Paranoid personality disorder

Paranoid personality disorder (PPD) is a mental disorder characterized by paranoia and a pervasive, long-standing suspiciousness and generalized mistrust of others. Individuals with this personality disorder may be hypersensitive, easily feel slighted, and habitually relate to the world by vigilant scanning of the environment for clues or suggestions that may validate their fears or biases. Paranoid individuals are eager observers. They think they are in danger and look for signs and threats of that danger, potentially not appreciating other evidence.

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. People with this particular disorder may or may not 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. Patients with this disorder can also have significant comorbidity with other personality disorders.



Causes
A genetic contribution to paranoid traits and a possible genetic link between this personality disorder and schizophrenia exist. Psychosocial theories implicate projection of negative internal feelings and parental modeling.



Diagnosis


WHO

The World Health Organization's ICD-10 lists paranoid personality disorder as (F60.0) Paranoid personality disorder.

It is characterized by at least three of the following:
excessive sensitivity to setbacks and rebuffs;
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 personal rights out of keeping with the actual situation;
recurrent suspicions, without justification, regarding sexual fidelity of spouse or sexual partner;
tendency to experience excessive self-importance, 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.
Includes:
expansive paranoid, fanatic, querulant and sensitive paranoid personality (disorder)
Excludes:
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 obligations.

APA
The American Psychiatric Association's DSM-5 has similar criteria. The central feature is "a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent...":

The diagnostic criteria are subject to copyright.


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




Obdurate (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 (including narcissistic features):
Grandiose delusions are irrational and flimsy; pretentious, expensive supercilious contempt and arrogance toward others; lost pride reestablished with extravagant claims and fantasies.

Querulous (including negativistic features):
Contentious, caviling, fractious, argumentative, faultfinding, unaccommodating, resentful, choleric, jealous, peevish, sullen, endless wrangles, whiny, waspish, snappish.

Insular (including avoidant features):
Reclusive, self-sequestered, hermitical; self-protectively secluded from omnipresent threats and destructive forces; hypervigilant and defensive against imagined dangers.

Malignant (including sadistic features)
Belligerent, cantankerous, intimidating, vengeful, callous, and tyrannical; hostility vented primarily in fantasy; projects own venomous outlook onto others; persecutory delusions.



Differential diagnosis
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, obsessive-compulsive disorder or alcohol and substance-related disorders. Criteria for other personality disorder diagnoses are commonly also met, such as:

schizoid personality disorder
schizotypal personality disorder
narcissistic personality disorder
avoidant personality disorder
borderline personality disorder



Treatment
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.


Epidemiology
PPD occurs in about 0.5%–2.5% of the general population. It is seen in 2%–10% of psychiatric outpatients. It occurs more commonly in males.

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 schizoid and schizotypal personality disorder.



History
See the history of paranoia.

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

Closely related to this description is 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 individuals 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. Kraepelin also noted that paranoid personalities were often present in individuals who later developed paranoid psychoses. Subsequent writers also considered traits like suspiciousness and hostility to predispose people to developing delusional illnesses, particularly "late paraphrenias" of old age.

Following Kraepelin, Bleuler described "contentious psychopathy" or "paranoid constitution" as displaying the characteristic triad of suspiciousness, grandiosity and feelings of persecution. He also emphasized that the false assumptions of these individuals do not attain the form of real delusion.

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.

Jaspers, a German phenomenologist, described "self-insecure" personalities who resemble the paranoid personality. According to Jaspers, such individuals 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.

In 1950, 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.

The descriptions of Leonhard and Sheperd from the sixties describe paranoid individuals 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.

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.

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 Millon who divided the features of paranoid personality disorder to four categories:
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 and
4) coping style of detesting dependence and hostile distancing of oneself from others.

The DSM-IV-TR describes the paranoid personality disorder as a pattern of pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent.To qualify for a diagnoses, the patient must meet at least 4 out of the following criteria:
(1) suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
(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 him or her
(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 his or her 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 does not list paranoid personality disorder as a specific type but still enlists traits that allow to describe it: suspiciousness, intimacy avoidance, hostility and unusual beliefs/experiences.



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