DSM-II

In DSM-II, this disorder is called Paranoid personality

This behavioral pattern is characterized by hypersensitivity, rigidity, unwarranted suspicion, jealousy, envy, excessive self-importance, and a tendency to blame others and ascribe evil motives to them. These characteristics often interfere with the patient's ability to maintain satisfactory interpersonal relations. Of course, the presence of suspicion of itself does not justify this diagnosis, since the suspicion may be warranted in some instances.

DSM-III

Diagnostic Criteria

The following are characteristic of the individual's current and long-term functioning, are not limited to episodes of illness, and cause either significant impairment in social or occupational functioning or subjective distress.

A. Pervasive, unwarranted suspiciousness and mistrust of people as indicated by at least three of the following:

  1. expectation of trickery or harm
  2. hypervigilance, manifested by continual scanning of the environment for signs of threat, or taking unneeded precautions
  3. guardedness or secretiveness
  4. avoidance of accepting blame when warranted
  5. questioning the loyalty of others
  6. intense, narrowly focused searching for confirmation of bias, with loss of appreciation of total context
  7. overconcern with hidden motives and special meanings
  8. pathological jealousy

B. Hypersensitivity as indicated by at least two of the following:

  1. tendency to be easily slighted and quick to take offense
  2. exaggeration of difficulties, e.g., "making mountains out of molehills"
  3. readiness to counterattack when any threat is perceived
  4. inability to relax

C. Restricted affectivity as indicated by at least two of the following:

  1. appearance of being "cold" and unemotional
  2. pride taken in always being objective, rational, and unemotional
  3. lack of a true sense of humor
  4. absence of passive, soft, tender, and sentimental feelings

D. Not due to another mental disorder, such as Schizophrenia or a Paranoid Disorder.

Differential Diagnosis

Paranoid Disorders and Schizophrenia

In Paranoid Disorders and Schizophrenia, Paranoid Type, there are persistent psychotic symptoms, such as delusions and hallucinations, that are never part of Paranoid Personality Disorder. However, these disorders may be superimposed on Paranoid Personality Disorder.

Antisocial Personality Disorder

Antisocial Personality Disorder shares several features with Paranoid Personality Disorder, e.g., difficulty in forming and sustaining close relationships, and poor occupational performance; but except when the two disorders coexist, a lifelong history of antisocial behavior is not present in Paranoid Personality Disorder.

DSM-IV

Diagnostic Criteria

A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

  1. suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
  2. is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
  3. is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her
  4. reads hidden demeaning or threatening meanings into benign remarks or events
  5. persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights
  6. perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack
  7. has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner

B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, or another Psychotic Disorder and is not due to the direct physiological effects of a general medical condition.

Note: If criteria are met prior to the onset of Schizophrenia, add "Premorbid," e.g., "Paranoid Personality Disorder (Premorbid)."

Differential Diagnosis

Psychotic Disorders

Paranoid Personality Disorder can be distinguished from Delusional Disorder, Persecutory Type, Schizophrenia, Paranoid Type, and Mood Disorder With Psychotic Features because these disorders are all characterized by a period of persistent psychotic symptoms (e.g., delusions and hallucinations). To give an additional diagnosis of Paranoid Personality Disorder, the Personality Disorder must have been present before the onset of psychotic symptoms and must persist when the psychotic symptoms are in remission. When an individual has a chronic Psychotic Disorder (e.g., Schizophrenia) that was preceded by Paranoid Personality Disorder, Paranoid Personality Disorder should be recorded, followed by "Premorbid" in parentheses.

Personality Change Due to a General Medical Condition, symptoms related to substance use, and traits associated with physical handicaps

Paranoid Personality Disorder must be distinguished from Personality Change Due to a General Medical Condition, in which the traits emerge due to the direct effects of a general medical condition on the central nervous system. It must also be distinguished from symptoms that may develop in association with chronic substance use (e.g., Cocaine-Related Disorder Not Otherwise Specified). Finally, it must also be distinguished from paranoid traits associated with the development of physical handicaps (e.g., a hearing impairment).

Other Personality Disorders

Other Personality Disorders may be confused with Paranoid Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more Personality Disorders in addition to Paranoid Personality Disorder, all can be diagnosed.

Schizotypal Personality Disorder

Paranoid Personality Disorder and Schizotypal Personality Disorder share the traits of suspiciousness, interpersonal aloofness, and paranoid ideation, but Schizotypal Personality Disorder also includes symptoms such as magical thinking, unusual perceptual experiences, and off thinking and speech.

Schizoid Personality Disorder

Individuals with behaviors that meet criteria for Schizoid Personality Disorder are often perceived as strange, eccentric, cold and aloof, but they do not usually have prominent paranoid ideation.

Borderline and Histrionic Personality Disorders

The tendency of individuals with Paranoid Personality Disorder to react to minor stimuli with anger is also seen in Borderline and Histrionic Personality Disorder. However, these disorders are not necessarily associated with pervasive suspiciousness.

Avoidant Personality Disorder

People with Avoidant Personality Disorder may also be reluctant to confide in others, but more because of a fear of being embarrassed or found inadequate than from fear of others' malicious intent.

Antisocial Personality Disorder

Although antisocial behavior may be present in some individuals with Paranoid Personality Disorder, it is not usually motivated by a desire for personal gain or to exploit others as in Antisocial Personality Disorder, but rather is more often due to a desire for revenge.

Narcissistic Personality Disorder

Individuals with Narcissistic Personality Disorder may occasionally display suspiciousness, social withdrawal, or alienation, but this derives primarily from fears of having their imperfections or flaws revealed.

Normal personality traits

Paranoid traits may be adaptive, particularly in threatening environments. Paranoid Personality Disorder should be diagnosed only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress.

 DSM-5

Diagnostic Criteria

A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

  1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
  2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
  3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
  4. Reads hidden demeaning or threatening meanings into benign remarks or events.
  5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
  6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
  7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.

Note: If criteria are met prior to the onset of schizophrenia, add "premorbid," e.g., "paranoid personality disorder (premorbid)."

Differential Diagnosis

Other mental disorders with psychotic symptoms

Paranoid personality disorder can be distinguished from delusional disorder, persecutory type; schizophrenia; and a bipolar or depressive disorder with psychotic features because these disorders are all characterized by a period of persistent psychotic symptoms (e.g., delusions and hallucinations). For an additional diagnosis of paranoid personality disorder to be given, the personality disorder must have been present before the onset of psychotic symptoms and must persist when the psychotic symptoms are in remission. When an individual has another persistent mental disorder (e.g., schizophrenia) that was preceded by paranoid personality disorder, paranoid personality disorder should also be recorded, followed by "premorbid" in parentheses.

Personality change due to another medical condition

Paranoid personality disorder must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the direct effects of another medical condition on the central nervous system.

Substance use disorders

Paranoid personality disorder must be distinguished from symptoms that may develop in association with persistent substance use.

Paranoid traits associated with physical handicaps

The disorder myst also be distinguished from paranoid traits associated with the development of physical handicaps (e.g., a hearing impairment).

Other personality disorders

Other personality disorders may be confused with paranoid personality disorder because they have certain features in common. It is therefore important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to paranoid personality disorder, all can be diagnosed.

Schizotypal personality disorder

Paranoid personality disorder and schizotypal personality disorder share the traits of suspiciousness, interpersonal aloofness, and paranoid ideation, but schizotypal personality disorder also includes symptoms such as magical thinking, unusual perceptual experiences, and off thinking and speech.

Schizoid personality disorder

Individuals with behaviors that meet criteria for schizoid personality disorder are often perceived as strange, eccentric, cold, and aloof, but they do not usually have prominent paranoid ideation.

Borderline and histrionic personality disorders

The tendency of individuals with paranoid personality disorder to react to minor stimuli with anger is also seen in borderline and histrionic personality disorders. However, these disorders are not necessarily associated with pervasive suspiciousness.

Avoidant personality disorder

People with avoidant personality disorder may also be reluctant to confide in others, but more from fear of being embarrassed or found inadequate than from fear of others' malicious intent.

Antisocial personality disorder

Although antisocial behavior may be present in some individuals with paranoid personality disorder, it is not usually motivated by a desire for personal gain or to exploit others as in antisocial personality disorder, but rather is more often attributable to a desire for revenge.

Narcissistic personality disorder

Individuals with narcissistic personality disorder may occasionally display suspiciousness, social withdrawal, or alienation, but this derives primarily from fears of having their imperfections or flaws revealed.

Other personality traits

Paranoid traits may be adaptive, particularly in threatening environments. Paranoid personality disorder should be diagnosed only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress.

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