Paranoid Personality Disorder

Paranoid personalities are aloof, emotionally cold individuals who display unjustified suspiciousness, hypersensitivity, jealousy, and a fear of intimacy. In addition they can be grandiose, rigid, contentious, and litigious.

Because of their hypersensitivity to criticism and tendency to project blame on others, individuals with paranoid personality disorder tend to lead isolated lives and are often disliked by others.

Millon (2011) conceived of the Paranoid Personality Disorder as a pathological syndromal continuation of the Narcissistic Personality DisorderOpens in new window, the Antisocial Personality DisorderOpens in new window, or the Obsessive-Compulsive Personality DisorderOpens in new window. As a result, the clinical presentation of the paranoid personality takes on characteristics of these three respective precursors.

Clinical Presentation

The Paranoid Personality Disorder is characterized by the following behavior interpersonal styles, cognitive style, and emotional style. Behaviorally, paranoid individuals are resistive of external influences. They tend to be chronically tense, because they are constantly mobilized against perceived threats from their environment.

Their behavior also is marked by guardedness, defensiveness, argumentativeness, and litigiousness. Interpersonally, they tend to be distrustful, secretive, and isolative. They are intimacy-avoiders by nature, and repudiate nurturant overtures by others.

Their cognitive style is characterized by mistrusting preconceptions. They carefully scrutinize every situation encountered and scan the environment for “clues” or “evidence” to confirm their preconceptions, rather than objectively focus on data. Thus, while their perception may be accurate, their judgment often is not.

The paranoid personalities’ prejudices mold the perceived data to fit their preconceptions. Thus, they tend to disregard evidence that does not fit their preconceptions. When under stress, their thinking can take on a conspiratorial or even delusional flavor. Their hypervigilance and need to seek evidence to confirm their beliefs lead them to have a rather authoritarian and mistrustful outlook on life.

The effective style of the paranoid personalities is characterized as cold, aloof, unemotional, and humorless. In adition, they lack a deep sense of affection, warmth, and sentimentality. Because of their hypersensitivity to real or imagined slights, and their subsequent anger at what they believe to be deceptions and betrayals, they tend to have few, if any, friends. The two emotions they experience and express with some depth are anger and intense jealousness.

DSM-5 Characterization

Individuals with this personality disorder are characterized by an unremitting pattern of distrust and suspicion, and interpret others’ motives as harmful. Without sufficient basis, they suspect that others are exploiting, harming, or deceiving them. They are obsessed with unfounded doubts about the loyalty of friends and associates.

Because of their unfounded fears, they are reluctant to confide in others. They are likely to interpret otherwise benign remarks and situations as threatening and dangerous. Not surprisingly, they are unforgiving of slights, insults, and injuries. These individuals are quick to react agrily or to counterattack when they believe that their character or reputation is being attacked. They are likely to continually suspect, without justification, that their spouse or sexual partner is unfaithful (American Psychiatric Association, 2013).

Case Example: Mr. P.

Mr. P. is a 59-year-old male referred for psychiatric evaluation by his attorney to rule out a treatable psychiatric disorder. Mr. P. had entered into five lawsuits in the past two and one-half years. His attorney believed that each suit was of questionable validity.

Mr. P. was described as an unemotional, highly controlled male who was now suing a local men’s clothing store “for conspiring to deprive me of my consumer rights.” He contends that the store manager had consistently issued bad credit reports on him.

The consulting psychiatrist elicited other examples of similar concerns. Mr. P. has long distrusted the neighbors across the street and regularly monitors their activity, since one of his garbage cans disappeared two years ago.

Mr. P. took an early retirement from his accounting job one year ago because he could not get along with his supervisor, whom he believed was faulting him about his accounts and paperwork. Mr. P. contends he was faultless. On examination, Mr. P.’s mental status is unremarkable except for constriction of affect and a certain hesitation and guardedness in his response to questions.

Biopsychosocial – Adlerian Conceptualization

The following biopsychosocial formulations may be helpful in understanding how the Paranoid Personality Disorder is likely to have developed. Biologically, a low threshold for limbic system stimulation and deficiencies in inhibitory centers seem to influence the behavior of the paranoid personality.

The underlying temperament can best be understood in terms of the subtypes of the paranoid disorder. Each of three subtypes is briefly described in terms of their underlying temperament, and correlative parental and environmental factors.

In the narcissistic type, a hyper-responsive temperament and precociousness, parental overvaluation and indulgence, as well as the individual’s sense of grandiosity and self-importance probably result in deficits in social interest and limited interpersonal skills.

The antisocial type of the paranoid personality is likety to possess a hyper-responsive temperament. This, plus harsh parental treatment, probably contributes to the impulsive, hedonistic, and aggressive style of this type.

In the compulsive type, the underlying temperament may have been anhedonic. This, as well as parental rigidity and overcontrol, largely accounts for the development of this type.

Finally, a less common variant is the paranoid passive-aggressive type. As infants, these individuals usually demonstrated the “difficult child” temperament, and later temperament is characterized by affective irritability. This plus parental inconsistency probably accounts in large part for the development of this type (Millon, 2011).

Psychologically, paranoid individuals view themselves, others, the world, and life’s purpose in terms of the following themes. They tend to view themselves by some variant of the theme: “I’m special and different. I’m alone and no one likes me because I’m better than others.”

Life and the world are viewed by some variant of the themes: “Life is unfair, unpredictable, and demanding. It can and will sneak up and harm you when you are least expecting it.” As such, they are likely to conclude: “Therefore, be wary, counterattack, trust no one, and excuse yourself from failure by blaming others.” The most common defense mechanism associated with the paranoid disorder is projection.

Socially, predictable patterns of parenting and environmental factors can be noted for the Paranoid Personality Disorder. For all the subtypes the parental injunction appears to be “You’re different. Don’t make mistakes.”

Paranoid Personality Disordered individuals tend to have perfectionistic parents who expose these children to specialness training. This, plus the parental style that that has been articulated for the subtypes of the disorder and parental criticism, leads to an attitude of social isolation and hypervigilant behavior.

To make sense of the apparent contradiction between being special and being ridiculed, the children creatively conclude that the reason they are special and that no one like them is because they are better than other people.

This explanation serves the purpose of reducing their anxiety and allowing them to develop some sense of self and belonging.

This paranoid pattern is confirmed, reinforced, and perpetuated by the following individual and systems factors:

A sense of specialness, rigidity, attributing malevolence to others, blaming others, and misinterpreting motives of others leads to social alienation and isolation, which further confirms the individual’s persecutory stance.

Treatment Considerations

Included in the differential diagnosis of the Paranoid Personality Disorder are the following personality disorders: Antisocial Personality DisorderOpens in new window, Narcissistic Personality DisorderOpens in new window, Obsessive-Compulsive Personality DisorderOpens in new window, and Passive-Aggressive Personality DisorderOpens in new window.

The most common symptom disorders associated with the Paranoid Personality Disorder are Generalized Anxiety DisorderOpens in new window, Panic DisorderOpens in new window, and Delusional DisorderOpens in new window. If a Bipolar DisorderOpens in new window is present, an irritable manic presentation is likely. Decompensation into Schizophrenic reaction is likely. The Paranoid and Catatonic subtypes of Schizophrenia are most commonly noted.

Until recently, the prognosis for treatment of the Paranoid Personality Disorder was considered guarded. Today more optimism prevails in achieving these goals of treatment: increasing the benignness of perception and interpretation of reality, and increasing trusting behavior.

The social-skills training intervention described by Turkat and Maisto (1985) focuses on changing the internal processes of attention, processing, response emission, and feedback from a pathological to a non-pathological mode of perceiving and thinking.

In essence, individuals are taught how to reduce their perceptual scanning and attending to inappropriate cues, to attending to more appropriate cues; and rather than using idiosyncratic logic and misinterpretation to process their cues, they learn to use more common logic and a more benign interpretation of cues.

In so doing they are able to respond in a more socially graceful fashion and are more likely to interpret feedback, including criticism, as constructive. This social-skills intervention approach can be combined with insight-oriented therapy to achieve positive therapeutic outcomes. Medication, particularly lower-dose neuroleptics, have been shown useful for decreasing anxiety secondary to loss of control (Reid, 1989).