Paranoid personality disorder

Template:Short description Template:Distinguish Template:Infobox medical condition (new) Template:Personality disorders sidebar Paranoid personality disorder (PPD) is a personality disorder characterized by paranoia, and a pervasive, long-standing suspiciousness and generalized mistrust of others. People with this disorder may be hypersensitive, easily insulted, and habitually relate to the world by vigilant scanning of the environment for clues or suggestions that may validate their fears or biases. They are eager observers and they often think they are in danger and look for signs and threats of that danger, potentially not appreciating other interpretations or evidence.<ref>Template:Cite book</ref>

They tend to be guarded and suspicious and have quite constricted emotional lives. Their reduced capacity for meaningful emotional involvement and the general pattern of isolated withdrawal often lend a quality of loneliness to their life experience.<ref>Template:Cite journal</ref> People with PPD may have a tendency to bear grudges, suspiciousness, tendency to interpret others' actions as hostile, persistent tendency to self-reference, or a tenacious sense of personal right.<ref>Template:Cite journal</ref> Patients with this disorder can also have significant comorbidity with other personality disorders, such as schizotypal, schizoid, narcissistic, avoidant, and borderline.Template:CN

It is one of the ten personality disorder categories in the DSM-5-TR, where it is listed among Cluster A ("odd or eccentric") personality disorders.<ref>Template:Cite book</ref> It is not specifically included as a diagnosis in the ICD-11 classification of personality disorders, which, rather than including distinct personality disorders, has a single, dimensional personality disorder presenting with pathological manifestations of personality traits.

Causes

A genetic contribution to paranoid traits and a possible genetic link between this personality disorder and schizophrenia exist.Template:CN 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.<ref name="pmid16893481">Template:Cite journal</ref>

Psychosocial theories implicate projection of negative internal feelings and parental modeling.<ref name="Bienenfeld" /> 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.<ref name="beckfreeman2">Template:Cite book</ref>

Diagnosis

ICD-10

The World Health Organization's ICD-10 lists paranoid personality disorder under (Template:ICD10). 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.<ref>The Classification of Mental and Behavioural Disorders (ICD-10) by WHO: "Diagnostic guidelines Template:Webarchive, p.158</ref>

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.

ICD-11

Template:Further The World Health Organization's ICD-11 has replaced the categorical classification of personality disorders in the ICD-10 with a dimensional model containing a unified personality disorder (Template:ICD11) with severity specifiers, along with specifiers for prominent personality traits or patterns (Template:ICD11).<ref>Template:Cite journal</ref> Severity is assessed based on the pervasiveness of impairment in several areas of functioning, as well as on the level of distress and harm caused by the disorder,<ref>Template:Cite journal</ref> while trait and pattern specifiers are used for recording the manner in which the disturbance is manifested.<ref>Template:Cite journal</ref>

Paranoid personality disorder is primarily associated with the ICD-11 trait domains Negative Affectivity (Template:ICD11) and Dissociality (Template:ICD11). The former reflects core features such as mistrust and suspicion, while the latter relates to hostility, self-righteousness, and a tendency toward self-centeredness.<ref name=":0">Template:Cite journal</ref> Some studies also report a link to Detachment (Template:ICD11), consistent with prior research and theoretical models.<ref name=":0" />

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.<ref name="DSM 5">Template:Cite book</ref>

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:<ref name="DSM 5" />

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<ref>American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association.</ref> version and lists associated features that describe it in a more quotidianTemplate:According to whom way. These features include suspiciousness, intimacy avoidance, hostility and unusual beliefs/experiences.Template:Citation needed

Alternative model

The Alternative DSM-5 Model for Personality Disorders (AMPD) does not list paranoid personality disorder as its own diagnostic entity.<ref name=":1">Template:Cite journal</ref> However, it is stated in the AMPD that what is conceptualized as PPD can instead be diagnosed as personality disorder – trait specified,<ref name=":1" /><ref>Template:Cite book</ref> which is a dimensional diagnosis that is constructed from the individual expression of personalty disorder,<ref>Template:Cite journal</ref> as manifested in both a general impairment in personality functioning along with at least one pathological personality trait.<ref>Template:Cite journal</ref>

Millon's subtypes

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:<ref name=millon2>Template:Cite book</ref>

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

Differential diagnosis

The paranoid may 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:<ref name="mentalhealth">Template:Cite web</ref> schizoid, schizotypal, narcissistic, avoidant, borderline and negativistic personality disorder.

Treatment

Partly as a result of tendencies to mistrust others, there have been few studies conducted over the treatment of paranoid personality disorder. Currently, there are no medicines FDA approved in treating PPD, but antidepressants, antipsychotics, and mood stabilizers may be prescribed under wrong assumptions to treat some of the symptoms.<ref>Template:Cite journal</ref> Another form of treatment of PPD is psychoanalysis, normally used in cases where both PPD and BPD are present. However, no published studies directly state the effectiveness of this form of treatment on specifically PPD, as opposed to its effects on BPD. CBT (cognitive behavioral therapy) has also been suggested as a possible treatment to paranoid personality disorder, but while case studies have shown improvement in the symptoms of the disorder, no systematic/widespread data has been collected to support this.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> A recent meta-analysis<ref>Template:Cite journal</ref> revealed that no specific randomized controlled trials (RCTs) currently focus solely on PPD. Instead, PPD was merely one of several possible diagnoses in a small number of existing trials, resulting in a minimal count of relevant recruited patients (e.g., an RCT on Schema Therapy<ref>Template:Cite journal</ref>). Treatments for PPD can be challenging, as individuals with PPD are reluctant in finding help and have difficulty trusting others.

Epidemiology

PPD occurs in about 0.5–4.4% of the general population.<ref>Template:Cite journal</ref><ref name="Bienenfeld">Template:EMedicine</ref><ref name="mentalhealth" /> It is seen in 2–10% of psychiatric outpatients.Template:Citation needed In clinical samples men have higher rates, whereas epidemiologically there is a reported higher rate of women.<ref>Template:Cite journal</ref>

History

Paranoid personality disorder is listed in the DSM-5 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.<ref name="Akhtar">Salman Akhtar (1990). Paranoid Personality Disorder: A Synthesis of Developmental, Dynamic, and Descriptive Features Template:Webarchive. American Journal of Psychotherapy, 44, 5–25.</ref>

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.<ref name="Akhtar" /> 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.<ref>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.</ref>

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.<ref name="Akhtar" />

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.<ref name="Akhtar" />

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.<ref name="Akhtar" />

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.<ref name="Akhtar" />

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.<ref name="Akhtar" />

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.<ref name="Akhtar" />

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:<ref name="Akhtar" />

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

Controversy

Due to repeated concerns of the validity of PPD and poor empirical evidence, it has been suggested that PPD be removed from the DSM.<ref>Template:Cite journal</ref> This is believed to contribute to low research output on PPD.<ref>Template:Cite journal</ref>

External links

• National Personality Disorder website for England
• Articles about Personality Disorders Template:Webarchive in Web4health web site