Paranoid Personality Disorder

a paranoid patient Credit: verywell mind Opens in new window

Paranoid personality disorder (PPD) is perhaps the commonest form of paranoia the general public has to cope with. In their eccentric fashion paranoids bring a degree of color, confusion, exasperation and quandary to the more prosaic measure of everyday life.

Paranoid personality involves a fixed system of false notions about the world, and characterized by a pervasive mistrust of the people in it.


Common features of the disorder include:

  • quarrelsomeness
  • hostility
  • emotional coldness
  • hypersensitivity to slights or criticism
  • stubbornness
  • rigidly held maladaptive beliefs of others’ intents

These symptoms may arise de novo or in the context of specific interpersonal events. They typically take the form of rigid ongoing interpersonal attitudes of a generally perverse and pessimistic nature, making patients with a paranoid personality disorder overly circumspect, evasive, secretive, highly suspicious, and hostile. They rarely trusts the seemingly benign appearance of things.

The prototypical picture is of someone who is preoccupied with real or imagined slights or threats, readily takes offence, mistrusts the intentions or motives of others, misinterprets remarks and actions, and usually maintain an attitude of mistrustful alertness to anticipated attack from others.

Why Paranoids Might Behave the Way They Do?

The guiding underlying assumption is that others are malevolent—they can betray, hurt, take advantage, or humiliate. Thus, measures must be taken to protect oneself.

They therefore resolve to protect themselves by:

  • keeping one’s distance from other people,
  • not appearing weak or vulnerable,
  • searching for signs of threat even in seemingly innocuous situations,
  • preemptively attacking others who are viewed as threatening, and
  • vigorously counterattacking when threatened or provoked.

Paranoids closely resemble compulsives Opens in new window in their cognitive style. Both are keen observers, attending to every detail and nuance of a situation; and both are intolerant of ambiguity.

For the paranoid, suspiciousness becomes the entire mode of thinking where all of their energy is spent discovering not it people are cheating them, but how they are cheating them. Their self-statements may include,

“I must always be on my guard,” and “I must be alert to hidden motives.”

Among paranoid personalities, the capacity for trust has been destroyed. While it is part of our normal human development to have some mistrust of others, especially when we are young (stranger anxiety) or if we live in life-threatening situations, a persistent and extreme mistrust of others is maladaptive.

Several variants exist of the paranoid personality that combine paranoids traits with other personalities.

  1. The fanatical paranoid is a mix with the narcissistic personalityOpens in new window who has had a serious narcissistic wound.
  2. The malignant paranoidOpens in new window combines the paranoid with the sadistic personality and is hypersensitive to issues of power and domination.
  3. The obdurate paranoidOpens in new window shares traits with the compulsive personalityOpens in new window and may function more normally in society than most paranoids.
  4. The querulous paranoidOpens in new window is a paranoid with negativistic traits who feels perpetually as though s/he has been cheated in life.
  5. Last, but not the least, the insular paranoidOpens in new window shares characteristics with the avoidant personalityOpens in new window, tending to be the most isolated of the paranoids.

While biologically, there does not appear to be a paranoid temperament, most likely the same irritable and aggressive temperament that may also lead to antisocialOpens in new window, sadistic, or borderline personalityOpens in new window plays a role in the paranoid, with early environmental factors playing a great role in determining the ultimate path of development.

Limited empirical research conducted on the heritability of a paranoid personality has been inconclusive as have been studies that try to link paranoid personality to schizophrenia and delusional disorder.

The classical psychodynamic perspective offers an interesting insight into the paranoid, namely their overdependence on the defense mechanism of projectionOpens in new window. Strict Freudian interpretation of the paranoid personality holds that the paranoia is a defense against homosexual urges that are unacceptable to the individual.

Later in century, object-representationalists began to see the paranoid as polarizing life into categories of all good and all bad.

By using projection to eliminate any of the bad in the self, they become all good; hence anything external becomes all bad. Because the negative thoughts are within the paranoid, they follow the paranoid wherever they go in life. Later dynamicists proposed secondary defense mechanisms such as using isolation, indignation, and megalomania or extreme overvaluation of the self as well as early abuse in the development of the paranoid personality.

From an evolutionary standpoint, paranoid traits are danger detectors, expressing an intense fear of imminent attack or impending predation, especially when associated with deceit and duplicity. The hypervigilance of paranoids, their constant mobilization for fight or flightOpens in new window, and their constant questioning of the obvious are not unlike an organism that senses something not quite right and fears that a camouflaged predator lurks nearby, ready to pounce at any moment, bringing sudden death from out of the darkness.

Interpersonally, Sullivan proposed that paranoids not only have an extreme insecurity related to a feeling of inferiority but also blame others instead of themselves for these perceived shortcomings.

Paranoids treat others as the enemy, which precludes the development of any attachments. Occasionally, paranoids surround themselves with loyal persons who can act as the eyes and ears of the paranoid, routing out evil plots being planned against them.

Paranoids traits have great survival value when moderately expressed. Organisms that sense threat and run away live to reproduce another day. Paranoid traits such as suspiciousness, vigilance, and a fear of novelty, then, should be expressed widely in any gene pool confronted with predatory threat or completion for resources.

All members of the species should, therefore, exhibit some low level of paranoid potential, which can be provoked to paranoid states given persistent objective threats, perhaps traumatic stress, for example.

Other members of the species will obtain relatively more paranoid potential through natural recombinant processes. Such “natural paranoids” express high vigilance and a low threshold for suspicion.


The treatment literature on PPD is limited to single-case studies. We could locate no report in the literature of a clinical trial of any treatment for PPD—psychotherapeutic or psychopharmalogical. Perhaps one reason for this is that PPD patients are perceived by some clinicians to be untreatable.

Clearly, their mistrust, antagonism, introversion, rigidity, and other features present challenges for psychotherapists, given that therapy is usually predicated on one’s ability to form a trusting relationship with the therapist and to examine one’s own assumptions about oneself, others, and the world.

A thorough discussion of possible treatment approaches to use with PPD patients is beyond the scope of this literature. However, a few general guidelines can be suggested.

First, the goal of therapy with PPD patients is to help them,

  • recognize and accept their own feelings of vulnerability;
  • heighten their feelings of self-worth and reduce their feelings of shame;
  • help them develop a more balanced, trusting view of others;
  • and reduce their reliance on counterproductive self-productive strategies, such as bullying  Opens in new window, threatening, and intimidating others and keeping others at a distance.

A variety of therapeutic approaches could be employed to accomplish these goals (e.g., cognitive-behavioral, psychodynamic). However, regardless of theoretical orientation, it is essential that the patient’s mistrust and self-protective mechanisms be confronted directly in an empathic but clear and straightforward manner.

It is an old adage that you cannot “talk a paranoid person out of his paranoia.” However, many individuals with PPD have some capacity to take perspective on their own suspicious cognitions. An approach of collaborative empiricismOpens in new window can be very helpful in this regard, in which the therapists invites the patient to join in a process of examining his or her beliefs in the light of objective evidence.

Thought records can be used to help the patient identify and modify his or her maladaptive cognitions by weighing the evidence supporting them and contradicting them. In conducting this sort of inquiry, it is import to acknowledge that the patient’s suspicions about others often contain a kernel of truth.

For example, a psychotherapist (D. P. B.) treated a PPD patient for 3 years using schema therapy, an integrative form of psychotherapy that combines cognitive, behavioral, psychodynamic object relations, and existential/humanistic approaches (Bernstein, 2005).

The patient had largely unfounded fears that his coworkers didn’t respect him and that his boss was looking for an excuse to fire him. While there was little objective evidence to support his belief that others disrespected him or that his own job was in jeopardy, his workplace environment did appear to be a ruthless one in which senior staff deliberately fostered competition among coworkers, and many of his colleagues worried about their job security.

The patient appeared to be relieved that his therapist validated the realistic aspects of his perceptions, rather than treating his beliefs as “crazy.” Moreover, recognizing that many of his coworkers might also be feeling insecure about their jobs helped the patient to accept his own feelings of vulnerability.

The patient was then able to engage in a process of collaborative empiricism with his therapist, in which they weighed the evidence supporting and contradicting his beliefs. The patient’s “evidence” that others disrespected him was based mainly on ambiguous social interaction in which colleagues had appeared unfriendly or hadn’t solicited his opinion during meetings.

After examining the evidence critically, the patient was able to recognize that his colleagues’ behavior could be open to a variety of alternative explanations. Moreover, the patient came to see that his own self-protective tendency to keep others at a distance was probably responsible for some of the unfriendliness he was experiencing. Similarly, his own tendency to keep quiet during meetings for fear of appearing stupid was probably responsible for the fact that others didn’t solicit his opinions.

    The research data for this work have been adapted from:
  1. Understanding Paranoia: A Guide for Professionals, Families, and Sufferers By Martin Kantor
  2. Personality Disorders: Toward the DSM-V By William O'Donohue, Katherine A. Fowler, Scott O. Lilienfeld.
  3. The Fundamentals of Psychological Medicine By R.R. Tilleard-Cole, J. Marks
  4. Personality Disorders in Modern Life By Theodore Millon, Carrie M. Millon, Sarah E. Meagher, Seth D. Grossman, Rowena Ramnath