Paranoid Personality Disorder (PPD)

What is paranoid personality disorder (PPD)?

Paranoid personality disorder is classified as a Type A personality disorder. People with PPD display an enduring pattern of distrust, suspicion, and paranoid thinking.

Paranoid personality disorder is considered a severe psychiatric disorder with a relatively poor long-term outlook, as many are unlikely to seek treatment voluntarily. The difficulty of establishing a trusting therapeutic relationship with providers is a barrier to treatment outcomes. 

However, psychotherapy focusing on skills building has been found effective at reducing symptoms for those who do seek help. Medication may also be helpful in some cases. 

Who is likely to get paranoid personality disorder?

Research on paranoid personality disorder is lacking due to the difficulty of finding voluntary participants. There is no clear understanding of who is more likely to develop PPD.

Experts previously believed that a family history of psychotic disorders was a risk factor for paranoid personality disorder ^[5].

Gender studies have had mixed results on whether the disorder occurs more often in males or females, but experts generally believe that PPD occurs more frequently in males ^[5]. 

Research consistently finds that childhood trauma is a risk factor for many types of personality disorders in adulthood, including paranoid personality disorder ^[4]. Childhood abuse and neglect are the most widely accepted risk factors for developing PPD. 

Signs and symptoms of paranoid personality disorder

Suspicion and distrust present in multiple settings are the primary symptoms of paranoid personality disorder. It can be a disabling condition, as symptoms of paranoia and hostile behavior are barriers to maintaining employment. Research has shown that those diagnosed with PPD are more likely to leave the workforce at a younger age ^[1]. 

People suffering from paranoid personality disorder likely developed these symptoms as a means of self-protection. Paranoia can become reinforced as others respond negatively to hostile behaviors, further complicating symptoms.

Paranoid personality disorder symptoms can include:

• Believing that people have hidden, malevolent motives with the intent to cause harm
• Social isolation
• Indifference to others and lack of empathy
• Hypervigilance
• Difficulty relaxing
• Misinterpreting others’ intentions, frequently accusing others of being disloyal
• Overt hostility, including aggressive or violent behavior ^[1]

Paranoid personality disorder symptoms generally begin emerging in late adolescence through early adulthood. Diagnostic criteria specify that the symptoms must be present by early adulthood. PPD cannot be diagnosed before adulthood ^[1]. 

Warning signs of paranoid personality disorder symptoms in children or teens may include:

• Social isolation
• Social anxiety
• Poor personal relationships with peers of the same age
• Underachievement in school
• Odd thoughts and behavior
• Eccentric behavior ^[1]

How common is paranoid personality disorder?

The American Psychiatric Association estimates the prevalence of paranoid personality disorder in the general population to be 0.5 - 2.5% ^[1]. Recent research, including one study that found 4.4% of 43,093 American adult participants met the criteria for paranoid personality disorder, suggests this may be higher ^[3].

Additional research into general population statistics is needed to determine how common paranoid personality disorder is. 

Diagnosing paranoid personality disorder

A psychological evaluation is most often used to diagnose paranoid personality disorder. This evaluation will include general questions about past mental health and medical history, relationships, employment, reality testing, and impulse control.

Psychological testing may be used to rule out alternative diagnoses such as schizophrenia, bipolar disorder, and other mental disorders. Additionally, a physical examination may be needed to rule out underlying illnesses causing the symptoms, such as brain trauma.

Causes of paranoid personality disorder

There is no known exact cause of paranoid personality disorder and only limited research into understanding its development. 

Childhood abuse, neglect, and social stress are risk factors for developing any personality disorder ^[4]. Mental health experts believe that personality disorders develop from maladaptive coping attempts that become a persistent pattern throughout life. 

Brain trauma has been identified as a possible risk factor for paranoia and may play a role in the development of PPD ^[4]. 

Treatment for paranoid personality disorder

People with paranoid personality disorder rarely seek treatment voluntarily, making outcomes difficult to measure. The complications of paranoid personality disorder, such as social isolation and difficulty maintaining school and work relationships, suggest that many with the disorder may not be encouraged to seek help.

Individual psychotherapy is usually the treatment recommendation for those who do seek help. Some medications have also been shown as helpful in reducing paranoid personality disorder symptoms. 

Psychotherapy 

Cognitive behavioral therapy (CBT) and Dialectal behavioral therapy (DBT) are two approaches that focus on skills building. The goals of these therapies are general skills development, communication strategies, and interpersonal skills building. 

Traditional dialectal behavioral therapy includes psychoeducational groups. The treatment provider may suggest an adapted individual approach, as people with paranoid personality disorder generally have poor outcomes in group settings due to paranoia and anxiety outweighing camaraderie. 

Trauma-focused approaches, such as narrative therapy, are difficult to implement because of distrust of the intent. These treatment plans may be helpful for people committed to treatment, given childhood trauma is the most widely accepted risk factor for developing paranoid personality disorder. 

Pharmacology

Mental health professionals do not always recommend medication as a treatment option for paranoid personality disorder. When medication is prescribed, it is recommended in conjunction with psychotherapy.

A healthcare provider may prescribe antidepressants, mood stabilizers, antipsychotic medication, and/or anti-anxiety medications.

Self-care for paranoid personality disorder

Paranoia tends to worsen or intensify during times of stress. Self-care and overall stress management strategies may help manage paranoid personality disorder symptoms.

General Self-Care Strategies:

• Get adequate sleep. Sleep plays an integral role in overall health and wellness, including mental wellness. Follow healthy sleep hygiene tips, such as going to bed at a scheduled time, avoiding electronics before bed, and waking up at the same time daily.
• Eat healthily. This includes eating regular meals throughout the day with nutritional value. Regular eating helps stabilize stress hormones and blood sugar in the body.
• Get sufficient exercise. Even a little movement can increase the feel-good hormones in the body and reduce stress levels.

Self-Care Strategies for Paranoia:

• Keep a journal or thought diary. This helps with identifying triggers, recognizing paranoid thoughts, and challenging whether they are realistic or not. Reviewing journal entries with treatment providers can also be helpful.
• Challenge paranoid thoughts. Asking questions can help identify alternative perspectives about triggers. Questions might include: What might other people believe in this situation? What evidence is there that this thought is invalid?
• Look for support. Having people able to listen and guide with questioning paranoid thoughts can help gain alternative perspectives.
• Maintain social relationships. Isolation and withdrawal from social support increase paranoia. Isolation limits the ability to consider alternative perspectives ^[6].

Living with someone with paranoid personality disorder

Abusive behavior is never acceptable under any circumstances. Loved ones may need to take steps to ensure their own mental and physical safety. Clear boundaries are important, including communicating what will happen if aggression or violence happens.

There are communication and coping strategies that loved ones can use. 

Communication strategies

• Validate feelings. People with paranoid personality disorder painfully suffer from their thoughts. It is possible to have empathy for the pain without validating the paranoia. Validating feelings can help reduce anger and hostility. Focus on the emotion expressed rather than the content of the thoughts. For example, "It must feel lonely not having anyone at work you trust." 
• Focus on listening. Pointing out errors in thinking is likely to be interpreted as further proof that these thoughts are real. Instead, allow open sharing of thoughts and feelings. Allowing space to express thoughts may reduce feelings of anger and anxiety your loved one experiences.
• Use clear language. Offer clarity with clear, concise wording. Try to avoid becoming defensive if your loved one misinterprets intent.
• Encourage self-care activities. Paranoia increases with stress. Participating in self-care activities such as exercise, healthy eating, and relaxation can help reduce stress and anxiety. 
• Encourage professional help. People with paranoid personality disorder can improve with treatment. In most cases, treatment is sought only after being urged to do so by loved ones ^[7].

Self-Care Strategies

It is important for loved ones to practice self-care strategies and strive for balance. Self-care includes finding support for themselves, taking time to relax, exercising regularly, getting adequate sleep, and eating healthily.

Frequently asked questions about PPD

What other medical conditions are associated with paranoid personality disorder?

Experts estimate that 75% of people with avoidant personality disorder have a comorbid personality disorder. The most common personality disorders that co-exist with paranoid personality disorder are avoidant personality disorder and borderline personality disorder ^[4]. 

People with PPD also have a higher likelihood of a diagnosis of substance use disorder or an anxiety disorder ^[2].

What is the long-term outlook if diagnosed with paranoid personality disorder?

Many people with paranoid personality disorder do not believe they need, or are simply resistant to, help. However, the long-term prognosis for PPD without effective treatment is poor.

Treatment with psychotherapy focusing on skills building can help reduce paranoia and increase adaptive skills. Medication can also be beneficial in conjunction with psychotherapy. The long-term prognosis for people with paranoid personality disorder who seek help depends on their commitment to treatment.