Personality Disorders: Toward the DSM-V
Chapter 3
Paranoid personality disorder

Description of the disorder

Paranoid personality disorder (PPD) is characterized by a mistrust of other people. Other features include: quarrelsomeness, hostility, emotional coldness, hypersensitivity to lights of criticism, stubbornness and rigidity held maladaptive beliefs of others’ intents.

The underlying assumption is that other are malevolent. Measures must be taken to protect oneself.

People with paranoid personality disorder tend to hold grudges, have enemies are often litigious, and can be pathologically jealous.

Paranoid personality disorder exemplifies one extreme pole of the agreeableness-antagonism dimension of the five-factor model of personality.

The pattern of antagonistic behaviour often causes difficulties in interpersonal relationships. It may provocate the kinds of attacks these individuals fear.

People with paranoid personality disorder are usually not psychotic, although they may experience transient psychotic-like symptoms under conditions of extreme stress. The beliefs in paranoid personality disorder are rarely of psychotic proportions.

Differential diagnosis

Unlike PPD, paranoid schizophrenia and delusional disorder involve frank delusions, false beliefs of psychotic proportions. Such beliefs are not always evident.

People with PPD sometimes develop transient delusions when under extreme stress.

Schizotypal individuals display odd or eccentric ideas, peculiar thinking or speech, unusual perceptual experiences and other ‘schizophrenia-like’ features that are not seen in PPD.

Schizoid individuals are socially withdrawn because of a preference of being alone rather than a desire to protect themselves from imagined threats.

Outstanding issues

PPD patients are seen in a variety of clinical populations, and they can pose special problems for treatment when their mistrust affects the therapeutic relationship.
Some PPD patients can achieve good outcomes when they are given treatments appropriate to their problems.

Descriptive and theoretical issues

Are the DSM-IV criteria for PPD valid descriptions of the disorder?

A long-standing debate, centres on the question of whether less severe paranoid disorders, such as PPD and delusional disorder, lie on a genetic continuum with schizophrenia, of whether it is a distinct spectrum.

The DSM-IV criteria for PPD appear to overrepresent the cognitive PPD trait mistrust/suspiciousness and to underrepresent the prototypical behavioural, affective, and interpersonal expressions of paranoid personality traits. Nearly all of the DSM-IV PPD criteria reflect the cognitive trait of mistrust. Three reflect the affective/interpersonal trait of hypersensitivity. Two reflect the  affective/interpersonal trait of anatognism. Two reflect the cognitive trait of hypervigiliance. One reflects the interpersonal trait of introversion. One reflects the cognitive trait of rigidity.

The DSM-criteria are: 1) suspects that others exploit, harm or deceive 2) doubt others’ loyalty or trustworthiness 3) are reluctant to confide in others for fear that information will be used against them 4) read hidden or demeaning meanings into benign remarks or events 5) bears grudges 6) perceive attacks on their character or reputation and are quick to react with anger or counterattack 7) have recurrent suspicions on the partner’s sexual infidelity.

What theoretical models might explain the features of PPD?

Traditional psychoanalytic models of PPD have focused on the defense mechanism of projection: the disavowing of one’s own aggressive feelings and thoughts by projecting them into another person. There is considerable empirical support for the notion that patients with severe personality disorder employ projection and other maladaptive defences.

Paranoid phenomena may be explained using cognitive processing models. Misattributions of people with PPD may be understood in terms of characteristic cognitive biases, including attentional biases, interpretative biases and memory biases.

Core cognitive schemas in PPD concern feelings of inadequacy. These feelings, in combination with poor social skills and external attribution of blame as a means to reducing anxiety, account for the features of PPD. People with PPD attribute the cause of their feelings of inadequacy to others. They ruminate on the injuries and injustices others have caused them.

The integrative cognitive model posited that early maladaptive schemas, schema modes and maladaptive coping mechanisms are the conceptual core of personality disorders. The early maladaptive schemas that appear most relevant to PPD are defectiveness/shame, abuse/mistrust, and vulnerability to harm. As a result, the person adopts a belligerent, overcompensating form of coping.

Empirical issues

The phenotypic manifestations of personality disorder exhibit a variable course over the life span.

Is PPD a true category or a dimension that cuts across categories?

Diagnostic comorbidity

Patients with PPD often exhibit features of other personality disorders. One rarely finds a case of PPD that is not accompanied by one or more comorbid personality disorders.

There are several potential explanations for the high degree of comorbidity: 1) phenomenological similarity between the personality disorders 2) artifactual overlap due to imprecision in the DSM criteria 3) the presence of shared or related underlying pathological processes.

Categories versus dimensions

The dimensional approach focuses on the degree to which one exhibits a syndrome or construct. There are two major variants of the dimensional approach: 1) personality disorders are conceptualized as the extreme ends of dimensions that are shared with normal personality 2) personality disorders are conceptualized as spectrum variants of mental illness, with Axis I disorders forming the extreme ends of the continuum.

PPD is negatively related to the personality dimension of agreeableness, and positively related to neuroticism.

Is PDD a schizophrenia-spectrum or Delusional-spectrum disorder?

Family/genetics studies

Suspiciousness, referential thinking, and peculiar ideas are prevalent among relatives of people with schizophrenia. Considerable evidence has been found to support the notion that schizotypal personality disorder falls on the schizophrenia spectrum. The evidence for PDD and schizoid personality disorder is less conclusive.

Which environmental factors might contribute to the development of PPD?

There is little research on the environmental factors in the etiology of PPD. Traumatic childhood events may play a role in the development of PPD.

Both genetic and environmental factors play significant roles in the development of the traits that make up personality disorders.

What kinds of treatment are likely to be most effective for people with PDD?

The goal of therapy with PPD patients is to help them: 1) recognize and accept their own feelings of vulnerability 2) heighten their feelings of self-worth and reduce their feelings of shame 3) develop a more balanced, trusting view of others 4) reduce their reliance on counterproductive self-protective strategies.

It is essential that the patient’s mistrust and self-protective mechanisms e confronted directly in an empathic but clear and straightforward manner.