We can experience being “paranoid” in our daily lives. It can show when we feel a sense of uncertainty or are threatened by a strange situation. 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. 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. It could be because you’ve experienced being robbed, betrayed, or simply learned from one too many cautionary tales. 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 placed in a new situation, we tend to be warier in our surroundings. We keep an eye on our drinks when we go to bars. We avoid walking alone at night. We greet new people with a handshake and keep them at arm’s length until we know more about them. To be suspicious towards new things is to be cautious. It may vary between cultures, but keeping our guard up has been an evolutionary trait that has helped us survive for centuries.

Paranoid Personality Disorder, on the other hand, is more than just being suspicious and distrusting people. It’s maintaining these beliefs that people are against them for a long time, despite evidence saying otherwise. 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 pervasive and characteristic symptoms in Paranoid Personality Disorder 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 when shown 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 Paranoid Personality Disorder if they present the following:

  • Suspecting others of exploiting, harming, or deceiving them
  • Conversations usually consisting of unjustified doubts about their friends’ loyalty and trust
  • Hesitant in opening up to others because it might be used against them
  • Finds hidden, 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

Causes

Mental disorders are known to be biopsychosocial in nature. Meaning, there are physical, psychological, and social influences that contribute to its development. There are many theories as to how Paranoid Personality Disorder arises in people. So it has been divided into 5 models:

Psychodynamic

It has been proposed that paranoia is a person’s outward projection of inward conflict. Projection means they see people the same way they subconsciously see themselves. Their paranoid beliefs come from the conflict between their negative view of themselves and their idealized 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.

Cognitive

It has been theorized that persons with paranoid personality disorder have low self-efficacy and believe others are malicious. 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 have the tendency to 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 would be when you stop talking to them for a while and they accuse you of plotting against them.

Social Cognition

According to studies, being in a lower social rank can lead to paranoia. When people perceive themselves to be in a lower social standing than another person, they are likely to perceive antagonistic behaviour towards them. This is a result of the self-consciousness that you would 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 Personality Disorder 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 Paranoid Personality Disorder use avoidance responses to escape situations when they feel like they can be scrutinized by others. This avoidance causes them to feel more isolated with their irrational thoughts. Thus perpetuating their paranoid ideations. 

Biological

It was studied that antipsychotic drugs that block the D2 (dopamine) receptors of the brain can suppress these conditioned avoidance responses in people with Paranoid Personality Disorder. We say “conditioned” because they have learned 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 paranoid personality disorder experience hypervigilance. They have an increased sense of alertness and are constantly on their guard, especially when interacting with others. Oftentimes, the dangers hypervigilant people are alert to are either overblown or not real.

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

Risk Factors

Personality disorders are brought about by interactions between the biological, psychological, and social aspects of people. There are several risk factors studied 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 intervention if possible:

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

Diagnosis

There are no diagnostic lab tests that can be used to diagnose personality disorders. After a thorough psychiatric examination, the diagnosis of Paranoid Personality Disorder can be made from the DSM-5 criteria. The most characteristic symptom is their persistent distrust and suspiciousness towards people. We say “persistent” because the paranoia must have been there for a prolonged time and affecting their daily lives.

Usually, the symptoms manifest in early adulthood. Personality disorders are not usually diagnosed 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…

Schizophrenia – While they may share the same features of having strong beliefs of persecution, those with paranoid personality disorder 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 paranoid personality disorder believe their friends do not like them. They also do not present with hallucinations, a symptom characteristic of schizophrenia.

Borderline personality disorder – Paranoid Personality Disorder is often comorbid with other personality disorders. This is one of the most serious ones. Being comorbid with 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 Paranoid PD have troubles with relationships.

Delusional disorder (persecutory type) – This is another disorder mistaken for Paranoid Personality Disorder. Delusional disorder is characterized by “fixed delusions”. This means that no matter what proof is presented to them, their irrational beliefs will still be there. Whereas, those with Paranoid PD may be convinced to an extent that their beliefs are irrational.

Depressive or bipolar disorder (with psychotic features) – People with Paranoid Personality Disorder are more susceptible to developing depression. Relatives who have depression are more likely to have a genetic relationship with Paranoid PD than schizophrenia. Moreover, when paired with depression, suicidal ideations and attempts can increase in likelihood. This emphasizes the importance of early intervention before developing more severe symptoms.

Treatment

Treatment for Paranoid Personality Disorder, like other personality disorders, involves psychotherapy more than medications. Ultimately, the treatment of choice is psychotherapy. It should be noted that the therapies should be tailored 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.

Self-help

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.

Medications

Using medications can help 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.

Prognosis

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.

Sources:

Lee, R. (2017). Mistrustful and Misunderstood: a Review of Paranoid Personality Disorder. Current Behavioral Neuroscience Reports, 4(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 https://psychcentral.com/disorders/paranoid-personality-disorder