Living a life where every moment is filled with suspicion and doubt – A review of Paranoid Personality Disorder

Paranoid Personality Disorder(PPD) belongs to the class of Personality Disorders. Paranoia involves extreme levels of distrust and suspicion. People with this personality disorder may be hypersensitive, easily insulted, and habitually relate to the world by vigilant scanning of the environment for clues or suggestions that may validate their fears or biases. They are eager observers and they think they are in danger and look for signs and threats of that danger, potentially not appreciating other evidence. Some other common recurrent beliefs include beliefs that someone is plotting against them, they are being watched closely, everyone is conspiring against them among others.

Following is a case study of a Paranoid patient:

A woman believed, without cause, that her neighbours were harassing her by allowing their young children to make loud noise outside her apartment door. Rather than asking the neighbours to be more considerate, she stopped speaking to them and began a campaign of unceasingly antagonistic behaviour: giving them “dirty looks,” pushing past them aggressively in the hallway, slamming doors, and behaving rudely toward their visitors. After over a year had passed, when the neighbours finally confronted her about her behaviour, she accused them of purposely harassing her. “Everyone knows that these doors are paper thin,” she said, “and that I can hear everything that goes on in the hallway. You are doing it deliberately.” Nothing that the neighbours said could convince her otherwise. Despite their attempts to be more considerate about the noise outside her apartment, she continued to behave in a rude and aggressive manner toward them. Neighbours and visitors commented that the woman appeared tense and angry. Her face looked like a hard mask. She was rarely seen smiling and she walked around the neighbourhood wearing dark sunglasses, even on cloudy days. She was often seen yelling at her children, behaviour that had earned her the nickname “the screamer” among the parents at her children’s school. She had forced her children to change schools several times within the same district because she was dissatisfied with the education they were receiving. An unstated reason, perhaps, was that she had alienated so many other parents. She worked at home during the day at a job that required her to have little contact with other people. She had few social contacts, and in conversation was often perceived to be sarcastic and hypercritical.

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[Image Courtesy: https://infograph.venngage.com/p/63184/paranoid-personality-disorder]

According to the DSM-V, PPD is characterized by a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts. To qualify for a diagnosis, the patient must meet at least four out of the following criteria:

  1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them.
  2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
  3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against them.
  4. Reads hidden demeaning or threatening meanings into benign remarks or events.
  5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
  6. Perceives attacks on their character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
  7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

Many of these symptoms are clearly reflected in the case study.

PPD first emerged as a cluster of symptoms for Schizophrenia. It was in 1921, that Kraepelin first proposed three distinct presentations of paranoia that resembled the diagnosis of schizophrenia, delusional disorder, and paranoid personality disorder. However, for a very long time, PPD was considered only as a cluster of symptoms for schizophrenia. Paranoid personality disorder first appeared in the DSM-III in 1980. The major problem facing the study of this disorder was the initial neglect of the scientists. Secondly, not many patients would agree to participate in research studies. Yet, in reality, PPD is a severe, relatively common clinical problem that is difficult to treat. Fortunately, our understanding of PPD has improved as research has accrued.

But the question is, why is PPD important? One of the major reasons is because PPD heavily dictates the adverse outcomes in the treatment of personality disordered patients. Persons with PPD, when not disabled, stop working earlier than non-personality disordered individuals. In clinical populations, it is one of the strongest predictors of aggressive behaviour. PPD is also associated with violence and stalking as well as excessive litigation. It also has serious implications on the individual’s mental well-being often resulting in depression and has less likeability to be cured despite intense psychiatric treatment.

There are multiple risk factors involved in the development of PPD as no direct biological causations have been attributed.  Childhood trauma has consistently been identified as a risk factor for PPD. Studies have shown that childhood emotional neglect predicted PPD symptom levels in adolescence and early adulthood. In adolescence, PPD has been cross-sectionally associated with elevated physical abuse in childhood and adolescence, but not sexual abuse. In a study of psychiatric adult outpatients, PPD was found associated with both sexual and physical abuse. Although these studies have focused on chronic trauma from caregivers, acute physical trauma in the form of childhood burn injury has also found to be a risk factor for adult PPD traits.

What can be some effective measures for treating PPD?

In a case report titled, “Paranoid Personality Disorder”, medics Amy Vyas and Madiha Khan have outlined certain major points with regards to treating PPD.

Because paranoid personality disorder patients are unlikely to seek or remain in psychiatric care, relevant treatments for this disorder have received less research relative to those of similarly prevalent personality disorders. Much of the published literature takes the form of case studies or case series. One such case report found cognitive analytic therapy to be an effective intervention,  while another suggested that in the short-term, the use of antipsychotics(drugs) in patients with paranoid personality disorder was associated with improved prognosis. Cognitive therapy has been endorsed as a useful technique for the general psychiatrist. Recommended approaches to psychodynamic psychotherapy for these patients include working toward helping patients “shift their perceptions of the origin of their problems from an external locus to an internal one”, while maintaining special attention to the management of boundaries, maintenance of the therapeutic alliance, safety, and awareness of how the therapy may be integrated into the patient’s paranoid stance.

In conclusion, PPD is a serious mental illness that requires more and more fruitful research and in-depth understanding. No such biological or physiological causes have been found but several risks factors have been identified. With regards to treatment, there is a need for more effective intervention.

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[Image Courtesy: https://www.papermasters.com/paranoid-personality-disorder.html]

To know more about Paranoid Personality Disorder:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5793931/

References

[1]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

[2]Paranoid personality disorder. (2019, March 11). Retrieved from https://en.wikipedia.org/wiki/Paranoid_personality_disorder#DSM-5

[3]Vyas, A., & Khan, M. (2017, May 16). Paranoid Personality Disorder. Retrieved from https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp-rj.2016.110103

 

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