Paranoid Personality Disorder – PPD

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The DSM-5 published by the American Psychological Association defines paranoid personality disorder as a Cluster A personality disorder (includes schizotypal and schizoid personality disorders) characterized by persistent feelings of suspicion and distrust of others and consistently paranoid thoughts. They may think a foreign government is spying on them, reading their minds or manipulating the way they think. They may suspect family members of plotting to kill them without any evidence to support their claims. Some individuals with PPD are so disturbed by their paranoid thoughts they take action to “protect” themselves from entities they think want to harm them by engaging in violent activity.

Symptoms and Signs of Paranoid Personality Disorder

Paranoid personality disorder is a mental disorder characterized by a recurring pattern of distrust in the actions and motives of other individuals. People suffering from this disorder assign malevolent intent to both the actions and thoughts of others. One important difference between this disorder and schizophrenia (and related disorders) is that people suffering from paranoid personality disorder only mistrust and assign these intentions to other people, as opposed to assigning malevolent intent to acts without intelligence behind them as is common for those with some form of schizophrenia.

In addition to harboring paranoid thoughts and an intense distrust of others, people diagnosed with PPD:

  1. Tend to socially isolate themselves and deliberately avoid developing friendships
  2. Act pathologically jealous, hold long-term grudges and expect their partner to remain in constant contact with them if involved in relationships
  3. Read sinister intentions into the innocuous and/or meaningless behavior of others
  4. Immerse themselves in “false” or conspiracy news narratives that have no basis in fact
  5. Tend to be male

Symptoms

Diagnosis of paranoid personality disorder can only effectively be made be a mental health professional that is able to fully evaluate the mental state of the patient. During such an evaluation, the mental health professional will look for at least 4 of the following 7 symptoms and ensure that the symptoms aren’t a result of a psychotic episode:

  1. Belief that others are being deceitful without any evidence of such deceit
  2. Questioning of trustfulness and loyalty of others
  3. A refusal to confide in anyone due to absolute certainty that they will be betrayed
  4. Interpretation of benign or neutral remarks as aggressive or some form of a threat
  5. Inability to let go of grudges
  6. Engaging in retaliation for perceived slights against character or reputation, despite a complete lack of evidence of such slights
  7. Constant suspicion and jealousy towards romantic partners, stemming from a fear of unfaithfulness

Another aspect of paranoid thinking observed in PPD patients involves personal attribution bias, or attributing anything bad that happens to them to other people’s irresponsible behavior. Whereas we all tend to indulge periodically in self-serving bias (believing external events cause specific problems), those with PPD exaggerate the concept of self-serving bias to blame people instead of non-human events. Attributional bias may also be a psychological defense mechanism used by people with paranoid personality disorder who also suffer from extremely low self-esteem.

Subtypes

Personality disorder psychologist Theodore Millon suggests there are five subtypes of paranoid personality disorder: Commonly diagnosed subtypes include

  • malignant
  • insular
  • querulous
  • fanatic
  • obdurate

Treatment

Cognitive behavioral therapy is consistently one of the more successful ways of treating any personality disorder. For paranoid personality disorder specifically, intervention tends to focus on helping the patient recognize and avoid information bias and helping the patient learn adaptive social techniques. There is no perfect cure, and drugs only provide limited benefits, primarily for anxiety, but regular long term therapy can usually help a patient avoid the more debilitating side effects that come from a complete lack of trust in others. And, like most personality, treating the symptoms is effective because this disorder will usually disappear during middle age.

In most cases, people diagnosed with PPD will need to take antidepressant, anti-anxiety and/or antipsychotic medication for a few months before counseling and psychotherapy is helpful. Because of their deep distrust of others, those engulfed by paranoid ideations are not readily receptive to psychological intervention. Trying to rationalize delusional beliefs with PPD patients is always frustrating for psychologists who are typically confronted with circular reasoning, attributional bias and other cognitive disturbances firmly supporting a paranoid person’s belief system.

Co-Occurring Mental Health Issues

Since similar characteristics are shared by several personality disorders, some people may be diagnosed with two personality disorders. Paranoid personality disorder is frequently co-diagnosed with schizoid, schizotypal and borderline personality disorders. Additionally, individuals with PPD are vulnerable to experiencing major depressive disorder, obsessive-compulsive disorder, agoraphobia and substance abuse disorders.

Famous People

Because some level of paranoia is common in just about everyone, it is not uncommon for famous individuals, who are subject to a much higher level of daily scrutiny, to receive an armchair diagnosis of paranoid personality disorder from the media or the average person on the street. However, like all mental disorders, this disorder can only be diagnosed by a mental health professional in a controlled setting. Any other diagnosis is bound to be incorrect and is unethical for members of the medical profession to even attempt to make. Thus, for example, while rumors persist that the people listed below all of these famous leaders may have had paranoid personality disorder (PPD), there is no evidence to prove it.

  • Adolf Hitler
  • Joseph Stalin
  • Saddam Hussein
  • Richard Nixon

Richard Kuklinski, a contract killer for the Gambino family, can be provably stated to have this disorder, because a psychiatrist while in prison diagnosed him.

Movies

However, because of the unique storytelling style of books and movies, it is possible (and ethical) to diagnose certain characters with this disorder. These movies are intended to represent people suffering from this paranoid personality disorder.

Mel Gibson in “Conspiracy Theory”

Philip Queeg from “The Caine Mutiny

Fred Dobbs from “The Treasure of Sierra Madre

The protagonist from “Falling Down

Thomas, played by Michel Bouquet, in “Toto Le Heros”

Alcohol & Personality Disorders

Alcohol and paranoid personality disorder can co-occur  surprising frequency. It is called “comorbidity”, (formerly known as dual diagnosis) see below.  The general belief about paranoia is that it is defined after the facts comes to light. But the truth is, at least for those with paranoid personality disorder, external factors are basically immaterial. A person suffering from this disorder experiences such high levels of distrust that they believe people are “out to get them” whether or not the facts support that belief.

According to clinical studies, the prevalence of personality disorders with alcoholism ranges from as low as 22-40% to as high as 58-78%. The studies have focused primarily on antisocial and borderline personality disorders, however, almost the whole spectrum of personality disorders can be encountered in alcohol dependence, such as the dependent, avoidant, paranoid and others.

An Oxford study indicated 40% or alcohol use disorder clients had at least 1 personality disorder. For more in-depth information, see this research alcohol & personality disorders.

Substance Abuse

In a study done in 2012 they discovered 46% of the substance abuse (SUD) patients had at least one Personality Disorder (16% antisocial [males only]; 13% borderline; and 8% paranoid, avoidant, and obsessive-compulsive, respectively).

Cluster C disorders were as prevalent as Cluster B disorders. SUD patients with PDs were younger at the onset of their first SUD and at admission; used more illicit drugs; had more anxiety disorders, particularly social phobia; had more severe depressive symptoms; were more distressed; and less often attended work or school.

 

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