Definition and Associated Features

Paranoid personality disorder (PPD) is characterized by an extreme level of distrust and suspicion of others; unjustified feelings of suspicion and mistrust of others, hyper sensitivity, expectation – without justification -that will be damaged and exploited by others and a tendency to find hidden meanings messages and comments that are in reality harmless behaviors as degrading or threatening. People with PPD often interpret even friendly gestures as manipulative or malevolent. They are often difficult to get along with, as they can be confrontational and aggressive; therefore, they generally lack close relationships with other people because they are constantly waiting for negative outcomes such as betrayal. As a result of others reacting negatively to their hostility, their negative expectations are often confirmed; for example, they may suspect that their neighbor takes the garbage out early in the morning just to bother them.

People who suffer with PPD do not only suspect strangers, but people they know as well, they believe those they know are planning to harm or exploit them without evidence to support their suspicions. If a person with PPD does form a close relationship, the relationship is often accompanied by jealousy and controlling tendencies. These individuals typically do not have psychotic features, that is, they are in clear contact with reality and usually do not experience hallucinations. They may also have less cognitive disorganization, therefore they are able to function socially in the work environment, although somewhat effectively as the rest of society.

When people with PPD suspect exploitation, harm, or deceit, it is almost always associated with friends or close partners because these are the people they are near the most. For example: They may suspect their spouse or partner is involved in an affair. This is where loyalty and trust issues come in, They are reluctant to give out any information that will hurt them or be used to put them down in any way, so they tend to keep secrets from those who are close to them because of a paranoid idea they will be harmed in the process.

Since they have trouble with trusting others, people with PPD have an excessive sense of self-sufficiency and autonomy. They are often rigid, unable to collaborate, and often have difficulty accepting criticism and instead blame others for their shortcomings. They may frequently be involved in legal disputes because of their tendency to counterattack in response to perceived threats. Sometimes PPD may appear antecedent of Delusional Disorder or Schizophrenia. Those with PPD may develop Major Depressive Disorder, and Substance Abuse or Dependence is frequent.

Individuals who have PPD typically do not have psychotic features, that is, they are clearly in contact with reality, and they usually do not have hallucinations. However, they may experience brief psychotic episodes in response to stress. The important thing to remember is that these individuals do not have Schizophrenia, Paranoid Type because they do not have hallucinations, and their cognitive disorganization, typical of the Schizophrenias, is not present. In addition, they are able to function socially and in the workplace, although their functioning is affected by this disorder. These individuals are always guarded and alert for attacks from other people in areas of employment, social areas and home life.

DSM-IV-TR Criteria

Defined as stated above. This can begin by early adulthood and present in a variety of contexts, as indicated by four (or more) of the items listed below.

1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
2. Preoccupied with unjustified doubts about the loyalty or trustworthiness of friends, family or associates.
3. 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, because they are unforgiving of insults, injuries, or practical jokes.
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 partner.

• Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic Features, or another Psychotic Disorder and is not due to the direct physiological effect of a general medical condition.
  • NOTE: If criteria are met prior to the onset of Schizophrenia, add “Pre-morbid,” e.g., “Paranoid Personality Disorder (Pre-morbid)”.

Child vs. Adult Presentation

According to the DSM-IV-TR, there are a few exceptions noting personality disorders are not generally diagnosed in individuals under the age 18. If the symptoms or behaviors, sometimes called features, have been present for at least 1 year, then the individual can be diagnosed with a personality disorder if he or she is less than 18 years of age.

Signs of Paranoid personality disorder can be seen in childhood, seen as having poor relationships, not doing well in school, odd thoughts, social anxiety, solitariness, hypersensitivity, and they may seen as “odd” or “eccentric” by others and as a result may attract teasing by other children.

Gender Differences in Presentation of Disorders

• Paranoid Personality Disorder affects more males than females and contains a few co-morbid disorders. Co-morbidity often occurs with Schizophrenia, Avoidant, and Borderline Personality Disorders.
• Females are generally more associated with the disorders of Borderline, Histrionic, and Dependent.
• Males are generally more associated with the disorders of Paranoid, Schizophrenia, and Antisocial.
• Diagnosis for males and females are also different even if both present the same symptoms.
• Females are also more apt to seek help than males because they are more willing to acknowledge the symptoms, acknowledge the need for help, and are more influenced by their social group to seek help.

Cultural Differences in Presentation

Most of the disorders listed and reviewed are Caucasian based. However for different cultural groups, symptoms and treatment may not be the same.

Some behaviors influenced by culture or life circumstances may be mistaken for Paranoia. Members of minority groups, immigrants, refugees, or those of different ethnic backgrounds may be guarded or defensive because of unfamiliarity or perceived as neglect by the majority society. These behaviors may produce anger in those who deal with these individuals, thus setting up a mutual mistrust, which would not be Paranoid Personality Disorder.

Epidemiology

The lifetime prevalence of Paranoid Personality Disorder is 0.5% to 2.5% of the general population. An increased prevalence of Paranoid Personality Disorder has a biological connection to relatives of chronic sufferers of schizophrenia and patients with persecutory delusional disorders, which is the presence of persistent delusions.

The prevalence rate for inpatient psychiatric hospitals is 10%-30%. Anywhere from 2% to 10% of patients in an outpatient treatment facility are also affected.

One study has found that 44% of those in treatment for alcoholism have Paranoid Personality Disorder, while other studies have only found it to be around 13.2% (SAMHSA, 2009).

Etiology

• The cause of Paranoid Personality Disorder is unknown, although there are some theories that it may be due to negative childhood experiences in a threatening domestic atmosphere or caretakers having PPD
  • In their childhood there was no way of predicting or escaping their environment; therefore, they develop paranoid ways of thinking in order to cope with the stressful situations.
• In addition, the incidence of PPD appears to be increased in families with a member who suffer from Schizophrenia.
  • Having a familial factor means that they are more likely to get the disorder because it was in the family genetics, thus having a higher chance of developing the disorder rather than someone whose family has a no known genetic disorders.
• The developmental path of PPD predominantly involves environmental responses of criticism, blame, and hostility. Studies have linked this diagnosis to caregivers who treated the individual with PPD in a sadistic, degrading, or humiliating manner, imposing the belief that he or she was fundamentally bad. A process that restricts the individual’s ability to trust, leads to an anxious withdraw from interactions that are later compensated for with rage and peremptory behaviors seeking to protect the individual from impending harm.
• Promotes belief that hateful criticism or abuse may result from interpersonal interactions. Leads to withdrawal from such interactions that may later be compensated for with rage.
• According to the Encyclopedia of Mental Disorders, other possible interpersonal causes have been proposed. For example, some therapists believe that the behavior that characterizes PPD might be learned and might be traced back to childhood experiences. According to this view, children who are exposed to adult anger and rage with no way to predict the outbursts and no way to escape or control them develop paranoid ways of thinking in an effort to cope with the stress. PPD would emerge when this type of thinking becomes part of the individual’s personality as adulthood approaches.
• Studies of identical (or monozygotic) and fraternal (or dizygotic) twins suggest that genetic factors may also play an important role in causing the disorder. Twin studies indicate that genes contribute to the development of childhood personality disorders, including PPD. Furthermore, estimates of the degree of genetic contribution to the development of childhood personality disorders are similar to estimates of the genetic contribution to adult versions of the disorders.

Medications

While individual supportive psychotherapy is the treatment of choice for PPD, medications are sometimes used on a limited basis to treat related symptoms. If, for example, the patient is very anxious, anti-anxiety drugs may be prescribed. In addition, during periods of extreme agitation and high stress that produce delusional states, the patient may be given low doses of antipsychotic medications.

Some clinicians have suggested that low doses of neuroleptics should be used in this group of patients; however, medications are not normally part of long-term treatment for PPD. One reason is that no medication has been proven to relieve effectively the long-term symptoms of the disorder, although the selective serotonin reuptake inhibitors such as fluoxetine (Prozac) have been reported to make patients less angry, irritable and suspicious. Antidepressants may even make symptoms worse.

A second reason is that people with PPD are suspicious of medications.They fear that others might try to control them through the use of drugs. It can therefore be very difficult to persuade them to take medications unless the potential for relief from another threat, such as extreme anxiety, makes the medications seem relatively appealing. The best use of medication may be for specific complaints, when the patient trusts the therapist enough to ask for relief from particular symptoms.

Prognosis

Paranoid personality disorder is often a chronic, lifelong condition; the long-term prognosis is usually not encouraging. Feelings of paranoia, however, can be controlled to a degree with successful therapy. Unfortunately, many patients suffer the major symptoms of the disorder throughout their lives.

Prevention

With little or no understanding of the cause of PPD, it is not possible to prevent the disorder.

Empirically Supported Treatments

Because those with PPD are very suspicious and untrustworthy of others, they are generally not likely to seek therapy on their own. Often, the legal system or the family of the person suffering from this disorder gets involved and encourages the person to seek treatment. However, it is extremely difficult to begin treatment with the person, as the therapist has to gain the trust of the patient.

The most successful form of treatment for this disorder is psychotherapy, which can be used to help the patient control his paranoid thoughts. Medications are sometimes used to treat related symptoms, such as anxiety or delusional states that some people with PPD suffer when under stress.

Some clinicians suggest that low doses of neuroleptics should be used for short-term treatment of PPD. Antidepressants such as Prozac have been reported to make symptoms of PPD worse and people with PPD are often suspicious of medication and believe that others might try to control them through drugs. Although psychotherapy and medication can temporarily control symptoms of PPD, most patients experience the symptoms of PPD for their entire life and require consistent therapy in order to manage their paranoia.

Psychotherapy

According to the Encyclopedia of Mental Disorders, the primary approach to treatment for such personality disorders as PPD is psychotherapy . The problem is that patients with PPD do not readily offer therapists the trust that is needed for successful treatment. As a result, it has been difficult to gather data that would indicate what kind of psychotherapy would work best. Therapists face the challenge of developing rapport with someone who is, by the nature of his personality disorder, distrustful and suspicious; someone who often sees malicious intent in the innocuous actions and statements of others. The patient may actively resist or refuse to cooperate with others who are trying to help.

Mental health workers treating patients with PPD must guard against any show of hostility on their part in response to hostility from the patient, which is a common occurrence in people with this disorder. Instead, clinicians are advised to develop trust by persistently demonstrating a nonjudgmental attitude and a professional desire to assist the patient.

It is usually up to the therapist alone to overcome a patient’s resistance. Group therapy that includes family members or other psychiatric patients, not surprisingly, isn’t useful in the treatment of PPD due to the mistrust people with PPD feel towards others. This characteristic also explains why there are no significant self-help groups dedicated to recovery from this disorder. It has been suggested, however, that some people with PPD might join cults or extremist groups whose members might share their suspicions.

To gain the trust of PPD patients, therapists must be careful to hide as little as possible from their patients. This transparency should include note taking; details of administrative tasks concerning the patient; correspondence; and medications. Any indication of what the patient would consider “deception” or covert operation can, and often does, lead the patient to drop out of treatment. Patients with paranoid tendencies often don’t have a well-developed sense of humor; those who must interact with people with PPD probably should not make jokes in their presence. Attempts at humor may seem like ridicule to people who feel so easily threatened.

With some patients, the most attainable goal may be to help them to learn to analyze their problems in dealing with other people. This approach amounts to supportive therapy and is preferable to psychotherapeutic approaches that attempt to analyze the patient’s motivations and possible sources of paranoid traits. Asking about a patient’s past can undermine the treatment of PPD patients. Concentrating on the specific issues that are troubling the patient with PPD is usually the wisest course.

With time and a skilled therapist, the patient with PPD who remains in therapy may develop a measure of trust. But as the patient reveals more of his paranoid thoughts, the clinician will continue to face the difficult task of balancing the need for objectivity about the paranoid ideas and the maintenance of a good rapport with the patient. The therapist thus walks a tightrope with this type of patient. If the therapist is not straightforward enough, the patient may feel deceived. If the therapist challenges paranoid thoughts too directly, the patient will be threatened and probably drop out of treatment.

Portrayed in Popular Culture

• George from Seinfeld
  • He is characterized by irrational suspicions and mistrust of others
• Cornelius Fudge from Harry Potter
  • He irrationally fears that Albus Dumbledore, and just about anybody, is trying to overthrow him as the Minister of Magic

DSM-V Changes

Paranoid Personality Disorder will be represented and diagnosed by a combination of core impairment in personality functioning and specific pathological personality traits, rather than as a specific type.

(APA, 2010)

Links

• The Encyclopedia of Mental Disorders