Paranoia, pervasive suspiciousness, generalized mistrust of others, hypersensitivity, scanning of environments for clues or suggestions that may validate fears or biases
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]
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 Norwegiantwin 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:
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]
Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them.
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 them.
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 their 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.
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.
Millon's subtypes
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]
Grandiose beliefs are irrational and flimsy; pretentious, expensive supercilious contempt and arrogance toward others; lost pride reestablished with extravagant claims and fantasies.
Reclusive, self-sequestered, hermitical; self-protectively secluded from omnipresent threats and destructive forces; hypervigilant and defensive against imagined dangers.
Belligerent, cantankerous, intimidating, vengeful, callous, and tyrannical; hostility vented primarily in fantasy; projects own venomous outlook onto others; persecutory beliefs.
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]
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]
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.
Narcissistic personality disorder (NPD) is a personality disorder characterized by a life-long pattern of exaggerated feelings of self-importance, an excessive need for admiration, and a diminished ability to empathize with other people's feelings. Narcissistic personality disorder is one of the sub-types of the broader category known as personality disorders. It is often comorbid with other mental disorders and associated with significant functional impairment and psychosocial disability.
Schizoid personality disorder is a personality disorder characterized by a lack of interest in social relationships, a tendency toward a solitary or sheltered lifestyle, secretiveness, emotional coldness, detachment, and apathy. Affected individuals may be unable to form intimate attachments to others and simultaneously possess a rich and elaborate but exclusively internal fantasy world. Other associated features include stilted speech, a lack of deriving enjoyment from most activities, feeling as though one is an "observer" rather than a participant in life, an inability to tolerate emotional expectations of others, apparent indifference when praised or criticized, all forms of asexuality, and idiosyncratic moral or political beliefs.
Obsessive–compulsive personality disorder (OCPD) is a cluster C personality disorder marked by a spectrum of obsessions with rules, lists, schedules, and order, among other things. Symptoms are usually present by the time a person reaches adulthood, and are visible in a variety of situations. The cause of OCPD is thought to involve a combination of genetic and environmental factors, namely problems with attachment.
Avoidant personality disorder (AvPD), or anxious personality disorder, is a cluster C personality disorder characterized by excessive social anxiety and inhibition, fear of intimacy, severe feelings of inadequacy and inferiority, and an overreliance on avoidance of feared stimuli as a maladaptive coping method. Those affected typically display a pattern of extreme sensitivity to negative evaluation and rejection, a belief that one is socially inept or personally unappealing to others, and avoidance of social interaction despite a strong desire for it. It appears to affect an approximately equal number of men and women.
Schizotypal personality disorder, also known as schizotypal disorder, is a cluster A personality disorder. The Diagnostic and Statistical Manual of Mental Disorders (DSM) describes the disorder specifically as a personality disorder characterized by thought disorder, paranoia, a characteristic form of social anxiety, derealization, transient psychosis, and unconventional beliefs.
In psychology, schizotypy is a theoretical concept that posits a continuum of personality characteristics and experiences, ranging from normal dissociative, imaginative states to extreme states of mind related to psychosis, especially schizophrenia. The continuum of personality proposed in schizotypy is in contrast to a categorical view of psychosis, wherein psychosis is considered a particular state of mind, which the person either has or does not have.
Thought broadcasting is a type of delusional condition in which the affected person believes that others can hear their inner thoughts, despite a clear lack of evidence. The person may believe that either those nearby can perceive their thoughts or that they are being transmitted via mediums such as television, radio or the internet. Different people can experience thought broadcasting in different ways. Thought broadcasting is most commonly found among people who have a psychotic disorder, specifically schizophrenia.
Paraphrenia is a mental disorder characterized by an organized system of paranoid delusions with or without hallucinations and without deterioration of intellect or personality.
Theodore Millon was an American psychologist known for his work on personality disorders. He founded the Journal of Personality Disorders and was the inaugural president of the International Society for the Study of Personality Disorders. In 2008 he was awarded the Gold Medal Award For Life Achievement in the Application of Psychology by the American Psychiatric Association and the American Psychological Foundation named the "Theodore Millon Award in Personality Psychology" after him. Millon developed the Millon Clinical Multiaxial Inventory, worked on the diagnostic criteria for passive-aggressive personality disorder, worked on editions of the Diagnostic and Statistical Manual of Mental Disorders, and developed subtypes of a variety of personality disorders.
A spectrum disorder is a disorder that includes a range of linked conditions, sometimes also extending to include singular symptoms and traits. The different elements of a spectrum either have a similar appearance or are thought to be caused by the same underlying mechanism. In either case, a spectrum approach is taken because there appears to be "not a unitary disorder but rather a syndrome composed of subgroups". The spectrum may represent a range of severity, comprising relatively "severe" mental disorders through to relatively "mild and nonclinical deficits".
The classification of mental disorders, also known as psychiatric nosology or psychiatric taxonomy, is central to the practice of psychiatry and other mental health professions.
Personality disorders (PD) are a class of mental health conditions characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the culture. These patterns develop early, are inflexible, and are associated with significant distress or disability. The definitions vary by source and remain a matter of controversy. Official criteria for diagnosing personality disorders are listed in the sixth chapter of the International Classification of Diseases (ICD) and in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).
A persecutory delusion is a type of delusional condition in which the affected person believes that harm is going to occur to oneself by a persecutor, despite a clear lack of evidence. The person may believe that they are being targeted by an individual or a group of people. Persecution delusions are very diverse in terms of content and vary from the possible, although improbable, to the completely bizarre. The delusion can be found in various disorders, being more usual in psychotic disorders.
Childhood schizophrenia is similar in characteristics of schizophrenia that develops at a later age, but has an onset before the age of 13 years, and is more difficult to diagnose. Schizophrenia is characterized by positive symptoms that can include hallucinations, delusions, and disorganized speech; negative symptoms, such as blunted affect and avolition and apathy, and a number of cognitive impairments. Differential diagnosis is problematic since several other neurodevelopmental disorders, including autism spectrum disorder, language disorder, and attention deficit hyperactivity disorder, also have signs and symptoms similar to childhood-onset schizophrenia.
The diagnosis of schizophrenia, a psychotic disorder, is based on criteria in either the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, or the World Health Organization's International Classification of Diseases (ICD). Clinical assessment of schizophrenia is carried out by a mental health professional based on observed behavior, reported experiences, and reports of others familiar with the person. Diagnosis is usually made by a psychiatrist. Associated symptoms occur along a continuum in the population and must reach a certain severity and level of impairment before a diagnosis is made. Schizophrenia has a prevalence rate of 0.3-0.7% in the United States.
The relationship between schizoid personality disorder (SzPD) and avoidant personality disorder (AvPD) has been a subject of controversy for decades.
Simple-type schizophrenia is a sub-type of schizophrenia included in the International Classification of Diseases (ICD-10), in which it is classified as a mental and behaviour disorder. It is not included in the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the upcoming ICD-11, effective 1 January 2022. Simple-type schizophrenia is characterized by negative ("deficit") symptoms, such as avolition, apathy, anhedonia, reduced affect display, lack of initiative, lack of motivation, low activity; with absence of hallucinations or delusions of any kind.
Passive–aggressive personality disorder, also called negativistic personality disorder, is characterized by procrastination, covert obstructionism, inefficiency, and stubbornness. The DSM-5 no longer uses this phrase or label, and it is not one of the ten listed specific personality disorders. The previous edition, the DSM-IV, describes passive–aggressive personality disorder as a proposed disorder involving a "pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance" in a variety of contexts. Passive–aggressive behavior is the obligatory symptom of the passive–aggressive personality disorder.
↑ Kendler KS, Czajkowski N, Tambs K, etal. (2006). "Dimensional representations of DSM-IV cluster A personality disorders in a population-based sample of Norwegian twins: a multivariate study". Psychological Medicine. 36 (11): 1583–91. doi:10.1017/S0033291706008609. PMID16893481. S2CID21613637.
↑ American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association.
↑ Bernstein, D. P., Useda, D., Siever, L. J. (1995). Paranoid Personality Disorder. In: J. W. Livesley (Ed.). The DSM-IV Personality Disorders. (pp. 45-57). New York: Guilford.
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