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Day #129: Paranoid Personality Disorder

Today we will continue our current theme of personality disorders as we discuss paranoid personality disorder (PPD).

Introduction 1

  • Individuals with paranoid personality disorder (PPD) have long-standing distrust and suspiciousness of others and often interpret motives as malicious.

  • They tend to refuse personality responsibility for their own problems and assign the blame to others. They may be described as an "injustice collector" which is someone who sees injustices in many, if not most, things that happen to them in life.

  • Common traits/symptoms may include being -> hostile, irritable, angry, easily offended, prejudiced, jealous, and suspicious.

Diagnostic Criteria 2

  • The diagnosis of PPD requires a pervasive distrust and suspiciousness of others, beginning by early adulthood and present in a variety of contexts.

  • ≥ 4 of the following must also be present: Mnemonic "SUSPECT"

  • Suspicious - (without evidence) that others are exploiting or deceiving him or her.

  • Unforgiving - Persistence of grudges (i.e., is unforgiving of insults, injuries, or slights).

  • Spousal/partner infidelity is suspected repeatedly without justification.

  • Perceives attacks - on his or her character that is not apparent to others; quick to counterattack.

  • Enemy or friend? - preoccupation with doubts of loyalty or trustworthiness of friends or acquaintances.

  • Confiding - reluctance to confide in others because of unwarranted fear that the information will be used against them.

  • Threats perceived - interpretation of benign remarks or events as threatening or demeaning.

  • Symptoms do not occur exclusively during the course of another mental illness such as schizophrenia, bipolar disorder, depressive disorder with psychotic features, or the effects of another medical condition. If criteria are met prior to the onset of schizophrenia, add "premorbid" as a specifier to the diagnosis.

Epidemiology/Pathogenesis 3, 4

  • Prevalence is estimated to be 2-4% of the general population, however this is difficult to study since those with the disorder rarely seek treatment themselves.

  • More commonly diagnosed in men than in women (interestingly, epidemiological research finds higher rates in women while clinical samples find higher rates in men).

  • Relatives of patients with schizophrenia show a higher incidence of paranoid PD than control participants, however some evidence suggests a more specific familial relationship with delusional disorder, persecutory type.

  • Higher prevalence among immigrants, minority groups, and persons who are deaf, however it is also more likely to be misdiagnosed or over diagnosed in these groups. Other risk factors include childhood trauma, low income, and other causes of social stress.

  • Prognosis: typically has a chronic course with lifelong marital/relational and job-related problems.

Clinical Pearls 5

  • Those with paranoid personality disorder rarely seek treatment themselves. If they are referred to treatment by a spouse or an employer, they can often present themselves as put together and appear undistressed.

  • Mental status exam: they may act in a way that is perceived as formal, serious, and humorless. They will likely be guarded and cautious in confiding in you or giving information that could be used against them. They may be tense with an inability to relax. In more extreme cases they may scan the environment to look for clues that you are trying to exploit or deceive them. Some premises of their arguments may be false, but does not reach the level of delusional thinking. Their speech is often goal-directed and shows evidence of prejudice, projection, and occasional ideas of reference that are logically defended.

  • Optional personality questionnaires: Personality Assessment Inventory (PAI) and Minnesota Multiphasic Personality Inventory (MMPI).

  • Differential diagnosis: consider and rule out schizophrenia, delusional disorder, or other psychotic disorders (patients with PPD do not have any fixed delusions and are not frankly psychotic, although they may have transient psychosis under stressful situations). Remember to consider social isolation or disenfranchisement because without a social support system, individuals can react with suspicion to others. Also consider other personality disorders in the differential diagnosis, particularly other cluster A disorders (schizoid, schizotypal). Keep in mind that an estimated 75% of PPD cases have a comorbid personality disorder. Avoidant and borderline PD are the most frequently comorbid (48% and 48%), along with Narcissistic PD (35.9%).

Treatment 6, 7

  • General approach to personality disorders: In general, the first-line treatment of all personality disorders is psychotherapy, however, the data is not robust and depending on the personality disorder, patients rarely seek treatment themselves unless they have other comorbid behavioral health conditions. Patients with personality disorders may be highly symptomatic and are often prescribed multiple medications in a manner unsupported by evidence.

  • Psychotherapy: Psychotherapy is the treatment of choice for paranoid personality disorder, however little is known about effective psychotherapeutic approaches for this condition. Cognitive behavioral therapy (CBT) has been advocated for and case studies support its potential effectiveness, however systematic data is lacking. Other approaches that have been used include psychodynamic therapy and social skills training. Therapists should strive to be professional, straightforward, consistent, and non-defensive in their approach to these patients. Overly warm styles or overzealous use of interpretation may increase the patient's mistrust or suspiciousness of your motives. Group psychotherapy should generally be avoided due to mistrust and misinterpretation of others' statements unless there is a clear therapeutic alliance and goal to improve social skills in this setting.

  • Pharmacotherapy: There are no FDA approved medications for paranoid personality disorder. There have been no clinical trials specific to paranoid PD and the evidence for adjunctive pharmacotherapy in paranoid PD is limited. Clinical practice is largely guided by expert opinion and experience, which support some efficacy for using a low-dose antipsychotic for brief periods to manage severe agitation, cognitive-perceptual symptoms such as quasi-delusional thinking, or transient psychosis during stress. Expectations for treatment response should be attenuated and the potentially limited benefits must outweigh the risks associated with medication treatment. Comorbid anxiety and depressive disorders should be treated accordingly (see treatment of depression; treatment of anxiety).


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