Paranoid Personality Disorder

Diagnostic criteria: Generalized distrust and suspicion.

The core defining feature of this clinical picture is a pervasive distrust and unwarranted suspicion of others, interpreting their intentions as malevolent.

For its formal diagnosis, this attitude must be persistent, start in early adulthood and manifest itself in various contexts, not limited to isolated episodes.

The individual lives in a state of constant hypervigilance, scanning his or her environment for evidence to confirm unfounded fears of being exploited, harmed or deceived.

At least four specific indicators are required to confirm the diagnosis.

These include unwarranted doubts about the loyalty of friends or associates and a marked reluctance to confide in others for fear that the information will be used against them.

Imagine an employee who refuses to share his ideas in a meeting out of the conviction that his colleagues will plagiarize his work to his detriment, without any real evidence.

In addition, they tend to read hidden or demeaning meanings into benign comments; a simple glance from a stranger on public transportation can be interpreted as a veiled threat or a taunt.

Persistent resentment and perceived attacks on their character that are not obvious to others are also common, reacting with anger or quick counterattacks.

Finally, recurrent suspicion about the partner's fidelity, without justification, is a classic symptom.

Epidemiology and associated comorbidity

In terms of preva lence, studies place this disorder between 2% and 4.4% of the general population, being more frequently diagnosed in men.

There is a significant genetic correlation, with a higher incidence observed in relatives of people with schizophrenia or delusional disorder, suggesting a biological link within the schizophrenic spectrum. Comorbidity is high and complex.

Due to the constant stress of living on alert, these patients are prone to brief (minutes or hours) psychotic episodes in response to intense stress.

They are also at high risk of developing major depressive disorders, agoraphobia and obsessive-compulsive disorder.

In relation to other personality disorders, they frequently overlap with schizotypal, schizoid, narcissistic and borderline personality disorders, sharing with them characteristics of isolation and severe interpersonal difficulties.

Therapeutic approach and management of mistrust

Treatment represents a major challenge due to the very nature of the disorder: mistrust.

They rarely come to consultation of their own free will; they usually do so pressured by family members or by problems derived from their hostile behavior.

The therapist's primary goal is not to confront their delusions initially, but to establish a working alliance based on open acceptance of their mistrust, without pressuring them.

Therapy should be clear, consistent and predictable to avoid feeding their suspicions.

We seek to increase their sense of self-efficacy and control, allowing them to manage certain aspects of the sessions.

At the cognitive level, work is done on restructuring dysfunctional thought patterns and social skills training to reduce interpersonal anxiety.

Pharmacologically, although there is no specific first-line treatment, short-term antipsychotics can be used to manage agitation or severe anxiety, always with caution given the patient's suspicion towards medication.

Summary

The core feature of this disorder is a pervasive distrust and unwarranted suspicion, where the individual interprets the intentions of others as malevolent, living in a state of constant hypervigilance to possible threats.

These subjects doubt the loyalty of friends without proof, read demeaning meanings into benign comments, and harbor lingering grudges, reacting with rapid hostility to perceived attacks on their character.

Treatment is a major challenge because of their baseline distrust. Therapy seeks to establish an alliance without initially confronting delusions, while the use of antipsychotics can help manage severe anxiety.