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Paranoid Personality Disorder–Trait Specified

BASICS

DESCRIPTION

- Thorough psychiatric history - Collateral history to establish pervasive pattern of behavior - DSM-5 section II diagnosis: based on fulfilling 4 of 7 criteria for the disorder (2)[C] - Suspects exploitation, harm, or deceit by others - Unjustified doubt of others ' loyalty/trustworthiness - Fears malicious retaliation if he/she confides in others and thus avoids doing so - Believes benign remarks or situations are threatening or demeaning - Unforgiving; persistently bears grudges - Unjustifiably perceives attacks on character/reputation and may become hostile or counterattack - Suspects infidelity of spouse/sexual partner

- Associated features include the following: - Strong sense of autonomy - Stubbornness - Litigiousness - Patient may be perceived as fanatic. - May form closed groups or cults

- DSM-5 section III diagnosis: An alternative model for personality disorders has been presented in section III of DSM-5 and categorizes paranoid personality disorder under PD-TS, diagnosed by the following: - Difficulties in two or more of the following areas: - Identity - Self-direction - Empathy - Intimacy

  • Paranoid personality disorder is a pattern of distrust and suspiciousness such that others ' motives are interpreted as malevolent.
  • Consequently, patients avoid intimate relationships, bear grudges, and expect to be exploited by others.
  • Paranoid personality disorder is one of the cluster A personality disorders.
  • Certain DSM-IV personality disorders (paranoid, schizoid, histrionic, and dependent, as well as the residual category of PDNOS) are now diagnosed in the DSM-5 as personality disorder " пїЅtrait specified (PD-TS), which is represented by the following:Significant impairment in personality functioningPathologic personality traits

EPIDEMIOLOGY

Incidence

  • Predominant age: first manifests during childhood or adolescence
  • Predominant sex: male > female
  • Increased in families with delusional disorder (persecutory type) and chronic schizophrenia

Prevalence

  • Thought to be underdiagnosed as these patients are less likely to seek treatment (1)[B].
  • 0.5 " пїЅ2.5% of the general population
  • 2 " пїЅ10% of psychiatric outpatients
  • 10 " пїЅ30% of psychiatric inpatients

ETIOLOGY AND PATHOPHYSIOLOGY

Paranoid sense of mistrust can result from childhood abuse/neglect and/or genetic predisposition to paranoia. Specific causes are unknown. пїЅ пїЅ

Genetics

Genetic predisposition may play a role (see "Incidence " пїЅ). пїЅ пїЅ

RISK FACTORS

  • Family history of paranoid personality disorder
  • Childhood abuse/neglect

COMMONLY ASSOCIATED CONDITIONS

  • May develop major depressive disorder
  • May be at increased risk for obsessive-compulsive disorder and agoraphobia
  • At risk for alcohol and/or other substance abuse/dependence
  • Most common co-occurring personality disorders are schizotypal, schizoid, narcissistic, avoidant, and borderline.

DIAGNOSIS

HISTORY

  • Thorough psychiatric history
  • Collateral history to establish pervasive pattern of behavior
  • DSM-5 section II diagnosis: based on fulfilling 4 of 7 criteria for the disorder (2)[C]Suspects exploitation, harm, or deceit by othersUnjustified doubt of others ' loyalty/trustworthinessFears malicious retaliation if he/she confides in others and thus avoids doing soBelieves benign remarks or situations are threatening or demeaningUnforgiving; persistently bears grudgesUnjustifiably perceives attacks on character/reputation and may become hostile or counterattackSuspects infidelity of spouse/sexual partner
  • Associated features include the following:Strong sense of autonomyStubbornnessLitigiousnessPatient may be perceived as fanatic.May form closed groups or cults
  • DSM-5 section III diagnosis: An alternative model for personality disorders has been presented in section III of DSM-5 and categorizes paranoid personality disorder under PD-TS, diagnosed by the following:Difficulties in two or more of the following areas:IdentitySelf-directionEmpathyIntimacyAnd one or more pathologic personality trait domains OR specific trait facet(s)Negative affectivityDetachmentAntagonismDisinhibitionPsychoticism
  • Impairments in personality functioning and pathologic personality traits are evaluated on a continuum and are the basis for this new model.
  • Diagnosis of PD-TS is separate from the six specific personality disorders (which in the DSM-5 include antisocial, avoidant, borderline, narcissistic, obsessive, and schizotypal personality disorders), which retained their original descriptors.

PHYSICAL EXAM

Mental status examination пїЅ пїЅ

DIFFERENTIAL DIAGNOSIS

  • Primary psychotic disorders including paranoid schizophrenia, delusional disorder (paranoid type), and affective disorder with psychotic features
  • Schizoid personality disorder, avoidant personality disorder
  • Medical disorders (e.g., temporal lobe epilepsy) with behavioral changes
  • Personality changes due to traumatic brain injury (3)[C]
  • Effects of substances, including medications
  • Culturally appropriate behavior, sometimes marked by defensiveness/guardedness, must not be mistaken for paranoia.Minorities, immigrants, and refugees also can present similarly but may be plagued by unfamiliarity.
  • Paranoid traits can develop in the face of physical handicaps, such as hearing impairment.

DIAGNOSTIC TESTS & INTERPRETATION

  • Psychological testing (e.g., Minnesota Multiphasic Personality Inventory)
  • Brain imaging may rule out organic disease for those with emerging symptoms.

TREATMENT

GENERAL MEASURES

  • Treatment is difficult and is often avoided by the patient (1)[B].
  • Outpatient individual psychotherapy that is predictable, respectful, and straightforward is preferred (4)[A].Overly warm and empathetic styles can be regarded as intrusive.Short- and long-term psychotherapies are efficacious and cost-effective in reducing symptoms (5,6)[A].
  • Mistrust issues can undermine group and behavioral therapy.Group therapy for mild personality disorders can be efficacious (4)[A].

MEDICATION

  • Although little evidence suggests that the core personality features of paranoid personality disorder respond to psychopharmacologic treatment, psychotic paranoid ideation, acute hostility, anxiety, or psychosis can respond to low-dose antipsychotics and/or short-term benzodiazepines (4)[B].
  • Short-acting benzodiazepines, such as diazepam or lorazepam, can be useful in treating acute agitation, hostility, or anxiety.
  • Acute psychotic states and delusional thinking can respond to low-dose antipsychotics, such as haloperidol.
  • Taking medications may be interpreted by the patient as a loss of autonomy or feeling powerless.

ISSUES FOR REFERRAL

The patient should be referred for individual psychotherapy and psychiatric follow-up if psychiatric medication(s) are indicated. пїЅ пїЅ

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

  • Patients who become suicidal or homicidal may require psychiatric hospitalization for safety and stabilization.
  • Patients in acute psychotic states may also require hospitalization if they are unable to care for themselves or if they pose a risk to others.

Discharge Criteria

  • A hospitalized patient usually is discharged after appropriate therapeutic interventions and discharge planning have taken place.
  • Suicidal ideation, homicidal ideation, and/or acute psychotic states must be resolved.

ONGOING CARE

PATIENT EDUCATION

National Institute of Mental Health: www.nimh.nih.gov пїЅ пїЅ

PROGNOSIS

  • Good prognosis for those with good ego strength and strong support system
  • Poor prognosis for those with poor insight, lack of primary support system, or comorbid Axis I psychiatric diagnosis

COMPLICATIONS

  • Impairment in work and interpersonal relationships
  • May develop concomitant psychiatric conditions

REFERENCES

11 Tyrer пїЅ пїЅP, Mitchard пїЅ пїЅS, Methuen пїЅ пїЅC, et al. Treatment rejecting and treatment seeking personality disorders: Type R and Type S. J Pers Disord. 2003;17(3):263 " пїЅ268.22 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.33 Riggio пїЅ пїЅS, Wong пїЅ пїЅM. Neurobehavioral sequelae of traumatic brain injury. Mt Sinai J Med. 2009;76(2):163 " пїЅ172.44 Verheul пїЅ пїЅR, Herbrink пїЅ пїЅM. The efficacy of various modalities of psychotherapy for personality disorders: a systematic review of the evidence and clinical recommendations. Int Rev Psychiatry. 2007;19(1):25 " пїЅ38.55 Leichsenring пїЅ пїЅF, Rabung пїЅ пїЅS. Effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. JAMA. 2008;300(13):1551 " пїЅ1565.66 Abbass пїЅ пїЅA, Sheldon пїЅ пїЅA, Gyra пїЅ пїЅJ, et al. Intensive short-term dynamic psychotherapy for DSM-IV personality disorders: a randomized controlled trial. J Nerv Ment Dis. 2008;196(3):211 " пїЅ216.

CODES

ICD10

F60.0 Paranoid personality disorder пїЅ пїЅ

ICD9

301.0 Paranoid personality disorder пїЅ пїЅ

SNOMED

paranoid personality disorder (disorder) пїЅ пїЅ

CLINICAL PEARLS

  • Paranoid personality disorder is a maladaptive, persistent pattern of behavior characterized by suspiciousness, inappropriate mistrust of people, and hostility toward others.
  • Although little evidence suggests that the core personality features of paranoid personality disorder respond to psychopharmacologic treatment, patients with psychotic paranoid ideation, acute hostility, anxiety, or psychosis can respond to low-dose antipsychotics or short-term benzodiazepines.
  • Poor prognosis for those with poor insight, lack of primary support system, or a comorbid Axis I psychiatric diagnosis
  • It is sometimes difficult to distinguish true paranoid personality disorder from other primary psychiatric or medical conditions manifesting with features of paranoia.