Paranoid Personality Disorder

People with paranoid personality disorder are generally characterized by having a long-standing pattern of pervasive distrust and suspiciousness of others. A person with a paranoid personality disorder will nearly always believe that other people’s motives are suspect or even malevolent. Individuals with this disorder assume that other people will exploit, harm, or deceive them, even if no evidence exists to support this expectation. While it is fairly normal for everyone to have some degree of paranoia about certain situations in their lives (such as worry about an impending set of layoffs at work), people with paranoid personality disorder take this to an extreme it pervades virtually every professional and personal relationship they have.

Paranoid Personality Disorder (PPD)
Paranoid Personality Disorder (PPD)

Individuals with Paranoid Personality Disorder are generally difficult to get along with and often have problems with close relationships. Their excessive suspiciousness and hostility may be expressed in overt argumentativeness, in recurrent complaining, or by quiet, apparently hostile aloofness. Because they are hypervigilant for potential threats, they may act in a guarded, secretive, or devious manner and appear to be “cold” and be lacking in tender feelings. Although they may appear to be objective, rational, and unemotional, they more often display a labile range of effect, with hostile, stubborn, and sarcastic expressions predominating. Their combative and suspicious nature may elicit a hostile response in others, which then serves to confirm their original expectations.

Because of individuals with Paranoid Personality Disorder lack trust in others, they have an excessive need to be self-sufficient and a strong sense of autonomy. They also need to have a high degree of control over those around them. They are often rigid, critical of others, and unable to collaborate, and they have great difficulty accepting criticism.

Symptoms of Paranoid Personality Disorder

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, as indicated by four (or more) of the following:

  • Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
  • 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 him or her
  • 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 his or her 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
  • Suspicion
  • Concern with hidden motives
  • Expects to be exploited by others
  • Inability to collaborate
  • Social isolation
  • Poor self-image
  • Detachment
  • Hostility

People with this disorder typically exhibit a strong need for self-sufficiency, are rigid and often litigious. Because of their avoidance of closeness with others, they may appear calculating and cold. Usually, men are diagnosed with it more than women.

Paranoid Personality Disorder (PPD)
Paranoid Personality Disorder (PPD)

Paranoid personality disorder should not be diagnosed if the pattern of suspicious behavior occurs exclusively during the course of schizophrenia or another psychotic disorder.

As with all personality disorders, the person must be at least 18 years old before they can be diagnosed with it.

The paranoid personality disorder is more prevalent in males than females and occurs somewhere between 0.5 and 2.5 percent in the general population.

Like most personality disorders, paranoid personality disorder typically will decrease in intensity with age, with many people experiencing few of the most extreme symptoms by the time they are in the 40s or 50s.

How is Paranoid Personality Disorder Diagnosed?

Personality disorders such as paranoid personality disorder are typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. So while you can initially consult a family physician about this problem, they should refer you to a mental health professional for diagnosis and treatment. There are no laboratory, blood or genetic tests that are used to diagnose a paranoid personality disorder.

Many people with the paranoid personality disorder don’t seek out treatment. People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere or otherwise impact a person’s life. This most often happens when a person’s coping resources are stretched too thin to deal with stress or other life events.

Paranoid Personality Disorder (PPD)
Paranoid Personality Disorder (PPD)

A diagnosis of paranoid personality disorder is made by a mental health professional comparing your symptoms and life history with those listed here. They will make a determination whether your symptoms meet the criteria necessary for a personality disorder diagnosis.

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

  • excessive sensitivity to setbacks and rebuffs;
  • the tendency to bear grudges persistently (i.e. refusal to forgive insults and injuries or slights);
  • suspiciousness and a pervasive tendency to distort experience by misconstruing the neutral or friendly actions of others as hostile or contemptuous;
  • a combative and tenacious sense of self-righteousness out of keeping with the actual situation;
  • recurrent suspicions, without justification, regarding sexual fidelity of spouse or sexual partner;
  • the tendency to experience excessive self-aggrandizing, manifest in a persistent self-referential attitude;
  • preoccupation with unsubstantiated “conspiratorial” explanations of events both immediate to the patient and in the world at large.

  • expansive paranoid, fanatic, querulant and sensitive paranoid personality disorder

  • delusional disorder
  • schizophrenia

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.

Causes of Paranoid Personality Disorder

Researchers today don’t know what causes paranoid personality disorder. There are many theories, however, about the possible causes of paranoid personality disorder. Most professionals subscribe to a biopsychosocial model of causation — that is, the causes of are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual’s personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible — rather, it is the complex and likely intertwined nature of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be “passed down” to their children.

Differential diagnosis of Paranoid Personality Disorder

Paranoid Personality Disorder can involve, in response to stress, very brief psychotic episodes (lasting minutes to hours). If long-lasting the disorder may develop into delusional disorder or schizophrenia. Individuals may also be at greater than average risk of experiencing major depressive disorder, agoraphobia, social anxiety disorder, obsessive-compulsive disorder or alcohol and substance-related disorders. Criteria for other personality disorder diagnoses are commonly also met, such as:

Paranoid Personality Disorder (PPD)
Paranoid Personality Disorder (PPD)
  • schizoid personality disorder
  • schizotypal personality disorder
  • narcissistic personality disorder
  • avoidant personality disorder
  • borderline personality disorder
  • negativistic personality disorder

Subtypes of Paranoid Personality Disorder

Psychologist Theodore Millon has proposed five subtypes of paranoid personality:

Obdurate paranoid (including compulsive features)

  • Self-assertive
  • unyielding
  • stubborn
  • steely
  • implacable
  • unrelenting
  • dyspeptic
  • peevish
  • cranky stance
  • legalistic and self-righteous
  • discharges previously restrained hostility
  • renounces self-other conflict.

Fanatic paranoid (including narcissistic features)

  • Grandiose delusions are irrational and flimsy
  • pretentious
  • expensive supercilious contempt
  • 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.
Paranoid Personality Disorder (PPD)
Paranoid Personality Disorder (PPD)

Malignant paranoid (including sadistic features)

  • Belligerent
  • cantankerous
  • intimidating
  • vengeful
  • callous
  • tyrannical
  • hostility vented primarily in fantasy
  • projects own venomous outlook onto others
  • persecutory delusions.

How to Treat Paranoid Personality Disorder

Treatment of paranoid personality disorder can be very effective in controlling the paranoia but is difficult because the person may be suspicious of the doctor. Without treatment this disorder will be chronic. Medications and therapy are common and effective approaches to alleviating the disorder.

Medications for Paranoid Personality Disorder

Medications are usually contraindicated for this disorder since they can arouse unnecessary suspicion that will usually result in noncompliance and treatment dropout. Medications which are prescribed for specific conditions should be done so for the briefest time period possible to be able to manage the condition.

An anti-anxiety agent, such as diazepam, is appropriate to prescribe if the client suffers from severe anxiety or agitation that interferes with normal, daily functioning. An anti-psychotic medication, such as thioridazine or haloperidol, may be appropriate if a patient decompensates into severe agitation or delusional thinking which may result in self-harm or harm to others.

Because of reduced levels of trust, there can be challenges in treating PPD. However, psychotherapy, antidepressants, antipsychotics and anti-anxiety medications can play a role when an individual is receptive to intervention.

Psychotherapy for paranoid personality disorder

Psychotherapy is the most promising method of treatment for paranoid personality disorder. People with this disorder often have deep-rooted problems with interpersonal functioning that necessitate intense therapy. A strong therapist-client relationship offers the most benefit to people with the disorder, yet is extremely difficult to establish due to the dramatic skepticism of patients with this condition. People with paranoid personality disorder rarely initiate treatment and often terminate it prematurely. Likewise, building therapist-client trust requires care and is complicated to maintain even after a confidence level has been founded. Most patients with this disorder experience symptoms for the duration of their lifetime and require consistent therapy.


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