Which disorder is characterized by pervasive distrust and suspicion of others?

Paranoid personality disorder

Paranoid personality disorder (PPD) has been in every edition of the APA diagnostic manual. However, it was proposed for deletion in DSM-5 (Skodol, 2012). The limited research in this area may not necessarily suggest an invalid diagnosis (Shedler et al., 2010), but it does indicate a relative lack of interest of researchers in the disorder (Hopwood and Thomas, 2012). Trust versus suspiciousness is a fundamental dimension along which all persons vary, and there are persons who are characteristically mistrustful and suspicious (McCrae and Costa, 2008).

PPD includes a pervasive and continuous distrust and suspiciousness of the motives of others (APA, 2013), but the disorder is more than just suspiciousness. Persons with this disorder are also hypersensitive to criticism, they respond with anger to threats to their autonomy, they bear grudges, they incessantly seek out confirmations of their suspicions, and they tend to be quite rigid in their beliefs and perceptions of others (Millon, 2011).

PPD paranoid ideation is inconsistent with reality and is resistant to contrary evidence, but the ideation is not psychotic, absurd, inconceivable, or bizarre. PPD will also lack other features of psychotic and delusional disorders (e.g., hallucinations) and will be evident since early adulthood, whereas a psychotic disorder will occur later in life (e.g., adulthood) and will often remit after a relatively brief period of time.

Persons with PPD may become socially isolated or perhaps fanatic members of groups that encourage or at least accept their paranoid ideation. They might maintain a steady employment but will be difficult coworkers, as they will tend to be rigid, controlling, critical, blaming, and prejudicial. They are said to become involved in lengthy, acrimonious, and litigious disputes (Millon, 2011). Persons with PPD would rarely seek treatment for their feelings of suspiciousness and distrust (Millon, 2011).

Paranoid Personality Disorder

The essential feature of this type of personality disorder is self-reference, the proper psychiatric sense of the wordparanoid; such people misinterpret the words and actions of others as having special significance for, and being directed against, themselves. Theoretically, self-referent ideas could imply that others are always noticing them in an admiring and benevolent way; in practice, such people would not consult a psychiatrist and those presenting in psychiatry have ideas of persecution. They mistrust other people and are very sensitive and suspicious, believing that others are against them and that what they say about them is derogatory. There are active and passive types of paranoid personality disorder; both types feel that others are ‘getting at them’ but their response differs.

The active paranoid personality manifests suspiciousness and is hostile and untrusting. Such a person is quarrelsome, litigious, quick to take offence, intensely suspicious and sometimes violent; he will go to enormous lengths to defend his rights or to address real or imagined injustices. He is extremely vigilant and tenacious in taking precautions against any perceived threat. This is the sort of person who will march fearlessly across a field of young corn because he sees there is a public right of way on his map and the farmer has no right to violate this. They repudiate blame and may be regarded by others as devious, scheming and secretive. Such a person is intensely jealous of what he regards as his own belongings, which may be people as well as objects, and he spends a lot of time planning to ‘get his own back’. He may be self-important and fanatical. Morbid jealousy may be shown, and such a person may be involved in acts of violence because of imagined injustice. Such a personality may find creative expression in social and political life but is likely to be very destructive within the family. A patient commented on this ruefully, ‘I have scarcely talked to my wife for the last 10 years’, because of his succession of court cases against those with whom he came into contact.

A person with passive paranoid personality faces the world from a position of submission and humiliation. He assumes that whatever happens to him will be damaging. Like the active type, he is suspicious, sensitive and self-referent and misconstrues circumstances and other people. He believes that other people will dislike him and that they will ultimately let him down. However, he accepts ‘the slings and arrows of outrageous fortune’ passively, bowing to the inevitable; he is vulnerable and frequently feels humiliated and unable to initiate any assertive activity. Other people tend to take advantage of him, thus fulfilling his pessimistic expectations.

A frequent manifestation of psychopathology within the context of paranoid personality is the presence of an overvalued idea (Chapter 8). This, alternatively described as a fixed idea (idée fixe), is a belief that might seem reasonable both to the patient and to other people. However, it comes to completely dominate the person's thinking and life, and instead of testing its validity he tends to consider that every circumstance of life substantiates it; it becomes the basis for action that is sometimes aggressive or self-destructive. It is quite distinct phenomenologically from bothdelusion andobsessional ideas.

Paranoid Personality Disorder

When interacting with a paranoid patient, the physician typically reacts with fear, mistrust, and a sense of danger. The physician may also feel blamed or accused. The patient may have a similar fear of being hurt, exploited, or invaded. Patients often react to suggestions for medical care with mistrust, excessive fault finding, sensitivity to criticism, or hypervigilance. They may collect small insults as proof of the world's injustices. When invasive medical procedures are performed, a paranoid patient may react with full-blown panic and anxiety; many paranoid patients unconsciously experience a body invasion as a homosexual assault. Patients with paranoid personality disorder rely most heavily on projection as their main defense. Using projection, they accuse the physician of hurts that reflect their own aggressive style of hurting others.

A physician working with the paranoid patient needs to empathize with the patient's mistrust and hypersensitivity. The physician should avoid arguing or attempting to reason the patient out of the paranoid worldview. It is extremely important to use confrontations and clarifications to help correct the patient's distorted perceptions about his or her medical care. Unfortunately, direct confrontation of a delusion or hallucinations (the most troubling deficits in reality testing) often has the paradoxical effect of making these patients more suspicious of the physician.

Acknowledging that the patient's suspicion has an emotional reality can be helpful. Rather than confronting mistrust or suspicions directly, the physician can acknowledge responsibility for any actions that the patient might have perceived as mistakes. For example, the physician could say, “I did not appreciate how it might hurt you when I ordered that lab test.” It may also help to express understanding and concern for the patient's rights. If there is a medical need for special testing of which the patient is suspicious, acknowledge the patient's fears and describe openly and honestly the details of the procedures, potential for pain, and likely risks and benefits. If the patient still refuses to comply, do not use direct persuasion. Ask the patient, “Is it all right with you if we have different opinions?” With the patient's consent to hearing a different opinion, openly discuss the medical necessity of the testing without trying to resolve the problem. At future office visits, attempt new and ongoing discussions of the patient's fears of complying with the request for specialized testing. It may take months for the paranoid patient to trust enough to consent to the appropriate treatment. Counterprojective statements by the physician can diffuse the projections and distortions directed at the physician. The physician can use counterprojective remarks to help the patient access his or her feelings while focusing angry or suspicious feelings away from the physician toward others who are not pre­sent. For example, a physician harassed by an angry, suspicious, or blaming patient could use a counterprojective statement such as, “You felt angry and hurt when the lab technician drew your blood. You must be fearful of the results of these tests.”

Paranoid Personality Disorder

Persons with paranoid personality disorder are characterized as being distrustful, secretive, and argumentative. They can be quite authoritarian in their relationships. Sperry25 stated that these persons often perceive interpersonal situations correctly, but their judgment and interpretation of interpersonal situations are impaired. A person with paranoid personality disorder may demonstrate considerable jealousy and anger in relationships. These affective responses can place a great strain on the nonparanoid spouse, who may be characterized as rather passive in contrast to the controlling, dominating partner with paranoid personality disorder.

Persons with paranoid personality disorder often have difficulty forming relationships. They can be isolated and very distrustful of everyone. However, if they have the ability to form relationships, they tend to become highly dependent in them. Paranoid persons, once they establish some trust, show an enmeshed style of relationships. These patients are also known to become highly dependent in a therapeutic relationship. Their interactions often demonstrate covert and overt controlling behaviors, and these behaviors may be an important part of what they use to maintain relationships. They may have had a parental figure who was hypercritical, but, in spite of the constant criticism, these patients may have ended up having a strong identification with those parental figures. Therefore, they may be hypercritical and expect others to be so. Underneath their prickly surface, they may have a great wish to be understood but a strong conviction that this will never happen, and, as a result, they feel isolated and alienated. Cognitively, paranoid patients tend to have dichotomous thinking and have selective attention to certain environmental stimuli. From these stimuli, they tend to overgeneralize from one interaction to all interactions.

In terms of engaging the paranoid patient, you have to expect the possibility of emotional attack during the interview. These patients can be quite challenging because of their interpretations of interpersonal interactions. Paranoid patients tend to project and see the world and others as hostile and ill willed. They tend to be distrustful of clinicians, so you should maintain a professional demeanor and not demonstrate any overfamiliarity with the person. In addition, you should be very predictable because unexpected situations or responses may increase the paranoia and drive these patients out of treatment. However, it must be remembered that once these patients are engaged, they tend to be highly dependent patients. As termination issues arise, the paranoid patient has some of the greatest difficulty with resolving the ending of the therapeutic relationship.

Paranoid Personality Disorder (Box 12-2)

Key Points of the Personality Profile of Persons Vulnerable to Developing Addiction

Clients with paranoid personality disorder can be attracted to the dominance drugs (alcohol, cocaine, and amphetamines), because they enhance the need for control that is central to the disorder (Benjamin, 1993). These drugs allow individuals with this personality to feel more powerful in a world that seems dangerous and hostile.

Clients with schizoid personality disorder may be attracted to psychedelic drugs and become addicted to the state of arousal and satisfaction involved in facilitated fantasy (Milkman & Sunderwirth, 1987).

Drugs such as marijuana and LSD may replicate the digressive, tangential quality of thought patterns already present in individuals with schizotypal personality disorder, and mere drug use can be enough to precipitate a psychiatric crisis. Psychoeducation is vital with these clients (Ekleberry, 1996).

Clients with antisocial personality disorders, perhaps due to low neurological arousal, often seek thrills and are likely to be most attracted to stimulants. Their use of alcohol and drugs bothers them only in terms of the pressure they receive from employers, family, or the criminal justice system (Ekleberry, 1996).

Clients with borderline personality disorder are the best candidates of all those with personality disorders for developing addictive disorders; they will use almost any drug of choice to worst advantage.

Clients with histrionic personality disorder may value drugs and alcohol or compulsive behaviors for social enhancement. Antianxiety drugs are often sought; but stimulants provide them with dramatic mood boosts.

Clients with avoidant personality disorder (AvPD) are vulnerable to substance use that can reduce interpersonal vulnerability or ease social paralysis. Drugs that will make a difference include sedative–hypnotics that calm anxiety and stimulants that provide a sense of strength or reduced vulnerability. Mild hallucinogens facilitate escape into fantasy and distract the AvPD client from the pain of his or her own self-absorption (Stone, 1993).

Clients with dependent personality disorder may use alcohol and other substances as a passive way to escape from problems (Beck, 1993).

Paranoid Personality Disorder

The core feature of paranoid personality disorder is a pervasive distrust and suspiciousness of others. Afflicted individuals are reluctant to confide in others; they assume that most people will harm or exploit them in some manner. In new situations, they search for confirmation of these expectations and view even the smallest slight as significant. They unjustifiably question the loyalty of friends and significant others, and consequently, are often socially isolated and avoid intimacy. They pride themselves on being rational and objective, but they appear to others as unemotional, affectively restricted, and hypervigilant. These individuals bear grudges and collect injustices. When their beliefs are challenged or they are stressed in any significant way, these individuals can show profound anger, hostility, and referential thinking.

The most common differential diagnoses for paranoid personality disorder include delusional disorder (paranoid type), schizophrenia (paranoid type), schizoid personality disorder, and avoidant personality disorder. With delusional disorder and schizophrenia, reality testing is lost; in paranoid personality disorder, formal reality testing is said to remain intact. However, reality testing is a continuum, and it may be difficult to distinguish the degree of reality testing of a person with mild schizophrenia from that of a person with a florid paranoid personality disorder, especially if in the latter cer-tain cultural factors or a potential gain from manipulating the examiner are present. With schizoid and avoidant personality disorder, the amount and degree of paranoia is significantly less, which distinguishes it from paranoid personality disorder.

The prevalence of paranoid personality disorder in the general population is approximately 0.5% to 2.5%. There appears to be an increased incidence in families with schizophrenia and delusional disorder. The diagnosis is far more common in males than it is in females.

Which personality disorder is characterized by a pervasive pattern?

What is suspicious personality disorder?

What personality disorder is characterized by irrational suspicion?

What is pervasive suspiciousness?