Paranoid personality disorder

Paranoid personality disorder (PPD) is a mental illness

characterized by paranoid delusions, and a pervasive, long- Paranoid personality
standing suspiciousness and generalized mistrust of others. People disorder
with this personality disorder may be hypersensitive, easily Specialty Psychiatry, clinical
insulted, and habitually relate to the world by vigilant scanning of psychology
the environment for clues or suggestions that may validate their
Symptoms Paranoid delusions,
fears or biases. They are eager observers. They think they are in
pervasive
danger and look for signs and threats of that danger, potentially not
appreciating other interpretations or evidence.[2] suspiciousness,
generalized mistrust
They tend to be guarded and suspicious and have quite constricted of others,
emotional lives. Their reduced capacity for meaningful emotional hypersensitivity,
involvement and the general pattern of isolated withdrawal often scanning of
lend a quality of schizoid isolation to their life experience.[3] environments for
People with PPD may have a tendency to bear grudges, clues or suggestions
suspiciousness, tendency to interpret others' actions as hostile,
that may validate
persistent tendency to self-reference, or a tenacious sense of
fears or biases
personal right.[4] Patients with this disorder can also have
significant comorbidity with other personality disorders, such as Differential Delusional disorder,
schizotypal, schizoid, narcissistic, avoidant and borderline. diagnosis schizophrenia, cluster
A personality
disorders, borderline
Contents personality disorder
Frequency Estimated between
Causes
0.5% and 2.5% of the
Diagnosis general population[1]
ICD-10
DSM-5
Other
Differential diagnosis
Treatment
Epidemiology
History
See also
References
External links

Causes
A genetic contribution to paranoid traits and a possible genetic link between this personality disorder and
schizophrenia exist. 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.[5]

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.[6]

Diagnosis

ICD-10

The World Health Organization's ICD-10 lists paranoid personality disorder under (F60.0 (https://icd.who.
int/browse10/2019/en#/F60.0)). 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 other
obligations.[7]

PPD is characterized by at least three of the following symptoms:

1. excessive sensitivity to setbacks and rebuffs;

2. tendency to bear grudges persistently (i.e. refusal to forgive insults and injuries or slights);
3. suspiciousness and a pervasive tendency to distort experience by misconstruing the neutral
or friendly actions of others as hostile or contemptuous;
4. a combative and tenacious sense of self-righteousness out of keeping with the actual
situation;
5. recurrent suspicions, without justification, regarding sexual fidelity of spouse or sexual
partner;
6. tendency to experience excessive self-aggrandizing, manifest in a persistent self-referential
attitude;
7. 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 and schizophrenia.

DSM-5

The American Psychiatric Association's DSM-5 has similar criteria for paranoid personality disorder. They
require in general the presence of lasting distrust and suspicion of others, interpreting their motives as
malevolent, from an early adult age, occurring in a range of situations. Four of seven specific issues must be
present, which include different types of suspicions or doubt (such as of being exploited, or that remarks
have a subtle threatening meaning), in some cases regarding others in general or specifically friends or
partners, and in some cases referring to a response of holding grudges or reacting angrily.[8]

PPD is characterized by a pervasive distrust and suspiciousness of others such that their motives are
interpreted as malevolent, beginning by early adulthood and present in a variety of contexts. To qualify for
a diagnosis, the patient must meet at least four out of the following criteria:[8]

1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them.
 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 them.
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 their 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 lists paranoid personality disorder essentially unchanged from the DSM-IV-TR[9] version and
lists associated features that describe it in a more quotidian way. These features include suspiciousness,
intimacy avoidance, hostility and unusual beliefs/experiences.

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:[10]

Subtype Features
Obdurate paranoid Self-assertive, unyielding, stubborn, steely, implacable, unrelenting, dyspeptic, peevish,
(including compulsive and cranky stance; legalistic and self-righteous; discharges previously restrained
features) hostility; renounces self-other conflict.
Fanatic paranoid Grandiose delusions are irrational and flimsy; pretentious, expensive supercilious
(including narcissistic contempt and arrogance toward others; lost pride reestablished with extravagant claims
features) and fantasies.
Querulous paranoid
Contentious, caviling, fractious, argumentative, faultfinding, unaccommodating, resentful,
(including negativistic
choleric, jealous, peevish, sullen, endless wrangles, whiny, waspish, snappish.
features)
Insular paranoid
Reclusive, self-sequestered, hermitical; self-protectively secluded from omnipresent
(including avoidant
threats and destructive forces; hypervigilant and defensive against imagined dangers.
features)
Malignant paranoid
Belligerent, cantankerous, intimidating, vengeful, callous, and tyrannical; hostility vented
(including sadistic
primarily in fantasy; projects own venomous outlook onto others; persecutory delusions.
features)

Differential diagnosis

Paranoid personality disorder can involve, in response to stress, very brief psychotic episodes (lasting
minutes to hours). The paranoid may also be at greater than average risk of experiencing major depressive
disorder, agoraphobia, social anxiety disorder, obsessive-compulsive disorder and substance-related
disorders. Criteria for other personality disorder diagnoses are commonly also met, such as:[11] schizoid,
schizotypal, narcissistic, avoidant, borderline and negativistic 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 a person is receptive to
intervention.[12]

Epidemiology
PPD occurs in about 0.5–2.5% of the general population.[1][11] It is seen in 2–10% of psychiatric
outpatients. It is more common in males.[11]

History
Paranoid personality disorder is listed in DSM-V 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.[13]

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.[13] 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.[14]

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.[13]

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.[13]

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.[13]

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.[13]

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.[13]
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.[13]

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:[13]

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

4) coping style of detesting dependence and hostile distancing of oneself from others.

See also
DSM-IV codes (personality disorders)
ICD-10 codes (personality disorders)
Delusional disorder
Delusions of reference
Paranoid anxiety
Paranoid schizophrenia
Persecutory delusions
Schizotypal personality disorder

References
1. Personality Disorders (https://emedicine.medscape.com/article/294307-overview) at
eMedicine
2. Waldinger, Robert J. (1 August 1997). Psychiatry for Medical Students (https://books.google.
com/books?id=WjbQGh0MwzYC). American Psychiatric. ISBN 978-0-88048-789-4.
3. Meissner & Kuper, 2008
4. MacManus, Deirdre; Fahy, Tom (August 2008). "Personality disorders" (http://www.medicinej
ournal.co.uk/article/S1357-3039%2808%2900174-6/abstract). Medicine. 36 (8): 436–441.
doi:10.1016/j.mpmed.2008.06.001 (https://doi.org/10.1016%2Fj.mpmed.2008.06.001).
5. Kendler KS, Czajkowski N, Tambs K, et al. (2006). "Dimensional representations of DSM-IV
cluster A personality disorders in a population-based sample of Norwegian twins: a
multivariate study" (https://semanticscholar.org/paper/b96905c99106c37edbdc017f32f587ee
c7ce2aeb). Psychological Medicine. 36 (11): 1583–91. doi:10.1017/S0033291706008609 (h
ttps://doi.org/10.1017%2FS0033291706008609). PMID 16893481 (https://pubmed.ncbi.nlm.
nih.gov/16893481). S2CID 21613637 (https://api.semanticscholar.org/CorpusID:21613637).
6. Aaron T. Beck, Arthur Freeman (1990). Cognitive Therapy of Personality Disorders (1st ed.).
The Guilford Press. ISBN 9780898624342. OCLC 906420553 (https://www.worldcat.org/ocl
c/906420553).
 7. The Classification of Mental and Behavioural Disorders (ICD-10) by WHO: "Diagnostic
guidelines (https://www.who.int/classifications/icd/en/bluebook.pdf#158) Archived (https://we
b.archive.org/web/20140323025330/http://www.who.int/classifications/icd/en/bluebook.pdf#
158#158) 2014-03-23 at the Wayback Machine, p.158
8. "Schizoid Personality Disorder (pp. 652–655)". Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (2013) (https://archive.org/details/diagnosticstatis0005unse). 2013.
ISBN 978-0-89042-555-8.
9. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition Text Revision (DSM-IV-TR). Washington, DC: American
Psychiatric Association.
10. Millon, Théodore; Grossman, Seth (6 August 2004). Personality disorders in modern life (htt
ps://books.google.com/books?id=mHnbLYVAn9kC). Wiley. ISBN 978-0-471-23734-1.
11. "Internet Mental Health — paranoid personality disorder" (https://web.archive.org/web/20130
131182232/http://www.mentalhealth.com/dis/p20-pe01.html). Archived from the original (htt
p://www.mentalhealth.com/dis/p20-pe01.html) on 2013-01-31. Retrieved 2004-06-01.
12. " "Paranoid Personality Disorder" at Cleveland Clinic" (https://web.archive.org/web/2012030
4045944/http://www.clevelandclinic.org/health/health-info/docs/3700/3796.asp?
index=9784). Archived from the original (http://www.clevelandclinic.org/health/health-info/do
cs/3700/3796.asp?index=9784) on 2012-03-04. Retrieved 2008-02-13.
13. Salman Akhtar (1990). Paranoid Personality Disorder: A Synthesis of Developmental,
Dynamic, and Descriptive Features (https://books.google.de/books?id=bU0eAAAAQBAJ&p
g=PA149#v=onepage&q&f=false) Archived (https://web.archive.org/web/20180401003944/h
ttps://books.google.de/books?id=bU0eAAAAQBAJ&pg=PA149#v=onepage&q&f=false#v=o
nepage&q&f=false) 2018-04-01 at the Wayback Machine. American Journal of
Psychotherapy, 44, 5–25.
14. Bernstein, D. P., Useda, D., Siever, L. J. (1995). Paranoid Personality Disorder. In: J. W.
Livesley (Ed.). The DSM-IV Personality Disorders. (pp. 45-57). New York: Guilford.

External links
National Personality Disorder website for England (https:// Classification ICD-10: F60.0 (htt D
web.archive.org/web/20060916172249/http://www.person
ps://icd.who.int/bro
alitydisorder.org.uk/index.php)
wse10/2019/en#/F
Articles about Personality Disorders (http://web4health.inf
60.0) · ICD-9-CM:
o/en/answers/border-menu.htm) in Web4health web site
301.0 (http://www.ic
d9data.com/getICD
9Code.ashx?icd9=
301.0) · MeSH:
D010260 (https://m
eshb.nlm.nih.gov/r
ecord/ui?ui=D0102
60) · SNOMED CT:
13601005 (http://sn
omed.info/id/13601
005)
External MedlinePlus:
resources 000938 (https://ww
w.nlm.nih.gov/medli
 neplus/ency/article/
000938.htm)

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