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Paranoid Personality Disorder (PPD)

By Robert M. A. Hirschfeld, MD, DeWitt Wallace Senior Scholar and Professor, Department of Psychiatry, Weill Cornell Medical College

Paranoid personality disorder is characterized by a pervasive pattern of unwarranted distrust and suspicion of others that involves interpreting their motives as hostile or harmful.

  • Because people with paranoid personality disorder suspect that others are planning to exploit, deceive, or harm them, they are always on the look-out for possible insults, slights, or threats.

  • Doctors diagnose paranoid personality disorder based on specific symptoms, including distrust and suspicion in many aspects of life.

  • No treatment is effective, but cognitive-behavioral therapy may be tried, and drugs may relieve some symptoms.

Personality disorders are long-lasting, pervasive patterns of thinking, perceiving, reacting, and relating that cause the person significant distress and/or impair the person's ability to function.

People with paranoid personality disorder distrust others and assume that others intend to harm or deceive them, even when they have no or insufficient reason for these feelings.

Paranoid personality disorder occurs in about 0.4 to 5.1% of the general population. Some evidence suggests that paranoid personality disorder runs in families. Emotional and/or physical abuse and victimization during childhood may contribute to the development of this disorder.

Other disorders are often also present. For example, people with paranoid personality disorder may also have one or more of the following:

Symptoms

People with paranoid personality disorder suspect that others are planning to exploit, deceive, or harm them. They feel that they may be attacked at any time and without reason. Even though there is little or no evidence, they persist in maintaining their suspicions and thoughts.

Interpretation of experiences

People with paranoid personality disorder often think that others have greatly and irreversibly injured them. They are on the look-out for potential insults, slights, threats, and disloyalty and look for hidden meanings in remarks and actions. They closely scrutinize others for evidence to support their suspicions. For example, they may misinterpret an offer of help as implication that they are unable to do the task on their own. If they think that they have been insulted or injured in any way, they do not forgive the person who injured them. They tend to counterattack or to become angry in response to these perceived injuries. Because they distrust others, they feel a need to be self-sufficient and in control.

Effect on relationships

People with paranoid personality disorder are hesitant to confide in or develop close relationships with others because they worry that the information may be used against them. They doubt the loyalty of friends and the faithfulness of their spouse or partner. They can be extremely jealous and may constantly question the activities and motives of their spouse or partner in an effort to justify their jealousy.

Thus, people with paranoid personality disorder can be difficult to get along with. When others respond negatively to them, they take these responses as confirmation of their original suspicions.

Diagnosis

  • A doctor's evaluation, based on specific criteria

Doctors usually diagnose personality disorders based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5—see Classification and Diagnosis of Mental Illness), published by the American Psychiatric Association.

For doctors to diagnose paranoid personality disorder, people must be persistently distrustful and suspicious of others, as shown by at least four of the following:

  • They suspect, without sufficient reason, that other people are exploiting, injuring, or deceiving them.

  • They are preoccupied with unjustified doubts about the reliability of their friends and coworkers.

  • They are reluctant to confide in others lest the information be used against them.

  • They misinterpret harmless remarks or events as having hidden belittling, hostile, or threatening meaning.

  • They hold grudges if they think they have been insulted, injured, or slighted.

  • They are quick to think that their character or reputation has been attacked and to react angrily or to counterattack

  • They repeatedly suspect that their spouse or partner is unfaithful, although they have no sufficient reason to suspect it.

Also, symptoms must have begun by early adulthood.

Treatment

  • Cognitive-behavioral therapy

General treatment of paranoid personality disorder is the same as that for all personality disorders.

Because people with paranoid personality disorder are so suspicious and distrustful, doctors often have difficulty establishing a cooperative, mutually respectful relationship with them. To help establish a relationship and thus encourage people to participate in treatment, doctors often try to acknowledge any suspicions that have any validity.

No treatments are effective for paranoid personality disorder. However, if people are willing to cooperate, cognitive-behavioral therapy may be helpful.

Drugs, such as antidepressants and second-generation antipsychotics, may be prescribed to treat specific symptoms. Second-generation antipsychotics may help decrease anxiety.