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Chapter: Essentials of Psychiatry: Personality Disorders

Paranoid Personality Disorder

Paranoid personality disorder (PPD) involves a pervasive and continuous distrust and suspiciousness of the motives of others) but the disorder is more than just suspiciousness.

Paranoid Personality Disorder




Paranoid personality disorder (PPD) involves a pervasive and continuous distrust and suspiciousness of the motives of others) but the disorder is more than just suspiciousness. Persons with this disorder are also hypersensitive to criticism, they respond with anger to threats to their autonomy, they incessantly seek out confirmations of their suspicions, and they tend to be quite rigid in their beliefs and perceptions of others. The presence of PPD is indicated by four or more of the seven diagnostic criteria pre-sented in the DSM-IV criteria for PPD.


Etiology and Pathology


Research has indicated a genetic contribution to the develop-ment of suspiciousness and mistrust. There is some support for a genetic relationship of PPD with schizophrenia but these find-ings have not always been replicated and the findings may have been due to the overlap of PPD with the schizotypal personality disorder


There are no systematic studies on possible psychosocial contributions to the development of PPD. There is some support for the contribution of excessive parental criticism and rejec-tion but there has not yet been adequate prospective longitudinal studies. Paranoid belief systems could develop through parental modeling, a history of discriminatory exploitation or abandon-ment, or the projection of anger, resentment and bitterness onto a group that is external to, and distinct from, oneself. Mistrust and suspicion is often evident in members of minority groups, immigrants, refugees and other groups for whom such distrust can be a realistic and appropriate response to the social environment. It is conceivable that a comparably sustained experience through childhood and adolescence could contribute to the development of excessive paranoid beliefs that are eventually applied inflex-ibly and inappropriately to a wide variety of persons, but it can be very difficult to determine what is excessive or unrealistic sus-picion and mistrust within a member of an oppressed minority. Paranoid suspiciousness could in fact be more closely associated with prejudicial attitudes, wherein a particular minority group in society becomes the inappropriate target of one’s anger, blame and resentment.


There has been little consideration given to the neuro-physiological concomitants of nonpsychotic paranoid personality traits. More attention has been given to cognitive, interpersonal and object-relational models of pathology. Paranoid beliefs do appear to have a self-perpetuating tendency resulting from the narrow and limited focus on signs and evidence for malicious intentions. The pathology of PPD, from this perspective, is inherent to the irrationality of the person’s belief systems and is sustained by the biased information processing. There may also be an underlying motivation or need to perceive threats in others and to externalize blame that help to sustain the accusations and distortions.


Differential Diagnosis


PPD paranoid ideation is inconsistent with reality and is resistant to contrary evidence but the ideation is not psychotic, absurd, incon-ceivable, or bizarre. PPD also lacks other features of psychotic and delusional disorders (e.g., hallucinations) and is evident since early adulthood, whereas a psychotic disorder becomes evident later within a person’s life or remits after a much briefer period of time. Persons with PPD can develop psychotic disorders but to diagnose PPD in such cases the paranoid personality traits must be evident prior to and persist after the psychotic episode. If PPD precedes the onset of schizophrenia, then it should be noted that it is pre-morbid to the schizophrenia (American Psychiatric Association, 2000). However, it may not be meaningful to diagnose a person with both PPD and schizophrenia, as the premorbid paranoid traits may in some cases have simply represented a prodromal phase of the schizophrenic pathology.




Epidemiology and Comorbidity


Trust versus mistrust is a fundamental personality trait along which all persons vary. Thirteen percent of the adult male popu-lation and 6% of the adult female population may be characteris-tically mistrustful of others (Costa and McCrae, 1992). However, only 0.5 to 2.5% of the population are likely to meet the DSM-IV-TR diagnostic criteria for a PPD. It is suggested in DSM-IV-TR that approximately 10 to 30% of persons within inpatient settings and 2 to 10% within outpatient settings have this disorder (Amer-ican Psychiatric Association, 2000) but the lower end of these rates may represent the more accurate estimate. It does appear that more males than females have the disorder.


Paranoid personality traits are evident in other personality disorders. Persons with avoidant personality disorder are socially withdrawn and apprehensive of others; borderline, antisocial and narcissistic persons may be impatient, irritable and antagonistic; and schizotypal persons may display paranoid ideation. The diagnosis of PPD often cooccurs with these other personality disorder diagnoses. Persons with PPD are prone to develop a variety of Axis I disorders, including substance-related, obsessive–compulsive anxiety, agoraphobia and depressive disorders (American Psychiatric Association, 2000).




Premorbid traits of PPD may be evident prior to adolescence in the form of social isolation, hypersensitivity, hypervigilance, social anxiety, peculiar thoughts, angry hostility and idiosyncratic fan-tasies (American Psychiatric Association, 2000). As children, they may appear odd and peculiar to their peers and they may not have achieved to their capacity in school. Their adjustment as adults is particularly poor with respect to interpersonal relationships. They may become socially isolated or fanatic members of groups that encourage or at least accept their paranoid ideation. They might maintain a steady employment but are difficult coworkers, as they tend to be rigid, controlling, critical, blaming and prejudicial. They are likely to become involved in lengthy, acrimonious and litigious disputes that are difficult, if not impossible, to resolve.




Persons with PPD rarely seek treatment for their feelings of sus-piciousness and distrust. They experience these traits as simply accurate perceptions of a malevolent and dangerous world (i.e., egosyntonic). They may not consider the paranoid attributions to be at all problematic, disruptive, or maladaptive. They are not delusional but they also fail to be reflective, insightful, or self-critical. They may recognize only that they have difficulty con-trolling their anger and getting along with others. They might be in treatment for an anxiety, mood, or substance-related disorder or for various marital, familial, occupational, or social (or legal) conflicts that are secondary to their personality disorder but they also externalize the responsibility for their problems and have substantial difficulty recognizing their own contribution to their internal dysphoria and external conflicts. They consider their problems to be due to what others are doing to them, not to how they perceive, react, or relate to others.


The presence of paranoid personality traits complicate the treatment of an Axis I disorder or a relationship problem. Trust is central to the development of an adequate therapeutic alliance, yet it is precisely the absence of trust that is central to this disor-der. It can be tempting to be less than forthright and open in the treatment of excessively suspicious persons because they distort, exaggerate, or escalate minor errors, misunderstandings, or inconsistent statements. However, therapists find that they weave an increasingly tangled web as they walk gingerly around the truth. Also, persons with PPD seize upon any kernel of deception to confirm their suspicion that the therapist is not to be trusted. It is preferable to be especially forthright and precise with para-noid patients. Details that are inconsequential and of no interest to most patients can be important to provide to persons with PPD so that they are ensured that nothing is being withheld or hidden from them.


Clinicians agree on several general principles in the treat-ment of paranoid personality. It is usually pointless and often harmful to rapport or to confront (or argue with) the paranoid beliefs. Such efforts may only alienate the patient and confirm his or her suspicions. The therapist should maintain a sincere and consistent respect for their autonomy and for their right to make their own decisions. However, one should not attempt to ingratiate oneself by being overly acquiescent and compliant. This can ap-pear to be obviously patronizing, insincere, or manipulative. The goal is to develop, in a nonthreatening way, more self-reflection and self-awareness (e.g., recognition of the contribution of the paranoid traits and behaviors to the difficulties they are experienc-ing within their lives). A useful approach can be to communicate a sincere and respectful willingness to explore the implications, logic and reality of the suspicions. Whenever one appears to be endangering rapport by moving too quickly, one should retreat to a more neutral and accepting position.


One must also be careful to avoid defensive reactions to the inevitable accusations. Any one of the conflicts they have had with others can develop within the therapeutic relationship and persons with PPD have a tendency to be contentious, rigid, accusatory, suspicious and litigious that can tax the empathy and patience of the therapist. One must attempt to maintain an empathic concern for their feelings of betrayal, and reassure them in an understanding, forthright manner that is neither patroniz-ing nor disrespectful. Termination of treatment may at times be necessary if continuation would only result in further acrimony.


The suspicions, accusations and acrimony often makes the person with PPD a poor candidate for group therapies. There is the potential to learn much about themselves within a group, but it is usually very difficult for them to develop the feelings of trust, respect and security that are necessary for successful group ther-apy. Their propensity to make unfair hostile accusations alienate them from other group members, and they may quickly become a scapegoat for difficulties and conflicts that develop within the group.


There have been a variety of studies on the pharmacologic treatment of psychotic paranoid ideation and of schizotypal PD (which often includes paranoid personality traits) but little to no research on the pharmacologic responsivity of the nonpsychotic suspiciousness and egosyntonic paranoid ideation of PPD. Persons with PPD may also perceive the use of a medication to represent an effort simply to suppress or control their accusations and suspicions rather than respectfully to consider and address them. However, they may be receptive and responsive to the benefits of a medication to help control feelings of anxiousness or depression that are secondary to their personality disorder.

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