What Is… Paranoid Personality Disorder

In this series, I dig a little deeper into the meaning of psychology-related terms. This week’s term is paranoid personality disorder.

Paranoid personality disorder (PPD) falls within the DSM-5‘s cluster A (odd/eccentric) personality disorders. People with PPD are distrustful and assume that others have negative intentions toward them. This pattern of suspiciousness is pervasive and occurs even when there is no evidence to support it, but it’s not to the extent that it becomes delusional.

Symptoms

Paranoid personality disorder symptoms include:

• persistent suspiciousness and mistrust of others
• suspicion, without justification, of being exploited, injured, or deceived by others
• fixated on unjustified doubts about the reliability of people in one’s life
• reluctant to confide in others out of concern that it will be used against oneself
• misinterpret things in the environment as having an underlying belittling, hostile, or threatening meaning
• holds onto grudges
• quick to interpret others as attacking one’s character/reputation, and quick to meet this with counterattack
• ongoing suspicions, without justification, that one’s partner is cheating

As with other personality disorders, it doesn’t pop up out of the blue in adulthood; rather, symptoms are already well established by early adulthood. It’s normal for people to have some of these symptoms (like grudges) some of the time. To rise to the level of disorder, the symptoms must cause significant distress and impairment in functioning, although the person may well misattribute the cause of that distress/impairment.

Other characteristics

The International Classification of Diseases 10th Edition (ICD-10), which came before the World Health Organization’s revamp of personality disorder diagnoses in the ICD-11, proposed several subtypes of PPD: expansive, fanatic, querulant, and sensitive paranoid personality. The querulant type may overlap with people who are persistently litigious. The DSM-5 doesn’t identify any PPD subtypes.

Most often there is another type of disorder present as well, such as psychotic disorders, anxiety disorders, PTSD, or alcohol use disorders. Around 75% of people with PPD have a co-occurring personality disorder. Borderline and avoidant are the most common, followed by narcissistic.

Unlike psychotic disorders, the paranoia in PDD is not delusional, although when people are under extreme stress, short micro-psychotic episodes may occur. Instead, paranoia in PPD is a rigid cognitive style that shapes how people interpret the world around them.

It’s estimated that PPD occurs in 2.3-4.4% of the population, although the figure jumps to about 23% in prison populations. It’s more common in males than females. It can be disabling, as functioning is limited by suspiciousness. It increases the risk of violence and criminal behaviour, but of course, not everyone in PPD engages in these types of behaviours.

Causes

There seems to be a hereditary component, and possibly a genetic link to schizophrenia. Emotional or physical abuse in childhood can increase the risk of developing PPD. Brain injury may be a risk factor, as rates of PPD are higher among people who have experienced a brain injury.

From a cognitive theory perspective, PPD is thought to be the result of a combination of poor self-awareness and the belief that people are unfriendly. Freud, unsurprisingly, got sexual with it, believing that paranoia was a defense mechanism against unconscious homosexual desires.

Treatment

People with PPD seldom seek out treatment, as they see others as the problem, not themselves. The condition is difficult to treat, in large part because of lack of insight combined with mistrust of mental health professionals. Cognitive therapy, psychodynamic therapy, and short-term use of antipsychotics may be helpful.

Paranoia vs. PPD

When I was working at a community mental health team, I had a patient who had a psychotic disorder and probable paranoid personality disorder. It was exhausting for me to hear about all the wrongs that were done to him; I can’t imagine how exhausting that would have been inside his head. I suspect other people found him exhausting too and reacted in ways that fuelled the paranoid mindset. The meds kept the psychotic stuff under control, so what I was getting from him seemed to be all personality stuff. It was fascinating.

There are a lot of suspicious people out there, and probably the vast majority of them don’t deserve a paranoid personality disorder diagnosis. I don’t think it’s particularly useful to try to pathologize batshit non-psychiatrically crazy folk like Alex Jones, as performative paranoia doesn’t give much meaningful information about someone’s underlying psychological characteristics.

What are your thoughts on maintaining a degree of separation between run-of-the-mill conspiracy theory paranoia and paranoia in a psychiatric sense, whether that be PPD or psychosis?

References

• Lee, R. J. (2017). Mistrustful and misunderstood: a review of paranoid personality disorder. Current Behavioral Neuroscience Reports, 4(2), 151-165.
• Merck Manual Professional Version: Paranoid personality disorder
• Wikipedia: Paranoid personality disorder
• Vyas, A., & Khan, M. (2016). Paranoid personality disorder. American Journal of Psychiatry Residents’ Journal, 11(01), 9-11.