This disorder is characterized by pervasive suspiciousness, mistrust, and hypersensitivity to criticism and hostility. Paranoid individuals live an isolated emotional life because they fear the malevolent intent of others. As a rule, paranoid people are ready to counter-attack, provoking repeated confrontations. In this way, they induce hostility and resentment in others.
The term paranoia may lead to some confusion if it is not properly delimited. Paranoid had been used as an adjective to label various delusional representations or syndromes. Kraepelin(!) differentiated paranoia as a distinct condition characterized by chronic and highly systematized delusional ideas (see Chapter4.4). Schneider(2) described people with this paranoid personality as fanatic psychopaths, stressing their intensity and rigidity in confrontation with others. He denied any relationship with paranoia. Freud(3) and other psychoanalysts construed the paranoid character as a pattern of mistrust and feeling of being attacked, based on distortions and externalization of the person's inner world.
Paranoid personality disorder was included in DSM-III with criteria of suspiciousness, mistrust, hypersensitivity, and restricted affectivity. This last criterion does not appear in DSM-IV and ICD-10, since restricted affectivity is neither necessary nor specific for paranoid personalities. Instead, emphasis is placed on mistrust and sensitivity to setbacks. The DSM-IV criteria for paranoid personality disorder are shown in Table !..
Table 1 DSM-IV diagnostic criteria for paranoid personality disorder
The prevalence of paranoid personality disorder is estimated at about 0.5 to ! per cent in the general population and at 10 to 20 per cent among psychiatric patients. The disorder is more commonly diagnosed in males.
This personality disorder has a familial relationship with delusional disorders and with schizophrenia, (4) and has been included in the so-called schizophrenic spectrum.(5) Deficits in cortical dopamine activity may be associated with a poor conceptual organization that could in turn be responsible for suspiciousness and distorted interpretations.^)
Mistrust and lack of confidence may reflect deficits arising in early developmental stages and resulting in a lack of basic self-confidence. (7) Lack of protective care and affective support in childhood could perhaps facilitate the development of paranoid features.
Paranoid individuals do not often ask for help from psychiatrists. They have no wish to be cured; instead, they believe that they have to be protected from other people's hatred and attacks. Subjects with this personality disorder suspect that others are acting to harm, exploit, or deceive them. These suspections are based not on objective evidence, but on internal conviction and an attempt to find a rational explanation for the supposed wrongs.
Paranoids are reluctant to confide in others; they tend to feel that others are plotting against them, and that the enemy may be found in unexpected places. They do not readily tell others about their suspicions. The disorder may be manifested by irritability, unusual defensive or self-protective behaviours (e.g. locking doors and closing windows and curtains to avoid being spied on, and hiding papers or documents), or emotional detachment.
Paranoid people lack confidence in others. They doubt the loyalty or trustworthiness of friends and partners, and check their behaviour repeatedly for evidence of malevolent intentions. They assume that others are not trustworthy, to the extent that they cannot believe it when friends demonstrate their loyalty. They withhold personal or significant information from friends, fearing that it will be used maliciously against them. They do not form close friendships and are often isolated. When in trouble, paranoids do not expect help from friends or others close to them; instead, they expect to be attacked or ignored.
Many of the suspicious and distrustful attitudes of paranoids are perpetuated by their intense interpersonal sensitivity. They react intensely to any comment or event that may relate to them. Hidden meanings that are demeaning and threatening may be read into benign events or the remarks of others. Unintended errors by colleagues or public servants are taken as deliberate attempts to harm or deceive them. Humorous remarks or jokes may be interpreted as attacks on their character. Paranoids are easily hurt, and their pride is easily damaged by minor critical comments or questioning. They are excessively preoccupied with attacks on their reputation or character, and minor slights may arouse major hostility and a counter-attack. They bear grudges and harbour hostile feelings for a long time, and are unwilling to forgive the insults, injuries, or slights that they think they have received. (8)
Pathological jealousy is a common presentation of paranoid individuals. They have unreasonable doubts about the loyalty and faithfulness of their partners, based on little or no evidence. They may try to gather trivial and circumstantial facts to justify their beliefs. To avoid betrayal they attempt to gain complete control of intimate relationships, continuously questioning and challenging partners about their whereabouts and intentions.
The interpersonal world of paranoids is a consequence of their suspiciousness and distrust. They have difficulty in relating to others, especially with close relationships. Hostility is always present and can be manifested as excessive argumentativeness, recurrent complaint and confrontation, or hostile aloofness. (8). Although they may appear rational, unemotional, and cold, the affect of paranoids is labile and oversensitive and they may be hostile, stubborn, and sarcastic. This mixture of secretive, cold, hostile, and sarcastic behaviours often elicits a hostile response in others which confirms the paranoid person's beliefs.
Paranoids blame others for their shortcomings. They are querulous and quick to counter-attack, so that they may become involved in frequent litigation. Since they do not confide in others, paranoids need self-confidence and a sense of autonomy and independence. They need to control people who might be harmful. While they do not accept criticism, they are highly critical.
One group of paranoids are close to Schneider's 'fanatics'.(2) They have hidden grandiose fantasies of power and negative views of other people, especially those belonging to another group who come to be considered as natural enemies. They simplify issues and avoid any ambiguous perspective. Some form cults or other tightly knit groups with people who share their paranoid belief systems.
Paranoid features may be present in childhood and early adolescence in the form of hypersensitivity, social anxiety, poor peer relationships, and eccentricity. These features sometimes elicit teasing from other children, which in turn may aggravate the paranoid attitudes.
In situations of stress, individuals with paranoid personality disorder may respond with brief psychotic episodes. During these episodes, they may have frank delusional ideas or distorted perceptions. Some paranoid personality disorders are the premorbid state for a delusional disorder or even schizophrenia.
Individuals with this personality disorder may be at increased risk for agoraphobia, obsessive-compulsive disorder, and substance abuse or dependence. This personality disorder is often codiagnosed with schizoid, schizotypal, narcissistic, and avoidant personality disorders.
Paranoid personality disorder should be distinguished from suspicious attitudes towards examination among immigrants, ethnic groups, or political groups. Members of these groups may display defensive and mistrustful behaviours owing to lack of familiarity with the language or the rules of a society, or in response to perceived neglect or rejection. Their behaviour may elicit further rejection from the majority, thus reinforcing the defensive behaviours.
Paranoid personality disorder is distinguished from delusional disorder, paranoid schizophrenia, and depression with psychotic symptoms, all of which are characterized by periods of persistent psychotic symptoms. Paranoid personality disorder present before the occurrence of these syndromes should be diagnosed as 'premorbid'.
People with schizotypal personality disorder are suspicious, have paranoid ideas, and keep their distance from others. However, they also experience perceptual distortions and magical thinking, and are usually odd and eccentric. Schizoid personality disorder is characterized by aloofness, coldness, and eccentricity, but these individuals usually lack prominent suspiciousness or paranoid ideation. Individuals with avoidant personality disorder are hypersensitive and do not confide in others. However, their lack of confidence is based on fear of being embarrassed or found inadequate rather than fear of other people's malicious intentions. Some antisocial behaviour by paranoid individuals originates in a wish for revenge or counter-attack, rather a desire for personal gain as in antisocial personality disorder. Paranoid features are often present in narcissistic individuals who fear that their imperfections could be revealed. The differential diagnosis should be based on the predominance of persistent need of praise versus persistent suspiciousness and distrust.
Antidepressant and anxiolytic treatment may be useful for anxiety and depression resulting from a paranoid response to stressful situations. Low-dose antypsychotics may be indicated during brief psychotic episodes or when ideas of reference are present.
Psychological treatment is difficult owing to the lack of insight. The approach is to attempt to gain the patient's confidence, avoiding early confrontation of distorted ideas, followed by a slow gentle attempt at cognitive restructuring.
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