Paranoid personality disorder

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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
FrequencyEstimated between 0.5% and 2.5% of the general population [1]

Paranoid personality disorder (PPD) is a mental disorder characterized by paranoia, and a pervasive, long-standing suspiciousness and generalized mistrust of others. People with this personality disorder may be hypersensitive, easily insulted, 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]

Contents

They tend to be guarded and suspicious and have quite constricted emotional lives. Their reduced capacity for meaningful emotional involvement and the general pattern of isolated withdrawal often lend a quality of schizoid isolation to their life experience. [3] [ verification needed ] People with PPD may have a tendency to bear grudges, suspiciousness, tendency to interpret others' actions as hostile, persistent tendency to self-reference, or a tenacious sense of personal right. [4] Patients with this disorder can also have significant comorbidity with other personality disorders, such as schizotypal, schizoid, narcissistic, avoidant, and borderline.

Causes

A genetic contribution to paranoid traits and a possible genetic link between this personality disorder and schizophrenia exist. 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 the other cluster A personality disorders, schizoid and schizotypal. [5]

Psychosocial theories implicate projection 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 of self-awareness. [6]

Diagnosis

ICD-10

The World Health Organization's ICD-10 lists paranoid personality disorder under (F60.0). It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria. It is also pointed out that for different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and other obligations. [7]

PPD is characterized by at least three of the following symptoms:

  1. excessive sensitivity to setbacks and rebuffs;
  2. tendency to bear grudges persistently (i.e. refusal to forgive insults and injuries or slights);
  3. suspiciousness and a pervasive tendency to distort experience by misconstruing the neutral or friendly actions of others as hostile or contemptuous;
  4. a combative and tenacious sense of self-righteousness out of keeping with the actual situation;
  5. recurrent suspicions, without justification, regarding sexual fidelity of spouse or sexual partner;
  6. tendency to experience excessive self-aggrandizing, manifest in a persistent self-referential attitude;
  7. 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 and schizophrenia.

DSM-5

The American Psychiatric Association's DSM-5 has similar criteria for paranoid personality disorder. They 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. [8]

PPD is characterized by 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. To qualify for a diagnosis, the patient must meet at least four out of the following criteria: [8]

  1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them.
  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 them.
  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 their 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.

The DSM-5 lists paranoid personality disorder essentially unchanged from the DSM-IV-TR [9] version and lists associated features that describe it in a more quotidian way. These features include suspiciousness, intimacy avoidance, hostility and unusual beliefs/experiences.

Other

Various researchers and clinicians may propose varieties and subsets or dimensions of personality related to the official diagnoses. Psychologist Theodore Millon has proposed five subtypes of paranoid personality: [10]

SubtypeFeatures
Obdurate paranoid (including compulsive 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 (including narcissistic 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 (including negativistic features)Contentious, caviling, fractious, argumentative, faultfinding, unaccommodating, resentful, choleric, jealous, peevish, sullen, endless wrangles, whiny, waspish, snappish.
Insular paranoid (including avoidant features)Reclusive, self-sequestered, hermitical; self-protectively secluded from omnipresent threats and destructive forces; hypervigilant and defensive against imagined dangers.
Malignant paranoid (including sadistic features)Belligerent, cantankerous, intimidating, vengeful, callous, and tyrannical; hostility vented primarily in fantasy; projects own venomous outlook onto others; persecutory beliefs.

Differential diagnosis

Paranoid personality disorder can involve, in response to stress, very brief psychotic episodes (lasting minutes to hours). The paranoid may also be at greater than average risk of experiencing major depressive disorder, agoraphobia, social anxiety disorder, obsessive-compulsive disorder and substance-related disorders. Criteria for other personality disorder diagnoses are commonly also met, such as: [11] schizoid, schizotypal, narcissistic, avoidant, borderline and negativistic personality disorder.

Treatment

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. [12] Another form of treatment of PPD is psychoanalysis, 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. [13] [14] Treatments for PPD can be challenging, as individuals with PPD are reluctant in finding help and have difficulty trusting others.

Epidemiology

PPD occurs in about 0.5–4.4% of the general population. [15] [1] [11] It is seen in 2–10% of psychiatric outpatients.[ citation needed ] In clinical samples men have higher rates, whereas epidemiologically there is a reported higher rate of women. [16]

History

Paranoid personality disorder is listed in DSM-V and was included in all previous versions of the DSM. One of the earliest descriptions of the paranoid personality comes from the French psychiatrist Valentin Magnan who described a "fragile personality" that showed idiosyncratic thinking, hypochondriasis, undue sensitivity, referential thinking, and suspiciousness. [17]

Closely related to this description is Emil 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. [17] 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. [18]

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. [17]

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. [17]

Karl Jaspers, a German phenomenologist, 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. [17]

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. [17]

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. [17]

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. [17]

In the 1980s, paranoid personality disorder received little attention, and when it did receive it, the focus was on its potential relationship to paranoid schizophrenia. The most significant contribution of this decade comes from Theodore Millon who divided the features of paranoid personality disorder to four categories: [17]

1) Behavioral characteristics of vigilance, abrasive irritability, and counterattack

2) Complaints indicating oversensitivity, social isolation, and mistrust

3) The dynamics of denying personal insecurities, attributing these to others, and self-inflation through grandiose fantasies

4) Coping style of detesting dependence and hostile distancing of oneself from others

Controversy

Due to repeated concerns of the validity of PPD and poor empirical evidence, it has been suggested that PPD be removed from the DSM. [19] This is believed to contribute to low research output on PPD. [20]

See also

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Paranoia is an instinct or thought process that is believed to be heavily influenced by anxiety, suspicion, or fear, often to the point of delusion and irrationality. Paranoid thinking typically includes persecutory beliefs, or beliefs of conspiracy concerning a perceived threat towards oneself. Paranoia is distinct from phobias, which also involve irrational fear, but usually no blame.

<span class="mw-page-title-main">Borderline personality disorder</span> Personality disorder of emotional instability

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<span class="mw-page-title-main">Narcissistic personality disorder</span> Personality disorder

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<span class="mw-page-title-main">Schizoid personality disorder</span> Medical condition

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<span class="mw-page-title-main">Avoidant personality disorder</span> Personality disorder

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<span class="mw-page-title-main">Persecutory delusion</span> Delusion involving perception of persecution

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  15. ↑ Schulte Holthausen, Barbara; Habel, Ute (2018-10-11). "Sex Differences in Personality Disorders". Current Psychiatry Reports. 20 (12): 107. doi:10.1007/s11920-018-0975-y. ISSN   1535-1645. PMID   30306417. S2CID   52959021.
  16. ↑ Grant, Bridget F.; Hasin, Deborah S.; Stinson, Frederick S.; Dawson, Deborah A.; Chou, S. Patricia; Ruan, W. June; Pickering, Roger P. (2004-07-01). "Prevalence, Correlates, and Disability of Personality Disorders in the United States: Results From the National Epidemiologic Survey on Alcohol and Related Conditions". The Journal of Clinical Psychiatry. 65 (7): 948–958. doi:10.4088/JCP.v65n0711. ISSN   0160-6689. PMID   15291684 . Retrieved 2022-04-24.
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  19. ↑ Schulte Holthausen, Barbara; Habel, Ute (2018-10-11). "Sex Differences in Personality Disorders". Current Psychiatry Reports. 20 (12): 107. doi:10.1007/s11920-018-0975-y. ISSN   1523-3812. PMID   30306417. S2CID   52959021.
  20. ↑ Triebwasser, Joseph; Chemerinski, Eran; Roussos, Panos; Siever, Larry J. (December 2013). "Paranoid Personality Disorder". Journal of Personality Disorders. 27 (6): 795–805. doi:10.1521/pedi_2012_26_055. ISSN   0885-579X. PMID   22928850.