Paranoid Personality Disorder

We can experience “paranoid” in our daily lives. It can show when we feel a sense of uncertainty. For example, when you read too much into a friend’s message, thinking there’s a deeper meaning to it. When you clutch tightly to your bag in a crowded area. Or when you hear rumours in your workplace and wonder if you can trust your co-workers. That’s paranoia. That’s different from a paranoid personality disorder, which is also different to mistrust.

There’s an amount of mistrust that is understandable– maybe even healthy. In the same way, we shouldn’t trust everything we read, we don’t have to trust everyone we meet. But when this mistrust starts to negatively affect your relationships and everyone you meet, it becomes a problem.


Paranoid Personality Disorder (PPD) vs Mistrust

Mistrust means to be suspicious of something. When we are in a new situation, we tend to be careful. We keep an eye on our drinks when we go to bars. We greet new people with a handshake and keep them at arm’s length until we know more about them. To be suspicious of new things is to be cautious. It may differ between cultures, but keeping our guard up is a good trait that always helps us to survive.

PPD, on the other hand, is more than just distrusting people. It’s maintaining these beliefs that people are against them for a long time. Because of this, they can be seen as hostile and quick to anger. Rather than believing their personality is a problem, they will push responsibility and blame onto others.


Signs & Symptoms

The most extensive and characteristic symptoms of PPD are distrust and suspiciousness towards others. They can be easily irritable and hostile. For example, they may think their partner is cheating on them. Despite telling them they are not– even if there’s proof– they won’t believe it and continue to suspect them.

Their spouses or employers are usually the ones who tell them to get professional help. But they’re capable of pulling themselves together and covering up their distress, making therapy a challenge. It may be possible that you or a person you know is going through PPDr if they present the following:

  • Suspecting others
  • Conversations usually consisting of doubts about their friends’ loyalty and trust
  • Hesitant in opening up to others 
  • Finds demeaning, or threatening meanings behind what people say
  • Carries grudges even towards small events
  • Hypervigilant towards insults and threats, and are quick to counterattack
  • Several instances of suspicions towards their partner



Mental disorders are biopsychosocial in nature. Meaning, there are physical, psychological, and social influences that contribute to its development. There are many theories as to how PPD arises in people. So there are 5 models:


Paranoia is a person’s outward projection of inward conflict. Projection means they see people the same way they see themselves. Their paranoid beliefs come from the gap between their negative view of themselves and their positive self-concept. As a result, they project this negative view towards others and believe it is their fault when things go wrong instead of their own.

Often, they do splitting. Splitting is categorizing people in absolutes, such as good vs. bad, with no room for grey areas. It is easier to believe someone can only be good or bad, rather than consider they may be something in between. So those with paranoid beliefs will treat people according to those beliefs. If you give them any reason to think you’re a bad person, they will automatically brand you as one. Even if they do see you as a good person, they will still have suspicions that you are capable of hurting them.


Persons with paranoid personality disorder have low self-efficacy and believe others are evil. This brings about their belief that they are vulnerable and easy to manipulate. Thus, they are always on their guard and afraid to get close to anyone. They believe that opening up can lead to others using that information against them.

Additionally, they also jump to conclusions. When you stop smiling at them or behave differently, they might assume that you are mad at them. A more extreme example is when you stop talking to them for a while and they accuse you of plotting against them.

Social Cognition

According to studies, lower social rank can lead to paranoia. When people think of themselves to be in a lower social standing than another person, they are likely to have antagonistic behaviour. This is a result of the self-consciousness that you feel when talking to an older person, your boss, or your parents. This may be a normal feeling for most people. But people with Paranoid PPD tend to feel, even on a subconscious level, that they are at a lower standing than others. This can make them feel like they are prone to personal attacks.

People with PPD use avoidance responses to escape situations when they feel like others judge them. This avoidance causes them to feel lonely with their thoughts. Thus sustain their paranoid ideations. 


Antipsychotic drugs that block the D2 receptors of the brain can suppress these avoidance responses in people with PPD. They learn to use these responses to cope with situations. By suppressing the D2 receptors, which are associated with learning and memory, it can be possible to block or lessen the flow in this learning pathway.

In studies involving electroencephalograms (EEG), it was suggested that those with PPD experience hypervigilance. They have a strong sense of alertness and are constantly on their guard, especially when interacting with others. Oftentimes, the dangers hypervigilant people are alert to are not real.

A genetic relationship also exists between relatives with affective disorders and delusional disorder and PPD. This implies some people are more genetically susceptible to developing a PPD. They are likely to develop PPD if there are enough risk factors and related events present to bring about the symptoms.


Risk Factors

Interactions between the biological, psychological, and social aspects of people bring Personality disorders. There are several risk factors that increase the chances of someone having this disorder. It is important to look out for these risk factors in friends and family to give them early if possible:

  • Childhood trauma
  • Emotional or physical neglect
  • Neglectful parenting styles in childhood
  • Physical and/or sexual abuse
  • Brain trauma
  • Being hard of hearing



There are no diagnostic lab tests that can use to diagnose personality disorders. You can make the diagnosis of PPD from the DSM-5 criteria after a thorough psychiatric examination. The most characteristic symptom is their constant distrust and suspiciousness towards people. We say “persistent” because the paranoia must have been there for a time and affecting their daily lives.

Usually, the symptoms manifest in early adulthood. We usually can’t see personality disorders in children or teens because these are the formative years of personality. They still have time to change the bad habits they may have. What is more important in those years is learning to build healthy coping styles and recognizing early signs for disorders.


Relationship with…


While they may share the same features of having strong beliefs of torment, those with paranoid PPD are capable of “reality testing”. Reality testing is our ability to stay grounded so that our beliefs are within the realm of possibility. Where those with schizophrenia may believe the government is out to get them, those with PPD believe their friends do not like them. They also do not present with hallucinations, a symptom characteristic of schizophrenia.

Borderline personality disorder

PPD is often comorbid with other personality disorders. This is one of the most serious ones. Borderline Personality Disorder can increase the risk of suicidal ideation and attempts. Often mistaken for the other, Borderline PD patients are capable of forming overly involved relationships. Those with PPD have troubles with relationships.

Delusional disorder (persecutory type)

This is another disorder mistaken for PPD. This means that no matter what proof they see, their irrational beliefs will still be there. Whereas, those with PPD may be convinced to an extent that their beliefs are irrational.

Depressive or bipolar disorder (with psychotic features)

People with PPD are more susceptible to developing depression. Relatives who have depression are more likely to have a genetic relationship with PPD than schizophrenia. Moreover, with depression, suicidal ideations and attempts can increase in likelihood. This emphasizes the importance of early intervention before developing more severe symptoms.



Treatment for PPD, like other personality disorders, involves psychotherapy more than medications. Ultimately, the treatment of choice is psychotherapy. The therapies should always tailor to each client:

Cognitive Behavior Therapy

This therapy is used for many mental disorders, especially for personality disorders. For those with Paranoid Personality Disorder, it is important this is individualized and long-term. This is also effective for those with affective disorders and anxiety. Therapists try to reduce suspicious thoughts, tension, anxiety, and depressive symptoms in their clients. The activities in this therapy can be derived from its name, “Cognitive Behavioral.” It can involve behaviour and thought to monitor. This is when the therapist and the client identify the maladaptive behaviours and irrational thoughts associated with them. They also have relaxation skills training to reduce the anxiety symptoms they feel when interacting with people.

Mentalization-based Treatment

This therapy makes use of approaches from psychodynamic therapy, cognitive behavioural therapy, and interpersonal psychotherapy. It focuses on skills in “mentalizing”. Mentalizing is a person’s capability to empathize and read into their own and others’ behaviours in a realistic way.


It may be difficult to find support groups or communities appropriate for people with Paranoid Personality Disorder. This is because the core characteristic of the disorder is their distrust towards others. It might be hard to have them go through therapy, let alone a support group.


Using medications can help with other symptoms. For example, anti-anxiety medications can be prescribed for those with severe anxiety symptoms. Antipsychotic medications can be prescribed for those who are severely agitated and having delusional thoughts, who may be a threat to themselves and others. These are not routinely given and discouraged for clients with Paranoid Personality Disorder unless necessary.


What can a mental health professional (i.e. psychiatrists, psychologists, & therapists) do?

These mental health professionals are trained and certified to do evidence-based psychotherapy. They approach each client differently. In general, their approach towards people with paranoid personality disorder requires straightforwardness, honesty, and consistency. Excuses will only make the client doubt the therapist. Rather than a warm style, they adopt a more professional approach because intimacy is an area of difficulty for these clients.

Interpreting a clients’ feelings and relationships is avoided because it can increase mistrust towards the therapist. The therapist also places limits on their actions to avoid any conflicts with the client. Oftentimes, the client may make delusional accusations towards the therapist. But they are equipped to handle this with gentle understanding and patience. Unlike other mental disorders, paranoid personality disorder will make it hard for the therapist to set support systems for the client. Most of the time, they cannot do family or group therapy. However, mental health professionals can keep the events of therapy confidential and individualized for the client to make them more comfortable.

Psychiatrists are medical doctors who are licensed to give medications to alleviate comorbid symptoms such as anxiety and depression. But the prescription of drugs is usually avoided for clients with Paranoid Personality Disorder. It can make the client suspicious and ultimately quit the treatment plan. If they must be given, it will be for a short time. Psychiatrists also have a good understanding of the neurobiological factors of the disorder, making them prepared to help clients understand their symptoms.



Paranoid Personality Disorder can be a great cause of disability. With the instability of forming relationships and the tendency to emotionally isolate themselves, persons with this disorder are likely to develop comorbid disorders. This is also the personality disorder with the strongest tendency to act aggressively towards others. It has been associated with acts of violence, stalking, and involvements in legal cases. This makes them a possible threat to themselves and others.

Because they find it hard to take responsibility for their actions, it becomes challenging to convince them that they have a problem. In the end, they do not seek help. Even if they do find help, they rarely cooperate. This results in a negative prognosis, even with psychiatric treatment. But getting treatment is still better than allowing the symptoms to persist. If you or a friend, family, or loved one is experiencing these symptoms, please refer them to a mental health professional to improve their outcomes and quality of life.



Lee, R. (2017). Mistrustful and Misunderstood: a Review of Paranoid Personality Disorder. Current Behavioral Neuroscience Reports4(2), 151-165. DOI: 10.1007/s40473-017-0116-7

Matusiewicz, A., Hopwood, C., Banducci, A., & Lejuez, C. (2010). The Effectiveness of Cognitive Behavioral Therapy for Personality Disorders. Psychiatric Clinics Of North America, 33(3), 657-685. DOI: 10.1016/j.psc.2010.04.007

Paranoid Personality Disorder. Retrieved 29 April 2021, from