by Joye C. Anestis
The Cluster A personality disorders (PDs), comprised of paranoid, schizoid, and schizotypal, are described as the "odd or eccentric" PDs. Perhaps just be looking at their names you might be able to surmise that these 3 disorders are considered to be part of the schizophrenia spectrum. I'll tackle each of these one at a time, in the hopes of clarifying often misunderstood diagnoses, but, as we discovered in my post on histrionic personality disorder, research on PDs leaves much to be desired (borderline PD and antisocial PD are the exceptions to this).
The hallmark feature of paranoid PD is...paranoia, i.e., "a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent" (APA, 2000, p. 694).The DSM-IV-TR lists the following 7 symptoms, at least 4 of which must be present to receive the diagnosis:
- suspects, without sufficient evidence, that others are exploiting or harming him/her
- preoccupation with unjustified doubts about the loyalty or trustworthiness of friends
- hesitant to confide in others due to unwarranted fears about the information being used maliciously
- reads threatening meaning into benign remarks or events
- persistently bears grudges
- perceives attacks on his/her character that are unapparent to others and quickly reacts angrily or counterattacks
- recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner
Importantly, this diagnosis cannot be given if the symptoms occur in the presence of another disorder with psychotic features. So if the symptoms only occur during a psychotic episode, a paranoid PD diagnosis is incorrect. But a person with a psychotic disorder can receive this diagnosis if paranoid PD symptoms occur during non-psychotic periods. Repeatedly the symptom list points out that the fears report by a person with this illness are persistent and unjustified or unwarranted. They are irrational fears that affect most aspects of an individual's life, and this disorder is associated with significant impairment in social and emotional functioning (Grant et al., 2004). How frustrating and difficult it must be to spend your life scared like this!
So, what kind of people generally get this diagnosis? The DSM-IV-TR estimates that 10-30% of inpatients and 2-10% of outpatients meet criteria for paranoid PD (APA, 2000). It is estimated to occur in approximately 4% of the general population (Grant et al., 2004). The DSM-IV-TR notes that paranoid PD is more common in males in clinical samples; however, it seems to be more common in women in the general population (3.8% men, 5% women; Grant et al., 2004). In my opinion, one of the more interesting things to discuss and study regarding this disorder is the racial and cultural differences in prevalence that emerge. For example, Grant et al. (2004) noted higher rates of this diagnosis in Native American, Hispanic, and African-American individuals compared to Whites. It could be argued that, in minority groups, symptoms of paranoid PD are warranted and understandable considering the historical treatment of members of these groups. Could this disorder be overdiagnosed in such individuals when cultural factors are not considered while making the diagnosis? This is an important research question that has yet to be answered.
As is the case with all PDs, paranoid PD often co-occurs with one or more other PDs. The most common ones are the other Cluster A PDs, schizoid and schizotypal (Grant et al., 2005). Paranoid PD is also frequently comorbid with borderline, narcissistic, histrionic, avoidant, obsessive-compulsive, and dependent PDs (GRant et al., 2005; Zimmerman et al., 2005). Paranoid PD also often co-occurs with major depressive disorder and the anxiety disorders (APA, 2000; Johnson et al., 2005). Such vast overlap raises questions about the validity of the paranoid PD symptoms. This is a topic that researchers are currently tackling as they overhaul the PDs for DSM-V.
Unfortunately, there is virtually no research on treatments of paranoid PD. Cognitive-behavioral therapy has been suggested by some (Beck et al., 2004), and I found one case description of dialectical behavior therapy with a man with comorbid paranoid and obsessive-compulsive PDs (Lynch & Cheavens, 2008). Other suggested treatments abound, but I have not come across any systematic investigations of a specific treatment for this disorder. It is frustrating to find so little treatment information on one of the more common PDs, but I am carefully watching the development of DSM-V and am hopeful that, as the PD criteria sets become more sound, treatment research will follow.
Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.
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