Paranoid personality disorder
Personality disorder involving mistrust of others
From Wikipedia, the free encyclopedia
Paranoid personality disorder (PPD) is a personality disorder characterized by paranoia, and a pervasive, long-standing suspiciousness and generalized mistrust of others.
| 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 |
| Risk factors | Adverse childhood experiences, possibly social stress |
| Differential diagnosis | Delusional disorder, schizophrenia; a bipolar or depressive disorder with psychotic symptoms; schizotypal, schizoid, borderline, histrionic, narcissistic, and avoidant personality disorders |
| Frequency | Estimated between 0.5% and 2.5% of the general population[1] |
Outlined in the main chapter on personality disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM), paranoid personality disorder is not specifically included in the Alternative DSM-5 Model for Personality Disorders (AMPD), nor in the eleventh revision (ICD-11) of the International Classification of Diseases; the latter two instead classify it in accordance with a dimensional approach to personality disorders.
The exact causes of PPD remain unknown, with research on this matter being limited; adverse childhood experiences are known to be a risk factor. Treatment of this disorder takes the forms of pharmacotherapy and psychotherapy; there are however no medications approved specifically for PPD and research on psychotherapeutic interventions is lacking.
Signs and symptoms
People with this 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 loneliness 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 to self-reference, or a tenacious sense of personal right.[4]
Causes
The causes of paranoid personality disorder have not been studied extensively. At the same time, there are studied causes of personality disorders in general; these include social, biological, psychological and developmental factors. Adverse childhood experiences are a risk factor for PPD, predominantly in the form of child abuse, itself occurring in various forms such as physical, sexual, and emotional abuse. Social stress may be another risk factor.[5]
A genetic contribution to paranoid traits and a possible genetic link between this personality disorder and schizophrenia exist.[citation needed] 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.[6]
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.[7]
Diagnosis
The two most prominent frameworks for classification of mental disorders – namely: the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases – prescribe diagnosis and classification of personality disorders. There is significant difference between the approaches embodied in the two, with only the DSM-5 section II classification containing PPD as a specific diagnosis. In addition to classification, there are also guidelines for differential diagnosis so that it can be ascertained that paranoid personality disorder is the correct diagnosis. Conditions that may be mistaken for PPD include other personality disorders as well as psychotic disorders.
Classification
The approaches to classification vary significantly between the latest editions of the DSM and ICD, these being the DSM-5-TR and ICD-11, respectively. While personality disorders, including PPD, are diagnosed as separate entities in the DSM-5; in the ICD-11, they are assessed in terms of severity levels, with trait and pattern specifiers serving to characterize the particular style of pathology.[8] The AMPD is a hybrid between the two approaches;[9] it defines personality disorder diagnoses through disorder-specific combinations of pathological traits and areas of overall impairment.[8]
In its main, categorical classification of personality disorders, located in section II,[8] the DSM-5 categorizes personality disorders into three clusters. Belonging to Cluster A,[10] PPD is characterized as a "pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent".[11] It is operationalized through seven symptoms, at least four of which must be present; as well as it not being attributable to a psychotic disorder or other medical conditions.[11]
The Alternative DSM-5 Model for Personality Disorders does not include paranoid PD as its own diagnostic entity.[12] What is conceptualized as PPD can instead be diagnosed as personality disorder – trait specified,[12] which is a dimensional diagnosis that is constructed from the individual expression of personalty disorder,[13] as manifested in both a general impairment in personality functioning along with at least one pathological personality trait.[14] Such traits that may be used for characterization of PPD are suspiciousness, restricted affectivity, and hostility.[15]
The ICD-11 classification of personality disorders has replaced the categorical classification of personality disorders in the ICD-10, introducing a dimensional model containing a unified personality disorder (6D10) with severity specifiers, along with specifiers for prominent personality traits or patterns (6D11).[16] 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,[17] while trait and pattern specifiers are used for recording the manner in which the disturbance is manifested.[18] Paranoid personality disorder is primarily associated with the ICD-11 trait domains Negative Affectivity (6D11.0) and Dissociality (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.[19] Some studies also report a link to Detachment (6D11.1), consistent with prior research and theoretical models.[19] The previous revision, ICD-10, lists paranoid personality disorder under (F60.0).[20]
Differential diagnosis
When paranoid personality disorder is considered, a differential diagnosis is supposed to be conducted in order to ascertain that it is the correct diagnosis. Per the DSM-5-TR, this includes both other personality disorders and several disorders involving psychotic symptoms.[5] Moreover, PPD is to be differentiated from symptoms stemming from substance use disorders and from personality change due to another medical condition. People who develop paranoid traits alongside a physical handicap, such as hearing loss, should also not receive a diagnosis of PPD.[11]
Psychotic disorders that PPD is to be distinguished from differ from it through the presence of psychotic symptoms such as hallucinations and delusions; these are not part of PPD. Schizophrenia, delusional disorder involving persecutory delusions, as well as bipolar or depressive disorders with psychotic features are such disorders.[5][11] Paranoid personality disorder is only applicable in case its manifestation preceded the emergence of psychotic symptoms and persists after remission of these symptoms.[11]
Unless deemed comorbid due to their criteria also being met, other personality disorders can be distinguished from paranoid personality disorder based on specific characteristic differences.[11] Schizotypal personality disorder differs from PPD in it involving unusual perception, speech and thought as well as magical thinking, while they share social withdrawal and paranoid ideation.[5][11] The latter is not central to histrionic and borderline personality disorders, which also tend to involve anger in response to minor stimuli;[11] nor is it commonly significant in schizoid personality disorder, which shares detachment with PPD.[5][11] Reticence in people with narcissistic and avoidant personality disorders tends to stem from fear of others discovering their imperfections. People with PPD may be driven to antisocial behavior by vengefulness; this is different from the intent to obtain personal gain seen in antisocial personality disorder.[11]
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:[21]
| Subtype | Features | Traits |
|---|---|---|
| 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. |
Treatment
Treatment of paranoid personality disorder can be challenging, as individuals with this disorder are reluctant to find help and have difficulty trusting others.[medical citation needed] They may lack insight into their disorder, and may not experience internal distress. Due to the impact of their behaviors of people around them, they may be persuaded by family members to enter treatment.[5] Partly as a result of tendencies to mistrust others, there have been few studies conducted over the treatment of paranoid personality disorder.[22]
Currently, there are no medications approved by the U.S. Food and Drug Administration (FDA) for treating PPD;[5] but antidepressants, antipsychotics, and mood stabilizers may be prescribed under wrong assumptions to treat some of the symptoms. The effects on aggression of the aforementioned medications have been studied in the case of borderline personality disorder (BPD), for which there are also no medications approved by the FDA; the results indicate that "antipsychotics as a class do not have a large effect on aggression", which in turn indicates that treatments for psychosis are not effective for treatment of PPD.[22] Paranoid ideation can be ameliorated by second-generation antipsychotics.[5]
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. Cognitive behavioral therapy (CBT) 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 on Schema Therapy[25]).
Epidemiology
PPD occurs in about 0.5–4.4% of the general population.[10][1][26] It is seen in 2–10% of psychiatric outpatients, while in inpatients the prevalence range is 10–30%.[22] In clinical samples men have higher rates, whereas epidemiologically there is a reported higher rate of women.[27][22]
It is estimated that 75% of people with PPD also have another, comorbid personality disorder, with the most common ones being avoidant and borderline personality disorders, followed by narcissistic personality disorder.[22] Schizoid and schizotypal personality disorders also frequently present alongside PPD.[5] Overall, it is estimated that personality disorder comorbidity occurs in 75% of people with PPD.[22] In addition, agoraphobia, anxiety disorders, major depressive disorder, obsessive–compulsive disorder and substance use disorders are other possibly comorbid disorders.[5]
History
Paranoid personality disorder is listed in the DSM-5 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.[28]
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.[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 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.[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 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:[28]
- Behavioral characteristics of vigilance, abrasive irritability, and counterattack
- Complaints indicating oversensitivity, social isolation, and mistrust
- The dynamics of denying personal insecurities, attributing these to others, and self-inflation through grandiose fantasies
- Coping style of detesting dependence and hostile distancing of oneself from others
