Summary Paranoid personality disorder is a neglected topic in clinical psychiatry, and is often the subject of diagnostic confusion and therapeutic pessimism. This chapter presents a summary of the key diagnostic issues relating to paranoid personality disorder and describes various psychological and social processes mooted to be central to the genesis of paranoid thinking and behaviours. The evidence relating to paranoid personality disorder and risk of violence is summarised and clinically useful guidance for the safe treatment of people with the disorder is outlined.
Trust is central to the relationship between doctor and patient. An important skill in psychiatry, therefore, is the ability to relate to and effectively treat patients in whom the capacity for trust is diminished as a consequence of psychopathology. The focus of this chapter is paranoid personality disorder, a condition in which mistrust of other people is the cardinal feature. It is not an uncommon disorder, with a prevalence in community samples of around 1.3% (Torgersen, 2005), rising to up to 10% in psychiatric outpatient samples (Bernstein et al, 1993). Despite this, the research base on the disorder remains relatively sparse (Bernstein & Useda, 2007).
Clarifying the diagnosis of a patient with paranoid thinking is an essential first step to management, with ramifications for prognosis, treatment and medico-legal issues such as involuntary treatment or criminal responsibility. The DSM-IV-TR criteria for paranoid personality disorder (American Psychiatric Association, 2000) have been criticised for underrepresenting the typical affective and interpersonal features of the disorder, features that give a richer sense of the typical presentation (Bernstein & Useda, 2007) (Box 4.1).
Box 4.1 Paranoid personality disorder: DSM v. Bernstein & Useda
Summarised DSM-IV-TR criteria (American Psychiatric Association, 2000)
• Extreme distrust of others from an early age
• Bearing persistent grudges
• Preoccupation with suspicions that others want to harm or deceive them
• Belief that sexual partners are Unfaithful
• Reluctance to confide for fear of malicious use of information given
• Perception of innocent incidents as Threatening
Primary traits identified by Bernstein & Useda (2007)
• Introversion/excessive autonomy