Paranoid personality disorder
People with paranoid personality disorder (PPD) have long-term, widespread and unwarranted suspicions that other people are hostile, threatening or demeaning. These beliefs are steadfastly maintained in the absence of any real supporting evidence. The disorder, whose name comes from the Greek word for "madness," is one of ten personality disorders described in the 2000 edition of the Diagnostic and Statistical Manual of Mental Disorders , (the fourth edition, text revision or DSM-IVTR ), the standard guidebook used by mental health professionals to diagnose mental disorders.
Despite the pervasive suspicions they have of others, patients with PPD are not delusional (except in rare, brief instances brought on by stress ). Most of the time, they are in touch with reality, except for their misinterpretation of others' motives and intentions. PPD patients are not psychotic but their conviction that others are trying to "get them" or humiliate them in some way often leads to hostility and social isolation.
People with PPD do not trust other people. In fact, the central characteristic of people with PPD is a high degree of mistrustfulness and suspicion when interacting with others. Even friendly gestures are often interpreted as being manipulative or malevolent. Whether the patterns of distrust and suspicion begin in childhood or in early adulthood, they quickly come to dominate the lives of those suffering from PPD. Such people are unable or afraid to form close relationships with others.
They suspect strangers, and even people they know, of planning to harm or exploit them when there is no good evidence to support this belief. As a result of their constant concern about the lack of trustworthiness of others, patients with this disorder often have few intimate friends or close human contacts. They do not fit in and they do not make good "team players." Interactions with others are characterized by wariness and not infrequently by hostility. If they marry or become otherwise attached to someone, the relationship is often characterized by pathological jealousy and attempts to control their partner. They often assume their sexual partner is "cheating" on them.
People suffering from PPD are very difficult to deal with. They never seem to let down their defenses. They are always looking for and finding evidence that others are against them. Their fear, and the threats they perceive in the innocent statements and actions of others, often contributes to frequent complaining or unfriendly withdrawal or aloofness. They can be confrontational, aggressive and disputatious. It is not unusual for them to sue people they feel have wronged them. In addition, patients with this disorder are known for their tendency to become violent.
Despite all the unpleasant aspects of a paranoid lifestyle, however, it is still not sufficient to drive many people with PPD to seek therapy. They do not usually walk into a therapist's office on their own. They distrust mental health care providers just as they distrust nearly everyone else. If a life crisis, a family member or the judicial system succeeds in getting a patient with PPD to seek help, therapy is often a challenge. Individual counseling seems to work best but it requires a great deal of patience and skill on the part of the therapist. It is not unusual for patients to leave therapy when they perceive some malicious intent on the therapist's part. If the patient can be persuaded to cooperate— something that is not easy to achieve— low-dose medications are recommended for treating such specific problems as anxiety, but only for limited periods of time.
If a mental health care provider is able to gain the trust of a patient with PPD, it may be possible to help the patient deal with the threats that they perceive. The disorder, however, usually lasts a lifetime.
Causes and symptoms
No one knows what causes paranoid personality disorder, although there are hints that familial factors may influence the development of the disorder in some cases. There seem to be more cases of PPD in families that have one or more members who suffer from such psychotic disorders as schizophrenia or delusional disorder .
Other possible interpersonal causes have been proposed. For example, some therapists believe that the behavior that characterizes PPD might be learned. They suggest that such behavior might be traced back to childhood experiences. According to this view, children who are exposed to adult anger and rage with no way to predict the outbursts and no way to escape or control them develop paranoid ways of thinking in an effort to cope with the stress. PPD would emerge when this type of thinking becomes part of the individual's personality as adulthood approaches.
Studies of identical (or monozygotic) and fraternal (or dizygotic) twins suggest that genetic factors may also play an important role in causing the disorder. Twin studies indicate that genes contribute to the development of childhood personality disorders, including PPD. Furthermore, estimates of the degree of genetic contribution to the development of childhood personality disorders are similar to estimates of the genetic contribution to adult versions of the disorders.
A core symptom of PPD is a generalized distrust of other people. Comments and actions that healthy people would not notice come across as full of insults and threats to someone with the disorder. Yet, generally, patients with PPD remain in touch with reality; they don't have any of the hallucinations or delusions seen in patients with psychoses. Nevertheless, their suspicions that others are intent on harming or exploiting them are so pervasive and intense that people with PPD often become very isolated. They avoid normal social interactions. And because they feel so insecure in what is a very threatening world for them, patients with PPD are capable of becoming violent. Innocuous comments, harmless jokes and other day-to-day communications are often perceived as insults.
Paranoid suspicions carry over into all realms of life. Those burdened with PPD are frequently convinced that their sexual partners are unfaithful. They may misinterpret compliments offered by employers or coworkers as hidden criticisms or attempts to get them to work harder. Complimenting a person with PPD on their clothing or car, for example, could easily be taken as an attack on their materialism or selfishness.
Because they persistently question the motivations and trustworthiness of others, patients with PPD are not inclined to share intimacies. They fear such information might be used against them. As a result, they become hostile and unfriendly, argumentative or aloof. Their unpleasantness often draws negative responses from those around them. These rebuffs become "proof" in the patient's mind that others are, indeed, hostile to them. They have little insight into the effects of their attitude and behavior on their generally unsuccessful interactions with others. Asked if they might be responsible for negative interactions that fill their lives, people with PPD are likely to place all the blame on others.
A brief summary of the typical symptoms of PPD includes:
- suspiciousness and distrust of others
- questioning hidden motives in others
- feelings of certainty, without justification or proof, that others are intent on harming or exploiting them
- social isolation
- aggressiveness and hostility
- little or no sense of humor
As of 2002, it has not been possible to determine the number of people with PPD with any accuracy. This lack of data might be expected for a disorder that is characterized by extreme suspiciousness. Such patients in many cases avoid voluntary contact with such people as mental health workers who have a certain amount of power over them. There are, nonetheless, some estimates of the prevalence of PPD. According to the DSM-IV-TR , between 0.5% and 2.5% of the general population of the United States may have PPD, while 2%–10% of outpatients receiving psychiatric care may be affected. A significant percentage of institutionalized psychiatric patients, between 10% and 30%, might have symptoms that qualify for a diagnosis of PPD. Finally, the disorder appears to be more common in men than in women.
There are indications in the scientific literature that relatives of patients with chronic schizophrenia may have a greater chance of developing PPD than people in the general population. Also, the incidence of the disorder may be higher among relatives of patients suffering from another psychotic disorder known as delusional disorder of the persecutory type.
There are no laboratory tests or imaging studies as of 2002 that can be used to confirm a diagnosis of PPD. The diagnosis is usually made on the basis of the doctor's interview with the patient, although the doctor may also give the patient a diagnostic questionnaire. In addition, input from people who know the patient may be requested.
Mental health care providers look for at least five distinguishing symptoms in patients who they think might suffer from PPD. The first is a pattern of suspiciousness about, and distrust of, other people when there is no good reason for either. This pattern should be present from at least the time of the patient's early adulthood.
In addition to this symptom that is required in order to make the PPD diagnosis, the patient should have at least four of the following seven symptoms as listed in the DSM-IV-TR :
- The unfounded suspicion that people want to deceive, exploit or harm the patient.
- The pervasive belief that others are not worthy of trust or that they are not inclined to or capable of offering loyalty.
- A fear that others will use information against the patient with the intention of harming him or her. This fear is demonstrated by a reluctance to share even harmless personal information with others.
- The interpretation of others' innocent remarks as insulting or demeaning; or the interpretation of neutral events as presenting or conveying a threat.
- A strong tendency not to forgive real or imagined slights and insults. People with PPD nurture grudges for a long time.
- An angry and aggressive response in reply to imagined attacks by others. The counterattack for a perceived insult is often rapid.
- Suspicions, in the absence of any real evidence, that a spouse or sexual partner is not sexually faithful, resulting in such repeated questions as "Where have you been?" "Whom did you see?" etc., and other types of jealous behavior.
Psychiatrists and clinical psychologists should be careful not to confuse PPD with other mental disorders or behaviors that have some symptoms in common with the paranoid personality. For example, it is important to make sure that the patient is not a long-term user of amphetamine or cocaine. Chronic abuse of these stimulants can produce paranoid behavior. Also, some prescription medications might produce paranoia as a side effect; so it is important to find out what drugs, if any, the patient is taking.
There are other conditions that, if present, would mean a patient with paranoid traits does not have PPD. For example, if the patient has symptoms of schizophrenia, hallucinations or a formal thought disorder, a diagnosis of PPD can't be made. The same is true of delusions, which are not a feature of PPD.
Also, the suspiciousness and other characteristic features of PPD must have been present in the patient for a long time, at least since early adulthood. If the symptoms appeared more recently than that, a person can't be given a diagnosis of this disorder.
There are at least a dozen disorders or other mental health conditions listed in the DSM-IV-TR that could be confused with PPD after a superficial interview because they share similar or identical symptoms with PPD. It is important, therefore, to eliminate the following entities before settling on a diagnosis of PPD: paranoid schizophrenia; schizotypal personality disorder ; schizoid personality disorder ; persecutory delusional disorder; mood disorder with psychotic features; symptoms and/or personality changes produced by disease, medical conditions, medication or drugs of abuse; paranoia linked to the development of physical handicaps; and borderline, histrionic, avoidant, antisocial or narcissistic personality disorders.
In some individuals, symptoms of PPD may precede the development of schizophrenia. Should a patient who as been correctly diagnosed with PPD later develop schizophrenia, the DSM-IV-TR suggests that the diagnosis on the patient's medical record be changed from "Paranoid Personality Disorder" to "Paranoid Personality Disorder (Premorbid)."
Because they are suspicious and untrusting, patients with PPD are not likely to seek therapy on their own. A particularly disturbing development or life crisis may prompt them to get help. More often, however, the legal system or the patient's relatives order or encourage him or her to seek professional treatment. But even after a patient finally agrees or is forced to seek treatment, the nature of the disorder poses very serious challenges to therapists.
The primary approach to treatment for such personality disorders as PPD is psychotherapy . The problem is that patients with PPD do not readily offer therapists the trust that is needed for successful treatment. As a result, it has been difficult to gather data that would indicate what kind of psychotherapy would work best. Therapists face the challenge of developing rapport with someone who is, by the nature of his personality disorder, distrustful and suspicious; someone who often sees malicious intent in the innocuous actions and statements of others. The patient may actively resist or refuse to cooperate with others who are trying to help.
Mental health workers treating patients with PPD must guard against any show of hostility on their part in response to hostility from the patient, which is a common occurrence in people with this disorder. Instead, clinicians are advised to develop trust by persistently demonstrating a nonjudgmental attitude and a professional desire to assist the patient.
It is usually up to the therapist alone to overcome a patient's resistance. Group therapy that includes family members or other psychiatric patients, not surprisingly, isn't useful in the treatment of PPD due to the mistrust people with PPD feel towards others. This characteristic also explains why there are no significant self-help groups dedicated to recovery from this disorder. It has been suggested, however, that some people with PPD might join cults or extremist groups whose members might share their suspicions.
To gain the trust of PPD patients, therapists must be careful to hide as little as possible from their patients. This transparency should include note taking; details of administrative tasks concerning the patient; correspondence; and medications. Any indication of what the patient would consider "deception" or covert operation can, and often does, lead the patient to drop out of treatment. Patients with paranoid tendencies often don't have a well-developed sense of humor; those who must interact with people with PPD probably should not make jokes in their presence. Attempts at humor may seem like ridicule to people who feel so easily threatened.
With some patients, the most attainable goal may be to help them to learn to analyze their problems in dealing with other people. This approach amounts to supportive therapy and is preferable to psychotherapeutic approaches that attempt to analyze the patient's motivations and possible sources of paranoid traits. Asking about a patient's past can undermine the treatment of PPD patients. Concentrating on the specific issues that are troubling the patient with PPD is usually the wisest course.
With time and a skilled therapist, the patient with PPD who remains in therapy may develop a measure of trust. But as the patient reveals more of his paranoid thoughts, the clinician will continue to face the difficult task of balancing the need for objectivity about the paranoid ideas and the maintenance of a good rapport with the patient. The therapist thus walks a tightrope with this type of patient. If the therapist is not straightforward enough, the patient may feel deceived. If the therapist challenges paranoid thoughts too directly, the patient will be threatened and probably drop out of treatment.
While individual supportive psychotherapy is the treatment of choice for PPD, medications are sometimes used on a limited basis to treat related symptoms. If, for example, the patient is very anxious, anti-anxiety drugs may be prescribed. In addition, during periods of extreme agitation and high stress that produce delusional states, the patient may be given low doses of antipsychotic medications.
Some clinicians have suggested that low doses of neuroleptics should be used in this group of patients; however, medications are not normally part of long-term treatment for PPD. One reason is that no medication has been proven to relieve effectively the long-term symptoms of the disorder, although the selective serotonin reuptake inhibitors such as fluoxetine (Prozac) have been reported to make patients less angry, irritable and suspicious. Antidepressants may even make symptoms worse. A second reason is that people with PPD are suspicious of medications. They fear that others might try to control them through the use of drugs. It can therefore be very difficult to persuade them to take medications unless the potential for relief from another threat, such as extreme anxiety, makes the medications seem relatively appealing. The best use of medication may be for specific complaints, when the patient trusts the therapist enough to ask for relief from particular symptoms.
Paranoid personality disorder is often a chronic, lifelong condition; the long-term prognosis is usually not encouraging. Feelings of paranoia, however, can be controlled to a degree with successful therapy. Unfortunately, many patients suffer the major symptoms of the disorder throughout their lives.
With little or no understanding of the cause of PPD, it is not possible to prevent the disorder.
See also Paranoia
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Dean A. Haycock, Ph.D.