Paranoid Personality Disorder (PPD)
Know someone who’s acutely mistrustful and suspicious of others, whose paranoia distorts their view of the world? Here’s how to recognise PPD and help your loved one get treatment.
What is paranoid personality disorder (PPD)?
Paranoid personality disorder (PPD) is a challenging mental health condition defined by mistrust and suspicion so intense that it interferes with thought patterns, behaviour, and daily functioning. A person with PPD may feel deeply wary of others, always on guard for signs that someone is trying to threaten, mistreat, or deceive them. No matter how unfounded their beliefs, they may repeatedly question the faithfulness, honesty, or trustworthiness of others. When they perceive they’re being persecuted, rejected, or slighted, they’re likely to respond with angry outbursts, controlling behaviour, or by deflecting the blame onto others.
The fearful, distrustful perceptions that accompany PPD can make forming and maintaining close relationships very difficult, affecting the person’s ability to function at home, work, and school. If you have a loved one with paranoid personality disorder, you may feel frustrated by their warped view of the world, exhausted by their continual accusations, or beaten down by their hostility and stubbornness. It can seem like they’re able to find and exaggerate the negative aspects of any situation or conversation.
Professional treatment can help someone with paranoid personality disorder manage symptoms and improve their daily functioning. But due to the very nature of the disorder, most people with PPD don’t seek help. As far as they’re concerned, their fears are justified and any attempts to change how they think only confirms their suspicions that people are “out to get them” in some way.
Despite the severe challenges of dealing with someone with PPD, though, you’re not totally powerless. There are steps you can take to encourage your loved one to seek help, support their treatment, and establish firm boundaries to preserve your own mental health and wellbeing.
Signs and symptoms of paranoid personality disorder
PPD often first appears in early adulthood and is more common in men than women. Research suggests it may be most prevalent in those with a family history of schizophrenia. Someone with paranoid personality disorder doesn’t see their suspicious behaviour as unusual or unwarranted. Rather, they see it as defending themselves against the bad intentions and deceptive, untrustworthy activities of those around them.
Common PPD symptoms include:
Suspecting, without justification, that others are trying to exploit, harm, or deceive them.
Obsessing on the lack of loyalty or trustworthiness of family, friends, and acquaintances.
Refusing to confide in people for fear that any information they divulge will be used against them, often leading them to isolate from others.
Interpreting hidden, malicious meanings in innocent gestures, events, or conversations.
Being overly sensitive to perceived insults, criticism, or slights, quickly snapping to judgment and holding grudges.
Responding to imagined attacks on their character with anger, hostility, or controlling behaviour.
Repeatedly suspecting, without basis, their romantic partner or spouse of infidelity.
Despite being one of the most common personality disorders, paranoid personality disorder can be difficult to detect until symptoms progress from mild to more severe. After all, most of us have behaved in mistrustful, suspicious, or hostile ways at some point in our lives without warranting a diagnosis of PPD.
Spotting the signs of paranoid personality disorder can be further complicated as it often co-occurs with another mental health problem, such as an anxiety disorder (often social anxiety), obsessive-compulsive disorder (OCD), substance abuse, or depression.
In order to confirm a diagnosis of paranoid personality disorder, a mental health provider will look for the presence of at least four of the above symptoms. They will also want to rule out paranoia stemming from a psychotic episode linked to another condition, such as bipolar disorder, schizophrenia, or depression with psychosis.
If you recognise the symptoms of paranoid personality disorder in someone you care about, it’s important to remember that you can’t fix them or force them into treatment. You can, however, encourage them to seek professional help and support them through recovery.
Treatment for PPD
Treatment for paranoid personality disorder largely focuses on psychotherapy. A therapist can help your loved one develop skills for building empathy and trust, improving communication and relationships, and better coping with PPD symptoms. Since the presence of others may fuel paranoid thoughts and anxious behaviour, your loved one is more likely to benefit from individual rather than group therapy.
Cognitive-behavioural therapy (CBT) can help someone with paranoid personality disorder recognise their destructive beliefs and thought patterns.
By changing how these beliefs influence their behaviour, CBT can help reduce paranoia and improve how well your loved one interacts with others.
CBT can also help them learn better ways to deal with their emotions, beyond lashing out at others.
Obstacles to treatment
The first major challenge is for the person with paranoid personality disorder to recognise there’s something disordered in their thinking and willingly embrace the need for treatment. Trying to force someone with PPD into seeking help will often backfire, adding to their resistance and fuelling their paranoia that people are conspiring against them.
Another obstacle to treatment is overcoming the person with PPD’s suspicion and mistrust of those trying to help them, including the therapist. As in all relationships, trust is a major component of an effective therapist-client connection. If your loved one is suspicious of the therapist’s motives, worried about disclosing personal details, or otherwise uncomfortable confiding in them, therapy is very unlikely to be successful.
Finding the right therapist for any mental health condition can often take time and effort—and that’s particularly true of paranoid personality disorder. The person with PPD needs to feel that they are working in collaboration with a therapist rather than having treatment forced upon them. It may take multiple attempts to find a therapist who’s a good fit and may require a long-term program of treatment to continually manage the symptoms of PPD.
There’s no medication specifically designed to treat paranoid personality disorder, although anti-psychotic drugs may be used to treat severe symptoms of paranoia. Other medications may also be prescribed to help manage related conditions such as anxiety or depression.
While these may be beneficial in combination with therapy, many people with PPD are suspicious of taking medication, especially if the benefits aren’t immediately apparent.
How PPD affects relationships
If you have a relationship with someone with paranoid personality disorder you already know how stressful and emotionally turbulent it can be. Whether you’re dealing with a spouse, partner, or family member, the suspicion, finger-pointing, and twisting of your words to mean something else can take a heavy toll. The verbal insults, lack of sensitivity to your feelings, and stubborn belief that they’re always right can make you feel like you’re walking on eggshells around them. And their jealousy and controlling behaviour can make it difficult for you to maintain other relationships and social ties, leaving you feeling isolated and alone.
You probably feel like the person with PPD doesn’t ever see you for who you really are. They’re so guarded about their feelings and paranoid about revealing anything personal about themselves, it can be difficult to ever feel close.
In healthy relationships, trust tends to deepen over time as two people get to know each other better. But in a relationship with someone with paranoid personality disorder, the opposite often occurs. The longer you’re in the relationship, the less the person with PPD trusts you and the more suspicious of you they become.
While it’s easy to become overwhelmed or lose hope, it is possible to stabilise your relationship by encouraging your loved one to get treatment and taking steps to establish healthy boundaries.
Coping with a loved one’s paranoia
As hurtful and confusing as a person with PPD’s behaviour can be, try to remember that your loved one’s paranoid beliefs and disordered thinking stem from fear. Even though their beliefs may be totally unfounded, the fear, anxiety, and distress they’re experiencing are very real.
Recognise their pain. While you don’t need to agree with your loved one’s groundless beliefs, you can recognise and offer comfort for the feelings that are fuelling these beliefs. Acknowledging their pain can help them feel more secure and diffuse their anger and hostility.
Don’t argue about their mistaken beliefs or instantly dismiss them. A person with PPD misinterprets events as threatening and trying to argue rationally with them will only reinforce their belief that you’re out to deceive them. Instead, respect their beliefs but focus on the fears behind their claims. Talking openly about what they’re feeling, without validating their paranoid thinking, can help to reduce their stress and anxiety.
Set boundaries. No matter how much pain your loved one is in, that doesn’t make it okay for them to take it out on you. Setting clear boundaries can help the person with PPD see the damaging effects of their behaviour, which in turn may encourage them to seek treatment. For example, you could make it clear that if they accuse you of cheating or prevent you from seeing friends, you’ll leave until they begin treatment. Make the rules and consequences clear—but only if you’re prepared to follow through with them.
Simplify how you communicate. Try to use clear, unambiguous language to reduce the chance of your loved one misinterpreting what you’re saying. If your loved one starts to twist your words, try to offer clarification without becoming defensive.
Encourage exercise. Regular physical activity releases endorphins that can relieve tension, boost your loved one’s mood, and help manage symptoms of stress, anxiety, and depression. Adding a mindfulness element—really focusing on how the body feels while exercising—may also help your loved one interrupt the flow of negative thoughts running through their head.
Promote relaxation. People with paranoid personality disorder often have difficulty relaxing. You can help by encouraging a regular relaxation practice such as yoga or meditation.
Taking care of yourself
Being in a relationship with someone who has paranoid personality disorder requires compassion, patience, and lots of understanding. But if you’re not careful, it can also be incredibly draining and take over your life. Your loved one’s pessimism can make the world seem like a dark and negative place, so it’s vital you take steps to bolster your own mood and self-esteem.
Maintain other relationships. Your loved one’s paranoid personality disorder and associated controlling behaviour may have caused you to isolate from family and friends. But it’s important to set boundaries about being able to maintain your social life. You need regular contact with family and friends for support, relaxation, and fun. If you’ve abandoned old social connections, it’s never too late to make new friends.
Take time to relax and unwind. When you’re dealing with someone with paranoid personality disorder it can feel like you’re in the eye of a storm. It’s important to regain your balance and perspective by adopting a daily relaxation practice, such as yoga, deep breathing, or meditation.
Exercise. Physical activity can be just as important for lowering your stress and anxiety levels as it is for your loved one with PPD. You may even be able to exercise or take a yoga class together, helping to motivate and encourage each other.
Eat well and get enough sleep. It’s easy to neglect your diet and skimp on sleep when you’re dealing with a loved one’s mental health problem. But when you eat well and get plenty of sleep, you’re better able to handle stress, remain patient, and control your own emotional response.
Authors: Lawrence Robinson and Melinda Smith, M.A.
Last updated: August 2020