Paranoid Personality Disorder is characterized by persistent deep distrust of others coupled with a belief that others will cause them harm. Paranoid personality disorder impairs life function and occurs most often in men.3,7 Individuals with paranoid personality disorder rarely seek therapy due to their suspiciousness. Individual treatment using cognitive behavioral and psychodynamic therapies, along with skills training, can be used to treat this disorder; however, treatability is low.8
What Is Paranoid Personality Disorder?
Personality combines an individual’s overall biological, psychological, and social learning together with their inherited genetic traits. Simply put, personality establishes how one thinks, feels and behaves. Personality determines if an individual can effectively live in and adapt to a changing world. Personality can be viewed in two ways: Looking at distinct traits, like friendliness or coldness; and understanding how the various parts of a person come together as a whole.3
Individuals with paranoid personality disorder have negative thoughts, feelings and behaviors related to the following:
- Thinking others want to intentionally cause them harm by exploiting or deceiving them
- Worrying constantly about others’ disloyalty
- Being unable to confide in others
- Finding negative hidden meaning in comments or events
- Holding grudges
- Feeling attacked and attacking back
- Inability to trust a partner’s fidelity without justification3
Persons with paranoid personality disorder have continual difficulty in forming personal relationships and behaving in socially acceptable ways. These characteristics negatively impact all aspects of their lives.
Signs of Paranoid Personality Disorder
Look for these characteristics to be prominent and consistent in those with paranoid personality disorder:3
- Quick to make negative judgments
- Hostile
- Aggressive
- Emotionally volatile or
- Completely unemotional
- Cold in personal relationships
- Controlling
- Brittle
- Blameful
- Extremely independent
- Rigid thinking
- Uncompromising
- Defensive
- Poor impulse control
- Unkind
- Too quiet or too loud
- Aloof
- Quick to anger or rage
- Overly concerned about status or rank
- Extremely suspicious
- Hyper-vigilant and anxious
- Holds grudges indefinitely
- Attacks and counterattacks
- Distrustful
- Dismisses cultural and societal norms
- Depressive
Individuals with paranoid personality disorder may also have substance use disorders, panic disorder, and a history with the criminal justice system (arrests, jail and prison). 75% of individuals with paranoid personality disorder have a comorbid personality disorder, usually avoidant personality disorder or borderline personality disorder.7 They are unlikely to seek treatment for any of their problems.
Symptoms of Paranoid Personality Disorder
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) provides specific criteria for diagnosing paranoid personality disorder.
The DSM-5 Criteria for paranoid personality disorder are:
- 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, as indicated by four (or more) of the following:
- Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
- Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends and associates.
- Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.<
- Read hidden demeaning or threatening meanings into benign remarks or events.
- Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
- Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
- Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.
- Does not occur exclusively during the course of schizophrenia, a bipolar disorder or a depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.1
The DSM-5 provides an alternate model for diagnosing personality disorders that measures impairments in personality function and pathological personality traits. This model takes into account the overlap of traits in the 10 personality disorders shown in the DSM-5. It also presents personality disorders on a spectrum instead of discrete diagnoses. Please see the DSM-5 for additional information.1
Causes & Triggers of Paranoid Personality Disorder
The causes of paranoid personality disorder are unresolved. There has been very little empirical research on this disorder. This is often attributed to the lack of paranoid personality disorder clients that are willing to participate in or remain in treatment. Clinicians don’t encounter paranoid personality disorder clients very often unless they are court ordered, incarcerated, or seeking help for another mental health disorder.
Most of the literature on paranoid personality disorder states that the interaction of genetically inherited traits and environmental influences are the likely cause. Some research has shown that individuals with paranoid personality disorder are often victims of childhood maltreatment.3,7 However, Dr. Gregory W. Lester points out that research data also show that aversive childhood experiences are not predictive of personality disorders. The majority of abused children (about 68%) recover without symptoms.8
There are several theories implicating the causation of personality disorders in general, they are attachment theory, excessive trait theory, and the Five-Factor Model. Attachment theory states that reliable, secure attachment (love, comfort, food and warmth) provided by a caregiver allows a young child to build internal working models that become traits of the personality structure. Without secure attachment, the child may build unhealthy views of self and others which increases the likelihood of developing psychopathology.9
Dr. Lester states that the personality is like a “toolkit” with tools or “traits” that aid in a person’s flexibility and adaptability. Individuals with personality disorders have one trait exclusively, like suspiciousness in paranoid personality disorder. They do not have enough other diverse traits to meet changing needs (trust in particular for paranoid personality disorder). Individuals with personality disorders do the same thing over and over no matter how negative the consequences. They lack the insight to see that it is their own behaviors that cause negative effects.8
The Five Factor Model (FFM) divides and measures personality structure using five domains: Negative Affectivity; Detachment; Antagonism, Disinhibition, and Psychoticism.1 Within the domains are 25 traits measured on a continuum to determine the extent of the trait. paranoid personality disorder displays the extreme Antagonism trait overwhelming all other personality traits. The sum of the five traits indicates the intensity of dysfunction. Individuals with paranoid personality disorder show up as inflexible and outside the cultural norms. They lack self-awareness which makes personal and social function problematic.3
Treatment of Paranoid Personality Disorder
Paranoid personality disorder can be treated through a variety of medications, types of therapy including cognitive analytical therapy, cognitive behavioral therapy, dialectical behavioral therapy, and lifestyle changes.
Medication
There are currently no US Food and Drug Administration approved medications for personality disorders, including paranoid personality disorder. Medication therapies consist of off-label use to treat symptoms or co-occurring disorders like major depressive disorder.3,7
Medication use for personality disorder symptoms focus on three dimensions: emotional dysregulation, such as anxiety, anger, depression, or severe mood swings; cognitive-perceptual symptoms, like hallucinations; and impulsivity, for example self-injury and suicidality.3 A psychiatrist or psychiatric nurse practitioner can work with the individual to diagnose and prescribe according to his or her needs.
There is so little research on medication effectiveness for paranoid personality disorder that there are no prescribing guidelines. One small study tested antipsychotic medications on 15 participants in Denmark with no conclusive results.6 Anti-anxiety and antidepressant medications may be prescribed, but there is little empirical evidence that they are an effective treatment for paranoid personality disorder.3,6,7,10
It may be that an individual with paranoid personality disorder has several disorders that need interventions. Medications for paranoid personality disorder must be managed on a case-by-case basis.
Therapy
Paranoid personality disorder therapy requires firm boundaries. This includes a clear written agreement regarding the terms of therapy, including: expected length, frequency, the time in sessions, phone calls, payments, crises, appropriate behaviors, explicit treatment targets and the consequences of violating any of the boundaries.8 The therapeutic relationship is important also. The therapist must demonstrate commitment to the long-term, provide validation, empathy and understanding while “prodding or demanding” the client make changes.
All therapies for paranoid personality disorder involve four analytical techniques used in sessions: Therapist pointing out the connections between thoughts, feelings and behaviors, “You do this then this happens…” in order to expand the Self; making observations on “what they are not seeing” to increase observing ego; identifying where the problem-solving stops and drama begins to increase problem-solving ability; and pushing for new thoughts, feelings and behaviors, “teaching skills” to increase adaptability.8
Cognitive Analytical Therapy
Cognitive Analytical Therapy involves reformulation, recognition and revision. In reformulation, the client and therapist produce a narrative statement that details the origin of the client’s distress and outlines the target problems. With the therapist’s help, the client maps out target roles or states. This map will be used and modified in each session. In the recognition stage the client monitors his state changes and records them on a diary sheet.
Using the map, the therapist and client make a plan for “exits” to avoid repeating problem states. During revision, they create new roles or states. All information is diagrammed on the evolving map by client and therapist and changes are noted over time.5
Cognitive Behavioral Therapy (CBT)
Cognitive Behavioral Therapy (CBT) models demonstrate the influence of events, thoughts, emotions, and body sensations on behaviors. By identifying the negative thoughts associated with negative consequences, the person’s thoughts, emotions and behaviors can be modified or changed to promote new positive outcomes.
CBT therapists guide clients on how to use tools to make these changes. Using homework, the client practices the tools outside the sessions. Clients are encouraged to chart each step of the change process and review it in treatment. The client also gains a deeper level of understanding about early influences that contributed to a negative sense of Self called a schema.
Dialectical Behavioral Therapy (DBT)
Dialectical Behavioral Therapy (DBT) is a specialized treatment specifically for personality disorders. It relies on building a new concept of the world using dialectics. DBT therapy targets behaviors that need to change and provides skill building to facilitate new behavior. DBT skills training focuses on: Mindfulness; Emotion Regulation; Interpersonal Effectiveness; and Distress Tolerance. Learning these skills along with a new paradigm creates the flexibility and adaptability that improves the lives of individuals with personality disorders.
Interpersonal Reconstructive Therapy
IRT focuses on the causes of personality disorder psychopathology. Treatment starts with a detailed case formulation based on early attachment patterns that affected the individual’s personality.
This becomes the client’s road map for treatment. During the course of therapy, the client is taken through five steps:
- Collaboration
- Learning about Patterns, Where They Are From, and What They Are For
- Blocking Maladaptive Patterns
- Enabling the Will to Change
- Learn New Patterns4
Dr. Greg Lester points out that it is the therapist’s job during treatment to point out connections between negative patterns of behavior and negative consequences; to offer observations on what is lacking; to push the client for new behaviors, thoughts and emotional responses; and to work with the client on learning effective problem solving.8 Basically, that is the purpose of each of the foregoing treatments. Each one offers a different approach, yet all are striving to change the psychopathology of the personality. And that is a truly monumental task.
How to Get Help for Paranoid Personality Disorder
Finding a qualified therapist to treat paranoid personality disorder is a bit tricky. There are many therapists who take short courses in personality disorder treatment, but that does not ensure they are qualified. It is important to seek professionals with specialized training in and experience with treating personality disorders, because inept treatment is worse than no treatment at all.
Do not be afraid to ask therapists about their education, training, certifications, experience and their personal treatment philosophy. It is important to have the right fit so that treatment goals can be accomplished within a safe, honest, trustworthy environment in as short a time frame as possible.
There are several online groups created for individuals with personality disorders, but they are only recommended for partners of individuals with paranoid personality disorder. The groups can be informative and encouraging. They remind a client’s partner that they are not alone. Try Personality Disorders Awareness Network Resources for a list of online personality disorder groups. Individuals with paranoid personality disorder are not very effective at group work and can “blow up” a group with mean, angry, sarcastic comments. Group work is not recommended for those with paranoid personality disorder.
Paranoid Personality Disorder Statistics
According to the DSM-5, the prevalence estimate for paranoid personality disorder from Part II of the National Comorbidity Survey Replication is 2.3% of the U.S. population. The National Epidemiologic Survey data suggests a prevalence of 4.4%.1
As cited in a more recent article by Dr. Royce Lee, “in the United States…paranoid personality disorder was the second most prevalent personality disorder (4.4%), after Obsessive Compulsive Personality Disorder (OCPD) … the prevalence in psychiatric clinics ranges from 2 – 10% and 10 – 30% in psychiatric inpatient hospitals. Although some work has suggested a lower prevalence in hospital settings, the high prevalence in prison populations, 23%, supports the validity of higher prevalence rates.”7
Dr. Lee goes on to state, Demographic risk factors include being male, low income, trauma exposure, and being Black, Native American or Hispanic. “Additional risk factors include relationship history, with paranoid personality disorder being associated with having been widowed, divorced, or separated or never married. In clinical settings, African-Americans are more likely to be diagnosed with paranoid personality disorder.”7 Paranoid personality disorder can be found in most cultures throughout the world.
Living With Paranoid Personality Disorder
For individuals living with paranoid personality disorder, they feel that life is always against them. They often say things like, “I can’t ever catch a break,” “I can’t trust anyone to help me,” “people are always talking about me behind my back and getting me in trouble,” “when I try to get help people turn on me,” “I am always getting screwed over.” paranoid personality disorder is a significant cause of disability and is a pathway to violence in various settings.7 Research has shown that individuals with paranoid personality disorder clog the courts with frivolous, unwinnable lawsuits because they feel wronged.7 Overall, paranoid personality disorder generally makes life an unrelenting misery.
Interactions with individuals with paranoid personality disorder usually include endless angry storytelling in which they are always the victim. They come across as sarcastic, argumentative, vindictive, thin-skinned and spoiling for a fight. People feel like they have to handle them with “kid gloves” as it is easy to become the target of their next attack, verbal or physical. Their likeability is very low with most people. They are difficult to live with for the above reasons and because they are unlikely to want to socialize, so their partners can feel trapped and victimized.
Example of Paranoid Personality Disorder
Harry was incarcerated in the jail for four months, so I came to know him well. He was very reluctant to talk with me; however, he needed some specific resources which prompted him to take the risk. Harry was belligerent, blameful, angry and highly suspicious of everyone, including me. This is a shortened version of his story:
I have been around here a long time and I never get a break. The police harass me all the time and arrest me for nothing. They throw me in jail because they don’t like me. I think they like to hurt me. I have been banned from riding the bus and most of the stores in town by hateful people. I always have to fight the idiots that won’t leave me alone. Everyone steals from me, so I can’t trust anyone. Every agency that is supposed to help me has screwed me over. I just want to get out of this town.
I wanted to believe that the only thing that kept Harry coming back to see me was my unending patience and empathy; however, that was inaccurate. He only visited with me so that I could provide him what he wanted. He told me that he could not trust me just as he could not trust anyone in his life. After providing referrals to resources out of the area, Harry was released and left town. I suspect that his inflexible thinking, inability to adapt to social norms, and his relentless suspicions, will continue. Harry could not alter his behavior because he is unable to realize that it is his own behavior that causes his distress.
For Further Reading
The following are helpful additional resources for anyone dealing with paranoid personality disorder:
Paranoid Personality Disorder Infographics
