of all: as Descartes said, I think, therefore I exist. The mere fact of asking “Do I exist?” proves that I do, and there’s nothing anybody can do to prove I don’t. On that foundation and with experiences gained over time, we build a vast, interlocking system of beliefs, about ourselves and our place in the world. Personality just is my unique set of beliefs and rules about life. Compare some elementary beliefs about stealing:
I believe people shouldn’t steal, and that also applies to me at all times even if it’s inconvenient. Knowing that people think I’m a decent person is more important than a free apple.
I believe I’ve had a terrible time and I’ve missed out on so much, and these people have got everything and never had to suffer, so they owe me something, and they won’t miss it anyway.
I believe I’m a really clever person and I can prove it by tricking these dumbos into handing over their lunch, and they’re too fat anyway.
If all my beliefs about myself and the world are reasonable and mesh together smoothly and with the rules of society, then life will cruise ahead, if not always smoothly then manageably. If my beliefs are self-contradictory and transgress society’s rules, they’ll cause me distress and friction with the world. The former represents normal personality, the latter personality disorder. The paranoid stance is simply a set of beliefs about the world, mainly the human part of it, based in a fundamental belief that says something like: “Look out, it’s a dog eat dog world, you can’t trust anybody or anything unless you’ve got it in your pocket, and then somebody will try to steal it.” As the study notes, this takes different forms, although I prefer my set to theirs. Traditionally, there are five elements to the paranoid stance, five forms it can take but there’s no limit to the number of beliefs people can have under each heading:
An intense preoccupation with matters of right and wrong and justice;
An intense level of suspicion, including jealousy;
An intense preoccupation with conspiracies;
An intense preoccupation with the supernatural;
An intense sense of persecution.
Intense means intense, it means dominating and controlling life to the exclusion of normal activity and relationships. It doesn’t mean “a fair bit, more than me.” I also prefer to add grandiosity to these because the central element in all of them is Me, as in: “You’re all looking at Me, you’re all thinking bad about Me, I know what’s right and you’re wrong, I understand the universe and you’re all out to get Me because I’m so important. In fact, I’m so important that even God talks to Me so there.” For the paranoid personality, there is an important belief right down near the belief “I exist.” This one says: “I’m never wrong.” Trump shows this brilliantly, as do most of the people in his orbit. If somebody points out that he’s wrong, he simply launches an attack on them until they’re silenced. Classic paranoid ploy.
How does all this come about? Well, it doesn’t come about because the child was valued as a person by happy, caring people in a safe and ordered environment. Anything less can result in a warped perspective, a distorted self-image and a view of the world as a dangerous, unpredictable place so that life becomes a constant battle for survival. Needless to say, mainstream psychiatry and psychology want to see personality disorders as genetic (e.g. the work of psychologist Robert Plomin) but after a hundred years of trying, they haven’t proven anything. In particular, the so-called gold standard of twin studies has completely failed to deliver the prize [4]. In my view, the reason is clear: one’s adult personality is heavily influenced by life experiences, and crucially, which the mainstream has never considered, we can do it ourselves.
That sounds completely crazy: how can we change our personalities? If it’s genetic then naturally enough, we can’t, we’re at the mercy of our genes, but if personality is purely a psychological state, then we can, quite easily. In fact, we do it all the time. We routinely tighten the screws as we go through life. We deliberately make ourselves tidier and more responsible for details or we resolve to be more suspicious of smooth talkers. In the main, we act to make ourselves safer, to reduce the risk of something going wrong in the future. We make ourselves more obsessional and rule-abiding because we see that’s the way to get ahead; also the best way of avoiding trouble. We soon learn we can use our obsessionality to push people around so it becomes even more fun. But above all other personality factors, suspicion feeds on itself and grows to take control of life. People get more paranoid as they get older, even though nothing much has gone wrong. By the time they’re running the show, they’re at their worst, which is why so many politicians and businessmen come across as overtly paranoid. Most of the time, of course, they conceal it but it spills out, often as aggressive grandiosity, e.g. Trump’s bizarre speech to the UNGA last week where he threatened everybody who didn’t do as he says. Similarly, tech bro Peter Thiel’s preoccupation with the “antichrist” qualifies him as psychotic.
Needless to say, the paranoid like to surround themselves with people who agree with them, which isn’t so difficult as normal people are driven away. Trump’s deputy chief of staff, Stephen Miller, is seriously paranoid while his press secretaries have all been practically off the guage. Recently departed Caroline Leavitt routinely attacked anybody who asked difficult questions, showing zero insight into her behaviour (look at her cold and contemptuous demeanour). But they’re not born like this and none of them can say they were mistreated as children (Trump himself was emotionally neglected and was specifically trained to be a greedy and self-righteous prick [5]). They mould themselves so they can get higher up the ladder and dominate more people just because domination is sooo reinforcing (i.e. ‘feels so good’).
So back to that study of paranoid ideas in personality disorder: Yes, we’re all paranoid to some extent, but it’s a personality dimension, not an all-or-none trait; only the paranoid survive, as they say. No, most of us can’t blame our parents; no, siblings don’t have equal emotional environments, the eldest gets to push the younger ones around, the youngest is protected as the baby and the middle ones are told to stop whining. Yes, life teaches us to be self-protective but my self-protection comes across to you as suspicion; and most important is the insidious effect of a paranoid culture. Most commonly, this is openly and deliberately subcultural, where people are trained to be paranoid, as in the military, a political party or in police services. If you want to get ahead, you have to know who the enemy is and you don’t question it. There are paranoid religions where people are told to see the devil lurking behind every minor upset, paranoid political cultures such as the Q-Anon movement in the US and, naturally enough, paranoid criminal subcultures. These are self-reinforcing in that people choose to join and choose to stay; in order to get ahead, they have to repeat the message and embellish it. This is also true of mainstream politics in most countries, which probably explains why the study on paranoid personality disorders concluded:
The present review suggests a lack of systematic studies on the link between personality disorders and paranoid presentations (p1228).
If, against all the evidence, you believe in genetically-determined categories of personality disorder, then you’re not going to start examining your own culture because it might turn out to be seriously embarrassing. The last thing they want to know is that we are taught to be paranoid.
References:
1. Fanti E, Di Samo M & Di Pierro R (2023). In search of hidden threats: A scoping review on paranoid presentations in personality disorders. Clin Psychol Psychother. 30:1215–1233. DOI: 10.1002/cpp.2913
2. Mak S, Thomas A (2022) Steps for Conducting a Scoping Review. J Grad Med Ed. DOI: http://dx.doi.org/10.4300/JGME-D-22-00621.1
3. McLaren N (2007). The categorical system of diagnosis: Personality Disorder. Chapter 8 in Humanizing Madness: Psychiatry and the Cognitive Neurosciences.; Ann Arbor, Mi.: Future Psychiatry Press.
4. Joseph J (2014) The Trouble with Twin Studies: A Reassessment of Twin Research in the Social and Behavioral Sciences. New York: Routledge.
5. Trump ML (2020). Too Much and Never Enough: How My Family Created the World’s Most Dangerous Man. London: Simon and Shuster.
****
My critical works are best approached in this order:
The case against mainstream psychiatry:
McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. https://bookshop.org/. (this also covers a range of modern philosophers, showing that their work cannot be extended to account for mental disorder).
Development and justification of the biocognitive model:
McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London, Routledge. At https://bookshop.org/
Clinical application of the biocognitive model:
McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press. At https://bookshop.org/
.Testing the biocognitive model in an unrelated field:
McLaren N (2023): Narcisso-Fascism: The psychopathology of right wing extremism. Ann Arbor, MI: Future Psychiatry Press. At https://bookshop.org/
The whole of this work is copyright but may be copied or retransmitted provided the author is acknowledged.