Paranoid personality disorder - description and diagnosis

This article is about personality disorder. For chronic mental disorder with monothematic, systematized delusional ideas, see paranoia; for more severe psychosis, see paranoid psychosis; for the form of schizophrenia, see paranoid schizophrenia.

Paranoid personality disorder

;
paranoid personality disorder
(from ancient Greek παράνοια -
madness
) (outdated names -
paranoid type personality disorder
,
paranoid type personality disorder
,
paranoid psychopathy
) - a personality disorder characterized by excessive sensitivity to frustration , suspicion, rancor, constant dissatisfaction with others and a tendency take everything personally. Included in ICD-10 and DSM-5.

Diagnosis

ICD-10

This section is transcribed from Personality Disorder. (edit | history)

Diagnostic criteria from the version of the International Classification of Diseases, 10th revision ICD-10, adapted for use in Russia (general diagnostic criteria for personality disorders, which must be met in all subtypes of disorders):[1]

Conditions that are not directly attributable to extensive brain damage or disease or other mental disorder and meet the following criteria:

• a) marked disharmony in personal attitudes and behavior, usually involving several areas of functioning, such as affectivity, excitability, impulse control, perceptual and mental processes, as well as style of relating to other people; in different cultural conditions it may be necessary to develop special criteria regarding social norms;
• b) the chronic nature of an abnormal style of behavior that arose a long time ago and is not limited to episodes of mental illness;
• c) the abnormal style of behavior is comprehensive and clearly disrupts adaptation to a wide range of personal and social situations;
• d) the above-mentioned manifestations always arise in childhood or adolescence and continue to exist into adulthood;
• e) the disorder causes significant personal distress, but this may only become apparent later in the course of time;
• f) usually, but not always, the disorder is accompanied by a significant deterioration in professional and social productivity.

— International Classification of Diseases (10th revision), adapted for use in the Russian Federation — /F60/ Specific personality disorders. Diagnostic criteria[1]

To classify a personality disorder into one of the subtypes defined in ICD-10 (for diagnosis of most subtypes), it is necessary that it meets at least three criteria defined for this type [1].

Diagnostic criteria from the official, international version of ICD-10 from the World Health Organization (general diagnostic criteria for personality disorders, which must be met in all subtypes of disorders):[2]

• G1. An indication that an individual's characteristic and consistent patterns of internal experience and behavior as a whole deviate significantly from the culturally expected and accepted range (or "norm"). Such a deviation must manifest itself in more than one of the following areas: 1) cognitive sphere (that is, the nature of perception and interpretation of objects, people and events; the formation of attitudes and images of “” and “others”);
• 2) emotionality (range, intensity and adequacy of emotional reactions);
• 3) controlling drives and satisfying needs;
• 4) relationships with others and the manner of solving interpersonal situations.

• G2. The deviation must be complete in the sense that inflexibility, lack of adaptability, or other dysfunctional characteristics are found in a wide range of personal and social situations (that is, not limited to one “trigger” or situation).
• G3. The behavior noted in G2 indicates
  personal distress or adverse effects on the social environment.
• G4. There must be evidence that the deviation is stable and long-lasting, beginning in late childhood or adolescence.
• G5. The disorder cannot be explained as a manifestation or consequence of other mental disorders of adulthood, although episodic or chronic conditions from sections F0 to F7 of this classification may exist simultaneously with it or arise against its background.
• G6. Organic brain disease, trauma or brain dysfunction should be excluded as a possible cause of the deviation (if such an organic condition is identified, rubric 07 should be used).

Original text (English)

• G1. Evidence that the individual's characteristic and enduring patterns of inner experience and behavior deviate markedly as a whole from the culturally expected and accepted range (or 'norm'). Such deviation must be manifest in more than one of the following areas: (1) cognition (ie ways of perceiving and interpreting things, people and events; forming attitudes and images of self and others);
• (2) affectivity (range, intensity and appropriateness of emotional arousal and response);
• (3) control over impulses and need gratification;
• (4) relating to others and manner of handling interpersonal situations.
• G2. The deviation must manifest itself pervasively as behavior that is inflexible, maladaptive, or otherwise dysfunctional across a broad range of personal and social situations (ie not being limited to one specific 'triggering' stimulus or situation).
• G3. There is personal distress, or adverse impact on the social environment, or both, clearly attributable to the behavior referred to under G2.
• G4. There must be evidence that the deviation is stable and of long duration, having its onset in late childhood or adolescence.
• G5. The deviation cannot be explained as a manifestation or consequence of other adult mental disorders, although episodic or chronic conditions from sections F0 to F7 of this classification may co-exist, or be superimposed on it.
• G6. Organic brain disease, injury, or dysfunction must be excluded as possible cause of the deviation (if such organic causation is demonstrable, use category F07).

— International Classification of Diseases (10th revision) — /F60/ Specific personality disorders. Diagnostic criteria[2]

According to ICD-10, this mental disorder is diagnosed if the general diagnostic criteria for personality disorder are met, plus three or more of the following signs:

• a) excessive sensitivity to failures and refusals;
• b) the tendency to constantly be dissatisfied with someone, that is, to refuse to forgive insults, damage and arrogant attitudes;
• c) suspicion and a general tendency to distort facts by misinterpreting neutral or friendly actions of other people as hostile or contemptuous;
• d) a militantly scrupulous attitude towards issues related to individual rights that is not adequate to the actual situation;
• e) renewed unjustified suspicions of sexual infidelity of a spouse or sexual partner;
• f) the tendency to experience one’s increased significance, manifested in the constant attribution of what is happening to one’s own account;
• g) being covered by insignificant “conspiracy” interpretations of events occurring with a given person or in the world in general.

Included:

• fanatical disorder;
• fanatical personality;
• expansive-paranoid disorder;
• expansive-paranoid personality;
• sensitive paranoid disorder;
• sensitive-paranoid personality;
• paranoid personality;
• paranoid personality disorder;
• paranoid personality;
• touchy-paranoid personality;
• Querulant personality disorder.

Excluded:

• schizophrenia (20.);
• delusional disorder (22.022.0);
• paranoia (22.0122.01);
• querulant paranoia (22.8822.88);
• paranoid psychosis (22.0822.08);
• paranoid schizophrenia (20.020.0);
• paranoid state (20.0820.08);
• organic delusional disorder (06.206.2);
• paranoids caused by the use of psychoactive substances, including alcoholic delusions of jealousy, alcoholic paranoid (10. - 19.)[1].

DSM-IV and DSM-5

Paranoid personality disorder is classified as Cluster A

(unusual or eccentric disorders). A person with this disorder is characterized by a global mistrust and suspicion of others, which leads to the interpretation of people's motives as malicious. The following manifestations of such a personality begin to be detected in early adulthood, in a wide variety of situations. To make a diagnosis, in addition to the general criteria for a personality disorder, four or more of them are necessary.

1. Suspicions, without sufficient reason, that others are exploiting, harming, or deceiving him or her.
2. Preoccupation with unreasonable doubts about the loyalty and reliability of friends or companions.
3. Reluctance to open up to others due to an unjustified fear that it will be used against him (her).
4. Detecting hidden derogatory or threatening meanings in favorable words or events.
5. Persistent hostility towards others, including refusal to forgive insults, disrespect or harm caused.
6. Recognizing subtle attacks on his or her reputation, with quick retaliatory attacks or anger.
7. Repeated unfounded suspicions of infidelity of a spouse or sexual partner.

To make a diagnosis, these manifestations must be recorded not only during the course of schizophrenia, a mood disorder with psychotic symptoms, another psychotic disorder, or generally a direct consequence of some other illness or general physical condition[3].

The latest edition of DSM-5 retains the same criteria as DSM-IV[4].

Symptoms of Paranoid Personality Disorder

Paranoid psychopaths are practically unable to maintain ordinary everyday relationships in the family and team. This is hampered by the inability to make compromises, the desire in all cases to act only in accordance with one’s own opinion. Their judgments are distinguished by peremptory, self-confident, categorical.

For a paranoid person, everything that is in one way or another connected with his own personality and affects his interests acquires special meaning and significance. They are deeply indifferent to phenomena outside the sphere of “attraction” of their “I”, simply excluding them from the area of ​​active attention. “Everything that is not closely related to his “I” seems to the paranoid little worthy of attention.”

In this aspect, it is necessary to emphasize one more feature of paranoids, which is hardly noticeable in everyday life, but clearly appears in the conditions of a somatic hospital - egodystony in relation to one’s own bodily sphere. Psychopathic personalities in this circle are not only indifferent to a number of events in external life, but also to the problems of their somatic state. The news of a serious somatic illness often leaves them indifferent - it does not entail anxiety, fear of the harmful consequences of the disease, fear of death, or decreased mood. This often leads to neglect of medical recommendations, refusal to take medications, and the patient may continue to perform life-threatening exercises and physical activities.

Constantly opposing oneself to others, perceiving the world as an opposite and even hostile phenomenon is manifested in paranoids by such traits as “hypervigilance” (constant search for a threat from the outside, readiness to respond to any alarm signal) and distrust of people. Fears of attacks on their rights, their property, or their spouse or sexual partner are often at the forefront. Such distrust of the intentions of others easily turns into suspicion in paranoid individuals. Thoughts arise that others treat them unfairly, without due respect, are jealous, or even want to humiliate or insult them; they are being undermined and their authority is being infringed upon. An incorrect, one-sided interpretation of the words and actions of others leads a paranoid person to unfounded and, for the most part, suspicions devoid of even the slightest reason. Any trifle that is not directly related to them can be interpreted as a manifestation of bad intentions, negative (or even hostile) attitude of others (usually relatives and colleagues).

The most typical, according to P.B. Gannushkin, property of paranoids is the tendency to form overvalued ideas, in the power of which they then find themselves. Overvalued ideas subjugate the entire personality and determine the behavior of the individual; It is not the paranoid person who controls his thoughts, but his thoughts that control him.

Depending on the topic of highly valuable ideas, several types of paranoid individuals are distinguished:

• jealous people
• inventors,
• querulants,
• fanatics.

However, a taxonomy based only on the content of highly valuable formations cannot reflect the structure of psychopathy as a whole.

There are two polar variants of paranoid psychopathy:

1. expansive (stronger, active, defiant, angry, litigious),
2. sensitive (weak, passive, secretive, touchy).

Expansive paranoid individuals are pathological jealousy, litigious people, people prone to conflicts, truth-seeking and reforming. From childhood, they are deceitful, vindictive, often slander and complain, they notice the shortcomings of others, but do not recognize them in themselves. As V.F. Chizh points out (1902), they are always satisfied with themselves, failures do not bother them. We are convinced that only they master this specialty, only they understand everything perfectly. They do not want to obey, limit themselves to a modest role, and usually fight with their personal enemies, and not for a common cause. Fighting opponents and asserting their importance fill their lives. As a rule, these are sthenic and even exalted individuals with an accelerated pace of mental activity and a constantly elevated background mood. They are energetic, active, sometimes fussy, do not know what fatigue is, and do not feel the need for rest. The group of fanatics also belongs to expansive paranoid individuals. Fanatics are people who, with exceptional passion, devote all their interests, activities, time, and ultimately their entire lives to one cause, one idea. The strength of their obsession is such that they are able to captivate, at least temporarily, other people with their idea. It must be emphasized that we are talking about blind faith (for example, religious fanaticism), which does not require logical justification. Although fanatics, unlike other paranoid individuals, do not put themselves in the foreground, they are far from true altruism, devoid of direct love for their neighbors, soulless, and often cruel.

A characteristic feature of the sensitive version of paranoid psychopathy is a combination of contrasting personality traits: asthenic, sensitive (awareness of one’s own inferiority, vulnerability, false modesty) and sthenic (ambition, increased self-esteem). These people are timid, shy, fearful and at the same time suspicious and irritable, prone to introspection, self-criticism and even self-torment. They are distinguished by a heightened sense of humiliating failure in relation to the standards (professional, everyday, etc.) that they have set for themselves.

Interpretations

Cognitive-behavioral

Psychoanalytic

In psychoanalysis, paranoid personality disorder is understood as a condition of a person with a paranoid personality type.

, located at the borderline level of development of the personality organization. Psychoanalysts believe that a person with this type of personality can also be on a neurotic (which corresponds to accentuations in Russian psychology) and psychotic levels, but the personal characteristics characteristic of this type will be preserved.

It is believed that the basis of the paranoid personality organization is the reliance on the defense mechanisms of “denial” and “projection”. Such a person has an increased tendency to deny some unacceptable parts of himself and project them onto others. For example, a paranoid person's suspicions that others are planning something evil against him are the result of denial and projection of his own aggressive thoughts. This, however, does not exclude the possibility that he may be right in his suspicions - moreover, thanks to their repulsive personal qualities, many paranoids literally run into conflicts and mistreatment through “projective identification.” There are extremely insightful people who are nonetheless paranoid. Paired with denial, the paranoid can also use “reactive formation” to further distance oneself from one’s own affects.

Paranoid individuals experience strong hostile emotions (anger, rage, desire for revenge, envy), shame, guilt and fear, all of which are usually denied and projected onto others, and therefore are inaccessible to awareness for the paranoid person themselves without special work[5].

Treatment of paranoid personality disorder

Drug therapy is usually ineffective.

Among the methods of psychotherapy, one can highlight the theory of psychodynamics of object relations (in this case, the doctor tries to explain to the patient what is behind his anger, and works on the person’s hidden desires to have a satisfactory relationship) and behavioral and cognitive psychotherapy, which are aimed at organizing help for such people in controlling anxiety and improving interpersonal problem solving skills. Patients are helped to interpret other people's actions and intentions more realistically and to better understand others' points of view.

Therapy

Cognitive-behavioral

Psychoanalytic

Psychoanalytic therapy of paranoid individuals is a rather labor-intensive task that requires the therapist to have high professional qualities and, above all, the ability to tolerate negative emotions directed at themselves. A paranoid client tends to project his negative (in the client’s opinion) qualities onto the therapist, suspect the therapist of all mortal sins and actively seek evidence of his fantasies, including provoking the therapist to have a negative attitude towards himself (the so-called “projective identification”).

Another tendency the therapist may encounter is temporary idealization. Typically, a paranoid client, denying those qualities of his that seem negative to him, perceives himself as a victim of external aggression, and sees those around him (including the therapist) as aggressive carriers of many vices. However, in the initial stages of therapy, he may identify with the therapist and idealize him along with himself. The more painful it will be for the therapist to face the inevitable wave of negativity when the period of idealization ends.

Successful psychoanalytic therapy requires the client to recognize that the qualities and desires that he does not like in others are his own qualities and desires. One of the main means of achieving this awareness is through transference analysis, during which the client can see that his fantasies about the therapist have no objective basis. To do this, the therapist needs to actually not give such reasons - to successfully withstand the client's provocations and to cope well with his feelings, especially negative ones.

Paranoid clients' reliance on denial has a significant impact on the speed of therapy. This defense mechanism works by categorically refusing to acknowledge something (and not by forgetting, as with repression). Direct interpretations of transference run into even greater denial. It takes considerable time and support from the client's observing position for him to begin to accept the very possibility that what he sees in others may come from within himself.

Despite all these difficulties, Nancy McWilliams, in her book, notes that the therapy process turns out to be extremely significant for such clients who, despite the fact that they express a huge number of reproaches and complaints to their therapists, stubbornly continue to attend sessions. McWilliams suggests that for a person with a paranoid personality type, who sees the whole world in dark, alarming tones, psychotherapy sessions in which someone listens to his negativity without responding with retaliatory attacks are a rare and very valuable outlet[5].

Professional self-realization

Paranoid psychopathy contributes to professional fulfillment. Such people can be valuable employees, because in their chosen narrow field they will work with their characteristic pedantry, perseverance, accuracy and systematicity, without being distracted by extraneous interests. However, all this ends, once the stage of open hostility with others begins, then the paranoid people throw all their strength into fighting imaginary enemies.

I recommend reading the article:

• Paranoia: what are its features and how to get rid of it.

• about the author
• Recent publications

Anna Nikolenko (Zaykina)

The author is a practicing psychiatrist with 11 years of experience. Master of Medicine and compassionate doctor. More information about the author is on this page.

Notes

1. ↑ 1 2 3 4 World Health Organization.
   F6 Personality and behavior disorders in adulthood [F60—F69] // International Classification of Diseases (10th revision). Class V: Mental and behavioral disorders (F00-F99) (adapted for use in the Russian Federation). - Rostov-on-Don: Phoenix, 1999. - P. 245-246. — ISBN 5-86727-005-8. Error in footnotes: Invalid tag: name "ICD_Def" defined multiple times for different content
2. ↑ 1 2 World Health Organization.
   The ICD-10 Classification of Mental and Behavioral Disorders. Diagnostic criteria for research. — Jeneva. — P. 149-150. — 263 p. (English)
3. 301.0 Paranoid Personality Disorder // Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. — 4th edition. - Washington: American Psychiatric Publishing, May 1994. - 620 p. — ISBN 0-89042-061-0, ISBN 978-0-89042-061-4.
4. American Psychiatric Association.
   Diagnostic and statistical manual of mental disorders (DSM-5). - Arlington, VA, 2013. - Vol. 5. - P. 649. - ISBN 978-0-89042-554-1, 978-0-89042-555-8.
5. ↑ 1 2 McWilliams, Nancy.
   Paranoid personalities // Psychoanalytic diagnosis: Understanding personality structure in the clinical process = Psychoanalytic diagnosis: Understanding personality structure in the clinical process. - M.: Klass, 1998. - 480 p. — ISBN 5-86375-098-7.