Paranoid Personality Disorder

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders notes that to diagnose paranoid personality disorder (PPD), an individual must have a pervasive distrust and suspicion of others that causes motives to be interpreted as malevolent, indicated by four or more of the following symptoms: 

• Suspecting that people are harming, exploiting, or deceiving them
• Being preoccupied with unjustified doubts about the loyalty of their friends, family, and associates
• Being reluctant to confide in others because of the fear that they will use the information against them
• Seeing hidden or threatening meanings in benign events or remarks
• Bearing grudges
• Perceiving attacks on the reputation or character that are not apparent to others and being quick to react in anger or counterattack
• Suspecting without justification that their spouse or partner is being unfaithful

These symptoms must not occur during an episode of schizophrenia or due to a mood disorder with psychotic features, another psychotic disorder, or the effects of general medical conditions.

Signs and symptoms of PPD that may be noticeable include the following: 

• Hypersensitivity 
• Taking criticism poorly
• Reading hidden meanings into innocent remarks
• Being cold and distant or controlling and jealous in relationships 
• Difficulty relaxing
• Believing they are always right
• Not accepting their role in conflicts or problems

It can be challenging for people with PPD to have a social life due to defensive behavior. They may struggle to confide in others and doubt the loyalty of the people close to them, which can make it difficult to develop close relationships. When other people respond negatively to them, they may consider these responses as proof that their original suspicions were correct.

The causes of PPD are unknown. It may be more common in families that have a history of psychotic disorders, which suggests that there may be some genetic links. Some research indicates that there may be multiple behavioral, cognitive, and social processes involved in the symptoms of PPD and that these factors reinforce one another.

People with paranoid thinking may try to blame others for the adverse events in their lives rather than considering how their behavior contributed to their circumstances. This behavior may be the result of low self-esteem. Information processing may also play a role. People with PPD may have impairments in their social skills related to emotional and social perception and the inability to understand the mental states and intentions of others. By not understanding other people's viewpoints, someone with PPD may take the behaviors of others personally. 

Some interpersonal processes can encourage paranoid thinking as well. People with PPD may sense that they don’t belong to a group for various reasons, which can lead to believing that they are under the scrutiny of other people. This type of paranoid thinking may be more likely to appear in situations with sudden social isolation or in a situation where previous social skills are no longer applicable. These combined factors may lead to challenging spirals of paranoia, making this condition even more difficult to treat.

No treatments for PPD have been thoroughly tested with randomized trials, but the condition may not be untreatable. The goal of treatment is often to help people with this condition recognize vulnerability, increase self-worth, develop more trust in others, and learn to put their distress into words. Progress may be slow, but possible treatments may include a mix of therapy, medication, and self-care. 

Medication

While there is no medication that specifically treats paranoid personality disorder (PPD), healthcare providers may prescribe medications to help with co-occurring conditions, such as anxiety or depression. Medications that might be prescribed include antidepressants, antipsychotics, mood stabilizers, and anti-anxiety medications. 

Consult a medical doctor before starting, changing, or stopping a medication for any condition. The information in this article is not a replacement for medical advice or diagnosis.  

Self-care

Self-care may not cure PPD symptoms, but recent research shows that self-care can improve mental health, which can benefit people with PPD or any comorbid mental health disorders. Below are several tips for practicing self-care.

• Get regular exercise, about 30 minutes a day. You can break exercise into smaller sessions, even taking two 15-minute exercise periods. 
• Eat well-balanced, regularly scheduled meals.
• Stay hydrated and avoid alcohol and caffeinated drinks like coffee and soda as much as possible.
• Prioritize sleep. Set a regular bedtime routine and try to get at least seven hours of sleep every night.
• Make time for relaxing activities, like journaling, meditation, breathing exercises, or yoga. 
• Stay connected to friends and family and ask for help when needed.

According to the American Psychiatric Association, PPD can be challenging to treat, but some forms of therapy may be effective. Therapists can make special considerations for people with a personality disorder like PPD. Online therapy may be a beneficial option for people with this condition as it allows them to talk to their therapist from the comfort of their homes and behind the safety of a computer screen. In addition, clients of online platforms like BetterHelp can choose between phone, video, or live chat therapy. 

The National Alliance on Mental Illness (NAMI) has a crisis hotline where you can talk to NAMI staff and volunteers. You can reach out by phone at 1-800-950-NAMI (6264) or text "HelpLine" to 62640. You can also email helpline@nami.org.

People with PPD who are in crisis can call, text, or chat online with the National Suicide Prevention Lifeline at 988. The 988 Lifeline is a national network of local crisis centers that provide emotional support to people in crisis or emotional distress 24/7.

For help with substance use, contact SAMHSA’s National Helpline at 1-800-662-HELP (4357).

For those experiencing abuse, contact the Domestic Violence Hotline at 1-800-799-SAFE (7233). Support is available 24/7. Please also see our Get Help Now page for more immediate resources.

Although researchers have not pinpointed a cause of paranoid personality disorder, recent studies indicate that childhood trauma and brain trauma might play a role. Researchers found childhood physical neglect, emotional neglect, and supervision neglect all predict symptoms of PPD in adolescence and young adulthood. When providers look at diagnosing this condition, they may keep this criteria in mind while reviewing the Diagnostic and Statistical Manual of Mental Disorders to make their final diagnosis. 

These studies also show that brain trauma is a risk factor for PPD, with research indicating that as many as 26% of brain injury patients meet the diagnostic criteria for PPD. More studies are needed to establish the exact association. 

Recent studies also show that people with PPD may be at a higher risk of violence. People with PPD have been associated with histories of antisocial behaviors and violence, although some researchers believe that violence in people with PPD often occurs due to provocation. However, because of their distorted thinking, people with PPD may believe they are being provoked in many situations. 

People with PPD often perceive the world as more threatening and hostile than it is. Because of their low self-esteem, they may be hypersensitive and likely to respond in a retaliatory manner. Comorbid disorders may also play a role.

Below are several statistics about paranoid personality disorder:

• Paranoid personality disorder is not uncommon, affecting about 1.3% of the general population and about 10% of psychiatric outpatients. 
• The prevalence of PPD in inpatient psychiatric facilities is significantly higher than in the community or outpatient populations, affecting as many as 30% of patients.
• The World Health Organization (WHO) estimated that about 6.1% of the population has a personality disorder. Cluster A disorders, which include PPD, have a prevalence of 3.6%.
• About 75% of people with PPD have another personality disorder, most commonly borderline personality disorder, avoidant personality disorder, and narcissistic personality disorder, which are also listed in the Diagnostic and Statistical Manual of Mental Disorders. 
• Progress for people with PPD in treatment may be slow. People with this condition take an average of 12 months to determine whether treatment works.
• In early studies, researchers found that cognitive-behavioral therapy may be effective for people with PPD, with one participant in the study finding remission in their anxiety, tension, and depression symptoms.