The Paranoid Patient - A Case Study

Notes of first therapy session with Dale G., male, 46, diagnosed with Paranoid Personality Disorder (PPD)

Dale's first enquiry is whether I am in any way associated either with the government or with his former employer. He doesn't seem reassured by my negative response. He eyes me skeptically and insists that I inform him if things change and I do become entangled with his persecutors. Why do I treat him pro bono? He suspects some ulterior motives behind my altruism and inexplicable generosity. I explain to him that I donate 25 hours a month to the community. "It's good for your image, gives you access to local bigwigs, I bet." - he retorts, accusingly. He refuses to allow me to tape record our conversation.

I set some boundaries by reminding him that the therapy session is about him, not me. He nods sagely: it's all part of an intricate scheme to "subdue" him and place him "under firm control". Why would "they" want to do that? Because he knows too much, having exposed fraud, lies, and deceit in the highest places. He has done all this from his position as a sanitary worker at the municipality? - I enquire. He is visibly offended: "There are more secrets in people's trash than in the CIA!" - he exclaims - "You think that your academic degree makes you more clever than I am or somehow superior to me?"

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I remind him that therapy was more or less forced on him by his long-suffering wife. Is she one of "them"? He sniggers. Well? "Yes," - he rages - "they got to her, too. She used to be on my side." His phones are tapped, his mail intercepted and inspected, there was a mysterious fire in his apartment only days after he complained against a senior law enforcement officer. Wasn't it the antiquated television set that burst into flames? "If you care to believe such nonsense." - he eyes me with pity.

When was the last time he went out with friends? He has to think hard to come up with an answer: "Four years ago." Why so long? Is he a recluse by nature? Not at all, he is actually gregarious. So, why the social isolation? Part of his defense. You never know when something you have said in company will be used against you. His so-called friends have been asking him too many intrusive questions lately. They insisted on meeting in new venues at odd times and he got suspicious.

So, what is he doing all alone at home? He laughs bitterly: "Won't they love to know my next moves!" He isn't going to give them the pleasure of evincing his strategy. All he is willing to say is that "they" will pay dearly for having underestimated him and for having turned his life "into a long nightmare in hell". Who are "they"? His superiors at the sanitary department. They reassigned him to a dangerous part of town, working night shifts, effectively demoting him from team foreman to "common janitor". He will never forgive them. But wasn't this a temporary arrangement owing to manpower shortages? "That's what they said at the time"- he admits reluctantly.

At the end of the session he insists on inspecting my phone jacks and the under-surfaces of my desk. "You can never be too careful." - he half apologizes.

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