Paranoid personality disorder is characterized by a pervasive pattern of unwarranted distrust and suspicion of others that involves interpreting their motives as malicious. Diagnosis is by clinical criteria. Treatment is with cognitive-behavioral therapy and sometimes medications.
(See also Overview of Personality Disorders.)
Patients with paranoid personality disorder distrust others and assume that others intend to harm or deceive them, even when they have no or insufficient justification for these feelings.
The estimated median prevalence is 3.2% but may be as high as 4.4% (1, 2). It is thought to be more common among men.
There is some evidence of increased prevalence in families. Some evidence suggests a link between this disorder and emotional and/or physical abuse and victimization during childhood.
Comorbidities are common. Paranoid personality disorder is rarely the sole diagnosis. Common comorbidities include thought disorders (eg, schizophrenia), anxiety disorders (eg, social phobia [social anxiety disorder]), posttraumatic stress disorder, alcohol use disorders, and another personality disorder (eg, borderline personality disorder).
General references
1. Grant BF, Hasin DS, Stinson FS, et al: Prevalence, correlates, and disability of personality disorders in the United States: Results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry 65(7):948-958, 2004. doi: 10.4088/jcp.v65n0711
2. Morgan TA, Zimmerman M: Epidemiology of personality disorders. In Handbook of Personality Disorders: Theory, Research, and Treatment. 2nd ed, edited by WJ Livesley, R Larstone, New York, NY: The Guilford Press, 2018, pp. 173-196.
Symptoms and Signs of Paranoid Personality Disorder
Patients with paranoid personality disorder suspect that others are planning to exploit, deceive, or harm them. They feel that they may be attacked at any time and without reason. Even though there is little or no evidence, they persist in maintaining their suspicions and thoughts.
Often, these patients think that others have greatly and irreversibly injured them. They are hypervigilant for potential insults, slights, threats, and disloyalty and look for hidden meanings in remarks and actions. They closely scrutinize others for evidence to support their suspicions. For example, they may misinterpret an offer of help as implication that they are unable to do the task on their own. If they think that they have been insulted or injured in any way, they do not forgive the person who injured them. They tend to counterattack or to become angry in response to these perceived injuries. Because they distrust others, they feel a need to be autonomous and in control.
These patients are hesitant to confide in or develop close relationships with others because they worry that the information may be used against them. They doubt the loyalty of friends and the faithfulness of their spouse or partner. They can be extremely jealous and may constantly question the activities and motives of their spouse or partner in an effort to justify their jealousy.
Patients with paranoid personality disorder often have difficulty with interpersonal relationships. When others respond negatively to them, they take these responses as confirmation of their original suspicions.
Diagnosis of Paranoid Personality Disorder
Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision (DSM-5-TR) criteria
For a diagnosis of paranoid personality disorder (1), patients must have
A persistent distrust and suspiciousness of others
This distrust and suspicion are shown by the presence of ≥ 4 of the following (1):
Unjustified suspicion that other people are exploiting, injuring, or deceiving them
Preoccupation with unjustified doubts about the reliability of their friends and coworkers
Reluctance to confide in others lest the information be used against them
Misinterpretation of benign remarks or events as having hidden belittling, hostile, or threatening meaning
Holding of grudges for insults, injuries, or slights
Readiness to think that their character or reputation has been attacked and quickness to react angrily or to counterattack
Recurrent, unjustified suspicions that their spouse or partner is unfaithful
Also, symptoms must have begun by early adulthood.
Differential diagnosis
Clinicians can usually distinguish paranoid personality disorder from other personality disorders by the pervasiveness of its paranoia regarding others (eg, as opposed to the more transient paranoia of borderline personality) and by the core feature of each disorder:
Schizoid personality disorder: Disinterest (as opposed to the mistrust in paranoid)
Schizotypal personality disorder: Eccentric ideas, speech, and behavior
Borderline personality disorder: Dependency
Narcissistic personality disorder: Grandiosity
Antisocial personality disorder: Exploitation
Avoidant personality disorder: Fear of rejection
Paranoid personality disorder can be distinguished from delusional disorder (persecutory type), schizophrenia, and a depressive disorder or bipolar disorder with psychotic features because in these disorders, episodes of psychotic symptoms (eg, delusions, hallucinations) are prominent.
Diagnosis reference
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision (DSM-5-TR). Washington, DC, American Psychiatric Association, 2022, pp 737-741.
Treatment of Paranoid Personality Disorder
Cognitive-behavioral therapy
Sometimes medications
The general principles for treatment of paranoid personality disorder are the same as those for all personality disorders.
No treatments have been proved effective for paranoid personality disorder.
The overall high levels of suspicion and mistrust in patients make establishing rapport difficult. Expressing recognition of any validity in patients' suspicions may facilitate an alliance between patient and clinician. This alliance may then enable patients to participate in cognitive-behavioral therapy or be willing to take any medications (eg, antidepressants, atypical antipsychotics) prescribed to treat specific symptoms. Atypical (2nd-generation) antipsychotics may help decrease anxiety (1) though no placebo-controlled studies have established efficacy.
Treatment reference
1. Birkeland SF: Psychopharmacological treatment and course in paranoid personality disorder: A case series. Int Clin Psychopharmacol 28(5):283-285, 2013. doi: 10.1097/YIC.0b013e328363f676
