| Paranoid personality disorder | |
|---|---|
| Specialty | Psychiatry,clinical psychology |
| Symptoms | Paranoia, pervasive suspiciousness, generalized mistrust of others, hypersensitivity, scanning of environments for clues or suggestions that may validate fears or biases |
| Differential diagnosis | Delusional disorder,schizophrenia,schizoaffective disorder,other cluster A personality disorders,borderline personality disorder |
| Frequency | Estimated between 0.5% and 2.5% of the general population[1] |
| Personality disorders |
|---|
| DSM-5 classification |
Cluster A (odd or eccentric) Cluster B (dramatic, emotional, or erratic) Cluster C (anxious or fearful) Other personality disorders |
| ICD-11 classification |
Personality disorder Prominent traits or patterns |
| Others |
Paranoid personality disorder (PPD) is apersonality disorder characterized byparanoia, and a pervasive, long-standing suspiciousness and generalizedmistrust of others. People with this disorder may be hypersensitive, easilyinsulted, and habitually relate to the world by vigilant scanning of the environment for clues or suggestions that may validate their fears or biases. They are eager observers and they often think they are in danger and look for signs and threats of that danger, potentially not appreciating other interpretations or evidence.[2]
They tend to be guarded and suspicious and have quite constricted emotional lives. Their reduced capacity for meaningful emotional involvement and the general pattern ofisolated withdrawal often lend a quality ofloneliness to their life experience.[3] People with PPD may have a tendency to bear grudges, suspiciousness, tendency to interpret others' actions as hostile, persistent tendency toself-reference, or a tenacious sense of personal right.[4] Patients with this disorder can also have significantcomorbidity with other personality disorders, such asschizotypal,schizoid,narcissistic,avoidant, andborderline.[citation needed]
It is one of the ten personality disorder categories in theDSM-5-TR, where it is listed amongCluster A ("odd or eccentric") personality disorders.[5] It is not specifically included as a diagnosis in theICD-11 classification of personality disorders, which, rather than including distinct personality disorders, has a single,dimensionalpersonality disorder presenting with pathological manifestations of personality traits.
A genetic contribution to paranoid traits and a possible genetic link between this personality disorder andschizophrenia exist.[citation needed] A large long-termNorwegiantwin study found paranoid personality disorder to be modestly heritable and to share a portion of its genetic and environmental risk factors with the other cluster A personality disorders,schizoid andschizotypal.[6]
Psychosocial theories implicateprojection of negative internal feelings and parental modeling.[1]Cognitive theorists believe the disorder to be a result of an underlying belief that other people are unfriendly in combination with a lack ofself-awareness.[7]
Classification of personality disorders differs significantly between the two most prominent frameworks forclassification of mental disorders, namely: theDiagnostic and Statistical Manual of Mental Disorders and theInternational Classification of Diseases, the most recent editions of which are theDSM-5-TR andICD-11, respectively. While personality disorders, including PPD, are diagnosed as separate entities in the DSM-5; in theICD-11 classification of personality disorders, they are assessed in terms of severity levels, with trait and pattern specifiers serving to characterize the particular style of pathology.[8] There is also a hybrid model,[9] called theAlternative DSM-5 model for personality disorders (AMPD), which defines personality disorder diagnoses through disorder-specific combinations of pathological traits and areas of overall impairment.[8]
The criteria in theAmerican Psychiatric Association'sDSM-5 require in general the presence of lasting distrust and suspicion of others, interpreting their motives as malevolent, from an early adult age, occurring in a range of situations. Four of seven specific issues must be present, which include different types of suspicions or doubt (such as of being exploited, or that remarks have a subtle threatening meaning), in some cases regarding others in general or specifically friends or partners, and in some cases referring to a response of holding grudges or reacting angrily.[10] While not listed as its own diagnostic entity in the AMPD,[11] what is conceptualized as PPD can instead be diagnosed aspersonality disorder – trait specified,[11] which is adimensional diagnosis that is constructed from the individual expression of personalty disorder,[12] as manifested in both a general impairment in personality functioning along with at least one pathologicalpersonality trait.[13]
TheWorld Health Organization'sICD-11 has replaced the categorical classification of personality disorders in theICD-10 with adimensional model containing a unifiedpersonality disorder (6D10) with severity specifiers, along with specifiers forprominent personality traits or patterns (6D11).[14] Severity is assessed based on the pervasiveness of impairment in several areas of functioning, as well as on the level of distress and harm caused by the disorder,[15] while trait and pattern specifiers are used for recording the manner in which the disturbance is manifested.[16] Paranoid personality disorder is primarily associated with the ICD-11 trait domainsNegative Affectivity (6D11.0) andDissociality (6D11.2). The former reflects core features such as mistrust and suspicion, while the latter relates to hostility, self-righteousness, and a tendency toward self-centeredness.[17] Some studies also report a link toDetachment (6D11.1), consistent with prior research and theoretical models.[17] The previous revision,ICD-10, listsparanoid personality disorder under (F60.0).[18]
Various researchers and clinicians may propose varieties and subsets or dimensions of personality related to the official diagnoses. PsychologistTheodore Millon has proposed five subtypes of paranoid personality:[19]
| Subtype | Features | Traits |
|---|---|---|
| Obdurate paranoid | Includingcompulsive features | Self-assertive, unyielding, stubborn, steely, implacable, unrelenting, dyspeptic, peevish, and cranky stance; legalistic and self-righteous; discharges previously restrained hostility; renounces self-other conflict. |
| Fanatic paranoid | Includingnarcissistic features | Grandiose beliefs are irrational and flimsy; pretentious, expensive supercilious contempt and arrogance toward others; lost pride reestablished with extravagant claims and fantasies. |
| Querulous paranoid | Includingnegativistic features | Contentious, caviling, fractious, argumentative, faultfinding, unaccommodating, resentful, choleric, jealous, peevish, sullen, endless wrangles, whiny, waspish, snappish. |
| Insular paranoid | Includingavoidant features | Reclusive, self-sequestered, hermitical; self-protectively secluded from omnipresent threats and destructive forces; hypervigilant and defensive against imagined dangers. |
| Malignant paranoid | Includingsadistic features | Belligerent, cantankerous, intimidating, vengeful, callous, and tyrannical; hostility vented primarily in fantasy; projects own venomous outlook onto others; persecutory beliefs. |
The paranoid may be at greater than average risk of experiencingmajor depressive disorder,agoraphobia,social anxiety disorder,obsessive–compulsive disorder, andsubstance-related disorders. Criteria for other personality disorder diagnoses are commonly also met, such as:[20]schizoid,schizotypal,narcissistic,avoidant,borderline andnegativistic personality disorder.
Partly as a result of tendencies to mistrust others, there have been few studies conducted over the treatment of paranoid personality disorder. Currently, there are no medicines FDA approved in treating PPD, but antidepressants, antipsychotics, and mood stabilizers may be prescribed under wrong assumptions to treat some of the symptoms.[21] Another form of treatment of PPD ispsychoanalysis, normally used in cases where both PPD and BPD are present. However, no published studies directly state the effectiveness of this form of treatment on specifically PPD, as opposed to its effects on BPD. CBT (cognitive behavioral therapy) has also been suggested as a possible treatment to paranoid personality disorder, but while case studies have shown improvement in the symptoms of the disorder, no systematic/widespread data has been collected to support this.[22][23] A recent meta-analysis[24] revealed that no specific randomized controlled trials (RCTs) currently focus solely on PPD. Instead, PPD was merely one of several possible diagnoses in a small number of existing trials, resulting in a minimal count of relevant recruited patients (e.g., an RCT onSchema Therapy[25]). Treatments for PPD can be challenging, as individuals with PPD are reluctant in finding help and have difficulty trusting others.
PPD occurs in about 0.5–4.4% of the general population.[26][1][20] It is seen in 2–10% of psychiatric outpatients.[citation needed] In clinical samples men have higher rates, whereasepidemiologically there is a reported higher rate of women.[27]
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Paranoid personality disorder is listed in the DSM-5 and was included in all previous versions of theDSM. One of the earliest descriptions of the paranoid personality comes from the French psychiatristValentin Magnan who described a "fragile personality" that showedidiosyncratic thinking,hypochondriasis, undue sensitivity, referential thinking, and suspiciousness.[28]
Closely related to this description isEmil Kraepelin's description from 1905 of a pseudo-querulous personality who is "always on the alert to find grievance, but without delusions", vain, self-absorbed, sensitive, irritable, litigious, obstinate, and living at strife with the world. In 1921, he renamed the condition paranoid personality and described these people as distrustful, feeling unjustly treated and feeling subjected to hostility, interference and oppression. He also observed a contradiction in these personalities: on the one hand, they stubbornly hold on to their unusual ideas, on the other hand, they often accept every piece of gossip as the truth.[28] Kraepelin also noted that paranoid personalities were often present in people who later developed paranoid psychosis. Subsequent writers also considered traits like suspiciousness and hostility to predispose people to developing delusional illnesses, particularly "late paraphrenias" of old age.[29]
Following Kraepelin,Eugen Bleuler described "contentious psychopathy" or "paranoid constitution" as displaying the characteristic triad of suspiciousness, grandiosity, and feelings of persecution. He also emphasized that these people's false assumptions do not attain the form of real delusion.[28]
Ernst Kretschmer emphasized the sensitive inner core of the paranoia-prone personality: they feel shy and inadequate but at the same time they have an attitude of entitlement. They attribute their failures to the machinations of others but secretly to their own inadequacy. They experience constant tension between feelings of self-importance and experiencing the environment as unappreciative and humiliating.[28]
Karl Jaspers, a Germanphenomenologist, described "self-insecure" personalities who resemble the paranoid personality. According to Jaspers, such people experience inner humiliation, brought about by outside experiences and their interpretations of them. They have an urge to get external confirmation to their self-deprecation and that makes them see insults in the behavior of other people. They suffer from every slight because they seek the real reason for them in themselves. This kind of insecurity leads to overcompensation: compulsive formality, strict social observances, and exaggerated displays of assurance.[28]
In 1950,Kurt Schneider described the "fanatic psychopaths" and divided them into two categories: the combative type that is very insistent about his false notions and actively quarrelsome, and the eccentric type that is passive, secretive, vulnerable to esoteric sects, but nonetheless suspicious about others.[28]
The descriptions of Leonhard and Sheperd from the sixties describe paranoid people as overvaluing their abilities and attributing their failure to the ill-will of others; they also mention that their interpersonal relations are disturbed and they are in constant conflict with others.[28]
In 1975, Polatin described the paranoid personality as rigid, suspicious, watchful, self-centered and selfish, inwardly hypersensitive, but emotionally undemonstrative. However, when there is a difference of opinion, the underlying mistrust, authoritarianism, and rage burst through.[28]
In the 1980s, paranoid personality disorder received little attention, and when it did receive it, the focus was on its potential relationship toparanoid schizophrenia. The most significant contribution of this decade comes fromTheodore Millon who divided the features of paranoid personality disorder to four categories:[28]
Due to repeated concerns of the validity of PPD and poor empirical evidence, it has been suggested that PPD be removed from the DSM.[30] This is believed to contribute to low research output on PPD.[31]
In addition, the alternative model does not provide specific criteria for each of the ten PDs listed in Sect. II of the DSM-5, as it recommends considering dependent, schizoid, histrionic, and paranoid PDs as variants of 'Personality Disorder - Trait Specified.'
PD-TS is diagnosed when (1) moderate or higher impairment in at least two out of four elements of personality functioning (Criterion A) is accompanied by (2) at least one elevated pathological trait domain or facet (Criterion B) in the absence of (3) a pattern of traits consistent with a specific disorder (Criterion B) and/or a pattern of difficulties in personality functioning characteristic of a specific disorder (Criterion A).
