Paranoid personality disorder is a psychiatric diagnosis characterized by paranoia and a pervasive, long-standing suspiciousness and generalized mistrust of others.
Those with the condition are hypersensitive, are easily slighted, and habitually relate to the world by vigilant scanning of the environment for clues or suggestions to validate their prejudicial ideas or biases. Paranoid individuals are eager observers. They think they are in danger and look for signs and threats of that danger, disregarding any facts. They tend to be guarded and suspicious and have quite constricted emotional lives. Their incapacity for meaningful emotional involvement and the general pattern of isolated withdrawal often lend a quality of schizoid isolation to their life experience.
Causes
A genetic contribution to paranoid traits and a possible genetic link between this personality disorder and schizophrenia exist. Psychosocial theories implicate projection of negative internal feelings and parental modeling.
Diagnosis
WHO
The World Health Organization’s ICD-10 lists paranoid personality disorder as (F60.0) Paranoid personality disorder.
It is characterized by at least 3 of the following:
- excessive sensitivity to setbacks and rebuffs;
- tendency to bear grudges persistently, i.e. refusal to forgive insults and injuries or slights;
- suspiciousness and a pervasive tendency to distort experience by misconstruing the neutral or friendly actions of others as hostile or contemptuous;
- a combative and tenacious sense of personal rights out of keeping with the actual situation;
- recurrent suspicions, without justification, regarding sexual fidelity of spouse or sexual partner;
- tendency to experience excessive self-importance, manifest in a persistent self-referential attitude;
- preoccupation with unsubstantiated “conspiratorial” explanations of events both immediate to the patient and in the world at large.
Includes:
expansive paranoid, fanatic, querulant and sensitive paranoid personality (disorder)
Excludes:
- delusional disorder
- schizophrenia
It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
Cultural sensitivities
World Health Organization, in the ICD-10, points out for different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and obligations.
Millon’s subtypes
Theodore Millon identified five subtypes of paranoid. Any individual paranoid may exhibit none or one of the following:
- fanatic paranoid – including narcissistic features
- malignant paranoid – including sadistic features
- obdurate paranoid – including compulsive features
- querulous paranoid – including negativistic (passive-aggressive) features
- insular paranoid – including avoidant features
- litigious paranoia – including a form of paranoia in which the person seeks legal proof or justification for systematized delusions
Differential diagnosis
The following conditions commonly coexist (comorbid) with paranoid personality disorder:
- very brief psychotic episodes (lasting minutes to hours)
- delusional disorder
- schizophrenia
- major depressive disorder
- agoraphobia
- obsessive-compulsive disorder
- alcohol and substance-related disorders
- schizoid personality disorder
- schizotypal personality disorder
- narcissistic personality disorder
- avoidant personality disorder
- borderline personality disorder
Treatment
Because of reduced levels of trust, there can be challenges in treating paranoid personality disorder. However, psychotherapy, antidepressants, antipsychotics and anti-anxiety medications can play a role when an individual is receptive to intervention.
Epidemiology
Paranoid personality disorder occurs in about 0.5%-2.5% of the general population. It is seen in 2%-10% of psychiatric outpatients. It occurs more commonly in males.
A large long-term Norwegian twin study found paranoid personality disorder to be modestly heritable and to share a portion of its genetic and environmental risk factors with schizoid and schizotypal personality disorder.
Paranoid Personality Disorder: Summarized
People with paranoid personality disorder are generally characterized by having a long-standing pattern of pervasive distrust and suspiciousness of others. A person with paranoid personality disorder will nearly always believe that other people’s motives are suspect or even malevolent. Individuals with this disorder assume that other people will exploit, harm, or deceive them, even if no evidence exists to support this expectation. While it is fairly normal for everyone to have some degree of paranoia about certain situations in their lives (such as worry about an impending set of layoffs at work), people with paranoid personality disorder take this to an extreme — it pervades virtually every professional and personal relationship they have.
Individuals with Paranoid Personality Disorder are generally difficult to get along with and often have problems with close relationships. Their excessive suspiciousness and hostility may be expressed in overt argumentativeness, in recurrent complaining, or by quiet, apparently hostile aloofness. Because they are hypervigilant for potential threats, they may act in a guarded, secretive, or devious manner and appear to be “cold” and lacking in tender feelings. Although they may appear to be objective, rational, and unemotional, they more often display a labile range of affect, with hostile, stubborn, and sarcastic expressions predominating. Their combative and suspicious nature may elicit a hostile response in others, which then serves to confirm their original expectations.
Because individuals with Paranoid Personality Disorder lack trust in others, they have an excessive need to be self-sufficient and a strong sense of autonomy. They also need to have a high degree of control over those around them. They are often rigid, critical of others, and unable to collaborate, and they have great difficulty accepting criticism.
Symptoms of Paranoid Personality Disorder
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 four (or more) of the following:
- Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
- Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
- Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her
- Reads hidden demeaning or threatening meanings into benign remarks or events
- Persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights
- Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack
- Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner
As with all personality disorders, the person must be at least 18 years old before they can be diagnosed with it.
Paranoid personality disorder is more prevalent in males than females, and occurs somewhere between 0.5 and 2.5 percent in the general population.
Like most personality disorders, paranoid personality disorder typically will decrease in intensity with age, with many people experiencing few of the most extreme symptoms by the time they are in the 40s or 50s.
How is Paranoid Personality Disorder Diagnosed?
Personality disorders such as paranoid personality disorder are typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. So while you can initially consult a family physician about this problem, they should refer you to a mental health professional for diagnosis and treatment. There are no laboratory, blood or genetic tests that are used to diagnose paranoid personality disorder.
Many people with paranoid personality disorder don’t seek out treatment. People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere or otherwise impact a person’s life. This most often happens when a person’s coping resources are stretched too thin to deal with stress or other life events.
A diagnosis for paranoid personality disorder is made by a mental health professional comparing your symptoms and life history with those listed here. They will make a determination whether your symptoms meet the criteria necessary for a personality disorder diagnosis.
Causes of Paranoid Personality Disorder
Researchers today don’t know what causes paranoid personality disorder. There are many theories, however, about the possible causes of paranoid personality disorder. Most professionals subscribe to a biopsychosocial model of causation — that is, the causes of are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual’s personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible — rather, it is the complex and likely intertwined nature of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be “passed down” to their children.
Paranoid Personality Disorder Treatment
Psychotherapy
As with most personality disorders, psychotherapy is the treatment of choice. Individuals with paranoid personality disorder, however, rarely present themselves for treatment. It should not be surprising, then, that there has been little outcome research to suggest which types of treatment are most effective with this disorder.
It is likely that a therapy which emphasizes a simple supportive, client-centered approach will be most effective. Rapport-building with a person who has this disorder will be much more difficult than usual because of the paranoia associated with the disorder. Early termination, therefore, is common. As the therapy progresses, the patient will likely begin to trust the clinician more and more. The client then will likely begin disclosing some of his or her more bizarre paranoid ideation. The therapist must be careful to balance being objective in therapy and with regards to these thoughts, and of raising the suspicions of the client that he or she is not trusted. It is a difficult balance to maintain, even after a good working rapport has been established.
During times when the patient is acting upon his paranoid beliefs, the therapist’s loyalties and trust may be called into question. Care must be used not to challenge the client too firmly or risk the individual leaving therapy permanently. Control issues should be dealt with in much a similar manner, with great care. Since the paranoid beliefs are delusion and not based in reality, arguing them from a rational point of view is useless. Challenging the beliefs is also likely to result in more frustration on both the part of the therapist and client, too.
All clinicians and mental health personnel who come into contact with the individual who suffers from paranoid personality disorder should be more keenly aware of being straight-forward with this individual. Subtle jokes are often lost on them and allusions to information about the client not received directly from the client’s mouth will raise a great deal of suspicion. Therapists should typically avoid trying to have the patient sign a release of information for information not essential to the current therapy. Items in life which usually wouldn’t give most people a second thought can easily become the focus of attention to this client, so care must be exercised in discussions with the client. An honest, concrete approach will likely gain the most results, focusing on current life difficulties which has brought the client into therapy at this time. Clinicians should generally not inquire too deeply into the client’s life or history, unless it’s directly relevant to clinical treatment.
Long-term prognosis for this disorder is not good. Individuals who suffer from this disorder often remain afflicted with prominent symptoms of it throughout their lifetime. It is not uncommon to see such people in day treatment programs or state hospitals. Other modalities, such as family or group therapy, are not recommended.
Medications
Medications are usually contraindicated for this disorder, since they can arouse unnecessary suspicion that will usually result in noncompliance and treatment dropout. Medications which are prescribed for specific conditions should be done so for the briefest time period possible to bring the condition under management.
An anti-anxiety agent, such as diazepam, is appropriate to prescribe if the client suffers from severe anxiety or agitation where it begins to interfere with normal, daily functioning. An anti-psychotic medication, such as thioridazine or haloperidol, may be appropriate if a patient decompensates into severe agitation or delusionsal thinking which may result in self-harm or harm to others.
Self-Help
There are not any self-help support groups or communities that we are aware of that would be conducive to someone suffering from this disorder. Such approaches would likely not be very effective because a person with this disorder is likely to be mistrustful and suspicious of others and their motivations, making group help and dynamics unlikely and possibly harmful.