Paranoid Personality Disorder

Primer

Paranoid Personality Disorder is a personality disorder that consists of a pervasive distrust or suspiciousness of others the the point that their motives are interpreted as malevolent. It is characterized by a pattern of distrust and suspiciousness of others. Individuals with this disorder tend to negatively interpret the actions, words, and intentions of others. They suspect that others intend to harm or deceive them, though there may be little supporting evidence for such concerns. Individuals can also hold grudges for long periods of time and are reluctant to confide in others.

Epidemiology
  • The prevalence for paranoid personality disorder is estimated to be between 2.3 to 4.4%.[1][2]
  • It is more common in males, minorities, and in those with hearing impairment[3]
Prognosis
  • Paranoid personality disorder begins in early adulthood and can present in different contexts. Individuals can have significant impairments in marital and occupational settings.
  • Small cohort studies have found that there is greater stability and less deterioration relative to schizoid personality disorder.[4]
Comorbidity
Risk Factors
  • Individuals with relatives who have schizophrenia or delusional disorder, persecutory type are at greater risk.[5][6]
  • Childhood trauma is also another risk factor, and individuals are more likely to have had physical abuse (but not sexual abuse) in childhood and adolescence[7]

DSM-5 Diagnostic Criteria

Criterion A

A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by 4 (or more) of the following:

  1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
  2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
  3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her
  4. Reads hidden demeaning or threatening meanings into benign remarks or events
  5. Persistently bears grudges (i.e. - is unforgiving of insults, injuries, or slights)
  6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack
  7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner
Criterion B

Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid” to the diagnosis, i.e. - “paranoid personality disorder (premorbid)”.

Psychopathology

The main psychological defense used in paranoid personality disorder is projection.[8]

Differential Diagnosis

  • Personality change due to another medical condition
    • Paranoid personality disorder must be distinguished from personality change from a medical condition (e.g. - traumatic brain injury) involving the central nervous system.
  • Other mental disorders with psychotic symptoms
    • Paranoid personality disorder can be distinguished from delusional disorder, persecutory type; schizophrenia; and a bipolar or depressive disorder with psychotic features because these disorders are all characterized by discrete periods of persistent psychotic symptoms (e.g. - delusions and hallucinations). Thus, for the diagnosis of paranoid personality disorder, the personality features must have been present before the onset of psychotic symptoms and must persist when the psychotic symptoms are in remission. In cases where an individual has another chronic mental disorder such as schizophrenia that came after the diagnosis of paranoid personality disorder, the diagnosis of paranoid personality disorder can still be recorded, with an additional specifier of “premorbid.”
  • Substance use disorders
    • Symptoms may develop from persistent substance use that resemble paranoid personality disorder (e.g. - stimulant or methamphetmaine use can cause features of paranoia)
  • Schizotypal personality disorder
    • Paranoid personality disorder and schizotypal personality disorder share the traits of suspiciousness, interpersonal aloofness, and paranoid ideation, but schizotypal personality disorder also includes features like magical thinking, unusual perceptual experiences, and odd thinking and speech. Individuals with behaviors that meet criteria for schizoid personality disorder are often perceived as strange, eccentric, cold, and aloof, but they do not usually have prominent paranoid ideation.
  • Borderline personality disorder or histrionic personality disorder
    • Individuals with paranoid personality disorder can react to minor stimuli with anger, which is also seen in borderline and histrionic personality disorders. However, these two disorders do not have the associated pervasive suspiciousness.
  • Antisocial personality disorder
    • Although antisocial behavior can be present in individuals with paranoid personality disorder, it is not usually motivated by a desire for personal gain or to exploit others as commonly seen in antisocial personality disorder. The antisocial behaviours are rather attributable to a desire for revenge in the context of suspiciousness.
  • Narcissistic personality disorder
    • Individuals with narcissistic personality disorder can also have features of suspiciousness, social withdrawal, or alienation, as seen in paranoid personality. However these features come from a fear of having their imperfections or flaws revealed to others.
  • Avoidant personality disorder
    • Individuals with avoidant personality disorder can be reluctant to confide in others, but this is from a fear of being embarrassed or found inadequate than from fear of malicious intent by others.
  • Paranoid traits associated with physical handicaps
    • Paranoid traits associated with the development of physical handicaps (e.g. - a hearing impairment) should also be ruled out.
  • Paranoid personality traits
    • Paranoid traits may actually be adaptive, particularly in threatening or high-stress environments. Thus, paranoid personality disorder should be diagnosed only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress.

Treatment

There have few studies on what treatments work best for individuals with paranoid personality disorder, given the nature of the disorder. Psychotherapies such as cognitive behavioural therapy and psychodynamic therapy have been recommended, though no formal trials have been done.[9] Regardless of the type of therapy used, the clinician should focus on improving the ability of the individual to trust others, and tolerate intimacy with others. Clinicians should be straightforward and careful about offering interpretations, especially in topics or areas that may feed into the individual's suspiciousness.

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Guidelines

Personality Disorder Guidelines

Guideline Location Year PDF Website
World Federation of Societies of Biological Psychiatry (WFSBP) International 2009 - Link

Resources

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References

1) Lenzenweger, M. F., Lane, M. C., Loranger, A. W., & Kessler, R. C. (2007). DSM-IV personality disorders in the National Comorbidity Survey Replication. Biological psychiatry, 62(6), 553-564.
2) Hasin, D. S., & Grant, B. F. (2015). The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 and 2: review and summary of findings. Social psychiatry and psychiatric epidemiology, 50(11), 1609-1640.
3) Lee, R. J. (2017). Mistrustful and misunderstood: a review of paranoid personality disorder. Current behavioral neuroscience reports, 4(2), 151-165.
4) Lee, R. J. (2017). Mistrustful and misunderstood: a review of paranoid personality disorder. Current behavioral neuroscience reports, 4(2), 151-165.
5) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
6) Kendler, K. S., Masterson, C. C., & Davis, K. L. (1985). Psychiatric illness in first-degree relatives of patients with paranoid psychosis, schizophrenia and medical illness. The British Journal of Psychiatry, 147(5), 524-531.
7) Lee, R. J. (2017). Mistrustful and misunderstood: a review of paranoid personality disorder. Current behavioral neuroscience reports, 4(2), 151-165.
8) Bowins, B. (2010). Personality disorders: A dimensional defense mechanism approach. American Journal of Psychotherapy, 64(2), 153-169.
9) Lee, R. J. (2017). Mistrustful and misunderstood: a review of paranoid personality disorder. Current behavioral neuroscience reports, 4(2), 151-165.