Paranoid personality disorder

Time to put aside the false dichotomy between personality disorders and psychotic symptoms

Unlike internalizing and externalizing symptoms, psychotic symptoms (e.g., hallucinations, delusions) are manifestations of personality disorders (PDs) that are more controversial and poorly understood. This leaves clinicians with very little guidance for clinical practice, especially for diagnosis. What is more, most reviews have focused strictly on the links between psychotic symptoms and the categorically defined borderline PD, which contrasts with the growing movement that emphasizes a dimensional perspective (especially in psychology). Thus, the objectives of this critical review will be to (a) expose typical cases where PDs and psychotic symptoms might cooccur; (b) assess the state of scientific knowledge surrounding PD and psychotic symptoms; and (c) provide clinicians and researchers with recommendations to keep the field moving forward. We conclude that researchers and clinicians should move past the false "PD or psychosis" dichotomy since they often cooccur, avoid (as far as possible) making psychotic symptoms an exclusion criterion in PD research to enhance ecological validity, and consider dimensional PD diagnosis as a potential unifying solution to the dilemma posed by this cooccurrence.

Evolutionary systems therapy for paranoid personality disorder: A seven cases series

Little is known about effective psychosocial treatments for paranoid personality disorder. This study explores the feasibility of a novel treatment, namely Evolutionary Systems Therapy, in supporting individuals diagnosed with paranoid personality disorder. Seven patients attended 10 months of individual therapy without receiving any psychopharmacological treatment. The primary outcome was the feasibility of the intervention, while the secondary outcomes were remission from the diagnosis and reliable changes in personality pathology and paranoid ideation. All recruited patients completed the intervention and did not report any adverse events. Six out of seven patients experienced remission from the diagnosis of paranoid personality disorder. All participants showed reliable changes in personality pathology and paranoid ideation, which were maintained at the 1-month follow-up. Further research is needed to confirm these encouraging results.

In search of hidden threats: A scoping review on paranoid presentations in personality disorders

Recent diagnostic developments suggest that paranoia is a transdiagnostic characteristic common to several personality disorders rather than a personality disorder per se. Nonetheless, empirical literature fails to provide comprehensive and univocal findings on whether and how paranoid presentations relate to different personality disorders. In the present scoping review, we map the empirical literature on paranoid presentations in personality disorders, considering the entire spectrum of paranoid manifestations (i.e., the paranoia hierarchy). In selecting original quantitative studies on paranoid presentations in personality-disordered patients, we screened 4,433 records in PsycArticles, PsycInfo and PUBMED. We eventually included 47 eligible studies in the review. Our synthesis indicates consistent empirical evidence of a wide range of paranoid presentations in Paranoid, Schizotypal and Borderline personality disorders. Conversely, little empirical literature exists on paranoid presentations in other personality disorders. Preliminary findings suggest broad-severity paranoid presentations, ranging from milder to severe forms, in Paranoid, Schizotypal and Borderline personality disorders. There is also some evidence of milder forms of paranoia in Avoidant, Antisocial and Narcissistic personality disorders. Conversely, there is poor evidence of paranoid presentations in Schizoid, Histrionic, Dependent or Obsessive-compulsive personality disorders. Research gaps and recommendations for improving empirical research on paranoid presentations in personality disorders are discussed.

Organization of Clinician-Rated Personality Disorder Types According to ICD-11 Severity of Personality Dysfunction

Objective: The International Classification of Diseases, 11th edition (ICD-11) model of personality disorders (PD) allows clinicians to classify personality dysfunction according to four levels of severity. This approach is partially inspired by Kernberg's levels of personality organization, in which various PD types are organized according to their level of severity. This study sought to investigate whether the established ICD-10 PD categories can be organized according to the four levels of ICD-11 PD severity, and to what extent this organization aligns with Kernberg's four levels of personality organization. Method: A sample of 247 patients were rated by their mental health professionals according to ICD-10 PD categories and ICD-11 PD severity levels. Results: The frequencies of ICD-10 PDs on the different ICD-11 PD severity levels were generally found to be consistent with Kernberg's model. Accordingly, borderline and antisocial PDs predominantly occurred at the most severe levels, whereas anankastic, avoidant, and dependent PDs typically occurred at the milder levels. Only paranoid and histrionic PDs were less consistent with Kernberg's model. Conclusions: The findings indicate that the new ICD-11 PD severity dimension largely aligns with Kernberg's model of personality functioning with respect to the organization of PD types. Clinicians may therefore conceptualize familiar PD types in terms of their ICD-11 PD severity and vice versa.

The growth and development of research on personality disorders: A bibliometric study

This study objective was to investigate publication trends on personality disorders (PD) and to identify patterns of historical development. Publication rates were determined using the Results by Year Timeline feature of PubMed. Time series autoregressive integrated moving average models were used to analyse the publication rates for PDs in quinquennial periods beginning in 1980 and ending in 2019 and to predict the number of publications in the 2024-2029 period. More than 300 articles on antisocial and borderline PD are being published each year, and the models suggest an accelerating growth rate. Approximately 100 articles are being published on average every year on schizotypal PD, and the regression model indicates linear growth in the near future. The mean number of publications per year for obsessive-compulsive, narcissistic and avoidant PDs is in the range of 10-30 with the corresponding models indicating linear growth. Fewer than 10 articles are being published each year on dependent, paranoid, histrionic and schizoid PD, whereas dependent PD shows modest growth and paranoid PD rates tended to stability, histrionic and schizoid PD exhibit declining rates. Personality disorders are a group of conditions with diverse etiological, prognostic, therapeutic, legal, research, social and cultural implications that influence publication rates.

Sex differences in personality disorders in a Chinese clinical population

INTRODUCTION

Sex differences in the frequency and severity of personality disorders (PDs) have been widely reported in Western countries. However, limited literature suggests a similar sex distribution in the Chinese clinical population. This study investigated sex differences in self-reported and interviewed patients with PDs in a clinical population in China.

MATERIALS AND METHODS

The participants were 1,389 consecutive outpatients with a mean age of 30.5 years, including 634 (45.6%) males and 755 (54.4%) females. Self-reported PD traits were assessed using the Personality Diagnostic Questionnaire Fourth Edition Plus (PDQ-4+). PDs were diagnosed according to the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Axis II (SCID-II).

RESULTS

Male outpatients reported more paranoid, schizotypal, antisocial, and passive-aggressive PD traits, whereas females reported more borderline PD traits on the PDQ-4+. Self-reported PD traits in male outpatients were more likely to reach the positive threshold of antisocial PD than in females (χ² = 5.293, p = 0.021). Males were more likely to meet the criteria for schizoid (χ² = 5.050, p = 0.025), narcissistic (χ² = 27.244, p < 0.001), antisocial (χ² = 11.430, p = 0.001), avoidant (χ² = 5.098, p = 0.024), and obsessive-compulsive PD (χ² = 5.496, p = 0.019) diagnoses in the SCID-II. In contrast, females were more likely to meet the criteria of histrionic (χ² = 12.327, p = 0.001), borderline (χ² = 28.538, p < 0.001), and dependent (χ² = 4.919, p = 0.027) diagnoses.

DISCUSSION

These findings indicate gender differences in the traits, frequency, and pattern of PDs when assessed in a Chinese clinical population.

Psychiatric Assessment of Social Impairment Across the Lifespan

Although autism spectrum disorder (ASD) is the prototypical psychiatric disorder of social impairment, several if not most psychiatric disorders are characterized by prominent impairments in social functioning. A challenge in clinically assessing and describing social impairment is that it has been variably defined and can be difficult to measure. In this article we consider the psychiatric differential diagnosis of social impairment within the DSM-5 framework. We describe the features of social impairment in 13 DSM-5 disorders from a developmental perspective and highlight diagnostic factors that differentiate among the disorders, including the main features of social impairment, verbal communication, nonverbal communication, course of social impairment, social cognition, and key features of accompanying neuropsychiatric symptoms. We conclude by describing an approach for assessing social impairment across the lifespan.

Effects of interaction of NOS1AP gene polymorphisms and childhood abuse on paranoid personality disorder features among male violent offenders in China

BACKGROUND

Paranoid Personality Disorder (PPD) results from a complex synergy between genetic and environmental factors. Childhood abuse is one of risk factors. Nitric Oxide Synthase 1 Adaptor Protein (NOS1AP) is a candidate gene of schizophrenia, which has similar pathophysiology to PPD. This study investigated the role of NOS1AP gene polymorphisms and a history of childhood abuse in predicting PPD features among male violent offenders in the Chinese Han population.

METHOD

Four NOS1AP Single Nucleotide Polymorphisms (SNPs), rs4145621, rs3751284, rs348624 and rs6680461 were genotyped in a sample of 423 male prisoners. Participant evaluations included demographic information, measures of childhood abuse (Child Trauma Questionnaire, CTQ), and PPD features (Personality Diagnostic Questionnaire-4, PDQ-4). Participants were divided into a PPD group and non-PPD group assessed by PDQ-4.

RESULTS

Regression analysis revealed that emotional abuse, NOS1AP SNPs rs348624 and rs4145621 predicted PPD features (P < 0.05) among prison samples. Significant interactions between childhood abuse history and NOS1AP SNPs rs3751284 and rs6680461 were also observed. Individuals carrying the C allele of rs3751284 were susceptible to PPD features when exposed to higher levels of emotional neglect (P < 0.05); Individuals with the G allele of rs6680461 were susceptible to PPD features when exposed to higher levels of emotional, physical and sexual abuse (P < 0.01).

CONCLUSIONS

These results suggest that the interaction between childhood abuse and NOS1AP gene polymorphisms may have an influence on PPD features, at least in male violent offenders.

Cognitive reappraisal capacity mediates the relationship between prefrontal recruitment during reappraisal of anger-eliciting events and paranoia-proneness

Difficulties in emotion regulation, particularly in using adaptive regulation strategies such as cognitive reappraisal, are a commonly observed correlate of paranoia. While it has been suggested that poor implementation of cognitive reappraisal in dealing with aversive events precedes the onset of subclinical paranoid thinking, there is little empirical research on neural activation patterns during cognitive reappraisal efforts that might indicate vulnerability towards paranoid thinking. Prefrontal EEG alpha asymmetry changes were recorded while n = 57 participants were generating alternative appraisals of anger-eliciting events, and were linked to a behavioral measure of basic cognitive reappraisal capacity and self-reported paranoia proneness (assessed by personality facets of hostility and suspiciousness; Personality Inventory for DSM-5). Mediation analysis revealed that less left-lateralized activation at ventrolateral prefrontal sites during reappraisal efforts predicted a higher degree of paranoia proneness. This relationship was mediated through poorer cognitive reappraisal capacity. Matching previous evidence, findings suggest that inappropriate brain activation during reappraisal efforts impairs individuals' capacity to come up with effective alternative interpretations for anger-evoking situations, which may accentuate personality features related to increased paranoid thinking. The findings add to our understanding of neurally underpinned impairments in the capacity to generate cognitive reappraisals and their link to maladaptive personality and behavior.

Symptoms, course of Illness, and comorbidity as predictors of expressed emotion in bipolar disorder

High levels of expressed emotions (EE) reflect the amount of criticism and/or over-involvement in families and has been linked to relapse risk in various psychiatric disorders including bipolar disorder (BD). Less clear is which factors contribute to the development and/or maintenance of EE. Therefore, we tested whether patient characteristics, specifically clinical features and personality disorder traits in BD predicted key aspects of EE as assessed by patients and their relatives. Patients with remitted BD and their relatives were asked to complete the Family Attitude Scale (FAS) and the Perceived Criticism Measure (PCM). Patient characteristics were assessed with a variety of measures including SCID I and II. The FAS and PCM shared 25% of the variance for patients and 14% for relatives, suggesting a conceptual overlap, but they may not assess identical constructs. The number of previous mood episodes, current self-rated manic symptoms, and comorbid symptoms of Cluster C personality disorder predicted patient-rated FAS. Relative-rated FAS was only predicted by comorbid symptoms of Cluster A personality disorder. In BD, specific patient characteristics seem to be linked to key aspects of EE even when in remission. However, it might depend whether the patient, his/her relative, or a neutral observer assessed EE.

Paranoia and risk of personality disorder in the general population

BACKGROUND

We hypothesized that paranoia is associated with personality disorder (PD) in the general population.

METHOD

This was a population-based cross-sectional survey carried out in Andalusia (Spain) using a representative sample of 4 507 participants. Paranoia was measured using the Green Paranoid Thought Scale, and risk of having a PD was screened using the Standardized Assessment of Personality Abbreviated Scale whilst borderline personality disorder (BPD) was measured with the CEPER-III Exploratory Interview of Personality disorder. Adjusted Pearsons' correlations between paranoia and PD or BPD were calculated.

RESULTS

Paranoia was associated with the risk of having PD and, more robustly, with BPD. Both associations held true for both personality outcomes (PD and BPD) when tested for two Green Paranoid Thought Scale paranoia subtypes (persecutory and reference) after accounting for the effects of age, sex and child abuse.

CONCLUSIONS

Paranoia seems to either augment the risk for, or be part of, PD/BPD. © 2019 John Wiley & Sons, Ltd.

Sex Differences in Personality Disorders

PURPOSE OF REVIEW

This review aims to give an overview on the current literature on sex differences in personality disorders and to highlight the potential of dimensional approaches.

RECENT FINDINGS

Empirical findings on sex differences in personality disorders are inconsistent and appear to be highly dependent on study settings. Current studies have mainly focused on borderline and antisocial personality disorder and the question whether these are sex-specific representations of a common substrate. In general, sexes differ in the manifestation of personality disorders as well as in comorbidities. Criticism of the established categorical model led to an additional dimensional model of personality disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Investigations on sex differences in personality disorders are sparse and mainly limited to antisocial and borderline personality disorder. The introduction of a dimensional model offers the chance to re-think the construct of "personality disorder" and thereby also opens the possibility for a better understanding of sex differences.

Clinical cut-off point for the Distrust dimension of the Dimensional Clinical Personality Inventory 2 (IDCP-2)

The Clinical Dimensional Personality Inventory 2 (IDCP-2) is a 206-item self-report tool developed for the assessment of 12 dimensions (divided into 47 factors) of personality pathology. One of the scales comprising the instrument, the Distrust scale, is intended to provide psychometric information on traits closely related to the Paranoid Personality Disorder (PPD). In the present research, we used the Item Response Theory and the Receiver Operating Characteristic curve analysis to establish a clinical meaningful cutoff for the Distrust scale. Participants were 1,679 adults, among outpatients diagnosed with PPD, outpatients diagnosed with other PDs, and adults from the community. The Wright map revealed that outpatients were located at the very high levels on the latent continuum of the Distrust scale, with a very large effect size for the mean difference between patients and non-patients. The ROC curve supported a cutoff at -1.00 score in theta standardization which yielded 0.87 of sensitivity and 0.54 of specificity. Findings from the present investigation suggest the IDCP-2 Distrust scale is useful as a screening tool of the core features of the PPD. We address potential clinical applications for the instrument and discuss limitations from the present study.

The co-occurrence between depressive symptoms and paranoid ideation: A population-based longitudinal study

BACKGROUND

The aim of this study was to examine longitudinally in the general population (a) whether depressive symptoms co-occur with paranoid ideation from late adolescence to middle age (b) whether depressive subsymptoms are differently linked with paranoid ideation (c) whether depressive symptoms are associated with state-level or trait-level paranoid ideation.

METHODS

Altogether 2109 subjects of the Young Finns study completed the Paranoid Ideation Scale of the Symptom Checklist-90 Revised and a modified version of the Beck Depression Inventory in 1992, 1997, 2001, 2007, and 2012, and the Beck Depression Inventory-II in 2007, 2011, and 2012.

RESULTS

Higher self-rated depressive symptoms were associated with the course of more severe paranoid ideation over age, especially in late adolescence and early adulthood. Regarding depressive subsymptoms, the associations of negative attitude and performance difficulties with paranoid ideation were evident over age, whereas the influence of somatic symptoms (such as changes in sleep and appetite) was not significant until after early adulthood. Additionally, depressive symptoms were more evidently associated with the development of trait- than state-level paranoid ideation.

LIMITATIONS

Our study mostly captured mild depressive and paranoid symptoms. The results cannot be directly generalized to clinical populations.

CONCLUSIONS

Depressive symptoms were associated with the course of paranoid ideation from late adolescence to middle age. Patients with paranoid ideation might merit from evaluation of potential depressive symptoms, especially in late adolescence and early adulthood. Among patients with co-occurring depressive symptoms and paranoid ideation, there may be a substantial need for neurocognitive rehabilitation and community-based treatments.

Longitudinal associations of temperament and character with paranoid ideation: A population-based study

The aim of this study was to examine (a) the associations of temperament and character dimensions with paranoid ideation over a 15-year follow-up in the general population (b) the associations of explosive temperament and organized character profiles with paranoid ideation. 2137 subjects of the Young Finns Study completed the Temperament and Character Inventory and the Paranoid Ideation Scale of the Symptom Checklist-90 Revised in 1997, 2001, and 2012. Temperament dimensions of high novelty seeking, high harm avoidance, low reward dependence and explosive temperament profile were associated with the development of higher paranoid ideation. Regarding character, high self-directedness, high cooperativeness, and low self-transcendence and organized character profile were associated with lower paranoid ideation. These associations sustained after controlling for age, gender, and socioeconomic factors. However, the associations between temperament and paranoia mostly disappeared after taking character into account. Our study supported the hypothesis that personality dimensions contribute to the development of paranoid ideation. Temperament and character might combine a variety of single previously found risk factors into a more comprehensive framework for the developmental etiology of paranoia. Our findings provide evidence for psychotherapeutic interventions that support the self-regulation of temperamental vulnerabilities by internalizing mature concepts about the self and social relationships.

A genetic locus for paranoia

The psychological effects of brain-expressed imprinted genes in humans are virtually unknown. Prader-Willi syndrome (PWS) is a neurogenetic condition mediated by genomic imprinting, which involves high rates of psychosis characterized by hallucinations and paranoia, as well as autism. Altered expression of two brain-expressed imprinted genes, MAGEL2 and NDN, mediates a suite of PWS-related phenotypes, including behaviour, in mice. We phenotyped a large population of typical individuals for schizophrenia-spectrum and autism-spectrum traits, and genotyped them for the single-nucleotide polymorphism rs850807, which is putatively functional and linked with MAGEL2 and NDN Genetic variation in rs850807 was strongly and exclusively associated with the ideas of reference subscale of the schizophrenia spectrum, which is best typified as paranoia. These findings provide a single-locus genetic model for analysing the neurological and psychological bases of paranoid thinking, and implicate imprinted genes, and genomic conflicts, in human mentalistic thought.

Mistrustful and Misunderstood: A Review of Paranoid Personality Disorder

PURPOSE OF REVIEW

Paranoid Personality Disorder (PPD) has historically been neglected by science out of proportion to its prevalence or its association with negative clinical outcomes. This review provides an update on what is known about PPD regarding its prevalence, demographics, comorbidity, biological mechanism, risk factors, and relationship to psychotic disorders.

RECENT FINDINGS

PPD has long been the subject of a rich and prescient theoretical literature which has provided a surprisingly coherent account of the psychological mechanism of non-delusional paranoia. Available data indicate that PPD has a close relationship with childhood trauma and social stress. Descriptive data on a sample of 115 individuals with Paranoid Personality Disorder is examined in comparison with a group of individuals with Borderline Personality Disorder. The descriptive data largely confirm previously identified relationships between Paranoid Personality Disorder and childhood trauma, violence, and race. We identify important similarities to and differences from Borderline Personality Disorder.

SUMMARY

PPD continues to be an important construct in the clinic and the laboratory. Available data lead to a reconsideration of the disorder as more closely related to trauma than to schizophrenia.

Genetic and Neuroimaging Features of Personality Disorders: State of the Art

Personality disorders often act as a common denominator for many psychiatric problems, and studies on personality disorders contribute to the etiopathology, diagnosis, and treatment of many mental disorders. In recent years, increasing evidence from various studies has shown distinctive features of personality disorders, and that from genetic and neuroimaging studies has been especially valuable. Genetic studies primarily target the genes encoding neurotransmitters and enzymes in the serotoninergic and dopaminergic systems, and neuroimaging studies mainly focus on the frontal and temporal lobes as well as the limbic-paralimbic system in patients with personality disorders. Although some studies have suffered due to unclear diagnoses of personality disorders and some have included few patients for a given personality disorder, great opportunities remain for investigators to launch new ideas and technologies in the field.

Review of pharmacologic treatment in cluster A personality disorders

Introduction:

A personality disorder is a pervasive and enduring pattern of behaviors that impacts an individual's social, occupational, and overall functioning. Specifically, the cluster A personality disorders include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder. Patients with cluster A personality disorders tend to be isolative and avoid relationships. The quality of life may also be reduced in these individuals, which provokes the question of how to treat patients with these personality disorders. The purpose of this review is to evaluate the current literature for pharmacologic treatments for the cluster A personality disorders.

Methods:

A Medline/PubMed and Ovid search was conducted to identify literature on the psychopharmacology of paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder. There were no exclusions in terms of time frame from article publication or country of publication, in order to provide a comprehensive analysis; however, only articles that contained information on the cluster A disorders were included.

Results:

Minimal evidence regarding pharmacotherapy in paranoid and schizoid personality disorders was found. Literature was available for pharmacologic treatment of schizotypal personality disorder. Studies evaluating the use of olanzapine, risperidone, haloperidol, fluoxetine, and thiothixene did yield beneficial results; however, treatment with such agents should be considered on a case-by-case basis.

Discussion:

Most of the literature analyzed in this review presented theoretical ideas of what may constitute the neurobiologic factors of personality and what treatments may address these aspects. Further research is needed to evaluate specific pharmacologic treatment in the cluster A personality disorders. At this time, treatment with pharmacologic agents is based on theory rather than evidence.

Personality Disorders in Female and Male College Students With Internet Addiction

A high rate of personality disorders (PDs) was found in individuals with Internet addiction (IA) in previous studies using clinical and limited sample sizes. The present study further made comparisons between sex and incorporated a control group to compare the frequencies of PD between individuals with IA and those without IA. Five hundred fifty-six college students (341 females) completed self-report surveys and were later given diagnostic interviews to assess for a PD diagnosis. Males with IA showed a higher frequency of narcissistic PD, whereas females with IA showed a higher frequency of borderline, narcissistic, avoidant, or dependent PD when compared with those without IA. The high rate of PD among Internet addicts may be associated with the core features of specific PD psychopathology. Sex differences in the PD frequencies among IA individuals provide indications for understanding the psychopathological characteristics of PDs in Internet addicts.