Paranoid Personality Disorder DSM-5 301.0 (F60.0)
DSM-5 Category: Personality Disorders
PPD (Paranoid Personality Disorder) is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), diagnosis assigned to individuals who have a pervasive, persistent, and enduring mistrust of others, and a profoundly cynical view of others and the world (American Psychiatric Association, 2013). Paranoid Personality Disorder is referred to as a Cluster A personality disorder, which involve “ odd or eccentric “ behavior patterns (Esterberg, Goulding, & Walker, 2010). Persons with PPD are hypervigilant to physical, verbal or social attacks, and do not trust others, and therefore tend to have few if any close or intimate associates. They tend to be aloof, cold, distant, argumentative, and frequently complain. They may appear guarded and secretive, very rational, logical, and unemotional, but at times will be sarcastic, hostile, and rigid. Generally they have a difficult time getting along with others People with Paranoid Personality Disorder tend to do poorly with group activities and collaborative projects. They will be highly critical of others, but will respond to criticism of themselves with hostility or defensiveness. Paranoid Personality Disorder is a non-psychotic disorder, in that it is a discrete diagnosis involving one's dysfunctional and maladaptive personality characteristics, rather then a thought or mood disorder. Persons with Paranoid Personality Disorder may develop brief psychotic reactions under stress, but by definition, a brief psychotic episode is discrete and does not endure. Paranoid Personality Disorder is not amenable to antipsychotic medications as there are not typically gross deficits in reality testing, and the paranoid thought content and beliefs are typically-non bizarre. PPD is also not regarded as a result of trauma, as the perception of being unsafe in the world which is typical of persons with PTSD (Post -traumatic Stress Disorder) is of a different quality and etiology.
Symptoms of Paranoid Personality Disorder
According to the DSM-5, there are two primary diagnostic criterion for Paranoid Personality Disorder of which criterion A has seven sub features, four of which must be present to warrant a diagnosis of PPD:
Criterion A is: Global mistrust and suspicion of others motives which commences in adulthood. The seven sub features of criterion A are:
1.The person with PPD will believe others are using, lying to, or harming them, without apparent evidence thereof.
2.They will have doubts about the loyalty and trustworthiness of others,
3.,They will not confide in others due to the belief that their confidence will be betrayed.
4.They will interpret ambiguous or benign remarks as hurtful or threatening, and
5. Hold grudges,
6. In the absence of objective evidence, believe their reputation or character are being assailed by others, and will retaliate in some manner and
7. Will be jealous and suspicious without cause that intimate partners are being unfaithful.
Criterion B is that the above symptoms will not be during a psychotic episode in schizophrenia, bipolar disorder, or depressive disorder with psychotic features,
A qualifier is that if the diagnostic criteria for PPD is met prior to the onset of Schizophrenia, it should be noted Paranoid Personality Disorder was premorbid (American Psychiatric Association, 2013).
The DSM-5 notes that Paranoid Personality Disorder features may be apparent in childhood and adolescence. Children may act strangely, resulting in teasing (American Psychiatric Association, 2013). This is an interesting note, in that it raises questions of premorbid causality. A child who exhibits abnormal behaviors and who is rejected by peers, may learn not to trust, and may become suspicious of others motives. This could be a contributing factor in the development of paranoid personality.
According to the DSM-5, the prevalence of Paranoid Personality Disorder is 2.3 % to 4.4 % of the US population, and is more frequently diagnosed in males. (American Psychiatric Association, 2013).
The DSM-5 indicates that a family history of Schizophrenia, or persecutory type delusional disorder are risk factors for Paranoid Personality Disorder (American Psychiatric Association, 2013).
The DSM -5 identifies the following conditions as comorbid: Other personality disorders, specifically, schizotypal, schizoid, narcissistic, avoidant, and borderline personality disorder. Substance abuse disorders, Major depressive disorder, OCD and agoraphobia are also noted as conditions which can develop in conjunction with PPD (American Psychiatric Association, 2013).
Treatment of Paranoid Personality Disorder
The DSM-5 does not specify treatment options (American Psychiatric Association, 2013). CBT (Cognitive Behavioral Therapy) is an effective means of treating Personality disorders, including Paranoid Personality Disorder . PPD is maintained through a deeply ingrained system of maladaptive beliefs, reinforcement of paranoid beliefs due to information bias, and lack of skills to provide adaptation. All of these features are amenable to intervention through CBT (Matusiewicz, Hopwood, Banducci, & Lejuez, 2010) People with Paranoid Personality Disorder will typically see others as the problem, rather than their own belief system they are projecting on others. This makes entering treatment difficult. Developing therapeutic trust and rapport will also be challenging.
Impact on Functioning
According to the DSM-5, persons with Paranoid Personality Disorder will have trouble operating with others in the workplace, educational or social settings (American Psychiatric Association, 2013). It is noted that people with PPD are more frequently unemployed or working more menial jobs than the general population (Mueser, Mischel, Adams, Harvey, McClure, Look, Leung, & Siever, 2013).They tend to be solitary, self sufficient, and secretive, and will have difficulty making or maintaining intimate relationships or close friendships. (American Psychiatric Association, 2013). Persons with PPD may experience a conflict, in that they want intimate relationships and friendships, but do not have a level of trust which is an essential element of such relationships.
There are multiple diagnostic rule-outs for the clinician to consider. The DSM-5 also notes that recent immigrants who are not yet acculturated and unfamiliar with local language and customs may be not trusting of individuals in their new land. This is especially true if they have come from a nation where they experienced warfare, civil strife, or social breakdown. Other rule-outs include changes in personality due to medical conditions, e.g., Alzheimer's Dementia, substance use, e.g., ethanol withdrawal or prolonged use of CNS (Central Nervous System) stimulants such as cocaine, or sensory deficits such as hearing loss, in which an individual may be suspicious others are talking about them (American Psychiatric Association, 2013). The individual's worldview formed by their past experience must be considered (Carroll, 2009). Many elements of Paranoid Personality Disorder appear to overlap with PTSD, Individuals with PTSD may become guarded, hypervigilant, for threats, and suspicious. This is due to a traumatic event which as altered their view of the world as a safe place, and they have become hypervigilant to threats, may withdraw from the world and isolate themselves to make the world more manageable, and may take numerous personal security precautions. The etiology of PTSD is much clearer, the onset will be following a traumatic event, and it will typically represent a post-morbid change in world view which was absent prior to the trauma, There are also individuals in high risk professions, who are hypervigilant, secretive, hyperaware, and suspicious as a result of their professional training and experience- e.g.- police officers, corrections officers, prosecuting attorneys, and forensic health care providers, This can be viewed as an adaptive survival response of increased awareness and threat recognition, or a normal response to adverse circumstances (Carroll, 2009). Clinicians who are not aware of the culture of individuals in high risk professions, or who do not have personal experience or knowledge of the dynamics of violence may misinterpret protective, adaptive behaviors as pathological.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders.(5th Edition). Washington, DC.
Carroll, A. (2009). Are you looking at me? Understanding and managing paranoid personality disorder. Advances in Psychiatric Treatment. 15:40-48. 10.1192/apt.bp.107.005421 DOI:
Esterberg, M.L., Goulding, S.M., and Walker, E.F. ( 2010). A Personality Disorders: Schizotypal, Schizoid and Paranoid Personality Disorders in Childhood and Adolescence. Journal of Psychopathological Behavioral Assessment. 32(4): 515–528. doi: 10.1007/s10862-010-9183-8 PMCID: PMC2992453 NIHMSID: NIHMS222925
Matusiewicz, A.K., Hopwood, C.J., Banducci, A.N., Lejuez, C.W., (2010). The Effectiveness of Cognitive Behavioral Therapy for Personality Disorders, Psychiatry Clinics of North America ;33(3): 657–685. doi: 10.1016/j.psc.2010.04.007 PMCID: PMC3138327 NIHMSID: NIHMS297280
Mueser, K.T., Mischel, R., Adams, R., Harvey, P.D., McClure, M.M., Look, A.E., Leung, W.W., and Siever, S.J. (2013). Psychiatry Research (210), 498-504 Vocational functioning in schizotypal and paranoid personality disorders. Psychiatry Research. Retrieved March 8, 2014, from http://www.psyjournal.com/article/S0165-1781%2813%2900335-1/abstract
Richie Rich Ray Charles O'Brien
St. Augustine Beach Mayor RICHARD BURTT O'BRIEN, WHO SOUNDED PARANOID AND CLAIMS HE TURNED OFF HIS HEARING WHILE JUDGE MCGILLIN WAS RULING